Rupture of the superficial dorsal vein of the penis

Rupture of the superficial dorsal vein of the penis during intercourse is an unfrequented entity that makes the differential diagnosis with other acute penile injuries that may require surgical exploration necessary. We report the case of a 58-year-old male patient with 24-hours evolution painless haematoma after intercourse; its evolution and characteristic physical exploration enable us to adopt a conservative approach that resulted in complete recovery without sequels.     

Penile Mondor's disease in a 22-year-old man

Penile Mondor's disease (superficial thrombophlebitis of the dorsal vein of the penis) is an important clinical diagnosis that every family practitioner should be able to recognize. Although penile Mondor's disease is rare, proper diagnosis and consequent reassurance can help to dissipate the anxiety typically experienced by patients with the disease. This article describes the symptomatology, diagnosis, and treatment of superficial thrombophlebitis of the dorsal vein of the penis.     

Mondor's disease of the penis

Mondor's disease of the penis has been reported after genital trauma such as stretching and torsion of the veins and can cause endothelial necrosis and thrombosis. We report a 35-year-old male with thrombosis of the penile superficial dorsal vein who did not respond to topical drug therapy. Surgical management, e.g. superficial vein resection, is the most effective therapy in refractory cases for relieving pain, diminishing skin induration and producing esthetically pleasing results.     

A case of Mondor's disease of the penis

A case of Mondor's disease of the penis in a 40-year-old man is reported. The patient complained of a small subcutaneous induration (0.5 x 1.0 cm) with slight tenderness in the dorsal region of the penile shaft. On examination, the linear cord was palpated running both distally and proximally from the induration. This lesion was removed under local anesthesia, and the induration and the cord were found to be part of the superficial dorsal vein of the penis. The venous wall was thick and the thrombus was packed in it. Histological findings showed the proliferation of connective tissue of the vessel wall and partially granulating thrombus in the canal. From these findings, we confirmed the diagnosis of Mondor's disease of the penis. The etiology of this disease, especially in comparison with non-venereal sclerosing lymphangitis of the penis (N.S.L.P.) is discussed.     

Trombosis of the dorsal penis vein (of Mondor's phlebitis). Presentation of a new case

ObjectiveWe present a new case of trombosis of the superficial dorsal penis vein called Penile Mondor´s disease. The characteristics of the disease are reviewed and the most usual diagnostic and therapeutic methods.MethodsThe case of a 41 year old man is reviewed who consulted for pain and induration on the proximal part of the penis.ResultsAfter phisical examination and Eco-doppler was made the diagnosis of Mondor´s disease. He receibed treatment with non steroidal antiinflamatories and antibiotics.ConclusionsThe dorsal vein thrombosis is a rare disease with pain an induration of the dorsal part of the penis. The ethiology can be traumatic, neoplasic, excesive sexual activity or abstinence. Is necesary the diferencial diagnosis with esclerosant linphangitis and the most important imaging is the Eco-doppler. The treatment is based in non steroidal antiinflamatories and antibiotics wit infection. The local aplication of heparine can be useful and the surgery with thrombectomy and resection is for persistent cases.     

Pathological findings of penile fractures and their surgical management

OBJECTIVE: In the present review we discuss the clinical presentation and the surgical approach, together with the intraoperative findings and postoperative complications which occurred in 7 patients presented for our observation with a penile injury and submitted to immediate surgical exploration. MATERIALS AND METHODS: Our series, despite the relatively small number of cases, provide a complete pattern of the different intraoperative findings that may be encountered when approaching a penile trauma. This includes extremely rare cases like a completely transected urethra, a fracture at the base of the penis and a rupture of the deep dorsal vein. CONCLUSION: After a thorough examination of the recent literature we conclude that the management of a penile fracture should not include any further investigation other than surgical exploration.     

Modified radical inguinal lymphadenectomy for carcinoma of the penis: technique and results

PURPOSE: Modified radical inguinal lymphadenectomy for carcinoma of the penis is presented that satisfies the requirement for complete groin dissection, while significantly decreasing postoperative complications. MATERIALS AND METHODS: Eight patients with squamous cell carcinoma and 2 with leiomyosarcoma of the penis underwent bilateral modified inguinal lymphadenectomy, including removal of the superficial and deep inguinal lymph nodes. To avoid damage to the vessels of the groin region that run parallel to the inguinal ligament and lie in the fat of the superficial layer of the superficial fascia dissection is done beneath this layer. The proper cleavage plane is just above the membranous layer of the superficial fascia, beneath which the superficial inguinal lymph nodes are located. The saphenous vein is preserved and the sartorius muscle is left in situ, so as not to disturb collateral lymphatic drainage. RESULTS: At a followup of 6 to 104 months no skin necrosis, infection or deep venous thrombosis occurred. In 2 patients early moderate lymphedema of the lower extremities resolved with time, 2 had scrotal edema and 3 had a transient lymphocele. CONCLUSIONS: As described, modified radical inguinal lymphadenectomy decreases the morbidity associated with groin dissection, while removing superficial and deep inguinal lymph nodes.     

Review and update of the anatomy of the penis

The knowledge of penile anatomy is basic to perform a proper diagnosis and direct the most adequate treatment of the various diseases that may appear: urethral stenosis, erectile dysfunction, congenital or acquired penile curvature, etc.; being its anatomical knowledge essential for a proper surgical management. The penis is the male organ involved in both voiding and sexual functions: the body of the penis is composed by three erectile bodies, (i.e the deep structures): the corpora cavernosa and the corpus spongiosum, this last surrounding and covering the urethra. Buck's fascia is in relation to the deep structures of the penis. The superficial fascia, dartos, is made up from a more areolar tissue and is in relation to skin and vessels. The vascularization of the deep structures comes from the common penile artery, a branch of the internal pudendal artery. Penile blood drains through three venous systems: superficial, intermediate and deep systems. Pudendal nerves are in charge of the sensitive and motor somatic innervations. Cavernosal nerves are a combination of parasympathetic and sympathetic afferent fibers, corresponding to the nerves of the autonomic system of the penis.     

背静脉复合体的应用解剖学研究

目的探讨背静脉复合体(dorsal vein complex,DVC)的解剖学形态、分支、走行、回流途径及周围组织关系,以指导膀胱癌、前列腺癌根治性切除手术中对 DVC 的准确处理.方法解剖6具男性成年尸体盆腔标本,记录 DVC、耻骨前列腺韧带、阴茎背深静脉(deep dorsal vein, DDV)及阴部内静脉等组织结构、走行特点.结果6具标本 DVC 分深、浅两层结构,浅层为前列腺浅表静脉,深层为前列腺静脉丛.前列腺浅表静脉在左右耻骨前列腺韧带之间,前列腺前面为单干,在膀胱颈处形成分支;前列腺静脉丛在前列腺筋膜深面局限于两耻骨前列腺韧带之间,平均宽度20．52 mm.DVC 远端与阴部内静脉、DDV 及闭孔静脉存在多种形式的广泛交通,近端则分别进入两侧膀胱前列腺静脉丛,可通过阴部内静脉、闭孔静脉及膀胱前列腺静脉丛回流入髂内静脉.结论 DVC 局限于前列腺前面两耻骨前列腺韧带之间.耻骨前列腺韧带前列腺附着部可作为确定DVC 位置及范围的解剖标志,在耻骨前列腺韧带外侧游离前列腺可有效避免 DVC 损伤.DVC 与阴部内静脉、DDV、膀胱前列腺静脉丛及闭孔静脉存在广泛交通.在前列腺尖部贯穿左右耻骨前列腺韧带外侧缝扎才能将 DVC 主干完全阻断,有效减少出血.     

Primary anastomosis of the traumatically amputated penis

Penile amputation is an uncommon condition for which immediate surgical replantation is warranted. This work aimed to represent intervention and management for an amputated penis by replantation and reconstruction. A 23-year-old man presented with traumatic penile amputation for 2 h where the penile proximal part was 1 cm far from the pubis. Replantation included end-to-end anastomosis of the urethral mucosa over a catheter, approximation of the corpus cavernosum and tunica albuginea, anastomosis of the deep dorsal vein, dorsal nerve, both dorsal arteries and superficial dorsal vein. At day 5 post-operatively, the replanted penis had preserved capillary filling. The catheter was removed at day 11, where the patient urinated smoothly. The preliminary cosmetic appearance was satisfactory with frequent morning erection, reported night emission twice within the first month post-operatively. Sensation was preserved in the distal anastomosed stump. It is concluded that meticulous microsurgical technique decreases the possibility of skin loss and increases the chance of erectile function.     

Split thickness porcine graft in the treatment of close-range shotgun wounds to extremities with vascular injury

The use of split thickness porcine skin grafts as a biologic dressing to cover exposed vascular anastomoses was evaluated in three patients who sustained close-range shotgun wounds to the thigh, causing massive soft tissue injuries and injuries to the superficial femoral artery, saphenous vein, and superficial femoral vein in each patient. In addition, one patient also had a fracture of the distal femur. Operative management consisted of extensive debridement, ligation of the femoral and saphenous veins, and vein graft reconstitution of the superficial femoral artery. The patient with associated femoral fracture was treated with balanced skeletal traction. The porcine skin grafts were changed every twenty-four to forty-eight hours, using sterile technic and general anesthesia as indicated.The porcine skin grafts appeared to protect the vein grafts from infection and trauma during the multiple dressing changes and contributed to limb salvage in two patients in whom the vein graft could be approximated to a viable muscle bed. Amputation was required in the third patient after rupture of the vein graft, which was suspended across a large soft tissue cavity and could not be approximated to a viable muscular bed. The intraoperative and postoperative management of such injuries is discussed in detail. In view of this experience, it appears that judicious use of split thickness porcine skin grafts as a biologic dressing may permit limb salvage in selected cases in which no viable soft tissue remains to cover a vascular anastomosis after soft tissue debridement is completed.     

Mycotic infections of the penis

Balanitis/balanoposthitis caused by Candida albicans is the most frequent mycotic infection of the penis. Its incidence is increasing and it seems to be primarily transmitted by sexual intercourse. Although the groin is a common site for tinea, dermatophytic infections of the penis are rare. Penile involvement in systemic mycosis is usually a sign of severe disease. In immunocompromised individuals, nearly every fungal agent may cause the disease. It normally presents as ulceration, and biopsy and culture can help to confirm the diagnosis. In most cases, superficial infections of the penis respond satisfactorily to local antifungal treatment, especially if provovatice factors and the possibility of sexual transmission are considered. Systemic treatment is recommended in cases of widespread dermatophytic infection, candidosis or systemic mycosis.     

Rupture of voluminous atherosclerotic superficial femoral artery aneurysm

Atherosclerotic aneurysms of the superficial femoral artery are very uncommon. We report a case of a ruptured superficial femoral artery aneurysm which was successfully treated surgically, and compare our data with those emerging from a review of the literature. We observed a 74-year-old man who presented with a suspected rupture of a superficial femoral artery aneurysm. After confirmation of the diagnosis with angio-CT, we treated the patient by performing an endoaneurysmectomy and replacing the arterial aneurysmatic segment with interposition of a polytetrafluoroethylene prosthetic graft. There has been no evidence of complications in the short to medium-term. In our review of literature, we collected 43 cases of superficial femoral artery aneurysms. These aneurysms were diagnosed after rupture (30-46%) or thrombosis and embolism (12-46%). Other aneurysms are frequently concomitant (27-69%). The best treatment is based on replacing the aneurysmatic segment with a prosthetic graft which may be autologous (saphenic vein) or heterologous (polytetra-fluoroethylene). In patients with obstructive arteriopathies exclusion of the aneurysm by ligation of the proximal and distal artery may be enough. The high incidence of complications suggests that resection and grafting should be performed electively, and the frequent association with aortoiliac or peripheral aneurysms means that thorough investigation and follow-up are mandatory.     

Venous augmentation of the free TRAM flap.

Venous congestion in a free TRAM or DIEP flap when the main pedicle is still patent (both the artery and the vein) is an occasional dire situation. Here, we describe ways of salvaging the free TRAM or DIEP flap from imminent loss. In the last 4 years, we have had three patients who developed venous congestion after the use of the TRAM or DIEP flap for breast reconstruction. This was detected as late as the third postoperative day in our first patient. On exploration, patent arterial and venous anastomoses were found. Fortunately, the opposite pedicle had been dissected and preserved with the flap. The patent congested vein in this pedicle was anastomosed to the cephalic vein using an interpositional vein graft, relieving the congestion. In the other two patients congestion was detected earlier and relieved using the superficial inferior epigastric vein. It has been our policy to dissect a length of the opposite pedicle and/or preserve a length of the superficial inferior epigastric vein or the superficial circumflex iliac vein. These can then be used to augment venous drainage if inadequacy is noted at the end of the operation or during the postoperative period.     

Dynamic cavernosography: venous outflow studies of cavernous bodies

Based on dynamic cavernosography studies in 15 patients, including 8 with simultaneous passive erection, we present more precise details of the venous drainage of the penis. The venous drainage is comprised of 3 different systems. The superficial dorsal vein drains mainly the penile skin and prepuce, and empties via the external pudendal veins into the femoral vein. The deep dorsal vein, located between the tunica albuginea and Buck's fascia, drains the glans and all 3 corpora. The venae profundae penis emerge from each crus of the corpora cavernosa and drain only the corpora themselves. Considerable individual differences were found regarding further drainage via the pelvic venous system, including the prostatovesical plexus and internal pudendal veins. Passive erection was tried in 11 patients and was successful immediately after cavernosography in 8. The flow rates to induce an erection averaged 111 ml. per minute (range 55 to 160 ml. per minute), while the rate to maintain the erection was 48 ml. per minute (range 12 to 90 ml. per minute).     

Autofluorescence and 5-aminolevulinic acid induced fluorescence diagnosis of penile carcinoma – new techniques to monitor Nd:YAG laser therapy

Nd:YAG laser coagulation is possible for superficial tumors of the penis. The value of photodynamic diagnosis (PDD) and autofluorescence imaging (AF) in detecting malignant lesions on the penis was evaluated. Twelve patients with biopsy-confirmed squamous cell cancer (SCC) of the penis were examined with PDD and AF. For the PDD and AF the penis was illuminated with the blue excitation light from a xenon arch lamp. Biopsies were taken from suspicious lesions detected by PDD or AF and then treated with Nd:YAG laser coagulation. Neoplastic lesions presented with a positive red fluorescence under PDD or a diminished appearance under AF. The HPV-analysis was positive in eight of the 12 lesions. Fluorescence diagnosis is used for the detection of neoplastic lesions. It assists the urologist in detecting neoplastic and preneoplastic lesions, ensuring a more reliable destruction of all tumor material in penile sparing surgery.     

A preliminary report of penile transplantation

A 44-year-old male recipient with traumatic penile defect that occurred 8 mo earlier was matched with a 22-year-old, male, brain-dead donor. Transplantation included anastomosis of urethra corpus spongiosum and corpus cavernosum, and sutures of deep dorsal vein, dorsal artery, dorsal nerve, and superficial dorsal vein. Systemic broad-spectrum antibiotics, anticoagulation, antispasm agents, and immunosuppressants were given postoperatively. The recipient could urinate smoothly in a standing position at day 10 after removal of Foley catheter. At day 14 postoperatively because of a severe psychological problem of the recipient and his wife, the transplanted penis was cut off. Pathologic examination showed no rejection.     

Anatomy and biopsy of sentinel lymph nodes.

Lymphangiograms performed via the dorsal lymphatics of the penis demonstrate drainage into a specific lymph node center, the so-called sentinel lymph node, which is located close to the superficial epigastric vein between the latter and the superficial external pudendal vein. Anatomically, clinically, and pathologically, the sentinel lymph node is the first site of metastasis and often is the only lymph node involved. We recommend preliminary bilateral sentinel lymph node biopsy, with inguinofemoral dissection being performed only when this node is involved. If the biopsies are negative for metastases, no further surgical therapy is immediately indicated, and the patient needs to be observed closely with monthly examination for 1 year and examination every 2 months for 3 years. The clinical staging of cancer of the penis needs a new review for further evaluation of different modalities of treatment. Sentinel lymph node biopsy must not be used to determine whether node dissection is needed in patients with evident clinically positive nodes. Also, the concept of sentinel lymph node should not be applied in the management of patients who will not be available for frequent follow-up. If during physical examination, suspect lymph nodes are found other than the classic sentinel node, these lymph nodes must be removed for staging and subsequent treatment planned according to the histologic report.     

外伤性阴茎海绵体破裂的诊断与治疗（附12例报告）

目的：总结外伤性阴茎海绵体破裂的诊断与治疗经验。方法：回顾性分析2001年1月～2010年1月收治的12例阴茎海绵体破裂患者的临床资料：12例患者年龄28～47岁,平均36．5岁。致伤原因为粗暴性交9例,硬物砸伤1例,骑跨伤1例,斗殴致伤1例。12例均急诊行阴茎折断修补手术,结果：术后随访2～26个月,发生1例阴茎勃起后疼痛,1例尿道狭窄,1例勃起功能障碍,均经恰当的治疗后在不同的时间内恢复。结论：急诊手术是外伤性阴茎海绵体破裂的恰当治疗方法。