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Objective: To identify the factors that determine the minimum length of biopsy sample required for accurate diagnosis., Materials and Methods: A retrospective analysis was conducted on 1202 cases that underwent rectal ultrasound-guided trans-perineal prostate biopsy (TPB) with standardized biopsy surgical procedures and pathological evaluation. Logistic regression correlation analysis and the imbalance between groups was eliminated by propensity score matching of patients' own factors between groups (positive group and negative group). ROC curve optimal threshold analysis were performed to identify the independent factors associated with cancer detection rate and the minimum length of biopsy sample required for accurate diagnosis., Results: The study included 1202 cases that underwent standardized 8-18 needle initial puncture biopsies from June 2020 to October 2023. The cancer detection rate was 40.02% (481/1202), with Gleason scores of 6, 7, 8, 9, and 10 in 164, 134, 107, 67, and 9 patients, respectively. The percentage of patients with clinical significance (International Society of Urological Pathology (ISUP) ≥ 2) was 65.90% (317/481). Multivariate analysis showed that age,prostate-specific antigen(PSA), prostate volume,positive multi-parametric magnetic resonance imaging (mp-MRI) and length of biopsy samples were significant factors (P < 0.05)。Interestingly, biopsy sample length did not correlate with the prostate volume (Pearson correlation P = 0.069). ROC curve analysis: The area under the curve AUC for sample length were 0.674 and 0.664 at before and after propensity score matching,respectively; the optimal thresholds were 12.25 mm and 11.00mm at before and after propensity score matching,respectively., Conclusion: The independent predictors of cancer detection rate during TPB are age, PSA, prostate volume, positive mp-MRI, and sample length. Among these, sample length is the most critical indicator affecting puncture quality, and the minimum value of biopsy sample length to be obtained is 11.00mm., (© 2024. The Author(s).)

Purpose: To validate the Barcelona magnetic resonance imaging predictive model (BCN-MRI PM) in men with pre-biopsy multiparametric MRI (mpMRI) reported with the Prostate Imaging Reporting and Data System (PI-RADS) v2.1, followed by transrectal and transperineal prostate biopsies., Materials and Methods: Prospective analysis of 3,264 men with PSA >3.0 ng/mL and/or abnormal digital rectal examination who were referred to ten participant centers in the csPCa early detection program of Catalonia (Spain), between 2021 and 2023. MpMRI was reported with the PI-RADS v2.1, and 2- to 4-core MRI-transrectal ultrasound (TRUS) fusion-targeted biopsy of suspected lesions and/or 12-core systematic biopsy were conducted. 2,295 (70.3%) individuals were referred to six centers for transrectal prostate biopsies, while 969 (39.7%) were referred to four centers for transperineal prostate biopsies. CsPCa was classified whenever the International Society of Urologic Pathology grade group was 2 or higher., Results: CsPCa was detected in 41% of transrectal prostate biopsies and in 45.9% of transperineal prostate biopsies (p < 0.016). Both BCN-MRI PM calibration curves were within the ideal correlation between predicted and observed csPCa. Areas under the curve and 95% confidence intervals were 0.847 (0.830-0.857) and 0.830 (0.823-0.855), respectively (p = 0.346). Specificities corresponding to 95% sensitivity were 37.6 and 36.8%, respectively (p = 0.387). The Net benefit of the BCN-MRI PM was similar with both biopsy methods., Conclusions: The BCN-MRI PM has been successfully validated when mpMRI was reported with the PI-RADS v2.1 and prostate biopsies were conducted via the transrectal and transperineal route., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Competing Interests: Declaration of competing interest All the authors have no potential conflicts of interest to disclose.

Objectives: the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE)., Methods: we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin., Results: sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239)., Conclusion: rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.

The Buschke-Löwenstein tumor is a rare disease associated with human papillomavirus infection. The condition manifests with an ulcerative, exophytic tumor localized in the perineal area. Generally considered as non-cancerous, the growth may develop malignant transformation. Our manuscript highlights the importance of early diagnosis with histopathological analysis.

Rationale: Embryonal rhabdomyosarcoma (ERMS) is a major subtype of rhabdomyosarcoma, mainly affect children. There is seldom report for perineal ERMS in adults, since its rare location and the age., Patient Concerns: A 20-year old male adult was admitted due to the perineal mass., Diagnoses: Diagnosis by histopathological examination of the biopsy sample was ERMS. Magnetic resonance imaging showed the tumor was found in the perineal region, with metastasis to pelvic cavity, right testis, lymph nodes and bone., Interventions: The patient received Isophosphamide and Epirubicin for 4 cycles, followed by Irinotecan and Vindesine Sulfate for 2 cycles, then cisplatin, Dacarbazine and Apatinib for 3 cycles., Outcome: The patient showed no response to chemotherapy., Lessons: Perineal ERMS in adults is very rare. There is still no standard therapy for adult ERMS. Personalized therapy might be promising treatment for each individual., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Aggressive Angiomyxoma is a benign, slowly growing, locally aggressive and recurrent tumour that occurs in the pelvic-perineal region of females in their reproductive years. It presents as a painless, soft, gelatinous mass and metastasizes rarely. Suspicion can be made based on clinical examination and radiological imaging but final diagnosis is confirmed only after histopathology and immunohistochemistry. The choice of treatment is surgical wide local excision., Case Presentation: We hereby present a case of a 19-year, unmarried lady, with a body mass index of 21 kg/m 2 , who presented with a chief complaint of painless mass in left vulva which progressively increased in size in the past one year. Clinical examination revealed a large, cauliflower like, exophytic mass of 10 cm × 10 cm size. Radiological imaging confirmed involvement of lymph nodes. Wide local excision with adequate tumour free margin and depth was used as a treatment modality. The diagnosis was confirmed via histopathological examination of the excised specimen. There is no recurrence in the patient up to date., Conclusion: Aggressive Angiomyxoma is a rare tumour and it is most often misdiagnosed. This report highlights the importance of considering Aggressive Angiomyxoma as a differential diagnosis of vulval masses and the two-step surgical approach for its treatment in low resource setting., (© 2022. The Author(s).)

Background: Aggressive angiomyxoma (AAM) is a locally infiltrative mesenchymal tumour that most commonly affects the pelvis and/or perineum in adult women. AAM is very rare in males, especially in infancy., Case Presentation: A 10-month-old fulani (African) male infant was referred to our department for a large painless mass in the right testicule. The mass was detected during the neonatal period and gradually increased in size. Ultrasound examination revealed a large heterogeneous lesion; computed tomography results led to the conclusion that the mass was a mesenteric hernia. An inguinal and scrotal surgical approach was adopted. Exploratory surgery found a normal right testicle displaced upwardly and a large scrotal mass. Radical excision of the mass and orchidopexy were performed. Subsequent histology and immunohistochemstry studies indicated that the mass was a scrotal angiomyxoma. The postoperative course was uneventful. No recurrence occurred during the 6-month follow-up., Conclusion: To the best of our knowledge, this is the youngest patient with AAM reported to date. Angiomyxoma should be included in the differential diagnosis of scrotal masses, for which radical excision is justifiable to prevent recurrence., (© 2022. The Author(s).)

Aggressive angiomyxoma (AA) is a rare neoplasm of mesenchymal origin. It most commonly occurs in young women, predominantly in the pelvi-perineal region. We describe a case of AA arising from the lesser curvature of the stomach in a young woman who presented with a lump in the abdomen for 6 months. The patient subsequently underwent en bloc resection of the tumour and the diagnosis was confirmed on histology. This is the first reported case of gastric origin of AA to the best of our knowledge., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

This case report describes a patient with complicated Crohn's disease who presented to a routine gastroenterology clinic complaining of increasing white discharge from a chronic perianal abscess. MRI of the perineum established the diagnosis of a seminal vesicle fistula connecting to the perianal skin. He was treated conservatively, with optimisation of his Crohn's disease medication regime. Seminal vesicle fistulation is a rare pathology., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Median raphe cyst is usually benign and asymptomatic male genitalia lesions. Although uncommon, infection may be a complication., Case Presentation: We report the case of a 4-year-old child presented to the emergency department for a serpiginous and redness lesion extended from the basis of the penis until the perineum. An infected median raphe cyst was suspected, and the patient underwent surgical treatment and antibiotic therapy with complete resolution of symptoms. Liquid culture resulted positive for Serratia Marcescens., Conclusion: Infection is a rare complication, especially in childhood. To prevent relapses and clinical symptoms, the majority of authors recommend surgical excision followed by primary closure. In case of infections caused by Serratia Marcescens, chronic granulomatous disease should always be rule out., (© 2022. The Author(s).)

Background: Aggressive angiomyxoma is a type of mesenchymal tumor occurring predominantly in the pelvic and perineal region. The aim of our study was to reveal our experience with gonadotropin-releasing hormone (GnRH) treatment in patients with angiomyxoma and provide a comprehensive review of management., Patients and Methods: This study is a case-series including seven female patients diagnosed with aggressive angiomyxoma from a single institution, between 2012 and 2020. Follow-up after surgery was ranged between 2-45 months with an average of 17.6 months. Resection was performed in all patients without any complications, and five had received GnRH analogue (Goserelin acetate) therapy after surgery. Immunohistochemistry analyses showed positivity for smooth muscle actin and desmin in all cases, while both estrogen receptor (ER) and progesterone receptor (PR) positivity were identified in 6 patients. None of the seven patients had recurrence during follow up period., Conclusion: The mean treatment of aggressive angiomyxoma is surgery, and the use of GnHR analogues in cases with positive ER and PR may be effective in preventing recurrence., Key Words: Aggressive Angiomyxoma, Gonadotropin-Releasing Hormone, Soft Tissue Neoplasm.

Folliculosebaceous cystic hamartoma (FSCH) is a benign lesion that presents as a solitary papule or nodule that typically affects the face and scalp of adults. A few reports have observed a congenital presentation. We present an infant boy exhibiting a tumor with overlap features between an FSCH and fibrofolliculoma in the perianal region that was first noticed at 6 months of age. The histological examination showed a hamartomatous benign proliferation of hair follicles and disordered sebaceous glands, which is consistent with the infundibular structures and radiating sebaceous glands that are typically observed in previously reported cases of FSCH. Sebaceous differentiation is a hallmark feature of FSCH. Folliculosebaceous cystic hamartoma is believed to be a late-stage form of trichofolliculoma (TF). Another consideration is that FSCH and TF are two distinct entities set apart by their degree of sebaceous or follicular differentiation and development of the mesenchymal stroma.

Rationale: Tarlov or perineurial cysts are nerve root lesions often found in the sacral region. Most perineural cysts (PCs) remain asymptomatic throughout a patient's life. While their pathogenesis is still unclear, trauma resulting in hemorrhaging into subarachnoid space has been put forward as a possible cause of these cysts. Recently, we worked with a patient experiencing symptomatic PCs after spontaneous subarachnoid hemorrhage., Patient Concerns: A 45-year-old man had a coil embolization procedure performed after being diagnosed with a subarachnoid hemorrhage from a ruptured anterior communicating artery. His symptoms were relieved after the procedure, but 7 days later he reported worsening pain in the left perineal area. The pain was intermittent at its onset and exacerbated by sitting, walking, and coughing., Diagnoses: Two weeks after the embolization procedure, a lumbar spine MRI revealed 2 PCs at the S1 and S2 level affecting the left S2 root with high signal intensity in T2 and T1 images, suggestive of bleeding within the cyst., Interventions: We operated using a posterior approach. Cyst fenestration was done after S1 laminectomy. We aspirated approximately 1 cc of old blood., Outcomes: His pain was relieved immediately after cyst removal and no neurologic deterioration occurred during the postoperative period., Lessons: Subarachnoid hemorrhage can be the source of the development of pain from asymptomatic PCs, making them symptomatic. Surgical extirpation is 1 treatment option for these symptomatic PCs., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: To compare the feasibility of transrectal and transperineal fiducial marker placement for prostate cancer before proton therapy., Materials and Methods: From 2013 to 2015, the first 40 prostate cancer patients that were scheduled for proton therapy underwent transrectal fiducial marker placement, and the next 40 patients underwent transperineal fiducial marker placement (the first series). Technical and clinical success and pain scores were evaluated. In the second series (n = 280), the transrectal or transperineal approach was selected depending on the presence/absence of comorbidities, such as blood coagulation abnormalities. Seven patients refused to undergo the procedure. Thus, the total number of patients across both series was 353 (262 and 91 underwent the transrectal and transperineal approach, respectively). Technical and clinical success, complications, marker migration and the distance between the two markers were evaluated., Results: In the first series, the technical and clinical success rates were 100% in both groups. The transrectal group exhibited lower pain scores than the transperineal group. The overall technical success rates of the transrectal and transperineal groups were 100% (262/262) and 99% (90/91), respectively (P > 0.05). The overall clinical success rate was 100% in both groups, and there were no major complications in either group. The migration rates of the two groups did not differ significantly. The mean distance between the two markers was 25.6 ± 7.1 mm (mean ± standard deviation) in the transrectal group and 31.9 ± 5.2 mm in the transperineal group (P < 0.05)., Conclusion: Both the transrectal and transperineal fiducial marker placement methods are feasible and safe., (© Crown copyright 2020.)

Perianal Paget disease (PPD) is a rare neoplastic condition defined by the presence of atypical Paget cells in the perianal skin, the aetiology of which remains largely unknown. It can be divided in primary forms, arising as an intraepithelial disease or manifestation of an underlying skin adenocarcinoma or secondary forms resulting from epidermotropic spread or metastasis of a concealed carcinoma. Indeed, because of its rarity, clear options regarding the treatment of these patients are yet to be clarified. A high level of suspicion is needed whenever dealing with any unhealed perianal skin lesions and, therefore, the need for close long-term follow-up must be highlighted. Herein, two cases of PPD, one primary and another secondary, treated at the same institution, are presented in an attempt to document the involved complexity and to bring further insight into the understanding of this entity., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Aggressive angiomyxoma is a rare mesenchymal tumour, primarily arising in the soft tissue of the pelvis and perineum in women of reproductive age. There is a paucity of evidence on optimal management because of the rarity of these tumours, but the consensus has been for surgical excision. We present the case of a 65-year-old woman who was admitted with left-sided buttock pain and initially diagnosed with a perianal abscess. She underwent examination under anaesthesia rectum with surgical excision of the lesion, subsequent histopathological and immunochemical analysis was suggestive of aggressive angiomyxoma. To complement our case report, we also present a literature review focusing on aggressive angiomyxoma in the ischioanal fossa (also known as the ischiorectal fossa) with only eight cases of primary aggressive angiomyxoma involving the ischioanal fossa documented to date. The primary aims of this case report and literature review are to familiarise clinicians with the clinical, histopathological and immunochemical features of these tumours, and to increase appreciation that despite the rarity of aggressive angiomyxoma, it might be considered in the differential diagnosis of ischioanal lesions.

Background: Perineal endometriosis is the presence of endometrial tissue in the perineal region. Early diagnosis and treatment is important due to anal sphincter involvement in almost half of the patients. Endoanal ultrasonography is a reliable technique in the assessment of perineal endometriosis with anal sphincter involvement. This report describes the presentation, clinical investigation, and surgical treatment of a perineal endometriosis case CASE REPORT: 32-year-old female patient presented with cyclic pain and swelling of an old episiotomy scar. Three-dimensional endoanal ultrasonography showed a lesion with involvement of the external anal sphincter muscles, and it was completely excised and primary sphincteroplasty was performed for the external anal sphincter defect.The final pathology result was reported as endometriosis. Postoperative periods were uneventful and anal incontinence was not observed., Conclusion: Perineal endometriosis is a rare disease and may involve the anal sphincter muscles. Incomplete excision to protect the sphincters is associated with high recurrence, while extensive excision can cause anal sphincter damage that may cause anal incontinence. Endoanal ultrasonography may be necessary in surgical planning. Primary sphincteroplasty with excision may be necessary in cases of perineal endometriosis with external anal sphincter muscle involvement., Key Words: Case Report, External Anal Sphincter, Endoanal Ultrasound, Sphincteroplasty Perineal Endometriosis.

Angiofibroma is a benign soft tissue tumour presenting as a gradually progressive swelling in the vulvovaginal area in women and in the inguinoscrotal region in men. Being a rare tumour, there are only a few case reports in the literature, and among them, presentation as perineal herniation is very rare. En bloc resection of angiofibroma either via laparoscopic or open approach is the choice of treatment to avoid recurrence. Detailed pathological examination and immunohistochemistry workup are imperative to distinguish it from various mesenchymal tumours. Perineal hernia is itself rare and may occur spontaneously or following abdominoperineal resection, sacrectomy or pelvic exenteration. Surgical repair via open transabdominal and transperineal approaches has been described. Here, we report a case of a young woman who presented with spontaneous reducible perineal hernia with a soft tissue tumour as its content, which on histopathological investigation was found to be an angiofibroma., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Abdominoperineal excision of rectum (APER) is one of the widely used surgical procedures to treat low rectal cancer, benign conditions like Crohn's proctitis with anal involvement and as a salvage procedure for anal cancer. Perineal wound infection is a well-recognised complication following such major surgery. Occurrence of appendicitis in a few weeks' time following such a major surgery is uncommon. However, here we present a rare case report of perforated appendicitis presenting as persistent perineal discharge in an elderly man, following laparoscopic APER for a low rectal tumour. To our knowledge, this is the first time such a rare clinical presentation of appendicitis is reported in the history of medical literature. Through this case report, we aim to highlight the importance of considering such an uncommon presentation in patients with perineal discharge, following APER., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

The increased use of monoclonal antibodies that target the immune checkpoint T cell receptor programmed death-1 (PD1) to treat numerous solid tumors has led to several reports describing associated cutaneous adverse events. Although lichenoid reactions have been well described, we propose that PD1 inhibitor-induced inverse lichenoid eruption (PILE) is a distinct variant. We describe two patients who presented with nearly identical deeply erythematous, malodorous, eroded anogenital plaques with focal crusting. Diagnosis of PILE was established given the biopsy findings and temporal association with PD1 inhibitor therapy. Treatment with clobetasol ointment was successful without necessitating discontinuation of immunotherapy. The findings were consistent with the only other previously published case of inverse lichenoid eruption in the groin secondary to PD1 inhibitors.

Background: Genital malignant neoplasms in mares are relatively rare. The treatment involve surgical removal of the tumour masses, chemotherapy or both., Case Presentation: Two elderly warmblood mares, aged 16 and 20 were presented in University Clinic with the lumpy lesions at the region of perineum and left labia. Surgical removals of tumour masses were performed on standing animals. Removed tissues were subjected to histopathological examination which confirmed SCC., Conclusions: Clinical and ultrasound examination of reproductive organs in both mares showed no inflammatory or neoplastic changes. Both mares healed within 2 weeks after surgery and showed no signs of tumour recurrence for the following year despite no chemotherapy treatment.

Competing Interests: Competing interests: None declared.

X-linked agammaglobulinemia (XLA) is a rare genetic disease caused by a mutation in the Bruton tyrosine kinase (BTK) gene. It is characterized by a profound deficiency of B cells and a decrease in all classes of immunoglobulins (Ig). We report one case in a 3-year-old boy seen for recurrent acute otitis media, perineal abscess, oligoarthritis. The serum immunoglobulin (Ig) assay showed an IgG level of 0.6g/l. IgM and IgA are indosable. Marrow immunophenotyping showed an absence of precursor B less than 1%. Molecular biology confirmed Burton's disease (stop mutation, C37C) in exon 2 of the BTK gene. Treatment with intravenous immunoglogulin was started., Competing Interests: The authors declare no competing interests., (Copyright: Kaba Condé et al.)

Background: Metastatic Crohn's disease (CD) is a rare manifestation of CD. It involves inflammatory skin lesions with histopathological findings (granulomas) similar to CD, without connection to the gastrointestinal tract. Hyperbaric oxygen therapy (HBO) has been suggested as a possible treatment option., Objective: This study aimed to identify and treat a consecutive series of patients with biopsy-proven metastatic CD and monitor wound healing using prospectively acquired outcomes., Methods: Pathology results of all patients with ongoing perineal wound-healing problems after proctectomy between 2005 and 2018 at the Amsterdam University Medical Centre were assessed for metastatic CD. Patients with a biopsy-proven diagnosis of perineal metastatic CD were offered HBO (40 daily sessions of 100% oxygen at 2.4 atmosphere absolute). Wound healing was monitored using photographs and standardised questionnaires (the Inflammatory Bowel Disease Questionnaire, EuroQol Visual Analogue Scale and the Female Sexual Function Index) at baseline and 1 and 3 months after HBO., Results: Out of 13 patients in the cohort with persisting perineal wounds after proctectomy, six (46%) had biopsy results consistent with metastatic CD. Of these, three accepted treatment with HBO. All three patients were female. One patient had complete healing of her perineal wound; another patient showed initial improvement but had a flare of luminal and perineal disease at the 3-month follow-up. The third patient showed improvement solely in the questionnaires, with higher scores on all three questionnaires., Conclusion: A high rate of metastatic CD was found in patients with ongoing wound-healing problems after proctectomy, implying that the disease might not be as rare in these selected patients as previously thought. HBO might be beneficial in the treatment of metastatic CD.

Poorly controlled and long-standing hidradenitis suppurativa (HS) increases the risk of squamous cell carcinoma (SCC). We report a 54-year-old woman with an over 20-year history of HS, who had previously undergone wide perineal excision with secondary intention healing and presented with a painful verrucous vulvar plaque and proximal non-healing perineal wound. The patient had four perineal scouting biopsies performed and excisional biopsy with no evidence of high-grade dysplasia or carcinoma on histology. Chromogenic in situ hybridization was negative for HPV 16 and 18 mRNA; the patient's HIV and HSV PCR were also negative. Our patient was treated with interferon alfa-2b with notable clinical improvement. There is currently no standardized stepwise approach to monitoring verrucous lesions in HS patients with significant risk factors for SCC. Our report highlights a vigilant approach to monitoring. If scouting biopsies are negative, complete testing for high risk HPV strains (HPV 16 and 18) is warranted. If negative, we recommend follow up every 6 months with no further biopsies except if overt clinical changes are observed. We also recommend treatment of verrucous changes to decrease risk of possible malignant conversion. Interferon alfa-2b was effective in decreasing the verrucous lesion burden in our patient and may be considered.

To summarize the clinical features, diagnosis, and treatments of perineal endometriosis (PEM).We retrospectively studied the clinical data of 35 patients with PEM between April 2012 and December 2018 in West China Second Hospital. Patients were divided into the gonadotropins releasing hormone (GnRH) agonist group and non-GnRH agonist group.The main clinical symptom was vulvar painful swellings related to menstrual cycles. Thirty-three patients' lesions (94.29%) were on the episiotomy scar while 1 case was at the opposite side of the scar. We even found 1 nullipara was diagnosed as PEM. Ten patients (28.57%) were found with anal sphincter involvement. All patients received complete excision of PEM. The recurrence rate of GnRH agonist group was 7.69% (1/13), while the rate of non-GnRH agonist group was 18.75% (3/16).Most PEM was associated with episiotomy history, but PEM could also exist in nullipara. Complete excision of PEM was inevitable. The effect of GnRH agonist on recurrence of PEM needs further studies.

Background: Transabdominal ultrasound is useful to assess inflammation in patients with ulcerative colitis (UC); however, the assessment of the rectum is challenging and a barrier for its widespread use., Aim: To evaluate if transperineal ultrasound is useful for predicting endoscopic and histological findings of the rectum in UC., Methods: Fifty-three consecutive adults with UC who required colonoscopy were included and transperineal ultrasound was performed in combination with transabdominal ultrasound within a week before or after colonoscopy with rectal biopsy. Mayo endoscopic subscore (MES) ≤1 was defined as endoscopic healing and Geboes score <2.1, Robarts histopathology index ≤6, and Nancy index ≤1 were defined as histological healing. Limberg score and bowel wall thickness were recorded with transperineal ultrasound. Faecal calprotectin was also measured., Results: Excellent correlation was confirmed between colonoscopy and transabdominal ultrasound in all segments except for the rectum. Rectal bowel wall thickness and Limberg score in transperineal ultrasound well correlated with rectal MES and histological indices. Bowel wall thickness ≤4 mm predicted endoscopic (Area under the curve [AUC] = 0.90) and histological (AUC = 0.87-0.89) healing. In multivariable logistic regression analysis, only bowel wall thickness in transperineal ultrasound was a significant independent predictor for rectal endoscopic and histologic healing (P < 0.05) and the predictability was better than faecal calprotectin., Conclusions: Transperineal ultrasound predicts endoscopic and histological healing of the rectum. The combination of transperineal ultrasound with transabdominal ultrasound visualises the entire colorectum and is an ideal modality for the treat-to-target strategy. Clinical Trials Registry number UMIN000033611 (https://upload.umin.ac.jp/cgi-open-bin/ctr&#95;e/ctr&#95;view.cgi?recptno=R000038323)., (© 2020 John Wiley & Sons Ltd.)

Background: Malignant endometriosis in an episiotomy scar is rare; only seven cases have been reported previously. Here, we compare two cases of benign endometriosis and clear cell carcinoma., Case Presentation: The first case was a 54-year-old woman who presented with a large perineal lesion in her episiotomy scar with high 18F-fluorodeoxyglucose uptake. This location had a history of endometriosis many years ago. She underwent radical excision of the mass and bilateral inguinal lymph node dissection. Histological and immunohistochemical analysis confirmed the presence of clear cell carcinoma arising from endometriosis. Assisted radiotherapy was performed after surgery due to a positive lymph node. No recurrence was detected over a 1-year follow-up period. The second case deals with a 3 × 2 cm mass in the episiotomy scar of a 33-year-old woman. Part of the anal sphincter was resected because of the close proximity of the lesion. Because the disease lay very close to the anus, she received anal sphincter reconstruction combined with mass excision. Pathology result showed typical endometrial glands and interstitial tissues., Conclusions: Deleterious change only happens in patients experiencing perineal endometriosis. Complete excision is crucial for this form of disease; sometimes impairment of the anal sphincter is also necessary. Patients with malignancy required a combination of treatments in order to improve their prognosis.

Purpose: Hyaluronidase (HAase) has many uses in medicine, and reports suggest that it affects perineal tissue during fetal passage through the vaginal canal. However, its potential use for preventing perineal trauma has yet to be determined. This study sought to evaluate the efficacy and safety of perineal HAase injections in reducing perineal trauma during vaginal delivery., Materials and Methods: A multi-center, double-blind, placebo-controlled, randomized study was conducted from January 2016 to March 2017. Nulliparous women who planned to undergo vaginal delivery were recruited, and the enrolled women were randomly assigned to the HAase injection group (HAase injection, 5000 IU, n=75) or the control group (normal saline injection, n=73). The degree of perineal laceration, rate of episiotomy, and grade of perineal edema at 1 hour and 24 hours after spontaneous vaginal delivery were compared between the two groups., Results: A total of 148 women who underwent vaginal delivery were recruited. No significant differences were observed between the HAase injection and control groups in the rates of perineal laceration ( p =0.422). Perineal edema significantly decreased 24 hours after delivery in the women treated with perineal HAase injections, compared to women in the control group ( p =0.008). The overall incidences of adverse events, such as redness of the injection site, infection, and wound dehiscence, were similar between the two groups., Conclusion: HAase injections in nulliparous women afforded no reductions in the rates of perineal lacerations and episiotomy. However, the use of perineal HAase injections did reduce perineal edema without severe adverse events., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2020.)

Background: Perineal wound complications are a long-lasting issue for abdominoperineal resection (APR) patients. Complication rates as high as 60% have been reported, with the most common complication being delayed perineal wound healing. The aim of this study was to identify risk factors for delayed perineal wound healing and its impact on prolonged hospital stay., Methods: We included low rectal tumor patients who underwent APR at a referral medical center from April 2002 to December 2017; a total of 229 patients were included. The basic characteristics and surgical outcomes of the patients were analyzed to identify risk factors for delayed perineal wound healing (> 30 days after APR) and prolonged hospital stay (post-APR hospital stay > 14 days)., Results: All patients received primary closure for their perineal wound. The majority of patients were diagnosed with adenocarcinoma (N = 213, 93.1%). In the univariate analysis, patients with hypoalbuminemia (albumin < 3.5 g/dL) had an increased risk of delayed wound healing (39.5% vs. 60.5%, P = 0.001), which was an independent risk factor in the multivariable analysis (OR 2.962, 95% CI 1.437-6.102, P = 0.003). Patients with delayed wound healing also had a significantly increased risk of prolonged hospital stay (OR 6.404, 95% CI 3.508-11.694, P < 0.001)., Conclusions: Hypoalbuminemia was an independent risk factor for delayed wound healing, which consequently led to a prolonged hospital stay. Further clinical trials are needed to reduce the incidence of delayed perineal wound healing by correcting albumin levels or nutritional status before APR.

Background: The free flap transfer of a latissimus dorsi flap (LDF) for the closure of sacral wound defects after pelvic exenteration and radiation therapy offers a successful tool of the plastic surgeon. This case report shows the successful coverage using an upstream arterio-venous (AV) loop in combination with an LDF., Case Presentation: We describe the case of a patient who underwent a pelvic exenteration and radiation therapy due to a local recurrence of rectal cancer. The initially used VRAM flap could not ensure a satisfactorily wound closure. An interdisciplinary approach first yielded an AV loop using both greater saphenous veins and was connected to the arteria and vena femoris followed by a free LDF transfer, which was performed 11 days later. The result was an excellent reconstructive and plastic coverage of the sacral wound defect with a well-perfused LDF. The long-term result showed a perfectly integrated flap in the sacral region., Conclusion: We recommend the free LDF for the coverage of large wound defects in irradiated areas after the failure of VRAM flap. If an AV loop is necessary within the flap transfer, we recommend conducting two procedures to guarantee the perfusion of the AV loop.

Necrotising fasciitis (NF) is a potentially lethal spread of infection that is uncommonly seen within the province of surgery. Seen mostly in the extremities and the perineal regions, it has been reported rarely to involve the retroperitoneal space and presents with a spectrum of symptoms and signs as such. Literature supports classification of NF based on the microbes involved. Irrespective of the aetiology and the causative organism, NF remains a serious surgical emergency with high morbidity and mortality not only associated with the disease process itself, but also with the extensive surgical debridement it requires in its management along with antimicrobial administration. We present a case of such an infection found in the retroperitoneal space secondary to a perineal infection forming a rare presentation of this deadly process, and how it was successfully managed secondary to timely surgical intervention., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Most analyses of genital immunity to herpes simplex virus type 2 (HSV-2) have been performed in females, consequently immune protection of the male genital epithelium is incompletely understood. We developed a model of male genital HSV-2 infection resulting from intrarectal inoculation of guinea pigs. Vesicular lesions developed transiently on the perineum and foreskin concurrent with acute virus shedding. Virus shedding and recurrent genital lesions were also detected after establishment of a latent infection. Analysis of perineum and foreskin RNA detected transcripts for IFNγ, proinflammatory and regulatory cytokines, and for genes involved in migration and regulation of leukocytes. HSV-specific T cells were detected in lymphoid and genital tissues after resolution of the primary infection whereas virus-specific antibody secreting cells were detected only in lymphoid tissue. Taken together, the ability to quantify pathogenesis and local immunity in this guinea pig model represent an important advance towards understanding immunity to HSV-2 in males., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Surgical closure of late-stage pressure ulcers (PUs) poses challenges in the immobilized population due to the high rate of complications, including infection, dehiscence, and recurrence. Muscle flap closure is the standard treatment for chronic, late-stage (stage 4) PUs, characterized by the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel as full-thickness tissue loss with exposure of bone, tendon, or muscle., Objective: The aim of this study is to evaluate the outcomes associated with the use of a cryopreserved placental membrane containing viable cells (vCPM) graft for the augmentation of surgical flap closure in nonhealing perineal ulcers., Materials and Methods: Four paraplegic patients (2 men, 2 women; average age, 61 years; range, 44-77 years) with stage IV PUs (ischial, gluteal, and sacral areas) with a mean duration of 4 years (range, 0.5-10 years) received muscle flap closure augmented with vCPM. Following surgical debridement, vCPM was placed between the wound bed and muscle flap closure prior to skin closure. Patients were kept offloaded in fluid-air beds for 6 weeks followed by a gradual return to mobilization., Results: All 4 patients achieved complete wound closure in an average of 7 weeks (range, 6-8 weeks) without complications or recurrence. All patients demonstrated complete take of the muscle flap and maintained their closed wounds for an average follow-up of 12 months., Conclusions: Preliminary clinical results indicate vCPM supports surgical wound closure of chronic perineal PUs in immobile, high-risk patients. In an effort to decrease postoperative recovery time and reduce complications, vCPM may be beneficial for patients undergoing perineal muscle flap closure.

Background: Invasive aspergillosis is a complication in immunocompromised patients and commonly detected in patients with hematological malignancies, which mostly affect the lungs. Because of its high iodine content, rich blood supply and capsule, the thyroid is considered to be less prone to microbial invasion thus most infectious thyroiditis cases are caused by bacteria. However, a few case reports have described thyroid gland aspergilloses, most of which were due to disseminated invasive aspergillosis., Case Presentation: We first report a case of thyroid gland and subcutaneous labium majus aspergillosis in a Chinese patient who received long-term glucocorticoid treatment for systemic lupus erythematosus (SLE) and lupus nephritis, and then we reviewed 36 articles describing similar aspergillus infections in 41 patients., Conclusion: We included 29 cases of diagnosed aspergillus thyroiditis and analyzed clinical findings, treatments and outcomes to provide clinical information for diagnosis and prognosis of thyroiditis caused by Aspergillus fumigatus.

We present a case of an unusual presentation of acute promyelocytic leukaemia (APML), which presented with Fournier gangrene (FG). A 38-year-old man presented with malaise, groin swelling, anal bleeding, fever and was found to have FG. Initial workup revealed pancytopaenia, borderline low fibrinogen, prolonged international normalized ratio (INR), which raised the suspicion for leukaemia. The peripheral blood differential revealed leucopaenia with absolute neutropaenia and a 5% abnormal promyelocytes but no blasts, suspicious for APML. Bone marrow biopsy was performed and fluorescence in situ hydridization (FISH), karyotype and PCR confirmed a t(15;17) translocation, establishing a diagnosis of APML. After 1 month of therapy for intermediate risk APML with All-trans retinoic acid (ATRA) and arsenic trioxide (ATO), repeat chromosomal analysis and repeat bone marrow biopsy revealed no evidence of residual APML. After the consolidation phase was started with ATRA and ATO regimen, the wound healed after 2 months and the patient achieved complete remission., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)