From the history of penis reconstruction

The authors present an account of the history of penis reconstruction following a diagnosis of transsexualism as well as after loss due to injury or for oncological reasons. A basic review is presented of the classical as well as microsurgical reconstruction methods.

Primary penile lymphoma: diagnostic difficulties and management options

A 76-year-old man presented with a painless penile ulcer. After an extensive negative workup, CO(2) laser excision was performed with penile reconstruction. Histologic examination revealed an anaplastic, large cell lymphoma with CD30(+) cells. Computed tomography scans of the thorax, abdomen, and pelvis were negative. He received no adjuvant therapy and was without evidence of recurrence after 18 months. We review published reports and discuss the management options for this rare lesion.

[Lymph node metastases in penis carcinoma. Therapeutic options and outcome]

Carcinoma of the penis is a malignant epithelial tumor of ominous prognosis if not adequately treated. To a large extent the probability of positive lymph nodes is determined by the grade of the primary lesion. In turn the number of positive nodes greatly influences the survival. In the past the complications of radical ilioinguinal lymphadenectomy have decreased their timely indication. If delayed lymphadenectomy is performed, the survival rate is reduced by approximately 50% as compared to the results of immediate lymphadenectomy. The modified inguinal lymphadenectomy described by Catalona leads to less complications. If performed without delay it should lead to improved survival in patients with higher stage and high grade penile cancer. Recently suggested employment of adjuvant and neoadjuvant chemotherapy may further enhance the survival.

[19 cases of Paget's disease]

OBJECTIVE

The clinical signs of Paget's disease are similar to those of chronic eczema. The two are often confused, especially extramammary Paget's disease. Only biopsy can help to differentiate them correctly.

METHODS

19 patients with Paget's disease were reviewed with regard to clinical analysis and treatment from 1987 to 1997.

RESULTS

Six patients had breast Paget's disease and 13 had extramammary one. The latter involved scrotum and penis in 11 patients, the groin in 1, and perianal and anal in 1. Follow up showed that 3 patients had recurrences in extramammary patients who had had positive surgical margin biopsy. One patient died of other disease.

CONCLUSIONS

Surgery is the first choice of treatment for Paget's disease either of breast or of extramammary regions. Negative margins must be achieved to prevent local recurrence.

Use of a vertical rectus abdominis myocutaneous flap in bilateral groin dissection for recurrent carcinoma of the penis

We present a 42-year-old man requiring bilateral groin dissection for recurrent squamous cell carcinoma of the penis. Tissue cover was obtained using a pedicled vertical rectus abdominis myocutaneous flap. This case is made interesting by the use of a unilateral flap to cover a large bilateral lower abdominal tissue defect, enabling minimal weakening of the abdominal wall, primary skin closure, and allowing early mobilization and hospital discharge.

[Perineal recurrence of resected penile cancer. A case report]

The authors report an unusual case of perineal recurrence of squamous carcinoma of the penis in a 50-year-old, white man, circumcised during infancy and operated 5 years previously for stage T3N0M0 squamous carcinoma of the penis by total amputation of the penis. Clinical examination revealed a very large, infected perineal tumour associated with bilateral inguinal lymphadenopathy. This stage T4N2M0 tumour was treated palliatively by cystostomy, emasculation with perineal tumour reduction and antibiotics. The patient became afebrile and the infection resolved and was referred to the radiotherapy department for further treatment.

Medical decision making for melanoma of the glans penis

This case report describes a rare presentation of penile melanoma in which 3 successive primaries arose and were operated from an area of melanosis on the glans penis and prepuce. One of the major factors accounting for the poor prognosis of this patient was the long delay in presentation. This was largely due to the patient's reluctance because of the site of the disease. When diffuse melanotic areas are present in the genital region, in particular given the reluctance of patients with skin lesions in this region to present, the index of suspicion should be high with respect to the risk of transformation and an aggressive follow-up policy should be advocated. Treatment guidelines should not significantly differ from the usual approach of cutaneous melanoma.

A case of classical Kaposi's sarcoma of the penis showing a good response to high-energy pulsed carbon dioxide laser therapy

Isolated Kaposi's sarcoma (KS) of the glans penis is rare; only 37 cases are reported in the literature. Treatment of KS consists mostly of old modalities, some old methods in updated improved versions, and some new and experimental therapies. We report a case of isolated classical Kaposi's sarcoma involving multiple sites of the penis in a 54-year-old man who was treated with high-energy pulsed carbon dioxide (CO2) laser therapy, resulting in complete resolution of the lesions and no evidence of recurrence.

Squamous cell carcinoma of the penis and microscopic pathologic margins: how much margin is needed for local cure?

BACKGROUND

Total or partial penile amputation is an effective treatment for invasive squamous cell carcinoma of the penis. The authors evaluated the relation between paraffin section microscopic pathologic margins and local recurrence.

METHODS

Seventeen cases of biopsy proven squamous cell carcinoma of the penis treated with partial or total penectomy were reviewed retrospectively. All resections were performed by one surgeon (K.R.L.). Permanent microscopic pathologic margins and pathologic classification were determined by one pathologist (A.A.R.) using the American Joint Committee on Cancer TNM classification of 1997.

RESULTS

Seven of the 10 patients who underwent a partial penectomy were followed for a mean duration of 33.1 months (range, 3-75 months). The average microscopic pathologic margin was 14.4 mm (range, 0-40 mm) for lesions classified as T1 or greater. Three patients had a microscopic margin < or = 10 mm. There were no local or regional recurrences in this group of patients. The 7 patients who underwent a total penectomy were followed for a mean duration of 25.2 months (range, 5-76 months). There were no local recurrences and only one inguinal recurrence. The average microscopic pathologic margin was 14.8 mm (range, 0-50 mm) for all stages. There were 4 patients who had microscopic pathologic margins < or = 10 mm, and all were free of local disease at the last follow-up.

CONCLUSIONS

None of the 14 patients followed developed local recurrence. Also, no recurrence occurred in 7 patients who had microscopic margins of < or =10 mm. This suggests that local control can be obtained with margins measuring less than the standard 15-25 mm.

[Hemangioma of the glans penis]

The haemangiomas are benign vascular tumors of frequent apparition in infant, but not very much described in penis glans in the literature. We present a case with location in penis glans, in a short age male, that it was treated through conventional surgery with good results. We accomplish a review of this pathology and we make reference to the different ways of treatment today.

Penile stump advancement as an alternative to perineal urethrostomy after penile amputation

PURPOSE

We describe a method for avoiding perineal urethrostomy, and maintaining penile cosmesis and function after penile amputation.

MATERIALS AND METHODS

Penile reconstruction was performed in 1 patient with traumatic total amputation of the penis and 1 undergoing near total penectomy for carcinoma by advancing the penile stump and covering the resultant phallus with rotational full thickness scrotal flaps.

RESULTS

Both patients were able to void while standing, and have intact sensation and erectile capability in the residual neophallus.

CONCLUSIONS

Perineal urethrostomy is not necessary after penopubic penile amputation. Advancement of residual cavernosal tissue and skin coverage with scrotal flaps minimize altered body image, and maintain sensation and normal voiding position.

Free vascularized appendix transfer for reconstruction of penile urethras with severe fibrosis

Despite the development of newer techniques with a free radial forearm tube flaps for phallus reconstruction, severe urethral strictures are still seen in such cases after irradiation or repeated infection because of the paucity of healthy, well-vascularized tissue. For urethral reconstruction in cases with poorly vascularized tissue as well as for total penile creation, a new technique involving a free vascularized appendix transfer combined with a radial forearm osteocutaneous flap was successfully used in two cases. The appendix provides a normal tube structure composed of a muscular tubular layer lined with mucosal epithelium. It has no hair and has rich vascularization. This results in little stricture at the junction with the original urethra, no occurrence of urethral stones, and possible postoperative enlargement of the diameter with changes in catheters. This method will allow a patient with severe fibrosis around the urethra to undergo one-stage phallus reconstruction with minimal complications.

The clinical superiority of continuous exposure versus short-pulsed carbon dioxide laser exposures for the treatment of pearly penile papules

Treatment of pearly penile papules was performed both with a conventional continuous-wave (CW) and a newer generation high energy pulsed carbon dioxide laser. When compared to the short pulsed laser, the CW laser, using relatively low power densities, provided superior hemostasis and improved visualization of the operative field. Despite the increase in thermal injury, wound healing was not compromised. The results of this case report support the CO2 laser in CW mode as the infrared laser treatment of choice for exophytic lesions with increased vascularity.

Penectomy: a technique to reduce blood loss

OBJECTIVES

Hemorrhage is potentially a major complication of partial or total penectomy that may result in the need for blood transfusion. The surgical technique of penectomy was evaluated to determine whether modifications may lead to reduced blood loss.

METHODS

A simple technique was used to minimize blood loss during penectomy. A Penrose tourniquet was used to minimize subcutaneous bleeding, incised urethral edges were oversewn, and a noncrushing vascular clamp was placed across the corporal bodies before transection.

RESULTS

Placement of a noncrushing vascular clamp on the corporal bodies before penectomy greatly reduced blood loss in patients who required either a partial or total penectomy. The procedure was performed in a clear field.

CONCLUSIONS

By modification of the surgical technique of partial and total penectomy, it is possible to minimize the potential complication of hemorrhage.

Conservative surgical therapy for penile and urethral carcinoma

OBJECTIVES

Invasive penile and urethral tumors are traditionally treated with aggressive excision that requires involved organ and adjacent organ sacrifice. An alternative approach seeks to completely excise the tumor with adequate margins while preserving form and function of the organ. We present 6 patients who underwent such organ-sparing surgery.

METHODS

Six selected cases (4 penile and 2 urethral) are presented with operative photographs and pertinent data.

RESULTS

Three distal tumors of the penis were treated with excision limited to the glans with histopathologic findings of verrucous carcinoma, melanoma, and angiosarcoma. One patient with squamous cell carcinoma of the distal shaft refused partial penectomy and underwent a local wedge resection. A patient with locally advanced bulbourethral transitional cell carcinoma (TCC) refused cystourethrectomy and underwent an anterior urethrectomy and perineal urethrostomy. A 48-year-old woman with an adenocarcinoma contained in a very distal urethral diverticulum underwent simple diverticulectomy and excision of distal urethra. Postoperative voiding and sexual function were well preserved. Follow-up was 12 to 48 months. The patient with angiosarcoma died of lung metastases at 48 months with no local disease, and the patient with bulbourethral TCC developed pelvic disease at 12 months with no local recurrence and died of metastases at 25 months.

CONCLUSIONS

Organ-sparing surgery is appropriate in selected patients on the basis of stage and location, high risk of distant failure, and patient disposition. Close follow-up is necessary. Comanagement with reconstructive and oncologic specialists optimizes results and outcomes.

Phantom erection after amputation of penis. Case description and review of the relevant literature on phantoms

BACKGROUND

Perception of a phantom limb is frequent after an amputation of an upper or lower extremity. Phantom penis is reported infrequently.

METHOD

Case description and literature review.

RESULT

The phenomenon of phantom penis followed total penectomy. Several aspects were unusual, particularly the existence with phantom only in the erect state, and associated recrudescence of a preoperative painful ulcer. General features of limb phantoms after amputation are reviewed including a résumé of recent studies of cortical reorganization. The phantom process is analyzed looking for clues to the nature of the underlying neural organization. The puzzle of phantom pain is briefly touched on.

CONCLUSION

The development of the phantom is attributed to activity in the deafferented parietal sensory cortex.

Interstitial brachytherapy in carcinoma of the penis

AIM

Keeping in line with the increasing emphasis on organ preservation, we at the Tata Memorial Hospital have evaluated the role of Ir-192 interstitial implant as regards local control, functional and cosmetic outcome in early as well as locally recurrent carcinoma of the distal penis.

PATIENTS AND METHODS

From October 1988 to December 1996, 23 patients with histopathologically proven cancer of the penis were treated with radical radiation therapy using Ir-192 temporary interstitial implant. Our patients were in the age group of 20 to 60 years. The primary lesions were T1 in 7, T2 in 7 and recurrent in 9 patients. Only 7 patients had palpable groin nodes at presentation, all of which were pathologically negative. The median dose of implant was 50 Gy (range 40 to 60 Gy), using the LDR afterloading system and the Paris system of implant rules for dosimetry. Follow-up ranged from 4 to 117 months (median 24 months).

RESULTS

At last follow-up 18 of the 23 patients remained locally controlled with implant alone. Three patients failed only locally, 2 locoregionally and 1 only at the groin. Of the 5 patients who failed locally, 4 were successfully salvaged with partial penectomy and remained controlled when last seen. Local control with implant alone at 8 years was 70% by life table analysis. The patients had excellent functional and cosmetic outcome. We did not record any case of skin or soft-tissue necrosis. Only 2 patients developed meatal stenosis, both of which were treated endoscopically.

CONCLUSION

Our results lead us to interpret that interstitial brachytherapy with Ir-192 offers excellent local control rates with preservation of organ and function. Penectomy can be reserved as a means for effective salvage.

Surgical management of penoscrotal lymphangioma circumscriptum

Lymphangioma circumscriptum of the penis and scrotum is an unusual entity that may be indistinguishable from genital warts. After confirmation of the diagnosis, a treatment plan consisting of wide excision should be outlined. To lower the chance of recurrence, not only the affected skin but all the subjacent subcutaneous tissue, including the deeper components of the lymphatic malformation just above the deep fascia, should be removed.

[Carcinoma of the penis. The basic principles of the diagnostic and therapeutic guidelines]

Despite the low incidence of penile cancer nowadays, this tumor presents a difficult diagnosis and staging methodology as well as difficult therapeutic options. The author emphasises the clear destruction between superficial and invasive neoplasms. In the latter, the simultaneous treatment of the lymphatic territories is considered of extreme importance.

[Reconstructive phalloplasty]

We examine some surgical techniques proposed for phallic reconstruction. Together with cutaneous flaps, muscle-cutaneous flaps, who present the advantage of more constant results, are progressively listed. We also present a personal technique of phallic reconstruction with double prosthesis: one external, vascular and one internal, for the erection.

[Nd:YAG laser in the treatment of superficial lesions of the penis]

In surgical treatment of benign and malignant lesions of the penis in addition to radicality also the demand of a favourable cosmetic result is stressed. The presented paper evaluates experience with the use of a Nd:YAG laser in condylomata acuminata and carcinoma of the penis. The author operated 51 men with condylomata acuminata of the glans, in 32 the external orifice of the urethra was affected. Treatment was successful in all patients with very good cosmetic results, relapses occurred in 11 patients. The author treated successfully also five patients with carcinoma of the penis classified as TIS and T1. In none of the patients a relapse was observed after a mean follow-up period of 15.4 months.

[A case of scrotal elephantiasis 30 years after treatment of penile carcinoma]

A 67-year-old man visited our hospital with complaints of scrotal swelling associated with occasional febrile episodes. Physical examination disclosed a huge scrotal mass, approximately the size of a child's head, with numerous papillomatous lesions on its surface. His past medical history was significant in that he was diagnosed with penile carcinoma at the age of 35 years old and was treated with partial penectomy followed by radiation and chemotherapy at other hospital. During this admission tumor marker squamous cell carcinoma (SCC) and microbiological tests for mcroflariae were both negative. Ultrasound (US), computed tomographic (CT) scan and magnetic resonance imaging (MRI) revealed markedly thickened scrotal skin and small hydrocele with no evidence of local recurrence of the previous penile carcinoma. A percutaneous cystostomy was created because of chronic urinary retention and possible urine extravasation into the scrotum. Histopathological examination of the biopsy specimen from the scrotal mass demonstrated lymphangiectasia consistent with elephantiasis of the scrotum. Surgical excision of this huge scrotal mass was performed in August 1997. The resected tissue weighed 1,400 g. Convalescene was uneventful. He subsequently underwent perineal urethrostomy in place of the suprapubic cystostomy.

[Treatment of hemangioma of the glans penis using Nd:Yag laser. Apropos of a case]

Hemangioma of urinary tract are unusual, being about 2% of all hemangiomas. We present a case of a glans penis hemangioma. There is controversy concerning their treatment and outcome. Our patient was treated with a Neodymium: Yag laser irradiation, with complete morphological recuperation.