LAUSR

A 70 year old male with a history of erectile dysfunction, who was using penile injection therapy, developed penile pain about six months after initiating therapy. Despite discontinuation of the injections, the patient's pain progressively worsened in the subsequent months. The pain was described as intermittent, sharp and localized to the glans, mainly on the right side. An MRI of the pelvis revealed a 2.7 cm cystic mass arising from the inferior aspect of the pubic symphysis, which was compressing the penis at the base (Fig. 1A and C). Shortly thereafter, the patient presented with acutely worsening penile pain, penile numbness and color change. His pain was now more distributed to the base of the penis. Genitourinary physical exam was consistent with a palpable, midline mass deep to the perineum; however the mass was not palpable on suprapubic examination and the patient was not tender to palpation in the penile area. A duplex ultrasound revealed no blood flow compromise to the penis. Due to the patient's severe uncontrollable pain we proceeded with an open incisional biopsy, and if benign, as expected, complete removal of the mass. After informed consent was obtained, the patient was taken to the operative room, and placed in the dorsal lithotomy position. Initial cystourethroscopy revealed an extrinsic mass effect on the dorsal bulbous urethra. A Foley catheter was kept in place and a vertical midline perineal incision was made. Dissection was carried down through the bulbospongiosus muscle, where the bulbar urethra and corpora cavernosa bodies were identified. A plane was then made between the bulbar urethra and corpora bodies, exposing the contour of the mass (Fig. 2A). An intra-operative biopsy of the mass demonstrated benign, cartilaginous fragments. The mass was then removed by dissecting the plane between the corpora cavernosum and the mass, and carried laterally and superiorly to the level of the bone. There was some noted fixation of the mass to surrounding structures and care was taken to protect the urethra and surrounding structures. The mass was then removed via electrocautery, in a piecemeal manner. There was some bleeding encountered at the base of the penis, near the inferior pubic region, which was controlled with figure of eight sutures (Fig. 2B). Repeat cystoscopy confirmed no injury to the urethra. The incision was closed at the layers of the bulbospongiosus muscle, dartos tissue and the skin in standard fashion. The final pathological specimen (Fig. 2C) was composed of fibrocartilaginous and fibrinous material, consistent with a cartilaginous cyst. Post-operatively, the patient's pain had completely resolved, though he had some numbness in the penile area. He was discharged on postoperative day one. He returned to the clinic one month later, where he described complete resolution of his penile pain, though he had persistent numbness of penis and persistent erectile dysfunction. Exam