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Penile Replantation: Current Concepts
0022-5347 /85/1332-0281$02 00/0 THE JOURNAL OF UROLOGY
Copyright© 1985 by The VVilliams & Wilkins Co.
PENILE REPLANTATION: CURRENT CONCEPTS PETER R. CARROLL,* TOM F. LUE, RICHARD A. SCHMIDT, GUY TRENGROVE-JONES JACK W. McANINCHt
AND
From the Department of Urology, and the Division of Plastic and Reconstructive Surgery, University of California School of Medicine and San Francisco General Hospital, San Francisco, California
ABSTRACT
We describe the microvascular repair of a traumatically lacerated penis (the fifth such case in the literature) and outline a uniform plan of management with which one can expect restoration of function and an adequate cosmetic appearance. Microvascular repair represents the most physiological method of reconstruction, with a lower incidence of urethral stricture disease, skin loss and sensory impairment. Amputation of the penis is seen rarely and may occur as an act of self-mutilation, iatrogenically at the time of surgery, or as the result of industrial accidents or criminal acts. The normal-appearing penis, in addition to being a urinary conduit and an organ of reproduction and sexual gratification, contributes to the male body image. A review of the limited literature on the subject reveals no uniform plan of management. We summarize our experience with a case of partial penile amputation, review and examine the results of various methods of surgical repair, and outline a uniform plan of management, reconstruction and rehabilitation. CASE REPORT
A 28-year-old white man with a history of "chronic schizophrenia" recalcitrant to drug therapy presented to the emergency room after lacerating the penis with a large kitchen knife. The patient was pale, hypotensive, agitated and delusional, claiming that while "battling powerful, demonic forces" he was overcome and compelled to amputate the penis. He was resuscitated with crystalloid and packed red blood cell infusions. The patient was covered with blood, and a la~ge pulsating clot was noted over the dorsal surface of the penis at the penopubic junction (fig. 1, A). Several superficial ventral lacerations also were noted. The glans penis, although perfused, had a somewhat prolonged capillary refill time. Because of the agitated condition of the patient and the magnitude of the initial blood loss, no attempt at a more detailed examination was made. Exploration and repair were performed 3½ hours after the injury. General anesthesia was induced and the patient was prepared carefully. A Penrose drain was looped around the proximal penile shaft as a tourniquet. The blood clot overlying the injury was removed carefully, exposing an approximately 75 per cent dorsal-to-ventral laceration of the penis with complete transection of both corpora cavemosa and partial transection of the corpus spongiosum (fig. 1, B). Despite an extensive dorsal laceration and several superficial ventral lacerations, the urethra was intact and a Foley catheter was placed without difficulty. The dorsal vein, artery and nerve complex had been severed completely in 2 places. The corporeal arteries were visualized with use of an operating microscope but judged to be too small for successful microvascular reanastomosis. The tunics of all 3 corpora were closed with interrupted 2-zero chromic sutures. The deep dorsal vein, 1 artery and 1 dorsal nerve were reanastomosed with 9-zero nylon suture material, using microvascular techniques (fig. 2). Because 2 lacerations were present in all 3 structures, 6 microvascular anastomoses were perAccepted for publication September 7, 1984. * Current address: Department of Urology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, New York 10021. tRequests for reprints: Department of Urology, U-518, University of California, San Francisco, California 94143. 281
formed. The subcutaneous tissue was approximated with 3-zero chromic suture material to provide a reanastomosis free of tension (fig. 3, A). The skin was closed with 4-zero chromic sutures and a percutaneous suprapubic bladder catheter was placed. The patient remained on bed rest and parenteral cephalosporin antibiotics were continued. He was evaluated by the psychiatric service immediately and sedation with haloperidol was begun. At 1 week no significant skin loss had occurred. Careful sensory examination revealed decreased sensation along the dorsal surface of the penis from the area of injury distally to the glans, which improved with time. The patient estimated that "70 per cent" of erectile function along with ejaculation had returned by 2 weeks. Several erections were witnessed by members of the health care team. Patency of the dorsal vein and artery anastomoses was confirmed at 3 weeks by Doppler flow studies (fig. 3, B). The patient was discharged from the hospital, although intermittent delusional ideation continued despite management with several antipsychotic medications. He was transferred to a psychiatric facility for continued care and rehabilitation. DISCUSSION
Penile amputation is an uncommon injury, with less than 50 cases reported in the literature. Although the first documented case of penile replantation was recorded in 1929,1 anatomical restoration was considered "futile" .and "hazardous" as recently as 30 years ago. 2 Currently, improvements in surgical technique and a better understanding of penile anatomy allow adequate cosmetic and functional restoration in the majority of cases in which replantation is attempted. Due to the rarity of such genital mutilation no uniform treatment program has been established. The objectives of treatment include not only restoration of the penis as the urinary conduit and reproductive organ but also evaluation and treatment of the commonly associated psychiatric illness in those patients with self-inflicted injuries. Greilsheimer and Groves noted that those individuals who intentionally mutilate or remove the genitals are a heterogeneous group: 87 per cent are believed to be psychotic at the time of the act (51 per cent with schizophrenia) and the remainder are nonpsychotic individuals with character disorders and transsexuals. 3 These acts are committed commonly under the influence of alcohol, and nonpsychotic patients do as much harm as those with an obvious psychosis. Although long-term management is aimed at correction of the associated mental illness, immediate management should include control of psychotic behavior to permit surgical repair. Severely disturbed patients should be given the benefit of penile replantation, since the ultimate prognosis for any associated psychiatric
282
CARROLL AND ASSOCIATES
The method of repair included restoration of corporeal and urethral continuity alone or in combination with anastomosis of the dorsal vein only, reanastomosis of 1 or both deep dorsal arteries, and microvascular repair of the dorsal vein and 1 or both of the dorsal arteries and nerves. Each case was evaluated for postoperative erection, sensation, urethral stricture, skin loss and capability of intromission. The different methods of repair then were compared with each other (table 2). A definitive comparison was impossible because the extent (partial versus complete) and site (proximal versus distal shaft) of injury varied, and descriptions and eventual outcome often were unclear or not stated. In addition, although erection and sensation returned postoperatively they were diminished in several cases. Despite the shortcomings of such a review, all methods were associated with an almost uniform return of erectile ability. Complete microvascular reanastomosis of the dorsal vein and 1 or both dorsal arteries and nerves has been accomplished in only 5 cases, including our patient. Such a meticulous repair seems to be associated with better preservation of skin and sensation, and also absence of urethral stricture disease (table 2). That penile replantation is possible without microvascular repair is a testament to the unique anatomy of the penile vasculature. Arterial blood is supplied by the 2 internal puden dal arteries that divide at the perineum into a peripheral branch, bulbar and urethral arteries that supply the corpus spongiosum, and a penile artery that divides at the crus of the corpus cavernosum into the dorsal artery and deep artery. The dorsal artery courses between Buck's fascia and the tunica albuginea,. giving off 4 to 5 circumflex arteries that enter the corpus spongiosum. It continues to the glans, where anastomosis occurs freely with the urethral artery. 20• 21 Ligation of 1 or both dorsal arteries reportedly has not been followed by Fm. 1. A, large pulsating clot on dorsal surface of penis. B, complete laceration of both corpora cavernosa and incomplete laceration of corpus spongiosum. Dorsal neurovascular bundle was cut in 2 places.
Fm. 2. Reanastomosis of dorsal vein (A) and 1 dorsal artery (B) and nerve (C).
illness is difficult to predict initially because of the severity of the psychosis. A detailed psychiatric assessment should await a more thorough and timely evaluation. In a review of more than 40 patients with penile amputations only 1 postoperative suicide and 1 repeated attempt at mutilation have been recorded. 3· ~ In our patient a microvascular repair was performed. To evaluate the merits of various methods of penile replantation 38 cases previously reported in which the method was noted clearly were reviewed (table 1).1• 4- 19 There were 15 cases of incomplete laceration and 23 cases of complete amputation.
FIG. 3. Repair. A, immediately postoperatively. B, 3 weeks postoperatively.
CURRENT CONCEPTS
PENILE REPLANTATWN: TABLE
Type
Reference Ehrich 1
Incomplete
Mendez and associates4
Complete Incomplete
Tuerk and Weir5
Complete
Cohen and associates6
Complete
McRoberts and associates 7
Complete
Einarsson and associates 8
Incomplete
Bhanganada and associates•
O'Brien and associates 10
Incomplete (6 pts.) Complete (12 pts.) Complete
Galleher and Kiser 11
Incomplete
Tamai and associates 12
Complete
Farah and Cerny 13
Incomplete
Schulman 14
Complete
Best and associates 15
Complete
Bux and associates 16
Complete Incomplete
Heymann and associates 17
Incomplete
Engelman and associates 18
Complete Incomplete
Price 19
Incomplete
283
L Results of 38 reported cases of penile reanastomosis Repair
Corpora and urethra repaired only Dorsal vein also repaired Corpora and urethra repaired only Corpora and urethra repaired only Dorsal vein repaired with 1 or both dorsal arteries and nerves Corpora and urethra repaired only Corpora and urethra repaired only Dorsal vein also repaired Dorsal vein also repaired Dorsal vein repaired with 1 or both dorsal arteries and nerves Corpora and urethra repaired only Dorsal vein repaired with 1 or both dorsal arteries and nerves Corpora and urethra repaired only Corpora and urethra repaired only Corpora and urethra repaired only Corpora and urethra repaired only Corpora and urethra repaired only Dorsal artery also repaired Corpora and urethra repaired only Corpora and urethra repaired only Corpora and urethra repaired only
Erection
Intro mission
Sensation
Stricture
Skin Loss
Present
Present
Present
Present
Present
Present
Unknown
Absent
Present
Present
Present
Present
Unknown
Present
Present
Present but noted as decreased Present but noted as decreased Present
Present
Present
Unknown
Unknown
Present
Absent
Absent
Present
Unknown
Present
Present
Present
Unknown
Unknown
Present
Present
Unknown
Unknown
Present but noted as decreased Absent (6 pts.)
Unknown
Present (8 pts.) Present
Present (2 pts.) Unknown
Present
Present
Present
Present
Absent
Present (5 pts.) Present (10 pts.) Present
Absent
Unknown
Unknown
Present but noted as decreased Present
Absent
Absent
Unknown
Unknown
Unknown
Absent
Present
Present but noted as decreased Present
Unknown
Absent
Present
Present
Present but noted as decreased Unknown
Present
Present
Present
Present
Unknown
Absent
Present
Present
Unknown
Unknown
Absent
Absent
Present but noted as decreased Present but noted as decreased Present
Unknown
Unknown
Present
Unknown
Present
Present
Present
Absent
Present
Unknown
Present but noted as decreased Present but noted as decreased Present but noted as decreased Present
Present
Present
Present
(12 pts.)
Absent
Unknown
TABLE 2 ··----·
Repair
Corpora and urethra only Dorsal vein Micro vascular repair Totals
Total No. Pts.
No. With Erection/ No. Evaluated
6
6/6
13
9/9 4/4
4
23
No. With lntromission/ No. Evaluated
No. With Sensation/ No. Evaluated
Surgical management of complete penile amputation 3/3 4/4
19/19
No. With Stricture/ No. Evaluated
No. With Skin Loss/ No. Evaluated
4/6
6/6
2/2 Unknown
1/13 4/4
0/1 0/4
11/13 2/4
5/5
9/21
4/11
19/23
Surgical management of partial penile amputation Corpora and urethra only Dorsal vein Dorsal artery Micro vascular artery Totals
8
8/8
4/4
6/6
5/8
4/6
6 1* 1
Not applicable 1/1 1/1
Not applicable Unknown Unknown
0/6 1/1 1/1
Unknown Not applicable Not applicable
5/6 1/1 0/1
10/10
4/4
8/14
5/8
10/14
16
* Significant edema noted after repair.
gangrene or impotence. 22 The paired deep arteries that penetrate the tunica albuginea with the cavernous nerves provide the nutritional needs of the cavernous muscles and the blood flow required to distend sinusoidal spaces during erection. The venous drainage of the penis is more complex and includes 3 major divisions: superficial, intermediate and deep. The superficial dorsal vein lies between the dartos and Buck's
fascias. Deep veins include bulbar, anterior and posterior urethral, and deep corporeal vessels that drain into the pudenda! plexus. The intermediate group consists of the deep dorsal vein superficial to the tunica albuginea, which receives straight veins from the glans, emissary veins piercing the tunica albuginea of the corporeal bodies, and circumflex veins draining the corpus spongiosum and corpora cavernosa. 21
284
CARROLL AND ASSOCIATES
FIG. 4. Postoperative dressing
severe partial or complete penile laceration can be outlined. All patients should be considered candidates for repair, even those presenting late or with active psychosis. If completely transected, the penis should be wrapped in gauze soaked with cold saline solution and transported on ice. Upon arrival at the hospital the patient should be evaluated by a urologist, a surgeon with skills in microvascular technique and a psychiatrist if the injury is self-inflicted. The entire team should coordinate immediate care and eventual rehabilitation. After the patient is stabilized and resuscitated the operation is performed. Proximal vascular control can be achieved rapidly by placing a soft rubber drain around the proximal penile segment as a tourniquet. Saline or Ringer's lactate irrigation, with or without antibiotics and heparin, should be used to clean the penile segment. A urethral reanastomosis should be performed over a catheter. The tunica albuginea can be closed with 2-zero interrupted, absorbable suture material. Similarly, Buck's and Colles' fascias can be approximated with 3-zero interrupted absorbable sutures to allow' a microvascular repair free of tension. The deep dorsal vein and 1 or both dorsal arteries and nerves can be reapproximated with fine suture material. Reanastomosis of the dorsal arteries provides immediate restoration of blood flow to the subcutaneous tissues and may decrease the possibility of skin necrosis. Patency of the dorsal vein is crucial, since it prevents edema, tissue tension and the possibility of distal ischemia. Microvascular repair of the deep corporeal arteries is unnecessary because transection of these vessels occurs after considerable branching of the corporeal nerves and arteries already has taken place. Arterial filling during erection may be slowed but it will be adequate to increase corporeal pressure and precipitate erection. Nerve reanastomosis may be followed by return of distal sensation. Proximal urinary diversion is recommended. Postoperatively the penis should be elevated and loosely wrapped to facilitat~ venous and lymphatic drainage. This was accomplished in our case with an external splint made from a plastic irrigation fluid bottle cut on both ends and padded with foam (fig. 4). Perioperatively, the patient should receive broad-spectrum antibiotics and close psychiatric evaluation. Periodic irrigation of the corpora and postoperative treatment with low molecular weight dextran, aspirin or heparin probably are unnecessary and may contribute to bleeding and hematoma formation. 6 • 16 Such a uniform program of evaluation and treatment satisfies the requirements for successful penile reconstruction, including maintenance of the penis as a urinary conduit, and organ of reproduction and sexual gratification as well as psychological rehabilitation of the patient.
Common to most reports of penile replantation is the high incidence of skin necrosis. Viability of the distal penile segment is a function of the extent of the laceration, the delay until reanastomosis and the type of repair. Incomplete lacerations, even those with a simple skin bridge, have a lower incidence of skin necrosis because of the extensive collateral network of penile arteries and veins. Microvascular repair avoids extensive skin necrosis because it establishes immediately subcutaneous circulation rather than relying on blood flow across the corpora cavernosa and subcutaneous tissue, as occurs when no attempt at vascular anastomosis is made. In those 5 cases in which complete microvascular repair was performed skin loss was documented clearly in only 2 patients, both of whom required skin grafting only. Techniques have been described that rely on removing penile skin and burying the shaft within the scrotum at the time of injury. 4 •7• 9 At a later date the penis is freed along with a covering of scrotal skin. This may be disadvantageous, since it requires a second procedure and use of scrotal skin for ultimate coverage, which is hair-bearing and substantially thicker than native penile skin and may place undue tension on the anastomosis. After partial and complete penile transections the uniform return of at least some erectile ability is surprising. Erection is a neurovascular phenomenon that has been described in the dog, monkey and man. 22- 25 Impulses from cavernous nerves result in active arterial dilation, sinusoidal relaxation and active venous outflow restriction. 21 • 23 • 26• 27 Autonomic nerve contributions from the thoracic lumbar and sacral cord segments converge in the pelvic nerve plexus lying along the lateral aspect of the rectum. In addition to providing branches that innervate CONCLUSION the bladder, rectum and seminal vessels, the cavernous nerves Penile amputation is a rare injury. All patients should be course along the posterolateral surface of the prostate to enter the corpus spongiosum and corpora cavernosa with accompa- considered for replantation unless the distal segment is mutinying vessels. Electrical stimulation of these nerves, either by lated severely or missing. Although microvascular reanastoattached electrodes, or by transperineal or transrectal methods ' mosis represents the most physiological approach to repair with results in erection. Fortunately, almost all of the penile tran~ a lower incidence of skin loss, sensory deficit and stricture sections with injury to the cavernous nerves and penile arteries disease, even simple replantation results in adequate cosmetic and veins occur distal to the main trunks after considerable and functional restoration of the penis in the majority of cases. branching already has occurred. Erectile capability persists REFERENCES because the proximal cavernous nerves and arteries are preserved. 1. Ehrich, W. S.: Two unusual penile injuries. J. Urol., 21: 239, 1929. As active arterial inflow increases, corporeal pressure rises 2. Kenyon, H. R. and Hyman, R. M.: Total autoemasculation: report and eventually overwhelms the venous outflow capacity, of 3 cases. J.A.M.A., 151: 207, 1953. 3. Greilsheimer, H. and Groves, J. E.: Male genital self-mutilation. thereby further increasing intracorporeal pressure and erection. Arch. Gen. Psych., 36: 441, 1979. In these patients the diminished erections probably result from 4. Mendez, R., Kiely, W. F. and Morrow, J. W.: Self-emasculation. J. scarring and cavernous nerve transection, which would inhibit Urol., 107: 981, 1972. active sinusoidal relaxation and venous outflow restriction 5. Tuerk, M. and Weir, W. H., Jr.: Successful replantation of a 12 22 distal to the site of injury . • Although erection may be dimintraumatically amputated glans penis. Plast. Reconstr. Surg., 48: ished, intromission is reported in a high percentage of cases 499, 1971. (table 2). 6. Cohen, B. E., May, J. W., Jr., Daly, J. S. F. and Young, H. H., II: With an understanding of the complex network of penile Successful clinical reimplantation of an amputated penis by veins, arteries and nerves, a uniform plan of management for microneurovascular repair: case report. Plast. Reconstr. Surg.,
PENILE REPLANTATION: CURRENT CONCEPTS
59: 276, 1977. 7. McRoberts, J. W., Chapman, W. H. and Ansell, J. S.: Primary anastomosis of the traumatically amputated penis: case report and summary of literature. J. Urol., 100: 751, 1968. 8. Einarsson, G., Goldstein, M. and Laungani, G.: Penile replantation. Urology, 22: 404, 1983. 9. Bhanganada, K., Chayavatana, T., Pongnumkul, C., Tonmukayakul, A., Sakolsatayadorn, P., Komaratat, K. and Wilde, H.: Surgical management of an epidemic of penile amputations in Siam. Amer. J. Surg., 146: 376, 1983. 10. O'Brien, D., Ambrose, S.S., Nahai, F., Bostwick, J. and Vasconez, L. 0.: Traumatic amputation of the penis with successful replantation: report of two cases. In: Proceedings of the Nineteenth International Congress of the Societe Internationale d'Urologie, p. 103, abstract 333, San Francisco, California, September 5-10, 1982. 11. Galleher, E. P., Jr. and Kiser, W. S.: Injuries of the corpus cavernosum. J. Urol., 85: 949, 1961. 12. Tamai, S., Nakamura, Y. and Motomiya, Y.: Microsurgical replantation of a completely amputated penis and scrotum: case report. Plast. Reconstr. Surg., 60: 287, 1977. 13. Farah, R. and Cerny, J. C.: Penis tourniquet syndrome and penile amputation. Urology, 2: 310, 1973. 14. Schulman, M. L.: Reanastomosis of the amputated penis. J. Urol., 109: 432, 1973. 15. Best, J. W., Angelo, J. J. and Milligan, B.: Complete traumatic amputation of the penis. J. Urol., 87: 134, 1962. 16. Bux, R., Carroll, P., Berger, M. and Yarbrough, W.: Primary penile
285
reanastomosis. Urology, 11: 500, 1978. 17. Heymann, A. D., Bell-Thomson, J., Rathod, D. M. and Heller, L. E.: Successful reimplantation of the penis using microvascular techniques. J. Urol., 118: 879, 1977. 18. Engelman, E. R., Polito, G., Perley, J., Bruffy, J. and Martin, D. C.: Traumatic amputation of the penis. J. Urol., 112: 774, 1974. 19. Price, K. A.: Accidental transection of all corpora of the penis: repair with good results. J. Urol., 68: 620, 1952. 20. Deysach, L. J.: The comparative morphology of the erectile tissue of the penis with especial emphasis on the probable mechanism of erection. Amer. J. Anat., 64: 111, 1939. 21. Newman, H. F. and Northup, J. D.: Mechanism of human penile erection: an overview. Urology, 17: 399, 1981. 22. Burt, F. B., Schirmer, H. K. and Scott, W. W.: A new concept in the management of priapism. J. Urol., 83: 60, 1960. 23. Walsh, P. C. and Donker, P. J.: Impotence following radical prostatectomy: insight into etiology and prevention. J. Urol., 128: 492, 1982. 24. Dorr, L. and Brody, M.: Hemodynamic mechanisms of erection in the canine penis. Amer. J. Physiol., 213: 1526, 1967. 25. Lue, T. F., Zeineh, S. J., Schmidt, R. A. and Tanagho, E. A.: Neuroanatomy of penile erection: its relevance to iatrogenic impotence. J. Urol., 131: 273, 1984. 26. Lue, T. F., Takamura, T., Schmidt, R. A., Palubinskas, A. J. and Tanagho, E. A.: Hemodynamics of erection in the monkey. J. Urol., 130: 1237, 1983. 27. Colleen, S., Holmquist, B. and Olin, T.: An angiographic study of erection in the dog. Urol. Res., 9: 297, 1981.
Copyright© 1985 by The VVilliams & Wilkins Co.
PENILE REPLANTATION: CURRENT CONCEPTS PETER R. CARROLL,* TOM F. LUE, RICHARD A. SCHMIDT, GUY TRENGROVE-JONES JACK W. McANINCHt
AND
From the Department of Urology, and the Division of Plastic and Reconstructive Surgery, University of California School of Medicine and San Francisco General Hospital, San Francisco, California
ABSTRACT
We describe the microvascular repair of a traumatically lacerated penis (the fifth such case in the literature) and outline a uniform plan of management with which one can expect restoration of function and an adequate cosmetic appearance. Microvascular repair represents the most physiological method of reconstruction, with a lower incidence of urethral stricture disease, skin loss and sensory impairment. Amputation of the penis is seen rarely and may occur as an act of self-mutilation, iatrogenically at the time of surgery, or as the result of industrial accidents or criminal acts. The normal-appearing penis, in addition to being a urinary conduit and an organ of reproduction and sexual gratification, contributes to the male body image. A review of the limited literature on the subject reveals no uniform plan of management. We summarize our experience with a case of partial penile amputation, review and examine the results of various methods of surgical repair, and outline a uniform plan of management, reconstruction and rehabilitation. CASE REPORT
A 28-year-old white man with a history of "chronic schizophrenia" recalcitrant to drug therapy presented to the emergency room after lacerating the penis with a large kitchen knife. The patient was pale, hypotensive, agitated and delusional, claiming that while "battling powerful, demonic forces" he was overcome and compelled to amputate the penis. He was resuscitated with crystalloid and packed red blood cell infusions. The patient was covered with blood, and a la~ge pulsating clot was noted over the dorsal surface of the penis at the penopubic junction (fig. 1, A). Several superficial ventral lacerations also were noted. The glans penis, although perfused, had a somewhat prolonged capillary refill time. Because of the agitated condition of the patient and the magnitude of the initial blood loss, no attempt at a more detailed examination was made. Exploration and repair were performed 3½ hours after the injury. General anesthesia was induced and the patient was prepared carefully. A Penrose drain was looped around the proximal penile shaft as a tourniquet. The blood clot overlying the injury was removed carefully, exposing an approximately 75 per cent dorsal-to-ventral laceration of the penis with complete transection of both corpora cavemosa and partial transection of the corpus spongiosum (fig. 1, B). Despite an extensive dorsal laceration and several superficial ventral lacerations, the urethra was intact and a Foley catheter was placed without difficulty. The dorsal vein, artery and nerve complex had been severed completely in 2 places. The corporeal arteries were visualized with use of an operating microscope but judged to be too small for successful microvascular reanastomosis. The tunics of all 3 corpora were closed with interrupted 2-zero chromic sutures. The deep dorsal vein, 1 artery and 1 dorsal nerve were reanastomosed with 9-zero nylon suture material, using microvascular techniques (fig. 2). Because 2 lacerations were present in all 3 structures, 6 microvascular anastomoses were perAccepted for publication September 7, 1984. * Current address: Department of Urology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, New York 10021. tRequests for reprints: Department of Urology, U-518, University of California, San Francisco, California 94143. 281
formed. The subcutaneous tissue was approximated with 3-zero chromic suture material to provide a reanastomosis free of tension (fig. 3, A). The skin was closed with 4-zero chromic sutures and a percutaneous suprapubic bladder catheter was placed. The patient remained on bed rest and parenteral cephalosporin antibiotics were continued. He was evaluated by the psychiatric service immediately and sedation with haloperidol was begun. At 1 week no significant skin loss had occurred. Careful sensory examination revealed decreased sensation along the dorsal surface of the penis from the area of injury distally to the glans, which improved with time. The patient estimated that "70 per cent" of erectile function along with ejaculation had returned by 2 weeks. Several erections were witnessed by members of the health care team. Patency of the dorsal vein and artery anastomoses was confirmed at 3 weeks by Doppler flow studies (fig. 3, B). The patient was discharged from the hospital, although intermittent delusional ideation continued despite management with several antipsychotic medications. He was transferred to a psychiatric facility for continued care and rehabilitation. DISCUSSION
Penile amputation is an uncommon injury, with less than 50 cases reported in the literature. Although the first documented case of penile replantation was recorded in 1929,1 anatomical restoration was considered "futile" .and "hazardous" as recently as 30 years ago. 2 Currently, improvements in surgical technique and a better understanding of penile anatomy allow adequate cosmetic and functional restoration in the majority of cases in which replantation is attempted. Due to the rarity of such genital mutilation no uniform treatment program has been established. The objectives of treatment include not only restoration of the penis as the urinary conduit and reproductive organ but also evaluation and treatment of the commonly associated psychiatric illness in those patients with self-inflicted injuries. Greilsheimer and Groves noted that those individuals who intentionally mutilate or remove the genitals are a heterogeneous group: 87 per cent are believed to be psychotic at the time of the act (51 per cent with schizophrenia) and the remainder are nonpsychotic individuals with character disorders and transsexuals. 3 These acts are committed commonly under the influence of alcohol, and nonpsychotic patients do as much harm as those with an obvious psychosis. Although long-term management is aimed at correction of the associated mental illness, immediate management should include control of psychotic behavior to permit surgical repair. Severely disturbed patients should be given the benefit of penile replantation, since the ultimate prognosis for any associated psychiatric
282
CARROLL AND ASSOCIATES
The method of repair included restoration of corporeal and urethral continuity alone or in combination with anastomosis of the dorsal vein only, reanastomosis of 1 or both deep dorsal arteries, and microvascular repair of the dorsal vein and 1 or both of the dorsal arteries and nerves. Each case was evaluated for postoperative erection, sensation, urethral stricture, skin loss and capability of intromission. The different methods of repair then were compared with each other (table 2). A definitive comparison was impossible because the extent (partial versus complete) and site (proximal versus distal shaft) of injury varied, and descriptions and eventual outcome often were unclear or not stated. In addition, although erection and sensation returned postoperatively they were diminished in several cases. Despite the shortcomings of such a review, all methods were associated with an almost uniform return of erectile ability. Complete microvascular reanastomosis of the dorsal vein and 1 or both dorsal arteries and nerves has been accomplished in only 5 cases, including our patient. Such a meticulous repair seems to be associated with better preservation of skin and sensation, and also absence of urethral stricture disease (table 2). That penile replantation is possible without microvascular repair is a testament to the unique anatomy of the penile vasculature. Arterial blood is supplied by the 2 internal puden dal arteries that divide at the perineum into a peripheral branch, bulbar and urethral arteries that supply the corpus spongiosum, and a penile artery that divides at the crus of the corpus cavernosum into the dorsal artery and deep artery. The dorsal artery courses between Buck's fascia and the tunica albuginea,. giving off 4 to 5 circumflex arteries that enter the corpus spongiosum. It continues to the glans, where anastomosis occurs freely with the urethral artery. 20• 21 Ligation of 1 or both dorsal arteries reportedly has not been followed by Fm. 1. A, large pulsating clot on dorsal surface of penis. B, complete laceration of both corpora cavernosa and incomplete laceration of corpus spongiosum. Dorsal neurovascular bundle was cut in 2 places.
Fm. 2. Reanastomosis of dorsal vein (A) and 1 dorsal artery (B) and nerve (C).
illness is difficult to predict initially because of the severity of the psychosis. A detailed psychiatric assessment should await a more thorough and timely evaluation. In a review of more than 40 patients with penile amputations only 1 postoperative suicide and 1 repeated attempt at mutilation have been recorded. 3· ~ In our patient a microvascular repair was performed. To evaluate the merits of various methods of penile replantation 38 cases previously reported in which the method was noted clearly were reviewed (table 1).1• 4- 19 There were 15 cases of incomplete laceration and 23 cases of complete amputation.
FIG. 3. Repair. A, immediately postoperatively. B, 3 weeks postoperatively.
CURRENT CONCEPTS
PENILE REPLANTATWN: TABLE
Type
Reference Ehrich 1
Incomplete
Mendez and associates4
Complete Incomplete
Tuerk and Weir5
Complete
Cohen and associates6
Complete
McRoberts and associates 7
Complete
Einarsson and associates 8
Incomplete
Bhanganada and associates•
O'Brien and associates 10
Incomplete (6 pts.) Complete (12 pts.) Complete
Galleher and Kiser 11
Incomplete
Tamai and associates 12
Complete
Farah and Cerny 13
Incomplete
Schulman 14
Complete
Best and associates 15
Complete
Bux and associates 16
Complete Incomplete
Heymann and associates 17
Incomplete
Engelman and associates 18
Complete Incomplete
Price 19
Incomplete
283
L Results of 38 reported cases of penile reanastomosis Repair
Corpora and urethra repaired only Dorsal vein also repaired Corpora and urethra repaired only Corpora and urethra repaired only Dorsal vein repaired with 1 or both dorsal arteries and nerves Corpora and urethra repaired only Corpora and urethra repaired only Dorsal vein also repaired Dorsal vein also repaired Dorsal vein repaired with 1 or both dorsal arteries and nerves Corpora and urethra repaired only Dorsal vein repaired with 1 or both dorsal arteries and nerves Corpora and urethra repaired only Corpora and urethra repaired only Corpora and urethra repaired only Corpora and urethra repaired only Corpora and urethra repaired only Dorsal artery also repaired Corpora and urethra repaired only Corpora and urethra repaired only Corpora and urethra repaired only
Erection
Intro mission
Sensation
Stricture
Skin Loss
Present
Present
Present
Present
Present
Present
Unknown
Absent
Present
Present
Present
Present
Unknown
Present
Present
Present but noted as decreased Present but noted as decreased Present
Present
Present
Unknown
Unknown
Present
Absent
Absent
Present
Unknown
Present
Present
Present
Unknown
Unknown
Present
Present
Unknown
Unknown
Present but noted as decreased Absent (6 pts.)
Unknown
Present (8 pts.) Present
Present (2 pts.) Unknown
Present
Present
Present
Present
Absent
Present (5 pts.) Present (10 pts.) Present
Absent
Unknown
Unknown
Present but noted as decreased Present
Absent
Absent
Unknown
Unknown
Unknown
Absent
Present
Present but noted as decreased Present
Unknown
Absent
Present
Present
Present but noted as decreased Unknown
Present
Present
Present
Present
Unknown
Absent
Present
Present
Unknown
Unknown
Absent
Absent
Present but noted as decreased Present but noted as decreased Present
Unknown
Unknown
Present
Unknown
Present
Present
Present
Absent
Present
Unknown
Present but noted as decreased Present but noted as decreased Present but noted as decreased Present
Present
Present
Present
(12 pts.)
Absent
Unknown
TABLE 2 ··----·
Repair
Corpora and urethra only Dorsal vein Micro vascular repair Totals
Total No. Pts.
No. With Erection/ No. Evaluated
6
6/6
13
9/9 4/4
4
23
No. With lntromission/ No. Evaluated
No. With Sensation/ No. Evaluated
Surgical management of complete penile amputation 3/3 4/4
19/19
No. With Stricture/ No. Evaluated
No. With Skin Loss/ No. Evaluated
4/6
6/6
2/2 Unknown
1/13 4/4
0/1 0/4
11/13 2/4
5/5
9/21
4/11
19/23
Surgical management of partial penile amputation Corpora and urethra only Dorsal vein Dorsal artery Micro vascular artery Totals
8
8/8
4/4
6/6
5/8
4/6
6 1* 1
Not applicable 1/1 1/1
Not applicable Unknown Unknown
0/6 1/1 1/1
Unknown Not applicable Not applicable
5/6 1/1 0/1
10/10
4/4
8/14
5/8
10/14
16
* Significant edema noted after repair.
gangrene or impotence. 22 The paired deep arteries that penetrate the tunica albuginea with the cavernous nerves provide the nutritional needs of the cavernous muscles and the blood flow required to distend sinusoidal spaces during erection. The venous drainage of the penis is more complex and includes 3 major divisions: superficial, intermediate and deep. The superficial dorsal vein lies between the dartos and Buck's
fascias. Deep veins include bulbar, anterior and posterior urethral, and deep corporeal vessels that drain into the pudenda! plexus. The intermediate group consists of the deep dorsal vein superficial to the tunica albuginea, which receives straight veins from the glans, emissary veins piercing the tunica albuginea of the corporeal bodies, and circumflex veins draining the corpus spongiosum and corpora cavernosa. 21
284
CARROLL AND ASSOCIATES
FIG. 4. Postoperative dressing
severe partial or complete penile laceration can be outlined. All patients should be considered candidates for repair, even those presenting late or with active psychosis. If completely transected, the penis should be wrapped in gauze soaked with cold saline solution and transported on ice. Upon arrival at the hospital the patient should be evaluated by a urologist, a surgeon with skills in microvascular technique and a psychiatrist if the injury is self-inflicted. The entire team should coordinate immediate care and eventual rehabilitation. After the patient is stabilized and resuscitated the operation is performed. Proximal vascular control can be achieved rapidly by placing a soft rubber drain around the proximal penile segment as a tourniquet. Saline or Ringer's lactate irrigation, with or without antibiotics and heparin, should be used to clean the penile segment. A urethral reanastomosis should be performed over a catheter. The tunica albuginea can be closed with 2-zero interrupted, absorbable suture material. Similarly, Buck's and Colles' fascias can be approximated with 3-zero interrupted absorbable sutures to allow' a microvascular repair free of tension. The deep dorsal vein and 1 or both dorsal arteries and nerves can be reapproximated with fine suture material. Reanastomosis of the dorsal arteries provides immediate restoration of blood flow to the subcutaneous tissues and may decrease the possibility of skin necrosis. Patency of the dorsal vein is crucial, since it prevents edema, tissue tension and the possibility of distal ischemia. Microvascular repair of the deep corporeal arteries is unnecessary because transection of these vessels occurs after considerable branching of the corporeal nerves and arteries already has taken place. Arterial filling during erection may be slowed but it will be adequate to increase corporeal pressure and precipitate erection. Nerve reanastomosis may be followed by return of distal sensation. Proximal urinary diversion is recommended. Postoperatively the penis should be elevated and loosely wrapped to facilitat~ venous and lymphatic drainage. This was accomplished in our case with an external splint made from a plastic irrigation fluid bottle cut on both ends and padded with foam (fig. 4). Perioperatively, the patient should receive broad-spectrum antibiotics and close psychiatric evaluation. Periodic irrigation of the corpora and postoperative treatment with low molecular weight dextran, aspirin or heparin probably are unnecessary and may contribute to bleeding and hematoma formation. 6 • 16 Such a uniform program of evaluation and treatment satisfies the requirements for successful penile reconstruction, including maintenance of the penis as a urinary conduit, and organ of reproduction and sexual gratification as well as psychological rehabilitation of the patient.
Common to most reports of penile replantation is the high incidence of skin necrosis. Viability of the distal penile segment is a function of the extent of the laceration, the delay until reanastomosis and the type of repair. Incomplete lacerations, even those with a simple skin bridge, have a lower incidence of skin necrosis because of the extensive collateral network of penile arteries and veins. Microvascular repair avoids extensive skin necrosis because it establishes immediately subcutaneous circulation rather than relying on blood flow across the corpora cavernosa and subcutaneous tissue, as occurs when no attempt at vascular anastomosis is made. In those 5 cases in which complete microvascular repair was performed skin loss was documented clearly in only 2 patients, both of whom required skin grafting only. Techniques have been described that rely on removing penile skin and burying the shaft within the scrotum at the time of injury. 4 •7• 9 At a later date the penis is freed along with a covering of scrotal skin. This may be disadvantageous, since it requires a second procedure and use of scrotal skin for ultimate coverage, which is hair-bearing and substantially thicker than native penile skin and may place undue tension on the anastomosis. After partial and complete penile transections the uniform return of at least some erectile ability is surprising. Erection is a neurovascular phenomenon that has been described in the dog, monkey and man. 22- 25 Impulses from cavernous nerves result in active arterial dilation, sinusoidal relaxation and active venous outflow restriction. 21 • 23 • 26• 27 Autonomic nerve contributions from the thoracic lumbar and sacral cord segments converge in the pelvic nerve plexus lying along the lateral aspect of the rectum. In addition to providing branches that innervate CONCLUSION the bladder, rectum and seminal vessels, the cavernous nerves Penile amputation is a rare injury. All patients should be course along the posterolateral surface of the prostate to enter the corpus spongiosum and corpora cavernosa with accompa- considered for replantation unless the distal segment is mutinying vessels. Electrical stimulation of these nerves, either by lated severely or missing. Although microvascular reanastoattached electrodes, or by transperineal or transrectal methods ' mosis represents the most physiological approach to repair with results in erection. Fortunately, almost all of the penile tran~ a lower incidence of skin loss, sensory deficit and stricture sections with injury to the cavernous nerves and penile arteries disease, even simple replantation results in adequate cosmetic and veins occur distal to the main trunks after considerable and functional restoration of the penis in the majority of cases. branching already has occurred. Erectile capability persists REFERENCES because the proximal cavernous nerves and arteries are preserved. 1. Ehrich, W. S.: Two unusual penile injuries. J. Urol., 21: 239, 1929. As active arterial inflow increases, corporeal pressure rises 2. Kenyon, H. R. and Hyman, R. M.: Total autoemasculation: report and eventually overwhelms the venous outflow capacity, of 3 cases. J.A.M.A., 151: 207, 1953. 3. Greilsheimer, H. and Groves, J. E.: Male genital self-mutilation. thereby further increasing intracorporeal pressure and erection. Arch. Gen. Psych., 36: 441, 1979. In these patients the diminished erections probably result from 4. Mendez, R., Kiely, W. F. and Morrow, J. W.: Self-emasculation. J. scarring and cavernous nerve transection, which would inhibit Urol., 107: 981, 1972. active sinusoidal relaxation and venous outflow restriction 5. Tuerk, M. and Weir, W. H., Jr.: Successful replantation of a 12 22 distal to the site of injury . • Although erection may be dimintraumatically amputated glans penis. Plast. Reconstr. Surg., 48: ished, intromission is reported in a high percentage of cases 499, 1971. (table 2). 6. Cohen, B. E., May, J. W., Jr., Daly, J. S. F. and Young, H. H., II: With an understanding of the complex network of penile Successful clinical reimplantation of an amputated penis by veins, arteries and nerves, a uniform plan of management for microneurovascular repair: case report. Plast. Reconstr. Surg.,
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