Penile Ossification: A Reconstructive Challenge

Case Review Penile Ossification: A Reconstructive Challenge Arthi Satyanarayan, MD, Nirmish Singla, MD, Allen F. Morey, MD Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX Penile ossification is a rare condition that occurs most commonly in acquired cases of penile deformity. We report the case of a 43-year-old man with Peyronie disease who was incidentally found to have significant ossified tissue in his penile corpora during complex placement of an inflatable penile prosthesis (IPP). His clinical course was later complicated by impending distal extrusion of his IPP laterally, necessitating corporoplasty. Penile ossification remains a poorly understood, unusual entity that may pose a reconstructive challenge for urologists. We discuss evaluation and management of this condition, focusing on important considerations for preoperative counseling and intraoperative pearls. [Rev Urol. 2017;19(1):64-67 doi: 10.3909/riu0722] ® © 2017 MedReviews , LLC Key words Penile ossification • Peyronie disease • Inflatable penile prosthesis • Corporoplasty P enile ossification is a rare condition that has been documented histologically in approximately 40 cases.1 Ossification arises from salt buildup in the soft tissues, leading to bone formation in areas of the body where there is connective tissue. It has been reported to occur in other rare locations as well, such as the mammary gland and testicles.2 Penile ossification is most commonly associated with Peyronie plaque formation, although less common associations have been reported, including 64 • Vol. 19 No. 1 • 2017 • Reviews in Urology trauma, hemodialysis, and metabolic diseases.1,2 Herein we report an unusual case of penile ossification in a patient with Peyronie disease. To our knowledge, ours is the first in which implantation of an inflatable penile prosthesis (IPP) was performed. We describe his complex clinical course and discuss evaluation, management, and contemporary theories surrounding this entity. We focus on reconstructive challenges and important considerations for preoperative counseling and intraoperative pearls. Penile Ossification: A Reconstructive Challenge Presentation A 43-year-old man was referred to the urology clinic for a 3-year history of “penile firmness.” The firmness began as a 2- to 3-cm area at the mid-shaft of penis, but eventually spread to the entire shaft. The patient also complained of difficulty having sexual intercourse. On examination, he had a circumcised phallus with induration and hardening at the proximal shaft circumferentially. Given concern for malignancy, the indurated area was biopsied and revealed fibromatous tissue consistent with Peyronie disease. He elected to undergo IPP placement for refractory erectile dysfunction 6 months after initial presentation. The procedure was performed using a transverse penoscrotal approach; however, there was extensive hardening of both corporal bodies, due to what appeared to be calcified tissue along 80% of the shaft. A decision was made to extend the corporotomy longitudinally; with the assistance of multiple scalpels, curved Mayo scissors, and rongeurs, the calcified tissue was successfully removed from the corpora following an extended dissection (Figure 1). Histologic analysis confirmed the presence of bone, Three months following surgery, however, he returned with a bump on his glans and was found to have impending lateral extrusion of the left distal IPP cylinder (Figure 3). The decision was made to proceed with a distal corporoplasty, initially Histologic analysis confirmed the presence of bone, consistent with penile ossification. consistent with penile ossification (Figure 2). A 14-cm AMS 700 CXR IPP (American Medical Systems, Minnetonka, MN) with 1.5-cm rear tip extenders was placed, as the smaller cylinders of the CXR model help optimize girth in the setting of prior fibrosis. Closure of ™ described by Mulcahy in 1999.3 Dissection was performed to expose the tunica albuginea, beneath which the corpora appeared attenuated with a nearly eroded cylinder. The distal cylinder tip was exposed, revealing the corporal lumen and surrounding pseudocapsule Dissection was performed to expose the tunica albuginea, beneath which the corpora appeared attenuated with a nearly eroded cylinder. the corporotomy was performed sutures using 2-0 Monocryl (Ethicon, Cincinnati, OH). At his 6-week postoperative follow-up appointment, his IPP was activated uneventfully. ® (Figure 4A-D). A tunnel was created dorsal to the pseudocapsule using Brooks dilators (Coloplast, Minneapolis, MN) toward the glans (Figure 4E). The cylinder was repositioned within the new tunnel ™ Figure 1. Grossly excised calcified tissue from corpora during inflatable penile prosthesis placement. Vol. 19 No. 1 • 2017 • Reviews in Urology • 65 Penile Ossification: A Reconstructive Challenge continued A B Figure 2. Histologic analysis of excised corporal tissue revealed compacted cavernous and dense fibroconnective tissue with adjacent metaplastic bone characteristic of ossification (circle). deep to the pseudocapsule with the assistance of a straightened needle and Furlow insertion tool (Figure 4F). The pseudocapsule was secured as a protective covering over the cylinder, and the corporal body was closed in several layers. His device continues to function satisfactorily, and he remains free from complications. Discussion Penile ossification has rarely been cited in the literature, with fewer than 40 case reports published. To our knowledge, none of these patients underwent IPP implantation. The etiology of penile ossification appears likely metaplastic in nature.4 Earlier studies suggested a possible evolutionary relationship between ossification and baculum (a bone located in the penile septum or glans to help prolong mating) in other mammals. Recent studies have refuted this theory, however.1,5 Many reports have found a correlation between buckling injury and presence of ossified tissue, suggesting an acquired etiology in a majority of cases.1 de Arruda and colleagues1 and Sarma and Weilbaecher6 describe cases of irregular calcification as a palpable mass inside the Figure 3. Impending lateral extrusion of an inflatable penile prosthesis seen on physical examination in (A) dorsal and (B) lateral views. to lamellar bone with an eosinophilic ossified matrix, evidence of lacunar spaces and Haversian canals, and osteoblastic rimming with multinucleated osteoclasts are frequently demonstrated.2 Many reports have found a correlation between buckling injury and presence of ossified tissue, suggesting an acquired etiology in a majority of cases. corpora and septum, which appear to be the most cited areas for ossified tissue to accumulate. Penile ossification often presents as a painless hard mass on the penile shaft. Although the condition has been reported in sporadic settings without any associated risk factors, These findings were consistent with the pathology of our patient’s surgical specimen prior to his IPP placement. Treatment of patients with penile ossification is variable and depends on the extent of corporal calcification and symptomatology.7 Asymptomatic patients may be managed with observation, whereas those with bothersome pain may be treated medically or with surgical excision of calcified tissue. associations with Peyronie disease, trauma, gout and other metabolic disorders, chronic hemodialysis, and malignancy have been postulated.2 Histologically, metaplasia 66 • Vol. 19 No. 1 • 2017 • Reviews in Urology Asymptomatic patients may be managed with observation, whereas those with bothersome pain may be treated medically or with surgical excision of calcified tissue.2,7 As Penile Ossification: A Reconstructive Challenge A B who require distal corporoplasty for impending IPP cylinder extrusion had vascular anomalies or Peyronie disease.3 We report the first use of this technique in a patient with penile ossification and recommend using a multilayer closure to help protect from erosion. The pseudocapsule provides for an extra protective layer that may prove beneficial in revision or repeat procedures. C Conclusions D E Penile ossification is a rare, poorly understood entity. Although IPP placement is possible in these cases, they put patients at a higher risk for complications such as cylinder erosion. Extensive preoperative counseling and close postoperative monitoring are imperative, as subsequent management may pose surmountable reconstructive challenges. F References 1. 2. Figure 4. Distal corporoplasty. (A) Exposure and (B-C) removal of distal tip of an inflatable penile prosthesis cylinder. (D) Exposure of corporal lumen and surrounding pseudocapsule. (E) Creation of tunnel dorsal to pseudocapsule using Brooks™ dilators (Coloplast, Minneapolis, MN) toward the glans. (F) Repositioning of the cylinder within the new tunnel deep to the pseudocapsule using a straightened needle and Furlow insertion tool. our case had demonstrated, IPP is a feasible option for cases of refractory erectile dysfunction; however, surgeons must bear in mind that reconstruction may pose additional challenges, and these patients may be at increased risk of complications. IPP complications have been widely studied in the general population, and the majority of patients 3. 4. 5. 6. 7. de Arruda HO, de Lima H, Ortiz V. Human penile ossification: case report. Sao Paulo Med J. 2007; 125:124-125. Yilmaz IE, Barazani Y, Tareen B. Penile ossification: a traumatic event or evolutionary throwback? Case report and review of the literature. Can Urol Assoc J. 2013;7:E112-E114. Mulcahy JJ. Distal corporoplasty for lateral extrusion of penile prosthesis cylinders. J Urol. 1999;161:193-195. Vermooten V. Metaplasia in the penis. The presence of bone, bone marrow and cartilage in the glans. N Engl J Med. 1933;209:368-370. Bett WR. The os penis in man and beast. Ann R Coll Surg Engl. 1952;10:405-409. Sarma DP, Weilbaecher TG. Human os penis. Urology. 1990;35:349-350. Carson CC, Levine LA. Outcomes of surgical treatment of Peyronie’s disease. BJU Int. 2014;113: 704-713. Main Points • Penile ossification is a rare, poorly understood entity that can pose a reconstructive challenge for urologists. • Placement of an inflatable penile prosthesis is possible in patients with penile ossification and refractory erectile dysfunction, but they may be at higher risk of complications such as cylinder erosion. Use of a multilayer closure may help protect from erosion. • Extensive counseling and close postoperative monitoring are imperative following operative intervention on patients with penile ossification, as subsequent management may pose surmountable reconstructive challenges. Vol. 19 No. 1 • 2017 • Reviews in Urology • 67