Corporoscopic excavation of the fibrosed corpora cavernosa for penile prosethesis implantation: optical corporotomy and trans-corporeal resection, Shaeer's technique

IntroductionImplantation of a penile prosthesis in cases of neglected or resistant ischemic priapism, or delayed re-implantation following prosthesis infection and extraction, is usually a difficult and risky procedure due to fibrosis of the corpora cavernosa. Among the common complications are perforation of the urethra, tunica albuginea, and infection. The complications are usually due to the use of blind force against resistance.AimWe propose the techniques of Trans-Corporeal Resection and Optical Corporotomy as adjuvant measures for excavating the fibrosed corpora cavernosa under vision, without the use of force against resistance.MethodsSix patients with diffuse fibrosis of the corpora cavernosa were operated on. The instruments and technique are the same as for optical urethrotomy and transurethral resection. Optical Corporotomy was started with, where the corpora are incised from within. After establishment of a satisfactory passage, Trans-Corporeal Resection followed to scrape the fibrous tissue. Implantation of penile prosthesis was completed as usual. The procedure was performed through 1.5 cm incision in the tunica albuginea.Main Outcome MeasuresLength, girth, and straightness in the erect position, as well as the incidence of complications.ResultsOperative time was an average of 90 minutes. No difficulty was encountered during the procedure. No complications were noted through 1 year of follow-up.ConclusionOptical Corporotomy and Trans-Corporeal Resection allow for force-free, visually monitored excavation of the fibrosed corpora cavernosa, aiming at safer penile prosthesis implantation. Shaeer O, and Shaeer A. Corporoscopic excavation of the fibrosed corpora cavernosa for penile prosethesis implantation: Optical Corporotomy and Trans-Corporeal Resection, Shaeer’s Technique. J Sex Med 2007;4:218–225.     

Simultaneous Total Corporal Reconstruction and Implantation of a Penile Prosthesis in Patients with Erectile Dysfunction and Severe Fibrosis of the Corpora Cavernosa

IntroductionImplantation of a penile prosthesis in severely scarred corporal bodies represents a great challenge as fibrosis can compromise dilatation and subsequent closure of the corpora cavernosa and limit size, type, and function of the device.AimThe aim of this study is to report our experience of simultaneous corporeal reconstruction and penile prosthesis implantation in patients with severe penile contracture consequence of diffuse fibrosis.MethodsBetween March 2006 and February 2010, 18 patients with severe penile contracture and coporeal fibrosis underwent simultaneous corporeal reconstruction and placement of a penile prosthesis.Main Outcome MeasuresSurgical outcome and complications have been recorded during postoperative follow‐up. Patients' satisfaction has been assessed 6 months postoperatively with the administration of the modified Erectile Dysfunction Index of Treatment Satisfaction questionnaire.ResultsAlthough the dilatation of the corpora was extremely difficult due to the severe fibrosis, a penile prosthesis has been implanted in all patients. A malleable penile prosthesis has been inserted in four patients and a three‐piece inflatable device in the remainder. After an average follow‐up of 26 months (range 6–36), revision surgery was required in four patients (elective exchange to three‐piece inflatable device in three patients and upsizing of the implant in one patient). Although all patients were able to achieve penetrative sexual intercourse, four patients were partially dissatisfied because of significant penile shortening.ConclusionIn expert hands, simultaneous penile prosthesis implantation and corporal reconstruction of severely scarred corpora yield satisfactory results. Patients must be warned that complication rate in presence of severe fibrosis is significantly higher than in virgin cases and that downsized cylinders might be required due to the contracture of the tunica albuginea. Sansalone S, Garaffa G, Djinovic R, Antonini G, Vespasiani G, Ieria FP, Cimino S, Loreto C, and Ralph DJ. Simultaneous total corporal reconstruction and implantation of a penile prosthesis in patients with erectile dysfunction and severe fibrosis of the corpora cavernosa. J Sex Med 2012;9:1954–1961.     

Erectile Function Significant Enough for Penetration During Sexual Intercourse after Removal of Inflatable Penile Prosthesis

IntroductionFifty‐two‐year‐old male with history of multiple insults to his erectile tissue, including insertion and removal of penile implant, presents with significant partial erectile function, substantial enough for anal penetration during sexual intercourse.AimErectile function rigid enough for anal penetration, let alone any erectile function after removal of an inflatable penile prosthesis (IPP), is rare. This article, to our knowledge, is the first case of a patient who has undergone multiple insults to his erectile tissue, including an episode of ischemic priapism followed by implantation and removal of an IPP, who presents with erectile function sufficient enough for coitus.Main Outcome MeasuresOutcome measured via standardized patient questionnaires and penile Doppler following injection of Trimix.MethodAn objective measure of the patient's erectile function was performed via penile Doppler.ResultsPenile Doppler after 10‐mcg injection of Trimix revealed numerous perforating vessels from the corpora spongiosum providing blood flow to the corpora cavernosa. The patient obtained approximately 60–70% rigid erection.ConclusionsTo our knowledge, and after thorough review of the literature, we could not find any reports of erectile function significant enough to take part in sexual intercourse and penetration after removal of a three‐piece IPP. The implant usually disrupts the normal anatomy which allows for cavernosal arterial vasodilation and increased blood flow into the corpora. Following dilation of the corpora the cylinders are inserted and inflated, and the smooth muscle that makes up the corpora cavernosum is compressed against the wall of the tunica albuginea. Theoretically, the remaining smooth muscle tissue may retain some of its physiologic function, adding some additional girth to the penis with an already activated IPP during sexual intercourse. Martinez DR, Mennie PA, and Carrion R. Erectile function significant enough for penetration during sexual intercourse after removal of inflatable penile prosthesis. J Sex Med 2012;9:2938–2942.     

Shaeer’s Punch Technique: Transcorporeal Peyronie’s Plaque Surgery and Penile Prosthesis Implantation

BackgroundPenile prosthesis implantation in cases of severe Peyronie’s disease may require plaque excision/incision and grafting, which may require mobilization of the neurovascular bundle or urethra, posing the risks of penile hyposensitivity or urethral injury, and is time-consuming, possibly increasing infection risk.AimEvaluating transcorporeal debulking of Peyronie’s plaques by “Shaeer’s punch technique.”MethodsPenile prosthesis implantation and punch technique (PPI-Punch) was performed for 26 patients. After corporotomy and dilatation, Peyronie’s plaques were punched out from within the corpora cavernosa using the punch forceps, and then a penile prosthesis was implanted. Comparison to a matching retrospective group of 18 patients operated upon by plaque excision-grafting and penile prosthesis implantation was performed.OutcomesThe study outcomes were straightness of the erect penis, complication, satisfaction with length on a 5-point scale, the International Index of Erectile Function-5, and the Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire.ResultsAverage preoperative curvature angle was 58.1 ± 11.7 in the Punch group and 58 ± 14.8 in the excision-grafting group, p=0.99. After surgery, all patients had a straight penis. No tunical perforations, urethral injuries, or extrusions were noted. Average additional operative time for Punch technique ranged from 5 to 10 minutes (7.3 ± 1.7), in contrast to the excision-grafting group where plaque surgery duration was 50.8 minutes ± 11.1, an 85% difference, p < 0.0001. Septal plaques in the latter group could not be removed. In the PPI-Punch group, penile sensitivity was preserved in all patients, compared with the excision/grafting group, with 7 of 18 patients reporting hyposthesia of the glans. Infection occurred in 1 of 26 patients in the PPI-Punch group, compared with 2 of 18 patients in the excision/grafting group. Satisfaction with length on a 5-point scale was 3.8 ± 0.9 in the punch group, versus 3.1 ± 1.1 in the excision-grafting group, p=0.009.Clinical ImplicationsThe proposed technique is minimally invasive and prompt, possibly decreasing the known complications of plaque surgery and PPI including sensory loss.Strengths & LimitationsOne limitation is the inability to accurately measure preoperative erect length in patients with erectile dysfunction with poor response to intracavernous injections.ConclusionShaeer’s punch technique is a minimally invasive procedure for transcorporeal excavation of Peyronie’s plaques before penile prosthesis implantation, omitting the need for mobilization of the neurovascular bundle or spongiosum, and hence, there is low or no risk for nerve or urethral injury and brief plaque surgery time.Shaeer O, Soliman Abdelrahman IF, Mansour M, et al. Shaeer’s Punch Technique: Transcorporeal Peyronie’s Plaque Surgery and Penile Prosthesis Implantation. J Sex Med 2020;17:1395–1399.     

Penile prosthesis implantation in cases of fibrosis: ultrasound-guided cavernotomy and sheathed trochar excavation

IntroductionImplantation of a penile prosthesis into fibrosed corpora cavernosa is a difficult and risky procedure. Specialized instruments that assist safer and more efficient excavation include Otis Urethrotome and various cavernotomes, all of which operate underneath the tunica albuginea, out of sight. The blind use of such instruments can result in perforation of the tunica albuginea or injury to the urethra.AimThis work describes the utility of ultrasonography for adding visual monitoring to any of the above-mentioned instruments, maintaining them in the mid-corpus cavernosum position to avoid perforation, and describes the application of alternative sheathed, sharp instruments that allow fast, efficient, and visually monitored drilling into fibrous tissue.Main Outcome MeasuresClinical outcome data were examined.MethodsSurgery was performed on five cases with extensive fibrosis of the penis. Initial blunt dilatation by Hegar dilators faced considerable resistance. An ultrasound probe was applied to the ventral aspect of the penis. A laparoscopy sheath was advanced under ultrasound guidance up to the fibrous tissue. A sharp laparoscopy trochar was inserted through the sheath. Its tip was oriented in the mid-corpus cavernosum by longitudinal and transverse sonography sections, as it drilled into the fibrous tissue. Laparoscopy scissors were used in the same fashion to cut fibrous tissue lumps. After full excavation, penile prosthesis was implanted.ResultsAll implants survived adequately. No complications occurred following implantation. Operative time ranged from 50 to 60 minutes. No difficulty was encountered at excavation.ConclusionUltrasound guidance can be a handy adjunct to any of the available techniques developed for excavating the fibrosed corpora cavernosa, with a possible decrease in difficulty and complication rate of the procedure. Utility of sheathed, sharp instruments guided by sonography is an alternative to the cavernotomes, allowing fast and efficient drilling into fibrous tissue. Shaeer O. Penile prosthesis implantation in cases of fibrosis: Ultrasound-guided cavernotomy and sheathed trochar excavation.     

Caspase Signaling in ED Patients and Animal Models

BackgroundCurrent treatments for erectile dysfunction (ED) are ineffective in prostatectomy and diabetic patients due to cavernous nerve (CN) injury, which causes smooth muscle apoptosis, penile remodeling, and ED. Apoptosis can occur via the intrinsic (caspase 9) or extrinsic (caspase 8) pathway.AimWe examined the mechanism of how apoptosis occurs in ED patients and CN injury rat models to determine points of intervention for therapy development.Methods and OutcomesImmunohistochemical and western analyses for caspase 3-cleaved, caspase-8 and caspase-9 (pro and active forms) were performed in corpora cavernosal tissue from Peyronie’s, prostatectomy and diabetic ED patients (n = 33), penis from adult Sprague Dawley rats that underwent CN crush (n = 24), BB/WOR diabetic and control rats (n = 8), and aged rats (n = 9).ResultsCaspase 3-cleaved was observed in corpora cavernosa from Peyronie’s patients and at higher abundance in prostatectomy and diabetic tissues. Apoptosis takes place primarily through the extrinsic (caspase 8) pathway in penis tissue of ED patients. In the CN crushed rat, caspase 3-cleaved was abundant from 1–9 days after injury, and apoptosis takes place primarily via the intrinsic (caspase 9) pathway. Caspase 9 was first observed and most abundant in a layer under the tunica, and after several days was observed in the lining of and between the sinuses of the corpora cavernosa. Caspase 8 was initially observed at low abundance in the rat corpora cavernosa and was not observed at later time points after CN injury. Aged and diabetic rat penis primarily exhibited intrinsic mechanisms, with diabetic rats also exhibiting mild extrinsic activation.Clinical translationKnowing how and when to intervene to prevent the apoptotic response most effectively is critical for the development of drugs to prevent ED, morphological remodeling of the corpora cavernosa, and thus, disease management.Strengths and limitationsAnimal models may diverge from the signaling mechanisms observed in ED patients. While the rat utilizes primarily caspase 9, there is a significant flux through caspase 8 early on, making it a reasonable model, as long as the timing of apoptosis is considered after CN injury.ConclusionsApoptosis takes place primarily through the extrinsic caspase 8 dependent pathway in ED patients and via the intrinsic caspase 9 dependent pathway in commonly used CN crush ED models. This is an important consideration for study design and interpretation that must be taken into account for therapy development and testing of drugs, and our therapeutic targets should ideally inhibit both apoptotic mechanisms.Martin S, Harrington DA, Ohlander S, et al. Caspase Signaling in ED Patients and Animal Models. J Sex Med 2021;18:711–722.     

Standard Operating Procedures for Peyronie's Disease

IntroductionPeyronie's disease (PD) refers to a penile deformity that is associated with sexual dysfunction.AimTo provide recommendations and Standard Operating Procedures (SOPs) based on best evidence for diagnosis and treatment of PD.MethodsMedical literature was reviewed and combined with expert opinion of the authors.Main Outcome MeasuresRecommendations and SOPs based on grading of evidence–based medical literature.ResultsPD is a fibrotic wound-healing disorder involving the tunica albuginea of the corpora cavernosa. The resulting scar is responsible for a variety of deformities, including curvature, shortening, narrowing with hinge effect, and is frequently associated in the early phase with pain. Patients frequently experience diminished quality erections. All of these conditions can compromise sexual function for the affected male. The etiopathophysiology of PD has yet to be clarified and as a result, effective, reliable, mechanistic directed non-surgical therapy is lacking.ConclusionsThe management of PD consists of proper diagnosis and treatment, ranging from non-surgical to surgical interventions. The main state of treatment for PD rests at this time on surgical correction that should be based on clear indications, involve surgical consent, and follow a surgical algorithm that includes tunica plication, plaque incision/partial excision and grafting, and penile prosthesis implantation. Levine LA and Burnett AL. Standard operating procedures for Peyronie's disease. J Sex Med 2013;10:230-244.     

Dorsal Vein Injuries Observed During Penile Exploration for Suspected Penile Fracture

IntroductionPenile fracture is a rare injury, bearing potential impairment of erectile function if not treated. Patients with clinical presentation of a penile fracture commonly undergo early surgical exploration with the intention to repair a tunica albuginea tear.AimWe present a group of men who presented with a penile hematoma following trauma to the erect penis. Exploration revealed an intact tunica albuginea and a dorsal vein tear.MethodsEighteen men (mean age 38 years, range 20–55) presented with suspected penile fracture during an 8-year period. One man presented twice. Two of the patients were managed expectantly and the remaining 16 patients underwent 17 immediate surgical explorations. Explorations were performed under general anesthesia, using a circumferential subcoronal incision and degloving of the penile skin. The tunica albuginea of both penile sides as well as the penile urethra were examined for injuries.Main Outcome MeasuresMedical records were retrospectively reviewed for etiology, symptoms, signs of physical examination, and information on findings of surgical exploration. Data on erectile function, medical treatment for erectile dysfunction, and penile curvature were obtained during follow-up.ResultsIn nine of the 17 procedures the tunica albuginea was intact and the only pathological finding was a ruptured dorsal vein. One procedure was negative for both tunical and vascular injury. A tunical tear was detected in the remaining seven procedures. At a mean follow-up of 40 months (range 4–91), five patients required medical treatment for erectile dysfunction, including the two who were managed expectantly, two with a tunical tear, and one with a venous tear.ConclusionsDorsal vein tears may mimic penile fracture. Suggestive findings following trauma to the erect penis prompted exploration for suspected tunica albuginea tear. In less than half of the men was the diagnosis of penile fracture established and treated at surgery. Bar-Yosef Y, Greenstein A, Beri A, Lidawi G, Matzkin H, and Chen J. Dorsal vein injuries observed during penile exploration for suspected penile fracture.     

Historical Review of Penile Prosthesis Design and Surgical Techniques: Part 1 of a Three-Part Review Series on Penile Prosthetic Surgery

IntroductionThroughout history, many attempts to cure complete impotence have been recorded. Early attempts at a surgical approach involved the placement of rigid devices to support the natural process of erection formation. However, these early attempts placed the devices outside of the corpora cavernosa, with high rates of erosion and infection. Today, most urologists in the United States now place an inflatable penile prosthesis (IPP) with an antibiotic coating inside the tunica albuginea.AimThe article describes the key historical landmarks in penile prosthesis design and surgical techniques.MethodsThe article reviews and evaluates the published literature for important contributions to penile prosthesis design and surgical techniques.Main Outcome MeasuresThe article reviews and evaluates the historical landmarks in penile prosthesis design and surgical techniques that appear to improve outcomes and advance the field of prosthetic urology for the treatment of erectile dysfunction.ResultsThe current review demonstrates the stepwise progression starting with the use of stenting for achieving rigidity in the impotent patient. Modern advances were first used in war-injured patients which led to early implantation with foreign material. The design and techniques of penile prostheses placement have advanced such that now, more complications are linked to medical issues than failure of the implant.ConclusionsToday's IPPs have high patient satisfaction rates with low mechanical failure rates. Gerard D. Henry. Historical review of penile prosthesis design and surgical techniques: Part 1 of a three-part review series on penile prosthetic surgery. J Sex Med 2009;6:675–681.     

Salvage and Extracapsular Implantation for Penile Prosthesis Infection or Extrusion

Introduction

When a penile prosthesis is implanted, a fibrous tissue capsule gradually forms around it. In case of penile prosthesis infection, salvage and immediate reimplantation into the same capsule that envelops the infected prosthesis is a trial to avoid the difficulty and shortening encountered with explantation and delayed reimplantation.

Electrophysiologic activity of the tunica albuginea and corpora cavernosa: possible role of tunica albuginea in the erectile mechanism

IntroductionIt is claimed that the tunica albuginea (TA) shares in the erectile mechanism by compressing the emissary veins passing through it. However, the TA does not contain smooth muscle fibers.AimWe investigated the hypothesis that TA lacks a contractile activity on the emissary veins passing through it.MethodsFourteen healthy male volunteers (mean age 35.2 ± 4.3 years) were studied. The electromyographic (EMG) activity of the TA and corpora cavernosa (CC) was individually recorded in the flaccid and erectile phases by EMG needle electrodes. Recording was performed in the upper, middle, and lower third of the TA and CC on one and then on the contralateral side.Main Outcome MeasuresThe TA lacks a contractile activity on the emissary veins passing through it.ResultsThe EMG of the CC in the flaccid phase recorded regular slow waves and random action potentials. The wave variables in the erectile phase exhibited a significant decrease (P < 0.01) compared with the variables in the flaccid phase of the same subject. The TA EMG showed no electric waves in the flaccid or erectile phases. These recordings were similar from the upper-, middle-, and lower-third of the penis, and were reproducible from the contralateral CC.ConclusionsElectric waves were recorded from the CC in the flaccid phase; wave variables decreased at erection. In contrast, the TA showed no electric waves in the flaccid or erectile phases. It appears that the TA acts as a CC covering sheet which expands passively at erection, and shares in compressing the subtunical venular plexus between it and the tumescent CC. Shafik A, Shafik AI, El Sibai O, and Shafik AA. Electrophysiologic activity of the tunica albuginea and corpora cavernosa: Possible role of tunica albuginea in the erectile mechanism.     

Effect of Penile Traction and Vacuum Erectile Device for Peyronie’s Disease in an Animal Model

BackgroundPenile traction therapy with the use of a traction device (TD) or vacuum erectile device (VED) has been studied as local modalities for Peyronie’s disease (PD).AimTo identify changes of penile curvature, erectile function, and possible cellular and molecular mechanisms between the TD and VED in a rat model of PD.MethodsPeyronie’s plaque was induced in 30 adult male rats. Then, rats were randomly divided into control (PD without treatment), VED, and TD groups. In the VED group, vacuum pressure was applied to the cylinder to induce penile engorgement inside the cylinder for 1 minute. The penis was allowed to deflate completely for another 1 minute. This was repeated for five cycles (inflate and deflate). In the TD group, the rat penis was straightened by a suspended tension gauge at the same tension by clamping the prepuce. This was performed three times per day at 20 minutes per session, with 5-minute intervals between sessions. The entire treatment duration was 4 weeks.OutcomesPenile curvature, intracavernosal pressure, and mean arterial pressure were measured. Immunohistochemistry for α-smooth muscle actin, transforming growth factor-β1 and mothers against decapentaplegic homolog 2/3 were performed.ResultsThe TD and VED groups had less penile curvature compared with the control group (15.3 ± 5.3° for TD, 28.4 ± 6.8° for VED, 38.6 ± 10.5° for control; P < .001 for TD vs control, P < .05 for VED vs control). The TD group also had less penile curvature compared with the VED group (P < .05). The VED group had a higher ratio of intracavernosal pressure to mean arterial pressure compared with the two other groups (0.56 ± 0.10 for VED, 0.38 ± 0.06 for TD, 0.32 ± 0.07 for control; P < .001). The immunohistochemistry results showed the VED group had more preserved α-smooth muscle actin with less transforming growth factor-β1 and mothers against decapentaplegic homolog 2/3 than the TD and control groups in the corpus cavernosa.Clinical TranslationVarious benefits can be observed with the TD and VED for the treatment of PD.Strengths and LimitationsThis study explored the mechanism and benefits of TD and VED therapies for the treatment of PD. The rat model might not represent the human condition.ConclusionPenile traction therapy with the TD or VED is beneficial to decrease penile curvature in animal models of PD. The underlying mechanism could be related to antiapoptosis, antifibrosis, and smooth muscle preservation.Lin H, Liu C, Wang R. Effect of Penile Traction and Vacuum Erectile Device for Peyronie’s Disease in an Animal Model. J Sex Med 2017;14:1270–1276.     

Human acellular matrix graft of tunica albuginea for penile reconstruction

IntroductionPenile curvature is one of the most common male conditions, affecting nearly 10% of men, and can impair sexual intercourse. Tunica albuginea (hTA) plays a key role in penile curvature, and reconstructive procedures may be necessary for its substitution. Although several grafts have been proposed for hTA repair, the ideal graft is not yet available.AimThe aim of this article is to evaluate a new human tunica albuginea acellular matrix (hTAAM) as potential graft for penile reconstructive procedures.MethodsTwelve penises were obtained during sex reassignment surgeries from male‐to‐female transsexual patients. After dissection, hTAs were assigned into two groups according to the decellularization methods: polyethylene glycol (PEG) 1000 method following ultraviolet‐C radiation, and Triton X‐100 modified method.Main Outcome MeasuresStructural analyses were assessed by hematoxilin and eosin, Masson's trichrome, Weigert's, and picrosirius‐polarization staining methods. Total protein, total glycosaminoglycan (GAG), and nucleic acid (DNA and RNA) concentrations were assessed by specific biochemical analyses. Uniaxial strength tests were performed to evaluate biomechanical properties.ResultsAll hTAAMs presented no nuclear or cellular remnants. Total protein concentration was significantly higher in PEG 1000 hTAAM. Despite GAG concentration decreased significantly in hTAAM, Triton X‐100 hTAAM retained the highest GAG concentration (1.0 ± 0.42 µg HexUr/mg dry tissue, P > 0.05). All decellularization methods were efficacious to remove nucleic acids. The maximal break point presented no difference between hTA and hTAAM groups (P > 0.05).ConclusionsPEG 1000 and Triton X‐100 decellularization methods provide equally successful hTAAMs, preserving original structural and biochemical properties. da Silva FG, Filho AM, Damião R, and da Silva EA. Human acellular matrix graft of tunica albuginea for penile reconstruction. J Sex Med 2011;8:3196–3203.     

The STAGE Technique (Superficial Tunica Albuginea Geometric-Based Excision) for the Correction of Biplanar Congenital Penile Curvature

IntroductionCongenital penile curvature can present with both uniplanar and biplanar defects, the latter of which entails more technically demanding surgery.AimThe study aims to demonstrate the efficacy and safety of our novel superficial tunica albuginea geometric-based excision (STAGE) technique based on multiple, small, superficial elliptical tunica albuginea excisions and geometrical principles for correcting biplanar congenital penile curvature.MethodsThe study represents a retrospective analysis of 145 patients with disabling congenital biplanar ventrolateral (n = 131; 90.3%) or dorsolateral (n = 14; 9.7%) curvature of the penis, which underwent stepwise STAGEs between June 2006 and March 2012. Multiple 3-mm elliptical excisions of the superficial tunica albuginea were performed without compromising the inner layer of the tunica albuginea, thus resulting in a stepwise correction of the curvature and improved distribution of the bending force of the curvature.Main Outcome MeasuresFunctional outcome regarding penile straightening, erectile function, and patient satisfaction were evaluated. Furthermore, clinical data concerning the early postoperative outcome were analyzed retrospectively.ResultsThe mean follow-up period was 21 months (range 6–62 months). Mean age at surgery was 23.8 years (range 15–47 years). Mean degree of curvature was 65° (range 45–90°). There was no recurrent curvature. Complete correction of the penile axis was obtained in 98.6% (n = 143). No change in erectile function according to International Index of Erectile Function-5 score was visible (P = 0.748). The mean loss of penile length was 0.7 cm (range 0.3–0.9 cm). The excellent functional outcomes resulted in a high level of patient satisfaction, including improved self-esteem, libido, sexual intercourse, and psychosexual relief. Two patients had a residual curvature of up to 30° requiring a reoperation. No intra- or postoperative complications were encountered.ConclusionsWe recommend the STAGE technique as the optimal surgical intervention for correcting both uniplanar and biplanar congenital deviations. Kuehhas FE and Egydio PH. The STAGE technique (superficial tunica albuginea geometric-based excision) for the correction of biplanar congenital penile curvature. J Sex Med 2014;11:299–306.     

Changes in the Penile Arteries of the Rat after Fractionated Irradiation of the Prostate: A Pilot Study

IntroductionExternal beam radiotherapy for prostate cancer leads to erectile dysfunction in 36%–43% of patients. The underlying mechanism is largely unknown, although some clinical studies suggest that the arterial supply to the corpora cavernosa is responsible. Two animal experimental studies reported on the effects of a single fraction of prostate irradiation on the penile structures. However, irradiation in multiple fractions is more representative of the actual clinical treatment.AimThe present prospective, controlled study was initiated to investigate the effect of fractionated prostate irradiation on the arteries of the corpora cavernosa.Main Outcome MeasuresHistological evaluation of the penile tissue in comparison with control rats at 2, 4, and 9 weeks after irradiation.MethodsThe prostate of twelve rats was treated with external beam radiation in 5 daily fractions of 7.4 gray. Three control rats were treated with sham irradiation. Prostatic and penile tissue was evaluated for general histology (hematoxylin–eosin). The penile tissue was further evaluated after combined staining for collagen (resorcin fuchsin) and α-smooth muscle actin (SMA) (Biogenex).ResultsThe prostate showed adequate irradiation with fibrosis occurring at 9 weeks after irradiation. The corpora cavernosa showed arteries that had developed loss of smooth muscle cells expressing SMA, thickening of the intima, and occlusions. All the control rats maintained normal anatomy.ConclusionThis is the first animal experimental study that demonstrates changes in the arteries of the corpora cavernosa after fractionated irradiation to the prostatic area. The preliminary data suggests that erectile dysfunction after radiotherapy might be caused by radiation damage to the arterial supply of the corpora cavernosa. van der Wielen GJ, Vermeij M, de Jong BWD, Schuit M, Marijnissen J, Kok DJ, van Weerden WM, and Incrocci L. Changes in the penile arteries of the rat after fractionated irradiation of the prostate: A pilot study. J Sex Med 2009;6:1908–1913.     

Removal of a Detached Head of the Brooks Dilator from the Corpora Cavernosa During Penile Prosthesis Implantation

IntroductionSeveral complications during and after penile implantation have been reported. The most difficult part of the procedure seems to be the dilatation of the corpora, especially in fibrotic cases.AimTo report a rare intraoperative complication during dilatation of the corpora and its management.MethodsDuring dilation of the corpora cavernosa with Brooks dilators for the implantation of penile prosthesis, its head was detached and stuck at the tip of the corpus cavernosum. Several trials to remove the head of the dilator using different kinds of clamps were unsuccessful. Finally, an incision was performed to the distal lateral part of the corpora cavernosa and the head of the dilator was removed. Implantation was completed uneventfully.ResultsThe patient instructed to inflate the prosthesis and use it for sexual intercourse after 6 weeks. Follow-up was 14 months and the patient is using properly the prosthesis.ConclusionsAlthough this is a very rare complication not previously described, we recommend examination of the dilators before use. Hatzimouratidis K, Koliakos N, Koutsogiannis I, Moisidis K, Giakoumelos A, and Hatzichristou D. Removal of a detached head of the Brooks dilator from the corpora cavernosa during penile prosthesis implantation.     

Rear Tip Extenders and Penile Prosthesis Rigidity: A Laboratory Study of Coloplast Prostheses

Background

Rear tip extenders (RTEs) are used commonly in penile prostheses, but their effect on erectile rigidity has not been extensively studied.

Surgical Technique for Complex Cases of Peyronie’s Disease With Implantation of Penile Prosthesis,Multiple Corporeal Incisions,and Grafting With Collagen Fleece

Introduction

Patients with Peyronie’s disease (PD) and erectile dysfunction (ED) concomitant with shortening or other malformations benefit from prosthesis implantation and penile lengthening procedures.

Technological Advances in Penile Implant Surgery

BackgroundDuring the last century, surgical management of erectile dysfunction has evolved from an experimental concept to a core treatment modality with widespread use among the men's health community. Over time, innovations in materials, mechanical design elements, device coatings, and surgical technique have provided patients with low-risk, reliable, and reproducible erectile function with high satisfaction rates.AimTo provide a foundation for future innovation by improving understanding of historical penile prosthetics and the rationale behind incremental technological improvements for the contemporary Men's Health physician.MethodsLiterature review was conducted to generate a comprehensive review of historical technological innovations in penile implant surgery. Companies with FDA approved penile prosthetics in use in the United States were contacted for information regarding technological innovations in the past and future devices in development. A separate literature review was performed to identify any significant future device design elements being tested, even in the ex vivo setting, which may have future clinical applications.OutcomesTechnological innovations in penile implant surgery were described.ResultsCurrent options for the prosthetic surgeon include malleable penile prostheses (MPP), self-contained (2-piece) inflatable penile prostheses, and multicomponent (3-piece) inflatable penile prostheses. Current MPPs consist of a synthetic coated solid core which allow for manipulation of the penis for concealability while maintaining sufficient axial rigidity to achieve penetration when desired. Multi-component (3-Piece) IPPs currently include the Coloplast Titan and Boston Scientific/AMS 700 which consist of a fluid reservoir, intrascrotal pump, and intracavernosal cylinders. The devices have undergone numerous design updates to the cylinders, pump, reservoir, tubing, and external coatings to increase reliability and decrease short- and long-term complications.Clinical ImplicationsFuture innovations in penile prosthetic surgery seek to broaden the indications and applicability to the transgender community and improve both safety and functionality for patient and partner.Strengths & LimitationsThe review is limited primarily to penile prosthetics approved for current or historical clinical use in the United States and may not be representative of the global prosthetic environment. Additionally, the research and development of future innovations, particularly those provided by device manufacturers, is likely limited by non-disclosure to maintain a competitive advantage.ConclusionsPenile prosthetic surgery will undoubtedly remain integral to the treatment of erectile dysfunction, and education regarding the current state of technological innovation will empower the prosthetic surgeon and biomedical engineering community to improve contemporary patient care and drive the development of the next generation of implantable penile prosthetics.Barnard JT, Cakir OO, Ralph D, et al. Technological Advances in Penile Implant Surgery. J Sex Med 2021;18:1158–1166.