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AUA AWARD WINNERS Penile Amputation and Replantation: Novel PENIS Scoring Criteria and Proposal of the PACKAGE Checklist

By: Bruno L.C. Machado, MD, University of Arkansas for Medical Sciences, Little Rock; Wayne J.G. Hellstrom, MD, FACS, Tulane University School of Medicine, New Orleans, Louisiana | Posted on: 17 Jul 2024

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

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Figure 1. Penile amputation. Reprinted with permission from the Indian Journal of Plastic Surgery (2013;143-146), Indian Journal of Plastic Surgery.1

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).

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Figure 2. Replantation of a penile amputation. Reprinted with permission from the Indian Journal of Plastic Surgery (2016; 49[1]:99-105), ©Indian Journal of Plastic Surgery.9

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

Topic Item Checklist Description
Title 1 The terms penile replantation and/or penile amputation should appear in the title. Case report can also help identify relevant literature. Avoid inaccurate terms such as reimplantation, autoamputation, and self-amputation to prevent further obscuration of the literature and to facilitate more efficient literature searches for future reviews.
Keywords 2 Case reports on penile amputation, with or without replantation, should include penile amputation, penile replantation, microsurgical or surgical, and case report specifiers.
PENIS Description and Score 3a Utilize the PENIS score to outline the description of the amputation and replantation. Describe whether preparation of the appendage required simple irrigation, debridement of contamination such as dirt, or debridement of nonviable tissue. Include the rationale for which neurovascular structures were repaired. Specify surgical details describing how the repair was performed; the number of veins, arteries, and nerves anastomosed; time from injury to intervention; and the length of warm and cold ischemia as separate values.
3b If the journal permits, photographs of the penis before and immediately after replantation should be included. Should they arise, include photographs of any complications as well as the final cosmesis following resolution.
Intervention 4a Preoperative patient optimization—explicitly state whether psychological support was offered or utilized.
4b Interventions—It is important to describe the rationale for choosing the intervention (eg, reconstruction due to missing appendage, unsalvageable necrosis or ischemic damage, surgical replantation due to lack of microsurgical expertise, no intervention due to lack of available surgical expertise or patient refusal).
Follow-up and Outcomes 5a Main outcome measures—Whenever possible, report uroflowmetry trends, IIEF-5 and/or EHS and IPSS scores for outcome measures. EHS is not preferred and should only be utilized in cases where evaluation with IIEF-5 is complicated by patient cooperation or other factors that make detailed evaluation difficult.
5b All complications and adverse or unanticipated events relevant to penile replantation should be described in detail and ideally categorized in accordance with the Clavien-Dindo classification (eg, wound complications, re-exploration or revision of anastomosis, reamputation). Explicitly state if there were no complications or adverse outcomes.
Abbreviations: EHS, Erection Hardness Score; IIEF-5, International Index of Erectile Function; IPSS, International Prostate Symptom Score; PACKAGE, Penile Amputation Case-Key Assessment Guidelines; PENIS, P for position along the shaft, E for extension through the penis, N for neurovascular repair, I for ischemia time and type, and S for severed edge condition and contamination.
Adapted with permission from Tran et al, Sex Med Rev. 2023;11(3):278-290.10

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

Grade
PENIS Criteria 1 2 3 4 5
P Position along the shaft ≤2 cm distal to the base >2 cm distal to the base and >0.5 cm proximal to the glans <0.5 cm proximal to the glans Total penile amputation including 1 testis Total penile amputation including both testes
E Extension through the penis Past the fascia, but <50% of the penile diameter, without urethral involvement >50% of the penile diameter, without urethral involvement >50% of the penile diameter, with incomplete section of the urethra Partial amputation, with a skin bridge, and complete section of the urethra Complete amputation
N Neurovascular repair 2+ veins, 2+ arteries, and 1+ nerves 2+ veins and 2+ arteries 2+ veins and 1 artery 1 vein 0 veins
I lschemia time and type <1 h warm and <2 h cold <1 h warm and 2-6 h cold <1 h warm and >6 h cold 1-2 h warm >2 h warm
S Severed edge condition and contamination Smooth edge requiring only irrigation Jagged edge requiring only irrigation Smooth edge +/- contamination requiring minor debridement Jagged edge +/- contamination requiring minor debridement Tissue damage requiring extensive debridement
Note: PENIS scores are reported as P1-5, E1-5, N1-5, I1-5, S1-5 with a superscript S for self-inflicted and E for external. Subscript numbers distinguish Extension and Severed edge scores from Erection and Sensation scores.
Adapted with permission from Tran et al, Sex Med Rev. 2023;11(3):278-290.

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.

  1. Petkar K, Lateef S, Vyloppilli S, Krishnakumar KS. Penile replantation. Indian J Plast Surg. 2013;46(1):143-146. doi:10.4103/0970-0358.113736
  2. Khan MK, Usmani MA, Hanif SA. A case of self-amputation of penis by cannabis induced psychosis. J Forensic Leg Med. 2012;31(6):355-357.
  3. Aggarwal G, Adhikary SD. Klingsor syndrome: a rare surgical emergency. Ulus Trauma Acil Cerrahi Derg. 2017;23(5):427-429.
  4. Tsanakalis F, Almadhyan A, Flondell-Sité D. A rare case of complete male genital self-amputation posing challenges in the psychiatric diagnosis and management. Heliyon. 2021;7(6):e07349. doi:10.1016/j.heliyon.2021.e07349
  5. Bhanganada K, Chayavatana T, Pongnumkul C, et al. Surgical management of an epidemic of penile amputations in Siam. Am J Surg. 1983;146(3):376-382.
  6. Ehrich WS. Two unusual penile injuries. J Urol. 1929;21(2):239-241. doi:10.1016/S0022-5347(17)73098-4
  7. Cohen BE, May JW, Daly JS, Young HH. Successful clinical replantation of an amputated penis by microneurovascular repair: case report. J Plast Reconstr Surg. 1977;59(2):276-280. doi:10.1097/00006534-197759020-00023
  8. Tamai S, Nakamura Y, Motomiya Y. Microsurgical replantation of a completely amputated penis and scrotum: case report. Plast Reconstr Surg. 1977;60(2):287-291. doi:10.1097/00006534-197708000-00028
  9. Garg S, Date SV, Gupta A, Baliarsing AS. Successful microsurgical replantation of an amputated penis. Indian J Plast Surg. 2016;49(01):99-105. doi:10.4103/0970-0358.182257
  10. Tran AA, Machado BLC, Kuykendall KH, et al. The Revised PENIS Score and proposal of the PACKAGE Checklist: a meta-epidemiologic study on penile amputation and replantation. Sex Med Rev. 2023;11(3):278-290. doi:10.1093/sxmrev/qead005

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