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INTRODUCTION

Self-mutilations of the external

genitals in psychiatric patients is

also known as Klingsor syndrome. (1)

These patients show a high

tendency to repeating self-aggressive

actions, especially when their

medical therapy is discontinued.(2,3)

In 1929, Ehrlich reported the first

successful penile reimplantation

of an amputated penis.(4) Although

reimplantation of the amputated

penis has a high success rate,

there may be some remaining

squeals such as skin necrosis and

urethral stricture or fistula.(5) We

report a case of a macroscopic

reimplantation of an amputated

penis.

CASE REPORT

A 30-year-old man, previously

diagnosed with

schizophrenia, came in

to the emergency room

after attempting suicide

by penile amputation

with a razor blade. The

time elapsed between

amputation and arrival

at the emergency room

was about 8 hours. The

amputated specimen

had been found by

the paramedics and

placed in a large

basin containing saline solution.

We found a clear-cut through all

penile structures without major

lacerations. The amputated penis

was carefully cleaned until all

visible contaminants and coagulated

blood had been removed. There

were diffuse bleedings from the

cavernosal bodies and an arterial

and venous bleeding from the

dorsal vessels.

Immediately a reimplantation of

the amputated penis was attempted.

We aligned the amputated part

with the stump in as natural a

position as possible (Figure 1). The

septum that separated the two

corpora cavernosa was sutured

using 3-0 vicryl catgut. Each corpus

cavernosum was anastomosed

using interrupted 3-0 vicryl catgut

sutures. The tunica albuginea was

brought together using interrupted 3-0 vicryl

catgut sutures. The deep dorsal vein of the

penis was anastomosed using 8-0 nylon sutures.

Anastomosis of the urethra together with the

corpus spongiosum was then performed using 6

interrupted sutures of 4-0 vicryl catgut. A 16-F

silicone balloon catheter was used as a splint. A

suprapubic cystosomy was done to divert urine

flow temporarily (Figure 2).

The operative time was 2 hours. Postoperatively,

the patient received broad-spectrum antibiotics

and low-molecular-weight heparin. On the 2nd

postoperative day, color Doppler ultrasonography

of the penile shaft showed low-resistance arterial

blood flow and normal venous flow distal to

anastomosis. On day 5, necrosis was observed at

the base of the penile skin, inferiorly between the

penis and the scrotum that propagated distally

to the subglandular area after 3 days. On day 9,

another color Doppler ultrasonography of the

penile shaft showed the same arterial and venous

blood flows as observed on day 2 (Figure 3). The

necrotic tissue was superficially debrided, and the

corresponding urethral segment was determined

to be intact. Two weeks later, granulation tissue

developed and a mesh-graft transplantation of

skin taken from the forearm was performed. The

Foley catheter was removed after 3 weeks, and

retrograde urethrography showed no leakage;

therefore, the cystostomy tube was clamped

and then removed. Examination 3 months later

revealed a normal-appearing penis with mild

meatal stenosis which responded to dilation.

Erectile function could not be adequately

evaluated because of the patient’s psychiatric

condition. Voiding function was normal.

DISCUSSION

The results of penile reimplantation efforts are

related to at least 2 factors: the completeness

of the amputation and the technique of

reimplantation. Complete amputations, both

experimental and clinical replanted without

specific microneurovascular anastomosis, such

as our case, all develop some degrees of skin

slough and are frequently complicated by

urethral fistulas and diverticuli(6); however, these

complications did not occur in our patient. The

possible mechanisms resulting in skin necrosis

are prolonged ischemic time, hematoma,

and inadequate circulation. In practice, the

wound edge oozing into the space between the

prepuce and tunica albuginea cannot be drained

effectively. The foreskin was gradually detached

from the shaft deep fascia. Increased pressure

resulted in skin necrosis.(7) It is agreed that

the use of microsurgical technique for penile

reimplantation can give better outcome when

compared with nonmicrosurgical technique

for penile preservation. Microscopic methods

provide better circulation in wound healing and

decrease the risk of complications.(8) However,

such techniques require special equipment,

instruments, and training which were not readily

available. Efforts have been made therefore

to develop a simple and standard technique

of management that could be performed by

any urologist.(9) The survival of the penis and

its functions depend, no doubt, on the unique

penile vascular system. It was reported that the

viability of the amputated part proved to be

surprising. Eight hours was the longest period of

time between the incident and successful surgical

repair,(9) like in our case. The final cosmetic

and functional results of the macroscopically

replanted penis were gratifying.

In patients with self-emasculation, it is sometimes

difficult to answer the question, if it was a failed

suicide or a successful male self-amputation. In

the early postoperative course, there remains

an increased risk of self-mutilation of the

replanted penis until the optimized therapy has

been prescribed. Auto-aggressive actions can

be prevented by adequate psychiatric medical

therapy.(10) Penile reimplantation using the

remaining stumps of the corpora cavernosa should

be the first line therapy in patients with traumatic

loss of the penis. It restores the functional and

cosmetic aspects of the organ. Reimplantation of

the penis must be attempted when the amputated

organ is recovered. A macrovascular technique

is recommended, as it can be performed in any

general hospital with an acceptable result.