REIMPLANTATION OF AN AMPUTATED PENIS IN PREPUBERTAL BOYS

Abstract

Case 1. A 7-year-old boy presented to the emergency room from elsewhere 1 hour after distal penile amputation, which had occurred accidentally during circumcision. The penis had been completely severed 5 mm. proximal to the corona, transecting the urethra and the corpora, and devascularizing the distal portion (fig. 1). The amputated part had been placed in sterile ice saline solution and it accompanied the patient. Using general anesthesia the proximal stump and amputated penis were irrigated with normal saline. Under operating microscopy the deep dorsal and cavernous arteries, veins and nerve fibers were not identifiable. A tourniquet was applied around the proximal stump to gain vascular control of the proximal cavernosum during the procedure. A 8Fr Foley catheter was inserted through the urethra of the amputated part and remaining proximal urethral stump, and passed on into the bladder (fig. 1). End-to-end urethral mucosa anastomosis was formed with 6-zero polyglactin interrupted sutures over the Foley catheter. The corpus spongiosum was then repaired using interrupted 6-zero polyglactin sutures. The tunica albuginea was closed with interrupted 5-zero polyglactin to restore corporeal continuity. The fascial layer and skin were then closed with a 6-zero polyglactin suture. A mild compressive gauze dressing was placed over the distal penis to control bleeding. Parenteral broad-spectrum antibiotics were administered for antimicrobial prophylaxis. Testosterone enanthate (25 mg.) was injected on day 1 after the operation. By the end of postoperative week 1 a thin eschar was forming around the meatus on the glans penis. The Foley catheter was removed at the end of postoperative week 3. The thin eschar around the meatus gradually peeled off, leaving appropriate glans tissue and a meatus with a good cosmetic appearance at week 4 (fig. 2). Two months postoperatively penile cosmesis was excellent, glans sensation was present, and early morning erection and erectile response to touch had been reestablished. Voiding was normal. Case 2. A 12-year-old boy presented 1 hour after accidental amputation of the distal glans penis during circumcision. The excised tissue included the whole glans penis and distal urethra. Amputation had occurred at the level of the coronal sulcus dorsolaterally and the urethra was transected just proximal to the meatus. A 8Fr Foley catheter was inserted into the bladder to stabilize the amputated penis. Under operating microscopy the urethra was anastomosed with interrupted 6-zero polyglactin sutures over the catheter. The edge of the amputated glans was closed over the reattached part of the proximal penile shaft skin and fascial layer with interrupted 6-zero polyglactin sutures. A mild compressive dressing was placed on the glans penis. Testosterone enanthate (50 mg.) was injected on day 1 after the operation. The Foley catheter was removed after 2 weeks. Eschar around the meatus remained until 7 weeks postoperatively. At 3 months there was mild meatal stenosis. Early morning erection was maintained and there was an erectile response during penile manipulation. Glans sensation was present but decreased.