Re: Sarah R. Ottenhof, Andrew Leone, Rosa S. Djajadiningrat, et al. Surgical and Oncological Outcomes in Patients After Vascularized Flap Reconstruction for Locoregionally Advanced Penile Cancer. Eur Urol Focus. In press. https://doi.org/10.1016/j.euf.2018.02.002

We read with great interest the article by Ottenhof et al [1]. We congratulate the authors for the very interesting multi-institutional retrospective study with the aim to quantify the surgical complications rate in patients with locoregionally advanced penile squamous cell carcinoma and balance the need for surgery and the eventual avoid-ance on behalf of other treatments; however, we have some elements to discuss. Surgical reconstruction on these patients involved a verti-cal (VRAM) or oblique rectus abdominis myocutaneous (ORAM) flap in collaboration with a plastic surgeon. The most common flaps used for skin cover of the penile shaft are local perforator flaps from the lower abdomen, but they may present some technical difficulties, thus increasing the com-plication rate. As already discussed in the article, VRAM flaps require muscle sacrifice, and donor site typically requires the use of biological mesh to cover the residual defect, whereas skin islands of ORAM flaps are strictly dependent on the reliability of the communicating perforator vessels. Further-more, satisfactory reconstruction requires regaining a good esthetical appearance, a valid recovery of functionality with redundant and durable skin envelope allowing a complete erectionandthereby, providing acceptable sexual intercourse and satisfactory sensation. We recently published a paper assuming that the scrotum seems to be the most suitable tissue to reconstruct the skin coverage of the shaft as it is the most similar [2,3]. Its multi-origin vascular system provides its support basing each side on four different vessels: the anterior and lateral scrotal artery, the lateral branch of posterior scrotal artery, and the septal scrotal artery. These vessels run through the Dartos fascia of the scrotum rendering the scrotal dartos-fascio- myo-cutaneous flaps an axial flap. This subcutaneous net-work supports the vascular system of the scrotum very well; therefore, these flaps can be considered very resistant to ischemia, permitting wide variability in their planning both regarding dimension and shape. The skin of the scrotum is the most similar to the skin of the shaft with respect to color and thickness, and particularly elasticity and consistency. Fur-thermore, it provides an adequate amount of tissue and satisfactory cosmetic results. Its thinness, pliability, and extensibility provide a better skin laxity during erection offering optimal functionality. Furthermore, contrary to abdominal flaps, donor site closure is easy to perform and the scars in the scrotum are hardly visible when compared to other parts of the body, with very low donor site morbidity. The main disadvantage is that the scrotum has a very high density of hair and may require laser hair removal. Therefore, we retain that when the scrotal tissue is not involved in any pathological condition or raising local flaps is oncologically safe, dartos-fascio-myo-cutaneous flap can represent a valid surgical solution for penile shaft covering.