Microscopic Replantation of Penile Glans Amputation Due to Circumcision

Summary

The present protocol describes the emergency management of microscopic replantation of penile glans amputation due to circumcision.

Abstract

Circumcision using a disposable stapler is becoming quite popular in China. However, improper surgical procedures also bring the risk of penile glans amputation, which is a very rare iatrogenic genital injury. Such complication is conventionally treated by simple hemostasis to achieve self-healing, early gross replantation, or delayed plastic surgery. However, these may lead to obvious unfavorable outcomes such as amputated glans loss, necrosis, malformation healing, or urethral orifice stenosis. In the present study, we adopted microscopic replantation as an emergency approach to achieve the precise anastomoses and anatomic reconstruction of penile glans. The goal of this protocol is to present a detailed emergency management strategy with meticulous surgical skills for the penile glans amputation. The postoperative results showed that the original shape of the glans was perfectly restored with satisfactory cosmetic appearance. The micturition function was completely restored to normal without any obvious complications. There was also no significant reduction in the sensation of amputated glans area. Hence, early meticulous microscopic replantation as soon as possible is an ideal emergency management strategy for the penile glans amputation due to circumcision.

Introduction

Around 25% of men worldwide are circumcised^1,2. Circumcision in China is mostly performed in childhood. Over the past decades, the improvements in surgical techniques and equipment have made circumcision less complicated, faster, and with fewer post-circumcision complications. However, the popularity of these devices has also brought new challenges.

The incidence of post-circumcision complications is around 1%-20%, mostly mild^3,4,5,6,7. In a recent meta-analysis, which included 351 studies with 4,042,988 participants, the overall complication risk was 3.84% (95% confidence interval 3.35-4.37)⁷. Circumcision-related glans amputation is a quite rare yet devastating injury during the surgery. Such complication is conventionally treated by simple hemostasis to achieve self-healing, early gross replantation, or delayed plastic surgery^8,9. However, these can result in permanent damage to penile appearance and function, along with psychologic problems, if not handled properly^8,9. The prevention and treatment of glans amputation have recently developed into a challenging problem for circumcision due to the increasing public health awareness and use of various suture devices in China. There are currently no existing protocols or guidelines for the treatment of such injury, which may be due to its rarity. As a result, there is no unified understanding of the injury mechanism of glans amputations, and there is a lack of early treatment management or prevention strategies.

In this study, we reported a case series of amputated penile glans caused by dispoable stapler during circumcision, which were successfully treated by microsurgery. The technical details of microsurgery were presented by video, and their possible injury mechanisms and prevention strategies were also discussed. This protocol is applicable for early microscopic replantation of all patients with penile glans amputation caused by accidental injury.

Protocol

The protocol was carried out in accordance with the principles of the Helsinki Declaration and all the methods described here have been approved by the ethics committee of Daping Hospital and written consent was obtained from the patients.

1. Instruments for operation

1. Conduct all the procedures under an operating microscope with 5-10x magnification to achieve precise anastomoses and anatomic reconstruction.

2. Inclusion and exclusion criteria

1. Use the following inclusion criteria: patients who experience penile glans amputation during circumcision; the injury of penile glans mainly contains glans and/or distal urethra.
2. Use the following exclusion criteria: penile amputation; injured not during circumcision or by disposable stapler; secondary stage repair.

3. Preparation for operation

1. Tie a rubber band at the root of the penis to stop bleeding in advance.
2. Keep the amputated glans in the sterile ice-cold saline during the transfer and before replantation.
   1. Once the glans is amputated, do not discard it.
   2. Immerse the amputated glans in about 10-20 mL of sterile normal saline (preferably sterile ice-cold saline), and wrap it with two layers of sterile gloves.
   3. Place it in an ice bucket or vacuum cup with ice and transfer it to a hospital where microsurgery can be performed as soon as possible.
3. Rinse and disinfect the amputated glans with iodophor three times before replantation.
4. Give antibiotics intravenously 30 mins before surgery. Use cefuroxime sodium 0.50-0.75 g with 100 mL of 0.9% sodium chloride solution according to patient's weight.

4. Procedure

1. Repairment of the amputated penile glans and frenulum if applicable.
   1. Remove the amputated glans from the preserved ice bag and disinfect. Observe the morphology and integrity of the glans under the microscope. If there is fragmentation, repair it first (Figure 1A).
   2. Apply 8-0 non-absorbable thread to suture the inner cavernous incision of the glans (Figure 1B). Meanwhile, use 6-0 absorbable thread to suture the tears on the surface of the glans (Figure 1C).
   3. Trim the alongside frenulum if applicable.
2. End-to-end urethral anastomosis
   1. Put the patient in a supine position.
   2. Observe and evaluate the damage of the stump of glans under the microscope (Figure 1D), and align the amputated glans and frenulum with the stump of glans. Insert an 8 Fr. Foley catheter via the urethral orifice for the drainage of urine (Figure 1E).
   3. Perform end-to-end urethral anastomosis using 6-0 absorbable thread through the intermittent suture method with precise positioning. Usually, suture one stitch at 12:00 and 6:00 o'clock of the urethra, respectively at first, and then on the base of two positioning points; suture about four stitches tightly on the left and right sides, respectively in a counterclockwise or clockwise direction (Figure 1F).
3. Anastomosis of amputated glans surface and reconstruction of the frenulum
   1. Suture the edge of amputated glans to the edge of the penile stump using 6-0 absorbable thread. Suture a few fixed points at 6, 12, 9, and 3 o'clock at first, and then suture the space between the fixed points with a space of 1 mm for each to achieve a precise anastomosis (Figure 1G).
   2. Trim the excess inner plate of prepuce on the ventral side of the penile glans if applicable.
   3. Reconstruct the frenulum by intermittent suture to achieve a satisfactory shape if applicable (Figure 1H,I).

5. Postoperative care

1. Evaluate the recovery of local blood circulation by closely observing the color of the replanted penile glans.
   NOTE: A dark red glans is expected (cherry pulp-like) and it should be observed dynamically. There are some blackish crusts on the surface after days and make sure not to remove them. Blackish crust does not mean necrosis of the amputated glans.
2. Maintain postoperative intravenous antibiotic treatment for 2-3 days and change to oral treatment for 5-7 days.
3. Keep the drainage of indwelling catheter unobstructed and remove it 1-2 weeks after the operation.

Results

Three 7-8 years old children, whose distal penile glans were completely (2 cases) or incompletely (1 case) amputated during circumcision using a disposable stapler, were admitted to the hospital within 2-3 h after injury from June 2019 to July 2021. Physical examination confirmed that about 1/3 of the distal end of the penile glans with 3-4 mm of distal urethra was completely or incompletely amputated. In one severe case, the inner plate of prepuce and frenulum on the ventral side of the glans were also seriously damaged...

Discussion

For religious or therapeutic purposes, about one-quarter of men around the world have had circumcision¹. The incidence of complications is far from negligible, approximately 1% to 20%^3,4,5,6,7. Circumcision-related glans amputation is extremely rare and there are no exact statistics depicting its incidence. Owing to its rarity, previous...

Materials

Name	Company	Catalog Number	Comments
Catheter	Guangzhou Weili Co., Ltd	12 Fr
Cefuroxime sodium	Yiyi Saite, Co., Ltd	0.75 g
Cis-atrecu besylate	Jiangsu Dongying CO.,  Ltd	10 mg
Operating microscope system	Carl Zeiss Co., Ltd	OPMI VARIO 700
Pentylpheptyl ether hydrochloride	Chengdu Lisi Co., Ltd	1.0 mg
Prolene	Ethicon, LLC	W2777/2780
Sufentanni citrate	Renfu Phermaceutical	50 µg
Vicryl	Ethicon, LLC	W9981