Arie Parnham

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 Bucks fascia. Dissection is performed over or under Bucks 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.

Retrograde ejaculation, painful ejaculation and hematospermia.

Although there has been an increased interest on premature ejaculation in the recent years, our understanding regarding the disorders of retrograde ejaculation, painful ejaculation and hematospermia remain limited. All three of these conditions require a keen clinical acumen and willingness to engage in thinking outside of the standard established treatment paradigm. The development of novel investigational techniques and treatments has led to progress in the management of these conditions symptoms; however, the literature almost uniformly is limited to small series and rare randomised trials. Further investigation and randomised controlled trials are needed for progress in these often challenging cases.

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

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.

Classification and definition of premature ejaculation.

Premature ejaculation (PE) is a poorly understood condition and is considered as the most common sexual disorder in men. The ambiguity surrounding PE is in part due to the difficulty in conducting and interpreting research in the absence of a standardised definition that adequately encompasses the characteristics of these patients. An enhanced awareness of sexual dysfunctions in the recent decades has lead to an increase in scientific research that has challenged the traditional paradigm regarding PE. This has also enabled to establish a universal definition and classification of the disease. A move to a more evidence based approach has improved the clinicians’ ability to define those who need medical treatment, as well as perform further research in this complex condition.

First, standardise the assay

With an increasingly mobile UK population, patients may be treated at more than one centre during their illness. Homogeneity in laboratory prostate specific antigen (PSA) tests is needed to prevent “overdiagnosis” and “overtreatment.”1 At the low end of the analytical range, age specific PSA values may trigger further assessment …

Diagnosis and management of symptomatic seminal vesicle calculi

Abstract 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.

Ergonomic use of the fourth arm to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP).

To demonstrate an ergonomic fourth arm technique to oversew the dorsal vascular complex (DVC) during robot‐assisted laparoscopic prostatectomy (RALP).

A rare presentation of hidradenocarcinoma within the penis

Penile carcinoma is a rare malignancy representing 1% of male cancers. Squamous cell carcinoma accounts for 95% of all penile cancers.1 Cutaneous adnexal tumours can be benign or malignant lesions and tend to present on the head, neck and extremities. Cutaneous adnexal tumours of the penis are extremely rare and have only been reported once in the literature.2 To our knowledge, metastatic spread from these tumours on the penis has never been reported before. We present a case of a malignant cutaneous adnexal tumour of the penis with progressive metastatic spread. Case presentation A 46-year-old man presented with a cystic mass on the shaft of his penis. He had no significant co-morbidities. On examination, there was a mobile nodule over the left side of the distal shaft of the penis, proximal to the coronal sulcus near the frenulum, measuring 8mm in diameter. There was no palpable groin lymphadenopathy. He underwent a wide local excision of the lesion. Histological examination revealed a multi-nodular, solid-cystic and poorly differentiated carcinoma located within the dermis, measuring 15mm by 10mm with a margin of less than 5mm. On closer evaluation, the tumour resembled a high-grade and malignant cutaneous adnexal tumour of hidradenocarcinoma sub-type. It was characterised by large lobulated islands of basaloid cells, an abundance of mitotic figures and multiple foci of necrosis. Lymphovascular invasion was present but perineal invasion was not (Fig. 1, Fig. 2). Open in a separate window Fig. 1 HE (b) primary lesion seen on high power view; (c) primary lesion demonstratin lymphovascular invasion; (d) recurrent lesion presenting with corpora cavernosa.

Priapism: A rare initial presentation for chronic lymphocytic leukaemia

A previously fit and well 54-year-old man presented with a seven-hour history of painful penile erection that was unrelated to sexual stimulation or history of trauma. Following failed aspiration and phenylephedrine injection, he was transferred to a tertiary centre for further management. He denied the use of prescription and recreational drugs. On examination he was pale, his penis was exquisitely tender, bruised and fully erect with a full glans (Figure 1). There was a large palpable mass in his upper abdomen and bilateral inguinal lymphadenopathy. His full blood count demonstrated a white cell count (WCC) of 434 × 109/l (98% lymphocytes), haemoglobin of 87 g/l and platelets of 91 × 109/l. A computed tomography (CT) of the thorax, abdomen and pelvis showed marked splenomegaly and widespread lymphadenopathy (Figure 2). Following a blood film and flow cytometry, a diagnosis of B-cell CLL was confirmed. A modest improvement in symptoms and WCC (308 × 109/l) resulted from three cycles of leucophoresis over a two-day period. He was transferred back to his local hospital where he successfully underwent systemic chemotherapy and his CLL is now in remission. Acute surgical management was deemed inappropriate due to the prolonged nature of his priapism. He now has ED refractory to medical management and is awaiting a penile prosthesis. Discussion

A mathematical model to predict the loss of length in patients undergoing plication corporoplasty for Peyronie’s disease

Introduction: Peyronie’s disease affects three to nine out of 100 men and can have significant emotional and sexual effects on patients and their partners. Treatment options vary but once the disease becomes quiescent they are predominantly surgical. The type of surgery adopted is dependent on the degree of angulation although no single procedure is without its disadvantages. Plication corporoplasty is one approach but patients experience and often complain of loss of penile length. We set out to devise a mathematical model that would allow us to predict the loss of length based on erect penile dimensions. Methods: By considering the bend in the erect penis as an arc, utilising the degree of curvature and the penile circumference at maximum angulation, we have been able to derive a simple equation using parameters that are easily obtained in the clinic. Results: Where L=length lost, C=circumference at point of curvature, Y=angle of curvature as measured by a goniometer: L = CY/180. We have then been able to create a quick reference table based on the average penile circumference (12–13 cm±5 cm). Conclusion: This formula provides a more scientific and accurate means to predict potential loss of penile length in patients undergoing plication corporoplasty. Although we recognise that applying a rigid mathematical model to a biological non-uniform pathology creates inaccuracies this is somewhat better than ‘by sight’ estimates, and will allow more informed counselling and consent for patients. As far as we are aware this is the first attempt to create a mathematical model to aid counselling for plication corporoplasty.