Reconstructive Urology Severe Penile Injuries in Children and Adolescents: Reconstruction Modalities and Outcomes Miroslav L. Djordjevic, Marko Z. Bumbasirevic, Zoran Krstic, Marta R. Bizic, Borko Z. Stojanovic, Ranko Miocinovic, and Richard A. Santucci OBJECTIVE
METHODS
RESULTS
CONCLUSION
To review our experience with severe penile trauma, mechanism of injury, and their treatment modalities in 16 children younger than 18 years. Management of penile trauma poses diverse challenges to the reconstructive urologist, as injuries vary from abrasions to total emasculation. Analysis of 16 patients with severe penile injuries referred to us between 2002 and 2011 was undertaken. The median age at surgery was 13 years (range, 5-17). Etiology of penile trauma and choice of treatment were evaluated. The management included a wide variety of surgical techniques that were tailored to the individual patient. Results were analyzed to define etiology, that is, mechanism of penile injury and to estimate modalities of surgical management and postoperative outcomes. Also, postoperative questionnaire was used, which included questions on functioning and esthetical appearance of participating patients and overall satisfaction. The causes of penile injury in these series were traffic accidents (2), iatrogenic trauma (5), selfamputation (1), electrocution (1), burns (3), dog bite (2), zipper injury (1), and mother’s hair strangulation (1). The mean follow-up was 46 months (range, 14-122), and examinations were uneventful, except for 2 fistulae formation after neophallic urethral reconstruction. The main goal of reconstructive surgery is to have a penis with normal appearance and functions. Severe penile injuries should be treated on a case-by-case basis using the most propitious techniques. UROLOGY 83: 465e470, 2014. 2014 Elsevier Inc.
S
evere trauma of the external male genitalia is rare because of the location and mobility of the penis and scrotum and includes injury of 2 or more penile entities (penile skin, corpora cavernosa, urethra, and glans). Underlying causes include iatrogenic injury, motor vehicle accidents, child abuse, animal bites, gunshot wounds, and self-mutilation.1-8 Reports of trauma to the external genitalia in pediatric population are sporadic and often raise a suspicion of sexual abuse. It is not surprising that most previous reports of the pediatric penile injuries were based on a small number of cases.9-15 The type and extension of nonsexual pediatric penile trauma vary in severity from small to more serious injuries and total emasculation. Owing to their rarity and disparity there is no universal therapeutic strategy in their management. The treatment often requires standard urologic care mixed with ingenuity and innovations. Superficial wounds can initially be treated with wound dressing or
Financial Disclosure: The authors declare that they have no relevant financial interests. Funding Support: Supported by the Ministry of Science, Republic of Serbia, project number 175048. From the Belgrade University, School of Medicine, Belgrade, Serbia; and the Detroit Medical Center, Detroit, MI Reprint requests: Miroslav L. Djordjevic, M.D., Ph.D., Department of Urology, Belgrade University, School of Medicine, Tirsova 10, Belgrade 11000, Republic of Serbia. E-mail: [email protected] Submitted: August 5, 2013, accepted (with revisions): October 13, 2013
ª 2014 Elsevier Inc. All Rights Reserved
suturing, after exploration. More extensive injuries require evaluation of both the urethra and corpora cavernosa and can be treated by local, free transfer flaps, and different grafts. The last resort, penile amputation, partial or total, requires complex reconstructive techniques, including phalloplasty.16-18 In the present treatise, we reviewed 16 patients who underwent single or multiple surgical procedures because of severe penile injury. We hypothesized that it is very important to delineate the mechanism of injury and treatment modalities used in the management of severe penile trauma in children and adolescents and to evaluate postoperative outcomes according to the choice of their treatment.
MATERIALS AND METHODS We retrospectively analyzed 16 patients aged from 5 to 17 years (mean, 13 years) treated for severe penile injury from March 2002 to July 2011. All injuries were classified into 3 groups: complete avulsion, penetrating injury, and amputation. Of the 16 patients, 6 patients (37.5%) were primarily treated at our department, whereas 10 (62.5%) were referred from other centers 3 months to 5 years after injury. In the first group, there were different etiologies as follows: burns (2), traffic accident (2), dog bite (1), and zipper sliders (1). Causes of penile trauma in the second group differed, and some patients were particularly 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.10.015
465
Table 1. Treatment according to causes and type of penile injury No.
Age (y)
1 2
6 16
3 4 5
14 8 13
6 7
17 15
Burns Iatrogenic e curvature repair Burns Electric burns Mother’s hair strangulation Motorcycle injury Dog bite
8
16
Dog bite
9 10
13 9
11 12 13 14
12 16 9 11
15
16
16
5
Cause
Type
Treatment (Single/Multiple)
Follow-up (mo)
Skin loss Semiamputation
FTSG (single) Phalloplasty (multiple)
22 68
Penile lengthening FTSG (multiple) Total phalloplasty (multiple) Urethroplasty with corporoplasty (single)
75 72 89
Zipper avulsion Iatrogenic e epispadias epair Iatrogenic e circumcision Self-amputation Traffic injury Iatrogenic e epispadias repair Iatrogenic e circumcision
Skin loss-trapped penis Amputation Corporeal and urethral injury Avulsion Skin avulsion Corporeal injury Penetrating skin and urethral injury Skin avulsion Amputation
Urethroplasty and skin reconstruction (single) Primary skin reconstruction (single) Total phalloplasty (multiple)
47 94
Glans semiamputation Total amputation Skin avulsion Penile loss
Buccal mucosa graft glanuloplasty (single) Total phalloplasty (multiple) FTSG (single) Total phalloplasty (multiple)
33 38 45 66
Glans injury
14
Burns
Penile skin loss
Glans reconstruction with preputial flap (single) Penile skin reconstruction with scrotal flaps (single)
Primary repair (single) Corporoplasty skin reconstruction (single)
21 122 27
23
FTSG, full thickness skin graft.
unusual: one boy presented with penile amputation caused by electrocution while urinating over a high-voltage electric-current wire. Another boy had a penetrating trauma caused by strangulation with the mother’s hair. Iatrogenic injuries in 5 cases were severe and proved to be devastating for the patient. One adolescent who underwent ventral penile curvature repair had lost the pendular part of the corpora cavernosa, urethra, and glans. In 2 others, several surgical attempts for correction of epispadias-exstrophy complex after primary Cantwell-Ransley epispadias repair were performed elsewhere and resulted in total penile loss. These patients underwent total phalloplasty using musculocutaneus latissimus dorsi free flap. Because most patients had combined injuries of 2 or more penile entities (penile skin, corpora cavernosa, urethra, and glans), management was individualized and based on the availability of viable penile tissue. In cases with severe defects, additional grafts were used for complete reconstruction (Table 1). In cases with skin avulsion, the treatment was based, in principle, on mobilization of remaining healthy genital skin and creation of island flaps whenever possible. In cases with genital burns and completely destroyed genital skin, full thickness skin grafts were used for covering the penile shaft. Pharmacologic erection by Prostaglandin E1 was used in all cases for precise measurement of the flaps and grafts in maximally stretched/erect penis. Postoperatively, in cases with skin avulsion and island flaps covering, compressive dressings were applied for 2 weeks, to prevent swelling and ensure good adhesion of the skin to the penile body. In other cases with graft reconstruction, the dressing was left on standard 5 days. Urethral reconstruction was performed in both cases with urethral injury using available remaining flaps. In the patient with penetrating strangulation injury with mother’s hair, urethroplasty was performed using penile skin flap (Fig. 1). In the adolescent who had a penetrating injury caused by a dog bite, remaining urethral plate was mobilized and tubularized to create 466
a new urethra (Fig. 2). In both cases, well-vascularized subcutaneous flaps were used to cover the newly formed urethra and to prevent postoperative fistula formation. The urethral stent was placed into the neourethra to enable drainage of urethral secretions during nocturnal ejaculations. Suprapubic tube was used in all cases involving urethral reconstruction. A partially lost glans after circumcision was reconstructed using buccal mucosa grafts, whereas total glanular reconstruction was achieved using an inner preputial skin flap over the tips of the corpora cavernosa. Glans corona was created using Norfolk technique.19 Total phalloplasty was performed using musculocutaneous latissimus dorsi free transfer flap using a similar technique to that described previously.20 Latissimus dorsi musculocutaneous flap was harvested with thoracodorsal artery, vein, and nerve. The flap was transferred to the pubic region and anastomosed to the femoral artery, saphenous vein, and ilioinguinal nerve. The remnants of corporal bodies were incorporated into the neophallus. Six months later, urethroplasty with an inlay of buccal mucosa grafts was performed. The graft was tubularized 6 weeks after the initial procedure. An inflatable prosthesis was implanted in 2 patients. Corporeal remnants were recruited as support for the proximal cylinders. Cylinders were covered with vascular graft socks that imitated tunica albuginea (Fig. 3). In addition, a postoperative questionnaire was used, which included questions about functioning and esthetical appearance. Patients and parents were asked about voiding, the quality of erection and penile sensation, and overall satisfaction with appearance of new genitalia and measured on a 3-point scale (1-dissatisfied, 2-somewhat satisfied, and 3-completely satisfied).
RESULTS Postoperative period ranged between 14 and 122 months (mean, 46). All included patients were evaluated at 3, 6, UROLOGY 83 (2), 2014
Figure 1. (A, B) Penile strangulation in an 18-months-old boy caused by mother’s hair. (C) Appearance in adolescence after a failed surgery. (D) Urethral reconstruction was done. Ventral surface of the penis is covered with well-vascularized subcutaneous flap. This manner, subglanular defect was minimized. (E) Appearance after glans and penile skin reconstruction. (Color version available online.)
and 12 months postoperatively. Patients and parents were asked about functioning and esthetical appearance of the new male genitalia, during last appointment. All 6 cases (37.5%) with primary penile reconstruction had a good cosmetic and functional outcome, without early or late complications. There was no report of erectile and voiding dysfunction or penile deformities. In the second group, with severe penile injuries and delayed surgery, results were assessed according to the type of procedure and overall functional (voiding, erectile function) and esthetic outcome. Good voiding was achieved in both patients with penetrating injury and urethroplasty and confirmed by voiding cystourethrogram and uroflowmetry. In 2 patients who had total phalloplasty with neourethral reconstruction, a urethral fistula occurred and was successfully repaired under local anesthesia 3 months after urethroplasty. Both patients with partial glans loss were treated successfully and with acceptable cosmetic UROLOGY 83 (2), 2014
results. According to patients’ self-reports (8 patients aged from 13 to 17 years) most were pleased with the esthetic appearance of their genitalia (6 “completely satisfied” and 2 “somewhat satisfied”). Erectile function was preserved in all adolescent patients based on their reports. In total phalloplasty cases, function of implanted penile prosthesis was satisfactory. The remaining 2 patients are waiting for penile prosthesis implantation, planned for late adolescence. Psychological status significantly improved in younger children, according to reports of their parents.
COMMENT Penile injuries are infrequently reported with the exception of circumcision disasters. Other etiologies include self-mutilation, iatrogenic misadventure, vehicular trauma, child abuse, animal bites, and gunshot wounds. Regardless of the cause, the potential for devastating 467
Figure 2. (A) Penetrating penile injury caused by a dog bite in a 15-year-old boy. Penile urethra is missing. (B) Urethra was reconstructed by tubularization of mobilized urethral plate. (C) Subcutaneous flap was created for covering the urethra. (D) Glans reconstruction was done. New urethra was covered with good vascularized subcutaneous tissue. (E) Appearance at the end of surgery after reconstruction of the penile and scrotal skin. (Color version available online.)
deformity and loss of length and function mandate that these patients receive expert attention immediately after stabilization. Diagnosis of a severe penile trauma is made when 2 or more penile entities are injured: penile skin, corpora cavernosa, penile urethra, or glans cap. The etiologies for childhood penile injury are different than those seen in adults.8-14 The largest number of penile trauma in the pediatric population is reported by ElBahnasawi and El-Sherbiny.15 They reported 64 boys with penile trauma. Sixty-three percent were caused by circumcision, with hair-tie strangulation the next most common cause. In those cases in which the coronal sulcus is lost after replantation, a buccal graft has been used with good result.17 Expeditious attention will do much to avert delayed complications such as infection, curvature, erectile 468
dysfunction, unrecognized urethral injury, and chronic pain. Severe penile trauma might present with adjacent comorbidity involving the scrotum, pelvis, buttocks, and thighs. More complex cases might require a staged treatment plan.21 As of yet, algorithms have not been formulated to cover every possible eventuality. The goal of reconstruction is to rebuild a penis that works similar to a penis with presentable gross anatomic features. The starting point of our approach is the recognition of those well-vascularized tissues that will serve as the support base for the complementary placement of grafts, flaps, fillers, and prostheses. In our urology department, 16 patients with severe penile injuries were seen during the last 5 years. The most common causes were avulsions, burns, and iatrogenic injuries associated with repair of UROLOGY 83 (2), 2014
Figure 3. (A) Self-amputation of the penis in 16-year-old psychogenic patient. (B) Phallus is created using musculocutaneous latissimus dorsi flap phalloplasty. (C) A satisfactory outcome 2 years after implantation inflatable penile prosthesis. (Color version available online.)
congenital penile anomalies. Although medical centere based urologic care should commence immediately, we regretfully report that 10 of 16 patients in this series were referred several months or years after injury. The mainstay of our approach is the augmentation of deficient areas with flaps. In penetrating injuries, corporal deformities were repaired depending on the case. Urethral reconstruction included simple closure with watertight, spatulated, catheter-stented technique and absorbable suture. The most severe cases underwent staged repair. Penile amputation might be treated using different free transfer flaps for partial or total phallic replacement. We usually used musculocutaneous latissimus dorsi flap because of its advantages. It has provided excellent length and circumference. However, phalloplasty in children generates certain questions about indications, age, size and, especially, neophallic growth during puberty. Performing genital reconstruction in this period is important to minimize any psychological impact of this surgery. Because genitals have an important role in creating body image and, without any doubt, determining future mental image, we assumed that phalloplasty with normal-looking external genitalia and physical appearance during the delicate period of puberty is of utmost importance to prevent psychological stress related to genital identity.20 Children and parents must be precounseled to expect a phallus of near adult-sized proportions. Neophallus size follows somatic growth patterns and is not influenced by pubescent surges. Neophallic retraction seems less likely to occur with muscle-based grafts than with use of a fasciocutaneous forearm flap, because well-vascularized muscle is less prone to contracting than connective tissue. Penile prosthesis implantation was technically easier and better tolerated in a muscular bed. However, the obvious disadvantage is the inability of a denervated graft to provide protective and erogenous sensitivity. Reports of thoracodorsal and ilioinguinal nerve anastomosis seem promising. Implantation of a penile prosthesis is recommended after phalloplasty to enable erectile function and penetration. Corporeal remnants are recruited as a UROLOGY 83 (2), 2014
support for the proximal cylinders. Because the crura are no longer serviceable, proximal cylinders tips in vascular graft sleeves can be secured to the periostium of the inferior pubic rami. The shortcoming of this study could be the inability to define the true classification of the penile injury because there are numerous variations on what constitutes an injured penis. The standard classification into avulsion, penetrating, and amputation injuries is generalized and insufficient to precisely describe all possible conditions. Thus, we consider it more appropriate to classify all injuries according to the involved penile entities, which could enable better understanding of this complex field, minimizing the risk of treatment and improving the outcome. Primary reconstruction should be recommended and reserved for specialized trauma centers. This manner, late complications and necessity for delayed reconstruction could be minimized. Iatrogenic penile trauma presents special problem because of insufficient penile tissue and requires complex staged repair. The limitation of this article is that our outcome evaluations were based on surgeon assessment, because it was impossible to create a quality of life study for patients of this age group. Objective evaluation using questionnaires and patient quality of life issues could give us more scientifically important information.
CONCLUSION There are no specific guidelines for the treatment of severe penile surgery, which is a complex and multifaceted subject. Care must be taken with the goal of optimizing long-term sexual, cosmetic, and voiding outcomes. Penile reconstructive surgery is a challenging and techniquedriven activity, perhaps best undertaken by experienced urologists working with a team of associates in allied specialties. References 1. Singh I, Josji MK, Jaura MS. Strangulation of penis by a ball bearing device. J Sex Med. 2010;7:3793-3797.
469
2. Gomez RG, Castanheira AC, McAninch JW. Gunshot wounds to the male genitalia. J Urol. 1993;150:1147-1149. 3. Redman JF. Genital dog bite in infants and children. Clin Pediatr. 1995;34:331-333. 4. Ralph D, Gonzalez-Cadavid N, Mirone V, et al. Trauma, gender reassignment and penile augmentation. J Sex Med. 2010;7:16571667. 5. Morey AF, Dugi DD III. Genital and upper urinary tract trauma. In: Wein AJ, ed. Campbell-Walsh Urology. 10th ed. Philadelphia: Elsevier Saunders; 2012:2507-2520. 6. Bjurlin MA, Zhao LC, Goble SM, et al. Bicycle-related genitourinary injuries. Urology. 2011;78:1187-1190. 7. Amukele S, Lee G, Stock J, Hanna MK. 20-year experience with iatrogenic penile injury. J Urol. 2003;170:1691-1694. 8. Benchekroun A, Jira H, Kasmaoui el-H, et al. Penile reconstruction following amputation by electrocution. Prog Urol. 2002; 12:129-131. 9. Gluckman GR, Stoller ML, Jacobs MM, et al. Newborn penile glans amputation during circumcision and successful reattachment. J Urol. 1995;153:778-779. 10. Gearhart JP, Rock JA. Total ablation of the penis after circumcision with electrocautery: a method of management and long-term follow up. J Urol. 1989;142:799-801. 11. Ochoa B. Trauma of the external genitalia in children: amputation of the penis and emasculation. J Urol. 1998;160:1116-1119.
470
12. Widni EE, Hoelwarth ME, Saxena AK. Analysis of nonsexual injuries of the male genitals in children and adolescents. Acta Paediatr. 2011;100:590-593. 13. Katz DJ, Chin W, Appu S, et al. Novel extraction technique to remove a penile constriction device. J Sex Med. 2012;9:937-940. 14. Mellick LB. Wire cutters and penis skin entrapped by zipper sliders. Ped Emerg Care. 2011;27:451-452. 15. El-Bahnasawy MS, El-Sherbiny MT. Pediatric penile trauma. BJU Int. 2002;90:92-96. 16. Perovic SV, Djinovic RP, Bumbasirevic MZ, et al. Severe penile injuries: a problem of severity and reconstruction. BJU Int. 2009; 104:676-687. 17. Cook A, Khoury AE, Bagli DJ, et al. Use of buccal mucosa to stimulate the coronal sulcus after traumatic penile amputation. Urology. 2005;66:1109-1113. 18. Charlesworth P, Campbell A, Kamaledeen S, et al. Surgical repair of traumatic amputation of the glans. Urology. 2011;77:1472-1473. 19. Garaffa G, Christopher NA, Ralph DJ. Total phallic reconstruction in female-to-male transsexuals. Eur Urol. 2010;57:715-722. 20. Djordjevic ML, Bumbasirevic MZ, Vukovic PM, et al. Musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children. J Pediatr Urol. 2006;2:333-339. 21. Santucci RA, Chen ML. Penile trauma. In: Djordjevic ML, Santucci RA, eds. Penile Reconstructive Surgery. Saarbrucken: LAP Lambert Academic Publishing; 2012:155-170.
UROLOGY 83 (2), 2014
METHODS
RESULTS
CONCLUSION
To review our experience with severe penile trauma, mechanism of injury, and their treatment modalities in 16 children younger than 18 years. Management of penile trauma poses diverse challenges to the reconstructive urologist, as injuries vary from abrasions to total emasculation. Analysis of 16 patients with severe penile injuries referred to us between 2002 and 2011 was undertaken. The median age at surgery was 13 years (range, 5-17). Etiology of penile trauma and choice of treatment were evaluated. The management included a wide variety of surgical techniques that were tailored to the individual patient. Results were analyzed to define etiology, that is, mechanism of penile injury and to estimate modalities of surgical management and postoperative outcomes. Also, postoperative questionnaire was used, which included questions on functioning and esthetical appearance of participating patients and overall satisfaction. The causes of penile injury in these series were traffic accidents (2), iatrogenic trauma (5), selfamputation (1), electrocution (1), burns (3), dog bite (2), zipper injury (1), and mother’s hair strangulation (1). The mean follow-up was 46 months (range, 14-122), and examinations were uneventful, except for 2 fistulae formation after neophallic urethral reconstruction. The main goal of reconstructive surgery is to have a penis with normal appearance and functions. Severe penile injuries should be treated on a case-by-case basis using the most propitious techniques. UROLOGY 83: 465e470, 2014. 2014 Elsevier Inc.
S
evere trauma of the external male genitalia is rare because of the location and mobility of the penis and scrotum and includes injury of 2 or more penile entities (penile skin, corpora cavernosa, urethra, and glans). Underlying causes include iatrogenic injury, motor vehicle accidents, child abuse, animal bites, gunshot wounds, and self-mutilation.1-8 Reports of trauma to the external genitalia in pediatric population are sporadic and often raise a suspicion of sexual abuse. It is not surprising that most previous reports of the pediatric penile injuries were based on a small number of cases.9-15 The type and extension of nonsexual pediatric penile trauma vary in severity from small to more serious injuries and total emasculation. Owing to their rarity and disparity there is no universal therapeutic strategy in their management. The treatment often requires standard urologic care mixed with ingenuity and innovations. Superficial wounds can initially be treated with wound dressing or
Financial Disclosure: The authors declare that they have no relevant financial interests. Funding Support: Supported by the Ministry of Science, Republic of Serbia, project number 175048. From the Belgrade University, School of Medicine, Belgrade, Serbia; and the Detroit Medical Center, Detroit, MI Reprint requests: Miroslav L. Djordjevic, M.D., Ph.D., Department of Urology, Belgrade University, School of Medicine, Tirsova 10, Belgrade 11000, Republic of Serbia. E-mail: [email protected] Submitted: August 5, 2013, accepted (with revisions): October 13, 2013
ª 2014 Elsevier Inc. All Rights Reserved
suturing, after exploration. More extensive injuries require evaluation of both the urethra and corpora cavernosa and can be treated by local, free transfer flaps, and different grafts. The last resort, penile amputation, partial or total, requires complex reconstructive techniques, including phalloplasty.16-18 In the present treatise, we reviewed 16 patients who underwent single or multiple surgical procedures because of severe penile injury. We hypothesized that it is very important to delineate the mechanism of injury and treatment modalities used in the management of severe penile trauma in children and adolescents and to evaluate postoperative outcomes according to the choice of their treatment.
MATERIALS AND METHODS We retrospectively analyzed 16 patients aged from 5 to 17 years (mean, 13 years) treated for severe penile injury from March 2002 to July 2011. All injuries were classified into 3 groups: complete avulsion, penetrating injury, and amputation. Of the 16 patients, 6 patients (37.5%) were primarily treated at our department, whereas 10 (62.5%) were referred from other centers 3 months to 5 years after injury. In the first group, there were different etiologies as follows: burns (2), traffic accident (2), dog bite (1), and zipper sliders (1). Causes of penile trauma in the second group differed, and some patients were particularly 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.10.015
465
Table 1. Treatment according to causes and type of penile injury No.
Age (y)
1 2
6 16
3 4 5
14 8 13
6 7
17 15
Burns Iatrogenic e curvature repair Burns Electric burns Mother’s hair strangulation Motorcycle injury Dog bite
8
16
Dog bite
9 10
13 9
11 12 13 14
12 16 9 11
15
16
16
5
Cause
Type
Treatment (Single/Multiple)
Follow-up (mo)
Skin loss Semiamputation
FTSG (single) Phalloplasty (multiple)
22 68
Penile lengthening FTSG (multiple) Total phalloplasty (multiple) Urethroplasty with corporoplasty (single)
75 72 89
Zipper avulsion Iatrogenic e epispadias epair Iatrogenic e circumcision Self-amputation Traffic injury Iatrogenic e epispadias repair Iatrogenic e circumcision
Skin loss-trapped penis Amputation Corporeal and urethral injury Avulsion Skin avulsion Corporeal injury Penetrating skin and urethral injury Skin avulsion Amputation
Urethroplasty and skin reconstruction (single) Primary skin reconstruction (single) Total phalloplasty (multiple)
47 94
Glans semiamputation Total amputation Skin avulsion Penile loss
Buccal mucosa graft glanuloplasty (single) Total phalloplasty (multiple) FTSG (single) Total phalloplasty (multiple)
33 38 45 66
Glans injury
14
Burns
Penile skin loss
Glans reconstruction with preputial flap (single) Penile skin reconstruction with scrotal flaps (single)
Primary repair (single) Corporoplasty skin reconstruction (single)
21 122 27
23
FTSG, full thickness skin graft.
unusual: one boy presented with penile amputation caused by electrocution while urinating over a high-voltage electric-current wire. Another boy had a penetrating trauma caused by strangulation with the mother’s hair. Iatrogenic injuries in 5 cases were severe and proved to be devastating for the patient. One adolescent who underwent ventral penile curvature repair had lost the pendular part of the corpora cavernosa, urethra, and glans. In 2 others, several surgical attempts for correction of epispadias-exstrophy complex after primary Cantwell-Ransley epispadias repair were performed elsewhere and resulted in total penile loss. These patients underwent total phalloplasty using musculocutaneus latissimus dorsi free flap. Because most patients had combined injuries of 2 or more penile entities (penile skin, corpora cavernosa, urethra, and glans), management was individualized and based on the availability of viable penile tissue. In cases with severe defects, additional grafts were used for complete reconstruction (Table 1). In cases with skin avulsion, the treatment was based, in principle, on mobilization of remaining healthy genital skin and creation of island flaps whenever possible. In cases with genital burns and completely destroyed genital skin, full thickness skin grafts were used for covering the penile shaft. Pharmacologic erection by Prostaglandin E1 was used in all cases for precise measurement of the flaps and grafts in maximally stretched/erect penis. Postoperatively, in cases with skin avulsion and island flaps covering, compressive dressings were applied for 2 weeks, to prevent swelling and ensure good adhesion of the skin to the penile body. In other cases with graft reconstruction, the dressing was left on standard 5 days. Urethral reconstruction was performed in both cases with urethral injury using available remaining flaps. In the patient with penetrating strangulation injury with mother’s hair, urethroplasty was performed using penile skin flap (Fig. 1). In the adolescent who had a penetrating injury caused by a dog bite, remaining urethral plate was mobilized and tubularized to create 466
a new urethra (Fig. 2). In both cases, well-vascularized subcutaneous flaps were used to cover the newly formed urethra and to prevent postoperative fistula formation. The urethral stent was placed into the neourethra to enable drainage of urethral secretions during nocturnal ejaculations. Suprapubic tube was used in all cases involving urethral reconstruction. A partially lost glans after circumcision was reconstructed using buccal mucosa grafts, whereas total glanular reconstruction was achieved using an inner preputial skin flap over the tips of the corpora cavernosa. Glans corona was created using Norfolk technique.19 Total phalloplasty was performed using musculocutaneous latissimus dorsi free transfer flap using a similar technique to that described previously.20 Latissimus dorsi musculocutaneous flap was harvested with thoracodorsal artery, vein, and nerve. The flap was transferred to the pubic region and anastomosed to the femoral artery, saphenous vein, and ilioinguinal nerve. The remnants of corporal bodies were incorporated into the neophallus. Six months later, urethroplasty with an inlay of buccal mucosa grafts was performed. The graft was tubularized 6 weeks after the initial procedure. An inflatable prosthesis was implanted in 2 patients. Corporeal remnants were recruited as support for the proximal cylinders. Cylinders were covered with vascular graft socks that imitated tunica albuginea (Fig. 3). In addition, a postoperative questionnaire was used, which included questions about functioning and esthetical appearance. Patients and parents were asked about voiding, the quality of erection and penile sensation, and overall satisfaction with appearance of new genitalia and measured on a 3-point scale (1-dissatisfied, 2-somewhat satisfied, and 3-completely satisfied).
RESULTS Postoperative period ranged between 14 and 122 months (mean, 46). All included patients were evaluated at 3, 6, UROLOGY 83 (2), 2014
Figure 1. (A, B) Penile strangulation in an 18-months-old boy caused by mother’s hair. (C) Appearance in adolescence after a failed surgery. (D) Urethral reconstruction was done. Ventral surface of the penis is covered with well-vascularized subcutaneous flap. This manner, subglanular defect was minimized. (E) Appearance after glans and penile skin reconstruction. (Color version available online.)
and 12 months postoperatively. Patients and parents were asked about functioning and esthetical appearance of the new male genitalia, during last appointment. All 6 cases (37.5%) with primary penile reconstruction had a good cosmetic and functional outcome, without early or late complications. There was no report of erectile and voiding dysfunction or penile deformities. In the second group, with severe penile injuries and delayed surgery, results were assessed according to the type of procedure and overall functional (voiding, erectile function) and esthetic outcome. Good voiding was achieved in both patients with penetrating injury and urethroplasty and confirmed by voiding cystourethrogram and uroflowmetry. In 2 patients who had total phalloplasty with neourethral reconstruction, a urethral fistula occurred and was successfully repaired under local anesthesia 3 months after urethroplasty. Both patients with partial glans loss were treated successfully and with acceptable cosmetic UROLOGY 83 (2), 2014
results. According to patients’ self-reports (8 patients aged from 13 to 17 years) most were pleased with the esthetic appearance of their genitalia (6 “completely satisfied” and 2 “somewhat satisfied”). Erectile function was preserved in all adolescent patients based on their reports. In total phalloplasty cases, function of implanted penile prosthesis was satisfactory. The remaining 2 patients are waiting for penile prosthesis implantation, planned for late adolescence. Psychological status significantly improved in younger children, according to reports of their parents.
COMMENT Penile injuries are infrequently reported with the exception of circumcision disasters. Other etiologies include self-mutilation, iatrogenic misadventure, vehicular trauma, child abuse, animal bites, and gunshot wounds. Regardless of the cause, the potential for devastating 467
Figure 2. (A) Penetrating penile injury caused by a dog bite in a 15-year-old boy. Penile urethra is missing. (B) Urethra was reconstructed by tubularization of mobilized urethral plate. (C) Subcutaneous flap was created for covering the urethra. (D) Glans reconstruction was done. New urethra was covered with good vascularized subcutaneous tissue. (E) Appearance at the end of surgery after reconstruction of the penile and scrotal skin. (Color version available online.)
deformity and loss of length and function mandate that these patients receive expert attention immediately after stabilization. Diagnosis of a severe penile trauma is made when 2 or more penile entities are injured: penile skin, corpora cavernosa, penile urethra, or glans cap. The etiologies for childhood penile injury are different than those seen in adults.8-14 The largest number of penile trauma in the pediatric population is reported by ElBahnasawi and El-Sherbiny.15 They reported 64 boys with penile trauma. Sixty-three percent were caused by circumcision, with hair-tie strangulation the next most common cause. In those cases in which the coronal sulcus is lost after replantation, a buccal graft has been used with good result.17 Expeditious attention will do much to avert delayed complications such as infection, curvature, erectile 468
dysfunction, unrecognized urethral injury, and chronic pain. Severe penile trauma might present with adjacent comorbidity involving the scrotum, pelvis, buttocks, and thighs. More complex cases might require a staged treatment plan.21 As of yet, algorithms have not been formulated to cover every possible eventuality. The goal of reconstruction is to rebuild a penis that works similar to a penis with presentable gross anatomic features. The starting point of our approach is the recognition of those well-vascularized tissues that will serve as the support base for the complementary placement of grafts, flaps, fillers, and prostheses. In our urology department, 16 patients with severe penile injuries were seen during the last 5 years. The most common causes were avulsions, burns, and iatrogenic injuries associated with repair of UROLOGY 83 (2), 2014
Figure 3. (A) Self-amputation of the penis in 16-year-old psychogenic patient. (B) Phallus is created using musculocutaneous latissimus dorsi flap phalloplasty. (C) A satisfactory outcome 2 years after implantation inflatable penile prosthesis. (Color version available online.)
congenital penile anomalies. Although medical centere based urologic care should commence immediately, we regretfully report that 10 of 16 patients in this series were referred several months or years after injury. The mainstay of our approach is the augmentation of deficient areas with flaps. In penetrating injuries, corporal deformities were repaired depending on the case. Urethral reconstruction included simple closure with watertight, spatulated, catheter-stented technique and absorbable suture. The most severe cases underwent staged repair. Penile amputation might be treated using different free transfer flaps for partial or total phallic replacement. We usually used musculocutaneous latissimus dorsi flap because of its advantages. It has provided excellent length and circumference. However, phalloplasty in children generates certain questions about indications, age, size and, especially, neophallic growth during puberty. Performing genital reconstruction in this period is important to minimize any psychological impact of this surgery. Because genitals have an important role in creating body image and, without any doubt, determining future mental image, we assumed that phalloplasty with normal-looking external genitalia and physical appearance during the delicate period of puberty is of utmost importance to prevent psychological stress related to genital identity.20 Children and parents must be precounseled to expect a phallus of near adult-sized proportions. Neophallus size follows somatic growth patterns and is not influenced by pubescent surges. Neophallic retraction seems less likely to occur with muscle-based grafts than with use of a fasciocutaneous forearm flap, because well-vascularized muscle is less prone to contracting than connective tissue. Penile prosthesis implantation was technically easier and better tolerated in a muscular bed. However, the obvious disadvantage is the inability of a denervated graft to provide protective and erogenous sensitivity. Reports of thoracodorsal and ilioinguinal nerve anastomosis seem promising. Implantation of a penile prosthesis is recommended after phalloplasty to enable erectile function and penetration. Corporeal remnants are recruited as a UROLOGY 83 (2), 2014
support for the proximal cylinders. Because the crura are no longer serviceable, proximal cylinders tips in vascular graft sleeves can be secured to the periostium of the inferior pubic rami. The shortcoming of this study could be the inability to define the true classification of the penile injury because there are numerous variations on what constitutes an injured penis. The standard classification into avulsion, penetrating, and amputation injuries is generalized and insufficient to precisely describe all possible conditions. Thus, we consider it more appropriate to classify all injuries according to the involved penile entities, which could enable better understanding of this complex field, minimizing the risk of treatment and improving the outcome. Primary reconstruction should be recommended and reserved for specialized trauma centers. This manner, late complications and necessity for delayed reconstruction could be minimized. Iatrogenic penile trauma presents special problem because of insufficient penile tissue and requires complex staged repair. The limitation of this article is that our outcome evaluations were based on surgeon assessment, because it was impossible to create a quality of life study for patients of this age group. Objective evaluation using questionnaires and patient quality of life issues could give us more scientifically important information.
CONCLUSION There are no specific guidelines for the treatment of severe penile surgery, which is a complex and multifaceted subject. Care must be taken with the goal of optimizing long-term sexual, cosmetic, and voiding outcomes. Penile reconstructive surgery is a challenging and techniquedriven activity, perhaps best undertaken by experienced urologists working with a team of associates in allied specialties. References 1. Singh I, Josji MK, Jaura MS. Strangulation of penis by a ball bearing device. J Sex Med. 2010;7:3793-3797.
469
2. Gomez RG, Castanheira AC, McAninch JW. Gunshot wounds to the male genitalia. J Urol. 1993;150:1147-1149. 3. Redman JF. Genital dog bite in infants and children. Clin Pediatr. 1995;34:331-333. 4. Ralph D, Gonzalez-Cadavid N, Mirone V, et al. Trauma, gender reassignment and penile augmentation. J Sex Med. 2010;7:16571667. 5. Morey AF, Dugi DD III. Genital and upper urinary tract trauma. In: Wein AJ, ed. Campbell-Walsh Urology. 10th ed. Philadelphia: Elsevier Saunders; 2012:2507-2520. 6. Bjurlin MA, Zhao LC, Goble SM, et al. Bicycle-related genitourinary injuries. Urology. 2011;78:1187-1190. 7. Amukele S, Lee G, Stock J, Hanna MK. 20-year experience with iatrogenic penile injury. J Urol. 2003;170:1691-1694. 8. Benchekroun A, Jira H, Kasmaoui el-H, et al. Penile reconstruction following amputation by electrocution. Prog Urol. 2002; 12:129-131. 9. Gluckman GR, Stoller ML, Jacobs MM, et al. Newborn penile glans amputation during circumcision and successful reattachment. J Urol. 1995;153:778-779. 10. Gearhart JP, Rock JA. Total ablation of the penis after circumcision with electrocautery: a method of management and long-term follow up. J Urol. 1989;142:799-801. 11. Ochoa B. Trauma of the external genitalia in children: amputation of the penis and emasculation. J Urol. 1998;160:1116-1119.
470
12. Widni EE, Hoelwarth ME, Saxena AK. Analysis of nonsexual injuries of the male genitals in children and adolescents. Acta Paediatr. 2011;100:590-593. 13. Katz DJ, Chin W, Appu S, et al. Novel extraction technique to remove a penile constriction device. J Sex Med. 2012;9:937-940. 14. Mellick LB. Wire cutters and penis skin entrapped by zipper sliders. Ped Emerg Care. 2011;27:451-452. 15. El-Bahnasawy MS, El-Sherbiny MT. Pediatric penile trauma. BJU Int. 2002;90:92-96. 16. Perovic SV, Djinovic RP, Bumbasirevic MZ, et al. Severe penile injuries: a problem of severity and reconstruction. BJU Int. 2009; 104:676-687. 17. Cook A, Khoury AE, Bagli DJ, et al. Use of buccal mucosa to stimulate the coronal sulcus after traumatic penile amputation. Urology. 2005;66:1109-1113. 18. Charlesworth P, Campbell A, Kamaledeen S, et al. Surgical repair of traumatic amputation of the glans. Urology. 2011;77:1472-1473. 19. Garaffa G, Christopher NA, Ralph DJ. Total phallic reconstruction in female-to-male transsexuals. Eur Urol. 2010;57:715-722. 20. Djordjevic ML, Bumbasirevic MZ, Vukovic PM, et al. Musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children. J Pediatr Urol. 2006;2:333-339. 21. Santucci RA, Chen ML. Penile trauma. In: Djordjevic ML, Santucci RA, eds. Penile Reconstructive Surgery. Saarbrucken: LAP Lambert Academic Publishing; 2012:155-170.
UROLOGY 83 (2), 2014
