Silicone-induced Penile Sclerosing Lipogranuloma: Magnetic Resonance Imaging Findings

MR imaging of the penis: What a radiologist needs to know!

Magnetic resonance imaging (MRI) plays an important role in imaging of penile pathologies due to its excellent soft tissue resolution and multiplanar imaging capabilities. This imaging review describes the MRI protocols and anatomical considerations in penile pathologies. MRI not only serves as a complementary tool to ultrasound in evaluation of trauma, infections, inflammatory diseases, and malignancies, but is also used as the definitive imaging modality for evaluation of penile prosthesis and complex cases.

Complications and outcomes following injection of foreign material into the male external genitalia for augmentation: a single-centre experience and systematic review

Injection of exogenous material into the penis and scrotum has been performed for augmentation purposes. Complications include cosmetic dissatisfaction, penile necrosis and lymphoedema. We report the complications and outcomes from a single centre with an updated systematic review of the literature. A retrospective review of all cases presenting with foreign substance injection into the genitalia, over a 10-year period was performed. Thirty-five patients with a mean (standard deviation (SD); range) age of 36.9 (±9.1; 22-61) years at presentation were included. The mean (SD; range) time between injection and presentation was 7.8 (±5.8; 1 day-20 years) years. The most common injected substance was silicone (n = 16, 45.7%) and liquid paraffin (n = 8, 22.9%). The penile shaft (94.3%) was the most injected site. The most common presentations were cosmetic dissatisfaction (57.1%) and pain and/or swelling (45.7%). Surgery was required in 32 (91.4%) cases. Primary procedures included local excision and primary closure (n = 19, 59.4%), circumcision (n = 5, 15.6%), excision with a split skin graft or a scrotal flap reconstruction (n = 5, 15.6%). Three (8.6%) patients presented with necrosis and required acute debridement. Overall, 18 patients had more than 1 procedure, and 8 patients required 3 or more procedures. A systematic search of the literature identified 887 articles of which 68 studies were included for analysis. The most common substance injected was paraffin (47.7%), followed by silicone (15.8%). The majority of patients (77.9%) presented with pain, swelling or penile deformity. 78.8% of the patients underwent surgical treatment, which included excision and primary closure with or without the use of skin grafts (85.1% of all procedures), the use of flaps (12.3%) and penile amputation (n = 2). Complications of foreign body injection into the male genitalia can be serious resulting in necrosis and autoamputation. Surgical intervention is often required to excise abnormal tissue to manage pain and improve cosmesis.

Retroperitoneal Sclerosing Lipogranuloma in an Adolescent With Congenital Atresia of the Inferior Vena Cava: Case Report and Literature Review

Sclerosing lipogranuloma (SLG) in children is a rare, benign disease of unknown etiology suspected to be due to abnormal fatty tissue reaction. A 13-year-old girl presented with progressively worsening back pain. Cross-sectional imaging identified a retroperitoneal mass compressing the left ureter as well as infrarenal inferior vena cava atresia with extensive venous collaterals and chronic partially occlusive thromboses of the iliac veins. Surgical biopsy was consistent with SLG and it resolved spontaneously. SLG is typically a disease of adulthood but may be seen in children. The association between inferior vena cava atresia with venous thrombosis and development of SLG has not been reported previously.

Nonsurgical Methods for Penile Augmentation: A Systematic Review

BACKGROUND

There is no standardized approach for nonsurgical techniques for penile augmentation despite the increase of demand for this intervention.

OBJECTIVE

To compare the efficacy and safety between different injection techniques.

MATERIALS AND METHODS

On October 8, 2019, a literature search was performed on PubMed, Embase, Ovid, and Cochrane database. All articles describing penile augmentation were included.

RESULTS

Thirteen studies were included in this article with a total of 1,311 patients. Five studies were prospective cohort. The most commonly described technique was hyaluronic acid fillers with a total of 4 articles and 205 patients. The mean injected volume ranged from 20 to 40 mL. In all included studies, a minority of patients had side effects, but some had disabling complications.

CONCLUSION

There are no defined clinical guidelines for penile augmentation techniques implemented yet. Hyaluronic acid seems to be safe, efficient, and with a high satisfaction score. Further randomized control trials are warranted.

EBM LEVEL OF EVIDENCEBASED MEDICINE

2a.

Role of MRI in Staging of Penile Cancer

Penile cancer is one of the male-specific cancers. Accurate pretreatment staging is crucial due to a plethora of treatment options currently available. The 8^th edition American Joint Committee on Cancer-Tumor Node and Metastasis (AJCC-TNM) revised the staging for penile cancers, with invasion of corpora cavernosa upstaged from T2 to T3 and invasion of urethra downstaged from T3 to being not separately relevant. With this revision, MRI is more relevant in local staging because MRI is accurate in identifying invasion of corpora cavernosa, while the accuracy is lower for detection of urethral involvement. The recent European Urology Association (EAU) guidelines recommend MRI to exclude invasion of the corpora cavernosa, especially if penis preservation is planned. Identification of satellite lesions and measurement of residual-penile-length help in surgical planning. When nonsurgical treatment modalities of the primary tumor are being considered, accurate local staging helps in decision-making regarding upfront inguinal lymph node dissection as against surveillance. MRI helps in detection and extent of inguinal and pelvic lymphadenopathy and is superior to clinical palpation, which continues to be the current approach recommended by National Comprehensive Cancer Network (NCCN) treatment guidelines. MRI helps the detection of "bulky" lymph nodes that warrant neoadjuvant chemotherapy and potentially identify extranodal extension. However, tumor involvement in small lymph nodes and differentiation of reactive vs. malignant lymphadenopathy in large lymph nodes continue to be challenging and the utilization of alternative contrast agents (superparamagnetic iron oxide), positron emission tomography (PET)-MRI along with texture analysis is promising. In locally recurrent tumors, MRI is invaluable in identification of deep invasion, which forms the basis of treatment. Multiparametric MRI, especially diffusion-weighted-imaging, may allow for quantitative noninvasive assessment of tumor grade and histologic subtyping to avoid biopsy undersampling. Further research is required for incorporation of MRI with deep learning and artificial intelligence algorithms for effective staging in penile cancer. Level of Evidence: 5 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2020;51:1612-1629.

MRI of the Penis: Indications, Anatomy, and Pathology

The purpose of this review is to discuss the role of magnetic resonance imaging (MRI) in the evaluation of penile pathology. Normal penile anatomy as well as the appearance of neoplastic and non-neoplastic entities on MRI will be reviewed. While ultrasound remains the first line imaging modality in evaluating most penile pathology, MR imaging has specific advantages owing to improved soft tissue resolution, ability to evaluate less accessible or complex anatomy (such as at the base of the penis), and the ability to detect subtle enhancement. Therefore, MRI is useful for when ultrasound and/or clinical findings are equivocal or incongruent. In addition, MR imaging is essential for preoperative surgical planning and is the imaging modality of choice in evaluating penile prostheses. The added value of MRI in these settings makes it an integral component to the management of many pathological entities affecting the penis.

Penile Paraffinoma

Penile paraffinoma is a rare cause of penile mass that can occur following injection of liquid paraffin, performed illicitly for penile augmentation. Over the past 2 yr, we have observed an increasing number of cases presenting with the complications of penile paraffinoma; three patients of central European origin have required inpatient treatment at our institution and posed a significant management dilemma. This mini-review aims to review the literature on the aetiopathogenesis, clinical features, diagnosis, and management of penile paraffinoma. A systematic search of PubMed and Scopus was performed with 10 case series and 26 case reports identified between 1956 and 2017. A total of 124 cases, with a mean age of 36.29 yr, were identified. The majority originated in Korea, and the most common injected material was liquid paraffin (80.6%). Patients presented with pain/swelling, ulceration/fistulae, and penile deformity. The majority required surgical excision of paraffinoma followed by reconstruction with a variety of procedures including split skin grafting, scrotal skin flap reconstruction, and prepuce grafting. Mean duration of follow-up was 15.8 mo. Penile paraffinoma remains a rare presentation; however, it can present management difficulties. We have had an increase in cases, with three patients presenting with complications following injection of paraffin in our unit in the past 2 yr. Definitive management includes surgical excision and reconstruction as required with early involvement of plastic surgeons. There may be a role for conservative management; however, long-term outcomes are unclear. There may be a need for targeted preventative measures through public health agencies in communities where the practice is more prevalent. PATIENT SUMMARY: Penile paraffinoma can occur following injection of liquid paraffin or similar substances, generally used by non-healthcare personnel for the purpose of penile augmentations, and can cause significant pain, ulceration, and penile deformity. Definitive management includes surgical excision with reconstruction as required. Prevention of its use through awareness and education may be required in communities where the practice is more common.

Surgical Management of Penile Lesions Secondary to Foreign Body Reaction: A Case Report and Systematic Review

BACKGROUND

To improve the penile contour, some men choose to undergo implantation or injection of nonbiological materials. Foreign body reactions in penile tissue may produce scarring, deformity, ulceration, necrosis, and even gangrene. Consensus is lacking regarding the most effective surgical procedure for reconstruction of these penile lesions.

OBJECTIVES

The authors describe one case study and the first systematic review focusing on reconstructive surgical management for penile lesions secondary to foreign body reaction.

METHODS

PubMed, Medline, and Cochrane databases were queried for publications written in English, French, Portuguese, and Spanish from 1951 to May 2017. Multiple search terms were applied.

RESULTS

Of the 3304 articles identified, 51 were included in the systematic review. All were retrospective studies, case series, or case reports. A total of 260 patients underwent surgical procedures, and the complication rate was 37.3%. The scrotal flap technique was performed most frequently (43.4%) and resulted in 65.6% of the total complications observed. One Brazilian case study was also described with an extensive and circumferential ulcer after six mineral oil bolls implant in the penile subcutaneous tissue.

CONCLUSIONS

Restoration of the penile shape preserving the functionality and maintaining a good physician-patient relationship may be a challenge. The scrotal pouch may be advantageous for patch grafting of penile soft-tissue lesions, owing to its skin laxity and good blood supply. A less aggressive surgical approach has the benefits of shorter healing time and fewer early complications. Penile injuries are best treated by experienced surgeons on a case-by-case basis with care given to identify the most appropriate treatment.

LEVEL OF EVIDENCE 5