African Journal of Urology (2017) 23, 253–257 African Journal of Urology Official journal of the Pan African Urological Surgeon’s Association web page of the journal www.ees.elsevier.com/afju www.sciencedirect.com Genito-Urinary Trauma Case report Successful penile reimplantation and systematic review of world literature J.E. Mensah , L.D. Bray ∗, E. Akpakli , M.Y. Kyei , M. Oyortey Department of Surgery and Urology, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, P.O. Box 4236, Accra, Ghana Received 20 July 2016; received in revised form 17 January 2017; accepted 22 February 2017 Available online 30 August 2017 KEYWORDS Abstract Traumatic; Introduction: There is paucity of case reports that describe successful non-microscopic penile reimplan- Penile amputation; tation. We report a case of a self-inflicted penile amputation in an apparently normal patient with first Reimplantation; psychotic break. Psychiatric illness; Observation: To report on a case of successful macrosurgical penile reimplantation, discuss the etiologies, Penile transplantation surgical techniques and outcomes of world literature on penile reimplantation and an update of current trends in penile surgery. A 40 year-old male, father of 3 children and a proprietor of a nursery school with no prior pschiatric disorder was rushed to our trauma centre following a self-inflicted total penile amputation at its base with incomplete laceration of the scrotum due to command hallucination. He was immediately resuscitated and underwent a non-microscopic penile reimplantation and scrotal closure by an experienced urologist (JEM) by reattaching the dorsal vein, urethra, corporal, fascial and skin layers. A functional outcome with respect to voiding, penile erection and cosmesis was excellent. Conclusion: Self-inflicted penile amputation may manifest as first psychotic break in apparently normal sub- jects. Though microscopic neurovascular reconstruction is the gold standard, macrosurgical reimplantation of penis by an experienced surgeon in the absence of a microscope yields satisfactory results. © 2017 Pan African Urological Surgeons Association. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).I ∗ Corresponding author. M E-mail address: atobray@yahoo.com (L.D. Bray). t Peer review under e responsibility of Pan African Urological Surgeons’ Association. a http://dx.doi.org/10.1016/j.afju.2017.02.003 1110-5704/© 2017 Pan African Urological Surgeons Association. Production a BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).ntroductionales are prone to have external genitalia injuries more frequently han female because males are more exposed to violence or extreme xercise [1]. External male genitalia injuries can be categorized s accidental i.e during circumcision, zipper injury or penile frac- nd hosting by Elsevier B.V. This is an open access article under the CC 254 J.E. Mensah et al. Tuni t T a i a f p i m ( d i W a a p t b l m u w c a u a E n p o s c o T s W n a a l o w p w C H e A s t D o d P b s d r t p t u b h o c b c p p 1 i p f Figures 1–3 (1) ER-Amputated penis. (2) ure or as traumatic in origin i.e motor vehicular accident (MVA), nimal bite, gunshots, penetrating injury, strangulation injury, self- mpulation, criminal, assault injury [2]. Self-emasculation of the enis may be as a result of Klingsor syndrome (disease of self- utilation by a psychiatric patient, often suffering from religious elusions). About 87% of penile amputations are due to an underly- ng psychiatric disorder [3,4]. Self-mutilation is a way of expressing nd dealing with deep distress, anger, dissociation, and emotional ain in order to have self-purification [5]. However, self-purification y self-mutilation does not last very long [5]. Also self-mutilation ay present an individual’s first psychotic break. Historically, there as an epidemic of penile amputation by Thai women in the decade fter 1970s [6]. xternal male genital injury by self-mutilation involves injury to the enis, the scrotum and the testicles. The type of injury varies from imple skin laceration to total amputation of the penis and laceration f scrotum and or testis as occurred in our patient. e, therein, report a case of a self-inflicted penile amputation in an pparently normal patient who had first psychotic break and review iterature on penile amputation. ase report 40 year old man, father of 3 children and a proprietor of a nursery chool with no prior medical history was rushed to our trauma cen- re following a self-inflicted penile amputation and partial laceration f his scrotum due to command hallucination from first psychotic epression. Further interrogation revealed he had been summoned y Metropolitan Authority to close down his nursery school or face emolition of his infrastructure due to unlawful citing. The directive riggered a reactive psychotic depression with command hallucina- ion resulting in dismemberment of his penis at its base with a razor lade. He was discovered 6 h later in his washroom lying in a pool f blood. He was in haemorrhagic shock on arrival at the ER with lood pressure of 98/66 mm Hg, weak and thready pulse of 121 beats er minute. His haemoglobin level was 6.5 g/dl (reference range 1–18 g/dl). He was immediately resuscitated with intravenous flu- w ds and haemotransfused with 2 units of whole blood and tetanus rophylaxis given. He was subsequently counseled and consented T or macroscopic penile reimplantation. ica albuginea closure. (3) Reimplanted penis. he surgery was done under general anaesthesia. Prophylactic ntravenous third generation cephalosporin antibiotic was given. A ormal cystostomy was done to divert the urine with a 16Fr sil- con catheter followed by meticulous reimplantation of the penis Fig. 1). e placed interrupted 3–0 monocryl sutures through the tunica lbuginea of the corporal bodies on the ventral aspect and snapped hem for future tying (Figs. 1 and 2). Next, we freshened and spatu- ated the urethra and attached it in a tension-free 360-degree fashion sing interrupted 4–0 monocryl sutures over a 20Fr silicon urethra atheter. The corporal bodies were then closed in interrupted fashion sing 3–0 monocryl sutures. Careful reapproximation of the tunica lbuginea near the vessels on the dorsal aspect was done in order ot to compromise the blood supply. Tension-free approximation f the dorsal vein then followed. Reimplantation was completed by losing the corporal bodies, fascial layers and skin (Figs. 1 and 3). he wound was then covered with povidone-soaked gauze and the crotum elevated. His would was complicated by partial dorsal skin ecrosis which healed with continuous wound dressings. Whilst on dmission, he was referred and reviewed by the psychiatrist and put n oral olanzapine 10 mg nocte and oral fluoxetine 20me nocte. He as discharged home on postoperative day 20 after clearance the by sychiatrist to continue treatment on outpatient basis. He is happy ith the penile cosmesis (Figs. 2 and 4 ) though regrets his action. e has since been voiding well (peak flow = 21 ml/s) and has mild rection dysfunction (IIEF-5 = 17). iscussion enile amputation is a urological emergency which requires urgent urgical intervention because the associated hemorrhage can be tor- ential and life threatening as occurred in our patient due of the rich enile vasculature (Figs. 2 and 5). Different weapons have been tilized in penile amputation cases, which range from sharp blades, eavy machinery to projectile objects [7]. Razor blades was the most ommon weapon used, as occurred in our case and other reported ases [7–17]. Earlier case reports of self -penile mutilation were ublished in the mid 1800s and successful penile reimplantation as reported in 1926 [18]. here is no consensus on the classification of external genitalia njuries because of the diverse nature of injury mechanism. Rashid Successful penile reimplantation and systematic review of world literature 255 gram T p f a d t E T i i I n o e h p b s t h g C i i o D p M o c o a i r Figures 4 and 5 (4) Four-months after penile reconstruction. (5) Dia et al. reported the classification of male genitalia injury by anatom- ical location [19]. Type I injury includes distal portion of the penis with proximal part of the penis being preserved. Type II injury includes severe injury on shaft of penis with penile crus being preserved. Type III injury includes the injury when urethral catheter- ization is necessary with external urethral part being preserved. Type IV injury, as in our case include injuries that requires a suprapu- bic cystostomy [19]. This classification, however, could not reflect injury mechanism by penetrating or strangulation. Penile amputation requires immediate surgical intervention without elaborate investigations due to the accompanying blood loss. How- ever, flexible urethroscopy may be necessary in certain cases for evaluation of the proximal urethra and bladder integrity to rule out associated injuries. Doppler studies or penile plethysmography may also be done after reimplantation to assess penile blood flow and erectile function. A systematic review of the literature revealed approximately 80 cases reported worldwide of penile self-amputation from 1966 to 2007, with at least 30 successful penile reimplantation [20,21]. The weapon utilised, underlying reason, ischemia time, operative measures undertaken, and postoperative complications and erectile dysfunction of various traumatic penile amputation case reports pub- lished in the literature are compared with our case report in Table 1. Exclusion criteria were non-English publication, those in which re- implantation was not attempted or not done and those for which operative details and complication were not stated. One limitation of published case in literature is the lack of objective assessment of the postoperative voiding and erectile dysfunction. Riyach et al. published their successful macrosurgial reimplantation of an amputated penis by approximation of only the corporal bodies and urethra without any attempt at neurovascular bundle reconstruc- tion and yet reported excellent voiding and erection. They, therefore, concluded that the corpus spongiosum may have a role in arterial supply, venous drainage and penile erection [8]. In our case, we repaired only the dorsal vein, urethra and corporal bodies due to lack of a microscope and yet had satisfactory results. We are, there- p fore, convised that the corporal bodies may serve as a conduit for t penile blood flow. of a cross section of the penis (source-google image). o date, there are no specific guidelines for the treatment of severe enile injury because the injury mechanism is complex and multi- aceted. However, the primary goal for the surgeon managing penile mputation is to achieve normal-like appearance, reduce functional amage such as erectile dysfunction and sensory loss, and minimise he postoperative sequelae. arly reimplantation of the amputated phallus is the gold standard. he amputated penis should be transported to the hospital wrapped n saline-moistened gauze and placed in a sealed plastic bag which s stored in ice slush “bag in bag”. f reimplantation fails or not possible due to penile loss, then a eophallus can be constructed by harvesting a graft or flap. A variety f local skin flaps can be used for penile skin cover but anterolat- ral thigh flap and radial forearm flap are in vogue. These flaps, owever, lack stiffness and will eventually need revision with a rosthetic devices for persistent erectile dysfunction. Many authors elieve that the best cosmetic results are obtained with the use of kin grafts. In particular, full-thickness skin grafts (FTSG) guaran- ee superior results to their split thickness counterpart since they eal with less contracture and therefore, preserve the physiological irth and length expansion during erection [22]. losure of the penile stump and suprapubic urine diversion or per- neal urethrostomy is an option if reimplantation or phalloplasty is mpossible. Delayed phalloplasty or penile transplantion could be ffered later. istal penile injuries tend to be more technically difficult articularly with vascular anastomosis due to smaller vessels. icrosurgical revascularization of the distal penis has the best utcomes and therefore recommended. If meticulous microvas- ular repair is not feasible, penile and erectile tissues ischemia ften develop and penile fibrosis ultimately sets in and eventu- lly contributes to severe erectile dysfunction [20]. The consensus n contemporary literature clearly acknowledges that microsurgical evascularization and approximation of the penile shaft structures rovide early and adequate restoration of penile blood flow with he best outcome of penile reimplant survival, erectile and voiding 256 J.E. Mensah et al. Table 2 Outcomes between macro and microsurgical repair Outcomes Macrosurgical Microsurgical repair repair Penile blood flow Satisfactory Excellent Erectile function Adequate Satisfactory Voiding function Satisfactory Satisfactory Cosmesis Satisfactory Satisfactory Penile sensation Decreased Satisfactory f r R n p a p i t M c a a p n t C P f g r f d i I I C N A T c R Table 1 A comparison of our case with a list of English publication of penile amputation. Author Weapon used Reason Sample size Ischemia Suprapubic Urethral Corpora Use of Sequelae Erectile function time (h) diversion anastomosis closure loupe (IIEF)/penile (primary/staged) sensation Raheem et al. [7] Blade Substance-induced 1 >6 h Yes Primary interrupted Yes Yes Acute kidney injury Partial Riyach et al. [8] Blade Criminal assault 1 6 h NS Primary interrupted NS No Partial skin necrosis Decrease penile sensation Leyngold and Blade Psychiatric disorder 1 12 h Yes Primary,inferior Yes Yes Partial skin necrosis NS Rivera-Servano [9] epegastic bypass El Harrach et al. [10] Blade Psychiatric disorder 1 5 h Yes Primary interrupted Yes No NS Erectile dysfunction Li et al. [11] Blade NA 109 6 h NS Primary interrupted Yes NA Partial skin necrosis, NS fistula formation Roche et al. [12] Blade Psychiatric disorder 1 6 h Yes Primary interrupted Yes Yes Partial skin necrosis NS Tazi et al. [13] Blade Traumatic amputation 1 4 h NS Primary interrupted Yes Yes NS NS Salem and Mostafa Blade Traumatic amputation 1 2 h NS Primary continuous Yes Yes Skin necrosis NS [14] Chon et al. [15] Blade Traumatic amputation 1 10 h NS Staged Yes Yes Skin necrosis NS Landström et al. [16] Blade Psychiatric disorder 1 9 h NS Primary interrutped Yes Yes Skin necrosis Spontaneous erection Darewkz et al. [17] Blade Psychiatric disorder 1 10 h NS Primary Yes Yes Skin necrosis NS NA—not applicable, NS—not stated.Penile skin necrosis High Low Fistula formation High Low unctions [20,23,24]. Outcomes between macro and micro surgical epair is shown in Table 2. ecent advances in penile transplantation also called genitouri- ary vascularized composite allograft (GUVCA) transplant is a romising novelty. Though we should be cautiously optimistic bout the success of penile transplantation, it expands our com- endium of surgical armamentarium. Immunosuppression, donor ssues, recipient’s and or spouse pscychological problems are impor- ant challenges to address. easures of assessment of successful penile reimplantation out- omes are variable and limiting due to the variability in the factors ffecting successful penile re-implantation, availability of resources nd skills, and also differences in the interpretation of success by atient or physician. Most common complications reported are skin ecrosis, decreased penile skin sensation, erectile dysfunction, ure- hral stricture and fistula formation. onclusion enile amputation is a rare and devastating injury caused by multi- aceted factors. Though microscopic neurovascular reconstruction is old standard, non-microscopic surgical reimplantation by an expe- ienced surgeon in a poor-resource setting yields satisfactory results or proximal penile amputation. With current increase in transgen- er surgeries, outcomes in phalloplasty for unsalvageable penis will mprove. nformed consent nformed consent obtained from patient onflict of interest one declared. cknowledgement he authors would like to thank the patient for his consent and o-operation for this publication. eferences [1] Djakovic NPE, Martinez-Pineiro L, Lynch T, Mor Y, Santucci R. Guide- lines on urological trauma. EAU Guidelines; 2009. [2] Perovic SV, Djinovic RP, Bumbasirevic MZ, Santucci RA, Djordjevic ML, Kourbatov D. Severe penile injuries: a problem of severity and reconstruction. BJU Int 2009;104(5):676–87. eratu [ [ [ [ [ [ [ [ [ [ [ [ [ Successful penile reimplantation and systematic review of world lit [3] Babaei AR, Safarinejad MR. Penile replantation, science or myth? A systematic review. Urol J 2007;4(2):62–5. [4] Volkmer B, Maier S. Successful penile replantation following autoam- putation: twice! Int J Impot Res 2002;14(3):197–8. [5] Klonsky D. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev 2007;27(2):226–39. [6] Bechtel Gregory, Tiller Cecilia. Factors associated with penile ampu- tation in Thailand. J Nurs Connect 1998;11(2):46–51. [7] Raheem OA, Mirheydar HS, Patel ND, Patel SH, Suliman A, Buckley JC. Surgical management of traumatic penile amputation: a case report and review of the world literature. Sex Med 2015;3:49–53. [8] Riyach O, El Majdoub A, Tazi MF, El Ammari JE, El Fassi MJ, Khal- louk A, et al. Successful replantation of an amputated penis: a case report and review of the literature. J Med Case Rep 2014;8:125. [9] Leyngold MM, Rivera-Serrano CM. Microvascular penile replanta- tion utilizing the deep inferior epigastric vessels. J Reconstr Microsurg 2014;30:581–4. 10] El Hares Y, Abaka N, Ghoundale O, Touiti D. Genital self-amputation or the Klingsor syndrome: successful non microsurgical penile replan- tation. Urol Ann 2013;5:305–8. 11] Li GZ, Man LB, He F, Huang GL. Replantation of amputated penis in Chinese men: a meta-analysis. Zhonghua Nan Ke Xue 2013;19:722–6. 12] Roche NA, Vermeulen BT, Blondeel PN, Stillaert FB. Technical rec- ommendations for penile replantation based on lessons learned from penile reconstruction. J Reconstr Microsurg 2012;28:247–50. [ 13] Tazi MF, Ahallal Y, Khallouk A, Elfassi MJ, Farih MH. Spectacularly successful microsurgical penile replantation in an assaulted patient: one case report. Case Rep Urol 2011:865489. [re 257 14] Salem HK, Mostafa T. Primary anastomosis of the traumatically ampu- tated penis. Andrologia 2009;41:264–7. 15] Chou EK, Tai YT, Wu CI, Lin MS, Chen HH, Chang SC. Penile replantation, complication management, and technique refinement. Microsurgery 2008;28:153–6. 16] Landström JT, Schuyler RW, Macris GP. Microsurgical penile replan- tation facilitated by postoperative HBO treatment. Microsurgery 2004;24:49–55. 17] Darewicz J, Gałek L, Malczyk E, Darewicz B, Rogowski K, Kudelski J. Microsurgical replantation of the amputated penisand scrotum in a 29-year-old man. Urol Int 1996;57:197–8. 18] Salehipour M, Ariafar A. Successful replantation of amputated penile shaft following industrial injury. Int J Occup Environ Med 2010;1:198–200. 19] Rashid M, Sarwar S. Avulsion injuries of the male external genitalia: classification and reconstruction with the customised radial forearm free flap. Br J Plast Surg 2005;58(5):585–92. 20] Jezior JR, Brady JD, Schlossberg SM. Management of penile amputa- tion injuries. World J Surg 2001;25:1602–9. 21] Selby EA, Bender TW, Gordon KH, Nock MK, Joiner Jr TE. Non- suicidal self-injury (NSSI) disorder: a preliminary study. Pers Disord 2012;3:167–75. 22] Garaffa G, Christopher AN, Ralph DJ. The management of genital lymphoedema. BJU Int 2008;102(4):480–4. 23] Roche NA, Vermeulen BT, Blondeel PN, Stillaert FB. Technical rec- ommendations for penile replantation based on lessons learned from penile reconstruction. J Reconstr Microsurg 2012;28:247–50. 24] Biswas G. Technical considerations and outcomes in penilereplanta- tion. Semin Plast Surg 2013;27:205–10.