Use of magnetic resonance imaging to guide direct repair of penile fractures---a change to the operative paradigm

Penile fractures are an uncommon urological emergency, typically diagnosed on clinical grounds and require urgent operative intervention. Examination findings include penile swelling and bruising, commonly referred to as an "eggplant deformity". Close palpation to identify the exact site of injury is often limited by pain. Subcoronal degloving, often with concurrent circumcision is the most utilised surgical approach, though risks include skin necrosis and decreased penile sensitivity. Magnetic Resonance Imaging (MRI) for penile fracture diagnosis is increasingly recognised, however, its ability to guide localised longitudinal incisions is currently undefined. A multi-centre retrospective observational study from February 2016 to February 2022 was performed. Electronic medical records were reviewed for patient demographics, presentation, injury characteristics, investigations and operative outcomes. MRI use and protocols were determined at the discretion of the treating urologist and on-duty radiologist respectively. Twenty-one patients were eligible for study inclusion. Ten patients underwent preoperative MRI. Median time from MRI request to image acquisition was 2.5 hours (1.5-3.0). Time from presentation to surgical intervention did not significantly differ between the two groups. All patients without pre-operative MRI underwent subcoronal degloving. Six patients underwent MRI-guided localised incision successfully without requiring secondary incision or conversion to subcoronal degloving. The remaining four patients in the MRI cohort underwent degloving. Operative times were significantly shorter (p = 0.44) in the pre-operative MRI group, with a median duration of 1.11 hours (0.98-1.17), compared to 1.5 hours (1.20-1.75) in the non-MRI cohort. Median length of stay was 1 day in both groups. No Clavien Dindo 2 or greater complications were observed in any patient. In this study, MRI in the pre-operative setting for penile fractures is associated with reduced operative time and was successfully used to guide localised incisions for direct repair of penile fractures. Its use has the potential to change the paradigm of penile fracture management and operative repair.