Phimosis
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? Phimosis? Prepuce cannot be retracted over the glans penis
? Physiologic Phimosis
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? Pliant, unscarred preputial orifice
? Pathologic Phimosis
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? Failure to retract secondary to distal scarring of the prepucePathologic Phimosis
? Occurs mostly by forcefully pulling back the prepuce in
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infancy
? Scarring after Infection
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? Failure of the phimotic preputial ring to retract afterchildhood
Osburn et al, Pediatrics 1981
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Treatment
? No forceful retraction of the prepuce
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? If no retraction at all after 5 years or scarring is present fromprevious attempts
? Betamethasone dipropionate 0.05% cream (Diprolene) ? no FDA
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approval under 16 years of age
? Most important: Parent education about the natural process
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? Handouts? Perform circumcision on parents request
Paraphimosis
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? Tight preputial ring is trapped behind the
glans after retraction
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? Very painful? Edematous preputial skin and glans
? Urinary retention
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? Requires immediate attention
? Pain
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? Possible necrosis? Management
? Compression
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? Dorsal slit
Peyronie's disease
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Definition
? Described by Francois Gigot
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de la Peyronie in 1743? Also known as induratio penis
plastica
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? Fibrotic induration of the penis
with concurrent curvature
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Clinical presentation
? Peak incidence
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? 4th to 6th decades? Pain and penile curvature during erection
? Difficult intercourse
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? Impotence in some cases
? A hard fibrotic mass is felt on palpation
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Etiology? Fibrosing condition of the tunica albuginea
? Repeatitive microtrauma is most probably the inciting
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event
? Dupuytran's contracture has been associated with PD
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? Always examine the hands? Possible genetic aetiology
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EtiologyClinical course
? Most cases are self limiting
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? Divided into acute and chronic phase
? In the acute phase
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? Pain? Worsening of the deformity
? Enlargement of the plaque
? 12 to 18 months duration
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? Chronic phase? No pain
? Stable deformity
Treatment
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? Medical
? Usual y during the acute phase
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? Oral therapy? Vitamin E
? Potassium para-amino benzoate
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? Colchicine
? Tamoxifen
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? PentoxifyllineTreatment
? Transdermal therapies
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? Verapamil
? Intralesional
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? Verapamil? INF alpha 2 beta
? Saline
? Intralesional therapies not for cure, but more for
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prevention of progression? Other therapies
? ESWL
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Surgical treatment? Reserved for patients with PD for at least 12 months
(chronic phase) and a stable deformity for at least 3
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months
? 3 groups of surgery
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? Penile shortening? Penile lengthening
? Penile prosthesis
Surgical Treatment
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ED
+
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-Penile Prosthesis
Normal length
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Short penis
< 30 degrees
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> 45 degreesPenile shortening
Penile lengthening
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procedure
procedure
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NesbitGraft
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Surgical treatment
Penile Shortening (Nesbit
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Plication)
Surgical treatment
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Penile prosthesisCarcinoma Penis
Introduction
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Uncommon malignancy in developed countriesHigher incidence rates are seen in Africa and Asia (10%
to 20%)
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Commonly affects those between 50 and 70 years of
age
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22% of patients are less than 40 years of ageEpidemiology
? Intact foreskin
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? Phimosis (25%)
? Precancerous lesions are found in 15%-20% of patients
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? Human papilloma virus(HPV 16,18)? Chronic inflammatory conditions (eg, balanoposthitis and
lichen sclerosus et atrophicus)
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Premalignant lesionsPathology
? Primary malignancies (those that originate from either the
soft tissues, urethral mucosa, or covering epithelium)
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? Secondary malignancies (ie, those that representmetastatic disease and often affect the corpus
cavernosum
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? MC: squamous cell carcinoma is found on
glans: 48%,prepuce: 21%,glans & prepuce:9%,coronal
sulcus: 6%, and shaft: <2%
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? Primary, non squamous malignancies comprise <5% of
penile cancers.
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? Sarcomas are the most frequent non squamous penilecancers, followed by melanomas, basal cell carcinomas,
and lymphomas
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Clinical Presentation
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? Area of induration or erythema to a non healing ulcer or a
warty exophytic growth
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? Palpable inguinal lymphadenopathy is present at diagnosisin 58% of patients ( 20%-96%)
? In non palpable inguinal lymph nodes at the time of resection
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of the primary tumor, 20% will found to have metastatic
disease
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Staging: Two staging systems
Jackson
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AJCC Cancer Staging Manual, 5th ed
TNM
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Prognostic Factors
? Grade
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? Depth of invasion? Number of positive lymph nodes
? Unilateral or bilateral inguinal extension
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? Pelvic nodes involvement
? Presence of lymph node extracapsular extension
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Diagnosis
? Physical examination
? Cytological and/or histological diagnosis
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? Chest x-ray
? CT scan/PET-CT scan
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? Bone scanPET CT scan
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Treatment of the Primary Lesion? Small tumors limited to foreskin:
? circumcision+2-cm margin
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Circumcision alone, especially with tumors in the proximalforeskin, may be associated with recurrence rates of 32%
? Small superficial penile cancers:
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? Moh's micrographic surgery? Radiation therapy (EBRT/brachytherapy)
? RT has yielded local control rates similar to surgical resection:
? Carcinomas involving the glans & distal shaft:
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? partial penectomy excising 1.5 to 2 cm ofnormal tissue proximal to the margin of the tumor.
This should leave a 2.5- to 3-cm stump of penis
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? Bulky T3 or T4 proximal tumors involving the base of the
penis:
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total penectomy with perineal urethrostomy
Lymphadenectomy in Penile Cancer
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? Lymphadenectomy is indicated in patients with palpableinguinal lymphadenopathy that persists after treatment of
the primary penile lesion following a course of antibiotic
therapy
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Srinivas 1987, Ornellas 1994
N0 Groin: Treatment Options
? Fine needle aspiration cytology
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? Isolated node biopsy
? Sentinel node biopsy
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? Extended sentinel LN dissection? Intraoperative lymphatic mapping
? Superficial dissection
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? Modified complete dissection
Fine needle aspiration cytology
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? Requires pedal / penile lymphangiograhy for nodelocalization & aspiration under fluoroscopy guidance
? Multiple nodes to be sampled
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? Sensitivity 71% (Scappini 1986, Horenblas 1993)
? Can provide useful information to plan therapy when +ve
Sentinel Node Biopsy
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? Based on penile lymphangiographic studies of
Cabanas (1977)
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? Accuracy questioned: False ?ve 10=50% (Cabanas1977, McDougal 1986, Fossa 1987)
? Extended sentinel node biopsy: 25% false ?ve
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? False ?ve due to anatomic variation in position of
sentinel node
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Unreliable method: Not recommendedIntraoperative Lymphatic Mapping
? Potential for precise localization of sentinel node
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? Intradermal inj of vital blue dye or Tc- labeled colloid
adjacent to the lesion
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? Horenblas 11/55: All +ve False ?ve in 3? Pettaway 3/20: All +ve No false ?ve
? Tanis (2002): 18/23 +ve detected (Sensitivity 78%)
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Promising technique for early localization of nodal metastases
Long-term data needed
Superficial Inguinal LND
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? Removal of nodes superficial to fascia lata
? If nodes +ve on FS: Complete inguino-pelvic LND
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? Rationale: No spread to deep inguinal nodes when superficialnodes ?ve (Pompeo 1995, Parra 1996)
? No clinical evidence of direct deep node mets when corporal
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invasion present
Complete Modified LND
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(Catalona 1988)? Smaller incision
? Limited inguinal dissection (superficial + fossa
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ovalis)? Preservation of saphenous vein
? Thicker skin flaps
? No sartorius transposition
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Identifies microscopic mets without morbidity
(Colberg 1997, Parra 1996)
Cancer Penis: Management of N+ groin
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? Surgical treatment recommended for operable inguinal
metastatic disease
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? Most patients with inguinal LN mets will die if untreated.? 20-67% patients with metastatic inguinal LN disease free 5
years after LND.
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? Better survival 82-88% with single / limited mets
Pelvic Lymphadenectomy
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? Staging tool? Identifies patients likely to benefit from adjuvant chemo
? Adds to locoregional control
? No additional morbidity
? If pre-op pelvic node identified : NACT followed by
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surgery in responders
Value of pelvic LND unproven
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Patients with minimal inguinal disease & limitedpelvic LN mets may benefit
Inguinopelvic Lymphadenectomy:
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Indications for adjuvant therapy? >2 metastatic inguinal nodes
? Extranodal extension of disease
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? Pelvic lymph node metastases
Penile Cancer
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Management of fixed nodes? Neoadjuvant chemo + surgery in responders
? Palliative chemotherapy
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? Chemotherapy + radiation therapy
Complications of lymphadenectomy
? Persistent lymphorrhoea
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? Wound breakdown, necrosis, infection
? Lymphocyst
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? Femoral blowout? Lymphangitis
? Lymphoedema of lower extremity
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Conclusion
? Uncommon disease
? No systematic study & complete absence of RCTs
? Small no of patients over a long time
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? RCTs to develop guidelines essential