CASE REPORT Successful Penile Replantation With Cavernoglandular Shunt Procedure In Urban Setting: A Case Series Exsa Hadibrata1*, Awang Dyan Purnomo1, Mars Dwi Tjahjo1, Andrian Rivanda2, Ahmad Farishal2 1Urology Department, Faculty of Medicine Lampung University / Abdul Moeloek General Hospital, Lampung, Indonesia. 2Medical Doctor, Faculty of Medicine Lampung University, Lampung, Indonesia. *Correspondence: Urology Department, Faculty of Medicine Lampung University / Abdul Moeloek General Hospital, Lampung, Indonesia. Tel: +62 821 8326 6655. Email: exsa.hadibrata@gmail.com. Received October 2020 & Accepted February 2021 Purpose: Traumatic penile amputation is a rare case with various etiologies. Penile reconstruction using replan- tation technique should be performed to prevent the decline of patients quality of life even in areas with limited facilites. Material and Methods: We report three cases of total penile amputation in children after circumcision, who were successfully replanted by macro-surgical technique and cavernoglandular shunt procedure. Results: Postoperative follow-up showed promising results with good micturition, erectile function, cosmetic, and minimal complications. Conclusion: Matters affecting the successful penile replantation in macro-surgical techniques have been discussed. In addition, we also highlight the potential of cavernoglandular shunt procedure that can be used as an alternative treatment for penile replantation in limited facilities. Keywords: amputation; cavernoglandular shunt; penis; replantation INTRODUCTION Traumatic penile amputation is a rare medical emergency case worldwide. Penile amputation can be caused by self-inflicting amputation, felonious assault, or accidental trauma(1). Since it is a rare case, there were only a few pieces of literatures reporting penile amputation incidences worldwide(2), and up until now, there is no litera- ture reporting the prevalence of penile amputation in Indonesia. Penile amputation can cause psychological effects Urology Journal/Vol 18 No. 5/ September-October 2021/ pp. 573-576. [DOI: 10.22037/uj.v18i.6495] Figure 1: Case 1, The cut located above corona glands (a) and (b), Anastomosis of his urethra and the cavernosal bodies (c), cavernoglan- dular shunt procedure (d), after replantation (e), 2-months follow up after replantation (f) such as loss of self-esteem and depression. Besides that penile amputation can also cause dysfunction of sexual function and micturition which affect the patients qual- ity of life(3). Penile amputation is a medical emergency case that needs prompt treatment to prevent complica- tions such as bleeding, infection, urethra stricture, and sexual dysfunction(4). One of the techniques developed to treat penile amputa- tion is penile replantation. In early 1978, there was two successful replantation of penile amputation by using micro-replantation reported(5). Micro replantation is the gold standard for the treatment of penile amputation. Unfortunately, this technique must be done in a hospi- tal that is completed with microsurgery equipment. In 1929 Ehrich et al. reported a case of penile amputation treated with macro surgery. He reported that the patient had a good outcome following the surgery. The out- comes were normalized of micturition and sexual func- tion within 2 years following the surgery(6). Based on this report, macro surgery can be used as an alternative approach to treating patients with penile amputation in limited resource hospitals. In this case series, we re- ported a series of penile amputation treated with macro surgery procedure by using cavernoglandular shunt, we elaborate on the outcome of our patients. PATIENTS AND METHODS In the last two years, We had three patients, age range from 7 to 10 years. The patients came to our emergency room with total penile amputation 6 hours post circum- cision with a penile specimen amputated using a 0.9% saline solution bag in an icebox. All cases were carried out at a mass circumcision event performed by an inex- perienced person under local anesthesia with the guillo- tine technique. On physical examination, the penis was completely amputated from the glans penis. In the first case, the cut was located above the corona glands (Fig- ure 1), and in the other two cases, the cut was located in the midshaft of the penile (Figure 2b and 3b). The patient was taken immediately to the operating room under general anesthesia. The cut surfaces were cleaned with sterile saline, an 8-Fr nasogastric tube or 8-Fr Foley catheter was inserted through the urethra of the amputated part, distal urethral into bulbar part [Figure 2c]. The same technique of replantation was ap- plied in all cases with macrosurgical repair of corpus cavernosum and urethra without arterial-venous anasto- moses. Anastomose corpus cavernosum was performed using synthetic monofilament non-absorbable suture 6/0 with continuous without locking suture technique (Figure 1c). Anastomose urethra uses 6/0 synthetic Case Report 413 Penile Replantation With Cavernoglandular Shunt-Hadibrata et al. Figure 3. Case 3, the cut located in the midshaft of the penile (a) and (b), after replantation (c), 2-months follow up after replantation (d) Case Report 574 Figure 2: Case 2, the cut located in the midshaft of the penile (a) and (b), 8-Fr Foley catheter was inserted transurethrally through the distal amputated part (c), after replantation (d), cavernoglandular shunt procedure (e), case 2 had meatal stenosis and already done me- atotomy (f) monofilament absorbable suture with a simple suture technique. After an anastomose, a cavernoglandular shunt procedure was performed using a 16G needle contained with heparin at a dose of 50 – 70 IU/kgBW was injected into the glans penis to the corpus caverno- sum (Figure 1d). A Cavernoglandular Shunt procedure improves venous circulation and arterial feeding from cavernosal imbibition. After replantation surgery, intravenous antibiotics and analgetics were given. The nasogastric tube or Foley catheter was maintained and then the wound dressing was performed using a petroleum gauze combined with sterile gauze around the glans to keep the penis immo- bilized. Wound care was carried out every day using 0.9% Nacl solution to clean the wound, After that, use tulle and moist Nacl gauze to dress the wound. The cavernoglan- dular shunt and heparin injection of 50-70 IU/kgBW dose was done through the glands to the corpus cav- ernosum during wound care by using sterile needle sized 16G once a day for 7 days (Figure 2e). Prior to this procedure, a topical spray of lidocaine was per- formed to reduce pain. After the 14th day of treatment, the catheter or nasogastric tube was removed then the patient was allowed to be outpatient on the 15th day. RESULTS In follow up 2 months after replantation, one case had meatal stenosis and had already done meatotomy [Figure 2f], the other cases did not show any surgical complications [Figure 1f and 3d]. Overall cases showed normal urinary flow, normal sensation in the glans pe- nis and good erectile function which was rated by early morning erection. DISCUSSION The successful rate of penile replantation is influenced by the blood flow of sinusoidal-corporal to the distal of the penis (glans penis)(7). Cavernoglandular shunt is a technique commonly used to treat patients with pri- apism(8). The technique was done by insertion of 16G needle through glands penis to corpus cavernous. The purpose of the technique is to create an iatrogenic fis- tula to make an outflow for the blood from the corpus cavernous(9). Heparin injection during this technique was done to prevent blood clots which can blockade the drainage of the vein and imbibition of the cavernosal artery. The outcome of those three cases was as good as the technique used by the microsurgery technique. Due to the limitation of resources in our hospital and the small size of the cavernous artery, we did not ma- nipulate the dorsal artery of the penis and the cavernous artery. The previous study by Landstorm et al (2004) showed that the healing of the cavernous artery will increase the viability of penile replantation(10). In this case series, we did not do anastomose of the cavernous artery and it did not affect the treatment outcome, so we concluded that anastomoses of the cavernous artery are not always needed in penile replantation procedure. Of the three cases above, the follow-up and wound care were done every day during hospitalization. We used normal saline to create a moist environment that has been proven to facilitate the healing process of the wound by preventing dehydration and enhancing angi- ogenesis and collagen synthesis together with increased breakdown of dead tissue. The puncture through the glans penis to the corpus cavernous with an injection of heparin was done daily during hospitalization to make sure good vein drainage and imbibition of the cavern- ous artery. Post-surgery monitoring was done by visual analysis. The outcome of the procedure was good, although the second case suffered from meatal stenosis. This was a common complication following the penile replantation procedure(11). The other minor complications that can happen following micro and macro surgery are delayed wound healing or loss of sensation on the distal part of the penis(2,4). Fortunately, we did not find any of that complication in our patients. This case series showed that there are no differences in outcome and compli- cations after the procedure between macro surgery and microsurgery replantation. For this reason, macro sur- gery replantation with a cavernoglandular shunt can be used as an alternative in replantation procedures espe- cially in hospitals with limited facilities. CONCLUSIONS Based on our literature searching, this is the first case series reporting the use of cavernoglandular shunt tech- nique as a combination of vascularization repair tech- nique without arterial anastomosis in penile replantation procedure with promising visual and functional results. This method can be used as an alternative procedure to replantation in a hospital with limited facilities. For more objective evaluation, Doppler is advisable to use as a measure of the success of the revascularization pro- cedure. 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