Rook to the Rescue: A Case Series on the Novel Use of Eggcrate Foam Bolsters for Skin Grafts in Penile and Genital Reconstruction: Rook Bolster Technique for Genital Reconstruction.

Abstract

Complex genital reconstruction of acquired buried penis after weight loss, Fournier's gangrene, Hidradenitis suppurativa, or trauma remains challenging due to contaminated wound beds, irregular surfaces, and shear forces that compromise graft survival. Eggcrate foam bolsters elicit successful outcomes in burns and mobile surfaces like the tongue. We present a rook-configured eggcrate foam bolster for stabilizing penile grafts in complex genital reconstruction. We aim to assess outcomes and develop a reproducible dressing protocol tailored to the challenges of this anatomical region. This consecutive retrospective case series included 21 adult men who underwent penile split-thickness skin grafting using an eggcrate foam "Rook bolster" at a single institution (2010-2025). The bolster consisted of bacitracin on a nonadherent dressing, saline-moistened silver dressing, gauze, and eggcrate foam oriented with spikes toward the wound. The penis was extended to length before cylindrical bolster placement and staple securement. Clinical, intraoperative, and follow-up data, including graft take, symptoms, and complications, were analyzed descriptively up to 3 months postoperatively. Mean age was 49.2 ± 9.9 years; mean body mass index was 37.2 ± 9.4 kg/m 2 . Obesity was present in 17/21 (81.0%), and ≥1 impaired wound-healing risk factor was present in 20/21 (95.2%). Median bolster removal was 4 days (interquartile range, 3-5), and median follow-up was 50 days (interquartile range, 33-64). Penile graft take remained high, with a median of 100% through postoperative day 14 and 95% between days 15 and 30, with 1/21 (4.8%) below the ≥80% threshold. Among 19/21 (90.5%) with paired symptoms, urinary dysfunction improved in 7/19 (36.9%, P  = 0.02; g  = 0.39), and pain with erection improved in 5/19 (26.3%, P  = 0.03; g  = 0.50). Recurrent urinary tract infection decreased in 2/19 (10.5%, P  = 0.32). Penile graft-site complications were infrequent and low grade, with incidence rates of ≤1.0 event/person-year. One patient required reoperation (Clavien-Dindo IIIb), and one experienced mortality (Clavien-Dindo V) unrelated to graft status. No penile graft-site complications occurred 31 to 90 days. The Rook bolster provides a simple, inexpensive, and adaptable method for penile graft stabilization with high graft take and low complication rates. Prospective comparison with alternative bolster methods is needed to define its broader reconstructive role in varying genital graft types.