Successful penile replantation after complete amputation and 23 hours ischaemia time: the first in reported literature

Abstract

Complete penile amputation is a rare and poorly documented injury with severe physical and psychosocial implications. Our institution presents a case of successful penile replantation following 23 hours of ischaemia time in a 34-year-old man with a history of paranoid schizophrenia who sustained a complete penile amputation during an act of deliberate self-harm. To the best of our knowledge, this is the longest documented ischaemia time for a successful penile replant in literature. The patient was able to achieve a full erection as early as 6 weeks postoperatively. Skin necrosis was noted as a common complication and this was successfully managed with debridement and skin grafting. Penile amputation injuries should be managed in a specialist centre with urological and plastic surgeons with expertise in microsurgical reconstruction. Penile replantation should be attempted, even if ischaemia time is prolonged, despite lower success rates given the significance of the injury to an individual.

Background

Complete penile amputation is a rare and poorly documented injury with severe physical and psychosocial implications for quality of life.^1–4 A variety of aetiologies are described in the literature; most commonly (87%) an acute psychotic illness involving an episode of self-harm (schizophrenia—51%, severe depression—19% or substance induced),¹ but also a significant number being described due to personality disorder, gender dysphoria,³ violent assault^{3 5} or occupational, combat-associated or iatrogenic injury.³

High-risk groups include:

1. Young psychotic men with sexual fears relating to homosexuality or gender identity.

2. Older men with psychotic depression.

3. Men who are violent when intoxicated, displaying aggressive feelings towards themselves or women.¹

Successful replantation is described in a number of small case series since the procedure’s inception in 1926 by Ehrich et al.^{2 4–7} Microscope-assisted anastomosis and dorsal repair is felt to be the gold standard.2–4 6 8 Previous studies highlighted that when total ischaemic time was limited to less than 15 hours (mean time 7 hours), it was associated with more successful outcomes.²

Case presentation

Our institution presents the first documented case of a successful penile replantation following complete amputation with a total ischaemia time of 23 hours. A 34-year-old man, with a history of paranoid schizophrenia, who is a non-smoker, carried out a suicide attempt in his home during a psychotic episode involving total amputation of his penis with a clean knife (figure 1), lacerations to both wrists and stab wounds to the neck and abdomen. The patient was found unconscious 15 hours later and taken to hospital by emergency services for assessment. The amputated penis was put on ice and transported with the patient via ambulance. Following adequate resuscitation, the patient was taken to the operating room for replantation.

Figure 1.

Amputated penile shaft.

Investigations

The patient was admitted through the emergency department and had a trauma CT scan of his chest abdomen and pelvis. The main significant findings were multiple stab wounds, in the upper neck traversing the sternocleidomastoid muscles bilaterally. No vascular injury or significant haematoma or arterial extravasation was seen. A traumatic left upper quadrant abdominal wall hernia with an 18 mm defect in the left rectus abdominis muscle containing omentum was present and a further penetrating tract superior to this not breaching the rectus muscle. No other injuries were detected.

Differential diagnosis

The diagnosis here was clinical and evident on presentation. The case was treated as a surgical emergency and the patient was taken to the operating theatre following initial resuscitation and trauma CT in the emergency department.

Treatment

The patient was taken to the operating theatre for penile replantation. Arterial flow was established a further 8 hours after arrival into hospital due to the patient’s concomitant injuries, thus making the total ischaemia time 23 hours. On inspection in the operating room, the penile stump was found to have been amputated 2.5 cm from the penile root. The amputated part was inspected in the operating room under a microscope. A dorsal artery, vein and nerve were all identified. The dorsal penile artery was flushed with heperanised saline; there was no resistance to flushing the artery, thus suggesting a patent vascular network. On flushing the artery with heparinised saline, back flow was observed from the corpus cavernosum thus indicating that viable circulation may be achieved and the procedure began. Both plastic and urological surgeons were present for the surgery. Prior to microvascular anastomosis, a suprapubic catheter was inserted, and the urethra was spatulated, tubularised and anastomosed around a size 10F silicon catheter, using 5–0 vicryl rapide sutures and the tunica albuguinae was closed directly, in a water tight fashion, using a 4–0 vicryl continuous stitch (figure 2). On inspection, recipient vessels at the site of the amputation appeared small and so vessels were prepared more proximally, closer to the suspensory ligament of the penis to achieve a wider vessel calibre for the anastomosis. Due to the presence of a gap between vessel ends, interposing vein grafts taken from the cephalic vein in the forearm were used for arterial and venous anastomosis. Arterial microvascular repair was carried out first using 9–0 ethilon sutures to perform an end to end repair with the interposing vein graft. The vein was repaired using a single 2 mm venous coupler at each anastamotic site. The proximal dorsal nerve had retracted and thus the dorsal nerve was not repaired. Finally, dorsal skin was closed using a 4–0 prolene stitch. The penis was secured to the scrotum with two temporary stitches for stability thus protecting the anastomotic site from excessive movement attributed to the pendulous nature of the penis.

Figure 2.

Penile anatomy—Illustrated by Henry Bergman.

After exploration by otolaryngology and general surgery teams, injuries to the patient’s neck and abdomen were found to be solely superficial. Bilateral median nerve injuries secondary to wrist lacerations were repaired 1 week later.

Outcome and follow-up

The patient was placed on bed rest for 7 days under a bair hugger warming blanket before mobilising. Initially, flap observations were carried out every 30 min for the first 12 hours, followed by hourly for the next 48 hours. Observations routinely noted penile skin colour, turgour, general viability, temperature and capillary refil time. Arterial flow was monitored using a hand held doppler device. The patient and penile observations were then extended to routine 4 hourly intervals until patient discharge. The patient was also given a postoperative course of antibiotics. It was noted that at all times, the glans of the penis was viable, though there was epidermal loss over the penile shaft at aproximately day 7 (figure 3). The penile shaft was cleaned and dressed daily with chlorhexidine and non adherent dressings such as ‘Urgotul’ and ‘Jelonet’. The patient was deemed medically fit for discharge at 2 weeks postinjury. On discharge to an inpatient psychiatric unit, the patient was followed up in clinic on a weekly basis. The penis was cleaned twice daily with chlorhexidine and dressed with ‘Flamazine’ and gauze in order to lift any eschar. The urethral catheter was left in situ for 4 weeks postdischarge to stent the urethral repair and the suprapubic catheter was used to divert urinary flow during this time. The patient reported return of sensation to the penis as well as spontaneous erection 6 weeks postoperatively. The surrounding eschar of the penis was subsequently debrided surgically, and the shaft of the penis was successfully skin grafted 2 months later (figure 4).

Figure 3.

Successfully replanted penis with skin necrosis on penile shaft evident at day 7 post urgery.

Figure 4.

Three months post-surgery following skin grafting to penile shaft.

Discussion

Penile amputation is a rare and challenging injury with minimal literature on its acute management. As with all trauma, initial management focuses on assessment and resuscitation of the patient, followed by closer assessment of the penile injury. Prior case series have been limited in number, but concluded that these injuries must be managed on a case-by-case basis, and in a highly specialised centre in order to achieve a satisfactory outcome.⁹ Such injuries require specialist input from urological and plastic surgeons capable of carrying out intricate microsurgical reconstruction.¹⁰

Microvascular anastomosis is the preferred technique for replantation. If a microsurgical unit is not available within the region, or the transfer time is likely to extend the total ischaemia time to more than 24 hours, then a macrovascular or corporal reattachment technique can be used, although there is a higher rate of failure and skin necrosis.^{8 10 11} The British Association of Urological Surgeons has issued guidelines on the management of these injuries, stating that outcomes depend on warm and cold ischaemia time. Replantation can be attempted up to 24 hours after the injury, as it allows for 4 hours of warm ischaemia time and 16 hours of cold ischaemic time. Beyond 24 hours, the success rate is very low.¹⁰ Induced hypothermia of the amputated portion in ice slush is felt to be valuable in extending the ischaemia time.¹² Given the significance of the amputated organ, replantation was attempted in this case despite the long warm and total ischaemia time, which is the longest in reported literature. The success of this case therefore should encourage surgeons to attempt penile replantation, even with prolonged ischaemia time, due to possible success and the potential physical and psychosocial effects of organ loss for the patient.

Outcome measures for successful penile replantation have been widely varying and limit the ability to clearly define a successful penile replantation of an amputated penis,¹³ but viable tissues with a reasonable aesthetic outcome, the ability to urinate through the penis and the regaining of sexual function are all important considerations. The most common complications reported were skin necrosis, decreased penile skin sensation, urethral strictures, erectile dysfunction and urethral fistulae.^{2 4} As with the presented case, skin necrosis can be successfully managed with good wound care, debridement and skin grafting.

Learning points.

• Penile amputation injuries should be managed in a specialist centre with urological and plastic surgeons with expertise in microsurgical reconstruction in the first instance.

• Penile replantation should be attempted, even if ischaemia time is prolonged, despite lower success rates given the significance of the injury to an individual.

• The most common complication of penile replantation is subsequent skin necrosis which can be managed successfully with adequate wound care, debridement and skin grafting.