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AV malformation of the penis

AVM of the glans penis is a very rare entity. It may be congenital or there may be a history of trauma. It may present asymptomatically. Meticulous surgery provides complete excision & good cosmetic results

Authors: Gupta, Anurag ; Jaideep, Mahajani
Corresponding Author: Gupta, Anurag

 

Introduction

AV malformations of genitalia have been reported very rarely in the literature. Although they are usually thought to be congenital, trauma has been implicated as a cause. For diagnosis, colour doppler ultrasound, digital subtraction angiography and magnetic resonance imaging can be used to identify the characteristics of a lesion. Because of its rarity, there is no clear guideline for treatment.

Case Report

A 24–year–old male presented with a painless swelling on the glans penis adjacent to the meatus (Fig.1), which expanded with erection and had gradually increased in size in the previous 2 to 3 years. There was no history of trauma. Physical examination revealed a slightly bluish lesion, soft on palpation, protruding from the surface of the glans penis. There was no history of voiding disturbances, haematuria, urinary tract infection, priapism or pain with erection. The main concerns were mild discomfort during coitus, cosmesis and psychological disturbance. On clinical examination there was no bruit. Color Doppler was suggestive of AVM. The blood cell count, urinalysis & coagulation profile were within normal limits.

A vertical skin incision extending from the base of scrotum to the anal margin was given. After incision of Colles’ fascia, urethra was located and dissected. The urethra was approached at the distal margin of the bulbospongiosum muscle. Buck’s fascia was opened on either side of the urethra and a plane was developed between the spongiosum and cavernous bodies. Once the urethra was separated from the corpus cavernosum, a vascular tape (or infant feeding tube) was placed to elevate the urethra and facilitate its proximal and distal dissection. The bulbospongiosum muscle was then opened in the midline and separated laterally on each side to expose the underlying corpus spongiosum. Mobilization of the whole length of the bulbar urethra was done. The AVM was excised completely including part of the glans and distal glanular urethra involving AVM was also excised (Fig.2). Feeding artery at glans was identified and ligated (Fig.3). Finally after achieving hemostasis, an orthotopic, widely patent neomeatus was created (Fig.4).

The postoperative course was uneventful, and there was no functional or cosmetic defect. Surgical excision was undertaken to give to best chance of definitive resolution and to achieve better cosmetic results. At the 6-months follow-up, there was no evidence of recurrence.

Discussion

Various active interventions have been reported to treat AVM of the glans penis, including sclerotherapy, embolization and surgical excision. In our patient, surgical excision was preferred as the initial treatment because the lesion was single, small, localized and involving the meatus.

Considerable additional urethral length was required to overcome the terminal urethral deficiency created by excision of the AVM and to create a tension-free anastomotic neomeatoplasty, so full length mobilization of the whole bulbar urethra was performed beforehand.

Mobilization and advancement of the penile urethra alone are rarely sufficient to achieve this without causing penile chordee. The only part of the urethra that can be mobilized to provide extra length without creating penile curvature chordee is the bulbar urethra. Mobilization of the whole length of the bulbar urethra through a perineal incision provides 2 to 2.5 cm of tension-free lengthening in children and 4 to 5 cm in adults. The bulbar urethra does not participate in an erection and can be extensively mobilized proximally to the genitourinary diaphragm and distally to the penoscrotal junction without causing erectile impairment. The bulbar urethra has a very rich blood supply, proximally from the bulbar and urethral arteries and distally by retrograde flow from the glans penis and from perforating arteries, branches of the cavernosal and dorsal arteries.

Our surgical technique is based on the principle of bulbar elongation and meatus advancement described by Turner Warwick5. Mobilization of only the distal and mid bulbar urethra was required. The proximal bulbar urethra was not mobilized and utmost precautions were taken to avoid injury to the bulbar artery on either side. As retrograde supply and supply through perforators to the urethra is hampered during the surgery; further injury to the bulbar artery could lead to complete urethral necrosis.

Conclusion

AVM of the glans penis is a very rare entity. It may be congenital or there may be a history of trauma. It may present asymptomatically. Meticulous surgery provides complete excision & good cosmetic results.

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References

1. Forstner R, Hricak H, Kalbhen CL, Kogan BA, McAninch JW.Magnetic resonance imaging of vascular lesions of the scrotum and penis. Urology. 1995 Oct; 46(4): 581-583.
2. Guz BV, Ziegelbaum M, Pontes JE. Arteriovenous malformation of spermatic cord. Urology. 1989 May;33(5):427-8.
3. Hamid S, Aquilina JW, Davidson W, Dhabuwala CB. Arteriovenous malformation of scrotum: A case report. J Urol. 1992 Jan;147(1):160-2.
4. Mathur P, Porwal KK, Pendse AK, Parihar US, Chittora R.Hemangiomatous penile horn. J Urol. 1996 May;155(5):1738
5. Warwick RT, Parkhouse H, Chapple CR. Bulbar Elongation Anastomotic Meatoplasty (BEAM) for Subterminal and Hypospadiac Urethroplasty. J Urol. 1997 Sep;158(3 Pt 2):1160-7.
6. Sule JD, Lemmers MJ, Barry JM. Scrotal arteriovenous malformation: Case report and literature review. J Urol. 1993 Dec;150(6):1917-9
7. Woolley MM, Stanley P, Wesley JR. Peripherally located congenital arteriovenous fistulae in infancy and childhood. J Pediatr Surg. 1977 Apr;12(2):165-76.

 

Date added to bjui.org: 24/11/2012

DOI: 10.1002/BJUIw-2011-132-web

Recurrent Arteriovenous Malformation of the Spermatic Cord

To our knowledge this is the first report of a recurrent AVM of the spermatic cord.

 

Authors: Harbin, Andrew MD; Anup Vora, MD; Bandi, Gaurav

Georgetown University Hospital, Department of Urology, 3800 Reservoir Road NW, Washington, DC 20007


Corresponding Author: Andrew Harbin MD, Georgetown University Hospital, Urology, Washington DC, USA. Email: [email protected]

Case Report
 
A 30 year old Hispanic male with no past medical history presented with a painful midline scrotal mass.  He reported a history of a similar mass which had been resected 5 years previously. Histologic analysis at that time showed a benign vascular lesion representing an arteriovenous malformation.  Physical examination at this latest presentation demonstrated a 3 cm tender, firm mass superiomedial to the right testis but attached to the spermatic cord.  Ultrasound showed a discrete 3.4×2.1×3.6cm cystic mass with thin, hypervascular internal septations (Figure 1).

 

Figure 1. Ultrasound image of the spermatic cord superior to the right testis displaying a cystic mass with multiple internal septations. 

 
The mass was adjacent to but separate from the right testis. Due to his persistent discomfort,  the patient elected to undergo surgical excision of the mass.

 

A midline scrotal incision was made and the testis was delivered.  Upon further dissection; a 3cm, dark, cystic mass with multiple septations was seen. The mass appeared to be attached to the spermatic cord (Figure 2).

 

Figure 2. Photograph demonstrating the AVM, arising from the spermatic cord cephalad to the right testis.

 

The mass was carefully resected from the cord, and did not obviously invade or arise from any particular cord structure.  Pathologic examination showed a benign vascular lesion consistent with an arteriovenous malformation.  At follow up several weeks later, the patient had complete resolution of his symptoms.

 

Discussion
AVM of the genital area is rare, and there is only a few documented cases of AVM of the spermatic cord (1-6).  To our knowledge this is the first report of a recurrent AVM of the spermatic cord.
AVM of the spermatic cord is typically found incidentally as a painless mass or on imaging during infertility workup.  There is one case in which the patient presented (as in our case) with a painful mass in the scrotum (6).  Scrotal AVM, on the other hand, frequently presents with bleeding, ulcerated lesions or a large, painful mass (7,8).  Differential diagnosis should include lipoma of the cord, adenomatoid tumor, leiomyoma, malignancy (sarcoma), or other vascular lesions, such as varicocele, hemangioma, lymphangioma or hamartoma (5,8).
Patients are usually young men in their second, third or fourth decade of life with little past medical history (1-6).  Several patients with genital AVM report a prior history of trauma to the area (5).  Physical examination may reveal palpable, dilated tortuous veins, skin discoloration, and possibly a bruit or thrill on auscultation (8).  Workup of the suspected AVM may include ultrasound evaluation or arterial angiography.  Doppler images will show increased vascularity in the cystic septations (5,6,8,9).  Arterial angiography is preferred for cases of larger masses or when the diagnosis is uncertain (6,10).  This modality offers the advantage of possible embolization at the time of diagnosis.  Magnetic resonance imaging has also been employed for imaging of these lesions (9).
Management options include observation (9), angiographic embolization (10), and surgical excision (5).  Surgical excision is the definitive therapy if less invasive therapies fail, and may involve orchiectomy or cord resection (6).  While AVM of the spermatic cord is a rare lesion, it should be considered in the workup of a scrotal mass.  This is the first documented case of a recurrent AVM of the spermatic cord.  While prior trauma (5) or scrotal surgery (1) are well established risk factors, history of scrotal AVM should also be considered when evaluating a patient with a mass of the spermatic cord.

 

References
1. Auman JR. Spermatic cord arteriovenous fistula: an unusual complication of vasectomy. J Urol. 1985 Oct; 134 (4) :768.
2. Bumpers PM Jr, Hulbert WC Jr, Jimenez JF. Arteriovenous malformation of the spermatic cord. J Urol. 1989 Jan; 141 (1) :103-4.
3. Guz BV, Ziegelbaum M, Pontes JE. Arteriovenous malformation of spermatic cord. Urology. 1989 May; 33 (5) :427-8.
4. Oktay B, Ozyurt M, Erol O, Simşek U. Arteriovenous malformation of the spermatic cord. Br J Urol. 1991 Feb; 67 (2) :216. PubMed PMID:2004242.
5. Kang TW, Choi YD, Jeong YY, Kwon DD, Park K, Ryu SB, Park YI. Intrascrotal extratesticular arteriovenous malformation. Urology. 2004 Sep; 64 (3) :590. PubMed PMID:15351608.
6. Sountoulides P, Bantis A, Asouhidou I, Aggelonidou H. Arteriovenous malformation of the spermatic cord as the cause of acute scrotal pain: a case report. J Med Case Reports. 2007 Oct 16; 1:110. PubMed PMID:17939869; PubMed Central PMCID: PMC2194703.
7. Hatten BW, Bryant E. Bleeding scrotal arteriovenous malformation. J Emerg Med. 2009 Aug 12; PubMed PMID:19682823.
8. Bandi G, Bianco FJ, Dhabuwala CB. Recurrent scrotal arteriovenous malformation. J Urol. 2004 Apr; 171 (4) :1628. PubMed PMID:15017239.
9. Skiadas V, Antoniou A, Primetis H, Moulopoulos L, Vlahos L. Intratesticular arteriovenous malformation Clinical course, ultrasound and MRI findings of an extremely rare lesion on a 7 year follow-up basis. Int Urol Nephrol. 2006; 38 (1) :119-22. PubMed PMID:16502065.
10. Monoski MA, Gonzalez RR, Thomas AJ, Goldstein M. Arteriovenous malformation of scrotum using virtual azoospermia. Urology. 2006 Jul; 68 (1) :203.e5-6. PubMed PMID:16808963.

 

Date added to bjui.org: 18/01/2012 


DOI: 10.1002/BJUIw-2011-101-web

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