Comment to: “Surgical treatment of penile foreign body granuloma: Penile shaft reconstruction with single‐ versus two‐stage scrotal flap techniques”

Dear Sir, We read with great interest the article titled “Surgical treatment of penile foreign body granuloma: Penile shaft reconstruction with single- versus two-stage scrotal flap techniques”.1The Authors compare the incidence of complications between single and two-stage scrotal flap reconstruction, reporting similar results regarding wounds healing, but shorter recovery and lower complications in the single-stage group.We congratulate with the authors for the presented article but we have some elements to discuss. The state of the art shows many different techniques for penile resurfacing, including skin grafts, local and free flaps. Although the simplicity of the method, skin grafts should not be the first reconstruction option because of the higher risk of retraction, poor tissue elasticity limiting extensibility during erection, and less resistance to sexual intercourse. Since the bulky nature of free flaps, if any, might represent some difficulties during penetration and poor aesthetical outcomes producing unnatural appearance, local flaps remain the gold standard for penile reconstruction. Basing on like-to-like principles, the scrotum seems to be the most suitable tissue for shaft repair, including color, thickness, pliability, elasticity and consistency, able to provide a large amount of tissue and obtaining satisfactory outcomes in terms of aesthetic and functional result, avoiding also mismatch disorder. The multi-origin vascular system providing the scrotum is supported on each side by four different vessels: the anterior and lateral scrotal artery, the lateral branch of posterior scrotal artery and the septal scrotal artery.These vessels running through Dartos fascia render the scrotal Dartos-myo-cutaneous flap an axial flap, allowing safely a single surgical operation avoiding discomfort related to a second procedure and the vascular network of the scrotum allows a large amount of tissue harvesting in a single step. We would like to ask to the Authors why they prefer to use the anterior part of the scrotum and not the lateral one? The “racquet-shaped” myocutaneous flaps harvested on the vertical axis from the lateral part of the scrotum, allowed to cover all the anterior surface of the shaft wrapping the entire circumference of the distal part of the penile shaft, while its proximal ventral part was covered advancing the remaining part of the scrotum containing the median rafe (Fig. 1).2,3 The consistency of scrotum allows to harvest large amount of tissue and the donor site was easily closed for primary intention, avoiding any distortion. At the same time the lateral part of the scrotum offers major elastic and pliable tissue to an easier primary closure avoiding any distortion. On the other hand, the high density of hair may represent a serious disadvantage, requiring an eventual laser removal. Did the Authors report related complications between flap dimension and post-operative especially in wound healing? Did the Authors retain that post-operativecare to reduce erections can reduce the incidence of complications?