A study protocol for a feasibility randomised controlled trial investigating videoendoscopic radical inguinal lymphadenectomy versus open radical inguinal lymphadenectomy in patients with penile cancer (VELRAD).

BACKGROUND: Penile cancer is a rare male genital malignancy. Surgical excision of the primary tumour is followed by radical inguinal lymphadenectomy if there is metastatic disease detected by biopsy, fine needle aspiration cytology (FNAC) or following sentinel lymph node biopsy in patients with impalpable disease. However, radical inguinal lymphadenectomy is associated with a high morbidity rate, and there is increasing usage of a videoendoscopic approach as an alternative. METHODS: A pragmatic, UK-wide multicentre feasibility randomised controlled trial (RCT), comparing videoendoscopic radical inguinal lymphadenectomy versus open radical inguinal lymphadenectomy. Patients will be identified and recruited from supraregional multi-disciplinary team meetings (sMDT) and must be aged 18 or over requiring inguinal lymphadenectomy, with no contraindications to surgical intervention for their cancer. Participants will be followed up for 6 months following randomisation. The primary outcome is the ability to recruit patients for randomisation across all selected sites and the rate of loss to follow-up. Other outcomes include acceptability of the trial and intervention to patients and healthcare professionals assessed by qualitative research and obtaining resource utilisation information for health economic analysis. DISCUSSION: There are currently no other published RCTs comparing videoendoscopic versus open radical inguinal lymphadenectomy. Ongoing study is required to determine whether randomising patients to either procedure is feasible and acceptable to patients. The results of this study may determine the design of a subsequent trial. TRIAL REGISTRATION: Clinicaltrials.gov PRS registry, registration number NCT05592639. Date of registration: 13th October 2022, retrospectively registered.

Long-term outcomes of penile squamous cell carcinoma in men age ≤50 years old compared with men >50 years old from a single tertiary referral centre: a propensity score matched analysis.

Penile cancer (PeCa) is rare, and the oncological outcomes in younger men are unclear. We aimed to analyse and compare oncological outcomes of men age ≤50 years (y) and >50 years with PeCa. A retrospective analysis of men ≤50 y with penile squamous cell carcinoma managed at a tertiary centre was performed. A propensity score matched cohort of men >50 y was identified for comparison. Matching was according to tumour, nodal stage and the types of primary surgery. Overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and metastasis-free survivals (MFS) were estimated using Kaplan-Meier plots and compared using log-rank tests. Between 2005-2020, 100 men ≤50 y (median (IQR) age, 46 y (40-49)) were identified and matched with 100 men >50 y (median (IQR) age, 65 y (59-73)). 10, 24, 32, 34 men age ≤50 y were diagnosed in 2005-2007, 2008-2012, 2013-2016 and 2017-2020 respectively. Median (IQR) follow-up was 53.5 (18-96) months. OS at 2 years: ≤50 y, 86%>50 y, 80.6%; 5 years: ≤50 y, 78.1%, >50 y, 63.1%; 10 years: ≤50 y, 72.3%, >50 y, 45.6% (p = 0.01). DSS at 2 years: ≤50 y, 87.2%>50 y, 87.8%; 5 years: ≤50 y, 80.9%>50 y, 78.2%; 10 years: ≤50 y, 78%, >50 y, 70.9% (p = 0.74). RFS was 93.1% in the ≤50 y group (vs. >50 y, 96.5%) at 2 year, and 90% (vs. >50 y, 88.5%) at 5 years, p = 0.81. Within the ≤50 y group, 2 years and 5 years MFS was 93% (vs. >50 y, 96.5%), and 89.5% (vs. >50 y, 92.7%) respectively, (p = 0.40). There were no statistical significance in DFS, RFS and MFS in men age ≤50 y and >50 y. PeCa in younger patients is fatal, public awareness and patient education are crucial for early detection and management.

Primary squamous cell carcinoma of the scrotum: Outcomes from a specialist center.

BACKGROUND: Squamous cell carcinoma (SCC) of the scrotum is a rare and aggressive cancer. There are no established guidelines on the management of scrotal SCC. OBJECTIVE: To analyze the clinical management and outcomes of scrotal SCC. PATIENTS AND METHODS: A retrospective analysis of patients diagnosed with primary scrotal SCC over a 10-year period was performed. The type of surgery, tumor stage and histological subtypes, recurrence rate and metastases, cancer-specific mortality (CSM), and other-cause mortality (OCM) were analyzed. RESULTS: Between 2012 and 2022, a total of 10 men were identified with primary scrotal SCC. The median (interquartile, IQR) age was 65.5 (55-77) years. Wide local excision was performed in 9 patients and 1 patient underwent a total scrotectomy. The pathological T-stage was: pT1, n = 3; pT2, n = 1; pT3, n = 5 (50%); pT4, n = 1. Four patients had pathologically positive inguinal lymph nodes and 2 had distant metastatic disease at presentation. At a median (IQR) follow-up of 10.5 (4-31) months 5 patients died, of which 3 died from scrotal SCC. CONCLUSION: Scrotal SCC is extremely rare in the UK with only 10 primary cases identified in our center over the past 10 years. Surgical resection of the tumor and appropriate inguinal node staging are required due to a high proportion of cases which metastasize to the inguinal lymph nodes. PATIENT SUMMARY: Scrotal cancer is rare. 10 cases were diagnosed over 10 years at a single center. Around half had disease spread to the groin nodes or distant organs at presentation. Surgical resection was required in all patients. At the time of analysis, half of the patients are alive. Due to the rarity and aggressiveness of the cancer, management should be carried out within a specialist center.

Outcomes of penile sarcomatoid squamous cell carcinoma from a single tertiary referral centre: a matched cohort study.

OBJECTIVE: To report the oncological survival outcomes of men with penile sarcomatoid squamous cell carcinoma (sSCC). PATIENTS AND METHODS: A retrospective analysis of men with penile sSCC diagnosed between January 2010 and January 2020 in a single centre was conducted. Disease-specific (DSS), recurrence-free (RFS) and metastasis-free (MFS) survival were evaluated. Outcomes were compared with a non-sarcomatoid penile SCC cohort matched to age, type of surgery and tumour stage. Kaplan-Meier plots were used to estimate survival outcomes. RESULTS: In all, 1286 men were diagnosed with penile SCC during the study period and of these 38 (3%) men had sSCC. The median (interquartile range) age and follow-up was 70 (57-81) years and 16 (7-44) months, respectively. Operations performed included: circumcision, one (2.6%); wide local excision, four (10.5%); glansectomy, 11 (29%); partial penectomy, 10 (26%); subtotal/total penectomy, 12 (32%). The Kaplan-Meier estimated 12-, 24- and 36-month DSS was 62% (vs non-sarcomatoid, 67%), 43% (vs non-sarcomatoid, 67%) and 36% (vs non-sarcomatoid, 67%), respectively (P = 0.03). The Kaplan-Meier estimated 12- and 24-month RFS was 47% (vs non-sarcomatoid, 60%) and 28% (vs non-sarcomatoid, 55%), respectively (P = 0.01). The MFS was 52% (vs non-sarcomatoid, 62%) at 12 months and 37% (vs non-sarcomatoid, 57%) at 24 months (P = 0.04). CONCLUSIONS: Sarcomatoid differentiation was associated with a lower DSS, RFS and MFS. Due to the rarity of its incidence and aggressiveness, expert histological review and multidisciplinary management is required in a specialist penile cancer centre.

Outcomes following radical inguinal lymphadenectomy for penile cancer using a fascial-sparing surgical technique.

PURPOSE: To describe our surgical technique and report the oncological outcomes and complication rates using a fascial-sparing radical inguinal lymphadenectomy (RILND) technique for penile cancer patients with cN+ disease in the inguinal lymph nodes. METHODS: Over a 10-year period, 660 fascial-sparing RILND procedures were performed in 421 patients across two specialist penile cancer centres. The technique used a subinguinal incision with an ellipse of skin excised over any palpable nodes. Identification and preservation of the Scarpa's and Camper's fascia was the first step. All superficial inguinal nodes were removed en bloc under this fascial layer with preservation of the subcutaneous veins and fascia lata. The saphenous vein was spared where possible. Patient characteristics, oncologic outcomes and perioperative morbidity were retrospectively collected and analysed. Kaplan-Meier curves estimated the cancer-specific survival (CSS) functions after the procedure. RESULTS: Median (interquartile range, IQR) follow-up was 28 (14-90) months. A median (IQR) number of 8.0 (6.5-10.5) nodes were removed per groin. A total of 153 postoperative complications (36.1%) occurred, including 50 conservatively managed wound infections (11.9%), 21 cases of deep wound dehiscence (5.0%), 104 cases of lymphoedema (24.7%), 3 cases of deep vein thrombosis (0.7%), 1 case of pulmonary embolism (0.2%), and 1 case of postoperative sepsis (0.2%). The 3-year CSS was 86% (95%Confidence Interval [95% CI] 77-96), 83% (95% CI 72-92), 58% (95% CI 51-66), respectively, for the pN1, pN2 and pN3 patients (p < 0.001), compared to a 3-year CSS of 87% (95% CI 84-95) for the pN0 patients. CONCLUSION: Fascial-sparing RILND offers excellent oncological outcomes whilst decreasing the morbidity rates. Patients with more advanced nodal involvement had poorer survival rates, emphasizing the need for adjuvant chemo-radiotherapy.

Management of small testicular masses: outcomes from a single-centre specialist multidisciplinary team.

OBJECTIVES: To report the management outcomes of men with ≤20-mm small testicular masses (STMs) and to identify clinical and histopathological factors associated with malignancy. PATIENTS AND METHODS: A retrospective analysis of men managed at a single centre between January 2010 and December 2020 with a STM ≤20 mm in size was performed. RESULTS: Overall, 307 men with a median (interquartile range [IQR]) age of 36 (30-44) years were included. Of these, 161 (52.4%), 82 (26.7%), 62 (20.2%) and 2 men (0.7%) underwent surveillance with interval ultrasonography (USS), primary excisional testicular biopsy (TBx) or primary radical orchidectomy (RO), or were discharged, respectively. The median (IQR) surveillance duration was 6 (3-18) months. The majority of men who underwent surveillance had lesions <5 mm (59.0%) and no lesion vascularity (67.1%) on USS. Thirty-three (20.5%) men undergoing surveillance had a TBx based on changes on interval USS or patient choice; seven (21.2%) were found to be malignant. The overall rate of malignancy in the surveillance cohort was 4.3%. The majority of men who underwent primary RO had lesions ≥10 mm (85.5%) and the presence of vascularity (61.7%) on USS. Nineteen men (23.2%) who underwent primary TBx (median lesion size 6 mm) had a malignancy confirmed on biopsy and underwent RO. A total of 88 men (28.7%) underwent RO, and malignancy was confirmed in 73 (83.0%) of them. The overall malignancy rate in the whole STM cohort was 23.8%. Malignant RO specimens had significantly larger lesion sizes (median [IQR] 11 [8-15] mm, vs benign: median [IQR] 8 [5-10] mm; P = 0.04). CONCLUSIONS: Small testicular masses can be stratified and managed based on lesion size and USS features. The overall malignancy rate in men with an STM was 23.8% (4.3% in the surveillance group). Surveillance should be considered in lesions <10 mm in size, with a TBx or frozen-section examination offered prior to RO in order to preserve testicular function.

Anterior Urethroplasty for the Management of Urethral Strictures in Males: A Systematic Review.

OBJECTIVE: To identify the currently utilised techniques of anterior urethroplasty described in literature for treatment of urethral strictures, assess the effectiveness of the identified techniques based on re-stricture and complication rates, evaluate, and suggest treatment options based on current evidence for urethral strictures at different locations and of different lengths. METHODS: A systematic review of the MEDLINE, EMBASE, Scopus and Cochrane Library databases from conception up to September 2020 was performed. Primary outcomes included success rates measured via re-stricture rates and the post-operative maximum urinary flow rate (Qmax). Secondary outcomes included patient reported complication rates. RESULTS: A total of 52 papers, including 7 RCTs, met the inclusion criteria. Forty studies described the use of free graft urethroplasty with a median success rate of 86.5% (IQR = 8.1). The best outcomes were found in dorsal onlay buccal mucosa grafting in the penile urethra (86.6%). Twelve described the use of pedicled flap urethroplasty with a median success rate of 76% (IQR = 14.4). Excision and Primary Anastomosis results were reported in 5 studies and showed an overall highest success rate of 89.7% (IQR = 7.0) but involved the shortest strictures of median lengths of 2.1 cm (IQR = 0.48). CONCLUSION: Graft urethroplasty showed optimal outcomes when utilised in penile and bulbar strictures, with dorsal onlay buccal mucosa grafting presenting with the largest evidence base and best outcomes overall. Flap urethroplasty had the highest success rates in panurethral and bulbar strictures, while anastomotic urethroplasty had the greatest success in bulbar and penobulbar strictures.

Clinical features, molecular characteristics and surgical management of primary penile mucosal melanoma based on the European Association of Urology Penile Cancer Guidelines.

Penile mucosal melanoma is an aggressive and rare genital malignancy. The aim of the present study was to review the management and outcomes of a homogenous cohort of patients with histologically confirmed penile mucosal melanoma, at a single specialist centre. A retrospective review of an institutional database identified patients with penile mucosal melanoma over a 10-year period. Patient demographics, histopathological characteristics, type of primary surgery, recurrence, presence of metastatic disease and molecular markers were evaluated. The management of the patients was initially based on the European Association of Urology (EAU) penile cancer guidelines which are primarily for squamous cell carcinoma with inputs from a melanoma multidisciplinary team. Twelve patients with penile mucosal melanoma were analysed. Median [interquartile range (IQR)] age was 69.5 (67.25-81) years. The overall median follow-up (IQR) was 69.5 (20-114) months, while median follow-up for cancer-specific survival (CSS) was 11.5 (8-37) months. Location of the primary tumour was glans penis (n = 7), urethra (n = 2) and inner prepuce (n = 3). The CSS at 1, 2 and 5 years after primary surgery was 33%, 16.7% and 0%, respectively. The recurrence-free survival at 1, 3 and 5 months after the primary surgery was 90%, 67% and 56%, respectively. All patients with metastatic disease or with inguinal lymph node invasion at presentation, died within 25 months of the primary diagnosis. Management based on the modified EAU penile cancer guidelines still led to poor outcomes. We present a management diagram based on our experience.

UK practice for penile prosthesis surgery: baseline analysis of the British Association of Urological Surgeons (BAUS) Penile Prosthesis Audit.

OBJECTIVES: To undertake a prospective multicentre national audit of penile prosthesis practice in the UK over a 3-year period. PATIENTS AND METHODS: Data were submitted by urological surgeons as part of the British Association of Urological Surgeons Penile Prosthesis National Audit. Patients receiving a penile prosthesis (inflatable or malleable) were included as part of a prospective registry over a 3-year period. Data were validated and then analysed using a software package (Tableau). RESULTS: A total of 1071 penile prosthesis procedures were included from 22 centres. The three commonest aetiological factors for erectile dysfunction were diabetes, prostate surgery and Peyronie's disease. Of the recorded data, inflatable penile prostheses were the commonest devices implanted, with 665 devices used (62.1%), whereas malleable prostheses accounted for 14.2% of the implants. Recorded intra-operative complications included urethral injury (0.7%, n = 7), corporal perforation (1.1%, n = 12) and cross-over (0.6%, n = 6). Known postoperative complications were recorded in 9.8% of patients (74/752), with the two most frequently reported being postoperative penile pain (n = 11) and scrotal haematoma (n = 14). CONCLUSION: This baseline analysis is the largest prospective registry of penile prostheses procedures to date. The data show that, over the 3-year collection period in the UK, there are now fewer surgeons performing the procedure, together with a reduction in the number of centres. Peri-operative complications were infrequent, and the rate of implant abortion (e.g. as a result of urethral injury) was very low. Further follow-up data will be required to publish long-term outcomes and patient satisfaction.

Twenty Years of Plaque Incision and Grafting for Peyronie's Disease: A Review of Literature.

INTRODUCTION: Plaque incision and grafting (PIG) is indicated for men with complex or severe penile curvature and, despite a multitude of incision types and grafting materials having been used, no individual technique has proven superiority. AIM: To assess outcomes following PIG and to understand the operative technique. METHODS: A systematic review was performed to find all relevant studies reporting on use of the PIG technique to correct curvature resulting from Peyronie's disease. Studies were included if they had >40 participants, were written in the English language, and no penile prosthesis was implanted. MAIN OUTCOME MEASURES: Primary outcome measures included deformity correction, erectile dysfunction, and degree of penile lengthening/shortening. Secondary outcome measures included satisfaction, reoperation rate, and complications. RESULTS: Twelve studies were included in the quantitative synthesis, which overall report on the results of 1,025 patients. Careful patient selection was critical, with erectile function requiring assessment with the International Index of Erectile Function (IIEF), subjective patient reports, and consideration of whether erections are pharmacologically aided. There was no evidence of superiority in favor of any particular incision type or grafting material, and absorbable sutures were clearly favored. Postoperatively, 4.6%-67.4% required pharmacologically aided erections and 0-11.8% were completely unable to achieve erections. Successful straightening occurred in 80.0%-96.4%, although there was no consistent definition of success. Penile length was unchanged in 44.2%-95.0%; 88.0%-92.0% of the patients were satisfied, and .7%-4.7% required reoperation. Altered sensation occurred in 2.0%-22.5% of patients, of which 80.0%-100.0% was only a transient loss. All outcomes were heterogeneously reported. There are no clear predictive factors for erectile dysfunction following PIG surgery. No single incision type or grafting material has proven superiority. CONCLUSION: PIG is an effective and safe technique for correction of complex or severe penile curvature in terms of satisfaction, length change, straightening, and complications. Rice PG, Somani BK, Rees RW. Twenty Years of Plaque Incision and Grafting for Peyronie's Disease: A Review of Literature. Sex Med 2019;7:115-128.

Redo-urethroplasty for the management of recurrent urethral strictures in males: a systematic review.

PURPOSE: Redo-urethroplasty is a challenge for any genitourethral surgeon, with a number of techniques previously described. This systematic review aims to identify the surgical techniques described in the literature and evaluate the evidence for their effectiveness in managing recurrent urethral strictures. MATERIALS AND METHODS: A systematic review of the MEDLINE and EMBASE databases from 1945 to July 2018 was performed and the urethroplasty procedures were classified according to the site and surgical technique. Primary outcomes included success rates measured via re-stricture rates and the post-op maximum urinary flow rate. Secondary outcomes included complication rates and patient-reported quality of life. RESULTS: A total of 39 identified studies met the inclusion criteria. Twenty-two studies described the use of excision and primary anastomotic urethroplasty with success rates showing wide variability (58-100%). Success rates reported according to the site of the stricture also varied: bulbar (58-100%) and posterior (69-100%) recurrent strictures. One-stage substitution urethroplasty was described in 25 studies with success rates of 18-100%, with the best outcomes reported for bulbar (58-100%) and hypospadias-related (78.6-82%) strictures. Two-stage substitution urethroplasty was described in 12 studies with the success rates of 20-100%, with the best evidence related to hypospadias-related and posterior urethral strictures. The buccal mucosa graft was the graft source with the best evidence for substitution urethroplasty (18-100%). CONCLUSIONS: Trends of effectiveness were identified for redo-urethroplasty modalities in different locations. However, the current levels of evidence are limited to small observational studies, highlighting the need for further larger prospective data to evaluate different techniques used for recurrent urethral strictures.

British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies - testicular trauma.

Male genital emergencies relating to the penis and scrotum are rare and require prompt investigation and surgical intervention. Clinicians are often unfamiliar with the management of these conditions and may not work in a specialist centre with on-site expertise in genitourethral surgery. A series of consensus statements have been developed by an expert consensus comprising British Association of Urological Surgeons (BAUS) Section of Andrology and Genitourethral Surgery together with experts from units throughout the UK. Testicular trauma requires prompt investigation and treatment in order to prevent the development of subfertility or hypogonadism. This series of consensus statements provide guidance for UK practice.

British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies - penile fracture.

Male genital emergencies relating to the penis and scrotum are rare and require prompt investigation and surgical intervention. Clinicians are often unfamiliar with the management of these conditions and may not work in a specialist centre with on-site expertise in genitourethral surgery. The aim of these consensus statements is to provide best practice guidance for urological surgeons based in the UK which are developed by an expert consensus. Penile fracture is a rare emergency and in most cases requires prompt exploration and repair to prevent erectile dysfunction and penile curvature.

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

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

BAUS consensus document for the management of male genital emergencies: priapism.

Male genital emergencies relating to the penis and scrotum are rare and require prompt investigation and surgical intervention. Clinicians are often unfamiliar with the management of these conditions and may not work in a specialist centre with on-site expertise in genitourethral surgery. A series of consensus statements have been developed by an expert consensus committee comprising members of the BAUS Section of Andrology and Genitourethral Surgery together with experts from urology units throughout the UK. Priapism requires prompt assessment and treatment and these consensus statements provide guidance for UK practice.

Open urethroplasty versus endoscopic urethrotomy--clarifying the management of men with recurrent urethral stricture (the OPEN trial): study protocol for a randomised controlled trial.

BACKGROUND: Urethral stricture is a common cause of difficulty passing urine in men with prevalence of 0.5 %; about 62,000 men in the UK. The stricture is usually sited in the bulbar part of the urethra causing symptoms such as reduced urine flow. Initial treatment is typically by endoscopic urethrotomy but recurrence occurs in about 60% of men within 2 years. The best treatment for men with recurrent bulbar stricture is uncertain. Repeat endoscopic urethrotomy opens the narrowing but it usually scars up again within 2 years requiring repeated procedures. The alternative of open urethroplasty involves surgically reconstructing the urethra, which may need an oral mucosal graft. It is a specialist procedure with a longer recovery period but may give lower risk of recurrence. In the absence of firm evidence as to which is best, individual men have to trade off the invasiveness and possible benefit of each option. Their preference will be influenced by individual social circumstances, availability of local expertise and clinician guidance. The open urethroplasty versus endoscopic urethrotomy (OPEN) trial aims to better guide the choice of treatment for men with recurrent urethral strictures by comparing benefit over 2 years in terms of symptom control and need for further treatment. METHODS/DESIGN: OPEN is a pragmatic, UK multicentre, randomised trial. Men with recurrent bulbar urethral strictures (at least one previous treatment) will be randomised to undergo endoscopic urethrotomy or open urethroplasty. Participants will be followed for 24 months after randomisation, measuring symptoms, flow rate, the need for re-intervention, health-related quality of life, and costs. The primary clinical outcome is the difference in symptom control over 24 months measured by the area under the curve (AUC) of a validated score. The trial has been powered at 90% with a type I error rate of 5% to detect a 0.1 difference in AUC measured on a 0-1 scale. The analysis will be based on all participants as randomised (intention-to-treat). The primary economic outcome is the incremental cost per quality-adjusted life year. A qualitative study will assess willingness to be randomised and hence ability to recruit to the trial. DISCUSSION: The OPEN Trial seeks to clarify relative benefit of the current options for surgical treatment of recurrent bulbar urethral stricture which differ in their invasiveness and resources required. Our feasibility study identified that participation would be limited by patient preference and differing recruitment styles of general and specialist urologists. We formulated and implemented effective strategies to address these issues in particular by inviting participation as close as possible to diagnosis. In addition re-calculation of sample size as recruitment progressed allowed more efficient design given the limited target population and funding constraints. Recruitment is now to target. TRIAL REGISTRATION: ISRCTN98009168 Date of registration: 29 November 2012.

Priapism in children: a comprehensive review and clinical guideline.

OBJECTIVE: We review the English literature between 1980 and 2013 and summarize the clinical classification, aetiology, physiology, and pathophysiology of paediatric priapism. We propose a clinical guideline for the management of priapism in children. PATIENTS: Male patients aged ≤ 18 years. RESULTS: Priapism, a prolonged penile erection lasting >4 h, is a rare condition in childhood. There are 3 widely accepted types of priapism: 1) ischaemic priapism, the commonest type seen in children; 2) stuttering priapism, recurrent, self-limiting prolonged erections; and 3) non-ischaemic priapism, rare in children, usually due to trauma. Neonatal priapism has also been described. Ischaemic priapism is a urological emergency causing fibrosis of the corpora cavernosa, subsequent erectile dysfunction and penile disfigurement. The commonest causes of priapism in children are sickle cell disease (65%), leukaemia (10%), trauma (10%), idiopathic (10%), and pharmacologically induced (5%). CONCLUSIONS: Priapism in children must be assessed urgently. Rapid resolution of ischaemic priapism prevents permanent cavernosal structural damage and is associated with improved prognosis for potency later in life. Stuttering priapism requires careful counselling for episodic management. Chronic prophylaxis may be obtained using α-adrenergic sympathomimetics, phosphodiesterase type 5 inhibitors and, in sickle cell disease, hydroxyurea. Non-ischaemic and neonatal priapism may generally be treated less urgently.

Treatment of carcinoma in situ of the glans penis with topical chemotherapy agents.

BACKGROUND: The use of topical agents in the treatment of carcinoma in situ (CIS) of the penis has been well described in the literature. Previous studies have been limited by small sample size and imprecise end points. OBJECTIVE: Establish the response rate of 5-fluorouracil (5-FU) and imiquimod (IQ) in the treatment of penile CIS in a large contemporary series in a supranetwork centre. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of all primary and recurrent cases of penile CIS treated with 5-FU and IQ identified from a prospective database over a 10-yr period. Therapy was standardised in all cases with application to the lesion for 12h every 48 h for 28 d. INTERVENTION: 5-FU was the first-line therapy, and IQ was the second-line topical agent. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary end point was defined as complete response (CR; i.e., resolution of lesion), partial response (PR; i.e., lesion reduced in size and or visibility), or no response (NR; ie, no improvement in lesion size and or visibility). The secondary end points included local toxicity and adverse events. No statistical analysis or software was used. RESULTS AND LIMITATIONS: A total of 86 patients were diagnosed with CIS of the penis over the 10-yr period. Forty-four (51%) received topical chemotherapy. The mean follow-up was 34 mo. CR to topical chemotherapy was seen in 25 (57%), PR was seen in 6 (13.6%), and NR was seen in the remaining 13 (29.5%) patients. Local toxicity was experienced by 10% of patients, and 12% had an adverse event following application of 5-FU. The retrospective design and short follow-up were the major limitations of this study. CONCLUSIONS: Topical chemotherapy agents are moderately effective first-line therapy in the treatment of penile CIS. Toxicity and adverse events were few with our treatment protocol. The issues of long-term surveillance and assessment of partial responders remain a challenge. Topical chemotherapy should remain a first-line treatment option for penile CIS.

Case study: the surgical management of angiokeratoma resulting from radiotherapy for penile cancer.

Angiokeratoma is a rare, benign skin lesion and a recognised complication of radiation therapy. Here we describe a case of extensive angiokeratoma of the groin and external genitalia resulting from external beam radiation to that area in a patient with penile carcinoma. Furthermore, we outline the management of this problem by surgical reconstruction.