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Table of Contents
Year : 2018  |  Volume : 26  |  Issue : 3  |  Page : 97-102

A systematic review of penile replantations: May it guide us in penile allotransplantation?

1 Department of Plastic, Ege University Plastic, Reconstructive and Aesthetic Surgery, Izmir, Turkey
2 JMS Burn and Reconstruction Center, MS, USA

Date of Web Publication2-Jul-2018

Correspondence Address:
Yigit Ozer Tiftikcioglu
Department of Plastic, Reconstructive and Aesthetic Surgery, Ege School of Medicine, Izmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_5_18

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Introduction: Penis replantation cases may serve as a model for identifying important elements in developing clinical penile allotransplantation. Material and Methods: We reviewed 82 published cases of penis replantation. Results: Besides the basic repair of urethra and corpora, we found that dorsal artery and dorsal nerve repair was associated with significantly better sensory return. Deep dorsal vein repair was associated with decreased sensation and increased complication rates. Conclusion: Penile allotransplantation may need to incorporate these findings.

Keywords: Penis, review, transplantation

How to cite this article:
Tiftikcioglu YO, Erenoglu CM, Lineaweaver WC. A systematic review of penile replantations: May it guide us in penile allotransplantation? . Turk J Plast Surg 2018;26:97-102

How to cite this URL:
Tiftikcioglu YO, Erenoglu CM, Lineaweaver WC. A systematic review of penile replantations: May it guide us in penile allotransplantation? . Turk J Plast Surg [serial online] 2018 [cited 2022 Dec 3];26:97-102. Available from: http://www.turkjplastsurg.org/text.asp?2018/26/3/97/235785

  Introduction Top

The unique shape and sensate, erectile, and complex neurovascular functions of the penis render a thorough reconstruction difficult. Although improvements in the reconstruction of penile defects are appreciable, there are still obstacles waiting to be overcome. Even though the visual replacement is satisfactory, restoration of sexual function is usually limited to artificial erections supplied by implants or osseocutaneous flaps that can only stay in erectile phase. [1] Total reconstruction of a penile defect with erogenous sensation and autonomous erection is not feasible using autogenous free flaps. Microsurgery has enabled some penile amputations to be solved by the replantation.

With the beginning of an era of reconstructive allotransplantation, cases of face and hand transplantation are widely reported. [2] Other reported composite tissue transfers include cases of arm, knee, abdominal wall, scalp, larynx, nerve, muscle, tongue, and trachea. [3] The literature for penile transplantation so far is limited to experimental studies on rats [4],[5] and two clinical cases on humans. [6],[7]

It is very probable that penile replantation will be performed increasingly, arising new ethical, immunological, and technical questions. [8] The world's experience of penile replantation may serve as a foundation for transplantation. We therefore made a systematic review of penile replantations evaluating age, injury features, repaired structures, and outcomes to identify critical elements of replantation and considered if these insights can be applied to allotransplantation. There are three penile transplantation cases reported in world literature. The first case was attempted in Guangzhou, China. [6] The recipient was a 44-year-old man with a traumatic penile defect. The operation had to be reversed because of the severe psychological problems in the patient and his partner. The second case was done in Cape Town, South Africa, after a period of intensive technical and ethical workup and donor finding. [7] The recipient was a 21-year-old man who lost his penis in circumcision. This report was more comprehensive, showing functional results including voiding, erection, and conception of a baby. The third case was a 64-year-old penile cancer survivor who had penectomy in 2012 and had penile allotransplantation in 2016 in the USA. [9] These successful operations aroused new ethical questions. Is penile allotransplantation worth the life-long immunotherapy? Why do a transplant instead of a good phalloplasty? What if rejection occurs? To whom would this operation be done? Is it ethical to harvest a penis before burial? These debates continue while further cases are pursued. [8] This inevitable progress in transplants necessitated new ethical, experimental, and anatomical research to be done.

This article analyzes the relevant penile structures described by replantation reports to begin to define the best surgical approach for a penile transplantation.

Literature was searched on PubMed and Embase databases for words "penile," "penis," "amputation," and "replantation." Two reviewers reviewed the results. The articles with cases of penile amputation and subsequent replantation were included. Reports of subtotal amputations, cases in which replantation was not attempted, and publications written in languages other than English were excluded from the study.

The cases in the articles were evaluated by the criteria of age, ischemia time, etiology, amputation level, repaired structures, and the subsequent outcomes including survival of the part, sensory and erectile function, complications, and additional procedures.

Fisher's exact test and Mann-Whitney tests were applied for statistical analysis on PASW Statistics for Windows, Version 18.0. Chicago, SPSS Inc.

  Results Top

A total of 82 case reports were extracted from 57 articles. [10-66]

The average age of the patients was 29.5 years. [1-70] Age was found unrelated to graft survival, erectile and sensory return, and complication rates. The most common reason for amputation was self-mutilation (43.9%, n = 36), followed by partner violence (25.6% n = 21), work injury (9.8% n = 8), circumcision complication (9.8% n = 8), assault (7.3% n = 6), and animal bite (1.4% n = 1) [Figure 1]. In two cases, the cause was not specified (2.4%).
Figure 1: Etiologic distribution of penile amputations

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The level of amputation was proximal in 42 (51.2%) patients, mid-shaft in 4 (4.9%), distal in 7 (8.5%), glandular in 3 (3.7%), and nonspecified in 26 (31.7%) [Figure 2]. The mean ischemia time was 6.2 h (0.5-18). Ischemia time was found to be unrelated to graft survival, erectile and sensory recovery, and complication rates. The common complications were skin loss (52.7%), partial glans loss (13.5%), urethral fistula (6.7%), urethral stricture (4.0%), and lateral chordae (2.7%). Two (2.4%) patients in the self-mutilation subgroup reamputated their replanted parts.

Adjunctive procedures were applied in a total of 46 (56%) patients. Scrotal burying and flaps (25.6%), skin grafting (9.7%), leech therapy (8.5%), and hyperbaric oxygen therapy (7.3%) were the most common additional therapies applied. Ectopic transplantation of the penis to forearm, [38] vein grafting, [45],[54],[66] sildenafil, [10],[60] urokinase [39] administration, and subcutaneous tunneling [19] was also reported. In all cases, corpora cavernosa, spongiosum, urethra, and skin were repaired.
Figure 2: Ratio of level of amputations

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One or both dorsal arteries (DA) were repaired in 45 (54.9%), not repaired in 30 (36.6%), and not reported in 7 (8.5%) patients. Dorsal artery repair was unrelated to the survival of the graft, erection, or complication rate, but was found to improve sensory return (P < 0.05). Deep penile artery (DPA) repairs were done in 9 (11%), not repaired in 43 (52.4%), and not reported in 30 (36.6%) cases. DPA repair was not found to be correlated with survival of the graft, complication rates, and erectile or sensory function.


The superficial dorsal vein (SDV) was repaired in 14 (17.1%), not repaired in 35 (42.7%), and not reported in 33 (40.2%) cases. SDV repair was not found to be correlated with graft survival, skin loss, complication rate, or sensory return. The deep dorsal vein (DDV) was repaired in 54 (65.9%), not repaired in 20 (24.4%), and not reported in 8 (9.8%) cases. The DDV repair was found to be correlated with decreased sensory recovery and increased complication rates (P < 0.05). No correlation was found between DDV repair and graft survival or erectile regain.


The dorsal nerve (DN) was repaired in 27 (32.9%), not repaired in 22 (26.8%), and not reported in 33 (40.2%) cases. DN repair was found to be correlated with sensory regain (P < 0.05), but no correlation was found with erectile function.

Rates of repaired, not repaired, and not reported dorsal neurovascular structures are shown in [Figure 3].
Figure 3: Rates of repaired, unrepaired, and unconsidered penile neurovascular structures. DA: Dorsal artery of penis, DPA: Deep penile artery, SDV: Superficial dorsal vein of penis, DDV: Deep dorsal vein of penis, DN: Dorsal nerve of penis

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[Table 1] shows the statistical relation of dorsal structures to outcomes.
Table 1: The statistical relation of dorsal structures to outcomes

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  Discussion Top

The history of penile replantation starts with Ehrich in 1929 reporting the first case of successful penile replantation with a macroscopic technique. [67] The first microscopic replantation was reported in 1977 by Cohen and Tamai. [39],[40] In 1983, Bhanganada et al. shared 18 cases of replantation series following penile amputations in Thailand, mostly due to partner violence. [10] In their technique, the only microstructure they repaired was the DDV and in one case a superficial dorsal vein. No arterial or neural repairs were done. On the follow-up, the patients could achieve erection, but sensory function did not return.

The failures of penile replantation reports to specify injury type, level, repaired structures, and subsequent outcomes make detailed analysis difficult. One of the problems concerning penile replantation reporting is unspecified statements such as "dorsal structures were repaired" or "artery was repaired." This level of description shows that the report lacks underlying anatomical background and does not clearly point out which structures were repaired. Another problem is represented by statements such as "dorsal artery and nerve were repaired" or "dorsal vein was repaired," where the DA and nerves are double (right and left) and the veins are deep or superficial at the level of injury. Another problem for analysis is the failure of many reports to describe the reason for leaving some structures unrepaired, neglecting to include additional procedures, and not describing outcomes such as sensory and erectile return. The limitations of these reports may have interfered to our results and led to some unreasonable conclusions such as irrelevance of age and ischemia time with graft survival, erection, sensory gain, and complication rate.

With a review of the available data, we have identified the following structures that are associated with optimum outcomes of replantation and that may be important in allotransplantation.

Dorsal artery

After the urethral and corporal repair, dorsal artery of penis is the first and most important structure to be repaired as it helps sensory return and reduces skin loss. The statistical irrelevance of DA repair to graft survival, erection, and complication rates may be the result of uneven reports. Despite this finding, according to their own experiences, the authors' opinion is that DA repair provides better circulation with less complication rates and more consistent erections capable of penetration. Bilateral repair may be attempted if possible. DA is a sine qua non of replantation technique and has the priority to be utilized in the penile transplantation setting.

Dorsal nerve

DN is essential for sensory return and is a must-repair structure and should be utilized in allotransplantation.

Deep dorsal vein

A significantly high complication rate and incidence of skin loss was found to be related to DDV repair. These findings may be associated with unreliable data or may reflect that DDV repairs create circulatory patterns unfavorable to portions of the replanted penis structure and function.

There is controversial literature describing ligation of DDV for the treatment of impotence in selected patients. [68-70] The observation of complications with DDV repair in penis replantation may overlap the vascular physiology underlying therapeutic ligation. In replantation, not repairing the DDV may increase circulation in the other parts of the complex vascular system.

Deep penile artery

The DPA is also a controversial structure to repair. Its anatomical course in the middle of the corpus cavernosa makes its dissection difficult and time-consuming. There is discussion in the literature that dissection of the DPA impairs erectile function. [71] In our review, no significant relation was found to any complication. To reveal its real prognostic impact, future replantation reports should state this structure as repaired or unrepaired, and the outcomes should be stated clearly and thus new analyses can be done in the light of the new knowledge. With the current knowledge, DPA repair is of secondary importance in a possible transplantation.

Superficial dorsal vein

The superficial dorsal vein repair is arbitrary, but may be helpful to the venous return of the thin penile skin.

  Conclusion Top

All penile replantations include macroscopic repair of urethra, corpora, fascia, and skin. These components would also be the part of allotransplantations.

The results of our review suggest that dorsal artery and DN repairs are the most important microsurgical elements of penile replantations, and they should also be the most important structures in the penile transplant setting. The high rate of complications related to DDV repair appears to render it an unfavorable structure for allotransplants.

High rates of unspecified structures and poorly described outcomes in replantation reports may have distorted the results from this review. We suggest a "penile replantation chart" for future replantation reports to prevent incomplete results and provide the accurate knowledge for prognosis of different anatomic structure repairs [Figure 4].
Figure 4: Penile replantation chart

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Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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