ORIGINAL PAPER M. Cakmak ® F. Caglayan ® U. Kisa ® O. Bozdogan A. Saray ® O. Caglayan Tourniquet application and epinephrine injection to penile skin: is it safe? Received: 3 November 2001 / Accepted: 27 March 2002 / Published online: 3 July 2002 Ó Springer-Verlag 2002 Abstract Although a tourniquet is frequently used in penile surgery there is still no consensus on safe appli- cation time. The aim of the present study is to investi- gate the effect of malondialdehyde (MDA) levels and histological changes in skin flaps after penile tourniquet application and epinephrine injection. A total of 36 male white New Zealand rabbits were randomly divided into six groups each containing six animals. A Mathieu-like flap was raised in all of the groups and a tourniquet was applied and the penis was subjected to ischemia for 10, 20 and 40 min in groups 1, 2 and 3, respectively. The flaps were then allowed to reperfuse for 5 min. Biopsies for MDA measurement were harvested in these groups. Subcutaneous 1/200,000 epinephrine was injected into penile skin in group 4 and 5 rabbits and biopsies for MDA measurement were harvested 10 and 40 min after injection. The control group was anesthetized without tourniquet usage or epinephrine injection. Specimens taken from the harvested flaps of all groups were sub- mitted for histological evaluation. The mean MDA levels in all experimental groups were higher than in the control group and the difference was statistically sig- nificant. Edema, congestion and extravasation were observed in groups 1, 2 and 3. Minimal congestion and edema were observed in group 4 and severe edema and extravasation in group 5. Tourniquet usage for a dura- tion of less than 10 min is clearly safer than prolonged usage. Epinephrine injection to penile skin may show a deleterious effect on wound healing. Keywords Penile tourniquet ® Epinephrine ® Malondialdehyde ® Ischemia-reperfusion ® Hypospadias repair Introduction The safe time for the application of a tourniquet in penile surgery has not been established and the times used vary according to the surgeon. Jean Louis Petit was the first surgeon to describe the screw tourniquet for limb surgery in 1718 and he was the first to use the term ‘‘tourniquet’’ [14]. Use of a rubber bandage for performing bloodless surgery was first introduced by Esmarch [14]. Several types of tourniquets have been used in different surgical specialties for the control of intraoperative bleeding. John Redman first described the application of a rubber band tourniquet in hypospadias surgery in 1983 [see 22]. This type of tourniquet is frequently used for several types of penile and clitoral surgeries. When blood flow is restarted following such an is- chemic period reperfusion injury may occur. This has been documented in many different tissues such as kid- ney, heart, intestines, liver, bone, skin and skeletal muscle. A similar cascade of events may also occur after the placement of a penile tourniquet. Different doses of epinephrine are also used in penile surgery, either solely for vasoconstriction or, when in combination with local anaesthetic agents, for prolong- ing the efficacy of these agents in penile skin. This experimental study was performed to investigate the time that a tourniquet can be safely used as well as to determine the effect of epinephrine on the skin in penile Urol Res (2002) 30:268–272 DOI 10.1007/s00240-002-0262-5 M. Cakmak (&) ® F. Caglayan Kirikkale University, School of Medicine, Department of Pediatric Surgery, Kirikkale, Turkey E-mail: cakmakma@hotmail.com Tel.: +90-312-2842462 Fax: +90-318-2252819 U. Kisa ® O. Caglayan Kirikkale University, School of Medicine, Department of Biochemistry, Kirikkale, Turkey O. Bozdogan Kirikkale University, School of Medicine, Department of Pathology, Kirikkale, Turkey A. Saray Kirikkale University, School of Medicine, Department of Plastic and Reconstructive Surgery, Kirikkale, Turkey M. Cakmak Baris¸ Sitesi, 80 Sok. No: 5, Mustafa Kemal Mah., Eskisehir Yolu, 06530 Ankara, Turkey