Penile Calciphylaxis Obscured by Phimosis in an End-Stage Renal Disease Patient: A Case Report.

Penile calciphylaxis is a rare and severe complication primarily observed in patients with end-stage renal disease (ESRD) undergoing dialysis. A 50-year-old man presented with severe penile pain and phimosis. He had a history of hypertension and diabetes mellitus for 10 years, complicated by ESRD and was awaiting a cadaveric kidney transplant. He was on cinacalcet therapy for tertiary hyperparathyroidism. The patient underwent circumcision at which discolouration and necrotic patches involving the glans penis were noted. The histological findings were consistent with calciphylaxis and suppurative inflammation. However, due to persistent severe pain and progressive gangrene, a partial penectomy was performed. This report demonstrates the importance of consideration of calciphylaxis in patients with ESRD when presenting with penile pain, even phimosis.

Surgical Management of Penile Calciphylaxis Without Penectomy.

Calciphylaxis, a rare and life-threatening condition, involves the calcification and occlusion of microvasculature, leading to tissue ischemia and necrosis. The pathophysiology of calciphylaxis remains complex, but it is often associated with derangements in calcium and phosphate metabolism, ultimately resulting in the deposition of calcium within small blood vessels. This process leads to compromised blood flow, tissue hypoxia, and subsequent skin necrosis and ulceration, often with catastrophic consequences. While calciphylaxis typically occurs in individuals with end-stage renal disease (uremic calciphylaxis), it can also afflict those without renal impairment (non-uremic calciphylaxis). Several risk factors predispose individuals to this condition, including diabetes mellitus, hyperparathyroidism, malignancies, warfarin-based anticoagulation, alcoholic liver disease, and autoimmune disorders. Understanding the etiology, risk factors, and clinical manifestations of calciphylaxis is critical for timely diagnosis and management to mitigate its devastating effects. Management includes sepsis control, wound debridement, and analgesic support.  We report a case of penile calciphylaxis in a 58-year old male with a past medical history significant for end stage renal disease on hemodialysis, diabetes mellitus, and hypertension. The patient presented with a painful lesion on the glans penis which rapidly progressed to necrosis and gangrene with wet features. The patient refused partial penectomy and wanted conservative management with local wound debridement and antibiotics.

Local Therapy and Reconstruction in Penile Cancer: A Review.

Local therapy for penile cancer provides robust survival and can preserve the penis functionally and cosmetically. Interventions must target the appropriate clinical stage. We reviewed studies regarding the primary therapy in penile cancer, from topical therapy to radical penectomy, and reconstructive techniques. Topical therapy (5-FU or Imiquimod) provides a robust oncologic response in patients with Ta or Tis disease. Multiple laser therapies are available for localized patients and those with low-grade T1 disease. There is a non-trivial risk of progression and nodal metastases in poorly selected patients. Wide local excision provides an oncologically sound option in patient with up to T1 disease; less evidence exists for Mohs microsurgery in the setting of penile cancer. Increasingly aggressive approaches include glansectomy and partial/radical penectomy, which provide 5- and 10-year cancer-specific survival rates of over 80%. Meticulous reconstruction is necessary for the durable function of the remaining penis. Preservation of voiding and sexual function occurs via penile skin grafting, glans resurfacing, creation of a functional penile stump, and phalloplasty with a penile implant. Perineal urethrostomy provides an alternative in pathology demanding extensive partial or radical penectomy, and a durable option for seated voiding. Clinical suspicion and timely diagnosis are paramount in terms of management as less-invasive options for earlier-stage disease develop.

Radiotherapy Versus Partial Penectomy for T1 Squamous Cell Carcinoma of the Penis.

BACKGROUND: Radiotherapy (RT) represents an alternative treatment option for patients with T1 squamous cell carcinoma of the penis (SCCP), with proven feasibility and tolerability. However, it has never been directly compared with partial penectomy (PP) using cancer-specific mortality (CSM) as an end point. METHODS: In the Surveillance, Epidemiology, and End Results database (2000-2020), T1N0M0 SCCP patients treated with RT or PP were identified. This study relied on 1:4 propensity score-matching (PSM) for age at diagnosis, tumor stage, and tumor grade. Subsequently, cumulative incidence plots as well as multivariable competing risks regression (CRR) models addressed CSM. Additionally, the study accounted for the confounding effect of other-cause mortality (OCM). RESULTS: Of 895 patients with T1N0M0 SCCP, 55 (6.1%) underwent RT and 840 (93.9%) underwent PP. The RT and PP patients had a similar age distribution (median age, 70 vs 70 years) and more frequently harbored grade I or II tumors (67.3% vs 75.8%) as well as T1a-stage disease (67.3% vs 74.3%). After 1:4 PSM, 55 (100%) of the 55 RT patients versus 220 (26.2%) of the 840 PP patients were included in the study. The 10-year CSM derived from the cumulative incidence plots was 25.4% for RT and 14.4% for PP. In the multivariable CRR models, RT independently predicted a higher CSM than PP (hazard ratio, 1.99; 95% confidence interval, 1.05-3.80; p = 0.04). CONCLUSION: For the T1N0M0 SCCP patients treated in the community, RT was associated with nearly a twofold higher CSM than PP. Ideally, a validation study based on tertiary care institution data should be conducted to test whether this CSM disadvantage is operational only in the community or not.

Enhanced Prognostic Factors for Disease-Free Survival in Penile Squamous Cell Carcinoma: Insights From Songklanagarind Hospital.

OBJECTIVE: This study aimed to investigate disease-free survival (DFS) outcomes and associated prognostic factors among surgically treated penile cancer patients at Songklanagarind Hospital, Thailand, over a 20-year period. METHODS: A retrospective analysis was conducted on 208 primary penile cancer patients treated between January 2001 and December 2022. Disease-free survival was assessed using Kaplan-Meier survival curves, and Cox proportional hazard models were employed for multivariate analysis. RESULTS: All of patients (100%) were squamous cell carcinoma of penis, with 38.9% having T1 tumors, 70.7% well-differentiated tumors, and 32.6% diagnosed at stage III. The recurrence rate was 16.8%, with a mean time to recurrence of 25.9 months. Disease-free survival rates at 1, 3, and 5 years were 82.1%, 72%, and 70.2%, respectively. Median overall survival was 18.2 months, with rates at 1, 3, and 5 years at 68.7%, 44.7%, and 36.4%, respectively. Significant associations were found between disease-free survival and higher T stage, clinical chronic inflammation, delayed onset of symptoms, primary lesion location, groin node metastasis, lymphovascular invasion, and pelvic lymph node metastases. However, multivariate analysis revealed that higher primary tumor stage (T) was the only independent prognostic factor for disease-free survival. CONCLUSION: This study provides valuable insights into disease-free survival outcomes in penile cancer treatment at a single institution over an extended period. Higher pathologic T stage emerged as the sole independent prognostic factor for disease-free survival. Further validation through large-scale prospective studies is warranted.

A Case of Fournier's Gangrene in a Patient With Malignant Priapism.

Fournier's gangrene is a rare and potentially life-threatening type of necrotizing fasciitis that affects the genital and perineal regions. Malignant priapism is a rare and serious medical condition characterized by persistent and painful erection of the penis that is not associated with sexual arousal or stimulation. We present a case of a 77-year-old man with concurrent Fournier's gangrene and malignant priapism. He first underwent surgical debridement to remove necrotic tissue and aspiration of blood from the corpora cavernosa. Then a palliative penectomy was performed. The patient succumbed to severe sepsis and died after 14 days of hospitalization.

Impact of pathologic features on local recurrence in penile squamous cell carcinoma after penectomy.

BACKGROUND: Penile squamous cell carcinoma (PSCC) is a rare malignancy that may be cured in cases of local disease by resection of the primary tumor. Risk factors and patterns of local recurrence (LR) have not been well described in cases requiring partial or radical penectomy. In this study, we evaluated risk factors for LR and the impact of frozen and final margin assessment. MATERIALS AND METHODS: We evaluated 119 patients with PSCC who had undergone partial or radical penectomy from 2007 to 2023. Data regarding clinical and pathologic features were collected by retrospective chart review. The primary outcome of interest was LR. Determinants of LR were analyzed by Student's t, Fisher's exact, chi-square and logistic regression analysis. Predictive statistics of frozen margin status on final margin were assessed and LR rates for subsets of frozen and final margin interaction were defined. Finally, all cases of positive margins and LR were described to highlight patterns of LR and the importance of margin status in these cases. RESULTS: There were 8 (6.7%) cases of local recurrence. There were no significant predictors of LR, although a trend toward increased LR risk was observed among those with a positive final margin. Positive final margins were found in 15 (13%) cases. Frozen margin analysis was utilized in 79 cases, of which 10 (13%) were positive. The sensitivity, specificity, positive predictive value, and negative predictive value of frozen margin status for final margins were 44%, 92%, 40%, and 93%, respectively. There were no LR among cases in which frozen margin was not sent. Analysis of all cases with positive margin and/or LR identified three subsets of patients: CIS or focally positive margin resulting in either no LR or LR managed with minimal local intervention, bulky disease in which survival is determined by response to subsequent therapy rather than local recurrence, and clinically significant local recurrence requiring continued surveillance and intervention despite negative margins. CONCLUSIONS: LR is rare, even in cases of larger, proximal tumors requiring partial or radical penectomy. In this study, no statistically significant risk factors for local recurrence were identified; however, analysis of frozen and final margins provided insight into the importance of margin status and patterns of local recurrence. When feasible, visibly intra-operative negative margins are an excellent predictor of low risk for LR, and, in cases of CIS or focally positive margins, further resection to achieve negative margins is unlikely to reduce the risk of clinically significant LR. Additionally, in cases of bulky disease, the goals of resection should be focused toward palliation and next line therapy.

Penile carcinoma: A retrospective analysis of 93 patients at a tertiary care center in Jakarta, Indonesia.

OBJECTIVES: Penile carcinoma (PC) is a rare disease with considerable physical and psychological impact. To date, there is no data regarding PC prevalence and characteristics in Indonesia. This study aimed to analyze the characteristics of patients with PC in Indonesia and determine cumulative survival rates and time to disease progression. METHODS: This was a retrospective study of all patients diagnosed with PC at Cipto Mangunkusumo General Hospital from 1995 to 2014, with a minimum of 1 year follow-up. The outcomes of the study were cumulative survival rates and time-to-disease progression. RESULTS: Ninety-three subjects were recruited, with a mean age of 49.44 ± 13.62. Inguinal lymph node dissection (ILND) was performed in 49 (53%) patients. The mean survival in the ILND group was better compared to the non-ILND group (80.7 months vs. 67.1 months; p = 0.032). Time-to-progression in the ILND group was significantly longer than in the non-ILND group (71.7 months vs. 54.3 months; p = 0.022). No significant difference in survival between the total and partial penectomy (PP) groups was observed (p = 0.701). Time-to-progression in total penectomy (TP) was significantly longer than in PP (68 months vs. 56.0 months; p = 0.023). In Cox-regression analysis, after adjustment of other variables, history of ILND, higher stage of cancer, and older age were found to affect the survival of patients. CONCLUSION: ILND in PC led to better survival and reduced disease progression. The type of penectomy is only associated with progression but not survival. TP had a longer time to disease progression compared to PP.

Improving Quality of Life and Psychosocial Health for Penile Cancer Survivors: A Narrative Review.

Treatment of penile cancer (PC) focuses on organ preservation, employing various surgical and non-surgical approaches. These interventions may lead to disfigurement, impacting patients' functional outcomes and psychosocial well-being. We reviewed studies related to penile health and PC up to February 2024, limited to studies published in English. Studies employing health-related quality of life (HRQoL) assessments have identified a detrimental association between aggressive treatment and overall health status, physical functioning, and relationships. In contrast, organ-sparing demonstrates improved measures related to HRQoL and sexual function. Assessment through validated questionnaires reveals diverse voiding outcomes, and varying impacts on QoL and sexual activity, emphasizing the necessity for multidisciplinary personalized care. Studies highlight substantial variations in sexual function, with patients reporting adaptations, reduced satisfaction, and concerns about body image and sexual well-being. Furthermore, unmet needs include challenges in patient-clinician communication, obtaining information, and accessing psychosocial support. Patient experiences underscore the importance of timely diagnosis, treatment access, and addressing psychological consequences. Organ-sparing approaches have higher QoL preservation and sexual function. Individualized support, including sexual therapy, support groups, and family counseling, is essential for post-treatment rehabilitation. Timely diagnosis and comprehensive care are paramount in addressing the multifaceted impact of PC on patients and families.

Penile Osteosarcoma: A Rare Extraosseous Site.

Primary penile extraosseous osteosarcoma (EOS) ranks the most uncommon amongst the differential penile masses, with only nine cases reported so far. In this report, we share the management of a 67-year-old Hispanic male who presented with a painful mass over his distal penile shaft and glans for the last two months. After initial imaging and complete blood investigations, he underwent partial penectomy. Histology revealed high-grade sarcoma, with osteoid production, favoring high-grade extra-skeletal osteosarcoma, with tumor necrosis involving approximately 5% of the tumor volume. The patient had bilateral palpable inguinal lymphadenopathy, which was seen even on a pre-op CT scan. The patient thus underwent bilateral robotic superficial and deep inguinal standard template lymph node dissection three weeks after his partial penectomy. His pathology was negative for malignancy in all examined lymph nodes. At his last follow-up, five months post his primary surgery, he had been doing well without concerns for recurrence.

Penile Epithelioid Hemangioendothelioma in a Child.

An 8-year-old boy initially thought to have a penile arteriovenous malformation was later diagnosed with a rare vascular sarcoma, epithelioid hemangioendothelioma (EHE). Despite challenges in diagnosis, he underwent supraselective angioembolization and partial penectomy for oncological clearance. EHE, a low-grade malignancy, requires prompt identification and treatment due to potential systemic involvement.

Partial penectomy for severe penile ulceration caused by cholesterol crystal embolization.

Introduction: Cholesterol crystal embolism is a rare microembolic disease caused by cholesterol crystals that can present with various symptoms after vascular surgery, catheterization, or anticoagulation therapy. We report a case of penile ulceration caused by cholesterol crystal embolism. Case presentation: A 72-year-old man undergoing maintenance dialysis for end-stage renal failure presented with penile pain and a black glans ulcer. Despite low-density lipoprotein apheresis, he was referred to our hospital because of lack of improvement. Based on his medical history and clinical presentation, including artificial vascular replacement and right toe amputation, cholesterol crystal embolism was suspected and partial penectomy was performed, thus confirming the diagnosis. Penile pain resolved after surgery, and he was discharged on Day 10. Unfortunately, he died after small bowel perforation developed 2 months after surgery. Conclusion: Penile ulcers caused by cholesterol crystal embolism may indicate the severity and progression of disease and typically require surgical intervention.

Penile-Sparing Surgery for Tumour Recurrence after Previous Glansectomy/Partial Penectomy: Treatment Feasibility and Oncological Outcomes.

We tested the feasibility and oncological outcomes after penile-sparing surgery (PSS) for local recurrent penile cancer after a previous glansectomy/partial penectomy. We retrospectively analysed 13 patients (1997-2022) with local recurrence of penile cancer after a previous glansectomy or partial penectomy. All patients underwent PSS: circumcision, excision, or laser ablation. First, technical feasibility, treatment setting, and complications (Clavien-Dindo) were recorded. Second, Kaplan-Meier plots depicted overall and local recurrences over time. Overall, 11 (84.5%) vs. 2 (15.5%) patients were previously treated with glansectomy vs. partial penectomy. The median (IQR) time to disease recurrence was 56 (13-88) months. Six (46%) vs. two (15.5%) vs. five (38.5%) patients were treated with, respectively, local excision vs. local excision + circumcision vs. laser ablation. All procedures, except one, were performed in an outpatient setting. Only one Clavien-Dindo 2 complication was recorded. The median follow-up time was 41 months. Overall, three (23%) vs. four (30.5%) patients experienced local vs. overall recurrence, respectively. All local recurrences were safely treated with salvage surgery. In conclusion, we reported the results of a preliminary analysis testing safety, feasibility, and early oncological outcomes of PSS procedures for patients with local recurrence after previous glansectomy or partial penectomy. Stronger oncological outcomes should be tested in other series to optimise patient selection.

Non-human papillomavirus penile squamous cell carcinoma with unusual coral-like polymorphic lesion.

Penile cancer is a rare malignancy of the male genital system. Approximately 98% of penile cancer corresponds to squamous cell carcinoma (SCC), with further morphological and molecular classification into human papillomavirus (HPV) dependent and non-HPV SCC. Compared to HPV-induced SCC, non-HPV SCC appeared to have a worse prognosis. Here, we present a case of an uncircumcised male with an unusual coral-like polymorphic lesion, and confirmed histopathology of well-differentiated non-HPV penile SCC with rapid growth progression.

Malignant priapism secondary from metastatic renal carcinoma: Case report: "Malignant Priapism from Kidney Neoplasm".

Malignant priapism (MP) is defined as a condition of persistent erection of the penile without sexual stimulation due to malignant cell invasion to the cavernous sinus and the efferent veins. We present a case of a man, 63 years old, with previous history of high-grade renal carcinoma pT3N0M0 had been through radical nephrectomy, diagnosed with MP secondary from metastatic renal carcinoma. The management of this case was aspiration of corpora cavernosa and distal shunting with the Al-Ghorab procedure, then continued to total penectomy and perineostomy.

Primary malignant melanoma of the male urethra: Case report and review of literature.

INTRODUCTION: We report a rare case of primary malignant melanoma with inguinal lymph node metastasis in the male urethra. CASE PRESENTATION: A 57-year-old male patient presented with a small tumor on the ventral surface of the penis, which was discovered 5 months ago and did not cause pain or discomfort. In the past month, the patient has developed symptoms of urinary incontinence. MRI and PET/CT scans revealed a primary tumor in the penile urethra, but no metastases were found. The patient underwent partial penectomy surgery and laparoscopic bilateral inguinal lymphadenectomy within one month. The pathological combined with immunohistochemical staining confirmed primary malignant melanoma in the urethra with right inguinal lymph node metastasis. Despite complying with surgical and immunotherapy treatment with Pembrolizumab for 18 cycles, the patient was diagnosed with recurrent cancer in the penile stump after 05 months and he passed away after 18 months. DISCUSSION: Urethral melanoma is a rare and highly invasive type of cancer. It was often diagnosed at a late stage because the initial symptoms were not obvious in the lower urinary tract. Additionally, cancer progressed very quickly, making it difficult to treat. CONCLUSION: Urethral melanoma, if detected at a late stage with lymph node metastasis, has a significantly poor prognosis irrespective of the treatment method employed. However, to our best knowledge, very few publications can be found on this disease, and the strategic treatment remained unknown.

Surgical Treatment of Penile Verrucous Squamous Cell Carcinoma in an HIV-Infected Patient: A Case Report.

Although uncommon, penile carcinoma can be a debilitating disease with various causes, and cancer is a significant contributor to morbidity and mortality in individuals infected with HIV. Verrucous carcinoma, a subtype of epidermoid carcinoma, is typically slow-growing and has a low propensity to metastasize. We present a case study of a 55-year-old HIV-positive patient with a massive squamous cell carcinoma of the penis that had been developing for over two years. To treat the condition, the patient underwent a total penectomy, perineal urethrostomy, and bilateral inguinal lymphadenectomy.

Penile gangrene due to improper application of a condom catheter: a case report.

BACKGROUND: Fournier's gangrene is a rare, fulminant, and usually localized necrotizing soft tissue polymicrobial infection of the perineum, with occasional extension up to the abdominal wall. CASE PRESENTATION: We describe an unusual case of penile gangrene in a 64-year-old Tunisian man suffering from urinary incontinence secondary to cerebrovascular accident. Gangrene developed due to continuous tourniquet effect on the penis caused by a condom catheter. Although source control was achieved with aggressive debridement, careful wound care, and wide-spectrum antibiotherapy, the patient died due to septic shock. CONCLUSION: Use of condom catheters is not without complications. Careful placement, strict hygiene, and regular monitoring of the local condition are necessary.

Clinicopathological characteristics of carcinoma penis over 10 years in a tertiary-level oncology center in Nepal: a retrospective study of 380 cases.

PURPOSE: This study was done to find out the clinicopathological characteristics of carcinoma penis in Nepali population and to evaluate various risk factors that predict its inguinal lymph node metastasis. METHODS: A retrospective cross-sectional study was carried out at the Urology Unit, Department of Surgical Oncology at BP Koirala Memorial Cancer Hospital, Bharatpur, Nepal. Case notes of biopsy-proven penile cancer, from January 2012 to December 2021, who underwent some form of surgical intervention were included. RESULTS: A total of 380 patients were included in the study. The mean age of the patients was 55.92 ± 13.81 years. At presentation, 78.5% had clinically node-positive disease. The most common treatment for the primary tumor was partial amputation of the penis (74.2%). Bilateral inguinal lymph node dissections were done in 370 cases. The most common histology was the usual SCC in 94.2% of cases and 69% were well differentiated. T3 was the most common staging in 49.4% cases. Pathologically nodal negative status was found in 58% cases. In univariate analysis, factors like duration of symptoms (≥ 6 months), high-risk histopathology (basaloid/sarcomatoid variant), increased T-stage, poorly differentiated tumor, and the presence of PNI or LVI were significantly associated with lymph node metastasis. CONCLUSIONS: Penile cancer is a common cancer in developing countries such as Nepal. The majority of the patients present late. Early recognition and prompt treatment are required to improve the overall outcome.