This web only provides the extract of this article. If you want to read the figures and tables, please reference the PDF full text on Blackwell Synergy. Thank you.

- Case report -

Coagulation of a giant hemangioma in glans penis with holmium laser

Emin Aydur¹, Bulent Erol¹, Lutfi Tahmaz¹, Hasan Cem Irkilata¹, Cenker Eken², Ahmet Fuat Peker¹

¹Department of Urology, ²Department of Emergency Medicine, Gülhane Military Medical Academy, Etlik, Ankara 06018, Turkey

Abstract

A 21-year-old man presented with an enlarged giant hemangioma on glans penis which also causes an erectile dysfunction (ED) that partially responded to the intracavernous injection stimulation test. Although the findings in magnetic resonance imaging (MRI) indicated a glandular hemangioma, penile colored Doppler ultrasound revealed an invaded cavernausal hemangioma to the glans. Surgical excision was avoided according to the broad extension of the gland lesion. Holmium laser coagulation was applied to the lesion due to the cosmetically concerns. However, the cosmetic results after holmium laser application was not impressive as expected without an improvement in intracavernous injection stimulation test. In conclusion, holmium laser application should not be used to the hemangiomas of glans penis related to the corpus cavernosum, but further studies are needed to reveal the effects of holmium laser application in small hemangiomas restricted to the glans penis. (Asian J Androl 2008 Sep; 10: 819_821)

Keywords: lasers, penis, erectile dysfunction; hemangioma; holmium laser

Correspondence to: Bulent Erol, MD, Acar sok. Kardelen Sitesi A Blok D:2 Florya-Istanbul, Turkey.
Tel: +90-532-352-6564 Fax: +90-212-532-1059
E-mail: erolbulent@yahoo.com
Receive 2007-04-17 Accepted 2007-10-08

DOI: 10.1111/j.1745-7262.2008.00359.x

1 Introduction

Hemangioma is the most common benign vascular tumor that results from proliferation of immature capillary vessels [1]. Penile hemangiomas are very uncommon mesenchymal tumors. Generally, they are small in size and clinically not relevant, except for complaints regarding the aesthetic aspect and the possibility of bleeding during intercourse. The localization of the hemangioma to the glans is rarer. Possible therapies include surgical excision, electrofulguration, cryotherapy, and sclerotherapy. We describe an extremely rare case of a large glans hemangioma originating from the corpus cavernousum that was treated by holmium laser because of cosmetic concerns.

2 Case report

A 21-year-old man was referred to our clinic as a result of an enlarged glans formation accompanied with mild erectile dysfunction. The patient did not complain of bleeding, hemospermia or macrohematuria. On physical examination, the tumor was mostly localized in the base of the glans. The surface of the tumor was very irregular and raspberry-colored (Figure 1). The formation decreased considerably in size after slight digital compression. Magnetic resonance imaging (MRI) was first performed to determine the borders of the hemangioma. Although the MRI findings indicated a glanduler hemangioma (Figure 2), a penile colored Doppler ultrasound revealed an invaded cavernausal hemangioma to the glans (Figure 2). We decided to apply the holmium laser to the glans to improve its cosmetic appearance (in accordance with the knowledge regarding of Nd:YAG laser usage in hemangiomas). The holmium laser (Lumenis, Tel Aviv, Israel) was used under general anesthesia at a maximal average power of 100 W (2 J at 50 Hz) to enucleate prostatic adenomata using a previously described technique [2, 3]. A power output of 25_40 W was used for 3 s with a contact probe (Figure 3). The holmium laser was applied to all the hemangiomatous lesions on the glans. The patient was discharged on the second day with topical nitrofurazone. In the follow-up period, erectile dysfunction (ED) did not improve based on the intraca-vernousal injection stimulation test and penile colored Doppler. Although the cosmetic appearance of the glans hemangioma was improved in the second month, it had returned to its original appearance 5 months after the operation (Figure 4).

3 Discussion

The etiology of glans hemangioma is not completely understood. Although some investigators maintain that it should be considered a congenital vascular anomaly or a benign vascular neoplasm [4_6], others believe that it could be produced by herniation of the cavernous body tissue, as in the present case [7], or that it could grow up through the revascularization of a previous penile hematoma [8]. Therapeutic options for small lesions include surgical therapy, electrofulguration and cryotherapy [9_11]. More recently, laser fulguration [12_14] and sclerotherapy [15, 16] have also been proposed.

Although glans penis hemangiomas can continue to grow, most lesions require no treatment, unless a patient is concerned regarding the appearance of the penis. Because of high vascularity, surgical excision of these tumors not only carries the risk of bleeding during the excision but also might cause nocturnal erections in the postoperative period. In addition to poor healing, scar formation is a frequent complication of the surgery of glans penis. For the first time, Jimenez-Cruz and Osca [12] have described a successful Nd:YAG laser treatment in a case of glans penis hemangioma. However, there is no evidence in the published literature regarding the application of the holmium laser in the treatment of glans hemangiomas.

The results of the holmium laser application were not impressive, as was expected during the 5-month follow-up period, despite the better cosmetic appearance in the 2-month period after the operation. The glans hemangiom was an extension of the cavernausal hemangioma in the present case. This might have been the cause the undesired outcome, rather than the ineffectiveness of holmium laser. The effectiveness of the holmium laser in small isolated glans hemangiomas is not known and an issue for future work.

Diagnosis is another challenging issue in these cases that is worth mentioning. The origin and extension of glans hemangiomas might not be clearly displayed by MRI, like in the present case. Penile colored Doppler should be used in these cases, with MRI, to demonstrate the cavernaousal extension of the hemangioma.

In conclusion, holmium laser application should not be used on the hemangiomas of glans penis related to the corpus cavernasoum, but further studies are needed to reveal the effects of holmium laser application in small hemangiomas restricted to the glans penis.

References

1 Jahn H, Nissen HM. Haemangioma of the urinary tract: review of the literature. Br J Urol 1991; 68: 113_7.

2 Gilling PJ, Kennett K, Das AK, Thompson D, Fraundorfer MR. Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience. J Endourol 1998; 12: 457_9.

3 Ahyai SA, Lehrich K, Kuntz RM. Holmium laser enucleation versus transurethral resection of the prostate: 3-year follow-up results of a randomized clinical trial. Eur Urol 2007; 52: 1456_63.

4 Lane JW. Hemangioma of the glans penis. U S Armed Forces Med J 1953; 4: 139_40.

5 Dehner LP, Smith BH. Soft tissue tumors of the penis. A clinicopathologic study of 46 cases. Cancer 1970; 25: 1431_47.

6 Senoh K, Miyazaki T, Kikuchi I, Sumiyoshi A, Kohga A. Angiomatous lesions of glans penis. Urology, 1981; 17: 194_6.

7 Mortensen H, Murphy L. Angiomatous malformations of the glans penis. J Urol 1950; 64: 396_9.

8 Gibson TE: Hemangioma of the scrotum. Urol Cutan Rev 1937; 41: 43_4.

9 Angulo JC, López JI, Iriarte I, Loizaga A, Flores N. Angioma of the glans, report of 2 cases. Arch Esp Urol 1993; 46: 47_8.

10 Goldwyn RM, Rosoff CB. Cryosurgery for large hemangioma in adults. Plast Reconstr Surg 1969; 43: 605_11.

11 Yamazaki S, Kawashima T, Nishimura K, Sasaki M, Nakagawa T. Penile hemangioma treated by cryosurgery: report of a case. Acta Urol Jap 1978; 24: 325_32.

12 Jimenez-Cruz JF, Osca JM. Laser treatment of glans penis hemangioma. Eur Urol 1993; 24: 81_3.

13 Amaro JL, Agostinho AD, Polido Júnior A, Costa RP, Trindade Filho JC, Trindade JC. Treatment of hemangioma of the glans penis using Nd:Yag laser: apropos of a case. J Urol (Paris) 1997; 103, 62_3.

14 Ulker V, Esen T. Hemangioma of the glans penis treated with Nd:YAG laser. Int Urol Nephrol 2005; 37: 95_6.

15 Hemal AK, Aron M, Wadhwa SN. Intralesional sclerotherapy in the management of hemangiomas of the glans penis. J Urol 1998; 159: 415_7.

16 Savoca G, De Stefani S, Buttazzi L, Gattuccio I, Trombetta C, Belgrano E. Sclerotherapy of hemangioma of the glans penis. Urology 2000; 56: 153.