A tie‐over dressing for graft application in distal penectomy and glans resurfacing: the TODGA technique

• Published in: BJU international Vol. 107; no. 5; pp. 836 - 840
• Main Authors: Malone, Peter R., Thomas, Johanna S., Blick, Chris
• Format: Journal Article
• Language: English
• Published: Oxford, UK Blackwell Publishing Ltd 01-03-2011; Wiley-Blackwell; Wiley Subscription Services, Inc
• Subjects: Adult; Aged; Aged, 80 and over; Bandages; Biological and medical sciences; Early Ambulation; Genital cancers; glans resurfacing; glansectomy; Gynecology. Andrology. Obstetrics; Humans; Immobilization; Male; Male genital diseases; Medical sciences; Middle Aged; neo‐glans; Nephrology. Urinary tract diseases; Paraffin; Patients; penile cancer; Penile Diseases - surgery; Penis; Penis - surgery; Reconstructive Surgical Procedures - methods; Skin; Skin & tissue grafts; Skin Transplantation; split‐skin graft; Squamous cell carcinoma; Stenosis; Surgery; Suture Techniques; Sutures; tie‐over dressing; Treatment Outcome; Tumors; Urologic Surgical Procedures, Male - methods; Urological surgery; Nephrology; Malignant tumor; Resurfacing; glans resurfacing; Urology; Dressing; Penile diseases; tie-over dressing; Treatment; penile cancer; Distal; neo-glans; split-skin graft; glansectomy; Graft; Penis cancer; Glans; Skin; Technique; Male genital diseases; Cancer
• ISSN: 1464-4096; 1464-410X
• DOI: 10.1111/j.1464-410X.2010.09576.x

Study Type – Therapy (case series)
Level of Evidence 4
What’s known on the subject? and What does the study add?
The treatment of penile cancer has been revolutionised by modern penile preserving surgery, particularly glansectomy and glans reconstruction using split skin graft. These techniques can produce a cosmetically good result but also preserve the sexual and urinary function of the penis.
Applying a split skin graft to the penis is technically difficult and most authors recommend a period of up to 5 days bed rest after surgery to maximize graft take. This is expensive in health economic terms and may increase the risk to the patient of thrombo‐embolic complications. The paper describes a new technique of tie‐over dressing which allows early mobilization and discharge without compromising graft viability.
OBJECTIVES
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To describe a novel method of split‐skin graft (SSG) fixation for neo‐glans formation after distal penectomy for penile cancer and glans resurfacing for carcinoma in situ or lichen sclerosus (LS); the TODGA technique.
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Rather than ‘quilting’ the graft onto the neo‐glans, which requires up to 5 days bed rest, the tie‐over method fixes the graft adequately enough to allow immediate patient mobilization.
PATIENTS AND METHODS
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In all, 41 consecutive operations, with a follow‐up of ≥12 months, were performed on 40 patients (mean age 62 years, range 32–83) from December 2000 to October 2008, where a SSG was applied to the raw glans or penile stump.
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The protocol varied for the first 12 operations on 11 patients. The tie‐over dressing was left in place for 6 (one patient) or 7 days (11) and various materials were used; paraffin gauze (one), expanded foam (five) and proflavine‐soaked gauze (six). The first two patients had their dressing removed under general anaesthetic but all subsequent patients had their dressing removed on the ward.
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The subsequent 29 operations used the same protocol where a proflavine‐soaked gauze dressing was left undisturbed for 10 days.
RESULTS
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In the original 11 patients, two required re‐grafting. After this initial development period, we amended the technique to use stronger sutures and left the dressing undisturbed for 10 days.
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In addition, we standardized the use of proflavin‐soaked gauze, as we found it easy to apply and remove. Since we adopted this protocol, we have performed 29 operations over a 3‐year period.
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The cosmetic results were excellent with only one patient requiring re‐grafting. The mean and median postoperative length of stay was 2 days.
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One patient with a urethral squamous cell carcinoma associated with urethral and glans LS required a urethral dilatation to allow a check cystoscopy, and a further asymptomatic patient had a meatal dilatation in the clinic but meatal stenosis was otherwise not seen, with no patients requiring regular meatal dilatation.
CONCLUSION
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The TODGA technique of SSG application and fixation allows immediate mobilization and reduces hospital stay whilst providing excellent cosmetic results with a high percentage of graft uptake.