LAUSR

Men with a history of bladder exstrophy place high value on the appearance and reconstruction of the phallus, ranking these (along with urinary issues) as their primary health concerns related to bladder exstrophy. Previous studies assessing sexual function in adults with EEC have largely focused on fertility outcomes and quantity, rather than quality, of sexual activity. A recent manuscript from this same institution acknowledged that just over half of men with EEC were “very satisfied” with their sex lives (reference 6 in article). This, combined with the knowledge that dissatisfaction with genital appearance was correlated with a lower satisfaction with sexual activity, underscores the importance of eliciting the patient’s perspective on and expectations for ideal and realistic genital appearance. The radial free forearm flap and pedicled anterolateral thigh flap are well described reconstructive techniques for conditions including gender confirming surgery and aphallia. Patients with EEC often have undergone multiple prior surgeries, with ensuing penile microvascular damage and scarring. Harris et al, in detailed “how we do it” format, describe the adaptation of these phalloplasty techniques for the cohort of patients with EEC, including a frank discussion of complications (including 1 perioperative death) and intermediate-term outcomes, outlining their rationale for the superiority of PALTF. The true value of a reconstructive surgical technique is not in whether it is technically feasible to perform in the operative theatre, but in how well it serves the patient in standing the test of time with regard to tissue integrity and functionality.