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Successful Penile Replantation with Adjuvant Hyperbaric Oxygen Treatment
Case Report Successful Penile Replantation with Adjuvant Hyperbaric Oxygen Treatment Zhaohui Zhong, Zhonggen Dong, Qing Lu, Yuanwei Li, Chen Lv, Xuan Zhu, Xiaokun Zhao, Xuanzhi Zhang, Frank Morales, and Thomas E. Ichim Penile amputation and successful replantation is very uncommon, and routine standardized procedures for dealing with this medical condition do not exist. A case of a penile amputation and successful replantation is presented. This report presents the microsurgical procedure and postoperative care that led to successful engraftment and function. Of particular interest was the use of hyperbaric oxygen to accelerate the healing process. A review of the published data and future methods of increasing success of such surgical procedures is provided. UROLOGY 69: 983.e3–983.e5, 2007. © 2007 Elsevier Inc.
P
enile replantation is a procedure rarely performed in standard urology practice today. Accordingly, the number of reports dealing with this procedure and the postoperative patient care are limited. In the present report, we provide our experience with one such case and note several interventions we believe accelerated patient recovery and function of the damaged organ.
CASE REPORT A 34-year-old man had suffered amputation of the penis approximately 1 cm distal from the pubic area by a pair of dressmaker’s shears. On presentation to a local hospital 10 minutes after the event, the penis was thoroughly washed with 0.9% saline and placed in a hypothermic container at 4°C and pressurized. The incision wound was bound with a dressing, and 5 hours later the patient was transferred to our hospital. The patient was administered tetanus prophylaxis. The removed penis was sterilized with 1% chlorhexidine solution and placed in a 1% sodium heparin-saline solution. The severed end of the penile body was doused several times in the solution, and evacuation of the hematoma was performed by applying gentle pressure on the area of swelling. Debriding of nonviable tissue was performed to allow clear identification of the deep dorsal veins, dorsal nerves, and dorsal arteries. Figure 1 illustrates the amputated penis and the area of injury subsequent to preoperative preparation. The patient was sedated under general anesthesia, and the remnant portion of the penile body, which was approximately 1 cm long, was ligated with a tourniquet proximal to the base. Sterilization and debriding was performed in a similar manner as for the severed penile body, as described above. Subsequent to evacuation of the hematoma, the urethra was drawn out approximately 0.5 cm. The deep dorsal vein, dorsal nerve, and
From the Department of Urology, The Second Xiangya Hospital of Central South University, Changsha, China; and Medistem Laboratories, Tempe, Arizona Address for correspondence: Zhaohui Zhong, M.D., Department of Urology, The Second Xiangya Hospital of Central South University, Changsha 410011, China. E-mail: [email protected] Submitted: October 15, 2006, accepted (with revisions): February 18, 2007
© 2007 Elsevier Inc. All Rights Reserved
dorsal arteries were isolated. A 16F silicone balloon catheter was inserted in a retrograde manner through the severed penis portion, extending inward through the penile remnant and passed into the bladder, followed by an end-to-end anastomosis of the urethra and corpus spongiosum using interrupted 6-0 synthetic absorbable suture. The cavernous body of the penis was reattached by suturing the tunica albuginea of each corpus cavernosum to the proximal corresponding segment using 4-0 polyglactic acid sutures. The two dorsal veins, dorsal artery, and dorsal nerve were anastomosed under a 10⫻ microscope with interrupted 9-0 nylon nonabsorbable sutures. Revascularization was established at 8 hours after the amputation. Subsequently, Buck’s and Colles’ fascia were sutured with 3-0 interrupted synthetic absorbable suture to relieve tension, and the skin was approximated loosely with 4-0 PCG sutures. After replantation, the tourniquet was released, and the color of the distal penis appeared to revascularize, as noted by the gradual increase in redness and size. The arterial pulse was detected, the superficial penile veins displayed normal turgor, and no bleeding was found. Postoperatively, the patient was given the broad-spectrum cephalosporin cefuroxime (1500 mg twice daily) and low-molecular-weight heparin (Nadroparin 7500 IU/day). Hyperbaric oxygen treatment was performed 90 minutes daily for 3 weeks at 2 atm absolute. On postoperative day 3, necrosis was observed in a 3 ⫻ 2-cm area of skin at the base of the penile shaft, inferiorly between the penis and the scrotum. On day 5, the necrotic tissue was superficially debrided, and the corresponding urethral segment was determined to be intact. Lateral repositioning of the proximal scrotal skin to cover the injured area using 4-0 PCG sutures was performed to create a transposition flap. The patient was observed for 3 weeks, during which minor sporadic edema in the penile body occurred; however, no serious infections were noted. At 3 weeks postoperatively, the cosmetic appearance of the penis was excellent, and the decision was made to stop the antibiotic, antithrombotic, and hyperbaric oxygen therapies. Figure 2 depicts the superior and inferior views of the penile area at 3 weeks postoperatively. Figure 3 shows the appearance of the penis after removal of the catheter. One year later, the patient had maintained a normal urinary flow, reported spontaneous erections, and reported the ability to intromit during 0090-4295/07/$32.00 983.e3 doi:10.1016/j.urology.2007.02.024
Figure 1. Penis midshaft and stump before replantation.
Figure 2. View of replanted penis 3 weeks postoperatively before removal of catheter.
sexual intercourse with full sensation in the glans. Nocturnal tumescence was observed in the patient at the 6 and 12-month follow-up visits using the Snap-Gauge test.
COMMENT Although, in principle, penile replantation can be performed using a variety of methods, few, if any, standardized procedures exist to deal with this medical emergency. The current concept is that microsurgical reapproximation of the penile shaft structures provides the optimal benefit; however, the number of such operations performed is fewer than 30 worldwide.1–3 The original penis replantation was reported in 1929 by Ehrich,4 who realigned the penile structures in the absence of anatomizing the blood vessels or nerves. This approach relied on natural inosculation to reattach the severed structures and was associated with excessive skin loss, edema, and poor functional recovery. The two independent reports in 1977 of microsurgical approximation of the dorsal nerve and blood vessels led to a paradigm shift in penis replantation owing to the ability, in some cases, to 983.e4
Figure 3. View of penis after catheter removal 3 weeks after replantation.
actually preserve not only erectile function, but also sensation.1,5 In our report, microsurgical replantation was performed with an excellent outcome. The contributing factors included that our patient presented with a relatively short ischemic time (0.5 hour of warm ischemia followed by 5 hours of cold ischemia), as well as our ability to clearly identify and successfully join the vital components of the penile structure. Mosahebi et al.6 reported a case of successful replantation after a 7-hour period of warm ischemia, suggesting the relative refractoriness of the penile structure to prolonged deprivation of oxygen and nutrients. However, various patient variables play an important role in the success of replantation. In a case similar to ours in which the patient was a heavy smoker, severe penile necrosis was reported after replantation.7 It is tempting to believe that factors such smoking-associated endothelial dysfunction contributed to the necrosis; however, the paucity of patients who have undergone microsurgical replantation makes it impossible to draw any firm conclusions. The decision to use hyperbaric oxygen as a part of the postoperative recuperation treatment was based on numerous reports that this approach not only provides accelerated wound healing through upregulating collagen synthesis and neoangiogenesis,8,9 but also exerts an antiapoptotic effect on nervous tissue through upregulation of bcl-2.9 This report is, to our knowledge, the first description of extended hyperbaric oxygen use for accelerating healing after penile replantation. Landstrom et al.10 reported on the use of hyperbaric oxygen in the 28th reported case of penile replantation. However, therapy was short-term: 6 days compared with 3 weeks for our patient and was used to treat a pseudomonas infection.
CONCLUSIONS We have presented one of the few cases of successful microsurgical penile replantation after complete amputation. The surgical technique described, as well as the UROLOGY 69 (5), 2007
adjuvant use of hyperbaric oxygen for acceleration of healing and prevention of neuronal damage, is presented as a method for the successful treatment of this rare emergency situation presented to the urologic surgeon. References 1. Tamai S, Nakamura Y, and Motomiya Y: Microsurgical replantation of a completely amputated penis and scrotum: case report. Plast Reconstr Surg 60: 287–291, 1977. 2. Jezior JR, Brady JD, and Schlossberg SM: Management of penile amputation injuries. World J Surg 25: 1602–1609, 2001. 3. Galek L, Darewicz B, Kudelski J, et al: Microsurgical replantation of sexual organs in three patients. Scand J Urol Nephrol 36: 14 –17, 2002. 4. Ehrich WS: Two unusual penile injuries. J Urol 21: 239 –243, 1929.
UROLOGY 69 (5), 2007
5. Cohen BE, May JW Jr, Daly JS, et al: Successful clinical replantation of an amputated penis by microneurovascular repair: case report. Plast Reconstr Surg 59: 276 –280, 1977. 6. Mosahebi A, Butterworth M, Knight R, et al: Delayed penile replantation after prolonged warm ischemia. Microsurgery 21: 52– 54, 2001. 7. Kayikcioglu A, and Ozcan G: Partial necrosis of an amputated penis following replantation in a heavy smoker: a case report. Microsurgery 18: 189 –191, 1998. 8. Al-Waili NS, and Butler GJ: Effects of hyperbaric oxygen on inflammatory response to wound and trauma: possible mechanism of action. Sci World J 6: 425– 441, 2006. 9. Wada K, Miyazawa T, Nomura N, et al: Mn-SOD and Bcl-2 expression after repeated hyperbaric oxygenation. Acta Neurochir Suppl 76: 285–290, 2000. 10. Landstrom JT, Schuyler RW, and Macris GP: Microsurgical penile replantation facilitated by postoperative HBO treatment. Microsurgery 24: 49 –55, 2004.
983.e5
P
enile replantation is a procedure rarely performed in standard urology practice today. Accordingly, the number of reports dealing with this procedure and the postoperative patient care are limited. In the present report, we provide our experience with one such case and note several interventions we believe accelerated patient recovery and function of the damaged organ.
CASE REPORT A 34-year-old man had suffered amputation of the penis approximately 1 cm distal from the pubic area by a pair of dressmaker’s shears. On presentation to a local hospital 10 minutes after the event, the penis was thoroughly washed with 0.9% saline and placed in a hypothermic container at 4°C and pressurized. The incision wound was bound with a dressing, and 5 hours later the patient was transferred to our hospital. The patient was administered tetanus prophylaxis. The removed penis was sterilized with 1% chlorhexidine solution and placed in a 1% sodium heparin-saline solution. The severed end of the penile body was doused several times in the solution, and evacuation of the hematoma was performed by applying gentle pressure on the area of swelling. Debriding of nonviable tissue was performed to allow clear identification of the deep dorsal veins, dorsal nerves, and dorsal arteries. Figure 1 illustrates the amputated penis and the area of injury subsequent to preoperative preparation. The patient was sedated under general anesthesia, and the remnant portion of the penile body, which was approximately 1 cm long, was ligated with a tourniquet proximal to the base. Sterilization and debriding was performed in a similar manner as for the severed penile body, as described above. Subsequent to evacuation of the hematoma, the urethra was drawn out approximately 0.5 cm. The deep dorsal vein, dorsal nerve, and
From the Department of Urology, The Second Xiangya Hospital of Central South University, Changsha, China; and Medistem Laboratories, Tempe, Arizona Address for correspondence: Zhaohui Zhong, M.D., Department of Urology, The Second Xiangya Hospital of Central South University, Changsha 410011, China. E-mail: [email protected] Submitted: October 15, 2006, accepted (with revisions): February 18, 2007
© 2007 Elsevier Inc. All Rights Reserved
dorsal arteries were isolated. A 16F silicone balloon catheter was inserted in a retrograde manner through the severed penis portion, extending inward through the penile remnant and passed into the bladder, followed by an end-to-end anastomosis of the urethra and corpus spongiosum using interrupted 6-0 synthetic absorbable suture. The cavernous body of the penis was reattached by suturing the tunica albuginea of each corpus cavernosum to the proximal corresponding segment using 4-0 polyglactic acid sutures. The two dorsal veins, dorsal artery, and dorsal nerve were anastomosed under a 10⫻ microscope with interrupted 9-0 nylon nonabsorbable sutures. Revascularization was established at 8 hours after the amputation. Subsequently, Buck’s and Colles’ fascia were sutured with 3-0 interrupted synthetic absorbable suture to relieve tension, and the skin was approximated loosely with 4-0 PCG sutures. After replantation, the tourniquet was released, and the color of the distal penis appeared to revascularize, as noted by the gradual increase in redness and size. The arterial pulse was detected, the superficial penile veins displayed normal turgor, and no bleeding was found. Postoperatively, the patient was given the broad-spectrum cephalosporin cefuroxime (1500 mg twice daily) and low-molecular-weight heparin (Nadroparin 7500 IU/day). Hyperbaric oxygen treatment was performed 90 minutes daily for 3 weeks at 2 atm absolute. On postoperative day 3, necrosis was observed in a 3 ⫻ 2-cm area of skin at the base of the penile shaft, inferiorly between the penis and the scrotum. On day 5, the necrotic tissue was superficially debrided, and the corresponding urethral segment was determined to be intact. Lateral repositioning of the proximal scrotal skin to cover the injured area using 4-0 PCG sutures was performed to create a transposition flap. The patient was observed for 3 weeks, during which minor sporadic edema in the penile body occurred; however, no serious infections were noted. At 3 weeks postoperatively, the cosmetic appearance of the penis was excellent, and the decision was made to stop the antibiotic, antithrombotic, and hyperbaric oxygen therapies. Figure 2 depicts the superior and inferior views of the penile area at 3 weeks postoperatively. Figure 3 shows the appearance of the penis after removal of the catheter. One year later, the patient had maintained a normal urinary flow, reported spontaneous erections, and reported the ability to intromit during 0090-4295/07/$32.00 983.e3 doi:10.1016/j.urology.2007.02.024
Figure 1. Penis midshaft and stump before replantation.
Figure 2. View of replanted penis 3 weeks postoperatively before removal of catheter.
sexual intercourse with full sensation in the glans. Nocturnal tumescence was observed in the patient at the 6 and 12-month follow-up visits using the Snap-Gauge test.
COMMENT Although, in principle, penile replantation can be performed using a variety of methods, few, if any, standardized procedures exist to deal with this medical emergency. The current concept is that microsurgical reapproximation of the penile shaft structures provides the optimal benefit; however, the number of such operations performed is fewer than 30 worldwide.1–3 The original penis replantation was reported in 1929 by Ehrich,4 who realigned the penile structures in the absence of anatomizing the blood vessels or nerves. This approach relied on natural inosculation to reattach the severed structures and was associated with excessive skin loss, edema, and poor functional recovery. The two independent reports in 1977 of microsurgical approximation of the dorsal nerve and blood vessels led to a paradigm shift in penis replantation owing to the ability, in some cases, to 983.e4
Figure 3. View of penis after catheter removal 3 weeks after replantation.
actually preserve not only erectile function, but also sensation.1,5 In our report, microsurgical replantation was performed with an excellent outcome. The contributing factors included that our patient presented with a relatively short ischemic time (0.5 hour of warm ischemia followed by 5 hours of cold ischemia), as well as our ability to clearly identify and successfully join the vital components of the penile structure. Mosahebi et al.6 reported a case of successful replantation after a 7-hour period of warm ischemia, suggesting the relative refractoriness of the penile structure to prolonged deprivation of oxygen and nutrients. However, various patient variables play an important role in the success of replantation. In a case similar to ours in which the patient was a heavy smoker, severe penile necrosis was reported after replantation.7 It is tempting to believe that factors such smoking-associated endothelial dysfunction contributed to the necrosis; however, the paucity of patients who have undergone microsurgical replantation makes it impossible to draw any firm conclusions. The decision to use hyperbaric oxygen as a part of the postoperative recuperation treatment was based on numerous reports that this approach not only provides accelerated wound healing through upregulating collagen synthesis and neoangiogenesis,8,9 but also exerts an antiapoptotic effect on nervous tissue through upregulation of bcl-2.9 This report is, to our knowledge, the first description of extended hyperbaric oxygen use for accelerating healing after penile replantation. Landstrom et al.10 reported on the use of hyperbaric oxygen in the 28th reported case of penile replantation. However, therapy was short-term: 6 days compared with 3 weeks for our patient and was used to treat a pseudomonas infection.
CONCLUSIONS We have presented one of the few cases of successful microsurgical penile replantation after complete amputation. The surgical technique described, as well as the UROLOGY 69 (5), 2007
adjuvant use of hyperbaric oxygen for acceleration of healing and prevention of neuronal damage, is presented as a method for the successful treatment of this rare emergency situation presented to the urologic surgeon. References 1. Tamai S, Nakamura Y, and Motomiya Y: Microsurgical replantation of a completely amputated penis and scrotum: case report. Plast Reconstr Surg 60: 287–291, 1977. 2. Jezior JR, Brady JD, and Schlossberg SM: Management of penile amputation injuries. World J Surg 25: 1602–1609, 2001. 3. Galek L, Darewicz B, Kudelski J, et al: Microsurgical replantation of sexual organs in three patients. Scand J Urol Nephrol 36: 14 –17, 2002. 4. Ehrich WS: Two unusual penile injuries. J Urol 21: 239 –243, 1929.
UROLOGY 69 (5), 2007
5. Cohen BE, May JW Jr, Daly JS, et al: Successful clinical replantation of an amputated penis by microneurovascular repair: case report. Plast Reconstr Surg 59: 276 –280, 1977. 6. Mosahebi A, Butterworth M, Knight R, et al: Delayed penile replantation after prolonged warm ischemia. Microsurgery 21: 52– 54, 2001. 7. Kayikcioglu A, and Ozcan G: Partial necrosis of an amputated penis following replantation in a heavy smoker: a case report. Microsurgery 18: 189 –191, 1998. 8. Al-Waili NS, and Butler GJ: Effects of hyperbaric oxygen on inflammatory response to wound and trauma: possible mechanism of action. Sci World J 6: 425– 441, 2006. 9. Wada K, Miyazawa T, Nomura N, et al: Mn-SOD and Bcl-2 expression after repeated hyperbaric oxygenation. Acta Neurochir Suppl 76: 285–290, 2000. 10. Landstrom JT, Schuyler RW, and Macris GP: Microsurgical penile replantation facilitated by postoperative HBO treatment. Microsurgery 24: 49 –55, 2004.
983.e5