Schwannoma of penis

Schwannomas may occur anywhere in the body, but their occurrence in the penis is rare and unusual. These tumors are important to urologists because findings mimic other urologic disease. Treatment is surgical removal; they are rarely multifocal and seldom metastasize. A patient with schwannomas of the penis is described.     

Chordee repair utilizing a novel technique ensuring neurovascular bundle preservation

Penile chordee, with and without hypospadias, is amenable to surgical correction. The Nesbit technique of dorsal plication of the ventral tunica albuginea is effective in correcting most cases of corporal disproportion. A hazard with this approach is the potential inclusion of the dorsal neurovascular bundle, with resultant erectile and sensory dysfunction. We developed a simple technique using the Freer elevator to isolate the neurovascular bundle prior to plication. This ensures that no injury occurs to the neurovascular bundle during plication. Since 1994, 37 boys with chordee have been repaired using this approach. Their ages at the time of operation ranged from 5 months to 28 years (mean 9 months). Following standard degloving of the penis, an incision through Buck's fascia is made lateral and parallel to the neurovascular bundle at the maximum level of the chordee. A similar incision is carried out on the contralateral side. A 4-mm-wide Freer elevator is positioned under Buck's fascia while hugging the tunica albuginea. The Freer elevator slides across the midline to the contralateral side, separating Buck's fascia and underlying layers from the tunica albuginea. Following isolation of the bundle, each corporal body is plicated by creating a longitudinal incision through the tunica albuginea, which then is closed transversely with a 5-0 polydioxanone suture. Buck's fascia subsequently is closed with an absorbable suture following confirmation of chordee correction. No complications have been encountered during a mean follow-up of 21 months (range 5-51 months). No patients have required reoperation for persistent chordee. We developed a technique that elevates the neurovascular bundle prior to plication, thereby ensuring no injury to this structure. We have successfully used this modified Nesbit technique since 1994 and have had no complications. Utilization of the Freer elevator adds an estimated 5 minutes to chordee correction compared to a standard plication lateral to the neurovascular bundles. Although long-term follow-up needs to be performed to confirm any erectile or sensory advantage, this approach should be considered whenever plication is to be performed.     

Formation of neoclitoris from glans penis by reduction glansplasty with preservation of neurovascular bundle in male-to-female gender surgery: functional and cosmetic outcome

PURPOSE: During male-to-female gender reassignment surgery we used an abdominal pedicled inverted penile skin technique to create a vagina and extra folds of skin to create a clitoral hood. Although patients had orgasms with that technique, there was a general request for the placement of a sensate, erectile clitoris. Therefore, in 10 such patients undergoing transsexual surgery a neoclitoris was fashioned from the glans penis. Surgical technique and results are described. MATERIAL AND METHODS: From 1980 to 1995, 57 male-to-female gender surgeries were performed at our university center. In the last 10 such patients undergoing transsexual surgery a neoclitoris was created. Glans volume is reduced to match that of a normal size clitoris and the entire length of the dorsal neurovascular bundle is preserved. The neoclitoris is placed through a buttonhole in the newly constructed introitus. There was minimal bleeding from the bundle intraoperatively. RESULTS: In 8 of 10 patients the neoclitoris remained intact postoperatively with good sensation to touch, vibration and light pressure (sexual sensation). The cosmetic and functional appearance was that of a normal clitoris, and patients were satisfied. In 2 patients the results were not satisfactory because of necrosis of the neoclitoris. CONCLUSIONS: This technique has excellent functional and cosmetic results in the majority of patients. Preservation of the somatic, tactile and vibratory sensation of the neoclitoris is surgically practical, and can afford the patient the possibility of a more functional outcome of gender reassignment surgery.     

Schwannoma of the penis: a case report

A 39-year-old man presented with a painless nodule on the left dorsal aspect of root of the penile shaft, which was first noticed in childhood, but had been left untreated. This nodule gradually increased in size, and he visited the Department of Urology. He had no urinary symptoms, and there was no interference with sexual intercourse. Upon physical examination, we observed a well-defined, firm 20 mm nodule on left dorsal aspect of root of the penile shaft that was tender and had no adhesion to overlying skin. There were no other abnormalities; in particular, no other similar lesions could be found. We suspected a benign tumor of the penis and removed it. Histological examination revealed a benign schwannoma composed of Antoni A and Antoni B areas.     

Erythropoietin receptor expression in the human urogenital tract: immunolocalization in the prostate, neurovascular bundle and penis

OBJECTIVE: To investigate whether the erythropoietin (EPO) receptor is expressed in human periprostatic (including the neurovascular bundles) and penile tissues, and define its distribution in these tissues, as the administration of exogenous EPO in cavernous nerve injury promoted the recovery of erectile function in a rat model. MATERIALS AND METHODS: Human prostate (six samples) and penile (two) tissue were collected and paraffin-embedded. Tissue was sectioned and processed for immunohistochemical studies using an antibody for the EPO receptor; immunolocalization was assessed using light microscopy. RESULTS: There was prominent staining for the EPO receptor in neuronal cell bodies of the periprostatic neurovascular bundles, and in the axons emanating from these ganglia. The glandular epithelium of the prostate also had weak staining. There was EPO receptor immunoreactivity in the penile specimens in the penile dorsal nerves, sinusoidal endothelium of the corpus cavernosum, and endothelial cells lining the dorsal veins and arteries. All slides processed with no primary antibody or blocking peptide showed no staining. CONCLUSIONS: EPO receptor expression was identified and localized in human penile tissues and in the periprostatic neurovascular bundles responsible for erectile function. This suggests a likely role for endogenous EPO within these tissues, and provides the rationale for its clinical use as a protective agent locally.     

Rapid communication: early potency outcomes with cautery-free neurovascular bundle preservation with robotic laparoscopic radical prostatectomy

PURPOSE: To report short-term potency outcomes with a cautery-free technique (CFT) to preserve the neurovascular bundles (NVB) during robotic laparoscopic radical prostatectomy (LRP). PATIENTS AND METHODS: All men were <66 years of age and had a Sexual Health Inventory in Men (SHIM) score of 22 to 25. They underwent unilateral or bilateral dissections. Group 1 (N = 23), the study group, had preservation of the NVB with CFT. Group 2 (N = 36) had traditional dissection using bipolar cautery. Data were collected prospectively via validated questionnaires. Potency was defined as an erection adequate for vaginal penetration. RESULTS: At 3 months, 10 patients (43%) in the CFT group reported potency versus just 3 (8.3%) in the bipolar-cautery group (P = 0.003). Additionally, only 2 (18%) of those having CFT reported zero penile fullness compared with 15 (68%) in the bipolar-cautery group (P = 0.01). CONCLUSIONS: The technique of controlling the vascular pedicle of the prostate and dissecting the NVB without cautery produced significant improvement in potency outcomes at just 3 months.     

Correlation of histomorphologic findings and partial neurovascular bundle preservation during laparoscopic and robotic radical prostatectomy

The objective of this work was to compare the amount of residual periprostatic tissue for radical prostatectomy performed by the partial NS (PNS) technique with that performed by the nerve-sparing (NS) or wide-resection (WR) techniques. Retrospective histomorphologic evaluation of radical prostatectomy specimens (RPSs) from patients undergoing laparoscopic radical prostatectomy (LRP) or robot-assisted radical prostatectomy (RARP) was performed. The posterolateral regions corresponding to the neurovascular bundle in RPSs from 48 patients who had undergone NS, PNS, or WR during LRP (n = 30) or RARP (n = 18) were examined by two pathologists unaware of the technique used. The RPSs were evaluated at the base, mid-gland, and apex. The amount of periprostatic tissue at each site was recorded. Measurements were analyzed by use of a linear mixed model. For both LRP and RARP, each gradation of nerve-preservation was associated with periprostatic tissue, except PNS and WR did not differ for LRP at the apex and base or for RARP at the apex, mid-gland, and base. For LRP, a greater amount of tissue was on the left side of the prostate than on the right at the mid-gland level (P = 0.004) whereas for RARP the opposite was found (P = 0.024). Of 18 separate analyses, 13 were significantly associated. The study is limited by its retrospective design. The amount of periprostatic tissue in the neurovascular bundle area correlates well with the nerve-preservation approach used during LRP and RARP, providing anatomic evidence supporting the PNS approach. We also describe a novel finding of laterality bias at the mid-gland level in LRP and RARP specimens.     

Modified technique for neurovascular bundle preservation during radical prostatectomy: association between technique and recovery of erectile function

OBJECTIVES

To prospectively evaluate whether a modified surgical technique for neurovascular bundle (NVB) preservation during radical prostatectomy (RP) is associated with an improvement in erectile function (EF) recovery after RP.

PATIENTS AND METHODS

Data from patients treated before technique modification was used to create a predictive model for EF at 6 months after RP using age, date of surgery, and nerve sparing (none vs unilateral vs bilateral) as predictors for patients who received the modified technique (MT) to estimate the expected outcomes had they received the standard technique (ST), and compared these with actual outcomes. In the MT, the neurovascular bundle (NVB) is completely mobilized off the prostate from the apex to above the seminal vesicles including incision of Denonvilliers’ fascia before urethral division and mobilization of the prostate off the rectum.

RESULTS

Of 372 patients with evaluable data, 275 (74%) underwent the ST from 1 January 2001 to 31 December 2004 and 97 (26%) underwent the MT from 1 January 2005 to 30 May 2006. Sixty‐five of 97 patients (67%) receiving the MT had EF recovery at 6 months, whereas the expected probability of 6‐month recovery of EF, had they received the ST, was 45%. The absolute improvement in EF recovery attributable to the MT was 22% (95% confidence interval 5–40%; P = 0.013).

CONCLUSIONS

Technical modifications to NVB preservation during RP were associated with improved rates of EF recovery.     

Schwannoma of the penis: a common tumour at a rare site

Schwannoma is a benign tumour arising from neurilemmal cells and is commonly seen along cranial nerves. We describe the case history and histologic findings of a young adult with a schwannoma at a very rare site: the penis. Surgical excision was done and the patient remains disease-free after 2 years.     

Anatomical radical retropubic prostatectomy: 'curtain dissection' of the neurovascular bundle

OBJECTIVE: To investigate the topographical relationship of the cavernosal nerves (CNs) to seminal vesicles, prostate, rhabdosphincter and urethra during the development of the prostate, and to use the resulting morphological data to modify the surgical technique of nerve-sparing radical prostatectomy. MATERIALS AND METHODS: The study included 29 male fetuses (gestational age 9-37 weeks) and eight adult specimens assessed anatomically and histologically. Using the plastination technique and anatomical dissection, the course of the CNs was investigated in all specimens. Based on these morphological results, the technique of dissecting the CNs during nerve-sparing radical retropubic prostatectomy was modified. RESULTS: During early fetal development the fibres of the CNs enclose the prostatic and membranous urethra dorsally and laterally. During the growth of the prostate, the CNs running along the prostate become displaced further anteriorly and spread, thus forming a concave shape (like a 'curtain') of the neurovascular bundles (NVB). Therefore, dissection of the NVB has to start anteriorly to preserve all the nerve fibres that are spread along the surface of the lateral lobes of the prostate. CONCLUSIONS: From these anatomical findings we propose a modified 'curtain dissection' to improve preservation of the CNs running in the NVB, in which the incision of the periprostatic fascia and dissection of the NVB is far more anterior than previously described.