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Microsurgical Penile / Glans Replantation

Microsurgical replantation is the gold-standard treatment for traumatic penile amputation, restoring cosmetic appearance, urinary function, erectile function, and sensation through meticulous microvascular and microneural anastomosis. Approximately 200 cases have been reported in the English and Chinese literature, mostly as case reports or small series.[1][2][3][4]

For acute trauma workup, transfer logistics, and the wider injury context see Genitoscrotal Trauma, GU Injury Overview, and Trauma Assessment. For broader penile-reconstruction options, see Penile Reconstruction. For salvage approaches when the amputated segment is non-viable, see Total Anterior Scrotal Flap (Zhao) and phalloplasty options under GAS — Masculinizing Surgery.

Etiology​

MechanismNotes
Self-mutilationMost common in Western literature — strongly associated with psychosis (schizophrenia, acute psychotic episode), gender dysphoria, severe psychiatric illness; 50% recurrent self-amputation in Sanger series[5][3]
Felonious assaultPartner-inflicted ("Bobbitt" scenario)
Accidental / iatrogenicCircumcision complications (Mogen, Gomco, disposable staplers), industrial accidents, mechanical injury[6][7][8]
Neonatal / pediatricCircumcision-related glans amputation is the dominant mechanism[6][7][8][9]

ACS 2025 Guideline Recommendations​

The American College of Surgeons Best Practices Guidelines for Management of GU Injuries (2025):[1]

  • Perform timely penile reconstruction including, at a minimum, anastomosis of the corporal bodies and the urethra
  • For optimal results, penile amputation requires urgent microsurgical replantation by a urologist and a microvascular surgeon
  • Transfer the patient urgently to a specialty facility if those specialists are not available
  • Transport the amputated penis in a two-bag system — wrapped in saline-soaked gauze in one bag, placed in a second bag on ice
  • If microsurgery is unavailable and transfer is not possible, perform macroscopic anastomosis of corpora, urethra, and skin with small absorbable sutures
  • Mental-health evaluation is mandatory because of the strong association with psychosis and self-amputation

Penile Vascular Anatomy​

ArteryMean diameter at basePerfusion territoryRelevance
Dorsal artery1.43 mmGlans, corpus spongiosum, distal skin (perforators)Primary microvascular target
Cavernosal artery0.80 mmCorpora cavernosa (helicine → lacunar)Important for erection; technically challenging
Inferior external pudendal artery (IEPA)0.94 mmPenile shaft skin (main supply)Optional anastomosis prevents skin necrosis
Urethral / bulbar arteryVariableCorpus spongiosum, urethraUsually not individually anastomosed

Key anatomical findings:[11][12][13][14]

  • Dorsal arteries principally perfuse the glans and spongiosum; perforating branches also supply the distal third of the corpora cavernosa
  • IEPA is the main supply to penile shaft skin with midline anastomoses; diameter sufficient for microanastomosis
  • Cavernosal artery strongly perfuses the corpora with minimal communication to skin
  • Extensive anastomotic connections between all four arterial axes around multiple neurovascular shunts

Venous: deep dorsal vein (primary), superficial dorsal vein. Nerves: dorsal nerves (somatic — penile skin sensation, in Buck's fascia, absent at 12 o'clock); cavernosal nerves (autonomic — erection).

Historical Evolution​

  • Macrosurgical era (pre-1977) — Ehrich 1929 first replantation; macroscopic-only reattachment had high rates of skin necrosis, stricture, fistula, and absent sensation
  • Microsurgical era (Cohen 1977 →) — vascular + neural anastomosis became standard; uniformly good outcomes[3][4][17]

Surgical Technique — Complete Penile Replantation​

Multidisciplinary team (urology + microvascular / plastic surgery) under general anesthesia.[1][2]

Preoperative​

  1. Two-bag preservation — saline-gauze in inner bag, ice in outer bag; viability up to 8 h (glans) and 16 h (complete penis) with hypothermic preservation[1][8][18]
  2. Patient stabilization — stump pressure dressing (do not clamp), IV fluids, type and screen, broad-spectrum antibiotics
  3. Early psychiatric assessment[5]

Wang / Luo video-demonstrated protocol[2]​

  1. Amputated-segment preparation under the operating microscope — identify, dissect, and tag dorsal arteries, deep + superficial dorsal veins, dorsal nerves
  2. Proximal-stump preparation — identify the corresponding structures and mobilize
  3. Urethral anastomosis — end-to-end mucosal repair over a Foley with 5-0 / 6-0 PDS; spatulate to reduce stricture risk
  4. Corporal body repair — 3-0 / 4-0 PDS interrupted to the tunica albuginea
  5. Deep dorsal vein anastomosis — 9-0 / 10-0 nylon under the microscope (prevents venous congestion)
  6. Dorsal artery anastomosis — 9-0 / 10-0 nylon; minimum one dorsal artery for adequate distal perfusion
  7. Superficial dorsal vein anastomosis — augments venous drainage
  8. Dorsal nerve repair — 10-0 / 11-0 nylon (multiple nerves) — the key advantage of microsurgery for sensation recovery
  9. Buck's fascia and skin closure

Optional additional anastomoses​

  • Inferior external pudendal artery (Lohasammakul, mean 0.94 mm) — prevents shaft-skin necrosis since IEPA is the main skin supply; 0% necrosis when anastomosed in cadaveric / clinical work[12]
  • Cavernosal artery — augments corporal inflow for erection (Tuffaha) but successful erections have been reported without it because dorsal-artery perforators supply the corpora[11][13][21]

Operative Parameters​

ParameterTypical
Operative time6–10 h (Wang 7 h)
Total ischemic time toleratedUp to 16 h with hypothermia
Minimum anastomosesUrethra + corpora + ≥ 1 dorsal artery + ≥ 1 dorsal vein
Optimal anastomoses+ both dorsal arteries, superficial dorsal vein, multiple dorsal nerves, ± IEPA

Functional Outcomes — Microsurgical Penile Replantation​

StudynIschemia timeErectile functionSensationVoidingFollow-up
Wang 2022[2]110 hEHS 4 at 6 moNear-normal at 6 moQmax 25 mL/s6 mo
Salem 2009[19]12 hMorning erections, nocturnal emissionsPreserved distallyNormal1 mo
Sanger 1992[5]4VariableNormal erections in all 4Excellent returnNormalLongest reported
Lowe 1991[26]1—Documented by NPT———
Szasz 1990[27]114 hFull erection by 32 wk (with testosterone)RecoveredNormal by 3 wk32 wk
Fan 1996[18]115 h——Skin + glans survived—
Jiménez-Cruz 1995[28]1—Spontaneous erectionsSensate glansNormal—

The Sanger series (n = 4, longest published follow-up) demonstrated excellent return of sensation and normal erections in all patients.

Microsurgical vs Macroscopic Replantation​

ParameterMicrosurgicalMacroscopic
Skin necrosisRare (preventable with IEPA repair)Common
Urethral strictureRare (1 / 4 in Sanger, mild, responded to dilation)Common
Urethral fistulaRareCommon
Sensation recoveryExcellent — near-normalIncomplete / absent
Erectile functionNormal in most patientsCompromised
Cosmetic resultNormal or near-normalVariable, often disfigured
AvailabilityMicrovascular surgeon + operating microscopeMost centers

Macroscopic replantation remains a viable salvage when microsurgery is unavailable — the penis can survive on cavernosal backflow, though outcomes are inferior. Putra reported a successful non-microscopic replantation with preserved appearance, sensitivity, and adequate Doppler arterial flow.[29]

Microscopic Glans Replantation (Isolated Glans Amputation)​

Glans-only amputation is a distinct entity — most commonly iatrogenic from circumcision (Mogen / Gomco / disposable stapler).[6][7][8]

Jin JoVE 2022 video protocol[6]​

  1. Amputated-glans preparation under microscope — identify terminal branches of dorsal arteries, spongiosal vessels, urethral mucosa
  2. Proximal-stump preparation — corporal tips and urethral stump; identify bleeding vessels as anastomosis targets
  3. Urethral anastomosis over a catheter with fine absorbable suture
  4. Spongiosal / vascular anastomosis under microscope
  5. Coronal skin closure

Outcomes:

  • Original shape of glans perfectly restored
  • Micturition completely restored to normal, no complications
  • No significant reduction in sensation of the amputated glans

Neonatal glans replantation (Sherman n = 7, including 6 neonates + 1 infant)[8]​

  • Excised glanular tissue viable up to 8 hours
  • All patients with acceptable cosmetic results
  • No long-term complications in neonates; distal urethral fistula formed in the 5-month-old

Complications​

ComplicationIncidenceManagement
Penile skin necrosisMost common; reduced with IEPA anastomosisDebridement ± skin graft or scrotal flap[30]
Venous congestion / edemaCommon earlyLeech therapy, topical heparin
Urethral strictureRare with microsurgery; common withoutDilation or urethroplasty
Urethral fistulaRare with microsurgerySurgical repair
Wound infection (incl. Pseudomonas)VariableAntibiotics ± HBO
Partial replant lossRare with adequate vascular repairDebridement, secondary reconstruction
Recurrent self-amputation50% (2 / 4) in SangerPsychiatric management

Skin necrosis salvage​

Ching reported salvage of a complicated penile replantation with skin necrosis using a bipedicled scrotal flap — satisfactory cosmetic and functional outcomes at 1 year.[30]

Adjunctive Postoperative Therapies​

Leech therapy (Hirudo medicinalis)​

For venous congestion in adults and neonates:[7][9][32]

  • Provides passive blood drainage + secretes hirudin (anticoagulant), hyaluronidase (tissue penetration), and vasodilators that improve microcirculation
  • Banihani — first report in neonatal replantation (7-day-old, Mogen-clamp amputation at penopubic junction) — successful replantation
  • Mousa — leeches + topical heparin + caudal analgesia in 28-day-old neonate with midshaft amputation — successful
  • Mineo — after non-microsurgical replantation — edema resolved quickly; overlying skin loss required debridement; glans re-epithelialized with normal voiding, sensation, and erection
  • Monitor for Aeromonas infection with prolonged leech use

Hyperbaric oxygen (HBO)​

  • Zhong — adjuvant HBO accelerated healing[33]
  • Landström — HBO for postoperative Pseudomonas wound infection threatening the replant; at 1 y normal flow, spontaneous erection with intromission, sensate glans[20]
  • Mechanisms: anti-inflammation, angiogenesis, fibroblast activity, bactericidal effects[34]

Standard postoperative protocol[2]​

  • Broad-spectrum antibiotics
  • Analgesia
  • Antithrombotic therapy (LMWH or aspirin)
  • Anxiolytics (especially after self-mutilation)
  • Urethral catheter 7–14 days
  • Bed rest with penile monitoring (color / temperature / capillary refill) q 1–2 h initially
  • Psychiatric evaluation and ongoing mental-health support

When Replantation Is Not Possible — Penile Allotransplantation​

When the amputated segment is lost or non-viable, penile allotransplantation is an alternative to phalloplasty. Van der Merwe (first functionally successful penile allotransplant, 24-mo follow-up post-ritual-circumcision aphallia, South Africa):[21]

  • Normal urination, erections suitable for vaginal penetration, normal orgasm and ejaculation
  • Inferior epigastric artery mobilized for anastomosis to the right dorsal artery when native dorsal arteries were obliterated by fibrosis
  • Dorsal arteries clearly supplied corpora and spongiosum (cavernosal backflow after clamp release)
  • Small contracted cavernosal arteries not anastomosed — did not affect erectile outcome (supports dorsal-artery-only repair concept)

Pediatric Replantation Considerations​

ConsiderationDetail
Most common mechanismCircumcision complication (Mogen, stapler)
Tissue viabilityUp to 8 h for glans tissue
Microsurgical feasibilityTechnically challenging due to vessel size; successful in neonates as young as 7 days
Leech therapySuccessful in neonates; monitor for Aeromonas
Caudal analgesiaSympathetic blockade → vasodilation → improved replant perfusion
Long-term outcomesAcceptable cosmesis; urethral fistula more common in older infants

Key Principles​

  1. Time is critical — hypothermic preservation extends viability (up to 16 h complete penis, 8 h glans), but earlier replantation yields better outcomes
  2. Microsurgical repair is the gold standard — uniformly good results vs macroscopic reattachment
  3. Minimum vascular repair — urethra + corpora + ≥ 1 dorsal artery + ≥ 1 dorsal vein
  4. Optimal repair — both dorsal arteries + superficial dorsal vein + multiple dorsal nerves + IEPA to prevent skin necrosis
  5. Nerve repair is essential for sensation recovery — the defining advantage of microsurgery
  6. Adjuncts — leech therapy, HBO, antithrombotics — can salvage compromised replants
  7. Psychiatric evaluation mandatory for self-inflicted injuries (50% recurrence risk)
  8. Transfer urgently to a specialty center if microsurgery is not available — ACS recommendation

Cross-references​

Trauma context​

Reconstruction​

Adjuncts​

References​

1. Johnsen N, Wessells H, Archer-Arroyo K, et al. "Best Practices Guidelines: Management of Genitourinary Injuries." American College of Surgeons. 2025.

2. Wang P, Luo Y, Li YF, et al. "Microscopic Replantation of Complete Penile Amputation With Video Demonstration." Urology. 2022;164:e303–e306. doi:10.1016/j.urology.2022.03.006

3. Jezior JR, Brady JD, Schlossberg SM. "Management of Penile Amputation Injuries." World J Surg. 2001;25(12):1602–9. doi:10.1007/s00268-001-0157-6

4. Jordan GH, Gilbert DA. "Management of Amputation Injuries of the Male Genitalia." Urol Clin North Am. 1989;16(2):359–67.

5. Sanger JR, Matloub HS, Yousif NJ, Begun FP. "Penile Replantation After Self-Inflicted Amputation." Ann Plast Surg. 1992;29(6):579–84. doi:10.1097/00000637-199212000-00017

6. Jin DC, Zhou B, Li J, et al. "Microscopic Replantation of Penile Glans Amputation Due to Circumcision." J Vis Exp. 2022;(184). doi:10.3791/63691

7. Mousa A, Keefe DT, Wong K, et al. "Leeches and Caudal Analgesia After Replantation for Glans Amputation During Neonatal Circumcision." Urology. 2022;165:e32–e35. doi:10.1016/j.urology.2022.02.015

8. Sherman J, Borer JG, Horowitz M, Glassberg KI. "Circumcision: Successful Glanular Reconstruction and Survival Following Traumatic Amputation." J Urol. 1996;156(2 Pt 2):842–4.

9. Banihani OI, Fox JA, Gander BH, Grunwaldt LJ, Cannon GM. "Complete Penile Amputation During Ritual Neonatal Circumcision and Successful Replantation Using Postoperative Leech Therapy." Urology. 2014;84(2):472–4. doi:10.1016/j.urology.2014.04.021

11. Tuffaha SH, Sacks JM, Shores JT, et al. "Using the Dorsal, Cavernosal, and External Pudendal Arteries for Penile Transplantation: Technical Considerations and Perfusion Territories." Plast Reconstr Surg. 2014;134(1):111e–119e. doi:10.1097/PRS.0000000000000277

12. Lohasammakul S, Turbpaiboon C, Ratanalekha R, Ungprasert P, Yodrabum N. "Inferior External Pudendal Artery Anastomosis: Additional Approach to Prevent Skin Necrosis in Replanted Penis." Plast Reconstr Surg. 2018;142(4):535e–540e. doi:10.1097/PRS.0000000000004818

13. Diallo D, Zaitouna M, Alsaid B, et al. "What Is the Origin of the Arterial Vascularization of the Corpora Cavernosa? A Computer-Assisted Anatomic Dissection Study." J Anat. 2013;223(5):489–94. doi:10.1111/joa.12094

14. Yiee JH, Baskin LS. "Penile Embryology and Anatomy." ScientificWorldJournal. 2010;10:1174–9. doi:10.1100/tsw.2010.112

17. Carroll PR, Lue TF, Schmidt RA, Trengrove-Jones G, McAninch JW. "Penile Replantation: Current Concepts." J Urol. 1985;133(2):281–5. doi:10.1016/s0022-5347(17)48918-x

18. Fan J, Eriksson M, Rosenlund AF, Nordström RE. "An Unusually Avulsed Penis Successfully Replanted by Using Microsurgical Technique." Plast Reconstr Surg. 1996;98(3):571–3. doi:10.1097/00006534-199609000-00044

19. Salem HK, Mostafa T. "Primary Anastomosis of the Traumatically Amputated Penis." Andrologia. 2009;41(4):264–7. doi:10.1111/j.1439-0272.2009.00925.x

20. Landström JT, Schuyler RW, Macris GP. "Microsurgical Penile Replantation Facilitated by Postoperative HBO Treatment." Microsurgery. 2004;24(1):49–55. doi:10.1002/micr.10192

21. van der Merwe A, Graewe F, Zühlke A, et al. "Penile Allotransplantation for Penis Amputation Following Ritual Circumcision: A Case Report With 24 Months of Follow-Up." Lancet. 2017;390(10099):1038–1047. doi:10.1016/S0140-6736(17)31807-X

26. Lowe MA, Chapman W, Berger RE. "Repair of a Traumatically Amputated Penis With Return of Erectile Function." J Urol. 1991;145(6):1267–70. doi:10.1016/s0022-5347(17)38597-x

27. Szasz G, McLoughlin MG, Warren RJ. "Return of Sexual Functioning Following Penile Replant Surgery." Arch Sex Behav. 1990;19(4):343–8. doi:10.1007/BF01541929

28. Jiménez-Cruz JF, Garcia-Reboll L, Alonso M, Broseta E, Sanz S. "Microsurgical Penis Replantation After Self-Mutilation." Eur Urol. 1995;27(3):246–8. doi:10.1159/000475170

29. Putra DE, Kusbin TBA, Satyagraha P, Widodo ST. "Case Report: Non-Microscopic Surgical Management of Incomplete Penile Amputation." F1000Res. 2020;9:681. doi:10.12688/f1000research.23775.1

30. Ching WC, Liao HT, Ulusal BG, Chen CT, Lin CH. "Salvage of a Complicated Penis Replantation Using Bipedicled Scrotal Flap Following a Prolonged Ischaemia Time." J Plast Reconstr Aesthet Surg. 2010;63(8):e639–43. doi:10.1016/j.bjps.2010.01.017

31. Chou EK, Tai YT, Wu CI, et al. "Penile Replantation, Complication Management, and Technique Refinement." Microsurgery. 2008;28(3):153–6. doi:10.1002/micr.20470

32. Mineo M, Jolley T, Rodriguez G. "Leech Therapy in Penile Replantation: A Case of Recurrent Penile Self-Amputation." Urology. 2004;63(5):981–3. doi:10.1016/j.urology.2004.01.019

33. Zhong Z, Dong Z, Lu Q, et al. "Successful Penile Replantation With Adjuvant Hyperbaric Oxygen Treatment." Urology. 2007;69(5):983.e3–5. doi:10.1016/j.urology.2007.02.024

34. Tanaka T, Minami A, Uchida J, Nakatani T. "Potential of Hyperbaric Oxygen in Urological Diseases." Int J Urol. 2019;26(9):860–867. doi:10.1111/iju.14015