JAIRAM R. ESWARA
STEVEN B. BRANDES
Penile amputation is a rare condition that may be life-threatening if the bleeding is not controlled early. In addition to the physical injury, the psychological injury can be devastating. Phallic injuries have been reported in both children and adults and arise largely from attempts at self-emasculation among psychiatric patients, assault, workplace injury, circumcision, or during war (1,2,3,4).
The first penile replantation was described in 1929 by Ehrich (5) from Evansville, Indiana. He described a patient whose penis had been severed with a circular saw. The penis was reattached using no. 1 plain gut for the urethra and no. 1 chromic gut for the corpora cavernosa, and the patient had adequate erectile function at time of follow-up. The advent of microvascular techniques led to the first such repair by Cohen et al. (6) from Massachusetts General Hospital in 1977, and this is now the standard of care. Their technique involved approximating the urethra, corpora, and microsurgical anastomosis of the dorsal vein, arteries, and nerves. To date, there have been approximately 100 reports of penile replantation, both microsurgical and nonmicrosurgical, in the literature.
The largest single series of penile amputation injuries comes from Thailand, where 100 cases were reported, 18 of which underwent nonmicrosurgical anastomosis using the technique described by McRoberts (anastomosis over Foley catheter with scrotal tunneling of the denuded shaft) (7,8). Stabilizing the patient hemodynamically and psychiatrically is critical in the acute setting. The hemorrhage can be severe and has led to death in several instances; therefore, aggressive fluid resuscitation and blood transfusion may be necessary.
The physical diagnosis is obvious with complete loss of the distal penis. Given the high rate of command psychoses and severe personality disorders in this group, the surgery staff must work closely with a psychiatrist. Traumatic amputations either from an assault or industrial equipment will also likely have a postsurgical need for psychiatric evaluation.
The act of self-mutilation during psychosis is known as Klingsor syndrome after the magician who castrates himself in Wagner’s opera Parsifal. Psychotic patients who carry out self-emasculation are typically schizophrenic. One study found that 87% of self-emasculating patients were psychotic at the time of injury (4). These patients are usually victims of command hallucinations that coerce the patient to mutilate his genitals. Nonpsychotic patients who self-emasculate are often diagnosed with severe personality disorders. These patients are more difficult to rehabilitate.
PRESERVATION OF SEVERED PENIS
The severed penis should be cleansed and gently debrided using normal saline. It should then be wrapped in damp saline dressings and kept cool by a separate ice compartment using the “bag-within-a-bag” technique. Placing the phallus directly on ice can lead to tissue edema and necrosis.
There are three ways to manage the amputated phallus: surgical replantation of the amputated penis, reconstruction of the remaining stump, and total phallic replacement. If the amputated penis is viable, penile replantation should be attempted. The penis should always be reimplanted because psychotic patients are typically remorseful after self-emasculation. If a patient experiencing psychosis refuses treatment, repair should still be attempted after competency has been determined.
Because penile tissue has a remarkable resistance to prolonged ischemia, all attempts to replant the penile remnant should be carried out unless the penis has been extremely mutilated. As successful replantation has been reported after 16 hours of cold ischemia and 6 hours of warm ischemia, penile replantation may be attempted up to 24 hours or longer after the injury (9).
Viable Penis for Replantation
To perform replantation, the initial surgical step is to obtain vascular control of the proximal edge of each corpus (Fig. 72.1). Depending on the extent of the bleeding, manual compression with gauze or a Penrose drain tourniquet may be necessary. After the bleeding is controlled, the tunica albuginea of the corpora cavernosa are reapproximated with 3-0 polyglactin (Vicryl) suture including suturing of the median septum for stabilization. The central cavernosal arteries do not need anastomosis because this is both technically very difficult and does not improve outcome (10). The proximal and distal urethral edges are mobilized off the corpora and the ends spatulated. The urethra is then anastomosed over a 16Fr silicone Foley catheter in the same manner as an anastomotic urethroplasty (Fig. 72.2). A two-layer closure is usually performed with interrupted 4-0 polydioxanone or Vicryl sutures soaked in mineral oil. A suprapubic tube is typically also placed to divert urine. In this way, the penile Foley may be capped.
Once the penis is stabilized, microscopic anastomosis of the dorsal vessels and nerves is performed. First, the deep dorsal vein is anastomosed with 11-0 nylon or polypropylene (Prolene); this anastomosis must be patent to prevent glans and corporal edema. Second, one of the dorsal arteries, but preferably both, is reapproximated in the same manner as the vein. The arterial anastomosis restores blood flow to the subcutaneous tissues and helps prevent postoperative skin necrosis. Finally, the epineurium of the dorsal nerves is reapproximated with a simple 10-0 nylon or Prolene suture. The autonomic cavernous dorsal nerves do not demand repair. Reapproximation of the nerves is suggested to help preserve penile and skin sensation, however.
Depending on the state of the amputated penile skin, interrupted 4-0 chromic sutures may be used to reapproximate the skin edges. If the penile skin is unusable or extensively denuded, a nonmeshed, split-thickness skin graft is placed. Shaft skin should be preserved with minimal debridement because skin that initially appears dusky may improve during the postoperative period.
Nonsalvageable Amputated Penis
If the amputated penis is not viable or cannot be located, then the remaining penile stump is then assessed for functionality and possible reconstruction. The length of the residual penile stump will dictate the method of subsequent reconstruction. In general, we use the cutoff of 4 cm flaccid or 7.5 cm stretched length as the minimum length of penis needed to have satisfactory vaginal penetration intercourse. When the penile stump is of sufficient length, the denuded corpora are covered with a split-thickness skin graft, from the tip of the neoglans to the mobilized shaft skin and the distal urethral spatulated.
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