there is absence of penis and urethral opening is located in the anterior rectal wall in the majority of cases .
phallic reconstruction using the free radial forearm flap ( rff ) or the pedicled anterolateral thigh flap ( altf ) has been routinely used in penile inadequacy or in female - to - male transsexuals . however ,
even if any reconstruction in infancy is carried out successfully , it is likely to cause encumberance during childhood and a further source of social embarrassment .
we describe a novel technique as a temporizing procedure which would see the patient through childhood .
we describe 2 patients who presented at the age of 9 months and 1 year with penile agenesis . both were passing urine and stools per rectum .
the physical examination revealed complete absence of a phallus , a well - developed scrotum and normal sized testes .
the urethral opening was located on the anterior rectal wall , about 2 cm . from the anal verge .
the voiding cystourethrography revealed a short urethra with urethro - rectal communication a short distance beyond the bladder neck . while mri confirmed the above findings , it also revealed a normal looking urinary bladder and absence of corpora cavernosa and the corpus spongiosum .
urinary bladder was seen to open lower down on the anterior rectal wall through the short posterior urethra ending approximately 2.0 cm from the anal verge .
bowel preparation is done by peglec solution ( polyethylene glycol with electrolytes ) administered orally for 48 hours before surgery . under general anesthesia , the child
urethral lumen is catheterized easily by inserting a # 8f feeding tube through the anal verge .
we use a pre - anal , anterior coronal approach , to detach and mobilize the urethral opening from the anterior rectal wall [ figure 1a ] .
a semilunar incision is given on the perineum , anterior to the anal verge , from 3 oclock to 9 oclock .
the urethra - easily identified over the feeding tube - is mobilized and detached from the anterior surface of rectum .
the rectal end of the opening is closed by a single layer of seromuscular , running , pds suture .
( a ) pre - anal anterior coronal approach : semilunar incision on the perineium , anterior to the anal verge , from 3 oclock to 9 oclock .
urethra easily identified with prior insertion of feeding tube , mobilized from anterior surface of rectum and the rectal end of opening closed in two layers ( b ) quadrangular incision on the anterior surface of scrotum for phalloplasty .
note the caudal projection for configuring the prepuce a quadrangular flap is taken from the anterior scrotal skin and raised with its dartos layer .
the two edges of the flaps are folded together and the edges sutured together to create a neophallus [ figure 1b ] .
the previously mobilized urethral opening is re - located in the midline , between the two scrotal halves and fixed to the root of the neophallus [ figures 2a and b ] .
there is no tissue loss and the adjoining tissues on the abdominal wall remain undisturbed for any possible future use .
six months later , a buccal mucosal graft can be laid on the undersurface of the neophallus [ figure 3a ] and later tubularized .
neo - phallus. please note the urethral opening in scrotal location ( b ) post - operative appearance after scrotal phalloplasty ( a ) appearance later with buccal mucosal graft being laid on the undersurface of neo - phallus ( b ) one year later
bowel preparation is done by peglec solution ( polyethylene glycol with electrolytes ) administered orally for 48 hours before surgery . under general anesthesia , the child
urethral lumen is catheterized easily by inserting a # 8f feeding tube through the anal verge .
we use a pre - anal , anterior coronal approach , to detach and mobilize the urethral opening from the anterior rectal wall [ figure 1a ] .
a semilunar incision is given on the perineum , anterior to the anal verge , from 3 oclock to 9 oclock .
the urethra - easily identified over the feeding tube - is mobilized and detached from the anterior surface of rectum .
the rectal end of the opening is closed by a single layer of seromuscular , running , pds suture .
( a ) pre - anal anterior coronal approach : semilunar incision on the perineium , anterior to the anal verge , from 3 oclock to 9 oclock .
urethra easily identified with prior insertion of feeding tube , mobilized from anterior surface of rectum and the rectal end of opening closed in two layers ( b ) quadrangular incision on the anterior surface of scrotum for phalloplasty .
a quadrangular flap is taken from the anterior scrotal skin and raised with its dartos layer .
the two edges of the flaps are folded together and the edges sutured together to create a neophallus [ figure 1b ] .
the previously mobilized urethral opening is re - located in the midline , between the two scrotal halves and fixed to the root of the neophallus [ figures 2a and b ] .
there is no tissue loss and the adjoining tissues on the abdominal wall remain undisturbed for any possible future use .
six months later , a buccal mucosal graft can be laid on the undersurface of the neophallus [ figure 3a ] and later tubularized .
neo - phallus. please note the urethral opening in scrotal location ( b ) post - operative appearance after scrotal phalloplasty ( a ) appearance later with buccal mucosal graft being laid on the undersurface of neo - phallus ( b ) one year later
aphallia is a rare birth defect seen in 1 in 30 million births . in the past ,
however , pre- and postnatal effects of androgens on brain , cause a male - typical shift in terms of psychosocial and psychosexual development , resulting in gender dysphoria later in life . as a result ,
urethral opening is typically present lower down in the rectum in the post - sphincteric location ( 87% ) and less commonly in the presphincteric or prostatourethral location . both our cases had the former , typical presentation .
cystography and mri are useful investigations to look for any associated anomaly as well as defining the anatomy .
cystography , through suprapubic route , is often difficult to perform in un - cooperative children .
mri should be the preferred modality of management as has been first demonstrated by us .
the development of microsurgical free - flap techniques made the first microsurgical phalloplasty possible using a free radial forearm flap .
however , there are several problems with early phalloplasty , such as , lack of further growth and the large neo - phallus being an encumberance to the young child .
the microvascular techniques are more demanding at a young age and any tissue utilized earlier would hinder , any later age appropriate surgery .
they are , anatomical phallic configurations in which , at best , penile implants could be inserted . at the same time , postponing surgery till post - pubertal period adds to parental anxiety , affects psychosocial development of the child who continues to pass urine per rectum .
therefore , a temporizing procedure is necessary which may see the child through childhood [ figure 3b ] .
scrotal phalloplasty , using scrotal skin to reconstruct a temporary phallus , can be performed easily .
urethro - rectal disconnection is easily performed by our pre - anal anterior coronal approach .
it provides an age - appropriate phallic appearance and does not disturb the tissues which may be required for post - pubertal phalloplasty .
therefore , scrotal phalloplasty serves as a temporizing procedure which may see the child through early school going years . adding buccal mucosal graft allows urethral reconstruction and thus enables the child to micturate while standing .
as he approaches teenage the other already available procedures could be introduced with ease , as , scrotal phalloplasty does not encroach on tissues used for any future surgeries .
 all the currently known reconstructions for aphallia are carried out around puberty . 
 we describe a novel technique as a temporizing procedure which would see the patient through childhood . 
 this would not cause any hindrance while undertaking any of the other established procedures later on after puberty . 
INTRODUCTION
CASE REPORT
TECHNIQUE
Urethral re-location
Scrotal flap-phallic reconstruction
DISCUSSION