# Teaching storyboard: traumatic penile amputation and replantation

Status: draft for anatomical and clinical review.

Case: constructed complete shaft amputation with an amputated segment available for assessment. No patient images. Excludes planned oncologic penectomy.

The continuous movie starts with normal external anatomy and scrotum, then shows division, separation, and repair of the same cut structures. It zooms to tunical closure, moves ventrally to urethral repair, then magnifies both dorsal arteries, the deep dorsal vein, and both dorsal nerves before returning to coverage. The supplementary viewer retains separate detail models for inspection. Reviewed device evidence does not establish penile replantation outcomes. Their thread paths and proportions are schematic; needle handling, preparation, clamps, grafts, and knot tying are not animated. The following eight stages are an explanation order, not a universal operative sequence.

## 1. Intact anatomy and orientation

- What changes: Move from pelvic context to the shaft while retaining dorsal, ventral, right, left, proximal, and distal markers.
- Why it matters: Establish the spatial map before injury.
- Identify: Paired corpora and tunica; ventral spongiosum with a patent urethral lumen; dorsal vessels and nerves.
- Principal failure modes: Laterality reversal or mistaking a label for demonstrable anatomy.
- Magnified inset: Cross-section of the intact shaft; small structures retain their relation to the corporal bodies.
- Evidence status: Anatomical description; constructed geometry requires review.
- References: [Garg et al., 2016](https://pmc.ncbi.nlm.nih.gov/articles/PMC4878254/)

## 2. Complete amputation and matching structures

- What changes: Show a complete shaft division, then separate the segment without rotating it. Both cut surfaces remain visible in linked section views.
- Why it matters: Identify the same tissue on each side of the injury.
- Identify: Urethral openings, spongiosum, right and left corpora, tunica, vessels, nerves, fascia, and skin.
- Principal failure modes: Wrong partners, axial rotation, or an empty-shell cut surface.
- Magnified inset: Opposing cut faces with explicit viewing direction and mirrored screen positions.
- Evidence status: Constructed transverse case. Incomplete injuries and other patterns are discussed separately.
- References: [Garg et al., 2016](https://pmc.ncbi.nlm.nih.gov/articles/PMC4878254/); [Geary et al., 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC11773072/)

## 3. Assessment, preservation, and coordination

- What changes: Hold the anatomical scene while introducing resuscitation, associated injury assessment, segment preservation, and coordination with reconstructive and microsurgical teams.
- Why it matters: Care of the injured person and preservation of the segment occur together.
- Identify: Stump, recovered segment, and separate cooling container.
- Principal failure modes: Delayed coordination, additional tissue injury, or direct contact with ice.
- Magnified inset: Source-backed concept: saline-moistened gauze, a bag, and indirect cooling with iced water. No time cutoff is taught.
- Evidence status: Guideline principle; local transport workflow remains for review.
- References: [EAU Urological Trauma, 2026](https://uroweb.org/guidelines/urological-trauma/chapter/urogenital-trauma-guidelines); [Geary et al., 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC11773072/)

## 4. Viability assessment and preparation

- What changes: Inspect both ends and identify the injury zone and available structures under magnification. Tag corresponding structures in the storyboard.
- Why it matters: Available tissue and vessel quality determine what can be reconstructed.
- Identify: Viable margins, urethra, tunical edges, vessel ends, and nerve ends.
- Principal failure modes: Assuming a clean model cut represents crush damage, or assuming every visible channel is repairable.
- Magnified inset: Wider stump remains visible while a selected structure is inspected.
- Evidence status: Case-based technique. No validated viability score is supplied.
- References: [EAU Urological Trauma, 2026](https://uroweb.org/guidelines/urological-trauma/chapter/urogenital-trauma-guidelines); [Geary et al., 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC11773072/); [Garg et al., 2016](https://pmc.ncbi.nlm.nih.gov/articles/PMC4878254/)

## 5. Corporal and urethral repair

- What changes: Play the paired tunical closure, then the urethral wall repair over a catheter on the original cut anatomy in the continuous movie. This is a teaching order, not an operative sequence.
- Why it matters: Explain urinary continuity separately from corporal structural support.
- Identify: Open lumen, apposed urethral edges, corresponding corporal bodies, and tunical edges.
- Principal failure modes: Malrotation, tension, narrowing, urinary leakage, or loss of corporal alignment.
- Magnified inset: Zoom to translucent corpora and tunical bites, then move ventrally to the translucent urethral wall. Covering tissue is hidden; cutaway and catheter controls expose the lumen.
- Evidence status: Technique variation: cavernosal artery repair may precede tunical closure in selected reports.
- References: [Krishnakumar et al., 2013](https://pmc.ncbi.nlm.nih.gov/articles/PMC3745104/); [Garg et al., 2016](https://pmc.ncbi.nlm.nih.gov/articles/PMC4878254/)

## 6. Microsurgical arterial, venous, and nerve repair

- What changes: Pan dorsally to arterial repair, move across to venous repair, then laterally to a Nerve Tape device-mechanism illustration around aligned dorsal nerve ends.
- Why it matters: Perfusion and later sensory function depend on different structures.
- Identify: Arteries, deep and superficial veins, and paired dorsal nerves with their partners.
- Principal failure modes: Wrong partner, twist, tension, thrombosis, venous congestion, or implying immediate nerve recovery.
- Magnified inset: Artery and vein remain spatially separate. At the nerve, the short wrap leaf closes before the longer overlapping leaf; microhooks engage epineurium. No sensory recovery is simulated.
- Evidence status: Vessel order varies across reports. Nerve Tape sources describe the device mechanism; they do not establish penile replantation outcomes.
- References: [EAU Urological Trauma, 2026](https://uroweb.org/guidelines/urological-trauma/chapter/urogenital-trauma-guidelines); [Krishnakumar et al., 2013](https://pmc.ncbi.nlm.nih.gov/articles/PMC3745104/); [Garg et al., 2016](https://pmc.ncbi.nlm.nih.gov/articles/PMC4878254/); [BioCircuit Nerve Tape IFU, Rev 07](https://www.biocircuit.com/_files/ugd/911ff7_779238cb615740a789237d6f891e9f40.pdf)

## 7. Coverage and completed reconstruction

- What changes: After the approved repair sequence, return fascia and skin while showing the reconstructed structures beneath.
- Why it matters: Coverage must protect the reconstruction without compression.
- Identify: Fascial planes, skin margins, and the course of repaired vessels.
- Principal failure modes: Tight closure, edema, or vascular kinking. Completion does not end vascular risk.
- Magnified inset: Relation of the covering layers to the dorsal repair.
- Evidence status: Case-based technique. Coverage and support details require review.
- References: [Geary et al., 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC11773072/); [Garg et al., 2016](https://pmc.ncbi.nlm.nih.gov/articles/PMC4878254/)

## 8. Monitoring, complications, and recovery

- What changes: Separate tissue viability from skin survival, urinary patency, sensation, erection, and psychological recovery.
- Why it matters: Survival is only one outcome.
- Identify: Clinical perfusion observations and the functional domains assessed over follow-up.
- Principal failure modes: Missed congestion, tissue loss, delayed stricture or fistula, and unsupported claims of functional restoration.
- Magnified inset: Color, temperature, capillary refill, and Doppler are reported monitoring observations; no frequency or drug regimen is prescribed.
- Evidence status: Guideline follow-up plus case reports. Recovery estimates and comparative claims are withheld.
- References: [EAU Urological Trauma, 2026](https://uroweb.org/guidelines/urological-trauma/chapter/urogenital-trauma-guidelines); [Krishnakumar et al., 2013](https://pmc.ncbi.nlm.nih.gov/articles/PMC3745104/); [Geary et al., 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC11773072/); [Garg et al., 2016](https://pmc.ncbi.nlm.nih.gov/articles/PMC4878254/)

## Other injury patterns

Incomplete injuries retain a tissue bridge. Crush, avulsion, other amputation levels, and missing segments require different assessment and reconstruction. The clean transverse geometry does not depict their zone of injury.

## Review decisions required

Confirm the injury plane, medial septum, fascial contours, urethral centerline, and neurovascular courses. Select a case-specific operative sequence. Decide whether any cavernosal arteries, superficial veins, grafts, drainage, and coverage details belong in that case. Approve monitoring and functional outcome language. No ischemia cutoff, medication regimen, outcome percentage, or superiority estimate is supplied.