J. Beilan

Advances in Surgical Reconstructive Techniques in the Management of Penile, Urethral, and Scrotal Cancer

This article reviews the most up-to-date surgical treatment options for the reconstructive management of patients with penile, urethral, and scrotal cancer. Each organ system is examined individually. Techniques and discussion for penile cancer reconstruction include Mohs surgery, glans resurfacing, partial and total glansectomy, and phalloplasty. Included in the penile cancer reconstruction section is the use of penile prosthesis in phalloplasty patients after penectomy, tissue engineering in phallic regeneration, and penile transplantation. Reconstruction following treatment of primary urethral carcinoma and current techniques for scrotal cancer reconstruction using split-thickness skin grafts and flaps are described.

Suspected Penile Fracture After Xiaflex Injection and Use of a VED

CLINICAL PRESENTATION A62-year-old Caucasian man presented to the emergency department for evaluation of penile pain and swelling. The patient had a history of Peyronie’s disease and elected to undergo collagenase clostridium histolyticum (CCH) injections in an effort to decrease his approximately 40° leftward phallic curvature. The patient had received multiple cycles of treatment and most recently finished cycle number 3, injection 2. Two days after this injection, in direct violation of the recommendations from the treating urologist, the patient used a vacuum erection device (VED) on the left lateral aspect of his penis, which caused the sudden onset of stabbing pain and eventual detumescence. The patient’s symptoms ultimately prompted the patient to present to the hospital 7 days after the injury. During that week, the patient had increasing penile swelling and ecchymosis. The patient did have 3 nocturnal erections over this time, but described each event as painful and achieving only partial rigidity. At the time of presentation to the hospital, the patient’s physical examination revealed swelling and significant ecchymosis of the phallus extending into the penoscrotal area (Fig. 1). The bruising affected the patient’s glans penis and discolored the right side of his penis more than the left. On the left lateral midshaft of the patient’s phallus, however, there was a tender, mobile, indurated mass with overlying ecchymosis most consistent with a subcutaneous hematoma. There was no blood per urethra and the patient denied hematuria. Given the patient’s history and physical examination, high concern was raised for a penile fracture vs a penile hematoma. Discordant factors for a corporal rupture in the clinical history were the slow loss of erection at the time of injury and the spontaneous partial erections the patient had experienced since the incident. Considering the confounding factors above, magnetic resonance imaging (MRI) was utilized to further elucidate the extent of the patient’s injury. An MRI of the pelvis without contrast was obtained, which revealed a focal disruption along the ventrallateral aspect of the left tunica albuginea (Fig. 2). The defect measured 1.1 cm in length and was associated with a small overlying hematoma in the same area where the patient had received his CCH injection and used his VED. The underlying corpus cavernosa appeared otherwise normal; the tunica albuginea on the right appeared normal without disruption. No urethral injury was identified and the urinary bladder was normal.