OBJECTIVES: Malacoplakia is a chronic granulomatous disease which can involve different areas of the body, being the genital renal system the most frequent site. We describe a case of unilateral renal malacoplakia. METHODS/RESULTS: We report the case of a female patient with the clinical working diagnosis of renal cell carcinoma that required drainage of a homolateral abscess which cultured positive for E. Coli. Nephrectomy was performed. Pathologic study showed the presence of Michaelis-Gutmann bodies, patognomonic of malacoplakia.

BACKGROUND: OBJECTIVE: We report a clinical case of renal carcinoma in horseshoe kidney and some anatomical particularities during surgery. METHODS: We describe the case of a 54 year old man who presented pain and prostatism. A renal tumor in horseshoe kidney was found in the diagnostic tests. RESULTS: We performed surgical treatment saving the left kidney . CONCLUSIONS: Horseshoe kidney is the most frequent fusion abnormality of the kidney. Renal carcinoma in this type of renal fusion is similar to those with normal anatomy. Anatomical particularities should be taken into account during surgery.

OBJECTIVES: We present one case of urinoma after gynecologic surgery and the surgical repair. METHODS: 46-year-old woman referred for urologic consultation for flank pain after hysterectomy. RESULTS: CT scan showed the existence of an urinoma with the ureter included in the radiological lesion. CONCLUSION: Early treatment after diagnosis with end-to-end anastomosis solved the problem.

OBJECTIVES: To report three cases of atherosclerotic embolic vascular disease with clinical presentation in the lower urinary tract. This disease is not frequent; it mainly affects the skin, kidneys and skeletal muscle. Other organs of the urinary tract are rarely affected and they are exceptionally the clinical site of debut without previous known involvement of other areas. METHODS/RESULTS: The first patient presented with hematuria associated with an ultrasound/cystoscopical image suspicion for neoplasia. Pathologic report of the transurethral resection chips showed polypoid cystitis with some small size arteries occupied by cholesterol needles, associated with inflammation, ulcers and hematic extravasation. The second patient underwent cystoprostatectomy for a transitional cell carcinoma and, incidentally, numerous cholesterol emboli were found, mainly in the lamina propria, but also in other layers of the bladder wall, prostate, urethra, veru montanum, and one seminal vesicle; this two latter sites have not being reported in previous publications. The third patient showed the embolus within a prostate biopsy core. CONCLUSIONS: This unfrequent disease may present as a bladder or prostatic process and be diagnosed by biopsy of these organs. It may simulate a bladder neoplasia on ultrasound or cystoscopy and should be included among related or etiologic entities of polypoid cystitis, a well-known simulator of neoplasia.

OBJECTIVE: To compare the morbidity of conventional inguinal lymphadenectomy for epidermoid carcinoma of the penis using ligation versus ultrasonic sealing of the lymph nodes with Ligasure. METHODS: 29 cases of carcinoma of the penis are analyzed; 8 underwent superficial and deep inguinal lymphadenectomy using the conventional procedure for ligation of lymph nodes (4 cases) and ultrasonic ligation with Ligasure (4 cases). The early and late complications are analyzed. RESULTS: The operating time was found to be significantly shorter in patients treated with Ligasure, no lymphoceles were observed and lymphedema was reduced. CONCLUSIONS: The use of Ligasure for sealing the lymphatic vessels in inguinal lymphadenectomy for carcinoma of the penis appears to have the advantages of a shorter operating time and reduced complications in comparison with conventional ligation.

OBJECTIVE: To determine the efficacy of urinary BTA-TRAK as a marker in monitoring superficial transitional cell carcinoma of the bladder and to compare urine cytology with urinary sediment testing. METHODS: 700 consecutive determinations using BTA-TRAK to monitor unselected patients that had undergone surgery for transitional cell carcinoma of the bladder were analyzed. Cystoscopy, urinary sediment and urine cytology were performed during follow-up. Urography was performed yearly or when tumor of the upper urinary tract was suspected.(positive cytology or hematuria with no bladder tumor). Cystoscopy was performed a few days after determination of BTA-TRAK and voiding urine cytology and urinary sediment analyses (considered positive when microhematuria was observed) were both requested. RESULTS: Of the 700 determinations, 95 (13.6%) were urothelial carcinomas (93 bladder, 2 upper urinary tract) that had been discovered during patient monitoring. Of the 93 bladder tumors, 39 were Ta (37 TaG1 and 2 TaG2), 29 T1 (4 T1G1, 20 T1G2 and 5 T1G3), 5 Tis and 20 muscle-infiltrating tumors (progression from T2-4 during monitoring). The sensitivity of urine cytology to detect urothelial tumor was 41.1% and the specificity was 97.3%. The urine cytologies were negative in 48.4% and inflammatory in 9.5% of the tumors. The sensitivity was 19% in low grade tumors. The sensitivity of urinary sedimentation testing to detect urothelial tumor (microhematuria) was 40% and the specificity was 96.7%. When associated with pyuria, it was considered to be a urinary infection or urothelial inflammatory condition, which was observed in 10.6% of the cases. Considering the proposed normal reference value for BTA-TRAK (< or = 14 U/ml), we have found a sensitivity of 62.1% and a specificity of 68.4%. A logistic regression model was developed, including BTA-TRAK, urinary sedimentation and cytology, to identify the independent variables that are useful for tumor detection during follow-up of superficial carcinoma of the bladder in this series. The combination of three variables showed an odds ratio of 18.5 (8.9-38.5) for urinary cytology, 11.8 (5.9-23.5) for urinary sedimentation and an odds ratio for BTA-TRAK that did not fall within the equation. CONCLUSIONS: Although overall the sensitivity of BTA-TRAK is higher than that of urine cytology and urinary sedimentation testing, it provides no additional information than that obtained from the combination of urine cytology and urinary sedimentation testing in the detection of tumor recurrence during monitoring for superficial bladder cancer.

OBJECTIVE: To report a rare case of penile paraffinoma caused by the subcutaneous or intra-urethral injection of foreign substances containing long-chain saturated hydrocarbons. These were injected in order to increase the penis size which generated a chronic granulomatous inflammatory reaction. This is a rare practice in the western world. METHODS: We present the case of a 32-year-old Bulgarian male who presented with a two-year history of elastic, slightly painful penis swelling after subcutaneous liquid paraffin injection. The proposed treatment was excision of the affected tissue and penile reconstruction in a two-stage procedure. RESULTS: The operative procedure was successful and the patient had good aesthetic and functional results. Paraffin and other materials injected into the penis can produce many complications. Foreign body granuloma, skin necrosis, penile deformity, chronic and unhealed ulcer, painful erection, and the inability to achieve a satisfactory sexual relationship are some of the resulting complications. Intralesional or systemic steroids have been used in primary sclerosing lipogranuloma resulting in the disappearance of the granuloma, but in our opinion the treatment of choice should be radical excision, and, if necessary, secondary reconstruction of the penis. CONCLUSION: The injection of foreign substances to enhance penis size is currently an unjustifiable practice. However, it is still carried out, especially in Eastern Europe and Asia. In most cases surgical treatment is needed to treat the complications and the best modality seems to be radical excision together with follow-up.

Various reports of long-term complications with semi-permanent fillers, appearing several years after injections have created some concern about their long-term safety profile. We report a case of foreign body granuloma secondary to dermal filler containing a copolymer of the acrylic hydrogel particles, hydroxyethylmethacrylate and ethylmethacrylate, occurring 2 years after the injection. The foreign body granulomas could not be treated satisfactorily with intralesional steroids, and the patient required a surgical excision of her granulomas. The physical and psychological consequences to such patients can be quite devastating.

Penile and scrotal skin avulsions are not common events and are caused usually by accidents with industrial machines or agricultural machines. We report a case of a 27-year-old newly married thin-built patient with avulsion and traumatic degloving of the penile and scrotal skin, with exposure of the corpora cavernosa and copus spongiosum of penis and testes as his loose clothes got entangled in a paddy harvesting machine accidently. Reconstruction was performed using a hypogastric flap and split skin graft, achieving a satisfactory aesthetic result and sexual functions.

OBJECTIVES: To study the presentations and treatment outcome of 8 consecutive patients for whom cod liver oil was injected in the subcutaneous area of their penises by a lay person for purpose of augmentation. METHODS: Various amounts of cod liver oil were injected in the subcutaneous area of the penis of 8 low socioeconomic class patients by a nonmedical person. They presented by various complications ranging from paraphimosis up to abscess formation and necrosis of penile skin. All the patients underwent emergency initial surgical intervention ranging from dorsal preputial slit to skin debridement. Definitive surgical treatment was carried out using local penile flap and V-Y plasty. RESULTS: The severity of complications was correlated to the amount of oil injected and the time interval between injections and presentation. All the 8 patients were cured after different staged surgical procedures. The postoperative course was uneventful in 6 patients, and 2 patients suffered from wound infection after the secondary treatment. All patients had acceptable cosmetic and functional outcome, and were satisfied regarding the length of the penis. None reported erectile dysfunction. CONCLUSIONS: Increased public awareness is indicated to avoid this problem. Early detection and prompt treatment give acceptable anatomic and functional results.

Scrotal lymphedema (scrotal elephantiasis) is uncommon outside of filariasis endemic regions. We present a case of a 65-year-old with idiopathic lymphedema of the scrotum and functional impairment of the penis. The patient underwent surgical excision of the edematous subcutaneous tissues and plastic reconstruction of his penis and scrotum. Three years later, the patient showed no signs of local recurrence, had complete restoration of urinary and sexual function and was extremely satisfied with the result. Surgical management was an effective strategy in the management of scrotal lymphedema in this case.

OBJECTIVES: Penile and scrotal lymphedema produces a monstrous deformity with psychological impact and occasionally extreme mental anguish. The penis is buried in the scrotal tissue, deformed, thickened, edematous, and curved. The scrotum changes to a great, very thick, hard skin mass, sometimes cracked, exudative, and fetid. Erection and sexual intercourse are very difficult or impossible, and the scrotal enlargement interferes with walking. To report a new case of male external genitalia lymphedema. METHODS/RESULTS: We present a technical variation of the surgical treatment of penile-scrotal primary lymphedema in a 32-year-old patient suffering this disease for several years, which had underwent several medical and surgical treatments, such as lymphangioplasty and penile root fasciotomy. Observation consisted in the performance of two incisions in w-plasty, one at the root of the penis, the other one in the preserved preputial mucosa, and excision of all the lymphedematous tissue with reconstruction using the preputial mucosa and a small area of non infiltrated skin at the root of the penis. In the scrotum, two butterfly-wing shape skin flaps were performed; the testicles and the spermatic cord were isolated to ease the operation, minimize the surgical time and avoid complications; the lymphedematous tissue was resected with a great fragment of scrotum; finally reconstruction was performed from the adjacent healthy skin. CONCLUSIONS: With this technique it was not necessary to perform a free or vascularized skin graft. The patient recovered his penile functional capacity improved aesthetically and his anguish disappear.

OBJECTIVE To report our experience with use of thrombolysis with streptokinase during cardiopulmonary resuscitation of patients with cardiac arrest due to myocardial infarction. DESIGN A case series. METHODS Thrombolytic therapy (streptokinase) was administered during cardiopulmonary resuscitation of 4 patients with suspected myocardial infarction as the cause of cardiac arrest. RESULTS 3 of the 4 patients survived and were discharged from the hospital without any major complications or neurological sequela. CONCLUSION Thrombolysis with streptokinase during cardiopulmonary resuscitation of patients with suspected acute myocardial infarction is associated with reduced mortality and favorable neurological outcome.

OBJECTIVE: Fracture of the penis is a relatively rare condition, defined as the rupture of the tumescent corpora cavernosa. The fracture is quite easily recognized, whereas its management remains controversial. Our experience regarding the early treatment of penile fractures is herein reported. MATERIALS AND METHODS: In a 7-year period (1997-2004) 10 patients aged 23 to 42 years, presented with a penile fracture, occurred during coitus. All patients were admitted to the hospital 1 to 10 hours after injury. Diagnosis was made on clinical examination. Six patients referred a snapping sound at the time of injury. Common clinical features included sudden penile pain, detumescence and penile deviation. All patients showed penile haematoma; 3 had scrotal and perineal haematoma as well. None of the patients had urethral bleeding. RESULTS: all patients were surgically treated; at the time of surgery unilateral albuginea rupture was found in all cases. With a mean follow-up of 37 months (range 1-78) all cases were able to achieve an adequate erection. No complications, such as deformations, penile plaque, urethral fistula or erectile dysfunction were reported. CONCLUSION: Immediate surgical repair in case of penile fracture is recommended in order to obtain better functional outcome and to avoid potential complications.

A case of granuloma which developed following a subcutaneous injection of leuprorelin acetate is presented. A prominent induration developed at the site of injection with a three-month type preparation, and radical retropubic prostatectomy and simultaneous excision of the granulomas were requested by the patient since they were large, infectious and painful. Our experience may indicate the necessity of conversion from leuprorelin acetate to other drugs (e.g., goserelin acetate, castration) if a local induration, caused by a subcutaneous injection of leuprorelin acetate, has developed to a large granuloma.

Cavernous hepatic haemangioma is the most frequent benign liver tumour, but the giant pedunculated form is rare because only 17 cases have been described in the literature. We report our experience of one case, and compare it to the 17 other described cases. Age, incidence and size of the lesion were the same as results in the literature. Our patient has had a left hepatic lobectomy because of an uncertain diagnosis. We discuss the diagnosis and the different treatments.