Pre-hormonal therapy combined with buccal mucosal graft for glans reconstruction in complete penile amputation: A case report and review of literature

Abstract

Penile amputation following circumcision is a rare but serious complication. Reconstructing the glans poses a complex surgical challenge, and several techniques have been proposed to address this issue. We present the case of a 10-year-old boy who experienced complete glans amputation 14 hours after circumcision. The initial remaining penile length was measured at 2 cm. We performed stump repair and planned for staged surgery. Buccal mucosal grafting for neo-glans reconstruction, combined with testosterone pre-hormonal therapy, proved to be a simple procedure with satisfactory results . This case provides valuable insights into the management of similar cases in the future.

Highlights

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Penile reconstruction following amputation presents a complex surgical challenge.
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Cosmetic appearance of the glans and penile length are key concerns following penile amputation.
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Buccal mucosal grafts are durable, flexible, and suitable materials for glans reconstruction.
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Pre-hormonal therapy with testosterone has successfully increased penile length in prepubertal children.
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Buccal mucosal grafts for neo-glans reconstruction, combined with testosterone pre-hormonal therapy, offer a simple procedure with satisfactory results.

1 Introduction

Circumcision remains a common practice worldwide for religious, ceremonial, aesthetic, and medical reasons, especially in Indonesia, the largest Muslim-majority country . In certain rural areas, the ritual circumcision of children is sometimes performed by uncertified paramedical personnel with limited surgical knowledge and inadequate aseptic practices, leading to complications.

Several complications following circumcision have been well-documented , including infection, hemorrhage, and meatal stenosis. Although glans penis amputation due to circumcision is rare, surgical repair options are limited in the literature . Glans injuries typically result from entrapment within circumcision clamps or the use of guillotine techniques, leading to partial or complete amputation.

The scarcity of reported cases poses challenges for surgeons performing reconstruction. The standard treatment for glans a mputation is microsurgical replantation with vascular and nerve anastomosis. However, replantation is generally not recommended if the injury occurs more than 24 hours prior to surgery. In such cases , neoglans reconstruction and penile lengthening become the focus. Techniques such as the use of gracilis muscle, scrotal flap, or rectus abdominis fascial island flap, with coverage by skin grafts, have been described .

Buccal mucosal grafts offer durable and flexible material for enhancing both the appearance and function of the reconstructed glans. Cook et al. first documented their use for recreating the coronal sulcus following traumatic penile amputation, yielding positive outcomes. ^, Other studies have described their successful application in circumcision-related injuries. ^, ^,

In this case report and literature review, we explore the use of pre-hormonal therapy for penile lengthening and buccal mucosal grafts for glans reconstruction in cases of complete penile amputation following circumcision. We also provide a detailed analysis of existing literature on these techniques.

2 Case report

We present the case of a 10-year-old boy who underwent surgical circumcision at home by a clinician from a peripheral hospital 14 hours before presenting to our facility . The patient was referred with suspected total glans amputation ( Fig. 1 a). Upon examination , the remaining penile length measured less than 2 cm. After consulting the parents and obtaining consent , we proceeded with stump repair and planned for staged surgeries ( Fig. 1 b).

One month after the initial surgery , follow-up examination revealed extended penile length, normal tissue consistency, and no palpable fibrous plaques. The parents requested cosmetic improvement and relief from urinary obstruction. Testosterone pre-hormonal therapy was initiated one month after the first surgery using intramuscular testosterone propionate injections at 2 mg/kg. After three cycles, a 1 cm increase in penile length was observed ( Fig. 1 c and d).

Six months later, we performed neoglans reconstruction using a buccal mucosal graft. Under general anesthesia, a 10-Fr Foley catheter was inserted, and the urethral meatus was dissected to prevent meatal stenosis. A circumferential incision was made around the distal penis, and the skin was degloved. The penile shaft’s raw surface measured 50 mm in diameter and 20 mm in length. A 20 mm × 50 mm segment of buccal mucosa was harvested from the left cheek, avoiding the Stensen duct . The graft was defatted, anastomosed to the urethral mucosa and penile skin using PDS 6/0 interrupted sutures, and secured with an anchor suture ( Fig. 2 ). Vaseline gauze was applied, and the dressing was maintained for 5 days.