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Penile duplication with long distance: joining with successful outcome
v21 PENILE DUPLICATION WITH SUCCESSFUL OUTCOME Perovic S.‘, Djordjevic
LONG
DISTANCE:
JOINING
WITH
Carmirmani
M.‘, Brdar R.‘, Ducic S.’
‘University Hospital, Urology, Belgrade, Orthopaedics, Belgrade, Yugoslavia
Yugoslavia,
“University
Hospital,
INTRODUCTION & OBJECTIVES: Complete diphallia is a very rare anomaly which is characterized with two separated penises which usually lie side by side (transversal duplication) or one on top of the other (sagital duplication). We present a unique case of pseudoexstrophy and transversal penile duplication and joining of both penises, which were 10 cm away from each other. MATERIAL & METHODS: A I5 months old boy with pseudoexstrophy and marked symphiseal diastasis underwent surgery with objective to join the two separated penises. Both penises had severe penoscrotal hypospadias with marked chordee. Also, both hemiscrotums with testicles were separated and laid below their respective penises. Associated anomalies were two separated bladders, each with its own urethra and huge ventral hernia. Each penis was dissected to glans cap with neurovascular bundle, hypospadiac urethra and corpora cavemosa. Extensive chordectomy solved the curvature. Complete symphiseal approximation was achieved by bilateral inominate osteotomies. This way, all four corpora cavemosa were joined in normal midline position. Urethras were anatomised and placed on the ventral side of the joined corpora cavemosa. Better-developed glans was fixed to the tips of the corporeal bodies while another one was removed. Both hemiscrotums were also joined and positioned in midline. Penile body skin reconstruction was done using vascularized sliding skin flaps. RESULTS: One year after surgery good aesthetic and functional results are present. Penis has good size and lies at normal anatomical position. Continence and erect& function are completely preserved. Repair of ventral abdominal hernia is left to be done at an older age. CONCLUSIONS: Unique and very radical approach enabled joining completely separated penises with successful outcome. This way reassignment surgery was avoided.
ONE STAGE PRIMARY RECONSTRUCTION OF EXSTROPHY WITH MODIFIED PENILE DISASSEMBLY Hafez A.. Elsherbiny Urology & Nephrology
M., Bazeed M., Ghoneim
G., Traverse P., Naselli A., Bertolotto F., Romagnoli
URETHRA:
A., Corbu C.
University of Genoa, Urology, Genoa, Italy INTRODUCTION & OBJECTIVES: Primary malignant melanoma of the urethra is extremely rare. Only 160 cases are reported worldwide, of which 37% occurred in males, The majority of the cases concern patients over 50’s (no cases described under 30 years). Symptoms are common to other urethral turnours. The most frequent sites of occurrence are fossa navicularis (55%) prostatic urethra (15%), penile urethra (15%) bulbar urethra and external urethral meatus. MATERIAL & METHODS: A 43 year old male presented with a diagnosis of malignant melanoma of the urethra after histologic examination of a polypoid lesion of the fossa navicularis. No other primary localization of the disease was found. The patient underwent a urography and a retrograde urethrography that showed an irregular urethral wall; CT scan showed a left inguinal lymph node of 1.5cm and PET an increased inguinal bilateral uptake. Flexible urethroscopy showed multiple small-pigmented lesions of the penile urethra. In this video we describe a two step surgical approach, which allowed a complete resection of the lesions, an extended lymphadenectomy and a good reconstruction of the distal urethra and a satisfactory cosmetic appearance of the widely resected glans. 1) At a preliminary step a dissection of the left inguinal superficial sentinel lymphnode was performed with a pathologic diagnosis of an isolated melanomatous metastasis. We then did a distal urethrectomy with partial excision of the glans. Corpora cavemosa remained fully intact. A reconstruction of the remaining wings of the glans, the preparation of the future neo-urethra by means of the transposition of a wide preputial flap, an urethrostomy at penile base and an extended inguinal and pelvic lymph node dissection were carried out. Pathologic examination confirmed multiple melanomatous nodules; surgical margins of resection and all the 25 lymph-nodes dissected were disease free. 2) After 3 months, a reconstruction of a complete neo-urethra with an orthotopic neomeatus was performed.
two sex
CONCLUSIONS: The small number of cases reported in medical literature is not sufficient to indicate a unique therapeutic solution that varies from partial resection of urethral tissue to radical urethrocystectomy. At 6 months from first diagnosis, our patient is disease free and has normal erections with a normal sexual life.
V23
V24
BLADDER
CARCINOMA OF THE PENIS: VIDEO-ALGORITHM LYMPHADENECTOMY Slmonato A.. Lissiani A.. Grcgorl A., Borzola A
M
Center, Urology, Mansoura,
v22 PRIMARY MALIGNANT MELANOMA OF THE RECONSTRUCTIVE SOLUTION IN A RARE CASE
Egypt
, Gal11 S..Gaboardi
FOR INGUINAL
F
I.. Sacco Hospital. Urology. Mdan. Italy
INTRODUCTION & OBJECTIVES:
INTRODUCTION & OBJECTIVES: In 1999. Grady and Mitchell popularized the complete primary repair of bladder exstrophy. They closed the bladder and urethral plate in continuity with epispadias repair using total penile disassembly. However, the procedure results in hypospadias in one third of children. We modified the penile disassembly part of the one stage exstrophy reconstruction by omitting distal division of the urethral plate to obtain an orthotopic urethral meatus. MATERIAL & METHODS: This video illustrates the operative steps of one stage exstrophy reconstruction in a 2-day-old neonate. These steps include I) Complete mobilization of the bladder plate with incision of the intersymphyseal bands, 2) Dissection of the urethral plate with its wedge of blood supply from the corporal bodies, 3) Bladder closure with continuous suture of 4/O polglycate, 4) Tubularization of the urethral plate using 710 polyglycate interrupted sutures, 5) Approximation of pubic symphysis using two interrupted sutures of 0.0 Polydixanone, 6) Approximation of the corporal bodies dorsally utilizing 610 polyglycate mterrupted sutures,. 7) Glans closure utilizing 710 polyglycate interrupted sutures, and 8) Wound closure with redistribution of the penile skin. RESULTS: The preliminary results of one stage primary reconstruction of bladder exstrophy have been encouraging. Early bladder cycling and concomitant epispadias repair might decrease the future need of bladder neck reconstruction, Moreover, the modified penile disassembly would obviate the need for a second procedure for hypospadias repair. CONCLUSIONS: We modified penile disassembly by preservation of the distal attachment of the urethral plate to the glans. The procedure results in orthotopic urethral meatus following one stage exstrophy reconstruction.
Urogenital neoplasms spreading to the mgumal lymph nodes are pende carcinoma (the most frequent), urethral and scrotum cancers. turnours of the testis wth scrotal violation. Penile carcinoma is an uncommon malignant disease and accounts for as many 0.4-0.6% of male cancers. Most patients are elderly. It rarely occurs in men under age 60 and its incidence increases progreswely until it reaches a peak in the eighth decade I. The risk of a lymph node invasion is greater with high grade and high stage tomours 2. Some mvestigators have reported the inaccuracy of the sentmel node biopsy 3,4. described by Cabanas 5. Patients with m&static lymph node penis cancer have a very poor prognosis If penectomy only is performed. Ilioinguinal lymphadenectomy is basically carried out as a treatment modality and not only as a staging act. Patients with lymph node invasion have a 30.40% cure rate. Ilioinguinal lymphadenectomy should be also performed m patients with disseminated neoplasms for the local control of the disease. The 5 years survival rate of patients with climcally negative lymph nodes treated with a mod&d inguinal lymphadenectomy is 88% versus 38% in patients not initially treated with lymphadenectomy 6. This videotape clearly shows a therapeutic algorithm, the anatomy of the ingurnal lymph nodes, according to Rouviere 7 and Daseler 8, the radical llioinguinal node dissection with transposition of the sartorius muscle and the modified inguinal lymphadenectomy proposed by Catalona 9. References: I. Lynch D.F. and Schellhammer P: Tumours of the penis. In Campbell’s Urology Seventh Edition, edited by Walsh P.C., Retlk A.B., Darracott Vaughan E. and Wein A.J. W.B. Saunders Company, Vol. 3, chapt. 79, p. 2458, 1998. 2. Pizzocaro G., Piva L., Bandieramonte G., Tana S. Up-to-date management of carcinoma ofthe pems. Eur. Ural. 32: 5-15, 1997 3. Perinetti E., Crane D.B. and Catalona W.J. Unreliability of sentinel lymph node biopsy for staging penile carcinoma. J. Ural. 124: 734, 1980 4. Fowler J.E. Jr. Sentinel lymph node biopsy for staging penile cancer. Urology 23: 352, 1984 5. Cabanas R.M. An approach for the treatment of penile carcinoma. Cancer 39: 456, 1977 6. Russo P. and Gaudin P. Management strategies for carcinoma of the penis. Contemporary Urology; 5:4X-66, 2000 7. Rouviere H. Anatomy of the human lymphatic system. Edwards Brothers, p. 218, 1938 8. Daseler E.H., Anson B.J., Reimann A.F. Radical excision ofthe ingumal and 111x lymph glands: a study based on 450 anatomnxl dissections and upon supportive chnical observations. Surg. Gynecol. Obstet. 87. 679, 1948 9. Catalona W.J. Modified ingumal lymphadenectomy for carcinoma of the penis with preservation of aaphenous veins. technique and preliminary results. J. Ural. 140: 306-3 IO. 1988 European
Urology Supplements 2 (2003) No. 1, pp. 209
LONG
DISTANCE:
JOINING
WITH
Carmirmani
M.‘, Brdar R.‘, Ducic S.’
‘University Hospital, Urology, Belgrade, Orthopaedics, Belgrade, Yugoslavia
Yugoslavia,
“University
Hospital,
INTRODUCTION & OBJECTIVES: Complete diphallia is a very rare anomaly which is characterized with two separated penises which usually lie side by side (transversal duplication) or one on top of the other (sagital duplication). We present a unique case of pseudoexstrophy and transversal penile duplication and joining of both penises, which were 10 cm away from each other. MATERIAL & METHODS: A I5 months old boy with pseudoexstrophy and marked symphiseal diastasis underwent surgery with objective to join the two separated penises. Both penises had severe penoscrotal hypospadias with marked chordee. Also, both hemiscrotums with testicles were separated and laid below their respective penises. Associated anomalies were two separated bladders, each with its own urethra and huge ventral hernia. Each penis was dissected to glans cap with neurovascular bundle, hypospadiac urethra and corpora cavemosa. Extensive chordectomy solved the curvature. Complete symphiseal approximation was achieved by bilateral inominate osteotomies. This way, all four corpora cavemosa were joined in normal midline position. Urethras were anatomised and placed on the ventral side of the joined corpora cavemosa. Better-developed glans was fixed to the tips of the corporeal bodies while another one was removed. Both hemiscrotums were also joined and positioned in midline. Penile body skin reconstruction was done using vascularized sliding skin flaps. RESULTS: One year after surgery good aesthetic and functional results are present. Penis has good size and lies at normal anatomical position. Continence and erect& function are completely preserved. Repair of ventral abdominal hernia is left to be done at an older age. CONCLUSIONS: Unique and very radical approach enabled joining completely separated penises with successful outcome. This way reassignment surgery was avoided.
ONE STAGE PRIMARY RECONSTRUCTION OF EXSTROPHY WITH MODIFIED PENILE DISASSEMBLY Hafez A.. Elsherbiny Urology & Nephrology
M., Bazeed M., Ghoneim
G., Traverse P., Naselli A., Bertolotto F., Romagnoli
URETHRA:
A., Corbu C.
University of Genoa, Urology, Genoa, Italy INTRODUCTION & OBJECTIVES: Primary malignant melanoma of the urethra is extremely rare. Only 160 cases are reported worldwide, of which 37% occurred in males, The majority of the cases concern patients over 50’s (no cases described under 30 years). Symptoms are common to other urethral turnours. The most frequent sites of occurrence are fossa navicularis (55%) prostatic urethra (15%), penile urethra (15%) bulbar urethra and external urethral meatus. MATERIAL & METHODS: A 43 year old male presented with a diagnosis of malignant melanoma of the urethra after histologic examination of a polypoid lesion of the fossa navicularis. No other primary localization of the disease was found. The patient underwent a urography and a retrograde urethrography that showed an irregular urethral wall; CT scan showed a left inguinal lymph node of 1.5cm and PET an increased inguinal bilateral uptake. Flexible urethroscopy showed multiple small-pigmented lesions of the penile urethra. In this video we describe a two step surgical approach, which allowed a complete resection of the lesions, an extended lymphadenectomy and a good reconstruction of the distal urethra and a satisfactory cosmetic appearance of the widely resected glans. 1) At a preliminary step a dissection of the left inguinal superficial sentinel lymphnode was performed with a pathologic diagnosis of an isolated melanomatous metastasis. We then did a distal urethrectomy with partial excision of the glans. Corpora cavemosa remained fully intact. A reconstruction of the remaining wings of the glans, the preparation of the future neo-urethra by means of the transposition of a wide preputial flap, an urethrostomy at penile base and an extended inguinal and pelvic lymph node dissection were carried out. Pathologic examination confirmed multiple melanomatous nodules; surgical margins of resection and all the 25 lymph-nodes dissected were disease free. 2) After 3 months, a reconstruction of a complete neo-urethra with an orthotopic neomeatus was performed.
two sex
CONCLUSIONS: The small number of cases reported in medical literature is not sufficient to indicate a unique therapeutic solution that varies from partial resection of urethral tissue to radical urethrocystectomy. At 6 months from first diagnosis, our patient is disease free and has normal erections with a normal sexual life.
V23
V24
BLADDER
CARCINOMA OF THE PENIS: VIDEO-ALGORITHM LYMPHADENECTOMY Slmonato A.. Lissiani A.. Grcgorl A., Borzola A
M
Center, Urology, Mansoura,
v22 PRIMARY MALIGNANT MELANOMA OF THE RECONSTRUCTIVE SOLUTION IN A RARE CASE
Egypt
, Gal11 S..Gaboardi
FOR INGUINAL
F
I.. Sacco Hospital. Urology. Mdan. Italy
INTRODUCTION & OBJECTIVES:
INTRODUCTION & OBJECTIVES: In 1999. Grady and Mitchell popularized the complete primary repair of bladder exstrophy. They closed the bladder and urethral plate in continuity with epispadias repair using total penile disassembly. However, the procedure results in hypospadias in one third of children. We modified the penile disassembly part of the one stage exstrophy reconstruction by omitting distal division of the urethral plate to obtain an orthotopic urethral meatus. MATERIAL & METHODS: This video illustrates the operative steps of one stage exstrophy reconstruction in a 2-day-old neonate. These steps include I) Complete mobilization of the bladder plate with incision of the intersymphyseal bands, 2) Dissection of the urethral plate with its wedge of blood supply from the corporal bodies, 3) Bladder closure with continuous suture of 4/O polglycate, 4) Tubularization of the urethral plate using 710 polyglycate interrupted sutures, 5) Approximation of pubic symphysis using two interrupted sutures of 0.0 Polydixanone, 6) Approximation of the corporal bodies dorsally utilizing 610 polyglycate mterrupted sutures,. 7) Glans closure utilizing 710 polyglycate interrupted sutures, and 8) Wound closure with redistribution of the penile skin. RESULTS: The preliminary results of one stage primary reconstruction of bladder exstrophy have been encouraging. Early bladder cycling and concomitant epispadias repair might decrease the future need of bladder neck reconstruction, Moreover, the modified penile disassembly would obviate the need for a second procedure for hypospadias repair. CONCLUSIONS: We modified penile disassembly by preservation of the distal attachment of the urethral plate to the glans. The procedure results in orthotopic urethral meatus following one stage exstrophy reconstruction.
Urogenital neoplasms spreading to the mgumal lymph nodes are pende carcinoma (the most frequent), urethral and scrotum cancers. turnours of the testis wth scrotal violation. Penile carcinoma is an uncommon malignant disease and accounts for as many 0.4-0.6% of male cancers. Most patients are elderly. It rarely occurs in men under age 60 and its incidence increases progreswely until it reaches a peak in the eighth decade I. The risk of a lymph node invasion is greater with high grade and high stage tomours 2. Some mvestigators have reported the inaccuracy of the sentmel node biopsy 3,4. described by Cabanas 5. Patients with m&static lymph node penis cancer have a very poor prognosis If penectomy only is performed. Ilioinguinal lymphadenectomy is basically carried out as a treatment modality and not only as a staging act. Patients with lymph node invasion have a 30.40% cure rate. Ilioinguinal lymphadenectomy should be also performed m patients with disseminated neoplasms for the local control of the disease. The 5 years survival rate of patients with climcally negative lymph nodes treated with a mod&d inguinal lymphadenectomy is 88% versus 38% in patients not initially treated with lymphadenectomy 6. This videotape clearly shows a therapeutic algorithm, the anatomy of the ingurnal lymph nodes, according to Rouviere 7 and Daseler 8, the radical llioinguinal node dissection with transposition of the sartorius muscle and the modified inguinal lymphadenectomy proposed by Catalona 9. References: I. Lynch D.F. and Schellhammer P: Tumours of the penis. In Campbell’s Urology Seventh Edition, edited by Walsh P.C., Retlk A.B., Darracott Vaughan E. and Wein A.J. W.B. Saunders Company, Vol. 3, chapt. 79, p. 2458, 1998. 2. Pizzocaro G., Piva L., Bandieramonte G., Tana S. Up-to-date management of carcinoma ofthe pems. Eur. Ural. 32: 5-15, 1997 3. Perinetti E., Crane D.B. and Catalona W.J. Unreliability of sentinel lymph node biopsy for staging penile carcinoma. J. Ural. 124: 734, 1980 4. Fowler J.E. Jr. Sentinel lymph node biopsy for staging penile cancer. Urology 23: 352, 1984 5. Cabanas R.M. An approach for the treatment of penile carcinoma. Cancer 39: 456, 1977 6. Russo P. and Gaudin P. Management strategies for carcinoma of the penis. Contemporary Urology; 5:4X-66, 2000 7. Rouviere H. Anatomy of the human lymphatic system. Edwards Brothers, p. 218, 1938 8. Daseler E.H., Anson B.J., Reimann A.F. Radical excision ofthe ingumal and 111x lymph glands: a study based on 450 anatomnxl dissections and upon supportive chnical observations. Surg. Gynecol. Obstet. 87. 679, 1948 9. Catalona W.J. Modified ingumal lymphadenectomy for carcinoma of the penis with preservation of aaphenous veins. technique and preliminary results. J. Ural. 140: 306-3 IO. 1988 European
Urology Supplements 2 (2003) No. 1, pp. 209