Successful microsurgical penile replantation following self amputation in a schizophrenic patient.

Amputation of the penis is a rare condition reported from various parts of the world as isolated cases or small series of patients; the common etiology is self-mutilating sharp amputation or an avulsion or crush injury in an industrial accident. A complete reconstruction of all penile structures should be attempted in one stage which provides the best chance for full rehabilitation of the patient. We report here a single case of total amputation of the penis in an acute paranoid schizophrenic patient. The penis was successfully reattached using a microsurgical technique. After surgery, near-normal appearance and function including a good urine flow and absence of urethral stricture, capabilities of erection and near normal sensitivity were observed.

INTRODUCTION

Total penile amputation is an uncommon injury.[1-6] About 87% of the patients reported had psychiatric problems. Self-amputation of external genitals is also known as Klingsor syndrome.[4-7] A few patients had poor gender identity feeling themselves inadequate as males. Some cases arise from felonious assault by jealous homosexual lovers.[1-6] In 1970 in Thailand, an epidemic was seen, of penile amputation as punishment for philandering by humiliated wives.[2-6] Microvascular penile replantation offers the best prospect for restoration of micturition function, return of sensations and erectile functions. This case highlights the management of such a patient not only in the operative room but also in the emergency resuscitation room.

CASE REPORT

We report the case of a 25-year-old man with acute paranoid schizophrenia who presented in our emergency with an alleged history of cutting his penis with a shaving blade 2 cm distal from the mons pubis. Immediately after the self-mutilation the amputated penis was kept in a clean plastic bag by the patient’s brother. The patient presented at our institution four hours later. Bleeding from the proximal penile stump was stopped by a tourniquet. The patient was prepared for general anesthesia. Intravenous administration of 2 gm Cefoperazone+Sulbactum along with 500 mg metronidazole was given. The patient was given 1500 units of anti-tetanus serum and 2 ml of tetanus toxoid. Four units each of red blood cells (RBC), fresh frozen plasma (FFP) and platelets were arranged. As the patient had lost blood before coming to our trauma center, we transfused one unit each, of RBC and FFP, in the emergency room. We found a clear cut through all penile structures without major lacerations at approximately 2 cm from the mons pubis [Figures 1 and 2]. Gross cleaning of the wound was followed by meticulous debridement using an operating microscope with assistant optic. After identification of all main vessels, the distal and proximal ends of both dorsal arteries were clipped and both ends of the urethra, together with the corpus spongiosum, mobilized. The amputate was then put on an 18F silicone Foley catheter [Figure 3], which was passed into the patient’s bladder. To achieve a stable basis, the tunica albuginea of both corpora cavernosa and the septum were attached by running suture using 3-0 vicryl [Figure 4]. The deep corporeal arteries were identified but not anastomozed. After irrigation with heparinized saline, both deep dorsal arteries were anastomozed with 9-0 prolene sutures [Figure 5]. Next the deep dorsal vein and the two nerves were anastomozed using 9-0 prolene for the vein and 10-0 prolene for the nerves. The urethra was repaired by spatulated end to end anastomosis with interrupted 4-0 vicryl sutures. Buck’s fascia was closed with 4-0 vicryl [Figure 6] and then the superficial vein was anastomozed with 9-0 prolene. Finally the skin was closed [Figure 7]. Next, a gentle pressure dressing was applied and the penis was fixed in an upright fashion. Transurethral catheter was kept for 21 days. Suprapubic cystostomy was done [Figure 8]. Five hundred ml per day, of low molecular dextran, was given for three days to reduce blood viscosity, decrease platelet adhesion, and promote antithrombotic property. On the first postoperative day, swelling at the anastomozed area was seen. Patient was taken to the operation theatre (OT) and removal of skin sutures, evacuation of hematoma and fasciotomy on anterior and lateral aspect of penis was performed. On the fourth postoperative day, patient was again taken to the OT for debridement of necrotic penile skin and application of split thickness skin graft over the raw area. After the first two post-operative weeks the patient developed a mummification of the tip of the glans that had to be resected. More than 80% of the glans remained intact. Retrograde urethrography is performed and Suprapubic cystostomy was removed after six weeks.

Figure 1

Self amputated distal part of penis

Figure 2

Proximal penile stump

Figure 3

Passage of Foley’s Catheter through urethral meatus of amputated penis into transected urethral opening in the proximal stump

Figure 4

Anastomosis of corpora cavernosa of proximal and distal penile stump

Figure 5

Anastomosis of dorsal artery and dorsal vein of penis

Figure 6

Muscular and subcutaneous repair

Figure 7

Final repair: Post aspect

Figure 8

Final repair: Anterior aspect

Postoperative psychiatric consultation was done and Olanzapine 10mg and Clonazepam 0.5mg were started.

At three-month follow-up examination [Figure 9], he reported infrequent nocturnal penile tumescence. At one-year follow-up [Figure 10], retrograde urethrography showed normal urethra with no stricture formation. Penile Color Doppler showed normal blood flow in the dorsal vessels and a normal Doppler waveform changes were seen in the cavernosal arteries during the onset of erection suggesting a good collateral formation in the unanastomozed cavernosal arteries as well.

Figure 9

At follow-up of 3 months

Figure 10

At one-year follow-up

Penile sensations showed recovery with appreciation of fine touch. The patient reported the restoration of his penile erection and ejaculation during sexual intercourse.

DISCUSSION

The first documented case of macroscopic penile replantation was reported in 1929 by Ehrlich.[4] Cohen et al. reported the first microvascular replantation of penis in 1977.[8] A review of the literature revealed that 80 cases underwent penile replantation, of which 30 cases underwent microsurgical replantation since 1970. These 30 cases have been reported to be of higher quality in terms of both functional and aesthetic result.[45] Many factors contribute to favorable final outcomes.[9] Analysis of our case revealed that the cleanly incised injury with a short duration of cold ischemia was an important factor that influenced the outcome. Another factor was the concept of microsurgical reapproximation. The macrosurgical replantation of the penis depends on corporal sinusoidal blood flow with the distal amputated part as a composite graft leading to high complication rates of skin necrosis, fistula formation, loss of sensations and erectile dysfunction. In contrast, the microsurgical approximation of the penile shaft structures provides early restoration of blood flow with the best prospects for graft survival, normal erectile function and optimal benefits with fewer complications.[4] Another critical factor for the success of replantation was the adequacy of venous outflow and the sequence of microsurgical anastomosis. Due to the dual vascular drainage in the penis, the superficial and deep dorsal veins, tributaries of saphenous and santorini plexus respectively, were both anastomozed for good venous return. The return of penile sensations over the glans was as expected in the yearly follow-up of our case with a distal amputated length of approximately 8 cm of total penile length. In our opinion, another important factor was the critical postoperative monitoring of the replantation. Timely intervention was done in the form of release incisions to relieve edema and maintain vascularity of the penis. The initial raw areas may appear as disfiguring but the final result was satisfactory, with near uniform girth of the penile shaft. We suggest similar measures to protect the anastomosis and prevent failure. Prophylactic release incisions can be an option when regular monitoring is not contemplated.

The adverse effect seen in our case was the skin loss due to necrosis of the proximal part of the penile skin, probably because we had anastomozed only the deep dorsal arteries, which are branches of the internal iliac artery. The external pudendal vessels were not anastomozed. It may be advisable to anastomoze the superficial system also to avoid skin necrosis. The microsurgical restoration of penile vascularity provides early restoration of blood flow with the best prospects for graft survival, normal erectile function and optimal benefits due to fewer complications.

CONCLUSION

The current concept of microvascular replantation for penile amputation is the treatment of choice with the best prospects for cosmetic restoration, physiological micturition and preservation of sensation and erectile function.