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Purpose To assess the surgical outcomes of augmentation urethroplasty (AU) using penile skin graft (PSG) compared to buccal mucosa graft (BMG) in anterior urethral stricture disease. Method Between January 2018 and January 2019, 100 patients with anterior urethral stricture planned for AU were randomized into PSG or BMG arms (CTRI/2018/07/015028). Anatomic and functional variables were compared pre-operatively and post-operatively. Primary outcome was success rate at 18 months and it was defined if any of the three criteria were met, i.e. either maximum urinary flow (Qmax) > 15 ml/s or urethral calibration of 16 French or ability to traverse the repair with 17 French cystoscope. Secondary outcomes were functional parameters such as International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF) Score, Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ-EJD), and Urethral Stricture Surgery-Patient Related Outcome Measure (USS-PROM). Results Pre-operative variables were comparable between both the arms. Median duration of follow-up was 22 months (18-24 months). At 18 months, the success rates of AU with PSG and BMG were comparable (89% v/s 91%; p = 0.70, 95% CI-0.33 to 5.21). The improvements in Qmax (p = 0.06), IPSS (p = 0.43) and USS-PROM (p = 0.49) were comparable between the two arms. There was no statistically significant difference in the IIEF-Erectile domain (p = 0.07), IIEF-Orgasmic domain (p = 0.11) and MSHQ-EJD (p = 0.20) following AU at 18 months. Clavien-Dindo grade I complications were 12.7% in PSG and 16.7% in BMG. Conclusion This study provides level 1 evidence of no statistical significant difference in outcomes of AU using BMG or PSG.

Gender dysphoria is a condition in which there is a discrepancy between gender identity and the birth-assigned sex. Its prevalence is rising worldwide. The primary objective of this study was to evaluate sexual function in transgender women after gender-affirming surgery using penile skin inversion vaginoplasty. The secondary objectives were to evaluate the most affected domain of the FSFI (female sexual function index) and quality of life (QOL) of these participants. This was a cross-sectional study. The data was collected from 69 transgender women who have undergone penile skin inversion vaginoplasty ≥ 3 months prior to the study initiation. The participants were requested to fill out two questionnaires, the FSFI and WHOQOL-BREF. Sexual dysfunction was diagnosed in transgender women with FSFI score ≤ 26 that is traditionally classified as sexual dysfunction. Eighty-two percent (82.61%) of participants reported a total FSFI score of less than 26. The mean total FSFI score was 22.95, with the lowest score in lubrication domain. However, poor quality of life by WHOQOL-BREF was present in only 2.9% of the tested participants. This study found a significant prevalence of sexual dysfunction by FSFI score in the transgender women who have undergone gender-affirming surgery using penile skin inversion. Quality of life by WHOQOL-BREF score was, however, generally high in this population. Level of evidence: Level IV, risk/prognostic study

Megaprepuce (MP) is a rare and challenging condition characterised by an excessive inner prepuce, paucity of penile skin and an extremely narrow phimotic ring. The aetiological factors leading to its development are poorly understood. A variety of surgical techniques have been described in the last 26 years mostly with small number of patients and short follow-up. It is also highly likely that some series have in the past included different variants of inconspicuous penis combining concealed penis, MP and webbed penis. This article is a systematic review of the literature on Megaprepuce; in particular the embryology, history, aetiology, and the surgical techniques available for the correction of this unique penile anomaly will be presented and discussed in this study.

Hypospadias is a congenital malformation of the male lower urinary tract, consisting of a ventral urethral opening proximal to the glans penis. This condition is corrected surgically in the paediatric age, with a great variety of techniques available. Traditionally, a tubularized genital skin was used for one- or two-stage repairs. Nowadays, the tendency is to use preputial or oral mucosa grafts, dorsally located, to avoid diverticula formation and prevent hair growth in the neourethra. We present a case of a patient born with proximal hypospadias with penoscrotal transposition, surgically corrected in his childhood, using dorsal penile skin island flap. The patient is referred to urology consultation in his adulthood for a weak urinary stream, recurrent infections, and a large amount of hair exiting through the urethral meatus.

Introduction: Penile skin flap urethroplasty is a technique for replacing or enlarging an obstructed urethra. We aim to report our experience in the practice of this surgical technique. Patients and method: This was a prospective and descriptive study of penile skin flap urethroplasty indicated for urethral stenosis between January 2014 and December 2019. Results: A total of 21 penile skin flap urethroplasties for urethral stenosis were performed. The average age was 38.6 years old. The stenosis was of sclero-inflammatory origin in 15 cases (71.43%). It was of bulbo-perineal, penile, and penile-bulbar topography in about a third each. A history of urethral surgery was reported in 80.95% of the cases. The average length of the stenosis was 6.8 cm. Mundy circular skin flap urethroplasty about 15 cases (71.43%), and Quartey rectangular skin penile flap urethroplasty about 6 cases (28.57%) were the surgical techniques performed. The postoperative follow-up was favorable in 19 cases (90.48%). Two cases of urethral fistula (9.52%) underwent the 2nd urethroplasty. Urination at 1 year was satisfactory. No relapse has been reported to date. However, 4 patients (19.04%) reported asthenic ejaculation, and 1 patient (4.76%) a marked decrease in sexual pleasure. Conclusion: This surgical technique is effective in terms of voiding when the surgical indications are well chosen. The sexual aspect must be taken into account and the intervention only offered to those who really need it.

The surgical treatment of extensive urethral strictures remains a controversial topic; although techniques have evolved, there is still no definite method of choice. Since 1968, when Orandi presented an original technique for one-stage urethroplasty using a penile skin flap, the Orandi technique has become the most prevalently used one-stage procedure for anterior urethral strictures. We present a 20-year follow-up experience with one-stage reconstruction of long urethral strictures using a longitudinal ventral tubed flap of penile skin, with some important technical changes to Orandi’s original technique to overcome the deficient vascularity caused by periurethral scar tissue. In 1997, a 55-year-old male patient complained of severe voiding difficulty and a weak urinary stream because of transurethral resection of the prostate due to benign prostatic hyperplasia. Another 47-year-old male patient had the same problem due to self-removal of a Foley catheter in 2002. In both patients, a urethrogram demonstrated extensive strictures involving the long segment of the anterior urethra. A rectangular skin flap on the ventral surface of the penis was used considering the appropriate length, diameter, and depth of the neourethra. The modified Orandi flap provided a pedicled strip of penile skin measuring an average of 8 cm. The mean duration of follow-up was 20.5 years. A long-term evaluation revealed stable performance characteristics without any complications.

Objectives To present a technical tip to be incorporated in the first stage of a 2-stage graft repair of proximal hypospadias associated with curvature, aiming at widening the graft bed and enhancing mobility of the lateral portions of the graft for subsequent urethroplasty. Methods After penile straightening, the dorsal dartos layer, carefully preserved attached to the dorsal penile skin used for penile coverage, is anchored to the lateral edges of the denuded corpora cavernosa with 3 to 4 interrupted 6-0 resorbable stiches on each side. The dartos creates a sort of hammock in-between the corpora, on which the central portion of the graft is quilted as in standard staged graft repair, and the skin margins laterally. Therefore, it widens the graft bed by 3-4 mm on each side. The lateral portions of the graft, laying on dartos, also remain supple for subsequent tabularization. Results Between 2017 and 2019, the technique was used in 16 cases (range 10-19 months). None of these patients required re-grafting because of severe longitudinal graft shrinkage. Conclusion The described modification seems a simple tip to be incorporate in staged graft urethroplasty. Putative advantages include that a wider graft can compensate for some graft shrinkage occurring in-between stages; during the second stage, it can facilitate dissection and improve mobility of the lateral graft portions for tubularization, and make retrieval of a dartos flap for urethroplasty coverage easier. Prospective evaluation and comparative data are needed.

Condylomata acuminata (genital warts) have been identified in transgender women after gender affirmation surgery. We describe a case of a 57-year-old transgender woman with biopsy-proven neovaginal condylomata acuminata following gender-affirmation vaginoplasty using the penile skin inversion technique. The patient was successfully treated with trichloroacetic acid. To our knowledge, this is the first case report demonstrating successful treatment of neovaginal condyloma with trichloroacetic acid. We provide a review of the relevant literature and highlight the evidence for the clinical utility of trichloroacetic acid in transgender women with condyloma of the neovagina.

Huge scrotal lymphedema is a rare problem that affects the patient's lifestyle and leads to physical and emotional disability. It also carries potential challenges for the treating surgeon, especially if the patient is noncompliant or morbidly obese. A 21-year-old morbidly obese trisomy 21 man with huge scrotal lymphedema and buried penis that developed within 2 years presented for excision scrotoplasty with reconstruction of the penis using the original invaginated penile skin. Giant scrotal lymphedema with buried penis can be treated successfully by excision scrotoplasty with preservation of the invaginated healthy penile skin to reconstruct the penis. Keywords: Lymphedema, Genitalia, Trisomy, Scrotoplasty

Background The management of short anterior urethral stricture is challenging. Our study aims to evaluate the outcome of augmented anastomotic urethroplasty (AAU) for the management of men with ultra-short penile urethral stricture, and to compare it with the dorsal onlay buccal mucosa graft. Methods Databases of two tertiary referral centres were retrospectively reviewed to retrieve data of men with ultra-short penile urethral stricture who underwent urethroplasty from 2013 to 2020. Patients who underwent AAU with ventral onlay pedicled skin flap were considered the study group, while patients treated with the dorsal onlay graft augmentation were included as controls. Surgical outcomes included urethral patency, improvement in the maximum flow rate (Qmax), change in sexual satisfaction, and any reported complications. Results Thirty-four patients (and 30 controls) with a median age of 26–27 years were included in the study. The maximum flow rate improved significantly in both groups compared to the preoperative value (p p = 0.788 and 0.913). The operative time was statistically significantly longer in the control group (p = 0.044), while the frequency of postoperative void dripping was much higher in the study group (p = 0.007). Conclusion The success rate and complications of AAU for men with ultra-short penile urethral stricture were comparable to the dorsal buccal graft.

Not required

Heated intraperitoneal chemotherapy (HIPEC) is commonly performed at the time of tumor resection for metastatic intraabdominal tumors. Post operative complications, such as superficial wound infections or bowel leaks are common. They are largely thought to be secondary to poor wound healing due to chemotherapy-associated neutropenia. Scrotal eschars resulting in full-thickness skin necrosis have rarely been reported as a delayed complication after HIPEC. Here, we present the first case report of penile full-thickness skin necrosis after abdominal cytoreduction with HIPEC combined with ventral hernia repair and mesh placement.

Pediatric penile skin grafting is rarely performed. We present a case series of four pediatric patients receiving skin grafting due to the loss of penile skin. The four boys were followed up for 1 to 5 years. One full-thickness skin graft and three split-thickness skin grafts (STSGs) survived well with low Vancouver scar scale scores. One boy gradually developed lymphedema of the distal foreskin and underwent a second preputioplasty. He presented with normal erectile function and did not experience any pain. We propose thick STSGs as the most appropriate choice for pediatric penile skin reconstruction. Lymphedema of the foreskin is an important long-term complication of penile skin grafting.

Voiding symptoms and penoscrotal mass with/without fistula are typical findings of urethral diverticulum. We present a case of 55-year-old male patient who was evaluated for voiding symptoms, soft palpable penoscrotal mass and fistula. Retrograde urethrography, scrotal ultrasonography and cystoscopy revealed a urethral diverticulum and fistula. The defect developed after excision of the diverticulum associated with the penile ventral urethra was closed with a penile skin flap. In the 6-month follow-up, the patient did not have any voiding complaints and no signs of recurrence. Urethroplasty using a penile skin flap may be preferred in the repair of penile ventral urethral defect.

Purpose To evaluate the surgical outcome and predictors of failure of substitution urethroplasty using either dorsal onlay buccal mucosal (BM) graft or ventral onlay penile skin flap (PS) for anterior urethral stricture ≥ 8cm. Patients and methods Between March 2010 and January 2016, 50 patients with anterior urethral stricture ≥ 8 cm were treated at our hospital. The surgical outcome and success rate were assessed. The predictors of failure were analyzed using multivariate analysis. Failure was considered when subsequent urethrotomy or urethroplasty were needed. Results Dorsal onlay BM graft was carried out in 24 patients, while PS urethroplasty in 26 patients. There was no significant difference between both groups regarding patients demographics, stricture characteristics or follow-up period. One case in the BM group was lost during follow-up. Stricture recurrence was detected in 7 (30.4%) patients out of BM group while in 6 (23.1%) patients out of PS group (p value= 0.5). No significant differences between both groups regarding overall early and late complications were observed. Occurrence of early complications and the stricture length were the only predictors of failure in univariate analysis, while in multivariate analysis the occurrence of early complications was only significant. Conclusion On short-term follow-up, both dorsal onlay BM graft and ventral onlay PS flap urethroplasty have similar success rates. However, BM graft has a potential advantage to reduce operative time and is also technically easier. The surgeon should avoid early local complications as they represent a higher risk for failure.

Summary Objectives To investigate the value of electrochemical skin conductance (ESC) measurement at penile level using Sudoscan ® for the diagnosis of neurogenic impotence in diabetics. Methods The following neurophysiological parameters were assessed in 25 male diabetics who complained of impotence and 25 age-matched normal male subjects without erectile dysfunction (age range: 29–70 years): ESC, sympathetic skin responses (SSR), warm detection thresholds (WDT), and cold detection thresholds (CDT) for the penis and the feet, vibration detection thresholds (VDT) for the penis, and sensory nerve conduction study of the dorsal nerve of the penis (DNP) with sensory nerve action potential (SNAP) recording. Results Diabetic patients with impotence differed from controls with regard to most neurophysiological results at both penile and foot levels. Among penile innervation variables in the group of impotent diabetics, penile ESC was found to be the most frequently abnormal (80% of patients), followed by penile WDT, CDT, and DNP-SNAP amplitude (52% of patients), and then penile SSR amplitude and VDT (44% of patients). Various combinations of abnormalities were observed: penile ESC was the only abnormal test in 2 patients, while all tests were abnormal in 2 patients and remained normal in only one patient. Conclusion Erectile dysfunction is common in diabetic men, but the diagnosis of a neurogenic origin is challenging. This study showed that ESC measurement using Sudoscan ® is feasible and more sensitive than SSR recordings to show penile sympathetic innervation impairment. This new test should be further studied to better define its diagnostic accuracy and clinical correlates.

A boy presented as a hypospadias cripple, with anatomy that included a very large diverticulum and little residual external penile skin. The degree of excess skin-like tissue of the diverticulum was sufficient to enable eversion of the longitudinally incised diverticulum and formation of a urethra from the diverticular tissue at a second operation with ultimately an excellent result.

Background: The complications after hypospadias repair still occurred in spite of much advancement of type of suture materials and suture techniques. This study offers new suture technique trying to improve the outcome of hypospadias repair. Methods: This study included 23 hypospadias cases (11 distal penile, 7 mid penile, 5 proximal penile hypospadias). The standard Tabularized Incised Plate (TIP) technique was used in all cases, but the suture technique is faraway, where the two suture limbs passed under the urethral edges. Every suture was tied faraway of urethral edges by about 1cm on one side. Then, the penile skin closed as usual. Lasheen urethral stent was used for two weeks. The mean follow up period was 12months.

The ability to use different flaps and grafts is critical in the successful management of complex urethral strictures. Intimate knowledge of relevant anatomy and principles of tissue transfer are necessary to optimize outcomes. Here, we briefly review these principles and discuss a variety of techniques commonly used by reconstructive urologists depending on stricture length, stricture location, presence or absence of intact corpus spongiosum, and availability of healthy penile skin. We present our algorithms for flap or graft choice and review the pertinent literature supporting their uses.

Penis size has been long regarded as a symbol of strength and sexuality. Attempts to make the penis bigger have been recorded since antiquity. Penile augmentation by injecting mineral oil has been practiced for a long time. The debilitating effect has been long known, and the procedure has been abandoned by most medical practitioners. Still in some places, the practice of penile injection with mineral oil is performed by non-medical persons. The mineral oil contains foreign lipid that cannot be metabolized by human body, thus foreign body reaction will occur. The inflamed tissue and foreign body reaction will result in sclerosing lipogranuloma. This disorder also known with the injected materials names, e.g. paraffinoma, siliconoma or vaselinoma of the penis. Complications of the injection vary from inflammation, swelling, pain, hardened penile skin, to disastrous effects like ulcers, skin necrosis, pain in erection, sexual disability caused by pain either the patient or the sexual partner, and death by embolism. The affected areas are not only localized in the injected site. It can also migrate to the scrotum and suprapubic area. This migration makes treating this disorder more difficult. Surgery is the best viable option to treat this disorder. Complete excision of the affected area, followed by covering the healthy area either by grafts or flaps. If available, scrotal skin is a good choice to cover the affected area. A good classification system of sclerosing lipogranuloma of the penis will be helpful in reporting and treating the disease.

Purpose Penile skin flap uretroplasty is a useful technique for a long urethral stricture due to the ample length and surgical handling characteristics. We investigated the surgical technique and initial results of uretroplasty for anterior urethral strictures using a dorsal penile skin flap. Patients and methods From January 2003 to January 2018, a total of 77 patients underwent substitution urethroplasty using dorsal penile skin flap for bulbar urethral strictures in our institution. All patients were assessed preoperatively, and followed postoperatively by physical examination, urinalysis, retrograde and voiding urethrography, uroflowmetry and post-void residual urine measurement. Success was defined as no requirement of additional urethral instrumentation. Results The mean age was 45 years (10-87). The mean stricture length was 5cm (3-10cm). The mean flap length was 6cm. Urinary fistula was the most common postoperative complication. The mean follow-up was 60 months (6-120). The overall success rate was 88%. Recurrent strictures were found in 4 patients (5%) at 1 year. At 3 year follow-up, 5 (7%) more patients had recurrences. All recurrences were managed by internal urethrotomy. Conclusions Substitution urethroplasty using penile skin flap appear to be a safe and efficient technique for the treatment of a long and complex anterior urethral stricture. It provides encouraging cosmetic and functional results.

Keloid following circumcision has been described in the literature despite the rarity of its occurrence in penile skin. In this paper, we review the literature and report the successful management of post-circumcision keloid scarring in a 2-year-old boy. After circumcision a 2-year-old boy of African origin developed keloid scarring at the circumcision site. This was treated with three intralesional injections of triamcinolone acetate over 3 months, followed by surgical excision. There was no recurrence at 6 months after excision. To our knowledge this is the 12th case of keloid following paediatric circumcision described in the literature. There is a wide range of techniques described but all are recurrence free at 6 months following repeated intralesional triamcinolone acetate injection and surgical excision. While there is no current consensus in treating post-circumcision keloid, we find that intralesional injection followed by surgical excision provides an acceptable aesthetic result, which is recurrence free.

Introduction The aim of this study was to analyze the outcomes of dorsolateral onlay buccal mucosal graft (BMG) and ventral onlay local penile skin flap (LPF) urethroplasty in the management of long segment penile urethral stricture (PUS). Material and methods Through a prospective study conducted between October 2014 and May 2018, 84 patients with long segment PUS were randomly assigned to receive either dorsolateral onlay BMG (Group 1 which included 42 patients) or ventral onlay PSF urethroplasty (Group 2 which included 42 patients). The success rate and surgical outcomes were compared in both groups. Results The success rate was 92.9% in Group 1 and 85.7% in Group 2 (p = 0.5). Postoperative short segment urethral stricture at the site of proximal anastomosis was reported in 3 patients in Group 1. Six patients in Group 2 were considered as a treatment failure, 3 of them due to recurrence of long segment urethral stricture after 6 months, and 3 patients developed ring urethral stricture at the site of proximal anastomosis managed by direct vision internal urethrotomy. Conclusions On an intermediate term follow-up, dorsolateral onlay BMG and ventral onlay LPF provide similar success rates in penile urethroplasty, with essentially comparable postoperative morbidity. However, further studies with bigger sample sizes and longer follow-up periods may be required to determine subtle differences between both techniques.

The hypospadiac genital tubercle (GT) can be defined as a development arrest of the tissues forming its ventral aspect which occurs during the “masculinization window” (6–16 weeks of gestation). The causes of this common congenital malformation are essentially unknown and probably multifactorial. Four main actors may be responsible of hypospadias: (1) The child's genes and hormonal system; (2) The placenta; (3) The mother, and (4) the environment with its potential hormonal disruptors. Assessment of the hypospadiac GT is an important step to evaluate the context and plan surgery which, in some cases, can be preceded by hormonal stimulation. Surgery entails three main steps: (1) Degloving the GT to identify the level of division of the corpus spongiosum which is the main criteria to define hypospadias severity; (2) Choosing the adequate technique of urethroplasty; (3) Covering the straightened GT with penile skin. Evaluation of outcome is another critical step and includes functional and cosmetic results until adulthood.

Scabies is a common contagious cutaneous disease and usually affects the young, characterized by polymorphous lesions that may present as burrows, pruritic papules, and inflammatory nodules. Bullous scabies (BS) is its rather rare subtype, mimicking bullous pemphigoid. We report a 15-year-old Chinese boy presenting with 1-month history of pruritic bullae on his penile skin, showing poor response to both topical steroids and systemic antihistamines, but cured by sulfur ointment alone. No recurrence occurred in the 5 years of follow-up. We also reviewed the published cases. Up to date, 44 cases, including the present, have been reported. Of them, 30 were male and 14 were female. The age range was from 1 to 89 years old, with a median age of 70.6 years. The bullous lesions may involve the arms, legs, trunk, genitals, feet, buttocks, thighs, neck, inguinal folds, and may even be generalized. Trunk and extremities are the most common involved locations. Facial or mucosa involvement had never been reported. The histological findings present as a subepidermal split with variable inflammatory infiltrate predominantly neutrophils, and eosinophilic spongiosis, or both. Eighteen of 32 patients showed positive deposition of linear-granular IgG or complement 3 alone or in various combinations, and five of 24 patients revealed circulating IgG. All the 40 cases with therapeutic details were cured by antiscabietic remedy. BS always involves the trunk and extremities. It has a predilection for elderlies and males. The treatments for BS are similar to those of classical scabies.

To investigate the surgical outcomes of dorsal onlay urethroplasty (DOU) using buccal mucosa graft (BMG) or penile skin graft (PSG) and to assess the effect of stricture length in men with anterior urethral strictures.A prospective cohort included men with anterior urethral strictures between 2008 and 2015. Patients underwent DOU using PSG or BMG. Patients had urethrography and uroflowmetry at 0, 3, 6, 12 months, and urethroscopy when needed. Student's t test, Mann-Whitney U tests, and Pearson's Chi-square test were used for analysis.Sixty-nine patients (43 ± 14 year) were included, 31 received BMG, and 38 received PSG. Mean stricture length was 8 ± 3 cm, mean operative time was 145 ± 31 min, and mean follow-up was 56 ± 10 mo. Success rate was 87 % (90 % BMG vs. 84 % PSG, p = 0.4). Mean operative time was significantly shorter in PSG group (136 ± 29 min vs. 256 ± 58 min, p = 0.0005). Complications of grade I developed in 36 % (wound infection = 10 %, postvoiding dribbling = 18.8 %). Thirty of 69 patients (43 %) had strictures ≥8 cm, and 39 (57 %) had strictures8 cm-success rate was equal for both subgroups (87 %). Mean blood loss, mean operative time, and incidence of postvoid dribbling were significantly lower in strictures8 cm.BMG and PSG have comparable success rates in treatment of long anterior urethral strictures. Operative time is significantly longer in BMG. Long-segment strictures are associated with longer operative time, more blood loss, and more occurrence of postvoid dribbling. However, the length of the stricture has no influence on the success rate and functional outcomes of DOU.

We present a 15 year old boy with multiple vesicular lesions involving the scrotum and penile skin which developed following circumcision. Surgical excision of the penoscrotal skin with local flap cover was done. Histopathology was consistent with lymphangioma circumscriptum. To our knowledge this was the first case of penoscrotal lymphangioma circumscriptum which was seen after circumcision.

Nicorandil, a nicotinamide ester, is used in the prevention of angina pectoris. There is now a well-established association of perianal ulceration and the use of the drug. However, in the recent years, there have been reports of penile skin, vulval and even vaginal ulcers caused by nicorandil. We report three cases of nicorandil-induced penile ulcers which were surgically managed, and present a review of current literature.

A 44-year-old man with a spinal cord injury was referred to a specialist urology service with a 7-year history of significant genital swelling. His condition had eluded diagnosis and was refractory to all previous treatments. The considerable swelling both impacted his quality of life and prevented the patient from adequately managing his neurogenic bladder. He was diagnosed with chronic idiopathic genital lymphoedema and underwent total scrotectomy, wide penile skin excision and split skin graft to the penile shaft. The patient made an excellent recovery. We present this unusual case with preoperative, intraoperative and postoperative images.

Summary Introduction With the growing shortage of pediatric urological surgeons, it was our aim to streamline our system to get patients with less complex penile procedures performed in a timely manner. To do this, an advanced practice provider (APP) was trained to perform minor penile procedures in children in the operating room(OR). Objectives The goal of our study was to show that with proper training an APP could safely perform a circumcision in the OR. Study design After approval of the study center’s credentialing committee, a NP was trained to perform revisions and initial circumcisions in children in the OR. The process involved: (1) observation, (2) first assisting and (3) performing the procedure with direct, and later in-direct, supervision. The first 100 cases were evaluated for surgical complications, post-operative complications and return rates to the OR. Results 100 independent cases were completed with 90 having only in-direct supervision. There were no operative complications, nor any documented emergency room or urgent care visits in the immediate post-operative period. There were no early returns to the OR and only 1 scheduled follow-up procedure for a penile skin bridge. Discussion It was demonstrated that with proper training a NP can safely perform minor penile procedures in the OR. This allows us to free up our pediatric urology physicians to see and operate on more complex pediatric urology problems. In addition, it allows those with minor penile issues to be cared for more expeditiously. A concern related to training NPs to do circumcisions could be the loss of control by urologists. In this situation, the attending physician is ultimately responsible from a medico-legal standpoint. That would not be true if the NP was practicing independently. With a shortage of urologists, this significantly expands the ability to care for our patient population. In additional, attending surgeons will have a greater freedom to perform major procedures. A limitation of the study was that a patient satisfaction survey was not obtained to see if there were concerns over a APP doing their circumcision. Personal feedback on 30 of the patients that did not return for the follow-up visit was not obtained. The authors of the study are primary providers of pediatric urology care in the study region, thus any individual with concerns would have been referred. Conclusions It was demonstrated that a well-trained APP can safely perform minor penile procedures independently in the OR with indirect supervision. Summary table . Age of child at time of circumcision. Age of child at time of procedure 6–12 months 28 12–24 months 21 3–5 years 19 6–10 years 25 11–13 years 7

Objective To present a single-stage repair of obliterative urethral strictures by simultaneous use of a buccal mucosa graft and longitudinal dorsal penile skin flap. Methods Between February 2007 and October 2016, 51 patients with obliterative anterior urethral stricture underwent single-stage substitution urethroplasty. A buccal mucosa graft was harvested and fixed to the corpora cavernosa as the dorsal part of the neourethra, and a vascularized dorsal penile skin flap was created, transposed ventrally and sutured to the buccal mucosa graft to form ventral part of the neourethra. Results The follow-up period was 12-129 months (mean 49 months). The mean age of the patients was 48 years (range 15-71 years). The mean length of the obliterated urethral segment, measured during the operative procedure, was 5.2 cm. The etiology of strictures was: unknown, hypospadias and trauma in 19, 27 and five patients, respectively. Five patients were lost to follow up, and 46 patients were analyzed for the outcome. At the end of the follow-up period, recurrence of the stricture occurred in seven (15.2%) patients, whereas 39 (84.8%) patients did not develop stricture. An additional three (6.5%) patients developed fistula, resulting in overall successful voiding in 36 (78.3%) patients. Conclusions A combined buccal mucosa graft and longitudinal dorsal penile skin flap could be a good choice for one-stage substitution urethroplasty in complex obliterative urethral strictures, with an acceptable complication rate.

To the best of our knowledge, we report the first case of recurring small red macules (petechia), exclusively localized on the gland secondary to fellatio in an adult man, who is on therapy with acetylsalicylic acid. No previous studies have been ever conducted on the possible onset of penis petechia after oral sex. Petechia are nonspecific cutaneous lesions appearing as circumscribed sub-epithelial hemorrhages, or appearing as small dark red or purplish spots as a result of capillaries rupture.

The use of various grafts and flaps plays a critical role in the successful surgical management of urethral stricture disease. A thorough comprehension of relevant anatomy and principles of tissue transfer techniques are essential to understanding the appropriate use of grafts or flaps to optimize outcomes. We briefly review these principles and discuss which technique may be best suited for a given anterior urethral stricture, depending on the location and length of the stricture, the presence or absence of an intact corpus spongiosum, and the availability of adequate and healthy penile skin.

Highlights • A split-thickness skin graft gave functional and cosmetically acceptable results to this completely degloved penis. • A 1:1 mesh made it possible to use any direction of the graft and achieve a good cosmetic result and can be recommended. • The risk of having to go through repetetive surgery in the genital area, made smoking cessation possible for this specific patient., Introduction Male genital degloving injuries are unusual and rarely caused by animal bite. Usually patients attend health care immediately if bitten in the genital area. Prophylactic antibiotics is routinely used (Gomes et al., 2000). A penile degloving usually begins just proximal of the coronal line and progress down to the base of the shaft. Deep erectile tissue and the spermatic cord are seldom damaged and the endogenous skin of glans usually survives (Brown and Fryer, 1957; Morey et al., 2004; Finical and Arnold, 1999). Presentation of case A heavily smoking man with a previous history of bladder cancer presented himself to the emergency department 24 h after a dog bite degloved his penis. The avulsed skin was necrotic and subsequently excised. Antibiotic treatment was started. A bacterial swab was found positive for canine oral flora. The skin defect was closed using a 1:1 meshed split thickness skin graft from the inner thigh. Smoking cessation was encouraged. At the three month follow up the patient expressed satisfaction with both cosmetic and functional result and was now non-smoking. Discussion Several approaches to reconstruct penile skin exist. Split thickness skin graft has been lifted as a preferable alternative (Brown and Fryer, 1957; Finical and Arnold, 1999; Paraskevas et al., 2003) [5]. In this case, the avulsed skin was necrotic and could not be used. A 1:1 meshed split-thickness graft was chosen with excellent results. Conclusion 1:1 mesh of the graft can be recommended for easy attachment with a good functional and esthetical result. The potential risk of losing intimacy appearance or having to go through repeated procedures in the genital area motivated smoking cessation for this patient.

To our knowledge, this is the first study that focuses on risk factor of urethral condyloma (UC). The subjects of our study included genital warts patients who had been diagnosed as having condyloma acuminatum of penile skin (CAPS) with/without UC. Relationship with UC of number of life time female partners, co-infection with urethritis, circumcision status, number of CAPS and wart diameter were studied by use of multivariate analysis. Co-infection with urethritis, circumcision status were risk factors of UC in heterosexual young male patients with CAPS. This information will be helpful for providing more professional counseling to patients with genital warts.

Background Rectoneovaginal fistulae (RnVFs) are abnormal connections between the rectum and a surgically created neovagina. Although very uncommon, they confer significant morbidity in patients and may require a multidisciplinary team approach to the repair. Risk factors for RnVF include rectal injury at the time of neovaginoplasty, malignancy in the neovagina, trauma (iatrogenic or otherwise), radiation, and neovaginal revision surgery. Case description The patient is a 64-year-old transgender woman with recurrent RnVF following penile skin inversion neovaginoplasty, which was complicated by an intraoperative rectal injury. After failing an initial attempt at repair, the fistula was successfully repaired with a buccal mucosa graft. Conclusions In some cases, RnVFs following vaginoplasty surgery for gender affirmation may be repaired successfully with a buccal mucosa graft.

A 12-year-old boy sustained a close-range shotgun wound with buckshot to the penis and lower abdomen. The proximal two-thirds of the corpora cavernosa was obliterated and the distal third was thrombosed. All dorsal penile skin was lost. The urethra remained intact. The patient underwent multiple debridements, allowing the wound to declare its borders. Employing the tissue transfer concept used by Cecil and Culp in hypospadias repairs, the penis was marsupialized onto the suprapubic area where it remained for 8 months. After 8 months, the patient underwent a graft delaying procedure followed by a graft harvest 2 months later and penoplasty tubularization.

Introduction The penis eventually needs specific cutaneous coverage in the context of reconstructive procedures following trauma or congenital anomalies. Local flaps are the first choice but are not always available after multiple previous procedures. In these cases, skin graft and dermal matrices should be considered. Materials and Methods This study was a retrospective review of the past 4 years of four patients with severe loss of penile shaft skin who underwent skin reconstruction. Dermal matrices and skin grafts were utilized. Dermal matrices were placed for a median of 4.5 weeks (3.0–6.0 weeks). The skin graft was harvested from the inner thigh region for split-thickness skin graft (STSG) and the inguinal region for full-thickness skin graft (FTSG). Results The four patients presented with complete loss of skin in the penile shaft. One patient had a vesical exstrophy, one had a buried penis with only one corpus cavernosum, one had a wide congenital lymphedema of the genitalia, and one had a lack of skin following circumcision at home. They underwent reconstruction with three patients undergoing split-thickness skin graft; two dermal matrices; and one full-thickness graft, respectively, thereby achieving a good cosmetic and functional result. There were no complications, and all the patients successfully accepted the graft. Conclusion Dermal matrices and skin grafts may serve as effective tools in the management of severe penile skin defects unable to be covered with local flaps.

Balanoposthitis can be caused by a disparate range of conditions affecting the penile skin. This guideline concentrates on a selected group of conditions and offers recommendations on the diagnostic tests and treatment regimens needed for the effective management of balanoposthitis.

Background: Injection of alloplastic material underneath the penile skin for penile augmentation causes many complications such as inflammation, infection, ulceration, and pain during sexual activity. One of the treatments for complications after these penile augmentation procedures is surgical excision of the foreign body granuloma followed by penile skin coverage with bilateral scrotal flaps. There are no prior prospective studies published about anatomical and functional outcomes. Objective: To study the anatomical and functional outcome of one-stage bilateral scrotal flap reconstruction in patients after surgical removal of paraffinoma from penile shafts. Methods: Patients who suffered from complications of penile foreign body granuloma were treated by surgical excision and reconstruction with bilateral scrotal flaps. The penile lengths and circumferences when flaccid and erect were recorded preoperatively and postoperatively. The patients were interviewed using questionnaires and satisfaction scored to determine their sexual experiences were recorded before and after surgery. Results: Thirteen patients were enrolled in this study. The mean follow-up time was 23.5 (11.5-40.5) weeks. The mean erectile length and the maximal circumference were 11.8 (9-15) cm, 14.5 (11.5-17) cm preoperatively, and 11.7 (10-14) cm, 11.8 (10-13) cm postoperatively. Satisfaction scores of sexual activity is 6.84 (0-9) preoperatively, and 8.38 (5-10) postoperatively. Conclusion: One-stage bilateral scrotal flap coverage is a good option for penile skin reconstruction. This technique can achieve satisfactory results both anatomically and functionally.

A phenomenon known as trapped penis has numerous origins, including injudicious circumcision. Materials and Methods: Surgery for trapped penis with glanular amputation was performed for 5 children. The surgical policy in these cases included complete penile degloving, excising the scarring due to circumcission, fixing the penile skin at the penopubic and penoscrotal angles and reconstructing the penile skin with full thickness skin graft. Results: Improvement was noted in all cases. Conclusion: Surgery for hidden penis using full thickness skin graft achieves very satisfactory aesthetic and functional improvement.

Objective We aim to report a single surgeon's experience of using a penile skin advancement flap with penile dartos interposition for hypospadias fistula repair. Patients & methods All hypospadias fistula repairs performed in our unit by this paediatric urologist between 2000 and 2012 were identified from a prospectively recorded database. Patients' case-notes were reviewed retrospectively gathering data on surgical technique, post-operative care and fistula recurrence on follow-up. Only those boys having repair by this advancement flap technique were included. A urethral catheter was left in situ in all patients for 5–7 days. Repairs performed using other techniques were excluded. Results 20 consecutive patients had fistula repair by the advancement flap technique. This was the primary repair in 19 boys, and was repair of a third fistula occurrence in one. The median age at fistula repair was 3.7 years (1.6–15.3). The median follow-up was 4 months (3–73). One boy failed to attend any follow-up. No recurrence has yet been identified in any of the 20 patients. Conclusion The penile skin advancement flap with dartos interposition technique was very successful in our series in both primary fistula repair, and in a patient who had multiple previous operations.

Penile skin loss may occur after trauma, infection, or as a result of surgical resection. This article reviews indications for reconstruction of the penile skin, skin anatomy, and skin graft physiology. Choice of reconstructive options, skin grafting techniques, and complications of skin grafting are also discussed.

Objectives To describe our experience with ‘minipatch’ penile skin graft (PSG) urethroplasty, as at our institution we prefer excision and primary anastomosis (EPA) urethroplasty whenever feasible, as it gives better outcomes than substitution urethroplasty. However, despite careful preoperative planning, the unanticipated need for a small graft is occasionally recognised intra-operatively, and in such cases we have found that harvesting a minipatch is an efficient alternative to harvesting a buccal mucosal graft. Patients and methods Bulbar urethroplasty using a

Background The epidemiology of bacterial vaginosis (BV) suggests it is sexually transmissible, yet no transmissible agent has been identified. It is probable that BV-associated bacterial communities are transferred from male to female partners during intercourse; however, the microbiota of sexual partners has not been well-studied. Results Pyrosequencing analysis of PCR-amplified 16S rDNA was used to examine BV-associated bacteria in monogamous couples with and without BV using vaginal, male urethral, and penile skin specimens. The penile skin and urethral microbiota of male partners of women with BV was significantly more similar to the vaginal microbiota of their female partner compared to the vaginal microbiota of non-partner women with BV. This was not the case for male partners of women with normal vaginal microbiota. Specific BV-associated species were concordant in women with BV and their male partners. Conclusions In monogamous heterosexual couples in which the woman has BV, the significantly higher similarity between the vaginal microbiota and the penile skin and urethral microbiota of the male partner, supports the hypothesis that sexual exchange of BV-associated bacterial taxa is common. Electronic supplementary material The online version of this article (doi:10.1186/s40168-016-0161-6) contains supplementary material, which is available to authorized users.

We present the case of a male neonate with imperforate anus and a fistula exiting on the penile skin. Anorectal malformations in boys often present themselves with an entero-perineal or entero-urinary tract fistula, the type of which is a key feature for the classification and the treatment plan. A fistula exiting in front of the scrotum, such as described in our case, is very rare and is not incorporated in the current classification and treatment algorithms. Scarce reports on misjudgment concerning the position of the blind rectal pouch in similar cases, led us to perform a colostomy instead of a one-stage correction. A posterior sagittal anorectoplasty was performed eight months later and the rectal pouch was found inside the levator sling, justifying the cautious approach. The colostomy was closed three months later and after six months the distal part of the fistula was excised. We believe that in cases with a rare fistula presentation, the position of the rectal pouch is not predictable and the surgeon should proceed with caution.

Urethral reconstruction is still a big challenge in urology. Traditionally, the penile skin or buccal mucosa was used as graft for replacement. However, the morbidity of the donor site was reported previously. Furthermore, there is a lack of an adequate autologous donor graft in many cases. The tissue engineered urethra may provide an alternative to the reconstruction. Herein, we reviewed the biomatrices for urethral substitution either in animal model or in clinical cases.