Evangelos Zacharakis

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

BACKGROUNDnThe management of carcinoma in situ (CIS) of the penis is controversial, with relatively high local recurrence rates after minimally invasive therapies.nnnOBJECTIVEnReport 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.nnnDESIGN, SETTING, AND PARTICIPANTSnBetween 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.nnnSURGICAL PROCEDUREnExcision 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.nnnMEASUREMENTSnPositive surgical margin (PSM) rates and rates of recurrence and progression were collated. Complications, cosmesis, and patient satisfaction were evaluated.nnnRESULTS AND LIMITATIONSnMean 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.nnnCONCLUSIONSnGlans 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.

Robot-assisted intracorporeal pyramid neobladder

To describe a robot‐assisted intracorporeal pyramid neobladder reconstruction technique and report operative and perioperative metrics, postoperative upper tract imaging, neobladder functional outcomes, and oncological outcomes.

Conservative Management of Urorectal Fistulae

OBJECTIVEnTo characterize conservative management of urorectal fistulae (URF).nnnMETHODSnURF are a recognized but rare complication of treatments for prostate and rectal cancers. URF can lead to incontinence, fecaluria, pain, urinary infection, and sepsis, and thus are usually treated surgically. We present a series of 3 patients whose complex URF were managed conservatively. Between 2004 and 2010, 43 patients were diagnosed with URF resulting from treatment for prostate or rectal cancer. All patients were evaluated and offered surgical treatment; 40 patients elected surgical therapy, and 3 patients chose conservative, nonoperative management of the URF. The primary outcome was the patient choosing or needing formal surgical URF closure. Because this was not a comparative study, no formal statistical analysis was undertaken.nnnRESULTSnThe 3 patients have been regularly monitored and have required symptomatic and episodic care. None, however, has opted for formal surgical fistula repair, and to date, all continue in conservative management of their URF.nnnCONCLUSIONnSpontaneous URF closure is uncommon and is unknown to occur in complex URF. Surgery is the mainstay of treatment. Patients should consider treatment options, potential outcomes, and their quality of life when choosing or not choosing treatment. The applicability and durability of conservative management of URF remains unclear.

Functional outcomes following immediate repair of penile fracture: a tertiary referral centre experience with 76 consecutive patients

Abstract Objective: The aim of this study was to report surgical and functional outcomes in patients who underwent immediate penile fracture repair following location of the tunical tear with ultrasonography. Methods: Patients’ clinical notes from September 2005 to October 2015 were reviewed. The inclusion criteria were the documented presence of an albugineal laceration at the preoperative ultrasonography and during surgical exploration. In total, 76 patients were enrolled in the study. The aetiology, presentation, imaging results, intraoperative findings, functional outcomes and complications of surgical repair were retrospectively extrapolated from the clinical notes. Patients were questioned about their erectile and urinary function 12 months after the traumatic event. Validated questionnaires were administered to enquire about sexual and urinary function. Finally, the accuracy of the ultrasound in detecting the site of the tunical defect was evaluated. Results: The mean age was 39.5 years (range 21–72 years) and the median follow-up was 13 weeks. The aetiology of the fracture was sexual intercourse in 70 patients, the taqaandan manoeuvre in three and trauma while sleeping in three. The intraoperative findings showed a ventral and transverse tear in 93.5% of cases. Urethral injuries were evident in one-quarter of the patients. Ultrasonographic findings were confirmed intraoperatively in all patients. Worsening of the quality of erections was reported by 5% of patients, and 5.2% reported a penile curvature postoperatively. Conclusion: Penile fracture is a rare urological emergency and requires early surgical exploration and repair. Ultrasonography is a cheap and readily available investigation that allows confirmation of the diagnosis, and identification of the location of the tear and the associated urethral injury.

PDE-5 Inhibitors for BPH-Associated LUTS.

Lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH-LUTS) are a highly prevalent problem, and with considerable burden to quality of life. Evidence has emerged that a strong correlation exists in men suffering both BPH-LUTS and erectile dysfunction (ED). Phosphodiesterase type 5 inhibitors (PDE5i) have been shown to be highly effective in treating ED and more recently there is evidence that men with LUTS also benefit. In this review article we discuss the common pathogenic pathways of ED and LUTS, the scientific basis of PDE5i use, the efficacy of PDE5i in LUTS either as monotherapy or in combination with other established medications used in LUTS.

Transperitoneal laparoscopic adrenalectomy for metachronous contralateral adrenal metastasis from renal cell carcinoma: a case report

BackgroundWe report a case of metachronous solitary metastasis of renal cell carcinoma to the contralateral adrenal gland treated by laparoscopic transperitoneal adrenalectomy.Case presentationA 58-year-old man presented to our institution for regular follow up, 2 years after a right radical nephrectomy with preservation of the ipsilateral adrenal gland, for a primary renal cell carcinoma. The patient remained asymptomatic but an abdominal computed tomography scan on follow up revealed a 6.5 × 4 cm2 mass in the left adrenal gland. A positron emission tomography scan was also performed to rule out other possible metastases, and a magnetic resonance imaging scan was used for accurate localization and determination of resectability of the adrenal tumour. A bone scan, metabolic screen, liver and renal function tests were all within normal limits. A laparoscopic transperitoneal adrenalectomy was then performed. The postoperative period was uneventful, and the patient was discharged on postoperative day two. The patient remains in satisfactory condition and no recurrence or adrenal insufficiency has been observed during 12 months follow up.ConclusionMetachronous contra lateral adrenal metastases from primary renal cell carcinoma are very rare but should always be suspected in any nephrectomised patient presenting with an adrenal tumour. Regular follow up in these patients accompanied with computed tomography imaging may help the surgeon to detect early lesions. Laparoscopic transperitoneal adrenalectomy is feasible, safe and effective, with minimal trauma to the patient.

Diagnosis and management of priapism

Priapism, a prolonged penile erection, is a rare urological emergency which can pose a significant management challenge. In this article the authors describe the pathophysiology and management of the condition.

Robot-assisted management of Zinner’s syndrome: report of seminal vesicle sparing technique and review of literature

AbstractnThe range of urological procedures performed with robotic assistance has widened with increasing experience with the da Vinci robotic system. We describe the use of the da Vinci SI Surgical System for excision of a seminal vesicle cyst in a patient who had associated ipsilateral renal agenesis (Zinner’s syndrome). The robotic platform afforded a minimally invasive procedure with precise dissection and no collateral damage to neighbouring vital anatomy.