A 37-year-old single man, a farm worker, who was sent to our department from another hospital because it did not have the necessary experience to treat the type of lesion he was suffering from; at that time he presented a penoscrotal lesion for which he had been urgently admitted 15 days earlier to the Urology Department of his hospital of origin with a diagnosis of suspected infected sarcoma or lymphogranuloma venereum. He had not previously been seen or treated in any other medical centre. During the 10 days he was admitted to the urology department, he was initially treated with Metronidazole and Ceftazidime, and once the antibiogram had been performed, with Amikacin, Trimethoprim/Sulfamethoxazole and Cefotaxime. The biopsy diagnosis was Buscke-Lowenstein warty carcinoma.
On admission, he presented with an exophytic tumour lesion on the penis measuring about 15 cm in diameter. The patient reported that it had started 6 months earlier as a small ulceration in the balanopreputial sulcus that progressively grew in the shape of a cauliflower and eventually infiltrated the surrounding tissues. In the penis, it affected the skin, dartos, Buck's fascia and albuginea, invaded the interior of the corpora cavernosa, destroyed the urethra and its spongiosa but respected the glans, and also infiltrated the pubic tissues, the scrotum and its contents.
The boundaries between the affected tissues and healthy tissues were not well defined; in the affected tissues there was a deformed, soft, fungal, ulcerated, purplish mass, foul-smelling and bleeding in some areas; the peripheral tissues were oedematous and there were palpable bilateral iliac and inguinal adenopathies. The patient urinated through an inconspicuous fistulous orifice located between the mass and the remains of the destroyed urethra.
Clinical tests were normal; serological tests for brucellosis, lupus and HIV were negative; bacteriological culture was positive for bacteroides caccae, proteus mirabilis and staphylococcus aureus. Pathological examination of the biopsy indicated giant Buschke-Lowenstein condyloma acuminatum.
Craniocaudal axial sections from the upper edge of the symphysis pubis to the root of the penis were performed using computerised axial tomography (CAT). The images showed bilateral lymphadenopathies in the internal and external iliac and inguinal chains; some of these lymphadenopathies exceeded one centimetre in diameter. The solid mass infiltrated the penis and scrotum and also appeared to infiltrate the fascia of the left adductor muscle, but no infiltration of the fat of the subcutaneous cellular tissue of the inner wall of the thighs or the fat of the perineum was observed, nor were there any bony lesions in the ischio-ileo-pubic branches suggestive of metastatic infiltration.

Given the characteristics of the tumour, the involvement of the lymph node chains and the possibility of malignancy, it was decided to perform radical surgical treatment, which was carried out 3 days after admission to Plastic Surgery.
Under general anaesthesia, with the patient in the supine position and the lower limbs apart, we made a perilesional incision through the pubis, inguinal folds and perineum, excising the tumour lesion en bloc; we then performed a lymphadenectomy of the affected chains, thus completing the emasculinisation of the patient. The incisions of the lymphadenectomies were closed in planes and the perineum-inguino-pubic area was covered with a skin graft taken from the left thigh.
 
Intraoperative study of an irregular biopsy specimen measuring 3 x 2 cm revealed a nodular formation with the appearance of a lymph node, suspicious for carcinoma metastasis due to the existence of non-conclusive atypical cells.
The anatomopathological study of the excised piece described: an irregular piece of warty appearance, which on one side shows the penile glans penis, measuring 18 x 15 x 12 cm of larger dimensions. The tumour occupies most of the piece, encompasses the penis circumferentially and affects the skin of the pubis, scrotum and perineum. When cut, the tumour is friable, with vegetative growth on the surface and papillomatous growth in depth, which also deeply affects the glans and perineal tissues; the testicles are engulfed by fibrosis and the tumour mass, although not infiltrated. The lymph nodes of the lymphatic chains sent for analysis are reactive, but free of tumour metastases.
After surgery, the patient was admitted to the resuscitation unit for 2 hours and then to the hospital ward for 25 days. A second operation was necessary due to partial necrosis of a small area of the wound of the left lymphadenectomy incision and the loss of approximately 25% of the skin graft used for the perineo-inguino-pubic closure.
During hospital admission, the usual postoperative medical treatment was administered and no blood transfusion was necessary. The patient remained catheterised since the operation and was discharged from hospital with the catheter, which he kept for a further month at home.
As a result of the operation, a small stump was left with a hole in the perineal region, where the urethra ends and through which urination takes place. Despite having been explained to the patient the different types of surgical procedures available for penile reconstruction (5), with their advantages and disadvantages, he has always refused to undergo reconstructive surgery.

 
As a consequence of emasculinisation, he developed hypergonadotropic hypogonadism, which is why he has been treated with testosterone since the operation (12 years to the present).
On the other hand, as it is a benign tumour, no postoperative medical treatment of any kind has been carried out, nor radio or chemotherapy as they are not indicated.