劉展榮、歐建慧、林永明¹

國立成大醫院 泌尿部¹

Chan-Jung, Liu, Chien-Hui Ou, Yung-Ming, Lin¹

Department of Urology, National Cheng Kung University Hospital, Tainan, Taiwan¹

 

Penile amputation is an uncommon injury resulting from self-mutilation, felonious assault, or accidental trauma. Although it is uncommon and rarely fatal, penile amputation is a challenging injury for Urologist to treat. Many factors should be taken into consideration of proper treatment. In this kind of patients, the mental and physical conditions are usually complicated. Rapid stabilization is very important to afford the appropriate time and specialization for surgical success. Currently, many reconstructive techniques provide an excellent outcome for penile replantation. We reported a case of soft palate squamous cell carcinoma under palliative chemotherapy who amputated his penis at the base with a sharp blade due to severe depression.

A 66-year-old man with soft palate squamous cell carcinoma, pT2N0M0, post surgery and local recurrence, was under palliative chemotherapy now. Two days before this emergent episode, he was just admitted due to dyspnea and electrolytes imbalance. He decided to discharge against advice before completing the treatment. After lunch, he locked himself in the bathroom and used kitchen knife to mutilate his penis. He was brought to our emergency department by his family. A clinical examination found a bloody and destroyed penis. One small piece of penile appendage was connected with actively bleeding penile stump by one side of prepuce. The exploratory surgery showed a complete transaction of corpus cavernosum, corpus spongiosum, and urethra. A 14-French Silicon catheter was threaded through the glans and aligned with the proximal urethra. We began with interrupted 4-0 Vicryl sutures in a 360-degree fashion to connect urethra. Interrupted 4-0 Vicryl sutures were placed from ventral side of the tunica albuginea of the corpus spongiosum. Till the dorsal aspect of amputated penis, we carefully applied tension-free, interrupted 4-0 Vicryl sutures to re-approximate the tunica albuginea of the corpus cavernosum. A pressure dressing was placed around the anastomosis wound. After surgery, the patient was taken daily wound care.

Penile amputation is a rare urologic emergency. The actual incidence of penile amputation is rare. The first documented case of macroscopic penile replantation was reported in 1929 by Ehric. Since then, there have been gradual rise of penile amputation, and 87% of cases were reported associated with an underlying psychotic disorder. Schizophrenia (51%) and depression (19%) were the two most common disorders. Immediate management includes two basic goals: resuscitation of the patient and preparation for surgical replantation of the penis. A secondary assessment is rapidly completed to identify additional injuries and stabilized the patients’ psychotic status. The penis should be rinsed in a normal saline solution, wrapped in saline-soaked gauze, and placed in a sealed sterile bag. The bag and protected penis should be maintained hypothermic conditions, but awareness should be paid that the ice is not in direct contact with the penile skin. As for microsurgery toward penile replantation, the first cases were independently reported in 1977 by Cohen et al. and Tamai et al. The development of microsurgical techniques improved success with regard to penile replantation and has become the primary method for managing these patients. Most case reports showed good outcome despite some complication, e.g. fistula formation, skin necrosis, urethral stricture, absent sensation, and erectile dysfunction.

Cases of penile self-amputation are rare urological and psychiatric emergencies. Other than timely penile replantation, it is important to organize surgical and psychiatric teams immediately.