Microscopic Replantation of Penile Glans Amputation Due to Circumcision

Around 25% of men worldwide are circumcised^1,2. Circumcision in China is mostly performed in childhood. Over the past decades, the improvements in surgical techniques and equipment have made circumcision less complicated, faster, and with fewer post-circumcision complications. However, the popularity of these devices has also brought new challenges.

The incidence of post-circumcision complications is around 1%-20%, mostly mild^3,4,5,6,7. In a recent meta-analysis, which included 351 studies with 4,042,988 participants, the overall complication risk was 3.84% (95% confidence interval 3.35-4.37)⁷. Circumcision-related glans amputation is a quite rare yet devastating injury during the surgery. Such complication is conventionally treated by simple hemostasis to achieve self-healing, early gross replantation, or delayed plastic surgery^8,9. However, these can result in permanent damage to penile appearance and function, along with psychologic problems, if not handled properly^8,9. The prevention and treatment of glans amputation have recently developed into a challenging problem for circumcision due to the increasing public health awareness and use of various suture devices in China. There are currently no existing protocols or guidelines for the treatment of such injury, which may be due to its rarity. As a result, there is no unified understanding of the injury mechanism of glans amputations, and there is a lack of early treatment management or prevention strategies.

In this study, we reported a case series of amputated penile glans caused by dispoable stapler during circumcision, which were successfully treated by microsurgery. The technical details of microsurgery were presented by video, and their possible injury mechanisms and prevention strategies were also discussed. This protocol is applicable for early microscopic replantation of all patients with penile glans amputation caused by accidental injury.

The protocol was carried out in accordance with the principles of the Helsinki Declaration and all the methods described here have been approved by the ethics committee of Daping Hospital and written consent was obtained from the patients.

1. Instruments for operation

1. Conduct all the procedures under an operating microscope with 5-10x magnification to achieve precise anastomoses and anatomic reconstruction.

2. Inclusion and exclusion criteria

1. Use the following inclusion criteria: patients who experience penile glans amputation during circumcision; the injury of penile glans mainly contains glans and/or distal urethra.
2. Use the following exclusion criteria: penile amputation; injured not during circumcision or by disposable stapler; secondary stage repair.

3. Preparation for operation

1. Tie a rubber band at the root of the penis to stop bleeding in advance.
2. Keep the amputated glans in the sterile ice-cold saline during the transfer and before replantation.
   1. Once the glans is amputated, do not discard it.
   2. Immerse the amputated glans in about 10-20 mL of sterile normal saline (preferably sterile ice-cold saline), and wrap it with two layers of sterile gloves.
   3. Place it in an ice bucket or vacuum cup with ice and transfer it to a hospital where microsurgery can be performed as soon as possible.
3. Rinse and disinfect the amputated glans with iodophor three times before replantation.
4. Give antibiotics intravenously 30 mins before surgery. Use cefuroxime sodium 0.50-0.75 g with 100 mL of 0.9% sodium chloride solution according to patient's weight.

4. Procedure

1. Repairment of the amputated penile glans and frenulum if applicable.
   1. Remove the amputated glans from the preserved ice bag and disinfect. Observe the morphology and integrity of the glans under the microscope. If there is fragmentation, repair it first (Figure 1A).
   2. Apply 8-0 non-absorbable thread to suture the inner cavernous incision of the glans (Figure 1B). Meanwhile, use 6-0 absorbable thread to suture the tears on the surface of the glans (Figure 1C).
   3. Trim the alongside frenulum if applicable.
2. End-to-end urethral anastomosis
   1. Put the patient in a supine position.
   2. Observe and evaluate the damage of the stump of glans under the microscope (Figure 1D), and align the amputated glans and frenulum with the stump of glans. Insert an 8 Fr. Foley catheter via the urethral orifice for the drainage of urine (Figure 1E).
   3. Perform end-to-end urethral anastomosis using 6-0 absorbable thread through the intermittent suture method with precise positioning. Usually, suture one stitch at 12:00 and 6:00 o'clock of the urethra, respectively at first, and then on the base of two positioning points; suture about four stitches tightly on the left and right sides, respectively in a counterclockwise or clockwise direction (Figure 1F).
3. Anastomosis of amputated glans surface and reconstruction of the frenulum
   1. Suture the edge of amputated glans to the edge of the penile stump using 6-0 absorbable thread. Suture a few fixed points at 6, 12, 9, and 3 o'clock at first, and then suture the space between the fixed points with a space of 1 mm for each to achieve a precise anastomosis (Figure 1G).
   2. Trim the excess inner plate of prepuce on the ventral side of the penile glans if applicable.
   3. Reconstruct the frenulum by intermittent suture to achieve a satisfactory shape if applicable (Figure 1H,I).

5. Postoperative care

1. Evaluate the recovery of local blood circulation by closely observing the color of the replanted penile glans.
   NOTE: A dark red glans is expected (cherry pulp-like) and it should be observed dynamically. There are some blackish crusts on the surface after days and make sure not to remove them. Blackish crust does not mean necrosis of the amputated glans.
2. Maintain postoperative intravenous antibiotic treatment for 2-3 days and change to oral treatment for 5-7 days.
3. Keep the drainage of indwelling catheter unobstructed and remove it 1-2 weeks after the operation.

Three 7-8 years old children, whose distal penile glans were completely (2 cases) or incompletely (1 case) amputated during circumcision using a disposable stapler, were admitted to the hospital within 2-3 h after injury from June 2019 to July 2021. Physical examination confirmed that about 1/3 of the distal end of the penile glans with 3-4 mm of distal urethra was completely or incompletely amputated. In one severe case, the inner plate of prepuce and frenulum on the ventral side of the glans were also seriously damaged. The complete amputated tissues after injury were kept sterile and temporarily stored in an ice bucket. Microscopic glans replantation and distal urethra anastomosis were successfully performed on all patients.

One day after surgery, the penile glans area was dark red and congested, and a little effusion could usually be seen on the surface. One week after surgery, blackish crusts were usually observed, and scabs appeared on the surface of the distal parts of the glans and the frenulum. The indwelling catheters were usually removed 1-2 weeks after surgery. The postoperative observation and follow-up of three children for 3-27 months showed that the penis glans of all the children healed very well, the original shape of the glans was perfectly restored with satisfactory cosmetic appearance, the micturition function was completely restored to normal, and no obvious complications such as urethral orifice stricture, urinary fistula, or deformity healing occurred (Figure 2 and Figure 3). The clinical features and surgical outcomes are summarized in Table 1.

Figure 1: Repairment of the amputated glans, replantation and reconstruction of the amputated glans and frenulum under the microscope (Case 1). (A) The amputated tissues of the glans with multiple irregular incisions. (B) Suture the inner cavernous incision of the glans with 0/8 nonabsorbable suture. (C) Repair the tears on the surface of the glans with 0/6 absorbable suture. (D) The stump of glans showing guillotine injury of the glans, with more damage on the ventral side relative to the dorsal side. (E) Align the amputated tissues of the glans and the frenulum with the glans stump. (F) End-to-end anastomosis of the urethra. (G) Suture the edges of amputated glans and the penile stump with 0/6 absorbable suture. (H) Trim the amputated frenulum tissue and suture the prepuce of the penis. (I) Appearance of the glans and preputial areas after finishing the operation. Please click here to view a larger version of this figure.

Figure 2: Observation of the recovery after glans replantation (Case 1). (A) One day after the operation, the glans area was dark red and congested. (B) One week after the operation, the surface of the replanted glans and frenulum turned blackish, suggesting epidermal scabbing. (C) One month after the operation, the morphology of the glans basically returned to normal, with little black scabs. (D) Two years later after the operation, the morphology of the glans and urination were completely normal. Please click here to view a larger version of this figure.

Figure 3: Replantation of the amputated glans under the microscope and follow-up observation (Case 2). (A) The amputated glans stump of the penis. (B) The amputated penile glans was sutured to the stump. (C) End-to-end anastomosis to the urethra. (D) The anastomosis to the edges of amputated glans and the penile stump was finished. (E) Two weeks after the operation, the surface of the replanted glans was covered by black scabs. (F) Two months after the operation, the morphology of the glans was completely returned to normal. Please click here to view a larger version of this figure.

Table 1: Clinical features and surgical outcomes of three cases of glans amputations caused by disposable stapler during circumcision.

For religious or therapeutic purposes, about one-quarter of men around the world have had circumcision¹. The incidence of complications is far from negligible, approximately 1% to 20%^3,4,5,6,7. Circumcision-related glans amputation is extremely rare and there are no exact statistics depicting its incidence. Owing to its rarity, previous reports were mostly case reports or case series^5,8,10,11,12. Early gross glans replantation, simple hemostasis by compression to achieve self-healing, or delayed formal repair are the three conventional strategies for this situation.

Among the three conventional strategies, early gross glans replantation has reported superior results. However, such strategy also delivered unsatisfactory cosmetic appearance and high possibility of post-operative complications due to the limitations of the technique^8,13,14. In a study of eight cases, neonatal glans amputations had an elapsed time between the injury to emergency room arrival of 1 to 6 h. Six of them had a simultaneous urethral injury, of which four cases underwent urethral anastomosis of the amputated glans and two were managed by urethrostomy together with glans anastomosis. The two patients with isolated glans injury underwent primary glans anastomosis. The results showed that the two patients with urethral injury and without urethral anastomosis developed secondary hypospadias and required additional surgery, while the others showed good functional and cosmetic results¹². This suggests that the appropriate selections of early surgical methods, including end-to-end urethral anastomosis are crucial for the satisfactory recovery of severe glans injury. In a recent study on the mass circumcision campaigns in Africa, three cases of glans amputations were reported. Although all three patients underwent early reconstruction of amputated glans, two patients subsequently developed an urethro-cutaneous fistula due to partial necrosis of reconstructed glans and required further reconstruction¹⁵. This early routine gross repair operation is not an ideal choice, which often leads to some complications and needs secondary reconstruction.

Previous simple hemostasis, meatoplasty, and/or secondary delayed repair strategies may also lead to serious complications and posttraumatic problems ranging from glans defect or dysmorphology, short penile stump, hypospadias, to sexual dysfunction^5,10,11 and bring about worse results. El-bahnasawy et al. summarized the largest sample size of penile injury in children: a total of 64 boys were hospitalized for penile injury over a 20-year period, of which 10 cases were complete or incomplete glans amputations during circumcision¹⁰. However, for those cases, only primary hemostasis and meatoplasty were applied. A delayed penile lengthening procedure was carried out in only one case. Similarly, Ceylan et al. reported 48 cases of circumcision-related severe complications, in which partial or total glandular amputation was observed in four cases (8%)⁵. Delayed repair of the glans with buccal mucosa was performed and a satisfactory appearance was obtained while this strategy objectively increases additional oral injury and may lead to related complications.

There are different opinions as to whether microsurgery should be used in the selection of early treatment strategies for penile glans amputation. Among previous reports, only two patients received microscopic replantation of the glans penis, but graft necrosis occurred subsequently in one patient^9,11. In our study, all the three children successfully underwent early microscopic replantation to the amputated glans. In all three cases, a meticulous end-to-end urethral anastomosis and anastomosis of the amputated glans were performed and achieved excellent functional and cosmetic outcomes.

Based on the experience from our three cases, we believe that microsurgery can provide clearer surgical vision and more accurate anastomosis, especially for newborns and children who have smaller penile structures. In one of our cases, the patient's glans was severely damaged. Several irregular incisions were observed on the amputated glans tissue, making it much more difficult to reconstruct with naked eyes. The use of a microscope assisted in distinguishing the damaged glans, identifying and ideally reconstructing the normal shape, performing micro-anastomosis and replanting the amputated glans with precise anatomic alignment. In this regard, it is strongly advised to routinely perform microscopic end-to-end urethral anastomosis and anastomosis of the surface of amputated glans for such an injury. In addition, compared with the replantation of complete penile amputation¹⁶, the microscopic replantation of penile glans does not require anastomosis of the blood vessels such as the dorsal artery, deep dorsal vein and superficial dorsal vein of the penis and the dorsal penile nerves, which makes the technology easier to master with less complications. The amputated glans can obtain a blood supply through the cavernous sinus; therefore, this direct tissue anastomosis can heal well and not lead to necrosis of the penile glans.

In Europe and the United States, Mogen-clamp circumcision is usually used, while in China, disposable circumcision suture devices have been widely employed for their convenient and easy-to-master characteristics. However, the popularity of these circumcision devices has brought new challenges. Interestingly, in our study, all injuries were oblique from dorsal to ventral, accompanied by the destruction of the urethral orifice. In one severe patient, the ventral frenulum was amputated together with the glans, indicating that this kind of injury has a common injury mechanism. Based on the interviews with the three operators and the views of experts, two possible hypotheses about the mechanism of glans injury were put forward. One is excessive lifting of the ventral foreskin and the other is the inappropriate equipment size. Pippi Salle et al. reported two cases of glans detachment after Morgan-forceps circumcision, which is likely due to incomplete release of the physiological balano-preputial adhesions around the frenulum. In our study, no adhesion was observed in the amputated glans and frenulum and this was confirmed by the three operators. This suggests that adhesion may not be the main cause of the glans injury during disposable suture device circumcisions.

Based on the above hypothesis of glans injury, further prevention strategies were also put forward. First, the bell cover in the disposable circumcision suture devices can be redesigned as a transparent material or pre-cut on the dorsal side of the prepuce during operation to determine the position of the glans and the scope of prepuce removal under direct vision. Second, before cutting, palpate again to confirm that the glans is completely covered by the bell cover and is not wrongly placed on the cutting plane. Third, it is more important to strictly abide by the operating procedures to avoid excessive lifting of the ventral foreskin. Fourth, avoid working continuously for a long time. Fifth, regular training and quality control can also avoid serious complications. Recently, in a study of three cases of amputated penile glans in high volume circumcision clinics in South Africa, to avoid this kind of injury, the author suggested that young children (younger than 13 years) should not be circumcised in the afternoon, frequent breaks (at least every 1-2 h) should be given to operators, young adolescents should have additional care, open surgical techniques (dorsal slit) should be used, and most importantly, all ranks of operators should receive continuous training and retraining¹⁵.

In this study, we reported a case series of complete or incomplete glans amputation during circumcision using disposable suture devices, described our successful early microscopic surgical experience, analyzed the new possible injury mechanisms, and most importantly, proposed several preventive strategies. Despite the strengths mentioned above, the limitations should also be noted. Firstly, the small number of cases is the main limitation of this paper, although it is reasonable due to its very low incidence. Secondly, the proposed injury mechanism and prevention strategies are based on interviews with operators and experts. There may be recall bias and subjective speculation. Thirdly, only one type of disposable suture device was presented as an example, which may not be the case in other devices. Nevertheless, this study can serve as a reminder and warning to operators and a reference for policy development.

In conclusion, early meticulous microscopic replantation as soon as possible is an ideal emergency treatment method, which can achieve a perfect cosmetic appearance without functional deficiency. Professional technical training, as well as careful and standardized operation may avoid such severe complications.