Penile reimplantation after amputation: microsurgical, on a urethral catheter

Operative visualisation

UrOops3D · UroRef · © Nity G

How to use this module. Play through the nine steps, or use Back and Next. Watch the part leave the iced water, the cut face read, the catheter thread both pieces and the dorsal mark line up, then each join in turn. The triggers show a congested part, a pale part, skin loss and a narrowed urethral join.

Operative steps

1. Prepare the part Reimplantation is considered for every patient whose part has been recovered and is not too badly damaged; the EAU guideline asks for it within 24 hours of the amputation. The part is washed with sterile saline, wrapped in saline-soaked gauze, sealed in a sterile bag and the bag is put in iced water. In theatre, under loupes, it is irrigated with warm saline and antibiotic solution and debrided as little as possible, which also confirms that it is viable. The cut face is read before anything is joined. If the injury was self-inflicted, psychiatric assessment is arranged early; it does not delay the reimplantation.
   where it bites: the part must never lie directly on the ice; and whatever is debrided is length that cannot be put back.
2. Prepare the stump Bleeding from the stump is controlled first with a pressure dressing or a tourniquet. In theatre a tourniquet goes round the base of the stump and is released at intervals through the case. Skin and dartos are dissected back a short distance from the stump edge to expose the corpora and the dorsal neurovascular bundle, with haemostasis by fine diathermy and ties. The ends of the deep dorsal vein, the dorsal arteries and the dorsal nerves are found and tagged before anything is joined.
   where it bites: diathermy at the bundle ends burns the vessels that are about to be joined; a tourniquet left on without release adds to the ischaemia.
3. Align on a catheter The part is put back in its anatomical position against the stump and a urethral catheter is passed through the meatus, through the part and the stump, into the bladder. The catheter stabilises the two pieces and marks the lumen for the urethral join. It does not control rotation: the part can turn about it. The dorsal midline, the septum and the urethra are lined up by eye before the first stitch.
   where it bites: a part stitched on with a twist cannot be corrected later without taking the corpora down.
4. Join the corpora The corpora cavernosa are aligned and the tunica albuginea of each is approximated all the way round with interrupted absorbable stitches. This is the structural repair, and it takes the tension off everything that follows. The cavernosal arteries inside the corpora are generally too small to join and are left alone.
   where it bites: a bite that misses the full thickness of the tunica cuts out; the septum must meet the septum.
5. Join the urethra The proximal and distal urethral ends are debrided as little as possible and spatulated on opposite sides. A one-layer anastomosis is completed with interrupted absorbable stitches over the catheter. Spatulation makes the join oblique and wider than either end.
   where it bites: a circular, unspatulated join narrows as it heals; a gap in the suture line leaks and becomes a fistula.
6. Repair the deep dorsal vein The operating microscope is draped and brought in. The deep dorsal vein is identified and freed proximally and distally, its ends are spatulated on opposite sides, and the venous anastomosis is completed with fine monofilament, interrupted or as two running halves. The book joins the vein before the artery: the part is given a way out before it is given a way in.
   where it bites: arterial inflow without venous drainage congests the part; venous congestion is among the complications reported most often.
7. Repair a dorsal artery One dorsal artery is identified, dissected and joined end to end in the same way; when both arteries are found and look usable, both are joined. The tourniquet is removed and both anastomoses are inspected for good pulsatile flow and for bleeding. The part regains colour slowly and incompletely on the table.
   where it bites: no pulse beyond the join is a technical fault until proven otherwise: a clamp left on, a kink, tension, or thrombus at the suture line.
8. Repair a dorsal nerve At least one dorsal nerve is repaired, and both when both are found and usable. The ends are brought together without tension and joined with interrupted fine stitches placed in the epineurium. In the pooled series more nerves joined went with better outcomes, but return of sensation is hoped for and never promised.
   where it bites: tension pulls a nerve repair apart: the ends must lie together before the first stitch goes in.
9. Close and counsel The wound is irrigated and haemostasis confirmed again. Dartos and skin are closed as separate layers with interrupted absorbable stitches. Antibiotic ointment and gauze go on the suture line, the penis is wrapped very loosely, the catheter is connected to drainage and the penis is supported against the abdomen to limit swelling. A suprapubic catheter may be added at the end; the EAU guideline places both. The patient is told what to expect: skin loss, stricture, fistula, altered sensation and erectile dysfunction all follow technically sound operations.
   where it bites: a snug dressing is a tourniquet on a part that depends on one small artery and one vein.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance

Curriculum. Supports learning relevant to the ISCP Urology Curriculum syllabus topics Genitourinary trauma and Andrology. Not a workplace-based assessment and not evidence of competence.