Med J Malaysia Vol 63 No 4 October 2008 343 SUMMARY Penile reconstructive surgeries are performed mainly as radical treatment for conditions associated with congenital abnormalities of the urethra or penis, after penile trauma, penile cancer, short penis, corporal fibrosis and in cases of gender reassignment. We present here a method of penile reconstruction with a pre fabricated radial forearm free flap incorporating the segment of the radius for structural support. KEY WORDS: Neourethra, Radial forearm osteocutaneous flap, Neophallus INTRODUCTION Penile amputations whether in a traumatic scenario or in the case of a penile carcinoma serves a severe blow to the male ego and psyche. The first case of microsurgical reconstruction of a phallus was reported in China by two groups in 1984 1 in which the radial forearm flap “tube in a tube” simultaneous reconstruction of a neourethra and phallus was devised. Ever since, there has been various flaps designed for the purpose of penile reconstruction namely from the lower abdomen, dorsalis pedis, lateral arm and lower extremity to name a few. A common problem which plagues the various flaps devised was stricturing and fistula formation of the neourethra. Japanese reconstructive surgeons have even suggested the use of the vermiform appendix transfer by supramicrovasvular surgery to address the problems. Here we present, possibly, the first successful case of penile reconstruction in Malaysia. CASE REPORT The 49 year old patient had his penis severed by his wife following an argument at their home in January of 2005. The penis was cut off at the base with a kitchen knife leaving a small stump of penile tissue around half an inch from the pubic symphisis. The testes and scrotal skin were intact. (Figure 1) He was admitted to a nearby district hospital and refashioning of the penis was done and he was then put on daily dressings and intravenous antibiotics. A urinary catheter was inserted at the time of debridement for bladder drainage. As there was no immediate access to a microvascular surgeon or urologist an appointment was made with our urologist a month after the incident. At the first appointment with our urologist it was found that although the patient was able to pass urine without a catheter, he had developed stricturing of the urethral opening causing him to take longer to pass urine than normal and he also had frequency in micturition. He underwent urethral dilatation and meatoplasty four months later and subsequently had a good flow. The problem of increased frequency was also no longer present. The patient however was depressed regarding the absence of a phallic structure on his groin and complained of feelings of inadequacy as a male member of society. Being reduced to squatting to pass urine posed problems to him habitually as well as psychologically. He was then referred to our plastic surgeon for the option of a penile reconstruction. The patient was planned for a 2 stage reconstruction of his penis, the first stage was to begin a year from the date of the trauma. The first stage reconstruction involved harvesting a full thickness graft from the groin crease to form a pseudo- urethra. A tunnel was created axially in the subcutaneous tissue of his left forearm where the radial forearm flap was to be harvested and the harvested groin skin was then attached at both ends to a Fr 16 bladder catheter. (Figure 2) The catheter carrying the skin graft was then passed through the subcutaneous tunnel. Both ends of the urethral cylinder were transfixed to the proximal and distal openings with absorbable sutures. Penile reconstructions are never without its inherent complications and we encountered similar such circumstances in this patient. Initially he developed a localized infection along the fabricated tunnel which resolved with intravenous antibiotics and daily flushing. Once the infection was resolved the fabricated tunnel was examined with a ureteric scope. We encountered two separate strictures, one at the proximal tunnel opening and another around 1cm from the distal tunnel opening. The rest of the skin graft was noted to be healthy. The scope however could be passed through the entire tunnel and so the second stage procedure was planned. In the second stage of the operation, four months from first stage, the prefabricated urethra along with a forearm, osteocutaneous flap was raised with a small axial segment of radial bone measuring 6cm in length and 0.5cm wide. The cephalic vein was included into the flap along with the superficial branch of the radial nerve to supply a sensate, structured phallus to the patient. (Figure 3) Two Stage Penile Reconstruction with Free Prefabricated Sensate Radial Forearm Osteocutaneous Flap S Ramesh, MBBS, A Serjius, MS, T B Wong, MS, S Jagjeet, MD, R John, MS Hospital Queen Elizabeth, Kota Kinabalu, Sabah, Malaysia CASE REPORT This article was accepted: 29 July 2008 Corresponding Author: Ramesh Sasidaran, PT 637, Jalan KK 2/73, Bandar Baru Kubang Kerian, 16150 Kota Bahru, Kelantan