A microsurgical approach to post-traumatic penile amputation: Towards standardizing the technique - A case report

INTRODUCTION

Penile amputation is an unusual situation reported globally as isolated cases and small series. It constitutes a urological emergency which requires microsurgical skills for the repair of the penis. We present a case of a penile amputation and discuss the management of this challenging condition.

CASE PRESENTATION

A 47-year-old patient presented to the emergency room with total amputation of corpora cavernosa of the penis resulting from knife aggression. The patient underwent successful microsurgical replantation, demonstrating positive progression and satisfactory results.

CLINICAL DISCUSSION

Microneurovascular repair of penile amputation is the gold standard. Recommendations include a meticulous anastomosis, and a focus on vein anastomoses for optimal outcomes as well as associating a psychiatric approach. The PENIS score classifies the severity of lesion and predict postoperative complications and main outcomes.

CONCLUSION

Penile amputation presents a distinctive challenge, necessitating microsurgical anastomosis, meticulous tissue management, and adherence to established protocols are imperative for effectively managing such intricate cases. Even in cases of posttraumatic partial penile amputation after a long period, can yield satisfactory morphofunctional outcomes.

Bilateral Pedicled Scrotal Flaps as an Alternative to Skin Graft in Penile Shaft Defects Repair

OBJECTIVE

To analyze surgical and functional outcomes of bilateral pedicled scrotal flaps for penile shaft reconstruction.

MATERIALS AND METHODS

A retrospective analysis was performed on 22 patients who underwent penile shaft reconstruction with bilateral pedicled scrotal flaps between 2009 and 2017. Demographics, peri-operative data, and surgical complications were collected. Functional outcomes were analyzed using a questionnaire made of the erection hardness score, the patient and observer scar assessment scale, and a 10-point Likert scale measuring patients... satisfaction about their skin coloration, sensitivity, elasticity and thickness, penile size, scrotal volume, erection quality, penetration ability, pain, sexual satisfaction, body image, masculinity, self-esteem, and global satisfaction.

RESULTS

Patients exhibited a wide range of indications, including buried penis (27.2%), or subcutaneous injections of foreign material (27.2%). Early complications were suture dehiscence (31.8%), infection (13.6%) and hematoma (4.6%), associated with 9.1% of surgical revisions. Late complications were skin retraction (27.3%), testicular ascension (22.7%), pyramidal shape (4.6%) or shortening (13.6%) of the penis, associated with 27.3% of surgical revisions. For the 12 patients who answered the questionnaire, median erection hardness score and patient and observer scar assessment scale score [IQR] were 3.5 out of 4 [2.5-4] and 11.5 out of 60 [9.5-22], respectively. The patients reported a positive impact of the surgery on their psychological condition, with a median score of global satisfaction of 8 [IQR 7.5-9.5].

CONCLUSION

Bilateral pedicled scrotal flaps seem.ßto be a safe alternative for shaft defects reconstruction despite a potential need of surgical revision, providing satisfactory functional outcomes.

Surgical approach to penile reconstruction for shaft skin excision from circumcision

PURPOSE

Circumcision is one of the most frequently performed surgical procedures. Complications are infrequent, including bleeding, though can be significant such as shaft skin excision. The aim of this study was to identify mechanism of injury and reconstructive techniques for skin excision using a full thickness skin graft (FTSG) or with the novel application of tissue expanders (TE).

METHODS

Patients who underwent penile reconstruction following shaft skin excision from an overzealous circumcision were retrospectively reviewed. The penis was covered using a FTSG, harvested from the groin/hip, or using TE, with expanders placed in residual shaft skin.

RESULTS

Twelve patients experienced significant skin loss (range 65-95%) including 2 with partial glans loss. Ten were reconstructed using a FTSG and 2 with TE. Injury was most frequently from a Mogen clamp (n = 9), or from a Gomco clamp, Plastibell device, and electrocautery burns. Six FTSG patients experienced complications with lymphedema (n = 3) most common.

CONCLUSION

Shaft skin excision is a devastating complication with risk greatest from Mogen clamp use. TE is preferred as this avoids donor site morbidity which reassures parents but requires sufficient residual skin that can be expanded. Both techniques effectively provide soft tissue coverage with acceptable appearance and long-term function.

[Scapular flap, an alternative to the radial forearm flap in phalloplasty: Advantages and limitations]

INTRODUCTION

Antebrachial phalloplasty is considered as the standard technique in total penile reconstruction. This technique allows the creation of a phallus and a neourethra in one step at the cost of significant sequelae of the donor site. Thus, this technique has been replaced in some centers by other techniques such as the MSLD flap or the ALT flap. However, in Western populations, these techniques require the addition of a technique dedicated to the urethroplasty. The scapular flap is a technique that is not widely described in the literature and, like the antebrachial flap, allows the creation of a phallus and a urethra in one step according to the "tube within tube" technique.

AIM

The aim of the study was to detail this technique, to study its vascularization and to adapt the measurements of the flap to a western population.

PATIENTS AND METHODS

Six cadaveric dissections were performed in the laboratory. Intravascular injection of colored latex allowed easier identification of the vessels of interest and study of the subcutaneous vascular tree. Scapular flaps of variable size were raised to adapt the size to a Western population.

RESULTS

Six dissections were performed in Caucasian subjects. The scapular circumflex artery was constant and had a mean diameter of 3.5mm (3.3mm-3.8mm). The mean pedicle length was 7.3cm (6.8cm-8.1cm). The size of the flaps was adapted to the subcutaneous tissue and flaps of at least 14×16cm allowed the "tube within tube" technique to be performed.

CONCLUSION

The scapular flap has the advantage of allowing phalloplasty with urethroplasty to be performed at the same time. The pedicle is constant and of good diameter. In addition, the sequelae of the donor site are minimal. On the other hand, the pedicle used is short and the flap cannot be surgically reinnervated. Nevertheless, the restoration of a protective sensitivity allows the implantation of a penile prosthesis.

Penile reconstruction: An up-to-date review of the literature

Objective

: To review the literature on adult penile reconstruction due to Peyronie’s disease, trauma and cosmesis, while emphasising specific surgical techniques and procedures such as phalloplasty, radial forearm free flap reconstruction, and penile transplant.

Methods

: A comprehensive review of the literature for the years 1992–2020 of the PubMed and SpringerLink databases was performed to identify articles on penile reconstruction. Search terms included ‘penile reconstruction’, ‘penile trauma’, ‘phalloplasty’, ‘penile transplant’, and ‘treatment of Peyronie’s’. Relevant articles were selected. All included studies were performed on adults and written in English.

Results

: We were able to identify 46 papers from PubMed and SpringerLink that included the research terms. From these, we included technical details of procedures and gleaned photographs of their works. Additionally, we included photographs from our institution’s own plication surgery cases.

Conclusions

: The field of adult penile reconstruction is performed for a plethora of reasons. From cosmetic to urgent and from routine to complex, it is most certainly a growing subset of Urology that plays a vital role for the men who need it. To our knowledge, this is the most up-to-date review of adult penile reconstruction.

Successful surgical treatment of giant scrotal lymphedema associated with Hodgkin's lymphoma: A rare case report

Scrotal lymphedema is a rare disease, caused by obstruction of the lymphatic vessels draining into the scrotum, and may be induced by malignant lymphoma.

A 27-year-old male, who was treated for Hodgkin's lymphoma, presented with scrotal swelling for 3 years. We observed huge scrotal swelling with extension to the suprapubic region and lower right limb, a significantly thickened scrotal wall, and nonpalpable testes. The patient underwent scrotal lymphedema excision followed by surgical scrotal and penile reconstruction.

Treatment of scrotal lymphedema is challenging. However, we were satisfied with our surgical result. Our patient experienced both physical and psychological improvements.

The bilateral scrotal flap: Anatomical study and it's use for the management of inflammatory granulomas following custom-made injections

INTRODUCTION

The management of 10 cases of penile inflammatory granulomas following a subcutaneous injection of non-absorbable substance for the purpose of penile augmentation is presented. We subsequently used the bilateral scrotal flaps to cover the post-excision skin defect. A simple decision aid chart outlining the management of penile foreign body injections is proposed.

METHODS

A total of 10 patients were included in this study. All required surgical management by penile degloving, followed by complete excision of the inflammatory granuloma and overlying skin. The dissection of 14 cadavers was carried out to study the blood supply to the anterior scrotal flap. Penile reconstruction was then performed using a bilateral scrotal flap in all but two cases. Post-operatively, the patients were followed up for a 1 year period.

RESULTS

We obtained good results in terms of the aesthetic outcome with all of our ten patients with the area covered having similar color to penile skin. There were no major post-operative complications. There were two minor complications involving wound healing. Sensory function was maintained and no penile shortening or curvatures were noted, in addition all patients were satisfied with both the shape and function of the penis.

CONCLUSION

Although much rarer, penile augmentation related complications are still seen in western countries. The treating doctor should be aware of its management. We had achieved acceptable outcomes in our experience with the bilateral scrotal flap. We believe it is a good and simple option for soft tissue coverage of the penis in cases following the complete inflammatory granuloma excision. It can achieve satisfactory aesthetic and functional results for this group of patients.

Partial penile amputation due to Klingsor syndrome: A case report with a successful macroscopic reconstruction

INTRODUCTION

Traumatic penile amputation is a highly uncommon surgical emergency that requires immediate intervention. Most reported cases involve genital self-mutilation induced by underlying psychiatric disorder, especially schizophrenia. The self-mutilation of external genitals in psychiatric patients, also known as Klingsor syndrome, is a rare form of urotrauma.

PRESENTATION OF CASE

We present a case of partial penile amputation in a 46-year-old male with Klingsor syndrome admitted to the hospital 3 days after the incident. Urological examination revealed a subtotal cut of the penis, including the distal part of the mons pubis, dorsal and lateral parts of the penile skin, corpus cavernosum, and corpus spongiosum, as well as a partial bulbous urethra rupture. The penis remained suspended by only a thin ventral part of the penile skin. After macroscopic surgical replantation, the patient recovered well and could urinate without any symptoms of urethral stricture. The entire penis remained viable with minimal scarring at the surgical site, and penile erection could be achieved and maintained.

CONCLUSION

The case demonstrates a rare instance of the successful proximal penile shaft amputation via macrosurgical techniques by an experienced urologic surgeon.

Benign tumours leading to total penile denudation treated with Manuka honey dressings: A case report and review of literature

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Penile denudation can be treated either with reconstructive surgery or conservatively using Manuka honey dressings.

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Split-, full-thickness skin graft or local skin flap are surgical reconstructive possibilities regarding penile denudation.

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Methylglyoxal is responsible for the antibacterial activity in Manuka honey contrarily to other types of honey.

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Manuka honey treatment requires a minimum of medical training and be used in the out-patient clinic.

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A wide variety of wound types can benefit from Manuka honey dressings.

Introduction

Penile denudation is a devastating condition often reconstructed with a split-thickness skin graft(STSG). As this kind of reconstruction is challenging, we present an non-invasive treatment using Manuka honey dressings with a satisfying result. This was performed as a salvage procedure after failed STSG.

Case

A 55-year-old non-smoking male was admitted from his general practitioner with a newly onset of phimosis and lower urinary tract symptoms. Benign tumours complicated with infection were found on all segments of the penis causing dehiscence of the skin. After surgical removal of tumours and an unsuccessful STSG, Manuka honey dressings was used. Full sexual function was regained, and the patient was satisfied with the result.

Discussion

Alternatives to STSG are full-thickness skin graft using the inguinal or scrotal borrowing method, or using a dermal matrix before a STSG.

A rediscovered method is using Manuka honey, with its unique combination of bactericidal, anti-inflammatory and healing-promoting properties. A wide range of wound types may benefit from Manuka honey dressings.

A recent Danish in vitro study on honey derived from various Danish floras even shows high antibacterial effect superior to commercial medical grade honey. Considering a growing resistance to antibiotics, medical honey may contribute as a alternative to extensive wound care.

Conclusion

We successfully treated a penile denudation with Manuka honey following a failed STSG. Wounds, ulcers, and burns may be infected, and can be challenging, time consuming, and expensive to treat. Manuka honey may be a good alternative to reconstructive surgery and can be managed on an out-patient basis.

Penile Reconstruction and the Role of Surgery in Gender Dysphoria

Gender dysphoria is the distress that occurs when there is a mismatch between birth-assigned gender and expressed gender. Penile reconstruction may ameliorate the risk of suicide due to mental illness, social harassment, and isolation commonly experienced by these individuals. The ideal aim is to allow micturition while standing and penetrative intercourse with full sensation, but there is no universal agreement on the ideal flap design. Contemporary options for penile reconstruction include metoidioplasty and phalloplasty using either a pedicled or free flap. The most common flap currently performed is the radial artery forearm free flap. Secondary procedures following phalloplasty may include glansplasty, scrotoplasty, and insertion of penile and testicular prostheses. Patient summary: Penile reconstruction is offered to transgender men as part of their transition from female to male. Penile reconstruction may ameliorate the high risk of suicide due to mental illness, social harassment, and isolation commonly experienced by these individuals. Many techniques can be used for penile reconstruction with good outcomes, but none can fully satisfy all the needs of individuals seeking penile reconstruction.

Aphallia: A Very Rare Congenital Anomaly, With Associated Genitourinary And Ano-Rectal Malformation

Aphallia or penile agenesis is very rare congenital anomaly of unknown cause occurring 1 in 30 million live births. Very little has been written in literature about aphallia. There is absent phallus and urethra may open abnormally in perineum or into rectum posing various surgical, social and psychological implications as the child grows. We are presenting 03 cases of aphallia with associated congenital anomalies such as unilateral renal agenesis, bilateral undescended testes, anorectal malformation and rectovasical fistula.

Minimal surgical management of penile paraffinoma after subcutaneous penile paraffin injection

Objectives

To describe our reconstructive technique, without flap or graft use, after penile self-augmentation with injected substances, such as paraffin, which are still performed with unfortunate consequences.

Patient and methods

Successful single-stage minimal surgical management of an already twice unsuccessfully managed ulcerative penile paraffinoma in a 38-year-old Greek man.

Results

The patient was discharged with no postoperative complications, with a five-item version of the International Index of Erectile Function score of 23/25 (i.e. normal erectile function) and flaccid penile length of 5 cm.

Conclusions

Penile paraffinoma is a serious complication that can be successfully managed with a single-stage minimal surgical procedure, with normal aesthetic and functional results.

Scrotal dartos-fascio-myo-cutaneous flaps for penis elongation after catastrophic iatrogenic skin shaft sub-amputation: A case of recovery using an extremely adaptable flap

Introduction

Genitalia are linked to self-esteem and male sexual identity, especially among young men, who sometimes require a surgical procedure to acquire more confidence. Among the surgical procedures requested for aesthetical purposes, circumcision is one of the most popular. Although it can be considered to be a simple surgical practice, it may cause severe complications such as penile skin necrosis.

Presentation of case

We report a case of a catastrophic situation after a circumcision performed on a 27-year-old HIV positive man resulted in a drastic reduction in the length of the penile shaft due to extensive skin loss; this was subsequently restored using dartos-fascio-myo-cutaneous flaps. Primary healing occurred in 10 days. No infection, dehiscence or flap ischemia were reported. Donor site morbidity was minimal. An adequate aesthetical appearance and satisfactory functional results were obtained.

Discussion and conclusion

Various techniques are available for penile skin covering, such as skin grafts or cutaneous flaps. The skin of the scrotum seems to be the most suitable tissue to be used to reconstruct the skin covering of the shaft as it is the most similar. Dartos-fascio-myo-cutaneous flap is a single stage procedure that is easy and safe to perform. It can provide satisfactory cosmetic and functional results, offering a large amount of tissue, with minimal donor site morbidity.

Pre-fabricated radial forearm phalloplasty with cadaveric bone graft

Phalloplasty is a complex set of procedures used in efforts to improve the anatomical, physiological, and aesthetic deficiencies caused by loss or absence of the penis. Methods have evolved significantly, and the use of free tissue transfer has become common amongst reconstructive surgeons. The inclusion of bone autograft, usually radius or fibula, within the neophallus has caused significant morbidity, and efforts continue to find the optimal solution. We present a novel approach using a pre-fabricated, radial forearm fasciocutaneous free flap containing cadaveric bone graft for phalloplasty following traumatic penis amputation.

Glans amputation during routine neonatal circumcision: mechanism of injury and strategy for prevention

OBJECTIVE

Glans injury during circumcision is an uncommon yet potentially devastating complication. Its mechanism remains poorly understood. Herein we critically evaluate a case series and, based on common characteristics, hypothesize the mechanism of injury as well as means to prevent it.

METHODS

Retrospective review of circumcision-related glans amputation cases referred for evaluation and management, focusing on detection of common history and presentation patterns in order to evaluate possible underlying mechanisms.

RESULTS

A neonatal elective circumcision was conducted using a Mogen clamp and an oblique injury to the ventro-lateral aspect of the glans was noted in 6 cases referred over a 5-year period, suggesting a similar trauma pattern. The urethra was consistently involved. The amputated segments were reattached as free composite grafts in 2/6 cases. Three patients underwent delayed glansplasty months after the trauma in an attempt to restore natural symmetry and cosmesis. In one case a buccal mucosa graft was employed to rebuild the ventral coronal sulcus.

CONCLUSIONS

Trauma pattern suggests that the ventral glans is at high risk for injury by traction on incompletely released ventral preputial adhesions with subsequent glans entrapment. Practitioners performing neonatal circumcisions, particularly with a Mogen clamp, should exercise adequate release of ventral adhesions to prevent this complication.

Surgical reconstruction of penile stump in a patient with Klingsor syndrome

Self-mutilation of genitalia is an extremely rare entity, usually found in psychotic patients. Klingsor syndrome is a condition in which such an act is based upon religious delusions. The extent of genital mutilation can vary from superficial cuts to partial or total amputation of penis to total emasculation. The management of these patients is challenging. The aim of the treatment is restoration of the genital functionality. Microvascular reanastomosis of the phallus is ideal but it is often not possible due to the delay in seeking medical attention, non viability of the excised phallus or lack of surgical expertise. Hence, it is not unusual for these patients to end up with complete loss of the phallus and a perineal urethrostomy. We describe a patient with Klingsor syndrome who presented to us with near total penile amputation. The excised phallus was not viable and could not be used. The patient was managed with surgical reconstruction of the penile stump which was covered with loco-regional flaps. The case highlights that a functional penile reconstruction is possible in such patients even when microvascular reanastomosis is not feasible. This technique should be attempted before embarking upon perineal urethrostomy.