LAUSR

Penile amputation is a rare injury that requires emergent surgical intervention and replantation. Trauma, iatrogenic injuries (traumatic circumcisions), and self-mutilation are the main causes [1]. Microsurgery is the preferred method for penile replantation to reduce postoperative complication rates. As a novel microsurgical tool, incorporation of the da Vinci robotic platform (Intuitive Surgical Inc., Sunnyvale, CA, USA) to standard microsurgical procedures has been demonstrated in various surgical disciplines including plastic surgery, otorhinolaryngology, orthopedics, and urology [2, 3]. SPY Elite laser angiographic system (Lifecell, Inc/Novadaq Technologies, Concord, Ontario, Canada) is another novel and effective method in order to demonstrate tissue perfusion, ischemia, and skin necrosis [4]. To the best of our knowledge the use of robotic assistance in penile replantation has not been previously reported. In this report, we present a case of self-inflicted penile amputation treated with robot-assisted microsurgery and managed with SPY angiography, postoperatively. A 35-year-old male patient with a 22-year history of schizophrenia was referred to the emergency room for complete penile amputation. The patient was hemodynamically stable. The length of the penile stump was 2 cm from mons pubis (Fig. 1a). The flaccid length of the amputate was 7 cm (Fig. 1b). The amputate was kept under appropriate conditions. The patient was consulted to the psychiatry department and an informed consent was obtained from his father before the surgery. Total cold ischemia duration was 7 h. The amputate was brought to the operating room before the patient. The superficial dorsal veins, deep dorsal vein, left-sided dorsal penile artery, and a total of six deep dorsal nerves were identified, dissected, and tagged under the microscope. The patient was prepped and draped under general anesthesia. The penile stump, urethra, corpus cavernosum, and corpus spongiosum were prepared by urology team. We were not able to find right dorsal penile artery within both the penis stump and the amputate. Urology team performed urethrourethrostomy over an 18F urethral catheter and corporoplasty by placing 4-0 and 3-0 absorbable interrupted sutures, respectively. The da Vinci robotic platform was docked for the dorsal penile artery anastomosis. We used Black-Diamond microforceps for the left hand and needle driver for the right hand and a total of 8 interrupted 9.0 nylon sutures were placed (Fig. 1c). The deep dorsal vein and superficial dorsal vein, were anastomosed using 9.0 nylon sutures. A total of six deep dorsal nerves (three right and three left) were coaptated using 8.0 nylon sutures (Fig. 1d). Refill of the glans penis was found to be optimal and the needle prick test showed bright red blood. Bucks fascia and skin were closed and the patient was taken to the intensive care unit. Six hours after the replantation, signs of venous congestion were seen in the glans penis. The patient was urgently taken to the operating room. Both deep and superficial dorsal veins were found to be occluded. A vein graft of 1.5 cm from small saphenous vein was harvested and interposed between the two ends of deep dorsal vein. Superficial dorsal vein was anastomosed with a better proximal vein. Patency of the arterial microanastomosis was intact. Following the venous revision surgery, the patient was again transferred to the intensive care unit. Subcutaneous injection of 0.4 ml enoxaparin was administered daily and ceased following discharge. Hundred milligrams of acetylsalicylic acid was given daily and continued for 1 month following discharge. The avulsed skin over the dorsum of penis became necrotic 4 days after the replantation. There was no hematoma or glans necrosis. Perfusion was confirmed by SPY angiography (Fig. 1e). Necrotic penile skin was debrided * Mahmut Muhsin Yilmaz [email protected]