Penectomy Research Articles

Cancer of the Penis: Clinical Features and Therapeutic Modalities in Senegalese Hospitals

Background: Penile cancer is a rare malignancy in Senegal. This rarity is probably related to the fact that circumcision, which has a protective effect, is a common practice in childhood. Some of the known risk factors include uncircumcised status, chronic inflammatory conditions, and a history of condyloma acuminata, smoking, and possibly human papillomavirus exposure. It is a pathology in adults with a maximum incidence after the age of 50. In our practice penile cancer is most often diagnosed at an advanced stage or only a radical and mutilating treatment may be proposed. Aims: To describe the clinical and therapeutic features of penis cancer in Senegal. Patients and methods: we carried out a retrospective, descriptive, bicentric study, collecting the records of patients with penis cancer in the Urology-Andrology department of the Aristide Le Dantec University hospital and the military hospital of Ouakam between January 2010 and December 2019. Results: fourteen cases of penile cancer were diagnosed. The mean age was 53.2 years with extremes of 29 and 84 years, the average consultation time was 21 months. All patients were circumcised in childhood. The tumor was limited to the glans in 2 cases and involved the entire penis in 5 cases. Six patients had bilateral inguinal adenopathies. The histological type was squamous cell carcinoma in all cases with a predominance of grade 2 (8 cases). Patients were classified as cT3 (7 cases), cT2 (5 cases), cT4 (1 case) and cT1 (1 case). Treatment consisted of partial amputation of the penis (5 cases), emasculation and perineal urethrostomy (4 cases) total amputation and perineal urethrostomy (2 cases). Three patients had refused total penis amputation. The average length of follow-up was 26 months (4 and 72 months), 3 lymph nodes recurrences and 2 local recurrences were observed. Two patients died among the operated patients. Conclusion: Cancer of the penis is rare in Senegal. The delay in diagnosis explains the frequency of advanced forms which can only be treated by radical surgery.

Penile Rings: No Innovation without Evaluation.

Penile strangulation is a rare clinical entity which if left untreated can cause serious urogenital problems. We present the case of 45-year-old male patient who presented with penile strangulation after applying a metallic ring. Strangulation of the external male genitalia is a serious problem that requires urgent intervention in order to avoid serious complications. If left untreated, it can result in gangrene and penile amputation. Management of penile strangulation is a real challenge for the treating surgeon and should be treated as an emergency in order to avoid vascular compromise.LEARNING POINTSPenile strangulation by metallic rings is not routinely encountered in daily emergency practice and can be a challenge for the treating surgeon.Problem awareness is a crucial part of the management of such a rare entity.Every attempt should be made as early as possible to preserve penile arterial supply.

Outcomes and special techniques for treatment of penile amputation injury

IntroductionManagement of severe penile trauma presents great challenges for reconstructive urologists since these injuries vary from abrasions to total emasculation. A review of our case experience with penile amputation is presented, emphasizing techniques used to salvage or reconstruct the most difficult of penile injury cases. Materials and methodsA total of 13 patients with penile amputation injury referred to us between 2007 and 2016 were analyzed. Mean age at surgery was 16 years (ranged from 4 to 29 years). Etiology of penile amputation (partial or total) combined with management and outcomes were evaluated. Management included different surgical procedures with the aim to achieve good functional and esthetical outcomes. Postoperative questionnaire was used for assessment of patient's overall satisfaction. ResultsFollow-up ranged from 13 to 182 months (mean 53). Causes of penile injury were iatrogenic trauma (8), self-amputation (2), electrocution (1), intentional sexual assault (1) and mother's hair strangulation (1). Outcome criteria including aesthetic appearance, urinary function and ability to engage in satisfactory coitus, were noted in 11 cases (85%). Two cases with ensuing complications relating to the total phalloplasty required additional treatment due to urethral fistula. ConclusionsSevere penile injuries should be treated on a case by case basis utilizing the most propitious techniques. We respectfully propose that the needs of such patients are best served by referral centers with extensive experience.

Partial penectomy or total penectomy for T1 and T2 squamous cell carcinoma of the penis

Background: To assess prognostic factors and survival outcomes for partial penectomy (PP) and total penectomy (TP) patients with T1 and T2 squamous cell carcinoma of the penis. Methods: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 708 penile cancer patients. Among these, 607 underwent PP and 101 underwent TP. Kaplan-Meier analysis was used to compare survival outcomes between PP and TP patients. Univariate and multivariate Cox proportional hazards regression models were used to determine prognostic factors. Results: There were significant differences in marital status and regional lymph node removal between patients of the PP and TP groups. Multivariate regression analysis demonstrated that age [odds ratio (OR) =1.045; 95% confidence interval (CI): 1.034–1.057; P<0.0001], T2 carcinoma (OR =1.388; 95% CI: 1.077–1.788; P=0.0114), node stage N1–3 (OR =3.351; 95% CI: 2.317–4.847; P<0.0001), and ≥4 regional lymph nodes removed (OR =0.498; 95% CI: 0.255–0.972; P=0.0411) were independent predictors of overall survival (OS). Age (OR =1.019; 95% CI: 1.005–1.033; P=0.0065), stage N1–3 (OR =5.127; 95% CI: 3.213–8.181; P<0.0001), and ≥4 regional lymph nodes removed (OR =0.452; 95% CI: 0.219–0.932; P=0.0315) were independent predictors of cancer specific survival (CSS). However, there was no significant difference between PP and TP in terms of OS and CSS. Conclusions: There was no significant difference in terms of OS and CSS between patients treated by PP or TP. T2 was associated with shorter OS, while age and N1–3 were associated with shorter OS and CSS. Removal of ≥4 regional lymph nodes was associated with longer OS and CSS.

Hair tourniquet syndrome of penis: A rare situation in boys with serious complications if not recognized.

Penile Hair Tourniquet Syndrome (HTS) is a rare event but a serious syndrome characterized by the presence of a hair coiled around the coronal sulcus of penis which causes a range of pathologies from glandular swelling to necrosis and amputation of penis. If diagnosis is delayed, long-term complications such as urethral fistula, urethral transection, and penile gangrene or amputation develop. Penile HTS is almost exclusively described in circumcised boys. Prevention of such major complications depends on awareness of the etiology and presence of a high index of suspicion. Herein, we aimed to present a boy who was 4 years old with a penile HTS caused by wrapping of his mother's hair coil.

Successful Penile Replantation and the Role of Postreplantation Sildenafil Therapy: Report of 2 Cases and Literature Review.

Penile amputation is a rare clinical emergency necessitating urgent urologic and microsurgical intervention. Microvascular replantation has become a conventional form of management, associated with significantly increased viability of the implanted tissue and a lower rate of complications. However, postreplantation treatment intended to promote early recovery of sexual function has been reported only seldomly. Here we report 2 cases of successful penile replantation with postreplantation daily sildenafil therapy. The patients were followed for 24 months and 8 months, respectively, from the date of repair. First intercourse was achieved at 92 days and 105 days, respectively. This is the first report of the use of phosphodiesterase type 5 inhibitors in postoperative care of penile replantation.Fu S, Zheng D, Xie M, et al. Successful Penile Replantation and the Role of Postreplantation Sildenafil Therapy: Report of 2 Cases and Literature Review. Sex Med 2019;7:352–356.

V78 - Penile skin flap neourethra after radical penile amputation

V78 - Penile skin flap neourethra after radical penile amputation

Malignant Tumors of the Penis - Dia-gnostics and Therapy.

Penile cancer belongs to group of relatively rare malignancies. It represents, on average, 0.5-1% of all tumours in males globally and occurs predominantly in older individuals (&gt; 65 years). The geographical distribution of malignant cancer of the penis is reported. A higher incidence is observed in less developed parts of the world, particularly in South America, Southeast Asia, and some areas of Africa (&gt; 2.0/100,000). In Slovakia, there has been a recent increase in incidence (1.1/100,000 in 2011). Mortality has stabilized at 0.3/100,000 in recent years. Significant risk factors for malignant cancers include social and cultural habits and hygienic and religious practices. Important risk factors are inadequate hygiene of the foreskin sac, phimosis, human papillomavirus infection, sexual promiscuity, smoking, genital infections, and a low socio-economic and educational status. The present paper provides an overview of pathology, symptomatology, diagnostic approaches, and classification of the extent of the disease. Treatment of the primary tumour depends on the extent of the disease and includes topical treatment, photodynamic treatment, cryoablation, laser photocoagulation, conservative surgical treatment, especially circumcision, and even radical treatment - penile amputation with perineal urethrostomy. An important part of the management of this malignancy is surgical treatment of metastases in inguinal lymph nodes. The article devotes more attention to non-surgical treatment modalities, in particular radiotherapy (external and brachytherapy) and systemic therapy (chemotherapy and biologic therapy), offering an overview of the indications and regimens in the adjuvant, neoadjuvant and palliative approaches, with and without concomitant chemoradiotherapy, and describes possible adverse effects of the treatments. Conclusion: Patients with penile cancer should be concentrated in centres that have abundant experience in the diagnosis and treatment of this disease. Key words penile cancer - surgical treatment - radiotherapy - chemotherapy - biologic therapy The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 12. 11. 2018 Accepted: 12. 12. 2018.

AB092. Surgical techniques and experience sharing of replantation of complete penile fracture

Penile amputation is a kind of rare urological condition with was firstly described in 1929, the common etiologies include emotional and family dispute, self-mutilation, trauma, and so on. In the early stage, traditional surgery is the only way to accomplish the replantation for penile amputation, but in recent years, microscopic surgery became the main treatment. In this study, we reported two cases of penile amputation and microsurgical replantation performed in our hospital in August 2016. In the first case, the patient was injured by sharp scissors due to family conflict, while in the second case, it was a mechanical injury. For both cases, the penile ischemia time exceeded 10 hours, and microsurgical approaches were adopted. After the microsurgical replantation, both the patients recovered well and showed normal urination, erectile function, return of sensations and satisfactory cosmetic appearance. With the development of microsurgical techniques, the successful re-anastomosis of blood vessel and nerve can increase the survival and functional recovery of the penis even in cases exceeding 10 hours of ischemia. This provides greater possibility of graft survival with minimum complication.

18F-FDG PET/CT as a prognostic factor in penile cancer.

Penile cancer (PC) is a rare neoplasm with an aggressive behavior and variable prognosis. Lymph node (LN) involvement and pathological features of the primary lesion have been proven to be the most important survival factors. Positron emission tomography/computed tomography with fluorodeoxyglucose labelled with fluorine-18 (18F-FDG PET/CT) provides information on tumor staging and works as a prognostic factor, with promising results in other carcinomas. The aim of the present study is to evaluate PET/CT as a prognostic factor in PC. Fifty-five patients (mean age 56.6 y) diagnosed with penile squamous cell carcinoma were prospectively evaluated from 2012 to 2014. All subjects underwent 18F-FDG PET/CT before treatment and were regularly followed after surgery. Out of the 53 patients selected, 17 (32.1%) had localized disease (cT1-2) and 24 (45.3%) had palpable nodes (cN+). Partial penile amputation was performed in 38 patients (71.7%) and inguinal lymphadenectomy (LND) in 30 (56.6%). From the LND group, 16 (53.3%) presented with positive neoplastic cells (pN+). Patients with more aggressive disease had a significantly (p = 0.019) higher 18F-FDG tumor uptake (pSUVmax), while inguinal LN uptake (nSUVmax) was able to recognize metastatic LN (p = 0.039). Some pathological prognostic features, when presented, have shown significant changes in pSUVmax values. Receiver operating characteristic (ROC) curves were performed and specific cutoff values of pSUVmax were evaluated to determine sensitivity and specificity. Regarding regional LNs, PET/CT presented a 76.2% accuracy in cN+ patients. After a 39-month follow up, pSUVmax of 16.6 (p = 0.0001) and nSUVmax of 6.5 (p = 0.019) were established as the ideal values to predict cancer-specific survival. The multivariate analysis confirmed nSUVmax as a predictor for LN metastasis (p = 0.043) and pSUVmax as a mean to estimate survival rate (p = 0.05). This study showed promising results on the use of 18F-FDG PET/CT as a prognostic tool for PC, using specific cutoff values of pSUVmax and nSUVmax.

Severity of malcircumcisions and circumcision-related complications in three tertiary health facilities in Southern Nigeria

Background: Complications following circumcision are well recognized. In our environment, it is relatively common and frequently encountered in pediatric surgical practice. While some may be easily corrected others may be more tasking and even life threatening. There is need to identify the serious complications, and to proffer ways of preventing them or managing them when they occur. We aimed to evaluate the spectrum of malcircumcision and circumcision related complications in our region and to identify the major challenging ones. Patients and methods: Data was prospectively obtained from all male children presenting with malcircumcisions or circumcision related complications in three tertiary health facilities in southern Nigeria between June 2006 and May 2013. Data included complication presented, age, circumcisionist, method of circumcision, treatment offered, outcome. Results: A total of 126 male children with 143 malcircumcisions or complicated circumcisions were seen within the period. The spectrum ranged from minor glandular adhesions to penile amputation and life threatening excessive bleeding. Procedures Included: manual removal of plastibell, suture ligation of bleeding vessel, adhesiolysis, preputial trimming, meatoplasty, urethroplasty, fistuloplasty, glanuloplasty and penile repair. Most tasking were urethral loss, fistula closure and glanular amputation. There were no deaths. Conclusion: Circumcision related complications are common in our region. Penile amputation, urethral loss, and fistulae are the most challenging complications. There is need to educate the health workers and general public on the hazard of untrained circumcisionists. Keywords: circumcision, complications, severity, management

271 Social deprivation trends in operative penile cancer

Penile cancer is a rare disease and accounts for less than 1% of total cancers diagnosed. Scotland has a higher incidence of penile cancer compared to many parts of the world and can have serious functional and sexual consequences for patients. Does social deprivation play a role in presentation, grade, stage and ultimate treatment of penile cancer? All cases of penile cancer in Glasgow, Scotland, an area of centralized NHS service, were identified over a 10-year period. Patients identified from operative notes performed by two consultant urologists from 2007 – 2017 were included. Social deprivation was determined using the Scottish Index of Multiple Deprivation (SIMD), the Scottish Government’s official tool to identify areas of multiple deprivation in Scotland. 200 patients were identified with an age range of 27 – 91 (mean = 63). The most deprived areas have a significantly higher number of cases of penile cancer. Moreover, histologically, a higher proportion of aggressive grade 3 cancers were diagnosed in the most deprived population and also more advanced staging. There is a significantly higher rate of penile amputation in the more socially deprived population. Patients took an average of 6 months to present to primary care and although there was no correlation in the number of missed appointments and social deprivation, a total of 200 appointments were missed.

Abstract 11.05 THE MICROVASCULAR “TUBE- IN- TUBE” CONCEPT FOR PENILE CONSTRUCTION IN FEMALE TO MALE TRANSSEXUALS

INTRODUCTION: In most female-to-male transsexual patients the construction of an aesthetic and functional neo-phallus after penile amputation represents the terminal step in a series of invasive and non-invasive procedures. For this surgery, a lot of different techniques have been described. Among these microsurgical free-flap phalloplasties remain the most popular method in clinical routine. For many years, the radial forearm free flap has been considered to be the best procedure. With the aim to reduce donor site morbidity and to optimize functional outcome many other flaps have been developed. Therefore, pedicled flaps have shown to be reliable and to decrease the risk of total failure. RESULTS: We describe a new “tube- in tube” technique combining either a pedicled SCIP (Superficial circumflex iliac artery perforator) flap or a free RFF (radial forearm) flap with an ALT (Anterolateral thigh flap) free flap. By using the SCIP/ radialis flap as part mobile of the Urethra the inner tube is formed. The ALT flap builds the outer tube. By presenting cases of this technique, first experiences, outcome and the most occurring complications should be showed. CONCLUSION: By combining the reliability of pedicled flaps with the benefits in aesthetic outcome of free flaps, this new “tube- in- tube” technique represents a method to reduce complete flap failure by simultaneously decrease complication rate.

British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies – penile amputation

Male genital emergencies relating to the penis and scrotum are rare and require prompt investigation and surgical intervention. Clinicians are often unfamiliar with the management of these conditions and may not work in a specialist centre with on-site expertise in genitourethral surgery. A series of consensus statements have been developed by an expert consensus committee comprising members of the British Association of Urological Surgeons (BAUS) Sectionof Andrology and Genitourethral Surgery together with experts from urology units throughout the UK. Penile amputation is a rare genital emergency, which requires prompt intervention and microsurgical reconstruction. The consensus statements will outline the management of these cases for non-specialist units, as well as recommendations for reconstruction for specialists.

Reconstructive surgery in penile cancer

Due to the rising incidence of penile cancer and increasing life expectancy in western nations, the current international guidelines recommend a less aggressive surgical approach with reduced safety margins and preferably with organ preservation. The goal of this review is to review the current data on stage-dependent reconstructive surgical techniques and their oncological and functional results. Five recently published reviews and several single studies and publications on the topic of organ-sparing surgical techniques and penile reconstruction were evaluated to draw conclusions for surgery in penile cancer. Due to the rare incidence of penile cancer and the absence of comparative, prospective studies in the literature, evidence levels of the actual statements and conclusions are low. Organ-sparing techniques in penile cancer lead to slightly elevated local recurrence rates compared with traditional partial or total penile amputation. Thus, sufficient patient compliance is mandatory and an intensified follow-up for more than the usual 5years postoperatively is required. On the other hand, these techniques enable the surgeon to offer improved functional and esthetic outcomes to the patient, maintaining erectile capacity and sensitivity. After extended partial or total penile amputation, penile reconstruction using free radial forearm flaps with later prosthetic implantation may be offered to younger and sexually active patients in cooperation with experienced plastic surgeons, even if the previously published case numbers do not permit standardization of these procedures.

Preputial reconstruction and urethrostomy after subtotal penile amputation in a dog

A 7-year-old, 4.2-kg intact male toy poodle was presented to the referring veterinarian with a persistent penile erection and secondary paraphimosis. A full-thickness longitudinal incision was made in the prepuce to release strangulation by the preputial orifice. Castration was also performed. However, the persistent erection did not resolve, which suggested idiopathic priapism. Although prescrotal or scrotal urethrostomy was considered, these procedures commonly have complications, such as severe hemorrhage, stricture of the urethral opening, urine scalding, and abnormal cosmetic appearance. Therefore, preputial reconstruction and urethrostomy were performed following amputation of the penis. A V-Y skin plasty was performed to retract the prepuce caudally. Two triangles of preputial skin at the middle of the prepuce were removed to shorten the prepuce. A 6-Fr catheter was kept in place for 9 days after surgery to prevent stricture formation and to divert urine during initial healing. After surgery, the dog was able to urinate through the natural preputial orifice, showing no urine scalding of the urethrostomy site. Six months after surgery, nomajor complications were observed. The owner was satisfied with the functional and cosmetic outcome.

Research Highlights

Research Highlights

Penile cancer: a case series in two tertiary care teaching hospitals with review of literature

Introduction Carcinoma of penis is a very rare disease most commonly affecting elderly men. This rare disease can have terrible and horrifying consequences on the social and emotional life of patients as well as their families. The objective of our case series is to describe the sociodemographic and clinical features, the standard investigations and treatment protocols and follow up of patients who presented to our hospitals. Methodology This is a prospective study of fourteen patients admitted in two tertiary care teaching institutions of Kolkata between January 2013 to December 2015 with a histopathological diagnosis of penile cancer. Results and discussion Age of patients varied between 45 to 82 years. Duration of disease varied between 3-13 months. Nine patients had palpable inguinal lymphadenopathy and 2 patients had liver metastases. Eight patients underwent partial amputation of penis and 4 patients underwent total amputation. Conclusion Penile cancer is a rare disease with devastating consequences. Patients often present late and the primary surgical treatment is often disfiguring. Aggressive surgical treatment of the primary disease and groin remains the cornerstone in the management of high-risk cases.

Редкий клинический случай. Формирование артифициальной уретры после ампутации полового члена

A brief overview of the problem of the penis amputation, the consequences and possible methods for their resolution is presented. The article describes epidemiological situation and the main causes of the penis amputation. The modern existing ways of surgical treatment are illuminated, depending on the cause of amputation. Variants of phalloplasty are described. A rare clinical case of a patient undergoing amputation of the penis and adjuvant chemoradiotherapy for penile cancer in the third stage is presented. Subsequently, the patient underwent obliteration of the urethraperineostomy, as a result of which a cystostomy was performed. The patient complained of the impossibility of independent urination, a decrease in the quality of life. The presence of the crotch stoma did not suit the patient, he asked to restore the ability to upstanding urination. To eliminate these problems, fulfill the requirements, we reconstructed the patient's preserved and the formed the artificial part of the urethra. In the postoperative period, a complication occurred - urethral fistulas, which required a repeated corrective operation. Described are remote, yearly and biennial results with the presentation of objective methods of control - urethrograms and uroflowmetry. Conclusions are given on the presented material, it was suggested to use this technique in certain groups of patients, to re-evaluate after accumulating a significant experience of such interventions.

Successful penile reimplantation and systematic review of world literature

IntroductionThere is paucity of case reports that describe successful non-microscopic penile reimplantation. We report a case of a self-inflicted penile amputation in an apparently normal patient with first psychotic break. ObservationTo report on a case of successful macrosurgical penile reimplantation, discuss the etiologies, surgical techniques and outcomes of world literature on penile reimplantation and an update of current trends in penile surgery. A 40 year-old male, father of 3 children and a proprietor of a nursery school with no prior pschiatric disorder was rushed to our trauma centre following a self-inflicted total penile amputation at its base with incomplete laceration of the scrotum due to command hallucination. He was immediately resuscitated and underwent a non-microscopic penile reimplantation and scrotal closure by an experienced urologist (JEM) by reattaching the dorsal vein, urethra, corporal, fascial and skin layers. A functional outcome with respect to voiding, penile erection and cosmesis was excellent. ConclusionSelf-inflicted penile amputation may manifest as first psychotic break in apparently normal subjects. Though microscopic neurovascular reconstruction is the gold standard, macrosurgical reimplantation of penis by an experienced surgeon in the absence of a microscope yields satisfactory results.