Receiving this distinguished mentor award from the AUA is an honor and a reminder of the profound impact mentorship can have on both mentor and mentee. I am thankful for the opportunity to contribute to the personal and professional development of others in my community, my country, and the world.

Wayne J.G. Hellstrom

Penile amputation is a morbid injury (Figure 1) that needs early urological assessment and surgical treatment.¹ Delayed correction will result in severe physical and psychological sequelae. Psychiatric disorders (schizophrenia and Klingsor syndrome), extreme religious piety, and substance abuse are the most common etiologies for self-inflicted amputation, while trauma, violent criminal acts, and cultural traditions may be other causes.^2-5

The first reported surgical replantation was in 1929.⁶ A half century later, the first penile and scrotal microneurovascular reports were published concurrently.⁷,⁸ The assumption has been promulgated that microsurgical repair is the gold standard for surgical management and penile amputation. However, almost 100 years after the publication of the first case, we still have a limited number of case reports and literature reviews. Until now, there have been no standardized stratification criteria for evaluating initial injuries and treatments, thereby impeding the comparison of cases and outcomes.

The traditional approach is to place the penile appendage (if a total amputation) in a sterile bag within an ice slush container. Hypothermia is considered crucial for a successful replantation, although a successful replantation has been reported after 24 hours of warm ischemia time. Penile tissue has adapted to longer times in low oxygenation states. The patient needs to be resuscitated and stabilized, both hemodynamically with transfusion and medically with psychiatric medications. The genital region is carefully debrided, and a proximal, wrapped penile Penrose drain may be used to prevent further blood loss. The neurovascular structures are identified. A Foley catheter is placed, the urethral anastomosis is accomplished, and the tunica albuginea is closed with 2-0 sutures. If plastic surgery is available, a microsurgical anastomosis of the dorsal artery, dorsal vein, and dorsal nerve is performed. The subcutaneous tissues (Buck’s and Colles fasciae) are closed, and an optional suprapubic tube is placed (Figure 2).

The aim of our study was to conduct the most extensive review of the current literature on penile amputation and replantation, using both PubMed and Embase databases. We reviewed 432 full-text articles in 20 different languages, of which only 163 provided sufficient data for analysis (123 microsurgical and 40 surgical replantations).¹⁰ Several inconsistencies were noted in the literature, particularly a lack of uniformity in describing the initial evaluation of penile injuries. Therefore, we recommended the use of the Penile Amputation Case-Key Assessment Guidelines (PACKAGE) Checklist, which highlights essential aspects that should be reported in future publications concerning penile amputation or replantation cases and series (Table 1).

Table 1. PACKAGE Checklist

We also identified a lack of semantic consistency in the literature, particularly concerning the terms self-amputation versus autoamputation and reimplantation versus replantation. The interchangeable use of self-amputation and autoamputation in the literature is imprecise and confusing. Self-amputation refers to an action performed by oneself, whereas autoamputation refers to a passive action such as a spontaneous detachment often associated with penile cancers or appendage infections. Similarly, reimplantation implies a repeated procedure involving the repositioning of a previous implant in a nearby or original organ area, such as a ureteral reimplant, whereas replantation suggests reattaching an organ or appendage to its original location, such as a limb replantation. To clarify, we proposed standardizing the use of the terms self-amputation and replantation in future case reports.

Moreover, we found a lack of standardized descriptions for injuries and procedures in our literature review. For instance, some authors did not specify the number of nerves and vessels repaired during replantation, only stating they reconnected the nerve or vessel. Additionally, the term distal injury varied across the literature, referring to either an amputated glans or an amputation at the distal shaft depending on the author. To address these inconsistencies, we developed the PENIS score, which grades injuries from 1 to 5 (from least to most severe), to provide a standardized quantitative evaluation (Table 2).

Table 2. PENIS Score

Our analysis revealed that less than half of surgical reports on penile replantation provided sufficient detail to fully assess all PENIS score criteria. Among the reports that were either fully or partially completed, the viability rates for penile microsurgical and surgical replantation were equivalent at 92% and 94%, respectfully. Surgical complications were similar for both microsurgical and surgical approaches. Additionally, the preservation of a skin bridge was linked to a 40% reduction in severe postoperative complications. Microsurgical and surgical approaches demonstrated equivalent rates of recovery for both erections and urinary function.

Surprisingly, microsurgical replantation with or without nerve repair resulted in similar rates of penile sensation recovery. However, microsurgical replantation (even without nerve repair) led to significantly higher rates of penile sensation recovery compared to surgical replantation. This may be due to microsurgical revascularization, which delivers growth factors and nutrients that may promote spontaneous neuroregeneration, potentially explaining the notable increase in the return of sensation in such cases.

In summary, replantation after penile amputation should always be considered, and a prompt referral to a microsurgical unit is optimal. However, if no microsurgical service is available in a reasonable time frame, traditional surgical replantation is a suitable alternative with comparable outcomes. There is no statistically significant difference between microsurgical and surgical replantation in terms of replantation survival, postoperative complication rates, or recovery of erectile function and normal urination. However, microsurgical replantation, with or without nerve repair, results in improved recovery of penile sensation. Implementing the PENIS score and PACKAGE Checklist will enable more robust conclusions in future studies.