Successful Replantation of Amputated Penis with Adjuvant Hyperbaric Oxygen Therapy

ABSTRACT

Successful penile replantations are rarely reported in the literature and are associated with significant complications. We present a case of a patient who auto-amputated his penis. Delayed microvascular replantation was performed approximately 14 hours following injury. He was treated with a phosphodiesterase inhibitor postoperatively, and adjuvant hyperbaric oxygen (HBO2) therapy was started 58 hours after replantation; 20 treatments at 2.4 atmospheres absolute (ATA), twice daily for eight days, followed by once daily for four days. Perfusion of the replanted penis was serially assessed using fluorescent angiography. With some additional surgical procedures including a split- thickness skin graft to the shaft due to skin necrosis he has made a complete recovery with return of normal urinary and sexual function. This unusual case illustrates the potential benefit of HBO2 therapy in preserving viability of a severed body part. Fluorescent angiography may have potential utility in monitoring efficacy of HBO2.

INTRODUCTION

Penile amputation is a rare genitourinary tract injury. The majority of cases are the result of self-mutilation in psychiatric patients [1-3]. Though rare, successful replantation of penile amputations has been reported in the literature with and without using microvascular techniques and adjuvant treatments, but are associated with significant complications. A standardized therapeutic approach for penile replantation does not exist. Hyperbaric oxygen therapy (HBO2) is an approved adjuvant treatment for individuals with compromised grafts and flaps and has been advocated for patients with decreased blood flow due to inadequate inflow and/or outflow.

CASE REPORT

The patient is a 22-year-old man with a history of depression and self-injury who auto-amputated his penis 2 cm from the base of the shaft using a knife. He was found by first responders approximately three hours after injury. The severed penis was located, placed in a clean plastic bag containing saline-soaked gauze and immersed in ice for transport with the patient to the hospital. The scrotum and testicles were intact. There was an adherent hematoma covering the penile stump without active bleeding. Replantation was performed approximately 14 hours following injury. Direct primary reanastomosis of the corpora and urethra were performed first with insertion of 14-French Foley catheter across the anastomosis. Microvascular anastomosis was then done, with repair of two large-caliber deep dorsal veins using grafts harvested from the right forearm and coaptation of three dorsal nerves. There were no identifiable arteries that
could be anastomosed.

Buck's fascia was repaired and primary skin closure was performed with placement of Penrose drains. Intraoperative transcutaneous Doppler studies signals were found over the repaired veins. Fluorescent angiography (indocyanine green) was also performed postoperatively using the SPY imaging system (Novadaq® Technologies Inc.) and showed no perfusion of the penis (Figure 1). However, there was active bleeding from the skin margins and oozing from the dorsal veins throughout the procedure. Active bleeding was also noted from the glans at the completion of surgery without evidence of venous congestion.

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Dr. Jeffrey Stone, DO, MPH, FCCWS, specializing in Wound Care and Hyperbaric Medicine, serves as Medical and Fellowship Director for the Hyperbaric Medicine Unit at the Institute for Exercise & Environmental Medicine at Texas Health Dallas. Dr. Stone received his medical degree from Western States University and received a Master of Public Health degree from Harvard University. Dr. Stone completed a residency in aerospace medicine at Brooks Air Force Base and a fellowship in hyperbaric medicine and Wound care at the U.S. Air Force School of Aerospace Medicine. He is one of the first 60 physicians in the U.S. to receive his certification in Wound Care. Dr. Stone currently provides care to patients in acute care, LTAC, long term care facilities SNF and Nursing Home) and outpatient care.

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