PENILE REPLANTATION, COMPLICATION MANAGEMENT,

AND TECHNIQUE REFINEMENT

ERH-KANG CHOU, M.D.,1* YU-TZU TAI, M.D.,2 CHAO-I WU, M.D.,1 MENG-SHI LIN, M.D.,1 HSIN-HAN CHEN, M.D.,1
and SOPHIA CHIA-NING CHANG, M.D., Ph.D.1

We describe a case of complete guillotine-type penile amputation at the proximal penile shaft. The blood flow was established 10 h after
trauma. Circulation in the replanted penis was quite good but there was progressive prepuce necrosis after the hematoma. Cosmetic and
urinary outcome was good 6 weeks later. The repair of deep dorsal penile vessels helps in corpus tissue healing and glans circulation.
The blood supply from the corpus tissue is sufficient for the survival of the replanted penis even when the repaired dorsal vessels were
occluded. Surgical pitfalls in replantation procedures and complication management are discussed. V C 2008 Wiley-Liss, Inc. Microsurgery

28:153–156, 2008.

Although amputation of the penis is a rare event, it CLINICAL HISTORY

nevertheless requires the best method of repair due to the
We report a male patient with a traumatic amputation
unique urinary, sexual, and psychological role that it plays
at the base of the penis due to domestic violence. This
in the life of an individual. Penile loss is a unique prob-
43-year-old male patient sustained a guillotine-type pen-
lem to be addressed both physically and psychologically.
ile amputation during a family conflict with his wife. His
Accidental, iatrogenic, and self-inflicted penile amputa-
penis was cut from the base of the shaft and the stump
tions have been reported to occur sporadically in the past
was retracted to the pubic area (Figs. 1A and 1B). Only
three decades. In the newborn, injuries to the external gen-
proximal one-fourth of the penile shaft was left on the
italia are almost related to iatrogenic events.1 Glanular
pubic area. The amputated penis is grossly intact which
amputations happened during circumcision surgery. The
consist entire prepuce, three-fourth distal the corporal
glans could be accidentally clamped during traction of the
body, and intact glans. Good arterial inflow and back
prepuce and amputated.2 In adolescents and adult patients,
flow was established 10 h after the accident. Four super-
penile amputations were highly related to domestic vio-
ficial dorsal veins were later repaired to enhance venous
lence by the patient’s sex partner, pelvic trauma, or self-
drainage. Although the replanted penis was initially with-
mutilation injury. Regarding the best urinary function and
out problems it suffered from fluid accumulation several
sexual symbol, microsurgical penile replantation should be
hours after surgery (Fig. 2). At the end of the first week,
performed.3 The viability rate of the amputated penis was
the color, texture, and circulation of the glans did not
directly related to the ischemic time, availability of micro-
change any further, but there was continual prepuce
vascular technique, and extent of injury. Successful micro-
necrosis due to distended hematoma that compromised
surgical replantation gave the best result than any other
the cutaneous circulation (Fig. 3). The repaired deep
reconstruction procedure. When vessel diameters are too
dorsal artery and superficial veins were all thrombotic
small or no recipient vessels can be found, glanular com-
and removed with necrotic prepuce tissue. All the
posite grafting in distal penile level amputation was
necrotic prepuce was removed 2 weeks later instead of
reported as a surgical option. It was, particularly, fre-
a skin graft. The glans and corpus tissue healed well
quently seen in a pediatric group and also gave good
without blood vessel nutrients (Fig. 4). Hyperbaric
results.4 Its success was believed to be dependent on sinu-
oxygen (HBO) treatment was induced 5 days after
soidal circulation. However, composite grafts can be com-
replantation to facilitate wound healing. There was no
plicated by skin necrosis, venous congestion, urethral fis-
wound infection during the treatment. The patient experi-
tula or stricture, and loss or failure of erection.5
enced a good cosmetic result and was discharged 4 weeks
1
later (Fig. 5). No fistula or stenosis developed at the
Plastic Surgery Department, China Medical University Hospital, Taichung
City, Taiwan anastomotic site and the foley catheter was withdrawn
2
Dermatology Department, Chung-Shan Medical University Hospital, Tai- 6 weeks after trauma. The patient can void well in a
chung City, Taiwan
standing posture. Postreplantation urodynamic study was
*Correspondence to: Erh-Kang Chou, M.D., Department of Plastic Surgery,
China Medical University Hospital, No 2, Yu-Der Rd, Taichung City, 404, normal and the voiding habit was as before. After 1 year
Taiwan. E-mail: erkang27@yahoo.com.tw follow up, he has a normal-appearing circumcised penis.
Received 8 June 2007; Accepted 22 July 2007
Published online 19 February 2008 in Wiley InterScience (www.interscience.
He states that he is able to maintain erection for intromis-
wiley.com). DOI 10.1002/micr.20470 sion and also ejaculation in a climax.
V
C 2008 Wiley-Liss, Inc.
154 Chou et al.
Figure 1. A: The amputated penis was 6.5 cm in length and ana-
tomically intact. B: The stump of the penile shaft shrunk back into
the pubic cavity. [Color figure can be viewed in the online issue,
which is available at www.interscience.wiley.com.]
OPERATION TECHNIQUE
Under general anesthesia, the patient was in the
supine position and the penile amputee was preparing on
another sterile draped table. Neurovascular structures
including deep dorsal artery, superficial dorsal vein, and
dorsal sensory branch were dissected and tagged with 7-0
nylon. The dissection was moved to the stump to identify
the proximal end of dorsal vein and arteries. The pro-
fundi central arteries were ill defined and embedded in
the corpus carvernosum tissue. The urethra was approxi-
mated first in replantation procedures. It was repaired in
an end-to-end fashion after passing the 18# Fr Foley
catheter as a support. The urethral mucosa and the corpus
spongiosum were approximated and sutured with 5-0
vicryl stitches. Next, the tunica albuginea of the corpora
cavernosa was approximated in the same manner. Water-
tight suture is necessary to decrease the edge oozing after
revascularization. Vein graft of 2 cm from dorsal hand
Microsurgery DOI 10.1002/micr
Figure 2. Tissue fluid accumulated in the loose connective tissue
layer that further compromises the prepuce circulation. [Color figure
can be viewed in the online issue, which is available at www.
interscience.wiley.com.]
Figure 3. Prepuce complete ischemic necrosis 2 weeks after
replantation. [Color figure can be viewed in the online issue, which
is available at www.interscience.wiley.com.]
was harvested and interposed between the two ends of
the artery. The dorsal artery was measured 0.8 mm in di-
ameter and was repaired with 10-0 nylon stitches in an
interrupted manner. Filling blood flow into the shrunken
penis and a good back flow from the dorsal veins were
seen. The vein is bigger in diameter and was repaired in
the same manner. There were a total of four dorsal veins
repaired for better drainage. The remaining foreskin was
brought together covering the replanted vessels and
nerves. The patient was transferred to the intensive care
unit after surgery, and 5,000 units of intravenous heparin
was administered per day. The replanted penis was laid
on the dorsal scrotum in the natural mid-axis of the body
to prevent any kinking of the penile vessels. Urethral
orifice should be released from any pressure from the

Figure 4. Distal portion of corpus carvenosum and spongiosum
survived well even after all dorsal vessels were thrombotic and
removed. [Color figure can be viewed in the online issue, which is
available at www.interscience.wiley.com.]
foley catheter to prevent the pressure ulcer. The ulcer
will result in an unpredictable hypospadia problem after
healing.
DISCUSSION
The first successful microsurgical replantation of the
penis was accomplished by Tamai et al. in June 1976,6
followed by Cohen et al. in August 1976. Single dorsal
penile artery repair in penile replantation is supported in
Landstrom’s work.7 It is agreed that the use of microsur-
gical technique for penile replantation can give better
outcome when compared with nonmicrosurgical technique
for penile preservation. Still there is a disagreement
regarding the number of vessels to be repaired. Micro-
scopic methods provide better circulation in wound heal-
ing and decrease the complications including urethral
injury, fistula, and stricture.8
Landstrom et al.7 defined that the penile amputation
should be a complete transection from the body without any
attachment. In their review, the complication rate after
replantation is very high. A total of 16 penis replantations
in 28 cases suffered from complications. Fourteen of these
16 cases had prepuce skin necrosis. The possible mecha-
nisms resulting in skin necrosis are prolonged ischemic
time, hematoma, or inadequate circulation. In practice, the
wound edge oozing into the space between prepuce and tun-
ica albuginia cannot be drained effectively. The foreskin
was gradually detached from the shaft deep fascia. Increased
pressure compromised the circulation of prepuce and
resulted in skin necrosis. In the early era of penile replanta-
tion, it was even recommended that the foreskin should be
removed in the initial reconstruction procedures, because
Penile Replantation Surgery 155
Figure 5. Three months after replantation surgery and skin graft,
the patient was capable of voiding in a standing posture without
any stenosis or fistula. Erection and ejaculation during intercourse
was also possible. [Color figure can be viewed in the online issue,
which is available at www.interscience.wiley.com.]
slough of skin is almost expected because of insufficient
blood supply.9 The suggestion is not well confirmed in the
literature after microsurgical techniques are applied. With
regard to the very high complication rate of the prepuce ne-
crosis, timing of debridement and foreskin excision in part
or in whole should still be closely monitored.
We anatomize one dorsal artery and four dorsal veins
in this patient. Deep central artery was not repaired as
given by Zenn et al.10 Ishida et al. recommended the pro-
vision of venous drainage as much as possible to reduce
postoperative edema and necrosis.11 Decongestion of the
venous system may play a role in improving tissue oxy-
genation and promoting better wound healing. In our
opinion, exudation is also related to the tissue reperfusion
injury and tissue trauma that cannot be corrected surgi-
cally. The other possible mechanism of hematoma forma-
tion is the ‘‘sinusoid’’ tissue character. Ruptured corpora
cavernosa is very bloody after revascularization. Achiev-
ing a complete hemostasis is very difficult. Multiple
drainages, even, delayed primary closure should be an
option for surgeons to prevent the hematoma disaster.
On the basis of the above findings, prolonged ische-
mic time is only one factor in complication formation.
On the contrary, the glans, copora spongiosum, and
copora cavernosum were healing well during the hospital
course and even the repaired dorsal vessels were all
thrombotic. We believe the blood flow from corpus tissue
is sufficient for the long-term shaft and glans’ survival.
Deep dorsal vessels help the replanted penis pass the first
week and then the sinusoid tissue can replace its role.
The urethra healed in the same rate as the corpus tissue.
The successful rate in penile replantation seems to
increase by adding more vessels.
Microsurgery DOI 10.1002/micr
156 Chou et al.
Hyperbaric oxygen (HBO) can be used not only in
postreplantation venous congestion but in further tissue
ischemia. HBO supersaturates the plasma with oxygen
that flows in the microcirculation when red blood cells
cannot. HBO increases the activity of superoxide dismu-
tase, preserves high-energy phosphates in tissues, and
was shown to inhibit xanthine oxidase. These effects
reduce oxygen free radicals, reduce cellular gap perme-
ability, and therefore allow endothelial cells in aerobic
metabolism.12,13 From this patient, HBO seems to
enhance wound healing in corpus cavernosum via sinu-
soid circulation. The viability of the glans was main-
tained because this tissue may be regarded as a controlled
arteriovenous fistula.14 Bux et al. reported the success of
penis replantation is possible simply by soft-tissue re-
approximation under HBO treatment if arteries are not
available for microsurgical repair.15 HBO treatment was
also a valuable adjuvant procedure to control infection.16
In our case, HBO also helps to control infection, facili-
tate wound healing, and promote granulation tissue
growth over the denuted penis.
SUMMARY
The ultimate goal of penile replantation is to restore a
functional and aesthetic penis. Expedient penile recon-
struction is essential and therapeutic delay is associated
with complications. Microvascular techniques should be
used in penile amputation at any level. The replanted
penis receives blood supply from deep dorsal vessels in
the early stage and could survive independent from these
vessels after the continuity of the sinusoid was estab-
lished 1 week after surgery. Prepuce had better closed
loosely or even delay primary suture to prevent the he-
matoma that compromises the viability of the foreskin.
HBO can be a valuable adjunctive treatment modality in
such a surgery.
Microsurgery DOI 10.1002/micr
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