Age‐stratified cut‐off points for the nocturnal penile tumescence measurement using Nocturnal Electrobioimpedance Volumetric Assessment (NEVA®) in sexually active healthy men

The current nocturnal penile tumescence (NPT) measurement is based on standard cut‐off levels defined regardless of age. This study was conducted to provide age‐stratified cut‐off points for NPT measurement. Forty sexually active healthy men between 20 and 60 years old were enrolled and divided equally into four groups defined by age (20–29, 30–39, 40–49 and 50–60 years.). None of the candidates had sexual dysfunction or sleep disturbance or used supportive medication to enhance sexual function. Erectile function was evaluated by using the 5‐item version of the international index of erectile function (IIEF‐5). NPT was observed using the nocturnal electrobioimpedance volumetric assessment (NEVA^®). The NPT values of healthy men aged 20–60 years varied from 268.7% to 202.3%. The NPT differed significantly between age groups (P < 0.0009); however, no significant differences between men aged 30–39 and 40–49 (P = 0.593) were observed. Age was weakly associated with IIEF‐5 scores (P = 0.004), whereas a strong and negative correlation between age and NPT (P < 0.0001) was found. IEF‐5 scores were not significantly associated with NPT (P = 0.95). Therefore, the standard values for NPT testing should be considered in the evaluation of the nocturnal penile activity of men of all ages.     

Non‐invasive methods of penile lengthening: fact or fiction?

What's known on the subject? and What does the study add? Penile lengthening methods remain a controversial issue. Surgical procedures of “lengthening phalloplasty” are characterized by poorly defined indications and an unacceptably high rate of complications, as recently outlined by a literature review, while non‐surgical techniques are largely popularized by the media but often lack scientific evidence. In the literature we found only ten articles/abstracts of studies pertaining to the topic of our review. With our review, we aimed to explore whether non‐surgical methods of penile lengthening may have some scientific background. We focused specifically on penile extenders, which among conservative methods are those whose efficacy is supported by some scientific evidence. It seems that penile traction devices should be proposed as the first‐line treatment option for patients seeking a penile lengthening procedure. Penile size is a matter of great interest among men who are affected by ‘short penis syndrome’ or just believe themselves to have a small penis, even though the dimensions of the organ fall within the normal range. Surgical procedures of ‘lengthening phalloplasty’ lack standardized indications and carry a high risk of complications. Several non‐invasive methods of penile lengthening have been described, such as vacuum devices, penile traction devices and penoscrotal rings; even ‘physical exercises’ have been popularized through the media. Most of these techniques, however, are not supported by any scientific evidence. We briefly analyse the efficacy and scientific background of such non‐surgical methods of penile lengthening. It seems that penile extenders represent the only evidence‐based technique of penile elongation. Results achieved do not seem to be inferior to surgery, making these traction devices an ideal first‐line treatment option for patients seeking a penile lengthening procedure.     

Fate of the retained reservoir after replacement of 3-piece penile prosthesis

PURPOSE: We evaluated patients who underwent surgery for implant malfunction to determine whether retaining the reservoir was associated with an increased risk of erosion or infection. We also reviewed the literature to study possible risk factors for reservoir erosion. MATERIALS AND METHODS: We reviewed the records of 85 patients who underwent 98 procedures for replacement of a malfunctioning 3-piece penile implant. Of these patients 13 underwent 2 replacement procedures. At the time of primary surgery the reservoir was placed in either the retropubic space or extraperitoneally in the lower lateral abdomen if the patient had undergone prior pelvic surgery. During surgery for replacement of the malfunctioning implant the cylinders and pump were removed, and the reservoir of the original 3-piece device was retained. During followup patients were assessed for implant function and the development of any complication such as infection and/or reservoir erosion into the bladder or bowel. RESULTS: Infection developed in 1 patient and implant malfunction occurred in 13 but no patient had erosion of the retained reservoir. All 85 patients had a functioning implant at a mean followup of 50 months (range 12 to 148). Review of the literature suggests that prior pelvic surgery and infection are major risk factors for reservoir erosion. CONCLUSIONS: Retaining the reservoir during replacement of malfunctioning 3-piece implants is not associated with a significant risk of erosion and routine removal is not necessary. Prior pelvic surgery and infection appear to be risk factors for reservoir erosion.     

阴茎转移癌18例临床分析

目的探讨阴茎转移癌的临床特点、诊治方法及预后。方法回顾性分析18例阴茎转移癌患者的临床及随访资料并复习相关文献。18例患者原发肿瘤包括膀胱癌8例,前列腺癌4例,直肠癌2例,结肠癌、肾癌、食管癌和肺癌各1例。其中9例患者接受了阴茎切除+静脉化疗,5例患者仅接受静脉化疗未行阴茎切除术,2例患者仅接受了阴茎局部放疗,1例肾癌患者仅接受了索拉菲尼靶向治疗。结果本组18例患者中,从确诊原发肿瘤至出现阴茎转移时间为1~100月,平均(18.7±1.9)月。从确诊阴茎转移至患者死亡时间为4~23月,平均(10.2±1.7)月。所有18例患者均死于出现阴茎转移2年内。结论阴茎转移癌是一种罕见且预后较差的疾病,即使进行治疗,多数患者仍死于确诊阴茎转移1年内。逆行性静脉途经是发生阴茎转移的主要机制。阴茎切除仅限于缓解局部症状而不应常规应用。     

A pilot phase-II prospective study to test the 'efficacy' and tolerability of a penile-extender device in the treatment of 'short penis'

OBJECTIVE

To assess a commonly marketed brand of penile extender, the Andro‐Penis® (Andromedical, Madrid, Spain), widely used devices which aim to increase penile size, in a phase II single‐arm study powered to detect significant changes in penile size, as despite their widespread use, there is little scientific evidence to support their potential clinical utility in the treatment of patients with inadequate penile dimensions.

PATIENTS AND METHODS

Fifteen patients were required to test the efficacy of the device, assuming an effect size of >0.8. Eligible patients were counselled how to use the penile extender for at least 4 h/day for 6 months. Penile dimensions were measured at baseline and after 1, 3, 6 and 12 months (end of study). The erectile function (EF) domain of the International Index of EF was administered at baseline and at the end of the study. Treatment satisfaction was assessed using an institutional unvalidated five‐item questionnaire.

RESULTS

After 6 months the mean gain in length was significant, meeting the goals of the effect size, at 2.3 and 1.7 cm for the flaccid and stretched penis, respectively. No significant changes in penile girth were detected. The EF domain scores improved significantly at the end of study. Treatment satisfaction scores were consistent with acceptable to good improvement in all items, except for penile girth, where the score was either ‘no change’ or ‘mild improvement’.

CONCLUSIONS

Penile extenders should be regarded as a minimally invasive and effective treatment option to elongate the penile shaft in patients seeking treatment for a short penis.     

阴茎缺损的治疗进展

阴茎为男性的重要外生殖器官,主要具有排尿、排精和性交功能。战伤、创伤、外伤以及某些疾病如阴茎癌均可造成阴茎完全或部分缺损,严重导致尿流改道和丧失性交能力,给患者精神和生活上造成巨大的创伤。因此阴茎缺损的修复日益受到患者和医生的高度重视,理想的治疗应达到具有良好的外形和感觉、通畅的站立排尿、顺利完成性交3个方面的和谐统一。目前阴茎缺损临床治疗主要采用阴茎再植术、阴茎延长术及阴茎再造术;随着移植免疫、组织配型、免疫抑制剂的研究进展,以及动物异体肢体移植的长期存活等令人鼓舞的结果,为人体异体阴茎移植治疗阴茎缺损奠定了坚实的基础;组织工程技术构建阴茎组织绝大部分尚处于实验阶段,如何在临床上将构建的组织与自体组织有效的融合,在重建阴茎外观的基础上,使之发挥持久的功能将是一项值得继续研究的课题。     

Implantation of AMS 700 LGX penile prosthesis preserves penile length without the need for penile lengthening procedures

Implantation of an inflatable penile prosthesis (IPP) is a well-established definitive solution for erectile dysfunction when conservative treatments fail. Penile implants may shorten the penis. The AMS 700 LGX IPP is in common use but reports on its mechanical reliability, medium-term postsurgical patient satisfaction, and mean penile length preservation are lacking. We investigate the mean penile length, mechanical reliability, and patient satisfaction at 6 and 12 months after implantation of the AMS 700 LGX. This prospective study consecutively enrolled men undergoing first-time IPP implant surgery from February 2009 to April 2012. Stretched flaccid penile length, penile length at 50% and 100% of stiffness (P50 and P100) and International Index of Erectile Function (IIEF) and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) scores, were measured at 6 and 12 months postsurgery. Of 45 patients who underwent AMS 700 LGX implantation (median age 61 years) and completed 6 months’ follow-up, 36 (80%) completed the study. A significant difference in stretched flaccid penile length was seen between 6 and 12 months (P = 0.033). P100 was also significantly increased at 6 and 12 months, with a mean 10% increase (1.3 ± 0.4 cm) from baseline to 12 months. Differences in mean IIEF scores at 6 and 12 months were significant for the desired domain (P = 0.0001) and for overall satisfaction (P = 0.002); however, mean EDITS scores at 6 and 12 months were not significantly improved. AMS 700 LGX is a powerful tool for preserving penile length in men undergoing penile prosthesis implantation.     

Organ‐preserving surgery for penile cancer: description of techniques and surgical outcomes

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Organ‐preserving surgeries for penile cancer have been described to reduce the morbidity associated with traditional operations. Patients derive better functional outcomes from penile‐preserving surgery, although local recurrence rates can be higher. Excellent results can be obtained at large‐volume centres. With close follow‐up, local recurrences can be identified and treated promptly (often with further local excision).

OBJECTIVE

• ? To describe the outcomes of organ‐preserving surgery for penile cancer at a UK tertiary referral centre.

PATIENTS AND METHODS

• ? Patients at Sunderland Hospital (UK) between 2001 and 2008 who had squamous cell tumours limited to the glans penis underwent penile‐preserving surgery including total glansectomy and glanuloplasty, partial glansectomy, glans relining and distal penectomy with glans reconstruction.
• ? Recurrence rates, cosmetic and functional outcomes were recorded.

RESULTS

• ? In all, 65 patients were identified with a median follow‐up of 40 months. Local recurrence was present in four patients (6%) despite 72% having intermediate or poorly differentiated tumours and 30% with T2 disease.
• ? Complications included partial graft loss (1.5%), graft contractures (4.5%) and meatal stenosis (7.5%).
• ? In all, 5% were deemed to have poor cosmetic outcome and 85% described good erections at 1 year after surgery.

CONCLUSION

• ? Penile‐preserving surgery can achieve good penile cancer control with minimal morbidity and reduced psychosexual side‐effects.

     

Nicorandil‐induced penile ulcerations: a case series

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Partial nephrectomy is the standard treatment for the management of small renal masses, and laparoscopy has been widely used in this setting as it has all the principles of open procedures combined with the advantages of minimal invasiveness. Laparoscopic partial nephrectomy is feasible and has acceptable pathological results not only for small renal masses but also for large tumours, even if complication rate and ischemia time are still matters of debate.

OBJECTIVE

• ? To investigate the perioperative safety of laparoscopic partial nephrectomy (LPN) for large renal masses (>4 cm).

PATIENTS AND METHODS

• ? After Institutional Review Board approval, data from 100 consecutive patients who had undergone transperitoneal or retroperitoneal LPN at our institution from January 2005 to June 2009 were obtained from our prospectively maintained database.
• ? The patients were divided into two groups according to radiological tumour size: group A (67 patients) with tumours ≤4 cm and group B (33 patients) with tumours >4 cm.
• ? Demographic, perioperative and pathological data were evaluated.

RESULTS

• ? The two groups were comparable in terms of demographic data. Mean tumour size was 2.4 and 5 cm (P= 0.0001) for groups A and B, respectively. Group B tumours were more complex, as reflected by significantly more with a central location (P= 0.002), and by significantly more transperitoneal LPNs, pelvicalyceal repairs and longer warm ischaemia time (WIT; 19 vs 28 min).
• ? Complications were recorded in nine group A patients (13.4%) and nine group B patients (27.2%) (P= 0.09).
• ? There was no difference between preoperative and postoperative serum creatinine levels in either group, while a significant difference was found in postoperative estimated glomerular filtration rate between groups (P= 0.004).
• ? The incidence of carcinoma was comparable between the two groups.
• ? The incidence of positive surgical margins (PSMs) was 3.9% in group A, whereas no PSM was recorded in group B (P= 0.3).

CONCLUSIONS

• ? Laparoscopic partial nephrectomy for large tumours is feasible and has acceptable pathological results. However, the complication rate, in particular WIT, remains questionable.
• ? Further studies are required to better clarify the role of LPN in the management of tumours of this size.

     

The correlation between penile tumescence measured by the erectometer and penile rigidity by the RigiScan

BACKGROUND: The goal of this study was to evaluate the correlation between increments of penile tumescence and penile rigidity measured by the erectometer and the RigiScan, respectively. METHODS: Nocturnal penile tumescence (NPT) was measured in 25 volunteers (mean age, 49.5 years). The erectometer and the RigiScan were used simultaneously for a total of 47 nights. We studied the correlation between maximum penile circumferential changes determined by the erectometer and penile rigidity patterns measured by the RigiScan. RESULTS: Maximum circumferential changes during NPT measured by the erectometer were well correlated to those determined by the RigiScan (correlation coefficient, 0.719). In addition, penile circumferential changes measured by the erectometer corresponded well to the penile rigidity pattern determined by the RigiScan (P=0.0001). Specifically, maximum penile circumferential changes of more than 30 mm and less than 10 mm had 70% positive predictive value and 100% negative predictive value for predicting the normal rigidity pattern, respectively. CONCLUSIONS: Penile circumferential changes measured by the erectometer were well correlated to penile rigidity measured by the RigiScan, particularly when the increments were larger than 30 mm or less than 10 mm. These results suggested that the erectometer was a useful tool to estimate the penile rigidity patterns of the RigiScan.     

Total phallic reconstruction after penile amputation for carcinoma

OBJECTIVE

To report our experience of total phallic reconstruction (TPR) with the use of the radial‐artery free flap (RAFF) in patients who have had a subtotal penectomy for penile or urethral cancer, as the goal of TPR is the creation of a sensate and cosmetically acceptable phallus with an incorporated neourethra that allows the patient to void while standing, and with the insertion of a penile implant to resume sexual activities, improving quality of life.

PATIENTS AND METHODS

The notes of the 15 patients who had undergone RAFF TPR between January 1998 and May 2008 were reviewed retrospectively. The surgical outcome, cosmesis of the phallus, complications, eventual need for revision surgery and patient satisfaction were recorded during the follow‐up.

RESULTS

This technique allowed the reconstruction of a cosmetically acceptable phallus in all patients. After a median (range) follow‐up of 20 (1–68) months all patients were satisfied with the cosmesis and size of the phallus, and 14 were able to void while standing. Among the seven patients who have subsequently had insertion of a penile prosthesis, five can now engage in sexual intercourse. Urethral strictures and fistulae were the commonest complications in, respectively, three and four cases, and one patient had his penile prosthesis explanted because of infection.

CONCLUSIONS

RAFF phalloplasty is an excellent technique for TPR, giving excellent cosmetic and functional results.     

Clinical Applicability of a New Tactile Sensor for Evaluating Rigidity of the Penis: A Comparative Study with Rigiscan

Background: A new tactile sensor was developed for detecting hardness of living tissue by Omata et al. in 1992. This paper reports applicability of the sensor for evaluation of penile rigidity.
Methods: Nine patients from a group of 12 patients with penile erectile dysfunction were selected as subjects of this study. All patients agreed to artificial erection and monitoring of penile rigidity by a new tactile sensor and the Rigiscan system. The 9 patients selected all developed more than 1 cm circumferential expansion of the penis after an injection of smooth muscle relaxant into the corpus cavernosum.
The sensor equipment consisted of a piezoelectric element that vibrated, and a pickup that detected vibration frequency. When the end of the sensor was pressed against a surface of the penis, the resonance frequency of the sensor changed and indicated rigidity of the organ. Rigidity of the penile shaft was simultaneously monitored with the sensor and the Rigiscan system before and after an injection of 40mg papaverine or 20μg prostaglandin E₁. The sensor's measurements of rigidity were compared with those of Rigiscan.
Results: Reproducibility of rigidity measured with the tactile sensor was satisfactory. Statistical analysis was made on 85 simultaneous pairs of rigidity values from the tactile sensor and Rigiscan. The analysis indicated significant correlation between the values.
Conclusion: The tactile sensor as well as Rigiscan will be of use for evaluating rigidity of the penis.     

阴茎修复和功能重建(附62例报道)

目的:探讨严重阴茎病变(畸形)的外科治疗方法。方法:62例患者年龄19～63岁(平均35岁),其中阴茎部分缺失4例,分别行阴茎缺损修复、阴茎延长术、尿道成形术;阴茎完全缺失3例,行阴茎再造术;阴茎严重弯曲22例,行"16点"弯曲矫正术;阴茎折断15例,1例保守治疗,14例分别修补阴茎海绵体、尿道海绵体,阴茎背深静脉结扎;假体植入术后并发症5例,包括假体从尿道穿出、水泵失灵、连接管断裂,勃起角度<60°和海绵体无法扩张,分别行假体取出、修补尿道裂口,更换新的假体,切除纤维化的瘢痕再次植入假体;阴茎完全离断4例,行阴茎再植术;撕脱伤3例,行皮瓣回植和游离植皮;阴茎Paget病6例,行病灶切除、游离植皮和阴茎埋入阴囊。结果:该组随访3个月至4年,平均9个月,4例阴茎部分缺失患者,2例术后阴茎外形满意,性功能恢复,较满意和不满意各1例。阴茎完全缺失3例术后外形满意,排尿好,1例不满意。22例阴茎严重弯曲均被矫正,1例复发。阴茎折断15例,失访1例,14例获得随访,性功能均恢复,术后并发症5例,分别为轻度弯曲、性交痛、皮下硬结、硬度差、性快感差,未作进一步处理。假体植入术后并发症5例,再次手术均成功,术后均能进行性生活,4例配偶满意,仅1例配偶不满意。阴茎完全离断4例,2例再植成功,2例坏死。撕脱伤3例植皮均获得成功。6例阴茎Paget病患者术后皮瓣均成活,随访2～4年,1例死于脑转移,5例无瘤存活至今。结论:该类病例需在泌尿男科手术的基础上,配合显微外科技术、皮瓣或皮肤移植技术等,设计个性化手术方案,能解决大多数患者的阴茎形态和勃起功能障碍,但部分患者仍不能达到理想的外形或功能,有待于寻求新的治疗方法。     

Organ‐preserving neodymium‐yttrium‐aluminium‐garnet laser therapy for penile carcinoma: a long‐term follow‐up

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To retrospectively analyse the long‐term follow‐up of 54 patients treated with organ‐preserving laser therapy for penile carcinoma, as such therapy provides excellent cosmetic and functional results, but recurrence rates are high, which might impair the oncological outcome and worsen tumour‐related survival.

PATIENTS AND METHODS

Between 1979 and 2008, 54 patients with penile carcinoma were treated with the neodymium‐doped yttrium‐aluminium‐garnet (Nd:YAG) laser at our institution; 11 were classified as having carcinoma in situ (Tis), 39 as T1 and four as T2.

RESULTS

There was local recurrence in 16 patients (42%); the mean (range) time to local recurrence was 53 (9–132) months. In half the patients the time to local recurrence was >53 months, with the latest recurrence at 132 months after initial therapy of primary tumour. There was no statistically significant difference in recurrence rates with Tis or invasive penile carcinoma. In lymph‐node‐negative patients at initial presentation, there were no newly developed positive lymph nodes during the follow‐up.

CONCLUSIONS

Organ‐preserving laser therapy showed a relatively high recurrence rate in patients with a long‐term follow up, but the oncological outcome and survival were not compromised by local recurrence. Therefore, laser therapy appears to be appropriate for treating premalignant lesions and early stages of penile carcinoma. Patients should be informed about the potential for late recurrence.     

Simple dorsal plication near the 12 o''clock position for the correction of congenital ventral penile curvature

Fourteen patients with congenital penile curvature without hypospadias were treated with a modified Essed dorsal plication method between 1998 and 2002 in our clinic. Patient age ranged between 20 and 25 years (mean 22.2). Eight cases (57.1%) had ventral curvature only and six had an additional lateral curvature. There were no significant postoperative complications. One (7.1%) patient had early suture breakage on the 21st postoperative day during erection and underwent re-operation after 9 months. After a mean follow-up period of 23.2 months (range 3-46) all patients were satisfied with the procedure except for one patient (7.1%) who had a residual curvature of 20 degrees. Four cases (28.6%) had minimal shortening of the penis. The overall satisfaction rate with the procedure was 93%. Simple dorsal plication near the 12 o'clock position is a minimally invasive and effective method for the treatment of congenital ventral penile curvature.