Postoperative Outcomes following Buried Penis Reconstruction: A Single-Institution Experience Using the Wisconsin Classification System

BACKGROUND

Adult acquired buried penis (AABP) is a complex condition often necessitating surgical intervention. This study sought to examine the validity of the Wisconsin Classification System (WCS) in guiding the surgical management of AABP. In addition, the authors aimed to identify which factors contribute to postoperative complications and persistent symptoms following AABP repair.

METHODS

The authors retrospectively reviewed all patients who underwent surgical repair of AABP from 2015 to 2021 by the senior author at our institution. Patients were categorized according to anatomical characteristics using the WCS. Preoperative symptoms, postoperative symptoms, and postoperative complications were evaluated.

RESULTS

Fifty-two patients underwent AABP repair. The mean patient age was 56.5 ± 14.8 years, and the mean duration of follow-up was 350.0 ± 517.4 days. The assigned preoperative WCS score was congruent with operative management in most patients (86.0%). Morbid obesity (body mass index >40.0 kg/m 2 ) and postoperative complications were associated with persistent symptoms following AABP repair ( P = 0.026 and P = 0.021, respectively). Increased WCS score was not associated with persistent postoperative symptoms ( P = 0.314). Morbid obesity ( P = 0.003), diabetes ( P = 0.029), and having a panniculectomy during AABP repair ( P = 0.046) increased the odds of developing postoperative complications. Patients with type I AABP had significantly fewer complications than those with type II, III, or IV AABP ( P = 0.032).

CONCLUSIONS

The WCS serves as a preoperative guide and an educational tool for patients, and it provides a framework for the discussion of intraoperative maneuvers and the likelihood of complications. It is imperative that patients are counselled on the surgical management of AABP and the postoperative course, as this may permit realistic patient expectations and optimize outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Surgical management of adult acquired buried penis syndrome: A systematic review of patient-reported outcome instruments

PURPOSE

Adult acquired buried penis (AABP) is a morbid condition often necessitating surgical intervention. Accurate assessment of pre- and postoperative symptoms is crucial to understand how AABP impacts a patients' quality of life, verify surgical effectiveness, and practice patient-centered care. There is no validated patient-reported outcome instrument specific for AABP evaluation. We undertook a comprehensive review of existing literature on patient-reported outcome instruments post-AABP surgery to highlight the importance of developing a specific tool.

METHODS

Following the preferred reporting items for systematic reviews and meta-analysis 2020 guidelines, we queried three databases using relevant keywords (e.g., "buried penis repair"). Inclusion criteria were studies that discussed surgical management of AABP with patient-reported outcomes. Pediatric and congenital cases were excluded. Information collected included study design, level of evidence, number of participants included in the study, etiology of buried penis, surgical technique, preoperative or postoperative patient-reported outcomes, and patient-reported outcome instrument used.

RESULTS

Initial query identified 998 records. After abstract screening and applying the inclusion or exclusion criteria, a total of 19 articles with 440 patients were included. Eight studies implemented patient-reported outcome instruments. The international index of erectile dysfunction-5 and Likert satisfaction scales were used most frequently. Although all instruments were validated, none were validated in the specific context of AABP surgical intervention.

CONCLUSIONS

There is considerable heterogeneity within the AABP literature regarding patient symptomatology, postoperative complications, patient-reported outcomes, and instruments used. The results of this study emphasize the need for a patient-reported outcome measure to examine the influence of AABP repair on patient satisfaction and health-related quality of life.

Surgical treatment and outcomes of acute and chronic ulcers on the penis following injection of foreign substances

In this paper, we present our experience with acute and chronic penile ulcers resulting from injection of an exogenous substance and their surgical treatment.

Optimal timing of surgical intervention for penile fracture: a narrative review of the modern literature

INTRODUCTION

Penile fracture is traditionally considered a surgical emergency warranting immediate repair with the goal to maximize long-term erectile function and minimize penile curvature. Nonetheless, consensus on the optimal timing for penile fracture repair remains to be elucidated and is the subject of continued research efforts.

OBJECTIVES

This review aims to summarize the contemporary literature pertaining to optimal timing of penile fracture repair and associated outcomes.

METHODS

We queried PubMed/MEDLINE and Google Scholar for relevant articles published between 2012 and 2022 to evaluate the most recent literature on the queried topic of early vs delayed intervention for penile fracture. All examined review articles were published within the last decade but may have included analyses of studies published prior to 2012. Reference lists of articles and reviews were manually reviewed to identify additional relevant articles.

RESULTS

We identified 16 articles that met inclusion criteria: 12 primary articles and 4 systematic reviews or meta-analyses. Importantly, definitions of early and delayed intervention varied greatly among studies, making quantitative comparison challenging. In summary, 6 primary studies and 2 systematic review articles favored early intervention. There were also 6 primary studies and 2 systematic review articles suggesting equivocal outcomes between early and delayed repair. No articles demonstrated improved outcomes with delayed repair relative to early intervention.

CONCLUSION

Surgical intervention for penile fracture remains the gold standard, with superior long-term sexual and functional outcomes when compared with conservative management. Optimal timing of penile fracture repair remains to be elucidated with data limited by low incidence, resulting in small case series and a lack of randomized controlled trials. Nonetheless, recent data suggest that a brief delay in surgical intervention for patients presenting with penile fractures does not affect long-term sexual and functional outcomes.

Evaluation of Z-plasty versus Heineke-Mikulicz scrotoplasty in the management of penoscrotal web in pediatric age group

BACKGROUND

The penoscrotal web may be congenital or acquired following excessive ventral skin removal during circumcision. Several surgical techniques were described for the treatment of congenital webbed penis without a clear comparison between their outcomes. This prospective study aimed at comparing the surgical results of Z-scrotoplasty and Heineke-Mikulicz scrotoplasty in the treatment of congenital webbed penis in uncircumcised pediatric patients.

METHODS

Our study included 40 uncircumcised patients who were divided randomly into two groups; Group A included 20 patients who were treated by Z-scrotoplasty and Group B included the other 20 patients who were treated by Heineke-Mikulicz scrotoplasty. All patients were circumcised at the end of the procedure.

RESULTS

The surgical outcome was good without a significant difference between the two groups in 36 patients. Recurrent webbing developed in one patient of Group A and in three patients of Group B (FE p = 0.605) The only significant difference between the two groups was the operative duration which was shorter in Group B than in Group A (P < 0.001*).

CONCLUSIONS

Treatment of congenital penoscrotal web in the pediatric age group could be done with either Z-scrotoplasty or Heineke-Mikulicz scrotoplasty with satisfactory results, however, without significant difference in the surgical outcomes.

TRIAL REGISTRATION

• Registration Number: ClinicalTrials.gov ID: NCT05817760. • Registration release date: April 5, 2023.

[Clinical case of penile fracture]

A clinical case of a penile fracture as a result of an unsuccessful sexual intercourse, which later required surgical treatment in the form of corporoplasty with opening and draining of the hematoma, is discussed in the article. Penile fracture is a rare urological emergency that requires immediate medical attention to avoid long-term complications, including penile curvature and erectile dysfunction.

Individualized care for patients with intersex (differences of sex development): Diagnosis and treatment of aphallia

This review discusses issues and concerns in the management of aphallia, updating status of a post-pubertal individual who required further surgery after having initial surgery for aphallia as an infant. Through this case, which discusses an 18-year-old young adult who had penile agenesis, who desired further phalloplasty involving glanuloplasty and implantation of an erectile device, we highlight the importance of periodic evaluation and close follow up. Surgery during infancy or early childhood to create a penis is important for gender development in a boy, especially if there were functional testes during fetal life, even if this surgery would only be the first stage. There is a strong probability of subsequent surgery after initial phalloplasty before puberty, even with the use of currently refined techniques. Here we discuss the changing techniques that document the ongoing, continued refinement of these procedures, highlighting that further outcome data are needed to identify ways to further optimize current techniques.

Penile Strangulation: Analysis of Postextrication Follow-Up, Sequelae, and a Review of Literature

Numerous case reports exist on penile strangulation injuries and extrication methods; however, the care and long-term consequences of penile strangulation injuries have been under-reported. Our aim is to investigate the long-term outcomes and sequalae following penile strangulation injuries. The PubMed Medline database was searched using the keyword string "penile strangulation," "penis strangulation," and "constriction" for all studies reporting outcomes of published penile strangulation injuries. Articles were evaluated for follow-up after strangulation injury, strangulating agent, extricating agent, and sequelae of injury. Fifty-six studies resulted with reports of 100 cases of penile strangulation and extrication from January 2000 to December 2019. The mean patient age was 41 (range: 3-86) years. Twenty-four (24/100) cases reported sequalae following extrication. Follow-up ranged from 2 weeks to 7 years with median follow-up time in the 7- to 12-month grouping. Metal rings comprised 36% (36/100) of strangulation agents and 50% of reported incidents were attributed to sexual activity. To our knowledge, this is the only study focusing on long-term outcomes after penile strangulation. This review provides a summary of 56 studies that document penile strangulation injuries over the last 20 years. Although a wide array of penile strangulation injuries have been documented in the literature, reports lack secondary management and long-term outcomes after removal of the strangulation device. We recommend that providers report long-term penile strangulation outcomes for future urologic evaluations after extrication.

Does local injection of long acting corticosteroid improve postoperative outcome of hypospadias repair? A randomized controlled trial

PURPOSE

To assess the safety and efficacy of local corticosteroid injection during hypospadias repair.

METHODS

Between May 2021 and March 2023 children less than 10 years who were admitted for hypospadias repair were divided by random allocation into two groups. We injected local corticosteroid 2 ml proximal to coronal sulcus in group A while in group B we didn't. All types of hypospadias were included in the study. We excluded patients older than 10 years and those with pre-existing complicated hypospadias (multiple fistulae and multiple surgeries), or bleeding diatheses. Pre-operative, intraoperative and postoperative variables were compared between the two groups.

RESULTS

A total of 120 patients (60 in each group) were enrolled in the study. The mean ages and preoperative variables were not significantly different. The site of hypospadias and the type of surgery were comparable in both groups. (Table) There were no significant differences between both groups regarding average blood loss and operative time in each type of surgical repair. There was a significant higher incidence of intraoperative and postoperative penile oedema in group B (P-value < 0.001) while the incidence of skin discolouration was higher in group A. Postoperative complications, described as Clavian classification, were significantly higher in group B. The incidences of superficial skin infection, meatal stenosis, urethral fistula, and recurrence with the need for redo repair were significantly higher in group B (P-value: 0.002, 0.018, 0.032, and 0.001, respectively).

CONCLUSION

Local corticosteroid injection during hypospadias repair minimize the penile oedema and decrease the incidence of postoperative functional and cosmetic complications.

A review of the literature and proposed algorithm for penile fracture management

INTRODUCTION

In the management of penile fractures, immediate surgical repair has resulted in better outcomes when compared with a conservative approach; however, there is currently no consensus on the treatment of patients presenting beyond the immediate period (>24 hours) following injury.

OBJECTIVES

To examine the latest literature on management strategies in penile fracture and propose an optimal algorithm for the treatment of patients with delayed presentation.

METHODS

A comprehensive search was conducted following the PRISMA-P 2020 guidelines. A search was performed in several databases with the following strategy: ("Penile fracture" OR "fracture of penis" OR "rupture of corpora cavernosa" OR "rupture of tunica albuginea") AND (management OR treatment OR surgery OR "surgical reconstruction" OR "surgical repair"). This resulted in 108 relevant articles. Two independent reviewers screened these articles according to the inclusion criteria. Full-text review of 56 articles was performed, and ultimately 20 studies were selected. Measures included the use of diagnostic imaging, timing of surgical repair (immediate, <24 hours after injury; delayed, >24 hours), surgical approach, and long-term complications (ie, erectile dysfunction and penile curvature).

RESULTS

The review highlighted the benefits of immediate surgical repair in penile fractures, demonstrating improved patient outcomes. Furthermore, it found that surgical repair should be considered even in cases with delayed presentation (>24 hours after injury). To better evaluate the long-term impact of delayed surgical intervention on patient outcomes, we recommend standardized postoperative follow-up, with routine assessments of erectile function and penile curvature.

CONCLUSION

Contemporary literature suggests that immediate and delayed surgical repair of penile fractures leads to adequate postoperative outcomes, and patients presenting >24 hours after injury should still be considered for surgery.

The outcomes of surgical management options for adult acquired buried penis

Functional and surgical outcomes after surgical correction of adult acquired buried penis (AABP) are limited in the current literature. We retrospectively recruited patients underwent surgical treatment of AABP in a single institution from 2017 to 2021. Surgical repair was classified according to surgical complexity following Pariser-Santucci's classification. The primary endpoint of the study was the recurrence-free rate survival. The secondary endpoints were surgical, functional and patients' reported outcomes. Overall 28 patients were included in the study. Median follow-up was 27.5 (18.5-34.5). The most common complaints at presentation were sexual (53.6%) and voiding (39.3%) dysfunction. Surgical management steps ranged from circumcision to more complex procedures, such as suprapubic fat pad excision, abdominoplasty and/or penile shaft skin grafting. Overall postoperative complications were recorded in 32.1%. High-grade complications (Clavien≥3) occurred in 7.1%. One-year recurrence-free survival was 88.7%. Postoperatively IPSS and IIEF-15 questionnaires showed a significant improvement in urinary 8 (0-12) vs 2 (0-3), p = 0.03 and sexual function 37 (23-68) vs 68 (45-72), p = 0.001 respectively. Overall, patients reported functional improvement and 93.8% experienced a positive impact of QoL. AABP surgical repair, despite the high incidence of complications, seems to allow satisfactory outcomes and a significant improvement in patients' QoL.

A new treatment of concealed penis: symmetrical pterygoid flap surgery

PURPOSE

Considerable controversy exists regarding the surgery for concealed penis. We describe a new technique for repairing concealed penis by symmetrical pterygoid flap surgery.

METHODS

From January 2016 to July 2022, we evaluated 181 cases of concealed penis that were surgically treated using the symmetrical pterygoid flap surgery. We measured the penile size preoperative and 2, 4, 12 weeks, and 1 year postoperative to confirm the improvement. A questionnaire was administered to the patients and parents to assess satisfaction regarding penile size, morphology, and hygiene.

RESULT

The perpendicular penile length was1.59±0.32cm preoperative and 3.82±1.02 cm after the procedure (p < 0.05), and 4.21±1.91cm after one year of postoperative (p < 0.05). The overall satisfaction of patients was 97.89%, while the overall satisfaction of older children patients (age>7) was 75.24%. Parents focus more on the penile exposure size, while patients focus more on the penile morphology. Almost every patient had postoperative penile foreskin edema. However, this symptom had spontaneously resolved by 4-6 weeks. The complications such as skin necrosis, tissue contracture, or wound infection were 4.42%.

CONCLUSION

The symmetrical pterygoid flap surgery is an effective surgical technique for the management of concealed penis in children producing predictable results and excellent satisfaction of the parents and patients.

Repair of penile prosthesis-induced impending erosion using xenograft during simultaneous inflatable penile prosthesis replacement

BACKGROUND

Penile prosthesis (PP)-induced impending erosion is a rare complication that has not been well characterized.

AIM

This study evaluates the role of prosthesis sizing and of the safety of xenograft windsock repair (AlloDerm, Tutoplast, ArthroFLEX) of impending erosion.

METHODS

This was a retrospective review of xenograft use during inflatable penile prosthesis (IPP) replacement. Patient demographics, prior PP characteristics, and xenograft-augmented IPP characteristics were obtained. Paired-samples t tests were used to compare the PP cylinder size, rear tip extender size, and calculated PP length between the most recent prior PP and the xenograft-augmented IPP. Complications and follow-up data were obtained.

OUTCOMES

The primary outcome was comparing the corporal body and device measurements between the PP presenting with impending erosion and the implanted xenograft-augmented IPP. The secondary outcome was evaluating the incidence of subsequent explantation.

RESULTS

A total of 24 patients underwent xenograft repair with simultaneous IPP replacement from 2012 to 2022. The median number of prior PP was 1 (interquartile range, 1-2.75). The median time between the most recent prior PP and xenograft-augmented IPP placement was 21 (interquartile range, 14-79) months. The prior PP was significantly longer at the time of explantation compared with the measured corporal body length in both the left (21.4 cm vs 20.1 cm; P < .01) and right (21.4 cm vs 20.1 cm; P < .01) sides. However, there was no significant difference in length between the xenograft-augmented IPP length at the time of implantation and measured corporal body length in both the left (20.1 cm vs 20.0 cm; P = .67) and right (20.2 cm vs 20.1 cm; P = .56) sides. A total of 16 (66.7%) cases required bilateral xenograft corporal body use. Only 1 (4.2%) patient had an IPP infection requiring explantation within 90 days of xenograft-augmented IPP placement. A total of 2 (8.3%) patients had device malfunction and 1 (4.2%) patient had impending erosion recurrence requiring removal/replacement of their initial xenograft-augmented IPP in a median time of 56 months from placement.

CLINICAL IMPLICATIONS

PP oversizing may increase risk of PP-induced impending erosion, which is a delayed process.

STRENGTHS AND LIMITATIONS

This is the largest retrospective study of xenograft use during IPP replacement for impending erosion but does not have a control cohort. This study is limited by its retrospective nature, limited follow-up, and absence of a treatment comparison.

CONCLUSION

PP-induced impending erosion may be due to PP oversizing but can be successfully repaired with xenograft windsock during simultaneous IPP replacement.

Smile Incision-Modified Technique for Better Scrotal Outcome in Surgical Management of Penile Paraffinoma

INTRODUCTION

Penile augmentation with foreign material injection is used to increase penile length, girth, or both. Most of these individuals develop complications due to an abnormal mass formation known as penile paraffinoma. Multiple surgical techniques for restoring penile function and correcting near-normal penile shape have been developed, but prior techniques have some post-operative complications.

METHODS

We explained the smile incision-modified technique for penile paraffinoma reconstruction using illustrations to describe step-by-step procedures. This study aimed to describe our modified surgical technique for reconstruction to correct complications due to disastrous consequences of failed penile augmentation.

RESULTS

A total of 16 patients aged 28-66 years (mean: 44.25 ± 2.63) were operated with a smile incision-modified technique from January 2017 until December 2020 in Semarang Dr. Kariadi tertiary hospital. There were no intraoperative complications observed. We found hematoma in 3 patients in a 1-week follow-up. After 2 weeks of post-operative surgery, all patients had no skin dehiscence or necrosis. Cosmetic appearance and functional improvement after reconstruction were acceptable by all patients.

CONCLUSION

Penile paraffinoma reconstruction using the smile incision-modified technique was a feasible and effective technique to manage penile paraffinoma patients with good esthetic results and minor complications.

Surgical management of acquired buried penis and scrotal lymphedema: A retrospective review

Acquired buried penis is a condition that can have detrimental physical and psychological consequences for patients. Factors such as elevated BMI, chronic scrotal lymphedema, hidradenitis suppurativa, and chronic inflammation can lead to the condition. Surgical intervention is the treatment of choice for advanced disease. Following IRB approval, a retrospective chart review was performed for patients with a diagnosis of acquired buried penis who required surgical intervention. Details of patient history, surgical management including intraoperative and post-operative photography, and complications were reviewed. Seven patient cases were reviewed. The average age at time of surgery was 44 with a mean weight of 344 pounds and an average BMI of 48. Severe scrotal lymphedema and hidradenitis were common concurrent comorbidities. Concurrent scrotoplasty and infraumbilical panniculectomy were standard parts of the operations. Native glans skin was salvageable in all but one case. Penile shaft skin was reconstructed with skin grafts or adjacent tissue transfer. 88% of the cases had some element of wound dehiscence post-operatively. Surgical management of an acquired buried penis can be challenging. The patient demographic with the disease is frequently complicated by morbid obesity, concurrent lymphedema, or hidradenitis. Post-operative complications are expected. The surgical techniques presented can aid in simplifying the management of this challenging surgical population.

Subcoronal Incision for Inflatable Penile Prosthesis Does Not Risk Glans Necrosis

PURPOSE

Glans vascular compromise had previously been considered a rare but devastating complication of the subcoronal incision for inflatable penile prosthesis surgery. Here, we describe the largest series of subcoronal implants to date to assess contemporary complication rates.

MATERIALS AND METHODS

A retrospective review of subcoronal prosthesis placements by a single surgeon from Seoul, South Korea, was performed. Patients were randomly assigned either Coloplast Titan or AMS 700 device per institutional practice.

RESULTS

A total of 898 patients who underwent subcoronal implants from May 2015 to March 2022 were analyzed. Median follow-up was 41 months (IQR 40). Preoperative patient comorbidities included diabetes (36.6%) and Peyronie's disease (4%). The most common complication was transient distal penile edema (74.7%). Transient incisional paresthesia (20.6%) was more common in patients with diabetes (31.9% vs 13.9%, P < .01). Five cases (0.5%) of distal penile skin necrosis were reported in patients who had previously been circumcised. Of these, 3 were managed successfully with wet-to-dry dressing, 1 required skin grafting, and 1 required device explant. Device infection without incisional compromise occurred in 2 cases (0.2%). There were no instances of glans necrosis or ischemia observed in this cohort. Of the first-time implants (817, 90.9%), most (62.3%) were successfully completed under local anesthetic alone, with the remainder of surgeries completed with the addition of adjunctive conscious sedation.

CONCLUSIONS

Subcoronal incision for first-time or revision penile implant surgery is not a risk factor for glans ischemia or necrosis and can be safely completed under local anesthetic with or without conscious sedation.

Severe penile torsion of 180 degrees in an adult patient: a uro-radiological case report

Penile torsion is the abnormal three-dimensional twisting of penile corporal bodies. It can be classified as mild, moderate, or severe, depending on the degree of torsion. Severe penile torsion (>90°) is a very rare condition, with an estimated incidence of 0.4%-1% among all penile torsion cases. Our patient was a 37-year-old man complaining of a 2-year history of lower urinary tract symptoms. These symptoms appeared after the patient sustained an iatrogenic injury during Foley catheter insertion. Physical examination incidentally revealed an obvious counterclockwise penile rotation of 180°. Several theories have been proposed to explain the etiology of penile torsion, including theories based on genetic factors, abnormal urethral development, and abnormal attachment of the dartos fascia to the skin. Penile torsion may be associated with other penile anomalies, including chordee, hypospadias, and epispadias; however, it is often detected as an isolated finding. Clinical examination is sufficient to confirm its diagnosis without the need for further imaging. While no standardized procedure has been indicated for all penile torsion cases, the severity of torsion and the presence of other anomalies determine the most suitable procedure. No reports on the imaging features of penile torsion (irrespective of the degree of torsion) are available. We present the first such report on the imaging features, including advanced magnetic resonance imaging findings, of a 180° penile torsion in an adult patient.

Penile implant infection part 3: the changing spectrum of treatment

Penile prosthesis infection remains a rare but devastating complication of implantation. Historically, management of device infection was always extirpation. While certainly effective, device removal leaves an unhappy patient with a shortened penis. In this last part of a three-part series on the topic of penile prosthesis infection, we seek to highlight new and emerging ideas of infection management which have allowed surgeons the option of preserving the implanted status in select patients.

Improving clinical diagnostic accuracy and management of False penile fractures characterizing typical clinical presentation: a systematic review and meta-analysis

PURPOSE

False penile fractures (FPF) represent a rare sexual emergency characterized by blunt trauma of penis in the absence of albuginea's injury, with or without lesion of dorsal penile vein. Their presentation is often indistinguishable from true penile fractures (TPF). This overlapping of clinical presentation, and lack of knowledge about FPF, can lead surgeons often to proceed directly to surgical exploration without further examinations. The aim of this study was to define a typical presentation of false penile fractures (FPF) emergency, identifying in absence of "snap" sound, slow detumescence, penile shaft ecchymosis, and penile deviation main clinical signs.

METHODS

We performed a systematic review and meta-analysis based on Medline, Scopus and Cochrane following a protocol designed a priori, to define sensitivity of "snap" sound absence, slow detumescence and penile deviation.

RESULTS

Based on the literature search of 93 articles, 15 were included (73 patients). All patients referred pain, most of them during coitus (n = 57; 78%). Detumescence occurred in 37/73 (51%), and all patients described detumescence occurrence as "slow". The results show that single anamnestic item have a high-moderate sensibility in the diagnosis of FPF, and the highest sensitive item was penile deviation (sensibility = 0.86). However, when more than one item is present, overall sensitivity increases greatly, closing to 100% (95% Confidence Interval 92-100).

CONCLUSION

Surgeons can consciously decide between additional exams, a conservative approach, and rapid intervention using these indicators to detect FPF. Our findings identified symptoms with excellent specificity for FPF diagnosis, giving clinicians more useful tools for making decisions.

[A Case of Penile Calciphylaxis in a Hemodialysis Patient]

In the present case of a 56-year-old male, hemodialysis was introduced from December 20XX-2 due to chronic renal failure caused by diabetic nephropathy. In February 20XX, a glans penis ulcer was observed. It gradually expanded. Angiography conducted in April revealed complete occlusion of the left internal pudendal artery and poor visualization of the bilateral penile arteries. Given the high risk of obstruction, endovascular treatment was not conducted. The glans penis ulcer continued to expand, and maintenance dialysis became difficult due to intractable pain. Opioids were introduced, but the pain could not be controlled. In May 20XX, the patient was referred to our department for surgical treatment, and partial penile resection was performed. The patient was diagnosed with penile calciphylaxis based on clinical findings and pathological diagnosis. After the surgery, the pain subsided considerably, and the patient is being followed on an out-patient basis.

[PENILE STRANGULATION CAUSED BY A METALLIC RING SUCCESSFULLY TREATED BY PENILE PUNCTURE PLUS BLOOD REMOVAL INSTEAD OF DESTROYING THE RING]

A 63-year-old man visited our hospital with a complaint of penile swelling caused by metallic ring entrapment in the penis. He had put the ring around his penis 4 hours prior and was subsequently unable to remove it. We attempted to remove the ring using a ring cutter but that was unsuccessful. We then inserted two 18 G needles into the corpus cavernosum through the glans penis and removed blood by manual compression according to a technique called the "string method." The swelling gradually decreased, and we successfully removed the ring without destroying it. The total duration of strangulation was about 5 hours. The patient was subsequently discharged after ensuring he had no urinary difficulties. No complications were observed during the follow-up period.In almost all penile strangulation cases caused by hard objects, such as metallic rings, reported in Japan, the objects were typically destroyed and penile puncture and blood removal, as was performed in our case, was rare. Although penile puncture and blood removal is not commonly performed in Japan, this technique can be performed quickly and inexpensively in the emergency room and should be considered an initial treatment for penile strangulation caused by hard objects.

An unusual presentation of penile Mondor's disease in an HIV-positive patient

Penile Mondor's disease (PMD), or thrombosis of the dorsal vein, is an under-reported benign condition. Its aetiology is poorly understood. Clinically, it presents as a palpable cord in the dorsal vein of the penis, with pain or local discomfort, especially during erection. PMD may be diagnosed based on the medical history and physical examination. Management of the condition is conservative, with practitioners opting for various strategies including sexual/masturbatory abstinence, localised anticoagulant topical therapy and oral nonsteroidal anti-inflammatory drugs. In many cases, PMD will resolve within 4-8 weeks of presentation. Thrombectomy and resection of the superficial penile vein are applied surgically in patients refractory to the medical treatment. We describe the case of a 33-year-old patient known to have HIV who presented for severe painful dorsal induration and swelling of the proximal third of the penis. The patient had no recent history of sexual intercourse, penile trauma or other well-known risk factors for PMD. The physical examination was unequivocal, so a Doppler ultrasound was performed. A diagnosis of PMD was made and conservative treatment was prescribed. During a follow-up visit after 6 weeks, the patient had no symptoms and physical examination did not reveal anything pathological.

Surgical management of massive penoscrotal lymphedema. Case report and literature review

INTRODUCTION

Giant lymphedema of the penis and scrotum is a rare and peculiar condition that carries many challanges for both the patient and the physician. The etiology of the disease is often difficult to trace, especially in geographical areas where filariasis is not endemic.

CASE PRESENTATION

We reported an advanced case of massive penoscrotal lymphedema presented to our plastic surgery department. Extensive physical examination and imaging investigations allowed for a wide surgical excision of the tumor with the preservation of the penile body and testicles. The reconstruction was performed with adjacent healthy skin flaps and a split-thickness skin graft for the penis. The outcome was a success and the follow-up revealed no recurrences.

DISCUSSION

Although the onset of the disease was poorly established, we regarded it as a secondary lymhpedema resulting from chronic local infection. The particularity of this case was the exclusive involvement of the superficial structures, as seen in similar cases from the literature. The clinical presentation explained by the distinctive lymphatic drainage offered a guided and rather secure surgical approach. The reconstruction techniques are varied and should not pose recurrence risks as long as functional tissue is used.

CONCLUSION

Massive penoscrotal lymphedema cases display unique evolution and features leading to great impairment. In most instances, surgery is the treatment of choice as the pathological changes are irreversible. Our technique was innovative and comprised similarities and differences compared to other research, nevertheless, the results were a success.

KEY WORDS

Penoscrotal Lymphedema, Surgical Excision, Reconstruction Techniques.

Penile Ultrasound: An Essential Tool in an Emergency Setting (Traumatic and Non-Traumatic Diseases)

Penile conditions requiring urgent care are uncommon and result from trauma and a variety of non-traumatic causes. Some cases could rapidly evolve into an emergency situation and require prompt treatment to prevent severe complications. Therefore, correct and rapid diagnosis is fundamental. Although clinical history and physical examination are essential, diagnostic imaging is usually required to confirm the clinical diagnosis. In this setting, the sonologist in the emergency department has to be familiar with the basic US penile anatomy and with the most common US findings in urgent penile care. US is the key imaging method because it is readily available, safe, cost-effective, and well-tolerated by the patient. US can differentiate intracavernosal from extracavernosal hematomas and detect rupture of the tunica albuginea, consistent with penile fracture, that requires early surgical exploration. Color Doppler evaluation and spectral analysis are necessary to depict vascular abnormalities.

The urethral plate and the underlying tissue; a histological and histochemical study

OBJECTIVE

To examine the urethral plate and the underlying tissues in children with proximal hypospadias associated with severe chordee.

MATERIALS AND METHODS

The urethral plate and the underlying tissue specimens were excised to correct severe chordee in 17 children with proximal and perineal hypospadias with severe chordee. The median age was 20 months (range 8-36). Sections samples were marked and examined from proximal to distal. Specimens were examined histologically using hematoxylin-eosin (H/E) and Elastic van Gieson (EvG) stain. Histochemical examination was also performed using smooth muscle actin (SMA) and factor 8 antibodies. For control, samples from four patients with hypoplastic urethra proximal to the meatus including the hypoplastic segments until the normal urethra were taken. In addition, the urethra of an adult patient with penile tumor was used as control.

RESULTS

The average size of the 17 tissue samples was 0.5 cm × 0.5 cm x 0.3 cm in depth. There was a common pattern that was seen in all the 17 specimens with a variable degree of expression. H/E staining showed that the epithelial lining changed from pseudostratified epithelium at the proximal intact urethra to non-keratinized stratified squamous epithelium at the urethral meatus to keratinized stratified squamous epithelium distally at the urethral plate level. EvG staining showed overall very few elastic fibres that increased slightly in the distal urethral plate. SMA staining showed a circular pattern of smooth muscle cells in the proximal intact urethra that changed to a U-shaped pattern at the level of the meatus, to a triangle shaped pattern just distal to the meatus. The distal urethral plate showed an irregular, disorganized rather flat pattern of the smooth muscles. Factor 8 antibodies staining the blood spaces revealed dysplastic unorganized large blood sinusoids underneath the urethral plate that were different from normal capillaries surrounding the proximal urethra.

CONCLUSION

The urethral plate and the underlying tissues in patients with severe chordee have different structure from normal urethra as compared to available literature and the adult control patient. The lack of elastic fibres may help to explain the rigidity of the ventral penis causing chordee. The disorganized irregular distribution of the smooth muscle fibres is suggestive of the hypoplastic corpus spongiosum. The abnormal large blood sinusoids may explain the poor healing quality of the ventral penis in patients with perineal and proximal patients associated with severe chordee. This may explain persistent/recurrent chordee observed later in those patients with severe chordee when dorsal plication is used. The study also supports the recent trend of 2 stage procedure as a plan of management for patients with proximal and perineal hypospadias with severe chordee and excision of all the dysplastic tissues during the first operation.

Significance and Surgical Options for Nontranssexual Phalloplasty: A Retrospective Single-Center Analysis of 166 Patients

OBJECTIVE

This study aimed to evaluate the long-term outcomes of phalloplasty and explore the clinical significance and selection of methods for penile reconstruction.

METHODS

The same surgical team performed primary phalloplasty in 166 nontranssexual patients using different surgical approaches between September 2000 and September 2020. All patients had at least 6 months of follow-up. Surgical techniques, complications, and outcomes were retrospectively recorded.

RESULTS

A total of 166 patients with indications such as penile trauma (n = 68 [41%]), amputation injury (n = 15 [9%]), iatrogenic (n = 13 [8%]), penile aplasia (n = 54 [32%]), genital ambiguity (n = 15 [9%]), and Peyronie disease (n = 1 [0.6%]) underwent different techniques of phalloplasty. Four patients (2.4%) had total flap necrosis, and 17 (10%) had partial flap necrosis. The total urethral complications rate was 32.5% (54 of 166); however, all the patients were able to void while standing after successful corrective surgery.

CONCLUSIONS

Individualized selection of appropriate penile reconstruction methods tailored to the cause of penile defect, patients' personal needs, thickness of donor site, and the blood supply of the flap are conducive to achieving satisfactory treatment results, reducing complications, and improving patient satisfaction. We believe that a scapular flap has certain advantages in nontranssexual patients, whereas other flaps also have their own indications.

Staged Urethroplasty for Repairs of Long Complex Pendulous Strictures of a Neophallic Urethra

BACKGROUND

Post-phalloplasty, patients may present with urologic complications, including strictures, urethrocutaneous fistulas and vaginal cavity remnants^1-3.

OBJECTIVE

To demonstrate the feasibility of staged repairs for long complex neophallus strictures.

METHODS

All post-phalloplasty patients who underwent pendulous (pars pendulans) or panurethral urethroplasty for strictures >7 cm were identified. In preparation for surgery patients were co-managed with their local providers, whenever possible, in treating symptomatic infections with culture-specific antibiotics, draining abscess and managing suprapubic catheters. During Stage-1, a ventral incision through the perineum and neophallus was created to expose remnants of the neo-urethral plate. Additional findings (fistula/remnant cavity) were treated at this stage if found, along with re-mobilization of a previously placed gracilis flap. The neourethral plate was augmented with buccal mucosal graft (BMG) with a goal of achieving an approximately 3-cm-wide plate. The lateral neourethral edges were sutured to the edges of the skin incision creating a temporary perineal urethrostomy. Stage-2 was performed in a delayed fashion and included mobilization and tubularization of the neourethra, with additional oral mucosa inlay (BMG or lingual), if needed, followed by a multi-layer closure. Postoperatively, patients were assessed in clinic when possible, or via telemedicine appointments for urethral patency, and queried using patient-reported outcome measures (PROMs). Failures were defined as need for additional revisions or urethral instrumentation.

RESULTS

Twenty-one patients presented between 12/2013-7/2021 with urinary obstruction due to long penile strictures. Seventeen patients, mean age 33(22-58), elected to undergo staged reconstruction. Prior phalloplasty techniques included radial forearm flap phalloplasty (RFFP) in 15/17 and anterolateral thigh (ALT) flap in 2/17. In 11/17 patients BMG was previously used during phalloplasty for urethral prelamination⁴. Mean stricture length was 12 cm (7-17). Concurrent procedures during Stage-1 included re-harvesting BMG (11/17), gracilis flap re-mobilization (7/17) and redo-vaginectomy (5/17)⁵. During Stage-2, fourteen patients (82%) required additional oral graft inlays: lingual 6/14 (including 2 bilateral), BMG 5/14 (including 1 bilateral) and lingual+BMG in 3/14. At a mean follow-up of 24 months (4-77), there were 2 failures (12%). Thirteen patients completed follow-up questionnaires and all reported upright voiding and at least a moderate improvement in their condition on Global Response Assessment (GRA): +3(markedly improved) in 11/13 (85%), and +2 (moderately improved) in 2/13(15%).

CONCLUSION

A staged urethroplasty is a feasible option for transgender men with long complex penile strictures of the neophallus. This technique demonstrates promising early functional outcomes and high patient satisfaction.

[Treatment of ischemic penile and scrotum gangrene]

Gangrene of the penis is a rare condition manifesting with purulent necrotization of penile tissues and systemic inflammatory response. In more than 90% of cases, the cause of the development of the penile and scrotal gangrene is rapidly progressive necrotizing fasciitis of polymicrobial etiology, which predominantly affected the external genital organs. Isolated cases of penile gangrene development when using the restraining rings of the penis are described in literature (condom urine collection bag, rings for erection, etc.). Cases of penile and scrotum gangrene, when treatment with bilateral orchiectomy and penectomy is required are quite rare. We present the case of penlie and scrotum gangrene in an 86-year-old patient with mental disorders. The cause of gangrene was long-term forced position of the patient with infringement of the penis and scrotum by the thighs. Active intensive therapy, surgical removal of the penis, scrotum and testicles and urine diversion by the imposition of a trocar cystostomy saved the patients life and he was discharged from the hospital in a satisfactory condition.

[Penile glans amputation during circumcision: causes, treatments and preventive measures]

INTRODUCTION

Penile glans amputation during circumcision is a rare but potentially devastating complication. The mechanism and causes are poorly understood and incomprehensible. It is important to identify the causes of these complications, to suggest a mechanism and to propose prevention measures.

MATERIALS

Between 2005 and 2019, six patients with penile glans amputationafter circumcision were analyzed. All were operated without medical evidence, for religious reasons.

THE RESULTS

The operations were performed by local anesthesia, at home - in 5 patients, in 1 child - at polyclinic. All children were circumcised by scalpel with guillotine method, without visualization of glans. Partial amputation of penile glans was observed in 2 children (33.3%). Complete cut-off of the glans at the level of the coronal sulcus was revealed in 4 boys (66.6%). Meatoplasty with urethral mobilizations was performed 2 patients (33.3%) with partial amputation. The tops of corpus cavernous was covered of with the remnants of the skin of penile shaft in two boys (33.3%). Glansplasty was performed in 2 other patients (33/3%), using a labial mucosa graft to reconstruct the shape of glans and glanular groove. The follow up have showed meatostenosis in two boys (33.3%) in the first 2 months after surgery. One child required repeated meatoplasty (16.6%), another had a recovery of normal urine flow rates after urethral dilatation and stenting (4 weeks).

CONCLUSION

Visual control of the glans position during circumcision will prevent the amputation. "Guillotine" techniques including, Mogen clamp-type devices, are considered potentially dangerous. Circumcision in newborns, without general anesthesia, in the presence of swelling of the foreskin have an increased risk of glans damage. Preliminary examination of the glans and adequate release of preputial adhesions help to prevent complication of circumcision and to identify combined malformations (hypospadia, epispadia, concealed penis.).

Massive penile lipogranuloma following olive oil injections

Penile self-injections are performed with the purpose of increasing the size of the penis. Commonly, mineral oils or mineral oil-like substances are used for this purpose. However, there are very few publications describing on the complications from vegetable oil injections especially olive oil. Following the injection, the resulting deformity of the male genitalia is described as penile paraffinomas lipogranuloma of the penis. We would like to report a case of penis augmentation by a 50-year-old gentleman using olive oil injections that caused a massive, severely deformed of the penis and scrotum. Surgical excision and reconstruction was done. The patient was discharged after five days postoperatively, with full graft take. Injecting any oily substances into the human body is hazardous. The differential diagnosis of nodules following injections should be kept in mind and in doubtful cases, biopsy should be done. Regular follow-up is essential to prevent the further inflammatory event. Safe and legal procedures should be implemented for penile enlargement so as to avoid self-injections and in the prevention of such debilitating problems.

Uncovering the Hidden Penis: A Nomenclature and Classification System

INTRODUCTION

A hidden penis can interfere with normal hygiene, prevent effective voiding, restrict sexual activity, and cause great embarrassment to the patient. The terms "hidden," "buried," and "trapped" penis are used interchangeably. To date, there is no classification system that adequately characterizes the spectrum of this condition. In this study, we propose a simplified nomenclature and classification system for adult-acquired hidden penis.

METHODS

We performed a retrospective review of all adult patients treated surgically for hidden penis by the senior author from 2009 to 2019. Patients were classified into either "buried" or "trapped" categories. A "buried" penis was defined as a hidden penis concealed by suprapubic fat without fibrous tethering. These patients were managed with panniculectomy, monsplasty, or both. In contrast, those with a "trapped" penis presented with scarred or fibrous tissue, which required surgical lysis, phalloplasty, and penile skin resurfacing.

RESULTS

Thirteen patients met the inclusion criteria. The cohort was aged 53 ± 15.7 years with a mean body mass index of 37.4 ± 4.3 kg/m2. Two patients required repeat operations, yielding a total of 15 operative encounters. Six were defined as buried, and 9 as trapped. Inability to achieve erection was the most common preoperative complaint in those with buried penis (67%), whereas difficulties in voiding were most common with trapped penis (78%). Patients with trapped penises had a significantly larger body habitus than those with a buried penis (39.8 vs 34.2 kg/m2, P = 0.0088). Operative duration and length of hospital stay were comparable between the trapped and buried penis groups (206 vs 161 minutes, P = 0.3664) (5 vs 1 day, P = 0.0836). One third experienced wound complications, but this was not significantly different between buried and trapped penises (17% vs 44%, P = 0.5804). Postoperatively, 5 patients experienced spontaneous erections, and 7 were able to void while standing.

CONCLUSIONS

Patients with a trapped penis present with a different preoperative symptom profile and body type than those with a buried penis. Our nomenclature and classification system offer a simple and clear algorithm for the management of hidden penis. Large cohort studies are warranted to assess differences in clinical outcomes between trapped and buried penises.

Congenital Lymphedema of the Foreskin in a 3-Year-Old Boy: A Case Report and Literature Review

Congenital lymphedema of the external genitalia is a rare, disfiguring disorder. We describe here a case of a 3-year-old male with primary foreskin lymphedema persisting since birth. A compact, heterogenous swelling of the foreskin's distal third was observed, inhibiting preputial retraction (phimosis). Right lower extremity lymphedema was also observed in this case, while no further abnormalities were found. Surgery was performed, maintaining the foreskin, producing an excellent result with no recurrence at 10-month follow up.

Penile Size Dissatisfaction

BACKGROUND

Men concerned about their penis size often consult professionals working in urology, andrology, surgery, and sexual medicine.

AIM

To inform professionals in the sexual medicine field about small penis syndrome as a clinical syndrome and to provide recommendations for treatment.

METHODS

This was an overview of the existing literature combined with our extensive clinical experience.

RESULTS

Small penis syndrome is a syndrome with psychiatric comorbidities and social consequences that impair life. Men with these concerns tend to be susceptible for treatment that is not evidence based and potentially harmful.

CLINICAL IMPLICATIONS

Treatment of men with concerns about penis size should start with a thorough biopsychosocial assessment, followed by extensive psychoeducation, counselling, and psychological interventions, even if surgery is being considered.

STRENGTHS & LIMITATIONS

The strength of this study is the concise overview of the existing literature combined with clinical experience which leads to important recommendations. Limitation is that this is not a systematic review.

CONCLUSION

Complaints about penis size should be taken seriously, and a thorough biopsychosocial and multidisciplinary assessment is required.

Clinical Recommendations From the European Society for Sexual Medicine Exploring Partner Expectations, Satisfaction in Male and Phalloplasty Cohorts, the Impact of Penile Length, Girth and Implant Type, Reservoir Placement, and the Influence of Comorbidities and Social Circumstances

INTRODUCTION

To date, several aspects of inflatable penile prosthesis (IPP) surgical procedure have been poorly studied.

AIM

The aim of this study was to review the evidence associated with IPP implantation and provide clinical recommendations on behalf of the European Society for Sexual Medicine (ESSM). Overall, 130 peer-reviewed studies and systematic reviews, which were published from 2007-2018 in the English language, were included.

METHODS

MEDLINE and EMBASE were searched for randomized clinical trials, meta-analyses, and open-label prospective and retrospective studies.

MAIN OUTCOME MEASURE

The panel provided statements exploring patients and partner expectations, satisfaction in male and phalloplasty cohorts, the impact of penile length, girth and implant type, reservoir placement, the influence of comorbidities, and social circumstances. Levels of evidence were provided according to the Oxford 2011 criteria and graded as for the Oxford Centre for Evidence-Based Medicine recommendations.

RESULTS

In the preoperative setting, it is fundamental to identify and interact with difficult patients with the intention of enhancing the surgeon's ability to establish the surgeon-patient relationship, reduce physical and legal risk, as well as enhancing patient satisfaction. To address this need, the mnemonic Compulsive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial, and Psychiatric ("CURSED") has been suggested to identify patients who are at high risk of dissatisfaction. The current recommendations suggest improving glycemic control in patients with diabetes. Available evidence suggests evaluating transplant recipients with the criteria of Barry, consisting of stable graft function for >6 months, avoidance of intra-abdominal reservoir placement, and low-dose immunosuppression. HIV status does not represent a contraindication for surgery. Smoking, peripheral vascular disease, and hypertension may be associated with an increased risk of revision surgery. Patients with spinal cord injury may receive IPP. Patients aged ≥70 years, as well as obese patients, can be offered IPP. The IPP implantation can be performed in patients with stable Peyronie's disease. Ectopic high submuscular reservoir placement can be considered as an alternative method.

CLINICAL IMPLICATIONS

There is a relevant lack of high-level data and definite conclusions in certain areas remain difficult to draw.

STRENGTH & LIMITATIONS

All studies have been evaluated by a panel of experts providing recommendations for clinical practice. Because of lack of sufficient prospective data, some of the included studies are retrospective and this could be stated as a limitation.

CONCLUSION

This ESSM position statement provides recommendations on optimization of patient outcome by patient selection, and individualized peri- and intra-operative management. ESSM encourages centers to collaborate and to create prospective, multicenter registries in order to address this topic of increasing importance. Osmonov D, Christopher AN, Blecher GA, et al. Clinical Recommendations from the European Society for Sexual Medicine Exploring Partner Expectations, Satisfaction in Male and Phalloplasty Cohorts, the Impact of Penile Length, Girth and Implant Type, Reservoir Placement, and the Influence of Comorbidities and Social Circumstances. J Sex Med 2020;17:210-237.

Circumferential penile defect reconstruction with pull-up double-opposing keystone-designed perforator island flaps: A case report

RATIONALE

The challenges with reconstruction of penile defects are plenty. In addition, no single and universally accepted reconstructive method exists for penile defect repair. Herein, we present the application of a circumferential penile shaft defect reconstruction using pull-up double-opposing keystone-designed perforator island flaps (KDPIFs) in one patient. This is the first case report of a circumferential penile shaft defect reconstruction using KDPIFs.

PATIENT CONCERNS

A 43-year-old man who injected petroleum jelly into his penis 10 years ago presented with multiple firm nodular mass-like lesions adherent to the overlying skin along the penile shaft. Our urologic surgeon removed the foreign bodies and performed a primary closure with undermining. However, wound dehiscence developed, and skin necrosis was exacerbated 5 days postoperatively.

DIAGNOSES

We performed debridement, and the final post-debridement defect was circumferential (5.5 × 12 cm) from the base of the glans to the midpoint of the penile shaft.

INTERVENTIONS

We covered the defect using pull-up double-opposing KDPIFs (10 × 13 cm each) based on the hot spots of the superficial external pudendal artery perforators on each side from the suprapubic area to the scrotum.

OUTCOMES

The flaps survived perfectly, with no postoperative complications. The patient was satisfied with the final outcome and had no erectile dysfunction or shortening of penile length after a 6-month follow-up.

LESSONS

We successfully reconstructed a circumferential penile defect with pull-up double-opposing KDPIFs both esthetically and functionally. Our technique can be a good alternative modality for extensive penile defect reconstruction.

Concealed cysts presenting as 'Club' penis: a case report

BACKGROUND

Penile swellings are not very common. They usually present as an obvious lesion visible and palpable either on the penile shaft, glans, or prepuce. Rarely, benign swellings may be concealed by phimosis and can present as "club" penis.

CASE PRESENTATION

We report the case of a 30-year-old Indian male man who presented with the complaint of difficulty in retracting his foreskin and a club-shaped distal penis. There were palpable lumps on either side of the glans penis which were concealed by the foreskin; hence, a proper preoperative clinical diagnosis was not possible. Circumcision revealed the presence of two discrete cystic swellings from inner prepuce which were excised. Histopathology was suggestive of epidermoid cysts.

CONCLUSIONS

Although epidermoid cysts are common cutaneous swellings, they are rarely seen on the penis. They generally present as a small solitary swelling on the penile surface and occurrence at multiple sites is very rare. Epidermoid cysts arising from inner prepuce, hiding within and presenting as club penis have not been reported. Thus, benign lumps should be considered an etiology for phimosis.

[Free grafting of internal preputial lamina for penile divided nevus in children]

OBJECTIVE

To evaluate the effect of free grafting of internal preputial lamina in the treatment of penile divided nevus in children.

METHODS

This retrospective study included 5 children with penile divided nevus, 4 complicated by redundant prepuce and the other 1 by concealed penis, all treated by free grafting of internal preputial lamina from October 2015 to November 2017. The patients ranged in age from 6 years and 8 months to 10 years and 4 months, averaging 8 years and 6 months. The surgical procedure involved complete excision of the lesions underneath the foreskin with a safety margin of 2 mm, collection of healthy internal preputial lamina for free grafting onto the defected glans, and simultaneously circumcision or concealed penis correction. The removed tissue of the divided nevus was subjected to pathological examination. The patients were followed up for 4－29 (mean 18) months postoperatively.

RESULTS

All incisions healed primarily and the free grafts of internal preputial lamina survived well, similar to the glans in color and with a desirable appearance. The patients lost no protopathic sensibility of the glans and experienced no recurrence. Pathological examination confirmed 1 case of intradermal nevus and 4 cases of compound nevus.

CONCLUSIONS

Free grafting of internal preputial lamina is an ideal method for the treatment of penile divided nevus in children, with the advantages of easy graft collection, little color difference between the graft and surrounding skin, desirable external appearance, and definite clinical effect.

Recurrent Pilonidal Sinus Cyst on Penis

Pilonidal sinus, including one or more sinus canals and hairs, is a disease with a chronic course showing acute attacks which is often encountered in the general population, usually affecting young adults, at a rate in males twice that of females. Pilonidal sinus on the penis is so rare that very few cases have been reported in literature. A 20-year-old male presented to the urology outpatient clinic with the complaint of a suppurative lesion with discharge on the skin of the penis which had been ongoing for approximately three months. Clinical examination revealed an indurated, erythematous, ulcerative lesion, 3 cm x 2 cm in size, in the middle of the ventral aspect of the penile shaft. We present the first case in literature of recurrent pilonidal sinus related to Actinomyces israelii, located on the penis.

Large penile plexiform neurofibroma in an 11-year old boy

Background

Neurofibromatosis is a genetically inherited disorder of the nervous system (brain and spinal cord) which mainly affects the development of nerve (neural) cell tissues, causing tumors (neurofibromas) to develop on nerves. It is the most common single gene disorder of the nervous system and inheritance is through autosomal dominance. They are usually classified into types 1 and 2, the type 1 is the commoner type and also known as superficial neurofibroma. Plexiform neurofibromas are the next most common type of tumor in individuals with type 1 neurofibroma. Plexiform neurofibromas are histologically benign tumors that are made up of a variety of cell types including neuronal axons, Schwann cells, fibroblasts, mast cells, macrophages, perineural cells and extracellular matrix materials such as collagen. They can occur in any part of the body and can grow throughout the person's lifetime, often becoming disfiguring, disabling or deadly via compression of vital structures or conversion to a malignant sarcoma or malignant peripheral nerve sheath turmor. The aim of this report is to present a large penile plexiform neurofibroma which required extensive dissection for complete excision and reconstruction of the phallus and glans penis.

Objectives

To present a huge penile plexiform neurofibroma and the mode of surgical treatment.

Methods

The huge penile plexiform neurofibroma was completely excised and the penile defect resulting from the excision was repaired.

Conclusion

Plexiform neurofibromas are congenital tumors of peripheral nerve sheaths which may also develop near nerve roots deep within the body. They are usually benign but carry a malignant potential in 5-10% of patients. Plexiform neurofibromas are commoner in the face, chest and limbs but the index case occurred on the penile shaft.

Early experience with shared medical appointments for penile problems

We examined the use of shared medical appointments (SMA) for educating and counseling children with penile problems. Forty-eight families were seen over 4 months with 21 participating in the SMA group and 27 in the traditional group. Using a questionnaire to assess adequacy of education, there was no difference in the overall scores between groups with a mean of 6.64/7 in the SMA and 6.56/7 in the traditional setting. With the increasing demands on providers, an SMA offers a solution to caring for more patients with penile problems in an efficient manner without impacting family education and satisfaction.

Genital myiasis associated with genital piercing. Case report

CONTEXT

Myiasis is caused by larval infestation that usually occurs in exposed wounds. Dermatobia hominis is the most common fly species responsible for this parasitic infection. Genital piercing is an ornamental practice used in certain social circles. At placement, it transverses the skin surface and, as such, may be related to complications.

CASE REPORT

We report a case of a 31-year-old man with a history of wound infection secondary to genital piercing who was exposed to an environment with flies, leading to myiasis. Mechanical removal and systemic antiparasitic drugs are possible treatments for myiasis. However, prevention that includes wound cleaning and dressing is the best way to avoid this disease.

CONCLUSIONS

Genital piercing can lead to potential complications and myiasis may occur when skin lesions are not properly treated.

Genital reconstruction with Integra™ artificial dermis after radical resection in a boy with diffuse lymphangiomatosis

OBJECTIVE

Lymphangiomatosis is a rare disease affecting lymphatic vessels that causes a marked increase of them in the affected area. The final objective of treatment of the genital disease is to preserve sexual function and voiding with a satisfactory aesthetic result with the aim to minimize the emotional impact.

METHODS

For the first time in children, we report a case of local reconstruction using artificial dermis after the excision of a genital lymphatic malformation in an eight year old patient.

RESULTS

We performed surgical excision of the lymphatic malformation genital component and reconstruction of the scrotal and penile area in two steps, using an autologous graft over artificial dermis. No complications were registered. Both aesthetic and functional results were excellent, and spontaneous erections that were not present before, were also evidenced. No local recurrence was seen at two year follow up.

CONCLUSION

The use of artificial dermis for genital surface reconstruction enables radical excision of tissues involved by diffuse lymphangiomatosis in this location. Surgical technique is simple, postoperative care is easy, being ambulatory care feasible. Final result is an elastic, fine skin, very satisfactory aesthetically, and functionally normal, which even keeps local sensitivity. In the long term, this will benefit the sexual field, so damaged in this patients.

Is Preputioplasty Effective and Acceptable?

Foreskin complaints in childhood, if not manageable conservatively, are usually treated by circumcision. A less radical surgical option, when balanitis xerotica obliterans is absent, is preputioplasty. We sent questionnaires to the parents of 23 boys who had had this procedure and 22 replied.

Mean interval since operation was 20 months (range 3-36). The main indications for surgery had been irretractable foreskin in 9, recurrent balanoposthitis in 10 and ballooning on voiding in 3 and the operation had dealt successfully with these in 7, 7, and 3, respectively. In all but one case the parents were satisfied with the cosmetic result. However, in 8 cases (36%) the parents said they would have preferred circumcision and 3 of the boys had been listed for further surgery.

Preputioplasty is a satisfactory alternative to circumcision in selected cases.

Troubles with the Foreskin: One Hundred Consecutive Referrals to Paediatric Surgeons

To assess the reasons for and outcomes of referrals concerning the foreskin, 100 consecutive patients seen in paediatric clinics were followed to discharge. 18 referrals were for circumcision on religious grounds. Of the other 82, the main reason for referral was non-retractability or phimosis. At clinic, 24 (29%) of these were deemed normal for age, 31 (38%) were treated with topical steroid (successfully in 25), 9 (11%) were listed for preputioplasty, 7 (9%) were listed for adhesiolysis, 7 (9%) were listed for circumcision, and 4 were listed for other forms of surgery. 6 patients were identified as having balanitis xerotica obliterans (BXO), a condition that had not been suggested on referral. With the advent of new treatments for foreskin disorders, circumcision is decreasingly necessary. Knowledge of the natural history of the foreskin, and the use of topical steroids, could shift the management of paediatric foreskin problems from the hospital outpatient department to primary care. BXO is not sufficiently recognized as a form of phimosis that requires operation.

An unanswered question in pediatric urology: the post pubertal persistence of prepubertal congenital penile curvature correction by tunical plication

OBJECTIVE

The aim of this study is to analyze post pubertal results of pre pubertal tunica albuginea plication with non-absorbable sutures in the correction of CPC.

MATERIALS AND METHODS

The files of patients who underwent tunica albuginea plication without incision (dorsal/lateral) were retrospectively reviewed. Patients younger than 13 years of age at the time of operation and older than 14 years of age in November 2015 were included. Patients with a penile curvature of less than 30 degrees & more than 45 degrees and penile/urethral anomalies were excluded. All of the patients underwent surgery followed by circumcision.

RESULTS

The mean age of patients at the time of the operation was 9.7 years (range, 6-13 years). The mean degree of ventral penile curvature measured during the operation was 39 degrees while it was 41 degrees in the lateral curvatures. All of the patients were curvature-free at the end of the operation. At the time of the follow-up examination, the mean age was 16.7 years (range, 14-25 years). Six patients had a straight (0-10 degrees) penis during erection and seven patients had recurrent penile curvatures ranging from 30 to 50 degrees.

CONCLUSION

Pre pubertal tunica albuginea plication of congenital penile curvature (30-45 degrees) with non-absorbable sutures performed without incision is a minimal invasive method especially when performed during circumcision. However, recurrence might be observed in half of the patients after puberty.