Archivio Italiano di Urologia e Andrologia 2017; 89, 2166 CASE REPORT Total phallic reconstruction after penile amputation for donkey bite: Case report and review of the literature Francesco De Luca 1, 2, Giulio Garaffa 3, Angela Maurizi 1, Emy Manzi 4, Carlo De Dominicis 1, David Ralph 3 1 Department of Gynaecological and Urological Sciences, Sapienza University of Rome, Rome Italy; 2 Department of Urology Azienda Ospedaliera San Camillo Forlanini, Rome Italy; 3 St. Peter's Andrology and the Institute of Urology, University College London Hospitals, London UK; 4 Department of Surgery P. Stefanini, Sapienza University of Rome, Rome, Italy. There are very few reported cases of trau- matic amputation of the male genitalia due to animal bite. The management involves thorough washout of the wounds, debridement, antibiotic prophylaxis, tetanus and rabies immunization followed by immediate reconstruction or primary wound closure with delayed reconstruction, when immediate reconstruction is not feasible. When immediate reconstruction is not feasible, long-term good functional and cosmetic results are still possible in the majority of cases by performing total phallic reconstruction. In particular, it is now possible to fashion a cosmetically acceptable sensate phallus with incorporated neourethra, to allow the patient to void while standing and to ejaculate, and with enough bulk to allow the insertion of a penile prosthesis to guarantee the rigidity neces- sary to engage in penetrative sexual intercourse. KEY WORDS: Penis; Animal bite; Phalloplasty; Male genital trauma. Submitted 6 March 2017; Accepted 27 March 2017 Summary No conflict of interest declared. ured 4 x 17 cm. The lateral skin plate, which was 14 cm long and 13 cm wide, was wrapped around the neo-ure- thra in a tube-within-a-tube fashion (3). The vascular supply was the disconnected from the forearm and the phallus was transferred to the recipient pubic region. The penile stump was disassembled with preservation of the crura, the neurovascular bundle and urethra. Inferior epi- gastric artery, long saphenous vein, deep dorsal vein of the penis, ilioinguinal nerves and deep dorsal nerve of the penis were carefully isolated and prepared for the subse- quent microsurgical anastomosis. The arterial anastomo- sis was performed between the inferior epigastric artery and the radial artery. Venous drainage was guaranteed by the deep dorsal vein of the penis and the long saphenous vein. Orgasmic sensation was guaranteed by the anasto- mosis between one of the flap nerves to the deep dorsal nerve of the penis while cutaneous sensation was ensured by the ilioinguinal nerve anastomosis. The native urethra stump was spatulated and anastomosed primarily to the phallic neo-urethra. An urethral stent and a suprapubic catheter placed in order to protect the urethral anastomo- sis whilst healing (4). The defect on the donor forearm was covered with a full- thickness skin graft (FTSG) harvested from the patient’s lower buttock creases (5) (Figure 2). After 6 months, a neo-glans was sculptured according to the Norfolk technique using a FTSG strip harvested from a relatively hairless area of the abdomen. Finally, 6 months later, a 18+1 cm long Titan Touch® inflatable penile prosthesis was inserted into the phallus to guarantee the rigidity necessary to engage in penetra- tive sexual intercourse. The crura were used to house the rear aspect of the cylinders while a Dacron® tip was fash- ioned to house the tip of the cylinders thus preventing distal erosion (Figure 3). After follow-up of 72 months from the last stage of the operation, the patient is fully satisfied with the cosmetic and functional results of surgery. He is able to void while standing and ejaculate from the tip of the phallus. Unfortunately his penile implant got infected 3 times, which required explantation and led to phallus shorten- ing. As a consequence, at present, his penile implant is 16 cm long. DOI: 10.4081/aiua.2017.2.166 CASE REPORT A 7-year old boy, living in rural Iran, was bitten through his clothing in the genital area by a donkey. The bite resulted in a partial penile amputation leaving a short penile stump while scrotum and testes were intact (Figure 1). Immediate penile reconstruction was not possible due to the absence of specialist medical facilities. Since the residual penile stump was inadequate for pen- etrative sexual intercourse, at age 23 the patient under- went total penile reconstruction with the use of a Radial Artery based Free Flap (RAFF). Total phallic reconstruction was carried out in 3 stages, each one performed at 6 monthly intervals. The first stage involved the formation of the phallus, the second stage the sculpture of the neo-glans and the last stage, the insertion of the components of a 3-pieces inflatable penile prosthesis. Preoperatively an Allen’s test was performed in to confirm the patency of the palmar arteries. The flap was formed by two sections separated by a 1 cm wide de-epithelial- ized strip. The medial section, which was tubularised to form the neo-urethra was of rectangular shape and meas- De Luca_Stesura Seveso 20/06/17 10:06 Pagina 166 167Archivio Italiano di Urologia e Andrologia 2017; 89, 2 Penile amputation due to donkey bite more common in children (60%) than adults (40%). Morbidity is directly related to the severity of the injury and to the time elapsed before seeking for medical assis- tance. Treatment includes thorough washing and irrigation with normal saline solution, debridement and broad- DISCUSSION To date, including the present case, there are 57 pub- lished cases of animal bites to male genitalia. A search was conducted using the following words: “trauma”, “male genitalia”, “penis”, “testis” and “animal bite” from December 1966 to December 2016. The majority of cases are due to dog 34 (66.6%), fol- lowed by snake 4 (7.8%), viper 2 (3.9%), horse 2 (3.9%), monkey 2 (3.9%), donkey 2 (3.9%), mule (1.9%), alligator 1 (1.9%), rat 1 (1.9%), pig 1 (1.9%), parrot fish 1 (1.9%) (Table 1 and 2). Animal bites cause penetrating genital trauma, and might increase the risk of infection. Genital bites are much Table 1. Cases reported in literature. Animal N Author Injury Man/child dog 1 Aineskog H. et al. 2016 penile skin avulsion adult parrot fish 1 Kobayashi SA, et al. 2015 avulsion of penile foreskin adult snake 1 Tamou Sambo B, et al. 2015 penoscrotal gangrene adult viper 1 Koffi NR, et al. 2015 swelling child viper 1 Hussain T, et al. 2015 swelling and hemorrhagic bullae adult dog 1 Miodrag A, et al. 2014 penile skin avulsion adult mule 1 Lakmichi MA, et al. 2011 complete penile avulsion adult rat 1 Haldar P, et al. 2011 transection of the urethra child snake 1 Kossoko H, et al. 2011 urethra injury adult dog 3 Bothra R, et al. 2011 emasculation, 2 lacerated wound child dog 1 Frank M, et al. 2010 genital avulsion adult dog 1 Saleh D, et al. 2009 lest testicular rupture adult dog 1 Bertozzi M, et al. 2009 damage of the right vas deferens child dog 1 Hon KL, et al. 2007 swelling child snake 1 Babata AL, et al. 2006 scrotum gangrene adult dog 1 Leung AK, et al. 2005 skin avulsion child dog 1 Ku JH, et al. 2005 amputation penis and testes child dog 1 Budhiraja S, et al. 2002 loss of right testis child Pig 1 Georgiou P, et al. 2001 subtotal avulsion of penile skin adult dog 8 Gomes CM, et al. 2000 5 skin loss,2 spermatic cord avulsion, 8 children horse 1 Gomes CM ,et al. 2000 1 partial penis avulsion adult donkey 1 Gomes CM, et al. 2000 1 complete scrotal avulsion adult dog 7 Cummings JM, et al. 2000 skin avulsion 4 adults 3 children monkey 2 Singla SL, et al. 1997 dog 1 Redman J. F., 1995 complete testes avulsion child alligator 1 Katlowitz NM, et al. 1995 testes avulsion dog 2 Tuggle DW et al. 1993 external genitalia loss children dog 1 Wolf et al. 1993 both testes loss child dog 1 Piza-Katzer H, et al. 1989 skin damage adult dog 2 Donovan JF et al. 1989 penile and scrotal skin avulsion children non specified animals 6 Landercasper J, et al. 1988 snake 1 Sinha SN, et al. 1975 scrotal skin necrosis horse 1 Noto L 1966 elephantiasis Table 2. Cases reported in literature. Animal N % dog 34 66,6 snake 4 7,8 viper 2 3,9 horse 2 3,9 monkey 2 3,9 donkey 2 3,9 mule 1 1,9 alligator 1 1,9 rat 1 1,9 pig 1 1,9 parrot fish 1 1,9 Figure 1. Penile amputation. Figure 2. Donor site forearm. Figure 3. Phalloplasty with penile prosthesis. De Luca_Stesura Seveso 20/06/17 10:06 Pagina 167 Archivio Italiano di Urologia e Andrologia 2017; 89, 2 F. De Luca, G. Garaffa, A.a Maurizi, E. Manzi, C. De Dominicis, D. Ralph 168 spectrum antibiotics prophylaxis, as the main risk is infection. Primary closure is often recommended in most cases delaying reconstructive surgery to a later date. When the victim is a child, or the wound has been caused by an animal, infectious complications are usual- ly minor, as medical treatment is sought reasonably quickly. Pasterurella multocida is often present (20-50% of dog bites). Cellulitis often results in premature sepsis (within 24 hours). Antibiotic treatment should be broad-spectrum beta-lac- tam with beta-lactamase inhibitors. Fluoroquinolones, cotrimoxazole or chloramphenicol are valid alternatives. The duration of treatment should be individualised and last at least 10-14 days. Rabies vaccination will depend on local sanitary policy. Appropriate tetanus vaccination is required. REFERENCES 1. Lakmichi MA, Wakrim B, Jarir R, et al. Mule bite to male geni- taliawith complete penile and anterior urethra amputation: unsual case and review of the literature. ISRN Urol. 2011; 2011:723154. 2. Evgeniou E, Markeson D, Iyer S, et al. The management of ani- mal bites in the United Kingdom. Eplasty. 2013; 13:e27. Print 2013. 3. Garaffa G, Raheem AA, Christopher NA, et al. Total phallic reconstruction after penile amputation for carcinoma. BJU Int. 2009; 104:852-6. 4. Massanyi EZ, Gupta A, Goel S, et al. Radial forearm free flap phalloplasty for penile inadequacy in patients with extrophy. J Urol. 2013; 190(4 Suppl):1577-82. 5. Doornaert M, Hoebeke P, Ceulemans P, et al. Penile reconstruc- tion with the radial forearm flap: an update. Handchir Mikrochir Plast Chir. 2011; 43:208-14. Correspondence Francesco De Luca, MD (Corresponding Author) francescodeluca10@gmail.com Angela Maurizi, MD angmau81@hotmail.com Carlo De Dominicis, MD carlo.dedominicis@uniroma1.it Viale dell'Università, 31/33, 00161 Roma, Italy Giulio Garaffa, MD giuliogaraffa@gmail.com David Ralph, MD dralph@andrology.co.uk 145 Harley Street London W1G 6BJ (UK) Emy Manzi, MD emymanzi@gmail.com Viale del Policlinico 155, 00161 - Roma, Italy De Luca_Stesura Seveso 20/06/17 10:06 Pagina 168