Penile skin necrosis after complex penile surgery with synthetic grafts: a case report

Introduction

Complex penile surgery is increasingly performed for functional and reconstructive indications, including correction of penile curvatures and length restoration (1-3). While these procedures can provide satisfactory outcomes, they may also be associated with severe complications, particularly when extensive dissection or synthetic materials are involved (2,3).

Postoperative infections and cutaneous necrosis of the penis represent challenging clinical scenarios, with potentially dramatic functional and psychological consequences for the patient (4). Management of such complications requires timely intervention, careful surgical planning, and close collaboration between urologists and reconstructive surgeons.

The presence of synthetic grafts in penile surgery may further complicate postoperative evolution, increasing the risk of infection, impaired wound healing, and tissue necrosis (5,6). In these cases, early recognition and prompt removal of foreign material are essential to prevent progression and allow effective tissue salvage (7). A staged reconstructive approach is often required, prioritizing control of infection and preservation of viable erectile structures before addressing definitive reconstruction and functional recovery (6,7).

We report a case of extensive penile skin necrosis following complex penile surgery with synthetic graft implantation, successfully managed through urgent surgical debridement, removal of prosthetic material, and staged reconstructive surgery. This case highlights key considerations in the management of severe penile complications and underscores the importance of a multidisciplinary, stepwise approach to optimize outcomes while preserving future reconstructive and functional options. We present this article in accordance with the CARE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0173/rc).

Case presentation

A 36-year-old man with no relevant medical comorbidities presented to our emergency department with progressive penile skin necrosis and signs of local infection. His medical history was notable for complex penile surgery performed at an external centre in November 2025, for correction of penile curvature. In addition to surgical correction of penile curvature, the patient expressed a desire to undergo vasectomy and to achieve an increase in penile length and circumference. The procedure included excision of a fibrotic plaque of corpora cavernosa and resection 5 cm of the lateral tunica albuginea for bilateral placement of synthetic grafts (Gore-Tex^®, W. L. Gore & Associates, Inc., Newark, DE, USA), penile lengthening through section of the suspensory ligament, circumcision, and vasectomy.

The immediate postoperative course was initially uneventful. However, 10 days after removal of the compressive dressing, the patient developed progressive penile swelling and hematoma, followed by skin discoloration and purulent discharge. In the days preceding presentation, he reported fever and worsening local pain. He was admitted to our institution 17 days after the index surgery.

Physical examination revealed extensive cutaneous necrosis involving the ventral and lateral aspects of the penile shaft, associated with signs of superimposed infection and partial exposure of the underlying synthetic grafts (Figure 1). The glans appeared viable, with preserved perfusion. Laboratory investigations showed elevated inflammatory markers, with a C-reactive protein level of approximately 50 mg/L, while the white blood cell count was within normal limits.

Figure 1 Extensive penile skin necrosis with signs of infection and partial exposure of synthetic grafts at presentation.

Given the severity of the clinical findings, urgent surgical exploration was undertaken. The patient underwent radical debridement of all necrotic tissues, evacuation of the hematoma, and complete bilateral removal of the synthetic grafts the day following admission. Intraoperatively, extensive cutaneous necrosis was confirmed. Following removal of the synthetic grafts, the underlying corpora cavernosa were found to be exposed but without evidence of necrosis. Given the contaminated surgical field and the priority of infection control, no immediate cavernosal reconstruction was attempted, and the erectile bodies were intentionally left uncovered as part of a staged reconstructive strategy (Figure 2). Multiple microbiological samples were collected. Temporary urinary catheterization was performed, and the wound was managed with non-adherent dressings.

Figure 2 Intraoperative view after radical debridement and complete removal of synthetic grafts, with exposed but viable corpora cavernosa.

Postoperatively, the patient received targeted antibiotic therapy and was managed with conservative wound care. Adjunctive hyperbaric oxygen therapy was initiated to promote tissue healing. Intraoperative specimens yielded the following organisms Pseudomonas aeruginos, Enterococcus faecalis, Enterobacter hormaechea and Digestive tract flora. The patient showed a favorable clinical evolution under hyperbaric oxygen therapy and antibiotic treatment with piperacillin-tazobactam 4 g four times daily intravenously, as it is appropriate for the documented polymicrobial infection, for a total duration of 14 postoperative days, followed by a 14-day antibiotic-free interval prior to reconsidering further surgical intervention. Progressive clinical improvement was observed, with stabilization of the wound bed and resolution of infection (Figure 3).

Figure 3 Postoperative wound stabilisation following debridement, antibiotic therapy, and hyperbaric oxygen treatment.

Definitive reconstruction was performed as part of a staged approach. The patient underwent second-stage surgery 58 days after the index surgery, consisting of superficial coverage of the penile shaft with a split-thickness skin graft combined with a dermal regeneration template (Matriderm^®, MedSkin Solutions Dr. Suwelack AG, Billerbeck, Germany), without cavernosa reconstruction. The reconstructive phase was performed jointly by urologists and a plastic surgeon. The graft was secured with temporary silk and quilting sutures (Figure 4). The silk sutures were used solely for initial graft fixation and were not intended to be permanent. A sewn-on tie-over dressing was applied to ensure immobilization and was removed on postoperative day 3.

Figure 4 Second-stage reconstruction with split-thickness skin graft and dermal regeneration template (Matriderm^®).

The postoperative course was uneventful, with satisfactory graft take and adequate coverage of the penile shaft. The patient was discharged on postoperative day 6 and reviewed in outpatient consultation on postoperative day 10, at which time the fixation sutures were removed, confirming good graft integration (Figure 5).

Figure 5 Late postoperative follow-up after removal of fixation sutures, showing complete graft take and stable penile shaft coverage.

At subsequent follow-up, wound healing was complete, with good cosmetic outcomes and preservation of penile anatomy. Further functional assessment was planned as part of the staged reconstructive pathway.

The timeline of clinical events is summarized in Table 1.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Patient perspective

After the infection resolved, I felt a great sense of relief. I am very satisfied with the reconstructive outcome and have noticed a significant improvement in the appearance of my penis and in my overall comfort. This has had a positive psychological impact on me. I remain motivated to continue with the planned staged functional evaluation if needed.

Discussion

Severe complications following complex penile surgery represent a challenging clinical scenario, particularly when synthetic materials are employed. Penile skin necrosis may rapidly progress in the presence of infection and foreign bodies, potentially compromising underlying erectile structures and resulting in major functional and psychological consequences (5,6). Early recognition and prompt intervention are therefore essential to prevent irreversible damage (7).

The use of synthetic grafts in penile surgery has been described in selected settings; however, their presence may increase susceptibility to infection and impair wound healing, especially in the context of extensive dissection or postoperative hematoma formation (6,7). Once infection and tissue necrosis develop, removal of prosthetic material becomes a critical step to halt disease progression (7). In the present case, exposure of the synthetic grafts was associated with extensive cutaneous necrosis, reinforcing the need for early and decisive surgical management.

From a therapeutic perspective, a staged reconstructive approach was fundamental to achieving a favourable outcome. Initial management prioritized eradication of infection, radical debridement of necrotic tissues, and preservation of viable erectile structures. This strategy allowed stabilization of local conditions and creation of an optimal wound bed for subsequent reconstruction. Adjunctive hyperbaric oxygen therapy was employed to enhance tissue perfusion and support wound healing, contributing to successful preparation for definitive reconstruction. The use of hyperbaric oxygen therapy in penile pathology, including ischemia, necrosis, and severe infections, has been reported in the literature, suggesting potential benefits in improving tissue oxygenation, promoting angiogenesis, and supporting wound healing (8,9).

In the present case, exposure of the corpora cavernosa following removal of the synthetic grafts required prioritization of infection control and tissue coverage, deliberately deferring cavernosal reconstruction to subsequent stages.

The use of a dermal regeneration template in combination with split-thickness skin grafting allowed reliable coverage of the penile shaft, with excellent graft take and satisfactory cosmetic outcomes. Dermal matrices provide a well-vascularized scaffold that enhances graft integration, improves skin elasticity, and reduces secondary contracture. These features are particularly advantageous in penile reconstruction, where tissue compliance and mobility are essential for both cosmetic and functional outcomes. In addition, this approach limits donor-site morbidity compared with thicker grafts or flap-based reconstructions and preserves local and regional tissues for potential future reconstructive procedures.

However, the use of dermal regeneration templates is associated with certain limitations, including increased cost, meticulous surgical technique, and a potentially higher risk of graft loss in the event of infection or inadequate immobilization. Despite these constraints, the combination of a dermal matrix with split-thickness skin grafting represents a valuable option in complex penile reconstruction, offering a favourable balance between surgical reliability, aesthetic outcome, and preservation of future reconstructive possibilities.

While erectile function was not the primary endpoint of the initial surgical management, preservation of the corpora cavernosa allows for dedicated functional assessment and targeted interventions at a later stage, if required. At this stage, functional evaluation was not feasible due to the extent of tissue loss and the staged reconstructive approach. Penile prosthesis implantation was also not appropriate in the acute setting but may be considered in the future depending on tissue healing and functional outcomes.

This case underscores the importance of multidisciplinary collaboration between urologists, infectious disease specialist, hyperbaric doctor, and reconstructive surgeons in managing severe penile complications. A structured, stepwise approach enables safe control of infection, effective tissue salvage, and successful reconstruction, while avoiding more radical procedures that could irreversibly compromise function.

This report has inherent limitations related to its single-case design and the absence of long-term functional outcomes. Although short-term anatomical and cosmetic results were satisfactory, further follow-up is required to evaluate erectile function and long-term reconstructive stability. Nevertheless, the detailed description of a structured staged salvage strategy may provide clinically relevant insights for the management of similar complex cases.

Conclusions

Severe penile skin necrosis following complex penile surgery with synthetic graft implantation requires prompt recognition and aggressive management. Early removal of foreign material, radical debridement, and a staged reconstructive strategy are key to successful tissue salvage and reconstruction. A multidisciplinary approach allows control of infection, preservation of erectile structures, and maintenance of future functional and reconstructive options, even in the setting of extensive complications.

Acknowledgments

The authors would like to thank the multidisciplinary team involved in the management of this patient, including the infectious diseases specialists and the hyperbaric medicine team at APHM, Marseille, for their valuable contribution to the patient’s care.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0173/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0173/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0173/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Gultekin MH, Al-Mitwalli A, Lee WG, et al. The evolution of penile reconstructive techniques in urology. Int J Impot Res 2026;38:155-60. [Crossref] [PubMed]
2. Chung E. Penile Reconstructive Surgery in Peyronie Disease: Challenges in Restoring Normal Penis Size, Shape, and Function. World J Mens Health 2020;38:1-8. [Crossref] [PubMed]
3. Falagario UG, Piramide F, Pang KH, et al. Techniques for Penile Augmentation Surgery: A Systematic Review of Surgical Outcomes, Complications, and Quality of Life. Medicina (Kaunas) 2024;60:758. [Crossref] [PubMed]
4. Gaspar SS, Dias JS, Martins F, et al. Sexual Urological Emergencies. Sex Med Rev 2015;3:93-100. [Crossref] [PubMed]
5. Cayetano-Alcaraz AA, Yassin M, Desai A, et al. Penile implant surgery-managing complications. Fac Rev 2021;10:73. [Crossref] [PubMed]
6. Ramazan M, Øbro LF, Wiborg MH, et al. Complications of penile augmentation: A narrative review of injectables, implants, and surgical grafts. Int J Impot Res 2026;38:238-46. [Crossref] [PubMed]
7. Pignanelli M, Williams JM, Fernandez Crespo RE, et al. Complications and management of penile enhancement procedures. Transl Androl Urol 2025;14:3367-76. [Crossref] [PubMed]
8. Pepe P, Pietropaolo F, Candiano G, et al. Ischemia of the glans penis following circumcision: case report and revision of the literature. Arch Ital Urol Androl 2015;87:93-4. [Crossref] [PubMed]
9. Della Camera PA, Cito G, Morselli S, et al. Healing of spongiosus-cutaneous fistula with hyperbaric Oxygen Therapy (HBOT): a case report. Urologia 2017; Epub ahead of print. [Crossref]