Hyaluronic acid and urology: a systematic review and meta-analysis.

INTRODUCTION: The use of hyaluronic acid as a nonsurgical treatment for various conditions within urology has been of great interest in recent literature. OBJECTIVES: In this study, we aimed to provide an updated review and analysis of the current state of hyaluronic acid use in urology, characterize its adverse effects, and briefly discuss future directions of research for hyaluronic acid in urology. METHODS: PubMed searches were run utilizing multiple terms, including "hyaluronic acid," "penile," "augmentation," "Peyronie disease," "premature ejaculation," and "cosmetic urology," among other related iterations. Relevant data extracted included International Index of Erectile Function score, intravaginal ejaculatory latency, glans circumference, penile girth, and plaque size. We also included studies which reported on complications of hyaluronic acid injections. Aggregated analysis was performed on studies with complete pre and post injection data at time closest to 6 months postinjection. RESULTS: A total of 33 studies met our inclusion criteria. Studies had marked heterogeneity in design, but most reported positive results. A total of 16 studies were included in our analysis. Intravaginal ejaculatory latency, penile girth, glans circumference, and International Index of Erectile Function were all increased on a fixed-effects model. Reduction in plaque size was not significant (P = .069). Complications were rare. CONCLUSION: Literature on hyaluronic acid for urologic issues demonstrates promising results; however, the quality of studies was variable. Our analysis of these studies largely corroborates these findings; however, the results are limited by the data available. Hyaluronic acid may be promising, but we highly implore standardization of study regimens in randomized controlled trials.

Combined Treatment of Tunnelled Composite Anterior-Lateral Inguinal Skin Flap, Buccal Mucosal Graft and Hyperbaric Oxygen Therapy for Catastrophically Lost Penis after Circumcision.

BACKGROUND: Catastrophic loss of the penis following post-circumcision necrosis is a rare and devastating complication. Treatment options are limited, and the process is highly challenging. This study aims to report the successful application of our combined treatment approach for a 6-year-old patient who experienced total penile loss due to progressive necrosis 1 year after circumcision. METHODS & RESULTS: Following penile degloving, proximal penile mobilisation and separation and reshaping of the corpora were performed. The penile shaft was covered with a tunnelled composite anterior-lateral inguinal skin flap. Glanuloplasty was performed using a left buccal mucosal graft, followed by 10 sessions of hyperbaric oxygen therapy. At 1.5 months postoperatively, urethral dilation was performed once because of minor voiding difficulties. At 10 months postoperatively, the patient had excellent voiding function and no additional complaints. The patient expressed high satisfaction with the outcome and is still under close follow up. CONCLUSIONS: A standard treatment for serious complications such as necrosis and total penile loss has not been established yet. Although scrotal skin flap is a straightforward technique, it was not preferred in our case because of fibrosis following scrotal necrosis and potential risk of hair growth. The developed approach could be an effective alternative to other techniques.

Risk of relationship separation in men with Peyronie's disease in a matched Swedish cohort.

Peyronie's disease (PD) has detrimental effects on the quality of life, mental health, sexual functioning and several other aspects that increase the risk of relationship problems. However, no study to date has assessed the risk of relationship separation in med with PD. Herein, we utilized data from Swedish national registers to examine the risk of relationship separation in men with PD. We conducted a matched cohort study on men born 1933-1992, followed from 1997 to 2013. PD was defined as a physician-assigned diagnosis according to the International Classification of Diseases, Tenth version. Each man with PD (n = 8020) was matched with 10 comparison men. We defined relationship separation as (1) ever separated, and (2) separation rate. We used log-linear regression to estimate the risk ratio, and rate ratio of relationship separation. We adjusted for matching variables (birth year and country of birth), and an indicator of each follow-up year. We found that men with PD had a 13% increased risk of relationship separation (risk ratio 1.13, 95% confidence interval [CI] 1.08-1.17). The rate of relationship separation events, measured on a yearly basis, was increased by 18% (rate ratio 1.18, CI 1.12-1.24), and remained similar when adjusting for follow-up year and socio-economic status.

New histological risk grading system for prediction of lymph node metastasis in patients with penile cancer.

Inguinal lymph node surgery is a standard treatment for penile cancer patients with intermediate or high risk for lymph node metastasis (LNM) according to European Association of Urology (EAU) risk grading. We are proposing a more objective histological prognostic grading system for inguinal LNM in these patients. We assessed worst pattern of invasion, lymphocytic host response, lymphovascular invasion, and perineural invasion in a population-based cohort of 306 penile cancer patients. Patients were classified into low, intermediate, and high risk for inguinal LNM. There was a significant association both between risk groups and pT stage (p < 0.001) and between risk groups and LNM. Univariate logistic regression showed 25.43 times higher odds of LNM for patients in the intermediate risk group compared with the low risk group (odds ratio (OR) 25.43; 95% confidence interval (CI): 5.94-108.97) and a 177.13 times higher odds in the high risk group compared to the low risk group (OR 177.13; 95% CI: 40.09-782.51). When comparing our histological risk grading with the EAU grading, we found a higher sensitivity, of 51.28% (95% CI: 45.68-56.88) versus 37.09% (95% CI: 31.68-42.50), as well as a higher area under the curve (0.86; 95% CI: 0.81-0.89; versus 0.65; 95% CI: 0.58-0.71) with our grading system. While our grading classified 111 patients as low risk, only 31 were considered low risk for LNM according to the EAU risk classification. The new histological risk grading system shows a higher sensitivity and includes a higher number of patients in the low risk group in whom lymph node surgery could be avoided, reducing morbidity and costs.

Selective Histopathology Examination for Circumcision Specimens: A Retrospective Observational Study.

Background Circumcision is a widely performed surgical procedure all over the globe. This can be for religious, cultural, or medical reasons. Routine histological examination of circumcision specimens is a standard practice in many healthcare systems, despite the relatively low incidence of premalignant or malignant lesions. The primary objective of this study was to evaluate the necessity of routine histopathological examination of foreskin specimens following adult circumcision. Secondary objectives included determining the frequency of malignancy in these specimens, comparing malignancy rates between clinically suspicious and non-suspicious cases, and assessing the correlation between preoperative clinical suspicion and histopathological findings. Aim This study aimed to evaluate the necessity of routine histopathological evaluation for the foreskin after circumcision. We investigated the frequency of malignancy upon histopathological examination, in clinically suspicious cases compared to non-suspicious cases. Method A retrospective observational study was conducted at the Royal Bournemouth Hospital, analyzing data from 334 consecutive adult male patients who underwent circumcision between January 2012 and December 2016. The cohort was retrospectively divided into two groups: those with preoperative suspicious clinical features and those without it. Clinical records on electronic patient records (EPR) were used for follow-up and to identify the percentage of malignancy after final histopathological examinations in both groups. Results Among the 334 patients, only nine patients (2.7%) were deemed as having suspicious clinical features preoperatively, of which, only three (0.9% of the total study sample) showed malignancy upon histological examination. The other six patients in this group were found to have balanitis xerotica obliterans (BXO). The other 325 patients (97.3%) were without clinically suspicious lesions preoperatively, and none were found to have any malignant lesions upon histopathological examination. Conclusion The low incidence of malignancy in circumcision specimens indicates that routine histological examination may not be essential for all cases. Among 334 samples, only three (0.9%) were malignant, and all were clinically suspected. Routine histopathological examination of the remaining 331 cases did not impact management or follow-up. Selectively submitting specimens for histology based on clinical suspicion could reduce opportunity costs and time, optimize resource allocation, and maintain appropriate diagnostic evaluation.

The value of electrophysiological testing in the adjunctive diagnosis of premature ejaculation.

BACKGROUND: Although the four-class system of classifying premature ejaculation (PE), including lifelong PE (LPE), acquired PE (APE), natural variable PE (NPE), and subjective PE (SPE), has existed for many years, objective classification standards in clinical practice are lacking. AIM: In this study, we sought to investigate the use of electrophysiologic parameters to assist in the classification of PE, thereby guiding subsequent treatment. METHODS: From July 2023 to April 2024, 187 study participants were enrolled. For each participant, the biological sensory threshold (BST), penile sympathetic skin response (PSSR), and dorsal nerve somatosensory evoked potential (DNSEP) were recorded. OUTCOMES: The differences in the PSSR latencies (PL) and DNSEP latencies (DL), the PSSR amplitudes (PA) and DNSEP amplitudes (DA), and the BST were compared among the LPE, APE, SPE, NPE, and healthy control (HC) groups. RESULTS: The participants were divided into the LPE (46 cases), APE (53 cases), SPE (20 cases), NPE (33 cases), and HC (35 cases) groups. The results showed shorter latencies of the PSSR (PL) and DNSEP (DL), larger amplitudes of the PSSR (PA) and DNSEP (DL), and smaller BST in the LPE group than in the NPE, SPE, APE, and HC groups (P < .05). In addition, the larger PA and shorter PL in the APE group than in the NPE and HC groups (P < .05). However, the electrophysiological parameters were not significantly different among the NPE, SPE, and HC groups (P > .05). In addition, PL <1262.0 milliseconds and DL <41.85 milliseconds were strong predictors of LPE, 1262.0 milliseconds < PL <1430.0 milliseconds was a predictor of APE, and PL >1430.0 milliseconds suggested possible SPE or NPE. CLINICAL IMPLICATIONS: Analysis of the electrophysiological parameters of PE may be helpful for classification and treatment. STRENGTHS AND LIMITATIONS: No previous study, to our knowledge, has analyzed the electrophysiological parameters of the four types of PE. The main limitation is the small sample size. CONCLUSION: APE is characterized by increased sympathetic excitability, whereas LPE is characterized by increased penile sensitivity and increased sympathetic excitability. However, penile sensitivity and sympathetic excitability in SPE and NPE patients may not differ significantly from normal.

Imaging findings in suspected penile fracture: alternative diagnoses and surgical correlation.

OBJECTIVES: The primary objective is to compare the imaging and surgical findings in a cohort of patients with suspected penile fracture (PF). METHODS: Retrospective cohort study of all patients with suspected PF over an 11-year period at a tertiary referral andrology centre. All dedicated presurgical imaging with ultrasound (US) and MRI was analysed and correlated with intraoperative findings; alternative diagnoses were recorded. RESULTS: 193 patients were included. 104 (54%) had alternative diagnoses to PF including dorsal vein rupture and haematoma. 99 (51%) underwent surgical exploration of which 89 (46%) had PF.US correctly confirmed the presence and marked site of fracture in 92% of cases. MRI was primarily used as a problem-solving tool (13 cases) and demonstrated a more extensive injury than US (12 cases). The reported size of tunical defect on imaging was a median of 7 mm (IQR 4-10) significantly smaller than on exploration, (median 20 mm, IQR 10-30) p < 0.0001. CONCLUSION: US has a high positive predictive value in the confirmation of penile fracture. MRI improves the detection and characterising the extent of injury. Imaging marking informs surgical incision but defect size is under appreciated on all imaging modalities. ADVANCES IN KNOWLEDGE: Penile imaging has a high positive predictive value to not only confirm the diagnosis of PF but to stage the extent of injury and mark the skin, which impacts the surgical technique. Alternative diagnoses to fracture are common and imaging could prevent unnecessary surgical exploration.

Bacillus cereus infection of the penis: an unusual infection.

Background: Bacillus cereus (B. cereus) is a Gram-positive, rod-shaped, motile organism, found in the environment and may exist in contaminated food sources such as reheated rice, vegetables and may lead to gastrointestinal symptoms after ingestion including diarrhea, nausea, and vomiting due to enterotoxigenic and emetic toxins. Non-gastrointestinal infections of Bacillus cereus have been reported in the literature, which include cutaneous and non-cutaneous infections in immunocompetent and immunocompromised individuals. Case presentation: A 38-year-old man presented with a one-week history of penile swelling and redness that started after an episode of severe diarrhea and vomiting, which soiled his genital region few hours after vigorous intercourse with his wife. This has led to infection of the penile skin by an unusual organism: Bacillus (B.) cereus. The patient was treated using fucidic acid ointment applications for 2 weeks achieving complete recovery. Clinical discussion: The recovery of B. cereus from the penile infection in our patient reveals the first case of such an unusual infection, though this pathogen has been reported to cause a wide range of non-GI tract infections, which include bacteremia, meningitis, endocarditis, endophthalmitis, pneumonia, and soft tissue diseases. Virulence factors allow this organism to induce diarrhea in addition to having dermonecrotic, cytotoxic, hemolytic properties resulting in a wide range of dermatologic presentations. Conclusion: The authors report a unique case of penile skin infection caused by B. cereus, an unusual culprit for an uncommon presentation successfully treated with fucidic acid ointment. This is the first case in literature describing such an entity.

Relationship between NLR and penile squamous cell carcinoma: a systematic review and meta-analysis.

OBJECTIVE: We conducted this study to summarize the results of studies reporting the role of NLR (neutrophil to lymphocyte ratio) in PSCC (penile squamous cell carcinoma). METHODS: This meta-analysis was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria. A systematic search was conducted on PubMed, Scopus, and web of science up to March 10, 2023. Fourteen studies were included in the review. The NOS (Newcastle-Ottawa Scale) was used to determine the quality of the included studies. This meta-analysis was conducted on the studies reporting the relationship between NLR and survival using HR (hazard ratio) and 95% CI (confidence interval). RESULTS: There was a significant association between NLR levels and the prognosis, nodal stage, and anatomical tumor stage of PSCC patients. In the meta-analysis of the association of NLR with survival, NLR level was significantly associated with lower cancer-specific survival (HR = 3.51, 95% CI = 2.07-5.98, p < 0.001) and lower disease-free survival (HR = 2.88, 95% CI = 1.60-5.20, p < 0.001). However, NLR was found to have no association with the stage, grade, location, and size of the tumor. CONCLUSION: NLR has a significant diagnostic and prognostic value in PSCC.

Hybrid Bladder Tumor: Urothelial Carcinoma With Squamous Cell Differentiation, Urothelial Sarcomatoid Carcinoma, and Concurrent Primary Mucinous Adenocarcinoma With Metastasis to the Penis.

The most common histological variants of bladder cancer include urothelial, squamous, and adenocarcinoma. In high-grade, invasive urothelial carcinoma, divergent differentiation can be observed, including glandular, squamous, trophoblastic, and small-cell types. Urothelial sarcomatoid carcinoma is characteristic of advanced carcinomas and is considered a possible common end route for all epithelial carcinomas. Adenocarcinoma of the bladder refers exclusively to true glandular carcinomas. Hybrid tumors are extremely rare and consist of more than one tumor type within the total tumor mass. Penile metastases are extremely uncommon, and there are no reported cases of metastatic adenocarcinoma of the bladder in the literature.

Preputial urethrostomy in a cat with suspected glandular hypospadias: case report and literature review.

Case summary: An 11-year-old neutered male Turkish Angora cat was referred for obstructive feline lower urinary tract disease (FLUTD). On physical examination, the penis was curved at the tip and had a smaller than normal urethral opening proximal to the end, consistent with singular glandular hypospadias with a dorsal penile curvature. Because of its recurrent obstructive FLUTD history and inability to catheterise the urethra, a preputial urethrostomy (PRU) was performed. The PRU resolved the clinical signs with no clinical recurrence and no short- or long-term complications. Relevance and novel information: To the authors' knowledge, this is the first description of singular glandular hypospadias in a cat. In addition, this is the first time feline hypospadias has been reported to occur with obstructive FLUTD and to be treated by preputial urethrostomy.

Penile compression devices for the treatment of urinary incontinence: current status and future prospects.

INTRODUCTION: Urinary incontinence (UI), especially stress UI, is common after prostatectomy. Penile compression devices (PCDs) may be a safe, tolerable option for conservative management in men who are not candidates for or not interested in surgical intervention for their UI. AREAS COVERED: This article examines the epidemiology of post-prostatectomy urinary incontinence (PPI), and options for management. All available studies on PCDs are explored, including those on biomechanics, safety, tolerability, and user experience. History, availability of PCDs, and areas for future development are discussed. EXPERT OPINION: PCDs are an option for conservative management of PPI. They are recommended for those men without impairment in cognition, dexterity, or sensation. They should be worn for short periods of time and are best used during situations when incontinence might be precipitated. Overall, data suggest they are well tolerated and effective when tested, but large randomized comparative trials and studies of long-term use with relevant patient reported outcome measures are lacking. More studies are needed on commercially available PCDs. Biomechanical studies suggest that there are superior designs and materials both for efficacy and tolerability. With an aging population, and more older men going for prostate surgery, a larger market for these devices is likely.

Outcomes of Intraoperative Frozen Section Examination of Surgical Resection Margins of the Penis in Penile Cancer.

INTRODUCTION: Frozen section examination (FSE) of the tumor resection margins is important during penile-preserving surgery (PPS) in penile cancer. The margin status will impact on how much penile or urethral tissue is excised. We aim to evaluate the outcomes of intraoperative FSE of resection margins in PPS. PATIENTS AND METHODS: A retrospective analysis of patients with penile squamous cell carcinoma (SCC) who underwent a FSE of resection margins between 2010 and 2022 was conducted. FSEs were compared with the final histopathological analysis and the Diagnostic Testing Accuracy (DTA): sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated. RESULTS: Overall, 137 FSE were performed. The median (IQR) age was 65 (53-75) years. 118 (86.1%) patients had negative FSE margins, 16 (11.7%) had positive FSE margins and 3 (2.2%) had equivocal (atypical cells) results. The sensitivity, specificity, PPV, NPV and diagnostic accuracy of penile FSE were 66.7%, 100%, 100%, 93.2% and 94% respectively. 18 patients underwent further resection in the same episode due to a positive or equivocal FSE and 12 (66.7%) achieved negative margins. Limitations include the retrospective nature of the study and lack of control arm to compare with. CONCLUSIONS: Intraoperative FSE performed at our center for the assessment of penile SCC margins is 66.7% sensitive and 100% specific. FSE should be considered in PPS, as it's an essential and a reliable diagnostic tool in minimizing over-treatment.

Molecular characterization of metastatic penile squamous cell carcinoma in developing countries and its impact on clinical outcomes: LACOG 2018 translational study.

BACKGROUND: Penile squamous cell carcinoma (PSCC) is a rare malignancy. However, in developing countries the incidence rate is higher. The understanding of molecular alterations is essential for evaluating possible targets for more effective systemic therapies. METHODS: We retrospectively collected clinical data of metastatic PSCC (mPSCC) patients who had received at least one prior systemic treatment from 3 Brazilian hospitals. Tumor samples were evaluated using the next-generation sequencing (NGS) Foundation One DX and immunohistochemistry (IHC). The objective was to identify and describe somatic genomic alterations known to be functional or pathogenic and their association with survival outcomes. RESULTS: Twenty-three patients were identified, 22 and 18 patients had tumor samples analyzed by IHC and NGS, respectively. PD-L1 expression (CPS ≥ 1%) was positive in 14 patients (63.6%). Regarding the genomic alterations, 16 patients (88.9%) had some clinically relevant genomic alterations. TP53, TERT, CDKN2A, PIK3CA, NOTCH1, and CDKN2B loss were identified in 66.7%, 50%, 50%, 33.3%, 27.8%, and 22.2% of the patients, respectively. No MSI or TMB high (≥10 mutations/MB) cases were identified. NOTCH1 mutation was identified only in HPV-negative patients and it was associated with worse OS (yes: 5.5 vs no: 12.8 months, P = .049) and progression-free survival (yes: 5.5 vs no: 11.7 months, P = .032). CONCLUSION: This study demonstrated that molecular alterations in mPSCC from developing countries are similar to those from developed countries. Predictive biomarkers for immunotherapy response such as TMB high or MSI were not identified. Specific gene mutations may identify patients with worse prognoses and open new avenues for therapeutic development.

A meta-analysis of Chinese men's penile size in a global context.

BACKGROUND: Penile size is a topic of significant interest among men and healthcare professionals. However, data on adult male penile dimensions in China are scarce, hindering clinical counseling and research. This study aimed to establish normative data for Chinese penile size and compare it with a global reference population. METHODS: We conducted a meta-analysis of published studies on penile size, focusing on Chinese and international data. Studies from East and Southeast Asia were excluded to minimize regional confounding factors. The analysis included 23 Chinese studies encompassing 34,060 men aged 16-57 years, and 19 international studies encompassing 15,216 men aged 16-91 years. Penile length and circumference were assessed in both flaccid and erect states. RESULTS: This study established the first nomogram and percentile distribution chart for adult male penile size in China. The mean flaccid length was 7.42 cm (standard deviation [SD] ± 0.95 cm), and the mean flaccid circumference was 8.54 cm (SD ± 0.62 cm). The mean erect length was 12.42 cm (SD ± 1.63 cm), and the mean erect circumference was 10.75 cm (SD ± 1.34 cm). Compared with the global reference population (flaccid length: 9.09 cm ± 1.51 cm, flaccid circumference: 9.12 cm ± 0.93 cm; p < 0.05 for both), Chinese men exhibited statistically significant shorter flaccid lengths and circumferences. No significant differences were observed in erect length or circumference between Chinese men and the global reference population (p > 0.05 for both). Notably, the growth coefficient during erection (defined as the percentage increase from flaccid length to erect length) was significantly higher in Chinese men (67.39%) compared with the global average (43.45%; p < 0.05), supporting the hypothesis of a proportionally greater increase in shorter penises. CONCLUSIONS: This study provides novel and comprehensive data on penile size in Chinese men. Compared with a global reference population, Chinese men exhibited shorter flaccid penises but a higher proportional increase upon erection. These findings may be of value for clinical counseling and future research on penile size variations. The newly developed nomogram and percentile chart can serve as a valuable tool for both patients and healthcare professionals.

A case of a lidocaine intoxication of a 12 week old boy due to a circumcision in a domestic setting - clinical, toxicological and forensic aspects.

Lidocaine is a local anaesthetic commonly used during circumcision for dorsal penile nerve block (DPNB). We describe a case of a 12-week-old infant who presented generalized seizures due to local anesthetic systemic toxicity after Lidocaine administration for circumcision in a non-hospital setting. Serum concentrations of Lidocaine (16.4 mg/L) and its main active metabolite monoethylglycinexylidide (MEGX, 1.36 mg/L) were determined by HPLC-DAD, in a sample collected shortly after administration, which were higher than in comparable cases reported in literature. The reason for the overdose was assumed to be accidental systemic application. Due to suspicion of an improperly performed circumcision and bodily harm, police was involved and a clinical forensic examination was carried out. Here, we present analytical, clinical and forensic aspects of this case.

Risk factors for distant metastasis and prognosis of the penile cancer with distant metastasis.

Background: Penile cancer (PC) is a rare malignant tumor, whose distant metastasis (DM) is associated with the poorest outcomes. The risk factors associated with DM and prognosis of the PC with DM remain elusive. This study was aimed at investigating risk factors associated with DM and constructing prediction models of PC with DM. Methods: This study analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database over a period of 2000-2020, including clinical characteristics such as age, marital status, tumor size, Tumor Node Metastasis (TNM) staging, and treatment information. Utilizing univariate and multivariate logistic regression, alongside cox regression analysis, we identified independent risk factors for DM and prognosis in the total cases and the cases with DM. Nomograms were developed for predicting DM and prognosis in PC patients. Results: Enrolling 1,488 cases, our study identified tumor size and N stage as independent predictors of DM. The predictive nomogram for DM achieved an area under the curve (AUC) of 0.904. Notably, the 1-, 3-, and 5-year cumulative survival rates for PC with DM were 35%, 17%, and 13%, respectively, with larger tumor size associated with prognosis of PC cases with DM. This study verified a correlation between advanced age and TNM stage, as well as chemotherapy with the poor PC prognosis. The nomogram yielded 0.72, 0.69 and 0.69, in predicting 1-, 3-, and 5-year overall survivals (OS), while 0.73, 0.70 and 0.69 in predicting 1-, 3-, 5-year cancer specific survivals (CSS), respectively. Conclusions: This study investigated risk factors of PC with DM. Also, nomograms for predicting DM, OS and CSS of PC patients were developed.

The surgical technique and protocol for dynamic sentinel node biopsy for penile cancer at a Southeast Asian regional hospital.

Lymph node status is a key prognostic factor in penile cancer. The European Association of Urology (EAU) recommends intermediate-risk (pT1a, Grade 2) or high-risk (pT1b or greater) penile cancer patients with clinically non-palpable inguinal lymph node (cN0) to undergo either an invasive bilateral modified inguinal lymph node dissection (ILND) or dynamic sentinel node biopsy (DSNB). DSNB has been reported to have acceptable false negative rates, and lower rates of long-term morbidity compared to ILND. We developed a protocol for DSNB at a regional hospital in Singapore that was adopted from St James's University Hospital, Leeds Teaching Hospitals Trust. Four patients with cN0 penile cancer underwent DSNB between November 2021 and October 2022 according to this protocol. Our surgical technique and protocol are described. The patients' oncological characteristics and their outcomes were evaluated. In this small case series, there was no complication attributable to the performance of DSNB, and there was no groin that was documented to be false negative over a median follow up of 15.5 months (range, 12 to 22 months). Using our protocol, 5 of 8 groins (62.5%) were able to avoid ILND in the cN0 setting. We recommend the adoption of DSNB for the surgical staging of inguinal lymph nodes for patients with intermediate to high-risk penile cancer and non-palpable inguinal nodes due to its significantly lower risks of long-term morbidity compared to ILND. Appropriate specialist training and a multi-disciplinary team is vital to ensure the success of the procedure.

Creation of a Novel Classification System (PTNM) for Peyronie's Disease and Penile Curvature Using Evidence-Based Criteria.

PURPOSE: Our goal was to identify new Peyronie's disease (PD) subtypes, non-PD penile curvature classifications, and define active (acute) vs stable (chronic) phases of disease using evidence-based analyses. MATERIALS AND METHODS: A retrospective review was performed of 1098 men who presented with penile deformity, including subjective standardized and nonstandardized questionnaires and objective measures. A second cohort of 719 men who were sent a mailed survey was also utilized for the relapsing/remitting subtype. Statistical analyses were performed to identify clusters of disease characteristics representative of distinct PD and non-PD categorizations, including sensitivity/specificity analyses and subtype comparisons. RESULTS: Comparative analyses identified 4 distinct subtypes of PD: (1) classical and nonclassical, (2) calcifying-moderate/severe calcification, (3) progressive-subjective worsening following disease onset, and (4) relapsing/remitting-reactivation following ≥ 6 months of stability. Additional, non-PD categorizations included congenital (lifelong), maturational (developed around puberty), and trauma induced. Statistical analyses demonstrated unique profiles among each category. Penile pain was not found to be a reliable predictor for disease progression or stability. Stable phase disease (historically "chronic") was variably defined by subtype: classical (≥3 months); progressive, calcifying, or trauma induced (≥12 months + ≥3 months stable OR ≥6 months stable). Similarly, PD subtypes may be assigned at ≥ 3 months following disease onset. A PTNM staging system is proposed to help communicate disease states, in which P = PD component (Ca-calcifying, Cl-classical, P-progressive, R-relapsing/remitting, U-undifferentiated), T = trauma component (0-absent, 1-present), N = non-PD component (C-congenital, M-maturational, U-undifferentiated), and M = mode (0-stable, 1-active); for example, PClT1N0M0 = stable classical PD with prior trauma. CONCLUSIONS: The current study provides an evidence-based proposal for the establishment of new PD subtypes and non-PD curvature categorizations as well as a standardized definition for active vs stable phases of disease.