The role of primary inguinal surgical debulking for locally advanced penile cancer followed by reconstruction with myocutaneous flap

ABSTRACT Purpose: To evaluate surgical complications and oncological outcomes of patients submitted to primary radical inguinal surgical debulking (PRISD) and myocutaneous pediculate flap reconstruction (MPFR) for locally advanced penile cancer (PC). Materials and Methods: Forty-two patients with ulcerated and/or fixed bulky inguinal masses underwent unilateral or bilateral PRISD with MPFR. Tensor fascia lata flap (TFL) was the standard of care for all patients. Additional use of the gracilis flap (GF) was carried out when necessary. Contra-lateral radical inguinal lymphadenectomy (RIL) was conduced when PRISD was performed unilaterally. Surgical complications were analyzed and stratified into minor and major according to the Bevan-Thomas classification. Adjunctive treatments were assessed and oncological outcomes analyzed. Results: Of the 42 patients evaluated, 10 (23.8%) underwent bilateral PRISD and 32 (76.2%) unilateral PRISD with contra-lateral RIL, totaling 84 lymphadenectomies. A total of 62 MPFRs were performed, 52 with TFL and 10 with GF. A total of 53 complications were identified, 49 related to PRISD with MPFR and 4 to RIL. Adjuvant chemotherapy was carried out in 16 patients. Median follow-up was 10.8 months with a median overall survival (OS) of 14.0 months against 6.0 months (p=0.006) for patients submitted to PRISD with adjuvant chemotherapy in relation to surgery alone. Conclusions: PRISD alone for advanced loco-regional PC is unlikely to promote long-term survival, although it can lead to temporary local control of the disease. Despite the feasibility of the procedure, it is related to high incidence of complications. Surgical treatment with adjuvant chemotherapy is associated with improved OS.

Testicular torsion: a modified surgical technique for immediate intravaginal testicular prosthesis implant

ABSTRACT Purpose: The aim of this paper is to propose a modified surgical technique for immediate intravaginal prosthesis implantation in patients undergoing orchiectomy due to testicular torsion, and to evaluate the wound healing process and patient's satisfaction. Material and methods: We prospectively analyzed 137 patients with testicular torsion admitted to our facility between April 2018 and May 2020. Twenty-five patients who underwent orchiectomy were included in this study. Fifteen had a testicular prosthesis implanted at the same time as orchiectomy using a modified intravaginal technique (summary figure) and 10 received implants 6 to 12 months after orchiectomy. Wound healing was evaluated at a minimum of four checkpoints (on days 15, 45, 90 and 180 after surgery). At the end of the study, a questionnaire was administered to measure patients' satisfaction rate. Student's t test was used for comparison of quantitative data between negative vs. positive cultures (p <0.05). The chi-square test was used to verify associations between categorical variables and immediate vs. late prosthesis implantation (p <0.05). Results: Patient's ages ranged from 13 to 23 years (mean 16.44 years). Overall time lapse from symptoms to orchiectomy ranged from 10 hours to 25 days (mean 7.92 days). Only one extrusion occurred and it happened in the late implant group. All wounds were healed in 72%, 88%, 95.8% and 100% of the cases on the 15th, 45th, 90th and 180th days after implant, respectively. At the end of the study, all patients stated they would recommend it to a friend or relative. The only patient that had prothesis extrusion asked to have it implanted again. Conclusion: There was no prosthesis extrusion using the modified intravaginal surgical technique for immediate testicular prosthesis implantation, which proved to be an easily performed and safe procedure that can avoid further reconstructive surgery in patients whose testicle was removed due to testicular torsion.

Findings regarding non-sexual penile fracture in a referral emergency hospital

ABSTRACT Purpose: To describe penile fracture (PF) findings with non-sexual etiology in a referral emergency hospital, with emphasis on demographic data, clinical and intraoperative findings and long-term outcomes. Materials and Methods: Patients with PF of non-sexual cause operated at our institution from January 2014 to January 2019 were submitted to surgical treatment and monitored for at least three months after surgery. Etiology of trauma, epidemiological and clinical presentation data, time to intervention and operative findings were reviewed retrospectively. The evaluation of postoperative erectile function was carried out by filling out the International Index of Erection Function - 5 (IIEF-5). The tool used to assess urinary function was the International Prostate Symptom Score (IPSS) questionnaire. Results: Of a total of 149 patients submitted to surgical treatment for PF, 18 (12%) reported non-sexual etiology. Twelve (66.6%) cases were due to penile manipulation through the act of bending the penis during morning erection, three (16.6%) when rolling over in bed with erect penis, one (5.5%) when embracing the wife during erection, one (5.5%) to laying on the partner with erect penis and the other (5.5%) when sitting on the toilet with an erection. Operative findings were unilateral corpus cavernosum injury in all cases. Only one (5.5%) patient had a partial urethral lesion. Follow-up time varied from 3 to 18 months (mean, 10.1 months). Three (16.6%) patients developed erectile dysfunction six months after surgery. However, all of them responded to treatment with IPDE-5 and reported improvement of erection, with no need for medication, on reevaluation after 18 months. One (5.5%) patient developed penile curvature < 30 degrees. Thirteen (72.2%) patients developed penile nodules. No patient presented voiding complaints during follow-up. Conclusions: PF is a rare urologic emergency, especially with the non-sexual etiology. However, PF should always be considered when the clinical presentation is suggestive, regardless of the etiology. Penile manipulation and roll over in bed were the most common non-sexual causes. These cases are related to low-energy traumas, usually leading to unilateral rupture of corpus cavernosum. Urethral involvement is uncommon but may be present. Early treatment has good long-term clinical outcome, especially when performed in specialized centers with extensive experience in FP.

Lessons learned after 20 years' experience with penile fracture

ABSTRACT Objective: To report our experience over the past 20 years in the diagnosis and surgical treatment of penile fracture (PF). Materials and methods: Between January 1997 and January 2017, patients with clinical diagnosis of PF were admitted to our facility and retrospectively assessed. Medical records were reviewed for clinical presentation, etiology and operative findings. Postoperative complications, sexual and urinary function were evaluated. Results: Sexual trauma was the main etiological factor, responsible for 255 cases (88.5%): 110 (43.1%) occurred with the "doggy style" position, 103 (40.3%) with "man on top" position, 31 (12.1%) with the "woman on top" position and 11 (4.3%) in other sexual positions. The most common findings in the clinical presentation were hematoma, in all cases and detumescence in 238 (82.6%). Unilateral corpus cavernosum injuries were found in 199 (69%) patients and bilateral in 89 (31%) patients. Urethral injuries were observed in 54 (18.7%) cases. Nine (14.7%) patients developed erectile dysfunction and eight (13.1%) had penile curvature. Only two (3.7%) patients had complications after urethral reconstruction. Conclusions: PF has typical clinical presentation and no need for additional tests in most cases. Hematoma and immediate penile detumescence are the most common clinical findings. Sexual activity was the most common cause. The 'doggy style' and 'man-on-top' was the most common positions and generally associated with more severe lesions. Concomitant urethral injury should be considered in cases of highenergy trauma. Surgical reconstruction produces satisfactory results, however, it can lead to complications, such as erectile dysfunction and penile curvature.

Treatment options and outcomes of penile constriction devices

ABSTRACT Purpose: To study the effect of penile constriction devices used on a large series of patients who presented at our emergency facility. We explored treatment options to prevent a wide range of vascular and mechanical injuries occurring due to penile entrapment. Materials and Methods: Between January 2001 and March 2016, 26 patients with penile entrapment were admitted to our facility and prospectively evaluated. Results: The time that elapsed from penile constrictor application to hospital admission varied from 10 hours to 6 weeks (mean: 22.8 hours). Non-metallic devices were used by 18 patients (66.6%) while the other nine (33.4%) had used metallic objects. Acute urinary retention was present in six (23%) patients, of whom four (66.6%) underwent percutaneous surgical cystotomy and two (33.4%) underwent simple bladder catheterization. The main reason for penile constrictor placement was erectile dysfunction, accounting for 15 (55.5%) cases. Autoerotic intention, psychiatric disorders, and sexual violence were responsible in five (18.5%), five (18.5%), and two (7.4%) cases, respectively. The mean hospital stay was 18 hours (range, 6 hours to 3 weeks). Conclusion: Penile strangulation treatment must be immediate through the extraction of the foreign body, avoiding vascular impairments that can lead to serious complications. Most patients present with low-grade injuries and use penile constrictors due to erectile dysfunction. Removal of constrictor device can be challenging. The use of specific tools for achieving penile release from constrictors is a fast, safe and effective method. Patients with urinary retention may require urinary diversion.

Penile refracture: a preliminary report

ABSTRACT Objective: To report our institutional experience with penile refracture, including demographic data, recurrence time, etiology and operative findings in the first and second episodes. Materials and methods: Between January 1982 and September 2017, 281 patients underwent surgical treatment for penile fracture (PF) at our institution. Demographic data, clinical presentation, besides operative findings and follow-up of patients with relapsed PF were retrospectively assessed by reviewing medical records. Results: Of a total of 281 cases of PF operated at our institution, 3 (1.06%) patients experienced two episodes of trauma. Age ranged from 38 - 40 years (mean: 39.3). The recurrence time varied from 45 to 1560 days (mean: 705). Two patients presented the new fracture episode at the same site of the previous lesion, while in the other case the lesion was observed at another site. Conclusion: Recurrent FP is an extremely rare entity. The risk factors for its occurrence are still unknown. Although the lesion of the corpus cavernosum ipsilateral to the scar tissue of the prior FP is more common, contralateral rupture may be present. Nevertheless, prospective studies with larger samples should be conducted.

Sexual complications of penile frature in men who have sex with men

ABSTRACT Objectives: Evaluate the demographic data, etiology, operative findings and results of surgical treatment of penile fracture (PF) in men who have sex with men(MSM) with emphasis on sexual complications. Materials and Methods: We studied 216 patients underwent surgical correction of PF at our hospital. Patients self-identified as MSM were followed for at least 6 months. Demographic data, presentation, operative findings, International Index of Erection Function - 5 (IIEF-5) and the Premature Ejaculation Diagnostic Tool. Results: Of 216 PF cases, 4 (1.8%) were MSM. All cases resulted from sexual activity and all patients reported using the "doggy style" position during anal intercourse. Unilateral or bilateral injury of corpus cavernosum was found in 2 patients each. One (25%) patient had complete urethral injury associated with bilateral corpus cavernosum lesion. During the follow-up period, all patients developed some type of sexual complication. One patient reported penile pain during intercourse. Another patient experienced low sexual desire and premature ejaculation. This patient was also dissatisfied with the aesthetic result of the surgical scar and complained about decreased penis size after surgery. The third case developed delayed ejaculation. The fourth patient experienced mild to moderate erectile dysfunction. This same patient presented with penile curvature. Finally, palpable fibrotic nodules in the operative area were observed in all cases. Conclusions: Sexual activity in the "doggy style" position was the commonest cause of PF in MSM. Sexual dysfunction is always present in gay man after surgery for PF. However, additional studies with larger samples should be coinducted.

Myiasis associated with penile carcinoma: a new trend in developing countries?

ABSTRACT Objectives The aim of this study is to report an unusual form of penile cancer presentation associated with myiasis infestation, treatment options and outcomes. Materials and Methods We studied 10 patients with suspected malignant neoplasm of the penis associated with genital myiasis infestation. Diagnostic assessment was conducted through clinical history, physical examination, penile biopsy, larvae identification and computerized tomography scan of the chest, abdomen and pelvis. Clinical and pathological staging was done according to 2002 TNM classification system. Radical inguinal lymphadenectomy was conducted according to the primary penile tumor pathology and clinical lymph nodes status. Results Patients age ranged from 41 to 77 years (mean=62.4). All patients presented squamous cell carcinoma of the penis in association with myiasis infestation caused by Psychoda albipennis. Tumor size ranged from 4cm to 12cm (mean=5.3). Circumcision was conducted in 1 (10%) patient, while penile partial penectomy was performed in 5 (50%). Total penectomy was conducted in 2 (20%) patients, while emasculation was the treatment option for 2 (20%). All patients underwent radical inguinal lymphadenectomy. Prophylactic lymphadenectomy was performed on 3 (30%) patients, therapeutic on 5 (50%), and palliative lymphadenectomy on 2 (20%) patients. Time elapsed from primary tumor treatment to radical inguinal lymphadenectomy was 2 to 6 weeks. The mean follow-up was 34.3 months. Conclusion The occurrence of myiasis in the genitalia is more common in patients with precarious hygienic practices and low socio-economic level. The treatment option varied according to the primary tumor presentation and clinical lymph node status.

Proteomics analysis of tissue samples from patients with squamous cell carcinoma of the penis and positive to human papillomavirus

ABSTRACTPurpose:The aim of this study was to identify possible protein biomarkers and/or candidates for therapeutic targets in tissues of patients with SCCP, infected by HPV, applying one dimensional electrophoresis (1DE), followed by direct mass spectrometry (MS) analysis.Materials and Methods:Tissues from 10 HPV positive patients with SCCP and from 10 patients with HPV negative non-tumorous penile foreskins were analyzed applying 1D electrophoresis, followed by analysis with direct mass spectrometry (MS).Results:Sixty-three different proteins were identified in the first group and 50 in the second group. Recognition was possible for 28 proteins exclusively detected in Group 1 and 21 proteins presented only in Group 2.Conclusion:Some proteins in the first group are directly involved in the development of other types of cancer, and therefore, suitable for analysis. Complement C3 protein is a strong candidate for evaluating SCCP patients.

Downregulation of C3 and C4A/B complement factor fragments in plasma from patients with squamous cell carcinoma of the penis

To investigate the use of ClinProt technique to identify cancer markers in plasma of patients suffering from squamous cell carcinoma of the penis (SCCP).

Plasma of 36 healthy subjects and 25 patients with penile carcinoma who underwent surgical treatment between June 2010 and June 2011 was collected and analyzed by the ClinProt/MALDI/ToF technique. Then the peptides were identified from the C8 MB eluted fraction of patients' and control subjects' plasma by LIFT MS/MS.

A cluster of 2 peptides (A=m/z 1897.22 ± 9 Da and B=m/z 2021.99 ± 9 Da) was able to discriminate patients from control subjects. Cross validation analysis using the whole casuistic showed 62.5% and 86.76% sensitivity and specificity, respectively. The cluster also showed very high sensitivity (100%) and specificity (97%) for SCCP patients that died due to the disease. Furthermore, patients with lymph node involvement presented sensitivity and specificity of 80% and 97%, respectively. These two peptides were identified by the proteomic approach based on a MALDI-TOF/TOF as fragments of C3 (m/z 1896.17) and C4a/b (m/z 2021.26) complement proteins.

The results showed that as the disease progresses, the fragments C3 and C4 A/B are less expressed in comparison with healthy subjects. These results may be useful as prognostic tools. .

Epidemiological aspects of penile cancer in Rio de Janeiro: evaluation of 230 cases

PURPOSE: To determine epidemiological characteristics of penile cancer in Rio de Janeiro, its associated risk factors and clinical manifestations. PATIENTS AND METHODS: Between 2002 and 2008 we evaluated 230 patients at three public institutions, considering age, ethnicity, birthplace, marital status, educational level, religion, tobacco smoking, presence of phimosis and practice of circumcision. RESULTS: The ages ranged from 25 to 98 years, with an average of 58.35 years. Of the 230 patients, 167 (72.7 percent) were from the southeast region of Brazil (which includes Rio de Janeiro) and 45 (19.5 percent) were from the northeast of the country. Most patients were white (67.3 percent), married (58.6 percent), smokers (56.5 percent) and had not completed primary school (71.3 percent). The predominant religion was Catholic (74.8 percent). Of the 46 (20 percent) circumcised patients, only 1 (2.2 percent) had undergone neonatal circumcision. Grade I tumors were present in 87 (37.8 percent) of the patients, grade II in 131 (56.9 percent) and grade III in 12 (5.3 percent). Lymphovascular embolization was observed in 63 (27.3 percent) and koilocytosis in 124 (53.9 percent) patients. Of the total, 41.3 percent had corpora cavernosa or corpus spongiosum infiltration, and 40 (17.4 percent) had urethral invasion. Prophylactic lymphadenectomy was performed on 56 (36.1 percent), therapeutic lymphadenectomy on 84 (54.2 percent) and hygienic lymphadenectomy for advanced disease on 15 (9.7 percent) patients. The median time between the lesion onset and clinical diagnosis was 13.2 months. The mean follow up was 28.8 months. CONCLUSION: Most of our patients were born in this state and had low socioeconomic status. Most of them were white men, married, smokers, uncircumcised, of the Catholic faith and in their sixties or older. Their disease was in most cases diagnosed only in the advanced stages.

Penile fracture: experience in 56 cases

OBJECTIVE: The aim of this work is to report the diagnostic and therapeutic options for 55 patients with clinical diagnosis of penile fracture. MATERIALS AND METHODS: The patients were retrospectively assessed between 1982 and 2002. The primary diagnostic evaluation method for 55 patients (56 fractures) was clinical history and physical exam. Ten (17.8 percent) cases required complementary exams. Ultrasound (US) was performed in 2 cases, and magnetic resonance imaging (MRI) in 1 case. Retrograde urethrocystogram was performed in suspicious urethral injury, which happened for 7 patients. RESULTS: Of 56 assessed cases, 49 (89.5 percent) were submitted to surgical exploration, and only 7 were conservatively conducted. Surgical treatment was performed in 48 patients (49 fractures), in these cases, 47 (95.9 percent) presented tunica albuginea disruption and solely 2 (4.1 percent) evidenced lesion of dorsal vein. Ultrasonography confirmed disruption of tunica albuginea in 1 (50 percent) case, and in the other it was not possible to determinate the origin of the lesion, and the patient was submitted to surgical exploration, which confirmed the condition. MRI was used only in 1 case, confirming the lesion. Among 7 patients submitted to conservative management, until now, 3 (42.8 percent) required surgical intervention to correct penile chordee. CONCLUSIONS: Penile fracture is an entity of eminently clinical diagnosis, which management should be surgical and immediate, avoiding thus complications related to erectile dysfunction. When suspecting an associated urethral injury, Urethrocystogram is recommended. In cases where there is diagnostic uncertainty, ultrasound and/or MRI may be used to reveal the condition