A microsurgical approach to post-traumatic penile amputation: Towards standardizing the technique – A case report

Abstract

Introduction

Penile amputation is an unusual situation reported globally as isolated cases and small series. It constitutes a urological emergency which requires microsurgical skills for the repair of the penis. We present a case of a penile amputation and discuss the management of this challenging condition.

Case presentation

A 47-year-old patient presented to the emergency room with total amputation of corpora cavernosa of the penis resulting from knife aggression. The patient underwent successful microsurgical replantation, demonstrating positive progression and satisfactory results.

Clinical discussion

Microneurovascular repair of penile amputation is the gold standard. Recommendations include a meticulous anastomosis, and a focus on vein anastomoses for optimal outcomes as well as associating a psychiatric approach. The PENIS score classifies the severity of lesion and predict postoperative complications and main outcomes.

Conclusion

Penile amputation presents a distinctive challenge, necessitating microsurgical anastomosis, meticulous tissue management, and adherence to established protocols are imperative for effectively managing such intricate cases. Even in cases of posttraumatic partial penile amputation after a long period, can yield satisfactory morphofunctional outcomes.

Highlights

• •Penile amputation is a urological emergency, reported globally as isolated cases, requiring microsurgical approach.
• •Microsurgical replantation as the gold standard
• •Microsurgical anastomoses preserve erectile and urinary function
• •PENIS score classify the severity of lesion and predict postoperative complications and main outcomes.

1. Introduction

Penile amputation is an uncommon condition, with isolated cases or small series reported worldwide [1]. It is considered as a traumatic emergency necessitating an immediate replantation, guided by a precise treatment plan regardless of the injury's mechanism.

The leading cause of penile amputation is psychiatric disorders, notably the well-documented Klingsor syndrome [2]. It associates the self-amputation of external genitalia with hallucinations and delusions stemming from substance abuse and religious scrupulosity. Additionally, it can also be related to circumcisions, accidental trauma, and domestic violence.

The management of such injury has been converted from the previous inevitable penectomy to a re-implantation by microvascular techniques. In 1977, Cohen et al. and Tamai et al. reported the first successful penile reimplantation by microsurgical techniques, which include the re-anastomoses of blood vessels and nerves [3]. In contrast, there is currently no universal consensus to the repair of penile amputation. Therefore, microsurgery is the preferred approach for penile replantation, as it leads to lower rates of postoperative complications.

Penile amputation is a delicate situation, often challenging to evaluate and treat. it constitutes surgical emergency, emphasizing the critical importance of timely perioperative care in achieving a successful outcome.

In this case report, we present a successful microsurgical management of penile amputation post aggression, performed 24 h after the incident. Additionally, we will discuss the surgical technique and factors influencing the outcome. Our work has been reported in line with the SCARE criteria [4].

2. Case presentation

A 47-year-old male patient, with no medical history, was referred to the emergency department for the management of polytrauma with cranial and perineal impact points by a bladed weapon, revealing a meningeal hemorrhage and a partial penile amputation in the lesion assessment.

The patient was hemodynamically stable, a Glasgow Coma Scale score at 14. Bleeding was controlled by applying pressure to the wound with gauze swabs. The patient was initially managed according to Advanced Trauma Life Support principles and tetanus prophylaxis was given.

Urologically, the clinical examination reveals a deep penile wound on the dorsal side, 2 cm from the pubis, with a total section of dorsal artery, and a total section of the two corpus cavernosum (Fig. 1) and only the corpus spongiosum was conserved. Total cold ischemia duration is 24 h.

Fig. 1.

Preoperative image showing partial penile amputation sparing the urethra at midshaft dorsally.

The patient then was brought to the operating room where he was prepped and draped under general anesthesia. The dorsal penile pedicule was identified, dissected, and tagged as well as right cavernosal artery under a magnification microscope ×6.

After necrosectomy of non-viable tissues. A microscopic suturing of the tunica albuginea of both corpus cavernosum was sutured with absorbable Vicryle 3/0. After that, the dorsal artery of the penis was anastomosed, using enoxaparin, under microscope using Vicryl 7/0. Refill of the glans penis was found optimal, and the needle prick test showed bright red blood. Then suturing of the buck's fascia and skin closure (Fig. 2).

Fig. 2.

post-surgery image showing successful anastomosis and catheter in situ.

The patient was transferred to the urology department with close monitoring. He received antibiotherapy while the subcutaneous injection of 0,4 ml enoxaparin was avoided due to the meningeal hemorrhage. Postoperatively, there was favourable clinical progress, except for skin necrosis, which underwent debridement under local anesthesia with a positive outcome (Fig. 3).

Fig. 3.

Postoperative image showing a complication after penile replantation.

A: Image illustrating skin necrosis on the dorsal side of the penis.

B: Image showing the aspect of the penis after debridement.

C: Image depicting the long-term progression after debridement.

A psychiatric assessment was requested to assess the psychological impact of this assault and, at the same time, to provide advice for his issues with alcoholism.

A six-month follow-up revealed a positive clinical progression with preserved sensitivity and a satisfactory erection (Fig. 4), allowing intimate relations with his partner, that sometimes aided by Tadalafil.

Fig. 4.

Long-term appearance of the penis.

3. Discussion

Penile amputation is a rare urologic emergency, often linked to psychiatric conditions like schizophrenia, substance abuse, and personality disorders, it carries major functional and psychological consequences regarding the patient's overall quality of life. There appears to be a rising incidence, though it remains uncertain if this is attributed to increased reporting [1]. The first report of penile replantation traces back to 1929 where the amputated penis was attached to the scrotum without any neurovascular anastomoses. After that, the development of more meticulous surgical techniques led to the birth of the first microneurovascular repair, reported in 1977 [3]. This marked a significant shift in the management of penile amputations.

Furthermore, several case reports have established the efficacy of anastomosing vessels and nerves of the amputated penis, showing better chances of organ survival and reduced complications. Although there is less convincing evidence, this has contributed to the establishment of microsurgical replantation as the gold standard [1,3,5], with the recommendation to perform twice as many vein anastomoses as artery anastomoses to alleviate venous congestion [5], through an experienced surgical team equipped with suitable technical facilities.

The microsurgical anastomosis of the amputated penis has become a feasible and practical treatment approach. It is widely recognized that minimizing tissue ischemia time is necessary for achieving favourable outcomes. Different studies suggest that the amputated part can be preserved up to 16 h [1]. Throughout this period, it is recommended to keep the amputated part cool, and it is advisable to avoid direct contact with ice and prevent potential frostbite injuries [3].

A consensus in the contemporary literature acknowledges that the microsurgical revascularization and approximation of the penile shaft structures provide early and adequate restoration of penile blood flow with the best outcome of penile replantation survival, erectile and voiding functions [1,6].

For an enhanced time efficiency, the therapeutic approach must be structured and well-planned. First, all the structures are inspected and identified then isolated for some millimeters. It is necessary to recover as many neurovascular structures as possible.

The microsurgical replantation procedure adheres to the standard steps, including an end-to-end anastomosis of the urethra and corpus spongiosum, the reapproximation of the tunica albuginea of the corpora cavernosa, along with the buck and colles fascia. Notably, there is a special emphasis on meticulously anastomosing vessels and nerves under a microscope [5], followed by skin closure. It is recommended to ensure arterial inflow by securing at least one robust pulsating artery, while venous outflow should be optimized by repairing as many veins as possible [1]. Additionally, creating a distal spongiocarvernosal shunt, suggested by Fuoco et al., can enhance venous drainage efficiency [7].

Regarding nerve repair, the reattachment is not essential; instead, it is closely associated with the viability of the skin edges and microsurgical revascularization [5,7,8]. This occurrence has led to the observation of spontaneous neuroregeneration facilitated by the presence of growth factors and nutriments, establishing a suitable environment leading at the end to a restoration of sensation [8].

Such delicate surgery is confronted to various complications. Initially, the PENIS score [Table 1] was developed to classify the severity of lesion. It demonstrates that 3 of its 5 criteria have a strong and significant correlation to postoperative complications and main outcomes which are the extension of lesion through the penis, the number of arteries, veins, nerves repaired and the ischemia time and its type [5].

Table 1.

Revised PENIS Score.^a

Penis criteria	Grade
	1	2	3	4	5
P: Position along the shaft	<2 cm distal to the base	>2 cm distal to the base and > 0.5 cm proximal to the glans	<0.5 cm proximal to the glans	Total penile amputation including 1 testis	Total penile Amputation including both testes
E: Extension through the penis	Past the fascia but <50 % of the penile Diameter without urethral involvement	>50 % of the penile diameter without urethral involvement	>50 % of the penile diameter with incomplete section of the urethra	Partial amputation with a skin bridge and complete section of the urethra	Complete amputation
N: Neurovascular repair	≥2 veins, ≥2 arteries, and ≥1 nerves	≥2 veins and ≥2 arteries	≥2 veins and 1 artery	1 vein	0 vein
I: Ischemia time and type	<1 h warm and <2 h cold	<1 h warm and 2–6 h cold	<1 h warm and >6 h cold	1–2 h warm	>2 h warm
S: Severed-edge condition and contamination	Smooth edge requiring only irrigation	Jagged edge requiring only irrigation	Smooth edge +/− contamination requiring minor debridement	Jagged edge +/− contamination requiring minor debridement	Tissue damage requiring extensive debridement

^aPENIS scores are reported as P1–5, E1–5, N1–5, I1–5, S1–5 with a superscript S for self-inflicted and E for external. Subscript numbers distinguish extension and severed edge scores from erection and sensation scores.

The occurrence of these complications is tightly linked to the severity of injury and the extent of surgical repair. They include erectile dysfunction, skin necrosis, and urinary fistula or stenosis. To prevent skin necrosis, measures like avoiding excessive hematoma formation due to venous congestion, employing diffuse oozing, leech therapy [9] and keeping the penis upright are recommended. In addition, a preventive-dose of anticoagulation is recommended for any vascular anastomosis to prevent thrombotic risks. Meanwhile, preserving the urethra structure is through leaving a Foley catheter combined with a suprapubic catheter for 7 to 10 days [1] to reduce fluid pressure on the urethral anastomosis.

However, the outcome measures for successful penile reimplantation have been widely varying and limiting the ability to clearly define a successful penile reimplantation of an amputated penis [10]. Moreover, numerous factors contribute to the successful penile reimplantation outcomes often desirable to both physician and patient alike, which include the severity of the penile injury or amputation, type and mechanism of injury, team expertise available, duration of ischemia time, and use of a microscope at time of neurovascular bundle repair [5].

Latest publications have evaluated the anatomical approaches to penile allografts and suggested that connection of cavernosal, dorsal, and pudendal arteries would allow for optimal reperfusion [11]. Morrison et al. analysed combined sexual, urinary, and sensation outcomes, it appears that ischemic time (up to 15 h), number of nerves, or number of vessels connected does not alter outcomes. However, Complete amputation of the penis may give the surgeon better access to nerves for neurorrhaphy, which ultimately could allow for better sensation [12].

Through this case report, it is important to focus on the underlying predisposing pathology that led the patient. Identifying the risk factors and predisposing psychiatric condition are essential for stabilizing them and reducing the risk of recurrence.

4. Conclusion

The microsurgical replantation is the gold standard in penile amputation cases, offering prospects for both functional and sensory recovery. The advancements in microsurgical approaches, including anastomoses of vessels and nerves, have significantly improved results.

Timely intervention, careful tissue handling, and adherence to established protocols remain critical for success. Additionally, a multidisciplinary approach with psychiatric evaluation and identification of underlying factors.

Consent

Written informed consent was obtained from the patient to publish this case report and accompanying images. On request, a copy of the written consent is available for review by the Editor-in-Chief of this journal.

Ethical approval

Ethical approval is not applicable. The case report is not containing any personal information.

Funding

No funding or grant support.

Author contribution

Imad ZIOUZIOU, Hamza DERGAMOUN: performed surgery, paper reviewing, supervision.

Amine SAOULI, Jihad LAKSSIR: Manuscript writing, picture editing.

Aziz EL GDAOUNI, Ossama JALAL: Literature review, Data curation.

Guarantor

Jihad LAKSSIR M.D.

Research registration number

Not applicable.

Conflict of interest statement

The authors declare that they have no competing interests relevant to the content of this article.