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5-year follow-up of replantation of penis and testis in a child

2003; Elsevier BV; Volume: 361; Issue: 9353 Linguagem: Inglês

10.1016/s0140-6736(03)12302-1

1474-547X

Mat Griffiths, Jonathan A. Britto, James D. Frame,

Ethics and Legal Issues in Pediatric Healthcare

In 1995, a 3-year-old boy had his genitals amputated by an acutely psychotic relative with a sharp implement.1Kangesu T Ho-Asjoe M Sood M Myint T Frame J Replantation of testis and penis in a child.Lancet. 1995; 345: 1368-1369Abstract PubMed Scopus (7) Google Scholar Both testes and penis were degloved of skin at the time of injury. The amputated organs were retrieved and placed on ice. One testis was unsalvageable, but the other was anastomosed onto the right inferior epigastric vessels. The penis was replanted over a urinary catheter with the left dorsal artery and dorsal vein after a total ischaemia time of 6 h. The penoscrotal skin was reapplied as a defatted full-thickness graft. Apart from some superficial necrosis of the skin of the penile shaft, convalescence was uneventful and the child was discharged at 4 weeks. After removal of the catheter at 10 weeks, the child was able to void spontaneously. At 6 months, a Z-plasty was done to release a band scar on the right side of the penis, but after a 4-week review, which showed a satisfactory result, the patient was lost to follow-up. Now, 5 years later, the patient has been traced and followed up. The boy has progressed well with no other medical problems. He reported no problems with micturition and his mother had noticed that he was capable of the occasional early morning erection before voiding his bladder. He only had a vague recollection of the traumatic events, but understood what had happened. He was doing well at school, made friends easily, and had no problems with changing for games. On examination, he appeared to be a cheerful, active, 8-year-old boy of normal height and weight who maintained an excellent rapport with the medical staff present. Abdominal examination was unremarkable. Inspection of his genitals revealed the scars of the surgery and a penis deviated to the right. Sensation was present. A palpable testis was not felt on scrotal examination. Since the child was so compliant, limited urodynamics were done, showing a normal flow rate. At age 9 years, we assessed hormone function by measuring gonadotropin concentrations, which were normal (luteinising hormone 0·7 units/L, follicle-stimulating hormone 3·0 units/L), indicating little evidence of gonadal endocrine failure. As in similar cases in adults,2Lidman D Danielsson P Abdiu A Fahraeus B The functional result two years after a microsurgical penile replantation.Scand J Plast Reconstr Hand Surg. 1999; 33: 325-328Crossref PubMed Scopus (18) Google Scholar this operation has successfully restored a number of features: body image, urinary function, erectile capability, and a normal endocrine status. The time to replantation was not as long as those described previously;3Hashem F Ahmed S Al-Malaq A AbuDaia J Successful replantation of penile amputation (post-circumcision) complicated by prolonged ischaemia.Br J Plast Surg. 1999; 52: 308-310Summary Full Text PDF PubMed Scopus (30) Google Scholar however, testicular atrophy seems to have occurred despite timely revasculari-sation.4Becker M Hofner K Lassner F Pallua N Berger A Replantation of the complete external genitals.Plast Reconstr Surg. 1997; 99: 1165-1168Crossref PubMed Scopus (19) Google Scholar Nevertheless, endocrine function is normal. The issue of fertility is still to be negotiated. Unfortunately, since the initial consultation, some behavioural problems have occurred at school as he has become “rather reclusive and totally distrustful”. These problems may have been related to the coincidental release of his relative from prison. After a severe mutilating injury, this child has done very well from paediatric, psychological, urological, and plastic points of view. Future follow-up is planned to offer correction of the residual physical deformity of his penis and to confirm satisfactory progress into the ever-difficult realm of puberty. We thank the patient and his mother for allowing us to submit this report.