Penile replantation.

Penile amputation is rare and hence the paucity of experience and publication. We present our case of self-inflicted penile amputation, which was successfully managed with microsurgical replantation, with relevant literature review.

INTRODUCTION

Penile amputation, although a rare occurrence, is nevertheless of crucial significance to the patient and his family, as it involves more than mere medical issues. Over decades, the philosophy of its management has shifted from an inevitable gender reassignment to simple re-attachment of the organ to re-implantation using microvascular techniques. However, owing to the rarity of its occurrence and reporting, we do not yet have protocols or guidelines for dealing with this condition. In the present case report, we provide our experience with one such case and discuss the current treatment trends and determinants of outcome.

CASE REPORT

A 70-year-old male with a history of psychiatric disorder presented to the casualty with a self-inflicted traumatic amputation of his penis, which he accomplished with a sharp vegetable-cutting knife in an attempted suicide. The penis was cut about 1.5 cm from the base. All but a skin-bridge of 0.5 cm width was transected in a clean-cut and the organ was ischemic and insensate [Figures 1 and 2]. The patient had no other co-morbidities.

Figure 1

Amputated penis

Figure 2

Skin bridge at the base

In the casualty the penis was thoroughly washed with normal saline. Initially the wound was bound with a dressing and tetanus prophylaxis was administered.

Under general anesthesia hematoma was evacuated with 1% sodium heparin solution irrigation and gentle pressure. Nonviable tissue was debrided. Tourniquet was applied to the stump. Dissection under magnification was done and deep dorsal vein, dorsal nerves, and arteries were identified on either side. We also took special care to dissect out the cavernosal arteries on both sides.

A 16 F Foley's catheter was inserted in a retrograde manner through the severed penile portion extending inward through the penile remnant and passed into the bladder. Urethra was spatulated and sutured over the catheter [Figure 3] and corpus spongiosum was repaired using interrupted 6-0 synthetic absorbable suture. Both cavernosal arteries were anastomosed using 10-0 nylon. The cavernous bodies were reconstructed by suturing the tunica albuginea of each corpus cavernosum to the proximal corresponding segment using 4-0 polyglactic acid sutures. The dorsal vein and two arteries were anastomosed under a microscope with interrupted 9-0 identified [Figure 4] and nylon sutures. Dorsal nerves were re-approximated and sutured with 10-0 nylon [Figure 5].

Figure 3

Urethra being sutured over Foley's catheter with ‘spatulation’

Figure 4

Penile vascular structures dissected out

Figure 5

Dorsal arteries, vein and nerves anastomosed

Vascularity was reestablished within 7 hours after the amputation. The fascia and skin were sutured loosely. After releasing the tourniquet the arterial pulse and venous return were detected, the superficial penile veins displayed normal turgor.

Postoperatively the patient was put on broad-spectrum antibiotics and heparin infusion for 5 days. Psychiatric consultation was provided. The suture-line got healed in 7 days after which dressings were discontinued [Figure 6]. Urethral catheter was left in-situ for 3 weeks. Cosmetic appearance of the penis was fair after two post-operative weeks. The patient was reviewed at an interval of 3 months. After 1 year patient had maintained a normal urinary flow. Since the patient was 70-year old and had psychiatric illness, the erection and sensation in the glans could not reliably be recorded.

Figure 6

Quiet healing observed on 5th post-operative day

DISCUSSION

Penile amputations occur due to a variety of etiologies. Assault (often by wives in a domestic dispute),[1] Klingsor syndrome (genital self-mutilation),[2] punishment, accidental injuries and as a complication of circumcision[3] are some of the more often reported causes. In earlier days, the victim was left alone or was compelled to change the gender. Later, surgical re-attachments of the dismembered organ were reported as individual case reports. The possible reporting bias in such endeavors prevents us from presuming the success rates. The only large series that came from Thailand[1] in early 1980s following an epidemic of incidents of women chopping off their philandering husbands’ penises and throwing them out the window, reported their success and complication rates.

The first microneurovascular repair[4] was reported in 1977 that led to a paradigm shift in management of penile amputations owing to the ability, in some cases, to actually preserve not only erectile function, but also sensation. Later, several other case reports have established the usefulness of anastomosing vessels and nerves of the amputated penis.[567] In general, microvascular replantation seems to have better chances of organ survival and lesser complication rates although statistically convincing evidence is not available. Moreover, even if successful, simple reattachments without microsurgical techniques have higher rate of complications like partial skin necrosis, urethral strictures and fistulas.[17] Even with microsurgical replantation, frequently reported complications are partial skin loss at the root of penis and necrosis of distal spongy body when ischemia time was more.[8] Venous congestion is identified as a frequent complication, sometimes necessitating leech therapy.[6]

The current standard of care is that of microsurgical reconstruction of neuro-vascular continuity although differences exist between reports in the structures repaired.[9] While in most reports, dorsal and/or deep dorsal vein was anastomosed without fail, cavernosal arteries were often left out.

Assessment of the outcome involves survival of the organ, a stricture-free urethra, return of sensation and erection. Although the latter were not assessed in our patient, some studies report of morning erection and night emission as early as within the first month post-operatively.[10] Determinants of success include the duration of ischemia, general condition of the patient and prompt repair of the vital structures.

In our case, microsurgical replantation was performed with a good outcome. We accomplished anastomosis of cavernosal arteries along with other structures and recommend so, as it ensures a better blood supply and possibly aids in erection. The other factors contributing for the success included a relatively short ischemic time, meticulous and prompt repair of the vital components of the penile structures and a holistic approach toward the patient.

CONCLUSION

We have presented one of the few instances of successful microsurgical penile replantation with good outcome. A more zealous reporting of similar experience and a compilation and analysis of the available reports seems to be the only way to fill the vacuum of large single-centre experience with this rare entity.