Penile trauma is difficult physical and psychological problem and rare because the penis is mobile and largely protected by its position; however, in erect state in adult, penis becomes more prone to trauma . Penile trauma has different underlying causes ? it may be iatrogenic or caused by motor vehicle accidents, child abuse, animal bites, gun shoot or self-mutilation [2-5]. Reports of trauma to the external genitalia are sporadic; the type and extension of penile trauma varies in severity from small to more serious injuries and total emasculation. We present our experience with severe penile injuries in unusual cases and choice of their treatment.
Material and methods
We retrospectively analyzed 34 patients aged from 10 to 52 years (mean 28 years) treated for penile injury in the period from March 1999 to August 2004. Etiology was different: traffic accident, burn, iatrogenic, electrocution, gun shoot and self-mutilation trauma. All injuries were classified in three groups: complete avulsion, penetrating injury and amputation. Different procedures for treatment of these injuries were used according to the case. Approach was individualized and based on using available vital penile tissue combined with different pedicled or free flaps and grafts (table 1).
Case 1. A 19-years-old boy was injured in traffic accident by prolonged contact with exhaust pipe of the car. Burning trauma involved 30% of the body including penile skin which was completely destroyed. Patient was referred to us six months after injury with completely trapped penis. Since the most surrounding skin was damaged and scarred, femoral pedicled flap was created and wrapped around the penile shaft, previously dissected from the scar tissue. Three months later the flap was divided from its base and reconstruction of the penile body was completed. Good aesthetic and functional outcome was achieved after two repeated liposuctions and fatty reduction of the new penile skin (Figs. 1-5).
Case 2. A 22-years-old man with penetrating penile injury due to traffic accident was admitted one year after trauma. Penis was completely burned ventrally. During surgery, midshaft urethral injury, as well as partial loss of ventral tunica albuginea were noted. This tunica defect resulted in severe ventrolateral curvature. The anterior urethra was mobilized and directly anastomozed. Curvature was corrected by incisional corporoplasty. Reconstruction of the penile body skin was done using vascularized sliding flaps created from remaining penile skin (Figs. 6-9).
Case 3. A 41-years-old man was injured in a traffic accident, by contact with exhaust pipe. Six months after the trauma, severe deformities of the penis were obvious. Dorsally, glans and penile severe curvature was noted. After scar resection, the distal part of the left corpora cavernosa were missing, while the tip of the right one was fibrous. Corpora cavernosa were reconstructed by joining the right corporal tip and remaining left one. The penile body skin was reconstructed using remaining sliding skin flaps. Six months later, hyaluronic acid was injected into the glans for its better sculpturing (Figs. 10-15).
Case 4. A 15-years-old boy was referred to us six months after injury caused by electrocution during voiding on high-voltage electric-current wire. He presented with penile shaft amputation and fibrotic remnants of corpora cavernosa. Three fingers of the left hand were also amputated. This patient underwent radial forearm fasciocutaneous flap phalloplasty. Two staged urethroplasty was performed using buccal mucosa graft. Initially, semirigid penile prosthesis was implanted to prevent neophallus retraction and replaced later by bicomponent inflatable penile prosthesis (Excel-Mentor). Glanular resculpturing was simultaneously performed during staged surgery  (Figs. 16-23).
Case 5. A 11-years-old child presented with difficult psychological problems due to iatrogenic penile amputation. He underwent exstrophy-epispadias repair in newborn elsewhere. Mitrofanoff stoma was created for bladder empting. We decided to perform total phalloplasty using musculocutaneous latissimus dorsi flap. The length of the neophallus is 16 cm. It is longer then normal for the age, but adequate for the adult, since the neophallus does not follow genital but only somatic growth. Psychological state of the child after surgery is completely improved. This patient is awaiting penile prosthesis implantation after puberty (Figs. 24-27).
Case 6. A 19-years-old man underwent congenital ventral penile curvature repair elsewhere. On physical examination corporal bodies and glans were missing due to vascular injury during initial surgery. Most of the penile skin survived. This patient underwent several surgical procedures. First, semirigid penile prosthesis were implanted into the remaining penile stumps proximally and covered with remaining skin distally. Three months later, urethroplasty with inlay buccal mucosa graft was started. Tubularization of the flap was done six weeks after initial procedure. To gain urethral coverage good vascularized flap from the scrotal skin was harvested. Finally, semirigid prosthesis was replaced with bicomponent inflatable prosthesis (Excel-Mentor). Functional results (voiding and erection) are satisfactory with acceptable aesthetic appearance (Figs. 28-36).
Case 7. A 20-years-old psychiatric patient performed glans self-mutilation in local anesthesia. Glans reconstruction was done using remaining inner preputial layer. Six months later glanular corona was created by injection of hyaluronic acid. Esthetic outcome is very good (Figs. 37-39).
The follow-up was from 6 months to 6 years (mean 2,8 years). The causes of penile injury in these series were traffic accidents (14 pts. -41%), iatrogenic trauma (13 pts. -38%), self-mutilation (2 pts. -6%), electrocution (1 pt. -3%), burns (2 pt. -6%) and gun shoot trauma (2 pt. -6%). Results of our treatment are showed in table; good aesthetic and functional results, including satisfactory sexual intercourse, were found in 30 patients (88%). In 4 cases with penile amputation complications occurred and required additional treatment; there were infection after penile prosthesis implantation in one and urethral complications (one stenosis and two fistulas) in three cases.
Severe penile injuries are rarely reported and caused by different mechanisms ? it may be iatrogenic or caused by traffic accidents, child abuse, animal bites, gun shoot or self-mutilation. Iatrogenic injuries are commonly reported after circumcision or difficult penile surgeries performed by inexperienced urologists (hypospadias, epispadias or curvature repairs). Despite the different mechanisms of injury, the end results of severe penile trauma vary from penile avulsion to total emasculation [2-5].
The management of penile injury depends on its mechanism and duration before presentation. Treatment should be taken immediately to prevent delayed complications such as infection, curvature, erectile dysfunction, missed urethral injury and chronic pain . However, severe penile trauma can be associated with injury of adjacent organs (scrotum, pelvis, buttock, tight) and staged treatment is recommended. There are yet no written algorithms for the treatment of severe penile trauma after stabilization of the patient. The reconstructive goals are to rebuild a penis of good conformation and to restore function. Well vascularized remaining penile tissues should be augmented with judicious use of grafts, flaps, fillers, and prosthetic components. The challenge of penile reconstructive surgery for the resourceful urologist is to blend time honored concepts with the latest technologies creating a uniquely eclectic approach. Patient needs may best be served at medical centers staffed with such reconstructive urologists who interfacing with allied disciplines will offer counsel regarding the various options, their pros and cons, and the anticipated post operative course.
We treated 34 patients with severe penile injury during five years. The most common causes were traffic accident with prolonged burns and iatrogenic injuries after repair of congenital penile anomalies. Although the treatment should undertaken immediately , all of our patients referred to us several months after injury. This way, their reconstruction included usage of all remaining penile tissue combined with local flaps and grafts. Good results of penile body reconstruction were achieved using various surrounding vascularized flaps. In penetrating injuries, corporal deformities were repaired depending on case. Urethral reconstruction included simple closure with watertight, spatulated, catheter-stented technique and absorbable suture. The most severe cases underwent staged repair.
Penile amputation may be treated by different free transfer flaps for partial or total phallic replacement . We usually used musculocutaneous latissimus dorsi flap due to its advantages. Neophallus has excellent length and circumference. It is important for phalloplasty in children when difficult psychological problems are occurred. Neophallic size in children should have an adult size since it follows only somatic growth. Neophallic retraction is more less then in fasciocutaneous phalloplasty (forearm flap) since muscle tissue could prevent contraction and makes penile prosthesis implantation much easier. Disadvantage is inability to provide protective sensitivity although anastomosis between thoracodorsal and ilioinguinal nerve could be promising. Implantation of semirigid prosthesis is recommended three months after phalloplasty to prevent phallic retraction. It could be replaced later with inflatable prosthesis. Corporeal remnants are very useful for proximal support of the cylinders and should be used always. In cases where penile stamps are absent, cylinders base can be extended with vascular prostheses to allow its fixation to the pubic periost .
There are no specific guidelines for the treatment of severe penile injury which is a complex and multifaceted subject. Care must be taken with goal of optimizing long-term sexual, cosmetic and voiding outcomes. Penile reconstructive surgery is a challenging and technique driven activity, perhaps best undertaken by experienced urologists working with a team of associates in allied specialties.