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Extramammary Paget disease (EMPD) is a rare malignant neoplasm arising in apocrine gland-rich skin, which may be classified as either of primary or secondary origin. Management of this condition is predominantly surgical, and is often characterised by lengthy diagnostic delays. Complete surgical excision is challenging, and local recurrence is common. Herein, we discuss a subtle presentation of recurrent scrotal EMPD in a 77-year-old male and review the available literature. Although relatively rare, the indistinct nature of this pathology merits special attention from treating surgeons, who are frequently responsible for initial management and follow-up. The risk of distant metastasis and concomitant prognostic implications necessitate a high clinical index of suspicion, and low threshold for definitive biopsy in similar cases.

How to do a Delorme's sleeve mucosectomy and muscular plication for full-thickness rectal prolapse Full thickness, or complete rectal prolapse, is a circumferential protrusion of all layers of the rectum through the anus. This disabling condition is common in the elderly and is associated with chronic complications such as difficulty maintaining perianal hygiene, faecal incontinence and mucus discharge, as well as acute complications related to the prolapse itself including pain, ulceration, bleeding, incarceration and gangrene. 1 Surgery is the only definitive treatment option for rectal prolapse and but there is no single, accepted standard procedure. [1][2][3] Minimally invasive trans-abdominal surgery, such as ventral rectopexy using synthetic or biologic grafts and resection rectopexy, have become widespread in this modern era, 4-6 and perineal approaches, such as the Altmeier's and Delorme's procedures, are generally offered to frail patients who are unable to tolerate pneumoperitoneum.The Altmeier's procedure is a perineal rectosigmoidectomy. 7 The Delorme's procedure on the other hand, is a perineal sleeve mucosectomy with muscular plication, and this cannot be offered to patients with prolapse necrosis requiring resection. Both perineal operations are associated with low morbidity and acceptable recurrence rates. 3 Prone jack-knife position provides both primary and assistant surgeons optimal comfort and space to work, as well as exposure and circumferential access to the prolapse. We do not place the patient in lithotomy as is commonly described where possible because, while it is standard for the primary surgeon to be seated square in between the patient's raised legs, it is usual for the surgical assistant to have to stand up and bend-over throughout the operation to see and assist. 8 We find it much easier to approach the prolapse in prone jack-knife and are able to suction any blood efficiently in this position. 9 Here, we offer a step-by-step description of the Delorme's procedure in our favoured prone jack-knife position for elective patients with full-thickness rectal prolapse. The principles of this technique are to reduce the prolapse, relieve incontinence and prevent obstructive defecation.