Inferior external pudendal artery anastomosis: Additional approach to prevent skin necrosis in replanted penis

Abstract

© 2018 by the American Society of Plastic Surgeons. Background: Microsurgical anastomosis of the dorsal artery of the penis either with or without anastomosis of the cavernosal artery is the preferred technique for penile replantation. However, postoperative penile skin necrosis is commonly reported with this technique. This study aimed to characterize the anatomy of the vascular supply of the penis pertinent to penile replantation surgery and to report a successful case of penile replantation without postoperative necrosis using anastomosis of the inferior external pudendal artery. Methods: The authors dissected 15 penises of fresh cadavers under acrylic dye injection by means of the inferior external pudendal and dorsal arteries of the penis to identify vascular anastomoses between arteries supplying the penis and to measure other parameters of the arteries. Results: Mean diameters at the base of the penis of the inferior external pudendal, dorsal, and cavernosal arteries were 0.94, 1.43, and 0.80 mm, respectively. Penile skin is mainly supplied by the inferior external pudendal artery under three patterns with anastomoses across the midline. Preputial skin receives additional blood supply from perforators of the dorsal artery without visible anastomosis between the perforators and the inferior external pudendal artery. Deep structures receive blood supply from the dorsal, cavernosal, and urethral arteries, with visible anastomoses between the arteries. In a patient with amputated penis, the inferior external pudendal artery diameter was 0.7 mm, which was sufficient for microsurgical anastomosis. No postoperative necrosis developed, and patency of the inferior external pudendal artery was confirmed with duplex ultrasound. Conclusion: The diameter of the inferior external pudendal artery at the base and midshaft of the penis is sufficiently large for microsurgical anastomosis, and additional vascular anastomosis of at least one inferior external pudendal artery may help to prevent postoperative penile skin necrosis.