The mean (range) follow-up was 47 (10 108) months. The aesthetic and functional results, including satisfactory

Transcription

1 . JOURNL OMPILTION 2009 JU INTERNTIONL Reconstructive and Paediatric Urology SEVERE PENILE INJURIES PEROVI et al. JUI JU INTERNTIONL Severe penile injuries: a problem of severity and reconstruction Sava V. Perovic, Rados P. jinovic*, Marko Z. umbasirevic*, Richard. Santucci, Miroslav L. jordjevic* and mitry Kourbatov Serbian cademy of Sciences and rts, *School of Medicine, University of elgrade, elgrade, Serbia, Wayne State University School of Medicine, etroit, MI, US, and Federal State Endocrinological Research entre, Moscow, Russia ccepted for publication 23 October 2008 Study Type Therapy (case series) Level of Evidence 4 OJETIVES To report our experience of treating severe penile injuries with different causes and treatments, as penile trauma presents a difficult physical and psychological problem, and the type and extent of injury varies from mild to severe, sometimes even with total amputation. PTIENTS N METHOS We analysed retrospectively 43 patients (mean age 28 years, range 5 52 years) with severe penile injuries referred to us from March 1999 to ugust The causes of penile injuries differed, including iatrogenic trauma (20), traffic accidents (11), burns (three), self-amputation (two), ritual circumcision (two), penile fracture (two), gunshot trauma (two) and electrocution (one). The management required a wide variety of surgical techniques tailored to each patient depending on the type and extent of injury. RESULTS The mean (range) follow-up was 47 (10 108) months. The aesthetic and functional results, including satisfactory sexual intercourse were good in 35 patients. There were complications in seven patients; infection after implanting an inflatable penile prosthesis in one, protrusion of a semirigid prosthesis in one, urethral complications (one stenosis and two fistulae) in three and partial skin flap necrosis in two. ONLUSIONS Severe penile injuries should be treated on an individual basis, applying different techniques. However, treatment can be effective and safe only in specialized centres. KEYWORS penis, trauma, reconstructive surgery INTROUTION Penile trauma presents a difficult physical and psychological problem and is rare, because the penis is a mobile organ enveloped into loose skin, well protected by its position; however, the penis is more prone to trauma during sexual intercourse while rigidly erect. The causes of penile trauma are varied; it can be iatrogenic or caused by traffic accidents, burns, ritual circumcision, animal bites, gunshots or self-mutilation. The type and extent of penile trauma varies from mild to severe injuries, sometimes even with total amputation. Reports of trauma to the external genitalia are sporadic. We present our experience in the surgical treatment of severe penile trauma with examples of unusual cases in aetiology and/or mode of treatment. hallenging and demanding problems are the key features of our presentation, illustrating difficulties in the management of complex penile trauma that urologists uncommonly face, as well as practical tips and tricks that surgeons can apply in their practice. PTIENTS N METHOS We analysed retrospectively 43 patients (mean age 28 years, range 5 52) treated for penile injury by one surgeon from March 1999 to ugust ll the patients were referred to our centre from Serbia or other countries 2 months to 4 years after injury. We identified two typical groups for referral; the first comprised patients already treated by one or more urological surgeons but wanting a second opinion and treatment; and the second patients who had undergone prolonged treatments by several specialists (plastic surgeons, general surgeons, reconstructive urologists) and desperately seeking help due to poor quality of life. ll the patients were assessed before surgery (physical examination, erectile function tests, colour oppler ultrasonography, uroflowmetry, urethrography, MRI) to obtain an exact diagnosis where possible. The site, type and extent of injury were precisely identified during surgery in most patients. The causes of penile trauma are shown in Table 1. auses of penile trauma differed, with most caused by iatrogenic injury or a traffic accident. mong these, some cases were particularly unusual; two patients had 676 JOURNL OMPILTION 2009 JU INTERNTIONL 104, doi: /j x x

2 SEVERE PENILE INJURIES TLE 1 The causes of penile injuries ause No. of patients Traffic accident 3 lunt trauma Laceration 8 urns Thermal 3 Electrical 1 Gunshot 2 Iatrogenic 20 Self-amputation 2 Penile fracture 2 Ritual circumcision 2 Total 43 FIG. 1., Penetrating penile injury caused by burns after a traffic accident in 22-year-old patient. omplex penile deformities in erect state are noticeable., fter degloving the injury of the urethra and left corporal body were revealed., The outcome immediately, and, at 1 year after surgery. thermal trauma due to a contact with an vehicle exhaust pipe during a vehicle accident (Figs 1 and 2) and one boy had penile amputation caused by electrocution during voiding over a high-voltage electric-current wire (Fig. 3). He also had amputation of three fingers of the left hand while holding the penis during voiding. Iatrogenic injuries can be severe and devastating for a patient. For example, an adolescent who had an isolated congenital ventral penile curvature repaired had lost the pendular part of the corporal bodies, urethra and glans (except for most of the penile skin), probably due to vascular injury and subsequent necrosis and infection (Fig. 4). In addition, a man who had a grafting procedure to repair Peyronie s disease sustained injury of the cavernous bodies, neurovascular bundle, urethra and glans (Fig. 5). ll the patients required complex reconstructive surgery. lthough most patients (36 of 43) had combined injuries of two or more penile entities, we considered an analysis according to the injured anatomical parts as more appropriate, as this, together with remaining healthy tissue, mostly influence the choice of surgical treatment (Table 2). The principle that we used in reconstructing lost penile skin involved mobilization and redistribution of the remaining healthy penile skin by creating peninsular or island flaps whenever possible (Figs 1 and 2 F). In cases where penile skin was insufficient to cover the penile shaft when erect or stretched, the second choice was the use of different scrotal skin flaps with an axial blood supply, even in cases where the scrotum was relatively small. The scrotal skin was widely mobilized, thinned and fully released from the septum and testicles to enable the creation of flaps with an axial blood supply based on external pudendal vessels, large enough to replace all missing penile skin. The size and type of flaps were created according to the defect of the penile skin in the stretched/erect state. dditional tucks were used to fix the scrotal flaps to the albuginea, especially at the penile base, to ensure good skin distribution onto the penile shaft and formation of penoscrotal and penopubic angles (Fig. 6 E). The scrotum was reconstructed using its remaining skin, with fixation of the testicles to the lowest position. ompressive elastic dressings were applied for at 1 month to prevent oedema and ensure good attachment of the scrotal skin to the penile shaft. JOURNL OMPILTION 2009 JU INTERNTIONL 677

3 PEROVI ET L. FIG. 2., 41-year-old man with a complex penile injury caused by burning during traffic accident., urned dorsal penile skin, corporeal bodies and glans, the appearance in the flaccid and erect state., The distal third of the left cavernous body was missing, while the other one was fibrotic. The neurovascular bundle was destroyed., The tips of the remaining cavernosa are joined. E, The appearance after penile skin reconstruction. F, The outcome 1 year later. E F However, one patient with extensive burns had completely destroyed penile skin, as well as damaged and scarred scrotal and the surrounding skin; we decided to use an anteromedial fasciocutaneous thigh flap to cover the penile shaft in a multistage procedure (Fig. 7 ). In a patient with complete avulsion of the penile and partly of scrotal skin, we used a full-thickness skin graft for penile shaft coverage. Reconstruction of the corporal bodies depended on the extent of injury and their remaining length. Incisional corporoplasty was used only in the adequate remaining penile length, while in all other cases grafting was the treatment of choice. Physiotherapy after surgery, using stretchers and a vacuum device, was advised for all patients who had corporal grafting, to avoid graft contracture. In one particular patient with a missing distal third of one cavernosal body, reconstruction was done by joining the other corporal tip with the remaining corpora, which resulted in mild penile shortening, but preserved erectile function (Fig. 2 F). In a 19-year-old man who had complete loss of the cavernous bodies and glans due to iatrogenic injury, but had mostly preserved penile skin, we succeeded in reconstructing the penis from the skin and implanting a penile prosthesis, enveloped into the vascular graft under it (Fig. 4 E). The urethra was reconstructed in several ways: anastomotic repair, ventral or dorsal augmented anastomotic repair, one- or twostage buccal mucosal grafting and extensive mobilization, with advancement of the healthy urethra (Figs 5 and 8 ). Suprapubic urinary drainage was used in all patients with a urethral reconstruction. The urethra was stented with a small-calibre catheter (10 12 F) to enable drainage of urethral secretions and sperm evacuation in young patients during nocturnal ejaculation. s semen is the main reason for infection, we advised all patients to void once outside the stent after any nocturnal ejaculation, to clean the urethra. partially lost glans was reconstructed by re-sculpturing, while total glanular reconstruction was done using a fullthickness skin graft, distal urethral or inner preputial skin flap over the tips of the cavernous bodies (Fig. 9 ). In patients with amputation, when the penile remnant had a satisfactory length, radical corporal advancement was used, while in other cases total phalloplasty was necessary. We used a musculocutaneous latissimus dorsi flap and radial forearm flap phalloplasty (Fig. 10 ). Urethroplasty, using a two-stage buccal mucosa graft and implantation of inflatable penile prostheses with tips and bottoms enveloped into vascular graft socks, was done in separate stages. 678 JOURNL OMPILTION 2009 JU INTERNTIONL

4 SEVERE PENILE INJURIES FIG. 3., 15-year-old boy: amputation of the penis and three fingers of the left hand caused by an electrical burn during voiding on high-voltage electrical wire., Total phalloplasty using radial forearm flap was performed with two-stage buccal mucosa graft urethroplasty and simultaneous semirigid prosthesis implantation; the neourethra is covered by a scrotal skin flap., t 6 months later, an inflatable prosthesis was implanted., The final outcome after 2 years. RESULTS The mean (range) follow-up was 47 (10 108) months; the results were assessed according to the treated entity/entities, and overall functional (voiding, erection) and aesthetic outcome. The result was good in 33 of 35 patients with penile skin injury where we reconstructed the penis by redistributing the remaining penile skin and by scrotal flaps; the remaining two developed partial flap necrosis, which was successfully treated conservatively. espite complete survival of a full-thickness skin graft that we used in one patient, the long-term result was inferior to penile and scrotal flaps. Good urethral patency was re-established in 10 of 13 patients with different injuries, while two developed stenosis and one a fistula, successfully treated by additional urethroplasty. ll patients with partial or total glans loss were treated successfully and with satisfactory aesthetic results; however, neoglans sensitivity was superior in a patient treated with an inner preputial layer flap than in those with resurfacing with a full-thickness skin graft. orporoplasty with penile straightening was successful in all patients treated either with grafting or the plication technique. In three JOURNL OMPILTION 2009 JU INTERNTIONL 679

5 PEROVI ET L. FIG. 4., Iatrogenic penile injury; corpora, urethra, glans and part of the penile skin are missing after repair of congenital curvature in a 19- year-old., semirigid prostheses was implanted into the corporeal crura and covered with remaining penile skin., Two-stage buccal mucosa graft urethroplasty., The neourethra is covered with a scrotal skin flap. E, satisfactory outcome 1 year after implantation of a three-component penile prosthesis. E 680 JOURNL OMPILTION 2009 JU INTERNTIONL

6 SEVERE PENILE INJURIES FIG. 5., failed repair of Peyronie s plaque, with destroyed distal urethra, hypotrophic glans and deformed penile skin., Extensive urethral mobilization;, and its advancement to the coronal level., Satisfactory outcome 1 year later after a small additional aesthetic correction. of four patients with cavernous fibrosis where a penile prosthesis was implanted, the outcome was successful, except in one who developed infection. He was treated by removing the implant and delayed reimplantation of a new prosthesis (salvage procedure). In only one patient with penile amputation have we succeeded in achieving an acceptable penile length for sexual intercourse, by ligamentolysis, pubic liposuction and penile skin redistribution, while in all others total phalloplasty was necessary. musculocutaneous latissimus dorsi flap gave better result for penile size, ability to perform urethroplasty and prosthesis implantation, but the sensitivity was lower than when using a radial forearm flap. One patient with a neophallus had protrusion of a semirigid prosthesis, which was later replaced with an inflatable implant. The overall aesthetic and functional results, including satisfactory sexual intercourse, and patient satisfaction, are shown in Table 3. omplications occurred in seven patients; five were treated by additional surgery while two with partial skin flap necrosis were treated conservatively (Table 4). JOURNL OMPILTION 2009 JU INTERNTIONL 681

7 PEROVI ET L. TLE 2 Treatment according to the involved penile entity, type and extent of injury Involved penile entity Type/extent of injury Mode of treatment N patients Penile skin Partial skin loss Penile skin redistribution 19 Scrotal flap/s 11 Total skin loss Scrotal flaps 3 ssociated scrotal skin loss nteromedial thigh flap 1 Full thickness skin graft 1 Total 35 Urethral Stenosis nastomotic repair 2 uccal mucosa urethroplasty 5 Penile skin flap 1 Obstruction nastomotic repair 1 ugmented anastomotic repair 1 Fistula Fistulorrhaphy 2 Urethral loss Two-stage buccal mucosa urethroplasty 1 Total 13 Glans Partial loss Full-thickness skin graft 2 Total loss Full-thickness skin graft 2 Inner preputial layer skin flap 1 Total 5 avernosal bodies Fibrosis Penile implant 4 Partial loss Grafting 5 Plication corporoplasty 9 Total loss Penis reconstructed from remaining penile skin and 1 implantation of penile prosthesis Total 19 mputation Partial Penile stump advancement with glans reconstruction 1 Total Total phalloplasty using radial forearm flap 1 Total phalloplasty using MLF 4 Total 6 Most patients (84%) had combined penile injuries of two or more combined penile entities, while penile trauma was isolated in only seven (16%). MLF, musculocutaneous latissimus dorsi flap. ISUSSION Severe penile injuries are rarely reported; they are caused by different mechanisms, e.g. iatrogenic injury or traffic accidents, burns, circumcision, animal bites, gunshot, electrocution, self-mutilation, accidental amputation, etc. Iatrogenic injuries are most commonly reported after difficult penile surgery (hypospadias, epispadias or other severe congenital penile anomalies) or after circumcision. The extent of injury can vary from penile avulsion to total amputation [1 5]. The most common causes of penile injury in the present patients were iatrogenic after repair of congenital penile anomalies and traffic accidents with burns. The greatest obstacle in classifying penile trauma is that there are numerous variations on what constitutes the injured penis. The standard classification into avulsion, penetrating and amputating injuries is generalized and insufficient to precisely describe all possible conditions that the reconstructive urologist can face. Thus, we consider it more appropriate to classify all injuries according to the involved penile entities and extent of their injury, which in our experience enables a better understanding of the complex field of penile trauma, reducing the risks of treatment and improving the outcome. The diagnosis of severe penile injuries is often obvious, although additional standard diagnostic procedures can be useful. However, the precise extent of damage can be 682 JOURNL OMPILTION 2009 JU INTERNTIONL

8 SEVERE PENILE INJURIES FIG. 6.,, omplete penile entrapment after a ritual circumcision accident and two attempts at repair in 4- year-old child., The undamaged penile shaft with a small remnant of the glans was revealed under the pubic skin. fter mobilizing the testes, two scrotal flaps for reconstructing penile skin were created., The appearance at the end of surgery, and E, 5 months later. E ascertained only during surgery in many patients. Management of the injured penis depends on the involved penile entities, the degree of their damage and on the remaining penile and local tissues. The first issue in treatment is an attempt to avoid complications by selecting appropriate patients and procedures that will minimize complications. The best course is to initiate treatment immediately to prevent delayed complications. Unfortunately, all the patients in the present series were referred to us a long time after the initial surgery. To date there are no precise algorithms for treating severe penile trauma [6] and no technique is appropriate for all types of penile injury, so that different techniques must be used, considering the type of injury, severity, site and the history of the patient. The reconstructive goal is to rebuild the penis and to restore its function. The preservation of all the remaining healthy tissue is a standard for all surgical options. The remaining well-vascularized penile tissues should be augmented with the judicious use of flaps, grafts and prosthetic components. The lost penile skin should be reconstructed using the most appropriate substitute, i.e. redistribution of the remaining skin, taking care to avoid penile entrapment. In patients whose penile skin was insufficient to cover the complete penile shaft in the stretched position or when erect, the second choice was scrotal skin, as it has similar characteristics, i.e. colour, elasticity and thickness, as well as excellent vascularity. It is very important to create appropriate scrotal flaps, i.e. mobile, thin and fully released from the septum and testicles, to enable the formation of a proper penoscrotal and JOURNL OMPILTION 2009 JU INTERNTIONL 683

9 PEROVI ET L. FIG. 7., 19-year-old with burns to large areas of the abdomen, thighs, penile and scrotal skin. The penis was completely trapped by exaggerated scars., Penile degloving and elevation of a peninsular anteromedial thigh flap., The penile shaft was wrapped with mobilized flap;, The flap was detached from its base and penile body skin reconstructed. E, The final appearance 2 years after surgery and liposuction. E penopubic angle. dditional tucks should be used for fixing scrotal flaps to the albuginea, especially at the penile base, to ensure firm skin distribution onto the penile shaft. prolonged application of a compressive dressing is very important to prevent skin swelling and sliding. The reconstruction of the scrotum was never a problem, even for a relatively small scrotum. This surgery can be successful and safe in one stage, as we used in all cases. Scrotal skin hairs can be treated by permanent laser depilation. When the scrotal skin was also damaged/missing we used a full-thickness skin graft for penile skin reconstruction as the last option, with satisfactory results. The urethra was reconstructed using standard procedures; a simple watertight closure, spatulated or augmented anastomotic repair, while the most severe cases had a staged buccal mucosal graft repair. Partial or total glans loss was successfully reconstructed using a full-thickness skin 684 JOURNL OMPILTION 2009 JU INTERNTIONL

10 SEVERE PENILE INJURIES FIG. 8., 40-year-old man with a penile fracture during sexual intercourse, with a very large ventral albugineal tear involving both cavernosal bodies with urethral rupture., n augmented urethral anastomotic repair., The ruptured cavernosal bodies were grafted with saphenous vein. graft, with a very good aesthetic outcome, but with low sensitivity. In one case we reconstructed the glans using the inner preputial layer, with much better sensitivity. The damaged tunica albuginea can be reconstructed by incisional plication, a modified Nesbit procedure or grafting. The decision depends directly on penile length and the extent of damage. The eventual result also depends on postoperative physiotherapy (vacuum device, stretchers). For fibrosis of the cavernous bodies the implantation of a penile prosthesis is the only appropriate solution. Very often the space inside the cavernous bodies is greatly reduced; thus albugineal widening with a long longitudinal incision and grafting is necessary to safely place the prosthesis without tension. In one particular case where one cavernous body was lost and the distal end of the other was partly fibrotic, we succeeded in preserving axial rigidity by joining the tip of the remaining cavernous body with the damaged one. JOURNL OMPILTION 2009 JU INTERNTIONL 685

11 PEROVI ET L. FIG. 9., Self-amputation of the glans in a 20-year-old patient., The glans was created using remaining inner preputial skin., The outcome 2 years after surgery. Penile amputation can be treated by different local or free transfer flaps for partial or total phallic replacement. lthough a radial forearm flap is frequently taken as a standard for total phalloplasty, we used a musculocutaneous latissimus dorsi flap in most patients, due to its excellent size [7]. It can be also used in children when the neophallic size should be as in the adult, to avoid major additional surgery in adulthood. The corporeal remnants are very useful for proximal support of the prosthetic cylinders and should be always used when present. In cases where the penile stump is absent, the cylinder base and tips should be enveloped into a vascular prosthesis to prevent protrusion and allow better fixation to the pubis [8]. In our experience, staged urethroplasty using a buccal mucosal graft had significant advantages over a skin urethroplasty in the neophallus. There are no specific guidelines for treating severe penile injuries, a complex and multifaceted subject. Such injuries should be treated on an individual basis, applying different techniques. The goal must be to optimize the long-term sexual, cosmetic and voiding outcomes. With this priority for treatment, we have found that most of our patients are happy, with unobstructed voiding and painless intercourse, and many patients choose not to pursue perfect cosmesis once the previous two goals have been attained. Penile reconstructive surgery is a challenging, demanding and technique-driven activity, best undertaken by experienced urologists working with a team of associates in allied specialities. ONFLIT OF INTEREST None declared. 686 JOURNL OMPILTION 2009 JU INTERNTIONL

12 SEVERE PENILE INJURIES FIG. 10., Penile amputation in 10-year-old boy after repair of exstrophy-epispadias complex with a Mitrofanoff stoma., The musculocutaneous latissimus dorsi flap design for total phalloplasty., The flap is elevated on a long neurovascular pedicle., The outcome 2 years later, with a neophallus size as in an adult. TLE 3 The overall functional and aesthetic results, and patient satisfaction Result n (%) Functional and aesthetic Good 35 (81) Fairly good 5 (12) Unsatisfactory 3 (7) Patient satisfaction Satisfied 37 (86) Fairly satisfied 4 (9) Unsatisfied. 2 (5) TLE 4 omplications of surgical treatment omplications Mode of treatment n patients Partial skin flap necrosis onservative treatment 2 Urethral stenosis Ventral onlay buccal mucosa urethroplasty 2 Urethral fistula Fistulorrhaphy 1 Infection after prosthesis implantation elayed salvage procedure after 1 week 1 Protrusion of semirigid prosthesis in neophallus Prosthesis explantation and reimplantation of inflatable 1 prosthesis enveloped into vascular graft Total 7 REFERENES 1 mukele S, Lee G, Stock J, Hanna M. 20-year experience with iatrogenic penile injury. J Urol 2003; 170: El-ahnasawy MS, El-Sherbiny MT. Pediatric penile trauma. JU Int 2002; 90: Gearhart JP, Rock J. Total ablation of the penis after circumcision with electrocautery: a method of management and long-term follow up. J Urol 1989; 142: Phonsombat S, Master V, Mcninch JW. Penetrating external genital trauma: a 30-year single institution experience. J Urol 2008; 180: Lee SH, ak W, hoi MH, Lee HS, Lee MS, Yoon SJ. Trauma to male genital organs: a 10-year review of 156 patients, including 118 treated by surgery. JU Int 2008; 101: Morey F, Metro MJ, arney KJ, Miller KS, Mcninch JW. onsensus on genitourinary trauma: external genitalia. JU Int 2004; 94: Perovic SV, jinovic R, umbasirevic M, jordjevic M, Vukovic P. Total phalloplasty using a musculocutaneous latissimus dorsi flap. JU Int 2007; 100: Hoebeke P, de uypere G, eulemans P, Monstrey S. Obtaining rigidity in total phalloplasty: experience with 35 patients. J Urol 2003; 169: orrespondence: Sava V. Perovic, School of Medicine; University of elgrade, Tirsova 10, elgrade 11000, Serbia. perovics@eunet.yu JOURNL OMPILTION 2009 JU INTERNTIONL 687