Avulsion injuries of the male external genitalia: classification and reconstruction with the customised radial forearm free flap

Between 1995 and 2003, 36 men underwent penile reconstruction for avulsion injuries with radial forearm free flap. Classification was according to location of the native urethra at presentation. In type I injury the meatus was at the corporal stump. In type II injury there was loss of corpora with preservation of the crura leaving the meatus near the pubic symphysis. In type III injuries there was a perineal urethrostomy. In type IV injuries urinary diversion via a supra-pubic catheter was required. In some instances, the flap was designed obliquely over the forearm rather than vertically to gain length. Secondly, we fashioned additional 8–11 cm length of the urethral portion of the flap (with separate draining vein) to tap into the perineal urethrostomy. Seven patients had type I injuries, 15 patients had type II injuries, 10 patients had type III injuries and four patients had type IV injuries. All 22 patients with type I/II injuries and 7/10 patients with type III injuries underwent phalloplasty in a single stage. Three patients with type III injuries had two-stage reconstructions while all four patients with type IV injuries underwent reconstruction in three stages. There was one flap loss, eight developed fistula and six patients developed late stricture. Overall patient satisfaction with the reconstruction was very high.