Penoscrotal Area Research Articles

(399) Effect of Bulbospongiosus Muscles Cutting with Frenular Delta Excision for Treatment Premature Ejaculation ( Alaa Aglan Operation)

Abstract Introduction Alaa aglan operation is a new procedure consists of two parts. First part is cutting bulbospongiosus muscles bilaterally, And 2nd part is cutting of elliptical part of frenular delta. it is the most sensitive area in penis and excision of its central part decreases penis sensitivity. The operation has it's own prediction test that allows us to know the expected time post operatively and if the operation is option or not. It is easy just spraying local anesthesia (procomail 10%®) at coronal ridge (inhibits glans-bulbospongiosus reflex) and at frenular delta (temporary excision) 30 minutes before having sex. The operation could be reversed by repairing the muscle again. Objective presentation of a simple, easy permanent solution for treatment of premature ejaculation with less side effects in comparison with all other treatments. Methods 1050 Cases were operated between 1/1/2015 and 3/10/2015 follow up was done at 1, 3,6,12 months intervals then yearly (5 years duration). 47 Cases didn't complete the 5 years duration but none of them have any complain. Results There are two types of patients: First type (non-psychic causes patients) the gained time was approximately as prediction test of each. Second type (secondary psychic or mixed causes patients) the results were much better than prediction tests after 3 months. The non- psychic premature ejaculation patients improved quickly. we calculate the time (IVEL) from the second intercourse as patient usually be congested unless he masturbated or had wet dreams so we avoid the 1st intercourse and calculate the time from 2nd time .clinically we noticed that all patients gets the final result after 1 month approximately from day of surgery. And the result still constant without change or with minimal positive change in few cases but in second type patients the results after 3 weeks resembles the prediction test results but improves gradually till the 3rd month with final constant result. Satisfaction was rate 99.6% this is due to prediction test application, in our early trials beyond this study Satisfaction rate was 71% (without prediction test). Side effects were minimal, No regression in results in any patient during the following up period. Only 4 patients were not satisfied although the operation was successful. 1st patient complained from neuroma due to adhesion (post operative), Adhesiolysis was done, total relief of pain reported by the patient immediately post operative, 2nd patient reported that the distance of expulsion of semen from penile orifice decreased in comparison to that before surgery. 3rd patient reported hematoma, Evacuation was done without complications. 4th patient reported that he lost the sensation of repetitive contraction of muscles at peno-scrotal area during ejaculation. Many patients reported absence or decrease in number of wet dreams post operative other side effects were minimal. Conclusions Alaa aglan operation is safe, Immediate, Curative technique for premature ejaculation provided that prediction test shows good response. Disclosure No

Acquired Lymphangiectasia of Peno-Scrotal Area following Hernia Repair: A Case Report and Review of Therapeutic Options.

Acquired Lymphangiectasia of Peno-Scrotal Area following Hernia Repair: A Case Report and Review of Therapeutic Options.

Extramammary paget disease of the penoscrotal region.

Extramammary Paget disease is an uncommon slow growing intraepithelial malignant neoplasm. It can be classified into primary and secondary subtypes, with secondary subtype associated with underlying malignancy. Extramammary Paget disease of the penoscrotal region is extremely rare with very limited literature available describing its clinicopathologic characteristics. We present 6 cases of penoscrotal EMPD diagnosed at our academic medical center over a 20 year period. These included 5 cases of scrotal EMPD and 1 case of penile EMPD. The mean age at diagnosis was 68.6 yrs. (Range 61-78 years), One case of scrotal EMPD had history of renal cell carcinoma and prostatic adenocarcinoma, while one other case presented as recurrent EMPD with initial disease in the left groin. EMPD in the glans penis was associated with a history of urothelial carcinoma in the ureter with pagetoid spread. 3 cases had no progression of the disease till recent follow up, 2 were lost to follow up while 1 case rapidly deteriorated resulting in death. This case had bone metastatic and associated peritoneal carcinomatosis. Thus, Extramammary Paget disease of the penoscrotal area is extremely rare, can be primary or associated with visceral malignancies and usually tends to present at an older age. Peritoneal spread and distant metastasis are associated with rapid progression of the disease.

Risk factors for fistula recurrence after urethrocutaneous fistulectomy in children with hypospadias.

This study aimed to investigate the risk factors of fistula recurrence after primary urethrocutaneous fistulectomy in children with hypospadias. The study included 63 children who underwent fistulectomy for urethrocutaneous fistula (UCFs) that occurred after urethroplasty for hypospadias, between February 2009 and December 2018. The patients were divided into 2 groups: successful group 1 and failed group 2. For data analysis, we included the demographics of the patients, the details of the previous urethroplasty (the type of hypospadias and the location of the meatus after complete chordectomy), the presence of meatal stenosis or urethral stricture after urethroplasty, and the size of the UCFs. The Student t-test and the chi-square test were performed to analyze the data using the Statistical Package for Social Sciences software. The overall success rate of primary urethrocutaneous fistulectomy was 81.0% (51/63 children). The most common location of a secondary fistula was the penoscrotal area 5 (41.6%). There were no statistically significant differences in age (p=0.501), weight (p=0.063), body mass index (p=0.924), history of low birth weight (p=0.454), and history of prematurity (p=0.381). The type of hypospadias (p=0.007) and urethral defect length (p=0.021) were identified as independent risk factors for failed urethrocutaneous fistulectomy. There were no statistically significant differences in meatal stenosis (p=0.431), postoperative stricture (p=0.587), fistula location (p=0.173), multiplicity (p=0.588), and fistula size (p=0.530). The type of hypospadias and the length of the urethral defect are the significant risk factors for secondary fistula recurrence after primary urethrocutaneous fistulectomy.

Коррекция стенозов уретры после оперативных вмешательств по поводу проксимальных форм гипоспадии у детей

Aim Urethral stenosis is one of the serious complications after proximal hypospadias repair. A variety of techniques has been suggested for its correction, such as urethral dilation using bougies, endoscopic incisions and one- or two-staged urethroplasty with buccal mucosa. The aim of our study was to improve results of urethral stenosis correction in children after multiple proximal hypospadias repairs. Materials and methods A total of 24 patients with urethral stenosis after proximal hypospadias repairs underwent treatment in the Department of Uroandrology of the Russian Childrens Clinical Hospital from 2015 to 2019. The age of the patients was from 3-17 years (average - 4.2) with penoscrotal form of hypospadias in 12, scrotal in 8, and perineal in 4 patients. All children previously underwent 2-8 hypospadias repairs. Patients were divided into 2 groups. In group I, 16 patients had urethral stenosis from the glans of the penis to the penoscrotal area, urethral diameter of 3-4 Ch and ventral penile curvature of 45-60o. These patients were treated with a two-staged urethroplasty, similar to Brackas technique. In group II, 8 patients with urethral stenosis in the penile shaft area, urethral diameter of 6 Ch, without penile curvature were included. They underwent to a one-stage urethroplasty with buccal mucosa graft, which was sutured on the dorsolateral aspect of the urethra, with a formation of the age-appropriate urethra (Dorsolateral Inlay). Results All patients in both groups had successful results with flow rate of 8-12 ml/sec. Conclusions The correction of urethral stenosis in children after proximal hypospadias repairs can be performed using buccal mucosa. In cases of long urethral stenosis, urethral diameter of 3-4 Ch, penile curvature, and scarring of the penile skin, a two-staged urethroplasty is recommended. In patients with stenosis of the penile shaft, urethral diameter of 6 Ch and lack of penile curvature, a one-stage urethroplasty with buccal mucosa fixation on the dorsolateral aspect of the urethra (Dorsolateral Inlay) allows to achieve successful results.

MULTIPLE LYMPHATIC-VENOUS ANASTOMOSES (MLVA) FOR MICROSURGICAL DRAINAGE OF PRIMARY PENO-SCROTAL LYMPHEDEMA: A CASE REPORT

Single site Multiple Lymphatic-Venous Anastomoses (MLVA) provides optimal functional and cosmetic results with low complication rates in treatment of lower limb lymphedema. However, no evidence exists in literature concerning the use of this technique in treatment of peno-scrotal lymphedema. We report a case of a 44-year-old male patient who developed secondary peno-scrotal lymphedema with severe lymphorrhea, following a laser treatment for scrotal pustolosis, leading to recurrent infections and finally an established peno-scrotal lymphedema. Utilizing MLVA, a complete remission of scrotal lymphedema was achieved with significant volume reduction of the penile lymphedema. The post-operative course was uneventful with clear improvement in lymphatic flow demonstrable on lymphoscintigraphy (6 months) and no recurrence of scrotal lymphedema at 2 years follow-up. This article reports very promising results of a novel application of MLVA in the treatment of genital lymphedema and suggests that MLVA provides the possibility to shunt both superficial and deep lymphatics to improve the lymphatic drainage from the peno-scrotal area using a single surgical site.

Fistula recurrence after urethrocutaneous fistulectomy in children with hypospadias: risk factors

To study the risk factors of recurrence after primary urethrocutaneous fistulectomy in children with hypospadias. In the period from 2009 to 2019 sixty-three patients underwent a urethrocutaneous fistulectomy after hypospadias repair in our hospital. Patients were divided into two groups: group 1, patients with successful urethrocutaneous fistulectomy 51 (81.0 %) and group 2, children who had a failed urethrocutaneous fistulectomy 12 (19.0%). The study was analyzed retrospectively, according to the demographic factors of the patients, findings of the previous urethroplasty and location, type, meatal stenosis, postoperative stricture, and size of the urethrocutaneous fistula. All data were statistically analyzed on SPSS. The overall success rate of primary fistula repair was 81.0% (51 of 63 fistulae). Most recurrences (8 of 12 fistulas, 66.6%) occurred in fistula at the penoscrotal area. Demographic factors show no difference between the two groups age (p=0.501), weight (p=0.063), low body weight (p=0.454), BMI (p=0.924) and prematurity (p=0.381). Types of hypospadias (p = 0.007) and urethral defect length (p = 0.021) were identified by Student’s t-test as independent risk factors for failed outcome. Other factors such as meatal stenosis (p=0.431), postoperative stricture (p=0.587), location of the fistula (p=0.173), multiplicity (p=0.588) and size (p=0.530), were performed by Chi-square test and they also not significant. Type of hypospadias and urethral defect length are significant risk factors of secondary fistula recurrence after primary urethrocutaneous fistulectomy.

High and intermediate anorectal malformation in males with perineal fistula: Beware of urethral involvement

Anorectal malformation (ARM) with recto-perineal fistula is considered low-type anomaly and standard management of perineal anoplasty without colostomy is recommended. Unusual variants are scarcely reported and present unique challenges in management. We present two cases of ARM with unusual fistula managed in our hospital. Case 1 A term baby boy status-post colostomy creation at birth in an overseas hospital for ARM presented to us at 4 months of age for definitive surgery. Distal loopogram demonstrated a very fine recto-penile fistulous opening at the peno-scrotal area hence perineal anorectoplasty was planned. Intra-operatively, the bulbar urethra was laid open for complete fistula tract excision due to a 3cm shared common wall between fistula tract and urethra. A double-layered urethral repair was performed and a neoanus created after mobilisation of a high rectal pouch. The baby recovered well post-operatively after 3 weeks of urethral stenting and is currently awaiting stoma closure. Case 2 A term male newborn was noted to have ARM with a recto-scrotal fistula. After initial stabilisation and workup, he was scheduled for perineal anoplasty on day 2 of life. Intra-operatively, we noted a fine, long cutaneous track running in the scrotal raphe close to the bulbar urethra. The bulbar urethra was inadvertently entered during fistula tract excision and needed repair. The rectal pouch located above the levator muscle was mobilised and anorectoplasty was performed. The baby was managed post-operatively with gut rest and total parenteral nutrition, and recovered well. Rare-variant ARM with recto-penile/recto-scrotal fistulae can be associated with high or intermediate type anomalies in contrary to classical recto-perineal fistula. Management of these cases should be planned carefully, with possible need for urethral repair during anorectoplasty.

A Giant Buschke-Löwenstein Tumor

A 70-year-old man with no notable medical history presented to our department with a huge tumor on his pubic area that had been evolving for over 20 years causing itching and foul smelling discharge. Physical examination revealed a cauliflower-like voluminous tumor on the patient’s pubis with extension to the penoscrotal area and the lower abdomen (Figure 1).

208 Use of the Subcoronal Approach during Placement of a Salvage Inflatable Penile Implant

The subcoronal approach to inflatable penile implant (IPP) placement is a relatively new technique that has a number of advantages to consider when preparing for surgical intervention in the treatment of erectile dysfunction (ED). Herein we describe use of the subcoronal method in the placement of a salvage IPP – the first documented case of its kind. The index patient is a 52 year old gentleman who had a three-piece IPP placed at an outside institution for the treatment of organic ED. One month later, he presented to our hospital with infection and the prosthetic pump protruding from his penoscrotal wound. All implant components were explanted and six months later he was taken for salvage inflatable penile implant placement via a subcoronal incision. A circumcision incision was used to deglove the penis and dissect down to the corporal bodies. This technique avoided the significant scar tissue the patient had in the penoscrotal area and provided excellent exposure for the dilation of the corporal bodies and placement of the IPP components. We placed 18cm cylinders bilaterally; the reservoir was placed into the left space of retzius without difficulty. The incision provided excellent cosmesis and patient satisfaction at his two-week follow-up.

Complete remission of two patients with recurrent and wide spread extramammary Paget disease obtained from 5-aminolevulinic acid-based photodynamic therapy and imiquimod combination treatment

Extramammary Paget disease (EMPD) is an uncommon malignant neoplasm affecting apocrine gland-bearing skin which usually occurs in the anogenital area of patients older than 50 years. However, as EMPD in old men develops in penoscrotal area and sometimes asymptomatic, in situ or dermal invasion is usually widely spread before a confirmed diagnosis was made. Skin graft is needed after surgery. Both photodynamic therapy (PDT) and topical use of imiquimod reported effective for EMPD. Two patients with recurrent and wide spread at penoscrotal and groin area were diagnosed EMPD by biopsy and histopathological and immunohistochemical examination. We use 6 cycles of 20% 5-aminolevulinic acid (ALA) photodynamic therapy guided by 5-ALA induced porphyrin fluorescence. After PDT, patients were treated by topical use of imiquimod to prevent the recurrence. After 6 cycles of PDT and imiquimod treatments, the patients' examination showed total remission. At the end of the 6 and 12 months, biopsy and pathology examination remain no signal of recurrence. No clinical recurrence after 24 and 36 months' follow up. The combination treatment with 20% PDT and imiquimod acquired complete remission in treatment for recurrent and wide spread extramammary Paget disease in two patients.

Disintegrating perineal disease in patients with urethral stricture and HIV infection: a review of 12 cases

The aim of this study was to defne disintegrating perineal disease (DPD) and to determine whether the fulminating nature of the condition could be explained by urine and perineal swab microbiology or perineal histology. A retrospective study that included 12 male patients with urethral strictures and DPD was performed. DPD was defned as a chronic, destructive, purulent perineal infammation with multiple fstulae or sinuses of the perineum, scrotum or penoscrotal area, which continued for more than six weeks despite a patent urethra after direct vision internal urethrotomy (DVIU) or urinary diversion by means of suprapubic cystostomy. The median patient age was 43.5 years (range of 22-68 years). The patients all tested positive for human immunodefciency virus (HIV) infection. Their mean CD4 count was 340 cells/mm3 (range of 244-1 252 cells/mm3). Histology of the fstula tracts showed non-specifc infammation in 8 patients (66.7%), tuberculosis in 2 (16.7%), hydradenitis suppurativa in one (8.3), and squamous ...

MP-08.05 Disintegrating Perineum Disease in Patients Who Present with Urethral Strictures: A Review of 21 Cases

We define disintegrating perineum disease (DPD) as a destructive, chronic, purulent perineal inflammation resulting in multiple fistulae on the perineum, scrotum, peno-scrotal area and thigh. The perineal sepsis and fistulae do not respond to appropriate antibiotic treatment and temporary urinary diversion via suprapubic catheter. The etiology of this entity may be underlying urethral stricture disease or perineal skin and rectal disease. The aim of this study is to describe the patient profile, management and outcome of the different treatment modalities of DPD in patients with underlying urethral strictures.

Extramammary Paget’s disease of the scrotum

Extramammary Paget’s disease is an uncommon intra-epidermal malignant neoplasm that arises in area rich in apocrine glands. Common sites of occurrence include the vulva, perianal region, perineum, and scrotum. The lesion may be accompanied by an invasive adenocarcinoma or adenocarcinoma in situ of the apocrine glands. Generally, the prognosis is poor. Herein, we report two cases of extramammary Paget’s disease, one involving the penoscrotal area with bilateral inguinal and pelvic lymph node metastases, the other involving the scrotal area without metastases.

Perineoscrotal reconstruction using a medial circumflex femoral artery perforator flap

Major scrotal defects may result from infection due to Fournier's gangrene, excision of scrotal skin diseases, traumatic avulsion of scrotal and penile skin, and genital burns. The wide spectrum of bacterial flora of the perineum, difficulty in providing immobilisation, and obtaining a natural contour of the testes make testicular cover very difficult. Various methods have been reported to cover the penoscrotal area, including skin grafting, transposing them to medial thigh skin, and use of local fasciocutaneous or musculocutaneous flaps. In this report, reconstruction using six local medial circumflex femoral artery perforator (MCFAP) flaps was undertaken in five male patients (mean age, 47 years) with complex penoscrotal or perineal wounds. The cause of the wounds in four patients was Fournier's gangrene, and was a wide papillomateous lesion in the other patient. Flap width was 6-10 cm and flap length was 10-18 cm. The results showed that a MCFAP flap provided the testes with a pliable local flap without being bulky and also protected the testicle without increasing the temperature. The other advantage of the MCFAP flap was that the donor-site scar could be concealed in the gluteal crease. Our results demonstrated that the MCFAP flap is an ideal local flap for covering penoscrotal defects.

P74 Resurfacing the penoscrotum with local pedicle flaps at large defects after ablation of penoscrotal extramammary Paget's disease

Purpose Penoscrotal extramammary Paget's disease is a rare cutaneous malignancy that primarily affects the elderly. To prevent local recurrence, adequate surgical excision with an intraoperative frozen section, proper reconstruction, and a long-term period of follow-up are required. The present study describes the treatment of patients with penoscrotal extramammary Paget's disease, with a focus on post-oncologic reconstruction. Methods Eleven patients who had undergone a local pedicle flap procedure due to the large body defects after ablation of extramammary Paget's disease of the penoscrotal area, during the period of 1999–2009. Local wide excision with intraoperative frozen sectioning was performed, and the penoscrotal wound was reconstructed with a local skin flap. Various flaps were chosen depending on the site and the defected size. If the defect size was small and scrotal tissue was adequate, only a scrotal flap (n=5) was completed for the reconstruction. Large defects with insufficient remnant scrotal tissue as well as cases in which the pubic or inguinal area was involved went through a groin flap (n=2) or an anterolateral thigh flap (n=4) among the local pedicle flaps. Results There were no complications with the postoperative wound. Furthermore, no local recurrence was noted during two to six years of follow-up (mean average 3.5 years). Conclusion For the resurfacing the penoscrotum at large defects after ablation of extramammary Paget's disease, we performed reconstruction with a local pedicle flap. In cases where the remnant tissue was sufficient, a scrotum flap was primarily used, and if additional tissue was needed a local pedicle flap; groin flap or anterolateral thigh flap, etc was applied for reconstruction. In terms of both function and cosmetic concerns, the results were satisfactory. Key Words: Penoscrotal extramammary Paget's disease, Scrotal flap, Groin flap, Anterolateral thigh flap

V1400 CIRCUMFERENTIAL HOLMIUM LASER ABLATION OF URETHRAL STRICTURE

You have accessJournal of UrologyInfertility, Sexual Dysfunction, Trauma & Teaching Techniques1 Apr 2010V1400 CIRCUMFERENTIAL HOLMIUM LASER ABLATION OF URETHRAL STRICTURE Hemendra Shah Hemendra ShahHemendra Shah More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1071AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To evaluate feasibility, safety and short term efficacy of transurethral Holmium laser circumferential ablation of urethral stricture. The hemostatic nature of the holmium laser along with its haemostatic property makes it an ideal energy source for ablation of urethral stricture. It was our presumption that removal of the fibrous tissue may help to minimize the possibility of recurrent stricture and improve the results of endoscopic managment of urethral stricture. METHODS From April 2003 to September 2009, 72 patients underwent circumferential holmium laser ablation of urethral stricture at our institute. The mean age was 47.3 years (range: 22 – 91 years). The etiology of stricture included: Post TURP (19); Post-HOLEP (3); Post other instrumentation (16); Post-exposure urethritis (13) & Idiopathic (21). Of these 28 patients had recurrent stricture. Ascending urethrogram was done in all patients to diagnose presence of stricture. The procedure was performed using 550 μ laser fiber and 20 W energy. It consist of deep cutting at 12 o clock position followed by vaporization and resection of circumferential scar tissue. A 16 Fr. Foleys catheter was placed postoperatively for 1-3 days depending on depth of spongio-fibrosis. At 2 weeks all patients underwent urethral calibration & were taught CIC with 16 Fr. Tiemen's catheter. Recurrence was defined as either failure to do CIC due to urethral narrowing or recurrence on symptoms. RESULTS No major intra-operative or post operative complications. One patient had extravasation of normal saline in the peno-scrotal area. At mean follow-up of 29.4 months (0 – 73 months), 14 patients (19.44 %) developed recurrent stricture.Remaining 48 patients were stable with CIC. 10 patients were lost for follow-up. CONCLUSIONS Holmium laser circumferential ablation of urethral stricture appear to have promising early results. It is a safe, effective and minimally invasive therapeutic modality for male urethral stricture. However further randomized studies with long follow-up are necessary to determine the clinical value of this modality in treatment of urethral stricture. Mumbai, India© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e540-e541 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hemendra Shah More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Extramammary Paget’s disease in Korea: its association with gastrointestinal neoplasms

Extramammary Paget's disease (EMPD) most commonly occurs in the perineal and genital areas of elderly people. The current treatment of choice is adequate surgical excision. Between 1990 and 2007, 28 patients (27 men and one woman) with EMPD were treated at Asan Medical Center, Seoul, Korea, by wide local excision (WLE) with a 2- to 3-cm normal skin margin. "Carcinoma in situ" (CIS) was defined as confinement of Paget cells to the epithelium, whereas "invasive carcinoma" was defined as infiltration of Paget cells into more than dermal connective tissue. Of the 28 lesions, 21 (75%) were located in the penoscrotal area. Six (21.4%) patients had associated gastrointestinal neoplasms, three with associated gastrointestinal malignancies and four with synchronous colorectal adenomas, including one with both. Surgical procedures included WLE with primary repair in 13 patients (46.4%), WLE with skin graft in 12 (42.9%), WLE with skin graft and Gracilis muscle transposition in two (7.1%), and combined abdominoperineal resection and distal gastrectomy in one (3.6%). Four patients (14.3%) also underwent inguinal lymph node dissection, with three found to have lymph node metastases. Of 11 patients with invasive carcinoma, three (27.3%) had lymph node metastases, compared with none of 17 patients with CIS. Patients with lymph node metastases showed a significantly lower disease-specific survival rate (P = 0.008). Patients with invasive carcinoma tended to have a lower disease-specific survival rate (P = 0.087). EMPD in Korea showed an absolute male predominance and an association with gastrointestinal neoplasms. Lymph node metastasis significantly affected, and depth of invasion tended to affect, disease-specific survival rate.

Neuroanatomy of the male urethra and perineum.

To describe the topography of the perineal nerves from their pudendal origin to their course into the male genitalia, with specific attention on the course of the perineal nerve along the ventral penis, including branches into bulbospongiosus muscle and corpus spongiosum. The study comprised 18 normal human fetal penile specimens at 17.5-38 weeks of gestation (determined by fetal heel-to-toe length). Specimens were fixed in formalin, embedded in paraffin wax and serially sectioned at 6 micro m. The penile specimens contained the whole penis from the glans to the crural bodies, beneath the pubic arch and the perineum up to the anal verge. Immunocytochemistry was assessed on selected sections with antibodies against the neuronal markers S-100 and nitric oxide synthase (nNOS). Three-dimensional computer reconstruction of serial sections allowed an in-depth analysis of the neuroanatomy of the fetal penis, perineum and surrounding structures. After the pudendal nerve leaves the pudendal canal it gives rise to the perineal nerve branches in the ischiorectal fossa. Perineal nerves travel alongside the ischiocavernous and bulbospongiosus muscles and before reaching the latter, nerve branches course into the bulbospongiosus muscle. During its pathway within this muscle, fine nerve fibres course into the corpus spongiosum by piercing through the junction of the muscle. At the penoscrotal area, the perineal nerves give branches to the scrotum, funnelling into the interscrotal septum. Perineal nerves continue their pathway over the ventral side of penis covering the ventral surface of corpus spongiosum. Branches of the dorsal nerve of the penis at the junction of corpus cavernosum and corpus spongiosum assemble into a network with the perineal nerves. All perineal nerves from their main trunk at the ischiorectal fossa until their interaction with dorsal nerve of penis at the base of penis were nNOS negative. After the interaction with the dorsal nerve of penis, they become nNOS positive. Integrating neuroanatomical knowledge about the perineal nerves and their communication with the dorsal nerve of penis should facilitate a strategic approach to reconstructive procedures on the penis. Special care should be taken at the junction between the corpora cavernosa and spongiosa, where the dorsal nerve joins the perineal nerve, and at the proximal bulbospongiosus muscle, thereby protecting the fine nerves piercing into the cavernosa spongiosa.

Penoscrotal extramammary Paget's disease: a review of 33 cases in a 20-year experience.

Extramammary Paget's disease in men most frequently involves the penoscrotal area. The uncertainty of the outcome and of the relationship to the underlying adnexal carcinoma and associated internal malignancy still exists. From 1982 to 2001, 33 patients with penoscrotal extramammary Paget's disease were treated and followed up. Therapeutic modalities included carbon dioxide laser ablation (two patients) and local wide excision (31 patients). Split-thickness skin graft (22 patients), local scrotal flap (six patients), and primary closure (three patients) were utilized to reconstruct the penoscrotal defects after local wide excision. An underlying adnexal carcinoma occurred in seven of 33 patients (21.2 percent). The incidence of associated internal malignancy was 9.1 percent (three of 33 patients), including one concurrently and two nonconcurrently associated malignancies. Eight of 33 patients had local recurrence, representing an incidence of 24.2 percent. Three patients (9.1 percent) had distant metastasis and ultimately died of metastatic carcinoma. Of these patients, 31 were grouped according to the degrees of involvement: limited to the epidermis (group 1, n = 14), involvement of the adnexal gland and/or hair follicle (group 2, n = 10), and the presence of an underlying adnexal carcinoma (group 3, n = 7). Local wide excision with subsequent reconstruction by split-thickness skin graft was favored in this series. Patients with an underlying adnexal carcinoma or pathological invasion of the dermis (group 2 or 3) had a worse prognosis than patients without. From this study, it is difficult to address the particular relationship between the outcome and the associated internal malignancy.