Sexual and urological reconstruction following penectomy for penile cancer: phalloplasty

Abstract

Phalloplasty following penectomy for penile cancer presents a complex reconstructive challenge, requiring restoration of urinary and sexual function while addressing anatomical and psychological sequelae. Unlike gender-affirming phalloplasty, this procedure is complicated by previous surgery and potential anatomical deficits. However, limited data exist to guide reconstruction in this cohort. This narrative review summarises available evidence on phalloplasty post-penectomy. A systematic search identified six relevant studies, including 48 patients, with follow-up ranging from 1 to 150 months. The radial artery free flap (RAP) and anterolateral thigh flap (ALTP) are the preferred techniques, each with distinct advantages and limitations. While RAP offers superior tactile recovery, ALTP reduces donor site morbidity. Complication rates are high, particularly urethral strictures and fistulae, affecting up to 64.3% of cases. Despite these risks, functional outcomes, including standing micturition and sexual activity, are achievable and patient satisfaction remains high. Challenges include extrapolating data from transgender cohorts and managing psychosocial concerns. A multidisciplinary approach is essential for optimising patient selection, counselling, and long-term outcomes. Further research is needed to refine surgical techniques, improve complication management, and explore innovative reconstructive strategies.

Fig. 1. Flowchart diagram.

The figure illustrates the selection process.

Fig. 2. Penile amputation.

The figures shows the outcomes of penile amputation with perineal urethrostomy.

Fig. 3. Outcome fo first stage phalloplasty.

The patient has a drain inside the phallus to prevent hematoma, a suprapubic catheter, and a transurethral catheter.

Fig. 4. Urethra construction.

Urethral tabularisation around a 16ch catheter following the harvest of the radial forearm flap at the time of the first stage.

Fig. 5. Phallus construction.

Construction of the phallus with integrated urethra by tubularising the phallus around the urethra. This technique is also referred to as “tube-in-tube”.

Fig. 6. Penile neurovascular bundle. The figure illustrates the 2 dorsal penile nerves (marked by the yellow sloops) and the superficial dorsal penile vein (blue sloop).

One of the nerves and the vein can be used for microsurgical anastomoses following penile amputation for cancer when viable.