(512) Nightmare Case Report: Novel Glans Reconstruction Using Fat Tissue and Urethral Reconstruction Using Buccal Mucosa Graft for the Treatment of Severe Glans Necrosis Following Plaque Incision and Grafting Due to Peyronie’s Disease

Introduction Due to its rarity, glans necrosis following penile procedures is an underreported topic in the urological literature with no well-established treatment protocol. Variable conservative treatments such as antibiotic treatment, hyperbaric oxygen therapy, PDE-5 inhibitors, and heparin are common treatments used in the acute case of glans ischemia. However, once the necrosis is settled, necrosectomy with deep debridement till healthy tissue is reached is the only solution, followed by a secondary reconstructive procedure. In contrast to total glans necrosis, where a glansectomy and formation of a neoglans with split-thickness graft is the standard reconstructive option, no surgical technique has been described up to now for partial glans necrosis. Objective To describe a novel staged reconstructive technique, including a urethroplasty with glansplasty primarily and lipofilling of the glans using autologous fat tissue to augment the lost glandular volume. Methods We describe a nightmare-case report of severe partial glans necrosis after a surgical procedure for Peyronie’s disease for complex deformity, including a two-point plaque incision and grafting. The patient presented some days following surgery with a severe necrosis of the right half of his glans penis, including the ventral part covering the urethra. Surgical debridement was utilized without direct coverage with a skin graft, and the defect epithelialized in time. The final extent of tissue loss was so severe that almost the entire right half of the glans penis and the ventral part of the glandular urethra were lost. It was thus a real challenge to reconstruct this defect in such a way as to achieve a cosmetic and functional result that was acceptable to the patient. The patient reported difficulty in sexual intercourse due to absent glandular engorgement and psychological distress regarding the appearance of his penis, therefore, he insisted on pursuing some form of reconstruction despite our concerns due to the lack of evidence-based therapy. The presumed causes of necrosis, the treatment steps, and the final result were analyzed. Results Six months following surgical debridement, a distal penile one-stage urethroplasty using a buccal mucosa graft in the dorsal-inlay technique extending from the sulcus coronarius till the meatus urethrae externus with simultaneous ventral glansplasty was successfully performed to correct an iatrogenic coronal hypospadias. One year later, a plastic reconstruction of the right half of the glans was performed using a two-session lipofilling treatment with autologous fat tissue harvested from the lower abdomen. The esthetic and functional outcome of the lipofilling in a one-year follow-up was very satisfactory for the patient. Voiding is normalized with a straight stream in a two-year follow-up. Conclusions This novel reconstructive technique, based on plastic surgery principles, is a viable option for glans penis reconstruction after severe volume loss due to partial glans necrosis. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Leonidas Karapanos: Consultant for Coloplast, Boston scientific