Penile conserving surgery is oncologically safe and a surgical excision margin of less than 5 mm is adequate. Higher local recurrence rates are associated with lymphovascular invasion, and higher tumor stage and grade. Local recurrence has no negative impact on long-term survival.

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Study Type – Harm (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Nicorandil is used as a vasodilator for the prevention and long‐term treatment of angina. However, ulceration induced by nicorandil has been reported in the past, involving the mouth, anus and other parts of the gastrointestinal system. We herein report the largest to‐date series of external genitalia ulceration, related to treatment with nicorandil. OBJECTIVE To report on the largest series to date of ulceration of the external genitalia, related to treatment with nicorandil – a vasodilator for the prevention and long‐term treatment of angina – and to review the literature on the subject, focusing on the clinical features and the pathogenesis of this rare, yet marked, side‐effect. PATIENTS AND METHODS Three patients (aged 71–83 years) were referred for severe ulceration of the penis. A complete work‐up was performed to exclude potential underlying causes, including malignancy and sexually transmitted diseases. After a careful review of the patients’ medical history, a potentially causal relationship was noted; all patients had been taking nicorandil for at least 2 years before the development of penile ulceration. RESULTS Penile ulcers associated with nicorandil are characteristically large, deep, painful and have punched‐out edges. They usually involve the prepuce or the penile shaft skin. Higher doses of nicorandil (at least 40 mg daily) and surgical procedures seem to increase the risk for nicorandil‐related ulceration. Response to topical steroids is poor, but complete healing is achieved by discontinuation of nicorandil, while surgical treatment should be discouraged. CONCLUSION The growing body of literature showing the link between treatment with nicorandil and ulceration at multiple sites has led to the recognition of this side‐effect by the World Health Organization. Nicorandil‐related ulcers rarely involve the penile skin and constitute a diagnostic and therapeutic challenge. The pathogenesis of this rare side‐effect is largely unknown, but mechanisms such as the ‘vascular steal phenomenon’ and the direct toxic effect of the drug or its metabolites have been implicated.

This study aims to evaluate the outcome of ureteroscopy/ureterorenoscopy (URS) as a salvage procedure for stones resistant to extracorporeal shock wave lithotripsy (ESWL). Between January 2009 and January 2012, 313 patients with upper tract lithiasis were treated by URS. Among them, 87 (27.8 %) had undergone URS after prior ESWL failed to achieve stone clearance (Salvage group). These patients were matched with a group of patients who underwent URS as first-line modality (Primary group). Stone-free rates and adjuvant procedures represented the primary points for comparison. Secondary points for comparison included complications, procedure duration, total laser energy used and length of hospitalization. Matching was possible in all cases. Stone clearance rates were 73.6 and 82.8 % for the Salvage and Primary group, respectively. The difference in stone clearance rates between the two groups was not statistically significant (p = 0.186). A total of 11 patients (12.6 %) in the Primary group and 18 patients (20.7 %) in the Salvage group underwent an adjuvant procedure (p = 0.154). No statistically significant differences were noted in terms of complications, procedure duration and length of hospitalization. In the Primary group, the laser energy used for stone fragmentation was higher (p = 0.043). The rate of ureteric stenting at the end of the procedure was higher for the Salvage group (p = 0.030). Previous failed ESWL is not a predictor for unfavorable outcome of URS. Salvage URS is associated, however, with an increased need for ureteric stenting at the end of the procedure.