Unusual presentation of a periurethral abscess following infection with Neisseria gonorrhoea.

We describe an unusual case of a male patient presenting with penile and testicular swelling following an unprotected and traumatic sexual encounter. It was suspected that an isolated penile injury occurred during intercourse; however, ultrasound imaging identified an intact tunical layer and right-sided epididymo-orchitis. Following screening for sexually transmitted infections (STIs), he was discharged with antibiotics and advice to attend the Sexual Health Centre for contact tracing. He represented with a periurethral abscess and an antimicrobial-resistant (AMR) strain of Neisseria gonorrhoea was identified. Appropriate antibiotic treatment was initiated. Examination-under-anaesthesia, following abscess drainage, revealed a contained collection with no urethral fistula; however, a flat urethral lesion was seen during urethroscopy. Repeat urethroscopy and biopsy of the lesion indicated polypoid urethritis. Periurethral abscess secondary to gonococcal urethritis is a rare complication, but one that we should be suspicious of, especially with the growing incidence of AMR-STIs.

Multidisciplinary Approach for the Management of Penoscrotal Extramammary Paget's disease -An eUROGEN study.

INTRODUCTION: We reviewed the medical and surgical management and long-term outcomes for patients diagnosed with penoscrotal extramammary Pagets disease (EMPD) within an eUROGEN centre. PATIENTS AND METHODS: Retrospective review of cases from an institutional database with biopsy proven penoscrotal EMPD. RESULTS: A total of 10 patients were identified with penoscrotal EMPD over a 10-year period. Two patients had a previous history of gastrointestinal and urogenital cancers (20%) and no synchronous or metachronous cancers were identified. Eight patients with non-invasive EMPD (80%) underwent wide local excision of the affected skin, with at least a 5mm macroscopic resection margin and in selected cases simultaneous multiple mapping biopsies around the lesion were performed. Residual disease was present at the margins in seven patients (87.5%), of which three required further surgical excision or adjuvant topical immunotherapy (42.8%). Recurrence after complete excision was 12.5% and was successfully treated with topical imiquimod immunotherapy and CO2 laser therapy. Two patients (20%) had invasive carcinoma and metastatic disease at diagnosis. CONCLUSION: Reported recurrence rates of non-invasive penoscrotal EMPD are high and residual disease is present in most cases requiring either close clinical surveillance or adjuvant treatment. We propose an algorithm in the management of this rare disease.

Primary Squamous Cell Carcinoma of the Male Proximal Urethra: Outcomes from a Single Centre.

BACKGROUND: Primary squamous cell carcinoma (SCC) of the male proximal urethra is an aggressive and rare urogenital malignancy. OBJECTIVE: To review the surgical management and outcomes for male proximal urethral SCCs within a single centre and to suggest an algorithm for the surgical management of these rare tumours. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective study of patients undergoing surgery for male proximal urethral SCC within a single tertiary academic centre managing rare genital tumours. Ten patients with a histological diagnosis of proximal urethral SCC were identified from an institutional database over a period of 10 yr with a median follow-up of 22.5 mo (standard deviation±25.77 mo). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Pathological staging, surgical treatment, and neoadjuvant and adjuvant treatment were recorded. Complications according to the Clavien-Dindo classification and overall survival rates were recorded. Kaplan-Meier curves were used for overall survival. RESULTS AND LIMITATIONS: A total of 10 patients were identified of whom eight underwent panurethrectomy and radical prostatectomy. Radical inguinal lymphadenectomy was performed in five patients, which confirmed bilateral metastatic disease. Perioperative complications were reported in six patients (Clavien I and II). Within 6 mo of surgery, 90% of patients developed distant metastatic disease. Nine patients died of urethra cancer during the follow-up. One patient is still on follow-up. The median overall follow-up was 13.92 mo (range: 5-91 mo). At 5 yr, cancer-specific/overall survival was 10%. A limitation of this study is the retrospective design, which is unavoidable for such a rare disease. CONCLUSIONS: Radical surgery allows local disease control, but despite neo/adjuvant treatment, proximal urethral SCC is associated with poor survival outcomes and progression to distant metastatic disease within 6 mo. PATIENT SUMMARY: Proximal urethral squamous cell carcinoma is a rare cancer in men which is often detected late. Patients often present with problems such as voiding, urethral bleeding, or a palpable mass. Aggressive surgery allows local control, but despite this the overall survival is poor. Adjuvant and neoadjuvant radiochemotherapy can improve survival. Multicentric randomised trials are needed to identify the correct treatment modality.

Long-term outcomes for penile cancer patients presenting with advanced N3 disease requiring a myocutaneous flap reconstruction or primary closure-a retrospective single centre study.

BACKGROUND: Penile cancer patients with advanced metastatic disease in the inguinal region present a therapeutic challenge. We compared the outcomes for patients with advanced inguinal node disease requiring myocutaneous flap reconstruction (MFR) against primary closure for N3 disease. METHODS: A retrospective comparative study of a consecutive cohort of advanced penile cancer patients with N3 disease was performed. Patient demographics, presenting symptoms, primary tumour site, stage and grade were recorded. The type of MFR used, patient outcomes and post-operative complications were recorded from an institutional database. Kaplan-Meier (KM) curves were calculated to analyse the cancer-specific survival (CSS) rates for the MFR group and compared with the no-MFR group. P values were calculated by log-rank and Chi square tests for CSS rates and complications respectively. RESULTS: Eighteen patients requiring MFR were identified; mean age 62 years. Ten (55.6%) patients had a first presentation with penile cancer and advanced nodal disease with the remaining 8 (44.4%) presenting with an inguinal recurrence having already undergone surgery. The majority (n=15) underwent a vertical rectus abdominis myocutaneous (VRAM) flap. The average length of stay was 23 days for the MFR group versus 8.5 days for the no-MFR group. The 5-year CSS was 20.9% for the MFR group and 39.8% for the no-MFR group (P<0.01). CONCLUSIONS: Aggressive surgical management for patients with extensive nodal disease and flap reconstruction is feasible and aids wound management although the long-term prognosis is still poor.

Glansectomy and Split-thickness Skin Graft for Penile Cancer.

BACKGROUND: Penile cancer is a rare malignancy that is confined to the glans in up to four out of five cases. Although descriptions of glansectomy exist, there are no contemporary video explanations or large published single centre series. OBJECTIVE: To show the efficacy and safety of glansectomy and split-thickness skin graft (STSG) reconstruction. DESIGN, SETTING, AND PARTICIPANTS: Data were collected retrospectively for patients identified from surgical theatre diaries between February 2005 and January 2016. 177 patients with histologically proven squamous-cell carcinoma on the glans underwent glansectomy and STSG at a tertiary referral centre in the UK. The median follow-up was 41.4 mo. SURGICAL PROCEDURE: The skin is incised at the subcoronal level and deepened onto Buck's fascia. Dissection is performed over or under Buck's fascia, depending on suspicion of invasion or risk of disease. The glans is excised and a neoglans is created using a STSG. MEASUREMENTS: Local recurrence, cancer-specific survival, overall survival, and complications. RESULTS AND LIMITATIONS: Sixteen out of 172 patients (9.3%) experienced local recurrence during the follow-up period. Eighteen out of 174 (10.7%) patients died of penile cancer, while 29 patients in total died during the follow-up period. Of 145 patients, 9% required operative intervention for complications, including graft loss and meatal stenosis. Limitations include the retrospective data collection and the lack of functional and sexual outcomes. CONCLUSIONS: Glansectomy and STSG comprise a safe procedure in terms of oncologic control and complications for patients with penile cancer confined to the glans penis. Further studies are required to assess functional and sexual outcomes in these patients. PATIENT SUMMARY: We report on the management of penile cancers confined to the head of the penis using glansectomy and a split-thickness skin graft to recreate the appearance of a glans. This technique is safe and effective, with limited complications.

Predictive factors for local recurrence after glansectomy and neoglans reconstruction for penile squamous cell carcinoma.

OBJECTIVES: To investigate predictive pathological factors for local recurrence (LR) after glansectomy for penile squamous cell carcinoma (SCC) and to develop a risk score for prediction of LR after glansectomy. PATIENTS AND METHODS: In this retrospective study, we analyzed 117 patients operated between February 2005 and January 2016 in a supraregional penile cancer center in the UK for LR after glansectomy and glans reconstruction. Univariate and multivariate Cox proportional hazards regression was used to identify 4 prognostic indicators for LR. The hazard ratio (HR) of LR was estimated in Kaplan-Meier analysis, and based on these data, we designed a postoperative model for prediction of LR based on 3 risk groups. RESULTS: Median follow-up period was 33.7 (95% CI: 26.8-40.3) months; 12.8% of the patients experienced LR. Univariate Cox proportional hazards regression revealed that the risk factors for recurrence were the presence of perineural invasion, carcinoma in situ, positive margin on definitive pathology, and high-grade disease. Based on Kaplan-Meier analysis stratified by number of factors present, we defined 3 risk groups for LR: low (0,1 risk factors) as reference, intermediate (2,3 risk factors) with HR of 13.9 (95% CI: 1.81-107.04, P = 0.0115), or high risk (all 4 risk factors present) with a HR of 34.2 (95% CI: 3.07-381.81, P = 0,0041). Limitations include the retrospective design and low number of events inherent to the rare nature of penile SCC. CONCLUSIONS: Perineural invasion, carcinoma in situ, positive definitive margins, and the presence of high-grade SCC predict LR following glansectomy. These factors can be used to stratify patients into low-, intermediate-, and high-risk groups for recurrence which may be used to tailor follow-up.

Large bilateral seminal vesicle calculi presenting with spermolithiasis.

A 34-year-old male presented with an 8-month history of passing increasingly painful 'grit' in his ejaculate. Semen analysis was normal as were urinary and blood tests. T1-weighted MRI revealed several bilateral high-signal areas measuring up to 1 cm in diameter, located in the seminal vesicles. These were confirmed as calculi on T2-weighted imaging and a seminal vesiculogram, with no drainage from the left ejaculatory duct and only minimal from the right duct. He is currently awaiting a robot-assisted laparoscopic vesiculotomy after completion of family.

Diagnosis and management of symptomatic seminal vesicle calculi.

OBJECTIVE: The aim of this study was to review the management of patients with symptomatic seminal vesicle calculi, from presentation and diagnosis to postoperative outcomes. MATERIALS AND METHODS: A systematic review of the English literature in MEDLINE and Embase was performed, based on the following model: patients with a diagnosis of seminal vesicle calculi; all interventions considered with or without control groups with single and comparator interventions; outcomes considered were incidence, presentation, diagnostic methods and treatment. A narrative synthesis of the data was performed according to PRISMA 2009 guidelines. The study protocol was registered on PROSPERO (CRD42016032971). RESULTS: In total, 213 cases of seminal vesicle calculi from 37 studies were identified between 1928 and 2016. Published articles included cohort studies (16), case-control studies (two) and case reports (19). The most likely aetiology was stasis of ejaculate secondary to impaired drainage of secretions from the seminal vesicles. Transrectal ultrasound remains the primary investigation for haematospermia and painful ejaculation; however, magnetic resonance imaging seems to play an increasingly important role, especially when considering surgery. Transurethral seminal vesiculoscopy and lithotripsy is the ideal procedure for small calculi but requires surgical expertise. For larger calculi a transperitoneal laparoscopic approach is safe in the hands of experienced laparoscopic surgeons. CONCLUSIONS: Modern imaging techniques and cross-sectional imaging are leading to an increased number of diagnosed cases of seminal vesicle calculi. Optimal treatment depends on the stone size and burden, and centralization of services will assist in the development of specialized centres.

Management of non-visualization following dynamic sentinel lymph node biopsy for squamous cell carcinoma of the penis.

OBJECTIVES: To review the management and clinical outcomes of uni- or bilateral non-visualization of inguinal lymph nodes during dynamic sentinel lymph node biopsy (DSNB) in patients diagnosed with penile cancer and clinically impalpable inguinal lymph nodes (cN0), and to develop an algorithm for the management of patients in which non-visualization occurs. PATIENTS AND METHODS: This is a retrospective observational study over a period of 4 years, comprising 166 patients with penile squamous cell carcinoma undergoing DSNB and followed up for a minimum of 6 months. All cases diagnosed with uni- or bilateral non-visualization of sentinel nodes in this cohort were identified from a penile cancer database. The management of the inguinal lymph nodes after non-visualization and the oncological outcomes including local and regional recurrence rates were documented. RESULTS: Out of 166 consecutive patients undergoing DSNB, 20 patients (12%) had unilateral non-visualization after injection of intradermal 99m Tc. Of these 20 patients, seven underwent repeat DSNB at a later date, with six having successful visualization. One patient had persistent non-visualization and proceeded to a superficial modified inguinal lymphadenectomy (SML). None of these patients experienced recurrence at follow-up. A further seven patients underwent modified SML with on-table frozen-section analysis of the lymph node packet; none of these patients were found to have micrometastatic disease in the inguinal lymph nodes, although one patient developed metastatic inguinal node disease at a later date. Six patients elected to undergo clinical surveillance and have remained disease-free. CONCLUSION: Patients with impalpable inguinal lymph nodes undergoing DSNB with ≥G2 T1 disease should ideally have bilateral visualization of the sentinel lymph nodes, reflecting the drainage pattern from the primary tumour. In the present series, 12% of patients were found to have unilateral non-visualization after DSNB. Among patients offered a repeat DSNB at a later date, localizing the sentinel node was successful in 86% of cases. Patients with favourable histological characteristics can be placed on clinical surveillance. Those with high-risk disease can be offered a repeat DSNB procedure on the proviso that SML may be carried out if there is repeated non-visualization. Larger cohorts are required to validate this proposed algorithm.

Partial segmental thrombosis of the corpus cavernosum presenting with perineal pain.

We describe the case of a man aged 43 years who presented with a 2-week history of a palpable lump in the right proximal penile shaft. This was preceded by a 6-month history of perineal pain, accompanied by erectile dysfunction. An urgent MRI scan of his penis identified a thrombus within the right crus and corpus of the penis. His thrombophilia screen was normal. The patient was started on oral anticoagulation and a phosphodiesterase inhibitor (PDE-5i) to prevent thrombus progression and maintain erectile function. At 5 months, the patients' symptoms had resolved and an MRI showed a reduction in the thrombus size. MRI is a useful imaging modality to diagnose a thrombus within the corpus cavernosum in patients presenting with a history of penile and perineal pain together with a palpable lump. The non-enhancement of the lesion helps to differentiate this from alternative rare lesions within the penis and perineum.

Necrotizing granulomatous inflammation of the glans penis.

We describe the case of a 73-year-old man who presented with a 10-month history of an ulcerating lesion on the glans penis. Initially this was thought to be an invasive squamous cell carcinoma but a biopsy showed histological features consistent with necrotizing granulomatous inflammation. Extensive serological, immunological and microbiological tests only showed a positive antinuclear and perinuclear antineutrophil cytoplasmic antibodies indicating a possible autoimmune aetiology but an underlying systemic cause was not identified. Treatment with oral corticosteroids limited the inflammatory process but due to the gross destruction of the glans penis, he still required a glansectomy and split-skin graft reconstruction from which he recovered well. Although this patient ultimately required surgery for this rare presentation, this case highlights the differential diagnosis of penile ulceration (that transcends neoplasia) and the importance of performing and interpreting penile biopsies before undertaking potentially mutilating definitive surgery.

Infection of Penile Prostheses in Patients with Diabetes Mellitus.

BACKGROUND: Controversy still exists in some centers on whether diabetes mellitus is a risk factor for penile prosthesis infection. The aim of this review is to examine the evidence correlating penile implant infections to the presence of diabetes mellitus in patients with organic erectile dysfunction. METHODS: We performed a systematic review searching through Medline database from 1960 to 2014, using keywords; penile prosthesis(es), penile implant(s), and diabetes mellitus. We used the Prisma 2009 Flow diagram for systematic reviews. Thirty-eight publications were selected for inclusion in this qualitative analysis. RESULTS: Most case series reporting a greater infection rate in patients with diabetes mellitus date from the 1970s to 1990s. These series reported an infection rate of 5.5 to 20% and contained small cohort of patients. In the 1990s larger case series reported a lower infection rate in patients with diabetes mellitus compared with patients with paraplegia, pelvic trauma, and patients on steroids, but still reported an infection rate as high as 10.6%. With the implementation of antibiotic coated implants in 2001, infection rates reduced further with reported rates becoming less than 2% in patients with diabetes mellitus. The latest and largest case series by Eid et al. (2012) reported an infection rate of 0.46% with antibiotic coated implants and "no touch" technique in a cohort of 1511 cases, out of which 41% were patients with diabetes mellitus. CONCLUSION: Strong evidence exists that the risk of penile prosthesis infection has reduced over the decades with device improvement and surgical expertise. In larger case series infection rates in patients with diabetes mellitus is not statistically significant from that experiences in the population at large.

A rare case of metachronous penile and urethral metastases from a rectal mucinous adenocarcinoma.

Metastatic lesions in the penis are uncommon in patients with prostate or bladder cancer but penile metastatic lesions from rectal tumours are rare with only 65 cases reported in the literature. We describe the case of a 70-year-old man who developed metastatic lesions within his corpus cavernosum 2 years after being diagnosed and treated for a mucinous adenocarcinoma of the rectum and a year after a wedge resection of an isolated lung metastasis. He proceeded with total penectomy and intraoperatively two skip lesions were also found within the wall of his urethra; histological analysis proved that these were also metastatic lesions. A perineal urethrostomy was formed with the remaining macroscopically healthy urethra. He made a good recovery from his operation and continued his treatment under the oncology team.

A case of metastatic adenocarcinoma on a background of penoscrotal extramammary Paget's disease.

A 77-year-old man presented with a chronic lesion located in the left penoscrotal area. Apart from pruritus, bleeding and an occasional discharge from this area, he also reported reduced appetite and weight loss. Examination revealed an ulcerated skin lesion attached to a firm subcutaneous mass. Wide local excision of the lesion revealed invasive adenocarcinoma on a background of extramammary Paget's disease. Staging studies showed disseminated metastatic disease within the lymph nodes, and liver and bone metastases. He was treated with carboplatin and paclitaxel chemotherapy initially, but then continued only on Carboplatin chemotherapy due to side effects from Paclitaxel. Eleven weeks after the start of his chemotherapy, his restaging imaging showed reduced lymphadenopathy, unchanged liver metastasis and sclerosis of bone metastasis. With completion of chemotherapy, repeat imaging showed stable disease. The patient is currently on follow-up.

Paratesticular liposarcoma and contralateral angiolipoma in a 60-year-old patient.

We present the case of a 60-year-old man who was referred with a 1-year history of a slow-growing right scrotal lump. Following surgical excision together with a radical orchidectomy, the histological diagnosis was of a paratesticular dedifferentiated liposarcoma. Radiological staging showed no metastatic disease. Six months later the patient presented with a new left scrotal lump, which was felt to be separate from the testis. Owing to the previous history of a liposarcoma and indeterminate ultrasound findings, this was surgically excised without orchidectomy. Histological analysis showed this to be an angiolipoma. The patient remained on clinical and radiological surveillance. Paratesticular tumours are rare neoplasms and liposarcomas of the spermatic cord only represent 7% of these lesions. Any link between lipomatous tumours and liposarcomas remains controversial and is still under investigation. This is the first case to report a paratesticular liposarcoma and a contralateral angiolipoma in the same patient.

Infected urinoma secondary to a ruptured renal calyx from a partial staghorn stone.

A urinoma is a collection of urine outside the urinary tract as a result of disruption of the collecting system. Obstructive causes of urine extravasation secondary to stones are not unseen but display a delayed diagnosis due to the gradual onset of symptoms, which can mimic pyelonephritis. We present the case of a 70-year-old female patient who was admitted to hospital with symptoms of right loin pain and sepsis. We describe her case from the initial clinical diagnosis of pyelonephritis to the final diagnosis of an infected urinoma after a calyceal rupture from an obstructive partial staghorn calculus. This case highlights the importance of early computerized tomography imaging in patients with renal stones and suspected pyelonephritis as ultrasound scans can sometimes be misleading. Misdiagnosis of infected urinomas delays definitive treatment and leads to increased morbidity.

Acute urinary retention in an adolescent girl and important learning points.

We presented a case of a 13-year-old girl who attended the emergency department with acute urinary retention and 1400 mL residual urine after catheterisation. She had no significant medical history, neurological examination was normal and she had not reached menarche. She was found to have a haematocolpos on ultrasound scan which was compressing the urinary bladder. Examination under anaesthesia confirmed an imperforate hymen and therefore an incision was performed and the haematocolpos drained. She managed to pass urine normally the day following her procedure. In this article, we emphasise on the differential diagnosis in this case and the learning points derived from it.

A complication of Artificial Urinary Sphincter: migration of pump onto the rectus sheath in a patient with cauda equina syndrome.

We describe a very rare complication of migration of Artificial Urinary Sphincter pump device, following an elective implantation in a male patient with significant stress incontinence secondary to cauda equina syndrome. Looking through existing literature there has not been a similar complication reported. Usual complications reported include erosion, infection and mechanical failure.

Incidental paraganglioma of the urinary bladder in a 66-year-old woman.

A 66-year-old female patient was referred to drology department when a bladder mass was incidentally found on a transvaginal ultrasound scan. Cystoscopy revealed a small, smooth mass just above the trigone which appeared to be covered with normal urothelium. The histology from this growth after transurethral resection revealed a paraganglioma of the bladder. We will discuss the management of this case and literature review of this finding in this study.