Asif Muneer

Glans Resurfacing for the Treatment of Carcinoma In Situ of the Penis: Surgical Technique and Outcomes

BACKGROUND The management of carcinoma in situ (CIS) of the penis is controversial, with relatively high local recurrence rates after minimally invasive therapies. OBJECTIVE Report the surgical technique and outcome of partial glans resurfacing (PGR) and total glans resurfacing (TGR) as primary treatment modalities for CIS of the glans penis. DESIGN, SETTING, AND PARTICIPANTS Between 2001 to 2010, 25 patients with biopsy-proven CIS underwent TGR (n=10) or PGR (n=15), defined as <50% of the glans requiring resurfacing. All patients were surveyed clinically every 3 mo for 2 yr and every 6 mo thereafter. SURGICAL PROCEDURE Excision of the glans epithelium and subepithelium of either the entire glans or the locally affected area, with a macroscopic clear margin. The penis was then reconstructed using a split skin graft. MEASUREMENTS Positive surgical margin (PSM) rates and rates of recurrence and progression were collated. Complications, cosmesis, and patient satisfaction were evaluated. RESULTS AND LIMITATIONS Mean follow-up was 29 mo (range: 2-120 mo). There were no postoperative complications, and 24 of 25 patients (96%) had complete graft take with excellent cosmesis. Overall, 12 of 25 patients (48%) had PSMs. Only 7 of 25 (28%) required further surgery, 2 of 25 (8%) for extensive CIS at the margin and 5 of 25 (20%) for unexpected invasive disease. Additional surgery consisted of further resurfacing in 4 of 25 cases (16%) or glansectomy in 3 of 25 cases (12%). Those undergoing further surgery had no further compromise to their oncologic outcome. The overall local recurrence rate was 4%. There were no cases of progression. CONCLUSIONS Glans resurfacing is a safe and effective primary treatment for CIS. The procedure maintains a functional penis without compromising oncologic control, while ensuring that definitive histopathlogy is obtained. Glans resurfacing has a low risk of recurrence and progression. Patients need to be warned that approximately 28% will require further surgery for PSM or understaging of their primary disease, although the need for further surgery does not compromise oncologic control.

Conservative Surgery for Squamous Cell Carcinoma of the Penis: Resection Margins and Long-Term Oncological Control

PURPOSE We assessed the oncological outcome of penile conserving surgery and identified parameters predicting local recurrence, including resection margins. MATERIALS AND METHODS A total of 179 patients with invasive penile cancer treated with organ sparing surgery at a tertiary center between 2002 and 2010 fulfilled our study criteria. Demographic, histopathological, management and followup data were recorded in a prospective database. Local, regional and distant recurrence rates, time to recurrence and survival rates were calculated. Survival analysis was performed by the Kaplan-Meier method. Multivariate analysis was used to identify predictors of local recurrence. RESULTS Mean followup was 42.8 months (range 4 to 107). Local, regional and distant metastatic recurrence developed in 16 (8.9%), 19 (10.6%) and 9 patients (5.0%) at a mean of 26.1, 26.8 and 11.7 months, respectively. The 5-year disease specific survival rate after recurrence was 54.7% (95% CI 46.1-63.3). For patients with isolated local recurrence the 5-year disease specific survival rate was 91.7% compared to 38.4% for those with regional recurrence. The overall 5-year local recurrence-free rate was 86.3% (95% CI 82.6-90.4). Tumor grade (p = 0.003), stage (p = 0.021) and lymphovascular invasion (p = 0.014) were identified as predictors of local recurrence on multivariate analysis. CONCLUSIONS Penile conserving surgery is oncologically safe and a surgical excision margin of less than 5 mm is adequate. Higher local recurrence rates are associated with lymphovascular invasion, and higher tumor stage and grade. Local recurrence has no negative impact on long-term survival.

Testicular and paratesticular tumours in the prepubertal population

Prepubertal testicular and paratesticular tumours are a rare group of tumours, distinct from postpubertal paediatric and adult tumours of this region. Tumours within this group are testicular germ-cell tumours (such as benign teratoma, epidermoid cyst and malignant yolk-sac tumours) and stromal tumours (such as juvenile granulosa-cell, Leydig-cell, and Sertoli-cell tumours). Paratesticular tumours can be benign (lipoma, leiomyoma, haemangioma) or malignant (rhabdomyosarcoma, melanotic neuroectodermal tumour of infancy). Because of their rarity, centralised pathology and treatment, and national collaborative clinical trials have been important in establishing the optimum management of malignant tumours in this group. We provide an up-to-date and comprehensive review of the clinical presentation, imaging, pathology, and clinical management of prepubertal paratesticular and testicular tumours.

Investigation of cavernosal smooth muscle dysfunction in low flow priapism using an in vitro model

The effects of hypoxia (pO2: 50 mmHg), acidosis (pH: 6.9) or glucopenia (absence of glucose) in vitro on the tone of the rabbit corpus cavernosum were investigated. The recovery of smooth muscle contractility following exposure to these conditions was also assessed. Hypoxia, acidosis or glucopenia alone or in combination showed a sustained reduction in the tone. Reperfusion of tissue strips showed complete recovery of smooth muscle tone for all conditions except when hypoxia and glucopenia were combined or when hypoxia, glucopenia and acidosis were used in combination. Incomplete recovery of tone was associated with a significant reduction in tissue ATP concentrations and an increase in the number of TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling)-positive nuclei. This indicates that following reversal of hypoxia, acidosis and glucopenia, failure of conventional α-adrenergic agonists to produce tumescence in low flow priapism is associated with irreversible smooth muscle cell dysfunction, which is linked to ATP reduction and smooth muscle cell death.

Stuttering priapism – a review of the therapeutic options

Introduction:  Priapism is a urological emergency which is commonly classified into low‐flow and high‐flow priapism. Immediate intervention is required for low‐flow cases as the development of ischaemia ultimately leads to long‐term erectile dysfunction. Stuttering or recurrent priapism is less well understood. This subtype is characterised by short‐lived painful erections and is commonly encountered in patients with sickle cell disease.

The 2‐week wait for suspected cancer: time for a rethink?

The 2‐week rule, stating that patients with suspected cancer should be seen by a specialist within 2 weeks of referral by their General Practitioner, was introduced in the UK in 2000. Although it has been the subject of much interest in the literature, to date there has been no review of the literature.

Molecular prognostic factors in penile cancer

ObjectivesPenile cancer is a rare tumour in developed countries but more common in South America and East Africa. Although pathological prognostic factors have been established, there is great interest in evaluating molecular markers which correlate with prognosis and outcome.MethodsWe have reviewed the current status of our understanding of the molecular biology of penile cancer in order to identify established and potential prognostic factors in penile cancer. We have conducted an extensive literature search to review the current understanding of the role of prognostic markers in penile cancer.ResultsAlthough several markers have been evaluated, currently the clinical application of these markers is limited. HPV positive tumours show a variable prognostic outcome. P53 status may correlate with survival in T1 disease but further studies are required to establish the link to lymph node spread.ConclusionsPathological variables are well-established but further work is required to investigate the role of molecular markers. The development of molecular prognostic markers is important for the surveillance of patients and prediction of lymph node involvement as well as a prognostic marker for survival.

Investigating the Effects of High-Dose Phenylephrine in the Management of Prolonged Ischaemic Priapism

INTRODUCTION Acute priapism can be managed by corporal blood aspirations and the instillation of alpha adrenergic agonists such as phenylephrine if patients present early. Following prolonged ischaemic priapism, this regimen is often unsuccessful, and the use of phenylephrine is limited due to systemic cardiovascular side effects. AIM To investigate the effects of high-dose phenylephrine on human corpus cavernosal smooth muscle obtained from patients presenting with refractory ischaemic priapism. METHODS Strips of corpus cavernosum were obtained from six patients presenting with prolonged ischaemic priapism (duration 60-240 hours), where detumescence was refractory to conventional doses of phenylephrine. The smooth muscle contractile response to high doses of phenylephrine were then compared with that of normal control corpus cavernosum obtained from four patients undergoing a penectomy for penile cancer. The tissue was then analyzed using TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling) to assess its viability. MAIN OUTCOME MEASURES The in vitro response to high-dose phenylephrine of corpus cavernosum smooth muscle obtained from patients with refractory priapism compared with normal human corpus cavernosum. RESULTS Corporal blood gas analysis confirmed hypoxia (pO(2) 1.5-2.3 kPa), acidosis (pH 6.9-7.1), and glucopenia (0-0.3 mmol/L) in all six patients confirming the ischaemic nature of the priapism. Application of high doses of phenylephrine produced a marked muscle contraction in the control tissue, but there was no contractile response at all in any of the priapism patients. Analysis with TUNEL indicated widespread smooth muscle cell apoptosis in all the priapism tissue. CONCLUSIONS This study has shown that patients with ischaemic priapism that fails to respond to conventional doses of an alpha-agonist are unlikely to benefit from continual or high-dose phenylephrine administration, as there is usually widespread apoptosis of the cavernosal smooth muscle preventing further contraction.

Malignant and premalignant lesions of the penis

#### Summary points Penile cancer can have devastating mutilating and psychological consequences for those affected. It is important for clinicians to be aware of the condition. Differentiation of benign genital dermatoses from premalignant penile lesions and early stage penile cancer, with prompt specialist referral, usually prevents progression, improves prognosis, and results in improved functional and cosmetic outcomes for affected men. A retrospective single centre study of all penile cancer cases in a specialist unit over five years found that general practitioners initiated most referrals, but that about 20% of patients were initially referred to specialties other than urology, such as genitourinary medicine, dermatology, or plastic surgery.1 This error delayed diagnosis by up to six months and potentially adversely affected quality of life, prognosis, and survival. Our article, written for the non-specialist, aims to provide an evidence based review of the causes and current trends in the diagnosis and management of premalignant and malignant penile lesions. #### Sources and selection criteria We searched PubMed to identify peer reviewed original articles, meta-analyses, and reviews. Search terms used were penile cancer, penile squamous cell cancer, penile neoplasm or neoplasia, risk factors for penile cancer, premalignant penile lesions, and prevention of penile cancer. We considered …

The use of high-resolution magnetic resonance imaging in the management of patients presenting with priapism

Study Type – Diagnosis (exploratory cohort)
Level of Evidence 2b