Extensive penile glans and corpus spongiosum necrosis due to catheter traction following laparoscopic radical cystoprostatectomy: a rare case report and literature review

Penile necrosis is a very rare and devastating pathology that can result in partial or total penectomy in most cases. A deep search in the literature identified one case report of glans necrosis following traction of the urethral catheter in a 69-year-old man who had undergone transurethral resection of the prostate for benign prostatic hyperplasia. It was confined to the glans and was managed conservatively on antimicrobial therapy and watchful waiting until the gangrenous part sloughed off, leaving a defect on the glans penis [5]. To our knowledge, our case is the second case of penile glans necrosis following catheter traction reported in the literature. Our case underwent a major operation which predisposes diminished blood supply, and compression of the dorsal vein complex from the traction of the catheter may block the retrograde flow of the blood, not only in the glans; we also think that it causes necrosis in the entire penile urethra. Necrosis spreads rapidly towards the bulbar urethra due to ischemia and weakening of the local defense following the deterioration of vascularization and bacterial colonization from the catheterization. Early detection and urgent imaging with a high index of suspicion ensure a favorable outcome. Pelvic MRI or CT to exclude abscess or compression form haematoma, penile MRI and even angiography could be useful for the differential.

The laparoscopic approach before open surgery could be performed safely for bladder cancer as well as many other surgical diseases. Laparoscopic minimally invasive surgery should be preferred to open surgery due to its advantages. However, both open surgery and laparoscopic surgery have their set of pros and cons [6].

Akagiet al. reported a case of complete necrosis of the corpus spongiosum and corpora cavernosa after repeated transurethral surgical procedures. They managed with total penectomy and perineal urethrostomy [7]. Compared to our case, our patient had an intact corpora cavernosa despite presenting an extensive length of penile glans and corpus spongiosum necrosis. It was managed successfully with penile preservation, enabling the best functional and esthetic results.

In the few cases reported in the literature, there are different causes related to glans or penile necrosis and a wide diversity of treatment approaches.

Vascular occlusive pathologies are the leading cause of glans and penile necrosis. It is mainly associated with renal failure, diabetes, and venous thromboembolic diseases [8]. In end-stage renal failure, as a result of the occlusion of increased calcium and phosphate products, especially in the intima of small and medium-sized vessels, associated with secondary hyperparathyroidism, it causes well-circumscribed plaque, necrosis, and ulceration in the glans due to insufficient vascular supply in the tissue. In a review of 15 Japanese patients with calciphylaxis-related necrosis of the penis, the mainstay management was partial penectomy for 11 patients and total penectomy in the remaining four cases [8]. The authors reported a poor prognosis with calciphylaxis-related necrosis. Kharbach and colleagues reported a 54-year-old patient with idiopathic necrosis of the glans penis managed with partial penectomy [9]. Agustino and Irdam reported a 30-year-old male with ischemic related to aortic dissection who presented with acute limb ischemia, necrosis of the penis, and scrotum gangrene managed with debridement of the penis and scrotum and urinary diversion with percutaneous cystostomy [3].

Very few reports mention the use of angiography for the diagnosis of penile necrosis. Shah and colleagues reported a known case of hypertension, diabetes, and chronic renal failure who underwent circumcision for phimosis and developed gangrene of the glans penis two weeks later. The patient underwent internal pudendal artery angioplasty and a partial penectomy [10]. Kim et al. reported unexpected penile glans ischemic necrosis after internal pudendal arterial embolization in a patient with a post-traumatic internal pudendal artery-urethral fistula [11]. The authors reported successful treatment of the patient with intravenous infusion of alprostadil, oral pentoxifylline, and tadalafil. In a case series of six patients with penile glans necrosis (PGN) following prostatic artery embolization (PAE) due to failed medical benign prostate hyperplasia (BPH) therapy [12]. The authors proposed the role of hyperbaric oxygen therapy (HBOT) for PGN. HBOT appears to accelerate recovery with better erection scores than conservative methods.

Penile strangulation and gangrene may follow a condom catheter frequently used to manage male urinary incontinence, as reported by Zaghbib and associates [13]. Even if it’s rare, it has devastating complications, so care should be given to debilitated and psychiatric populations.