Translating Penile Erectile Hydraulics to Clinical Application in Inflatable Penile Prosthesis Implant

Purpose of Review

To review the concept of erectile hydraulics and the scientific advances in modern inflatable penile prosthesis implant.

Recent Findings

Penile erection requires the presence of nitric oxide, relaxation of the penile vasculature, and engorgement of corpora cavernosa sinusoids. It is generally accepted that the development of erectile dysfunction is frequently attributed to both psychogenic factors as well as physiological alterations in neural, vascular, hormonal and endothelial function. Despite the advent of oral and intracavernosal erectile drugs, penile prosthesis implant remains a relevant and desired option as many men became refractory to medical therapy and/or seek a more effective and permanent solution.

Summary

The inflatable penile prosthesis is considered a superior option to malleable prosthesis as it closely replicates a normal penile erection. While the ideal penile prosthesis is probably yet to be developed, scientific advances in prosthesis design, device technology, and surgical techniques have made the penile prosthesis more natural, durable and reliable device.

     

国产可膨胀型三件套阴茎支撑体治疗勃起功能障碍的疗效、并发症及预后分析

目的:分析国产可膨胀型三件套阴茎支撑体治疗勃起功能障碍的疗效、并发症及预后。方法:选取我院2006年5月至2016年5月收治的勃起功能障碍患者80例,依据随机数字表法将这些患者分为国产可膨胀型三件套阴茎支撑体组(研究组,n=40)和常规药物治疗组(对照组,n=40)两组,对两组患者的疗效、并发症及预后进行统计分析。结果:研究组患者治疗的总有效率95.0%显著高于对照组的65.0%(P0.05),同房满意度90.0%显著高于对照组的60.0%(P0.05),但两组患者的并发症发生率15.0%、12.5%之间的差异不显著(P0.05)。结论:国产可膨胀型三件套阴茎支撑体较常规药物治疗勃起功能障碍的疗效显著,患者预后好,且不会提升患者的并发症发生率,值得在临床推广。     

Management of intraoperative penile implant complications

The three-piece inflatable penile prosthesis has the highest patient satisfaction and lowest mechanical revision rate of any medically implanted device. Revisions of inflatable penile prostheses are more often required for nonmechanical reasons than for device failure. Intraoperative complications of penile implant placement can be distressing for the prosthetic surgeon, but with recognition of the dilemma, most of these complications can be navigated with excellent postoperative results. More than half of these intraoperative complications occur during dilatation of the corpora cavernosa. Dilation of the corpora cavernosa is a critical step in the placement of any type of penile prosthesis and can be especially difficult in a patient with corporal fibrosis. This review article summarizes the techniques, outcomes, and new developments in the field of complicated penile prosthetic surgery.     

Management of intraoperative penile implant complications

The three-piece inflatable penile prosthesis has the highest patient satisfaction and lowest mechanical revision rate of any medically implanted device. Revisions of inflatable penile prostheses are more often required for nonmechanical reasons than for device failure. Intraoperative complications of penile implant placement can be distressing for the prosthetic surgeon, but with recognition of the dilemma, most of these complications can be navigated with excellent postoperative results. More than half of these intraoperative complications occur during dilatation of the corpora cavernosa. Dilation of the corpora cavernosa is a critical step in the placement of any type of penile prosthesis and can be especially difficult in a patient with corporal fibrosis. This review article summarizes the techniques, outcomes, and new developments in the field of complicated penile prosthetic surgery.     

Counseling of patients prior to penile implant surgery

Despite the success of medical therapies for many patients with erectile dysfunction, a significant population of men will require penile prosthesis implants to regain their sexual function. Although patient satisfaction rates for penile implant surgery are among the highest of all therapies, proper patient selection and detailed preoperative counseling are still of the utmost importance. Physicians can maximize patient and partner satisfaction while helping to restore their sexual function and intimacy by letting them know what to expect during preoperative and postoperative periods, discussing the potential adverse events and expected changes, allowing adequate time to address concerns, and ensuring a detailed and documented informed consent.     

Purulent penile ulcers of patients in Singapore.

In 80 patients with painful purulent penile ulcers who attended the outpatient service of Middle Road Hospital in Singapore, Haemophilus ducreyi was isolated from 18 (22%), herpes simplex virus type 2 from nine (11%), and Neisseria gonorrhoeae from eight (10%). Primary pathogens were not isolated from 45 (57%) men. Painful purulent penile ulcers were more common in uncircumcised men, and patients had often acquired the disease after sexual intercourse with prostitutes in Singapore.     

Genital colonisation and infection with candida in heterosexual and homosexual males.

OBJECTIVES: To determine the penile, perianal, and oropharyngeal candidal colonisation rates among homosexual and heterosexual males attending an STD clinic. To determine the prevalence of balanitis and candidal balanitis in the two groups. SUBJECTS: 252 heterosexual and 210 homosexual male patients attending consecutively the STD clinic in Coventry, England. DESIGN: A prospective study recording sexual behaviour, relevant history, symptoms, and examination. Specimens for candida culture were collected from the glans penis, perianal area, and oropharynx. RESULTS: Among the 462 men studied, penile, perianal, and oropharyngeal colonisation rates were 74 (16%), 70 (15%), and 116 (25%) respectively. On examination, 47 (10%) were found to have balanitis. Of the 74 patients with penile colonisation, 26 (37%) were symptomatic and 20 (27%) had balanitis. The 223 heterosexual and the 196 homosexual males who had sexual intercourse within 3 months had comparable colonisation rates of candida on the penis, perianal area, and oropharynx. Balanitis was seen in 31 heterosexuals (14%) and candidal balanitis in 16 (7%); the incidence was significantly less in homosexuals where balanitis was seen in 12 (6%) and candidal balanitis in four (2%). CONCLUSIONS: Itching or burning sensations after sex were the most common symptoms associated with penile colonisation with candida and were present in more than one third. Candidal balanitis was commoner in those who had vaginal than those who had anal intercourse within 3 months.     

西地那非联合苁蓉益肾颗粒治疗2型糖尿病性勃起功能障碍的疗效及安全性分析

目的:探讨西地那非联合苁蓉益肾颗粒治疗2型糖尿病性勃起功能障碍(erectile dysfunction,ED)的疗效及安全性分析。方法:将70例二甲双胍药物控制的2型糖尿病性ED患者随机分为A、B两组,A组35例,服用西地那非;B组35例,联合服用西地那非和苁蓉益肾颗粒,两组均治疗4周。分别对治疗前后国际勃起功能指数-5评分(international index of erectile function,IIEF-5)、每周性交频率、夫妻双方性生活满意程度进行统计分析,并观察两组患者治疗期间的不良反应。结果:A、B两组在IIEF-5评分、每周性交频率、夫妻双方性生活满意程度方面均较治疗前增加,差异具有统计学意义(P0.05),但B组治疗后在IIEF-5评分、夫妻双方性生活满意程度高于A组治疗后,差异具有统计学意义(P0.05)。两组患者治疗期间未发生严重不良反应。结论:西地那非联合苁蓉益肾颗粒治疗2型糖尿病性ED较单用西地那非可显著改善患者的勃起功能,提高夫妻性生活质量,安全、有效。     

Surgical decisions in Peyronie’s disease

In this review, we examine recent advances assisting surgical decision in Peyronie’s disease. Surgical treatment is indicated in penile deformities that have persisted for at least 6 months and functionally impair or preclude intercourse. Procedures shortening the longer side of the penis are invariably associated with length reduction, which may displease patients, despite penile straightening. Procedures lengthening the shorter side by means of grafting provide the best possible gain from a reconstruction procedure, although they may not restore the penis to its original length. Penile rectification and rigidity are required to achieve complete functional restoration of the penis. Most patients experience associated erectile dysfunction, and penile straightening alone may not be enough to restore complete function. Therefore, in some cases, phosphodiesterase inhibitors, self-injection, or a penile prosthesis may need to be added. Issues concerning surgical indication, patient selection, surgical techniques, and grafting are discussed.     

Bone markers predict survival in castration-resistant prostate cancer patients treated with docetaxel

AIM: To investigate the relationship between clinicopathological features and bone turnover markers in castration-resistant prostate cancer(CRPC) patients treated with docetaxel.METHODS: Thirty-three patients were enrolled in this study. Serum levels of carboxyterminal cross-linked telopeptide of type 1 collagen generated by metalloproteinases(1CTP) and alkaline phosphatase(ALP) were measured at the start of docetaxel chemotherapy. We examined the relationship between clinicopathological features and serum levels of 1CTP and ALP levels in CRPC patients treated with docetaxel.RESULTS: For the total patient group, the mean ± standard deviation(SD) values for docetaxel chemotherapy dose, dose intensity, dosage interval, and num-ber of cycles were 59.3 ± 10.6 mg/m2, 13.9 ± 5.2 mg/m2 per week, 4.7 ± 1.2 wk, and 11.2 ± 7.4, respectively. Fourteen patients died from prostate cancer. Patients were divided into two groups according to mean + SD of serum 1CTP(8.2 ng/m L) and ALP(538.2 IU/L) levels at the start of docetaxel chemotherapy. Patients with lower levels of serum 1CTP and ALP had significantly better survivals than those with higher serum levels(P 0.05).CONCLUSION: Serum levels of 1CTP and ALP are predictors of survival in patients with CRPC who are treated with docetaxel.     

舍曲林联合伐地那非与单用舍曲林治疗早泄的疗效及安全性比较

目的：探讨舍曲林联合伐地那非与单用舍曲林治疗早泄的疗效及安全性比较。方法：选择80例早泄患者随机分为对照组和联合组。对照组患者口服舍曲林50rag,1次／d,性生活前4—6h服用;联合组患者除了同样服用舍曲林外,在性生活前O．5b左右加用伐地那非10mg。两组的疗程均为4周。观察两组患者治疗前后平均阴道内射精潜伏期、性交满意度及治疗期间的不良反应。结果：治疗4周后,两组患者的阴道内平均射精潜伏期时间均较治疗前明显延长（P〈0．05或P〈0．01）,且联合组延长的时间明显长于对照组（P〈0．05）;同时联合组的性交总满意率明显高于对照组（x2=6．27,P〈0．05）;对照组和联合组治疗期间分别出现不良反应5例和8例,症状均较轻,未发生严重的药物不良反应。两组患者治疗期间不良反应发生率比较无明显统计学差异（x2=0．83,P〉0．05）。结论：舍曲林联合伐地那非治疗早泄的疗效确切,安全性较好,可明显延长患者阴道内平均射精潜伏期时间,提高夫妻双方的性交满意度。     

How to improve a urology outpatient service? A survey of patient satisfaction

AIM: To investigate and improve our out-patients department patient satisfaction, provide minimum consultation delay and appropriate consultation duration to meet with targets. METHODS: We distributed the modified satisfaction with outpatient service (SWOPS) questionnaires developed for use in Irish hospitals by the Health Services Research between August and December 2012. The patient disclosed their age and sex and completed the modified SWOPS questionnaire anonymously. Every patient was eligible to participate in the study who attended any of the Urology Outpatient Clinics. Patients lacking capacity to consent were excluded. Additionally, each patient was only permitted to complete one questionnaire regardless of repeat attendances within the 4 mo study period. The answers to every question were presented as percentages. One-way ANOVA was used to establish whether there was a significant difference in appointment delay and “Overall Satisfaction” on the different clinic days. The unpaired t-test was applied to establish whether “Overall Satisfaction” was affected by diagnosis (benign or malignant). Paired t-test was used to establish whether “Overall Satisfaction” was affected by appointment delay and appointment length. RESULTS: Three hundred and forty-eight questionnaires were completed with an overall > 65% participation rate. Eighty-one point six percent were male and 18.4% female with a mean age of 65 ± 21 years. Mean delay time was 32 min, which 30.6% stated should be an improvement priority. The delay times for Wednesday (mean 13 min) were significantly (P < 0.05) lower than for other days (mean 36 min). Generally 12-15 min outpatient appointment length is acceptable and adequate for patients as 97.70% suggested, however 31.60% of patients would favour longer duration. Eleven point four nine percent do not want to see different doctors each time, and 31.60% of the patient feel that no change is required. Average satisfaction was 84.65%. There was no significant relationship between satisfaction and clinic day, diagnosis and consultation length, whether the patient was reviewed by a registrar or consultant. Satisfaction was universally high and independent of consultation delay/length and diagnosis. Dissatisfaction in delay times with a significant improvement on Wednesday suggests necessary and achievable improvements. Notably, the Wednesday clinic has less patients per doctor per hour and enforces a 1 patient per 15 min slot with a no over-booking policy. CONCLUSION: Surveying our patient dissatisfaction would require more frequent audits by clinicians to improve patient satisfaction and to achieve better quality of care.     

1400W reduces ischemia reperfusion injury in an ex-vivo porcine model of the donation after circulatory death kidney donor

AIM: To investigate the effects of 1400W-a selective inducible nitric oxide synthase (iNOS) inhibitor in a model of donation after circulatory death (DCD) kidneys. METHODS: Porcine kidneys were retrieved after 25 min warm ischemia. They were then stored on ice for 18 h before being reperfused ex vivo with oxygenated autologous blood on an isolated organ perfusion system. The selective iNOS inhibitor 1400W (10 mg/kg) was administered before reperfusion (n = 6) vs control group (n = 7). Creatinine (1000 μmol/L) was added to the system, renal and tubular cell function and the level of ischemia reperfusion injury were assessed over 3 h of reperfusion using plasma, urine and tissue samples. RESULTS: Kidneys treated with 1400W had a higher level of creatinine clearance (CrCl) [area under the curve (AUC) CrCl: 2.37 ± 0.97 mL/min per 100 g vs 0.96 ± 0.32 mL/min per 100 g, P = 0.004] and urine output [Total: 320 ± 96 mL vs 156 ± 82 mL, P = 0.008]. There was no significant difference in levels of fractional excretion of sodium (AUC, Fr ex Na+: Control, 186.3% ± 81.7%.h vs 1400W, 153.4% ± 12.1%.h, P = 0.429). Levels of total protein creatinine ratio were significantly lower in the 1400W group after 1 h of reperfusion (1h Pr/Cr: 1400W 9068 ± 6910 mg/L/mmol/L vs Control 21586 ± 5464 mg/L/mmol/L, P = 0.026). Levels of 8-isoprostane were significantly lower in the 1400W group [8-iso/creatinine ratio: Control 239 ± 136 pg/L/mmol/L vs 1400W 139 ± 47 pg/L/mmol/L, P = 0.041]. CONCLUSION: This study demonstrated that 1400W reduced ischaemia reperfusion injury in this porcine kidney model of DCD donor. Kidneys had improved renal function and reduced oxidative stress.     

Addressing residual penile deformity in the Peyronie’s disease patient during penile implant surgery

Peyronie’s disease frequently presents as a painful curvature of the erect penis. Once stabilized, a proportion of patients will require a surgical intervention to correct the curvature. Reconstructive surgery should be considered separately in each patient as those with significant erectile dysfunction may be better suited to the implantation of a penile prosthesis, which will correct both the curvature and impaired erection. The erect penis usually is straightened after the prosthesis insertion, but in a minority of patients, some curvature remains. When this occurs, additional procedures will be necessary to straighten the penis by plaque incision (with or without grafting) or by the modeling technique. These additional techniques are necessary to improve patient satisfaction.     

Sexual lifestyle and clinical findings related to HTLV-III/LAV status in homosexual men.

A study of 304 sexually active homosexual men, most of whom had multiple casual partners, showed that receptive anogenital intercourse, independent of anal bleeding, was the only risk factor for HTLV-III/LAV transmission. There was no evidence that HTLV-III/LAV infection, measured by seropositivity, was transmitted by oroanal or orogenital routes, or that insertive penile intercourse constituted a risk. The strongest predictor of seropositivity proved to be homosexual activity for more than five years, which may lead to enhanced susceptibility to infection. Sexual exposure to European men seemed to be even more hazardous than sexual exposure to men from the United States of America, and emphasised the epidemiological importance of the promiscuous homosexual abroad. Skin complaints were the most common presenting symptoms in men with antibody to HTLV-III/LAV. Extrainguinal lymphadenopathy was the commonest sign, which was present in just under half of those who were seropositive. More than one quarter of seropositive patients had had sexual intercourse with a woman in the five years before being tested.     

Comparison between intrathecal hyperbaric bupivacaine and levobupivacaine for ambulatory knee arthroscopy

AIM: To compare the effect of hyperbaric levobupivacaine and bupivacaine on the quality of the block, patient satisfaction, and discharge time in patients undergoing arthroscopic knee surgery under unilateral spinal anesthesia. METHODS: One hundred and thirty-two patients, American Society of Anaesthesiologists I or II, scheduled for elective ambulatory knee arthroscopy were randomly assigned to four double-blind groups. To achieve a unilateral spinal block, Group BF received 5 mg of hyperbaric bupivacaine plus 20 μg of fentanyl intrathecally, Group LF received 5 mg of hyperbaric levobupivacaine plus 20 μg of fentanyl intrathecally, Group B received 5 mg of hyperbaric bupivacaine intrathecally, and Group L received 5 mg of hyperbaric levobupivacaine intrathecally. The level and duration of the sensory block, the intensity and duration of the motor block, the time to first analgesic requirement, and the time elapsed until the patient’s discharge were recorded. Hemodynamic values and adverse effects were also recorded. RESULTS: The duration of time needed to reach the T12 dermatome level was significantly longer in Group L [7 (3-20) min] than in Group B [6 (3-12) min] (P = 0.006). The maximum sensory level reached on the side undergoing the operation was significantly higher in Group BF than in Group B (P < 0.05). The intensity of the motor blockade was greater in Group BF than in Group LF and L. Complete recovery from motor blockade occurred earlier in Groups LF [75 (45-165) min] and L [63 (35-120) min] than in Group BF [115 (60-180) min] (P < 0.05). The length of time needed for the sensory block to regress to the level of S2 was shorter in Group L (154 ± 50) than in Group BF (192 ± 66) (P < 0.05). The quality of the block was significantly lower in Group L than in Groups BF, LF and B (P = 0.012, P = 0.003, and P < 0.001, respectively). The time elapsed until Visual Analog Scale ≥ 4 was significantly shorter in Group L (110 ± 48) than in Groups BF (200 ± 60), LF (156 ± 61) and B (162 ± 52) (P < 0.05). The time elapsed until the patient’s discharge was shorter in Groups B (244 ± 54) and L (229 ± 55) than in Group BF (288 ± 64) (P = 0.021 and P = 0.001, respectively). There were no differences among the groups regarding hemodynamic parameters and adverse events, except for pruritus. The occurrence of pruritus was significantly more frequent in Groups BF and LF than in other groups. CONCLUSION: In conclusion, 5 mg of hyperbaric bupivacaine and 5 mg of hyperbaric levobupivacaine plus 20 μg of fentanyl provided a better spinal anesthesia than 5 mg of hyperbaric levobupivacaine alone.     

子宫全切手术患者性生活的影响因素分析及对策

目的：观察分析子宫全切手术患者性生活的影响因素以及探讨相关的对策。方法：选取我院从2011年3月至2013年3月收治的子宫切除患者共168例。通过调查问卷的方式调查患者在手术前后的性生活情况,以及患者的心理状态变化。结果：手术后分别有67.9％患者出现性欲下降,有52.4％的患者在性交过程中出现疼痛情况,有45.2％的患者在手术后的性交频率出现下降。入选患者在手术后其性交频率明显下降,其中每2个月有1次性交以及每月1次性交对比手术前明显有所提高;而性交频率每周1～2次则是出现下降,手术前后对比有显著性差异。入选患者在手术后SCL-90评分显著上升,而SAS评分以及SDS评分也出现明显升高,手术前后对比有显著性差异;而患者的性生活满意度,患者手术后对于性生活的满意度出现明显下降,手术前后对比有显著性差异。结论：子宫切除后影响患者性生活的原因主要是性欲下降,其次是性交疼痛干涩以及性交频率下降等。同时患者术后产生的抑郁和焦虑等心理情绪也同样影响患者的性生活质量。     

Exercise manual for liver disease patients

AIM: To increase inspiratory muscle strength and improve the quality of life of candidates for liver transplantation. METHODS: Twenty-three candidates for liver transplantation participated in the control group and 14 made up the intervention group. The control group consisted of 18 men and 5 women, body mass index (BMI) 27.3 ± 4.5 kg/m² and Model for End-Stage Liver Disease (MELD) 18.2 ± 6.1. The intervention group consisted of 11 men and 3 women, BMI 28.6 ± 5.4 kg/m² and MELD 18 ± 4.5. The presence or absence of ascites was identified in the first patient evaluation and after three months. We evaluated maximal inspiratory pressure (MIP) and maximal expiratory pressure, spirometry, root mean square (RMS) of diaphragm and rectus abdominis, and the quality of life. The exercises were performed daily by patients at home for three months and were supervised at distance monthly. The manual consisted of diaphragmatic breathing exercises, diaphragmatic isometric exercise, Threshold IMT^®, lifting upper limbs with a bat and strengthening the abdomen. RESULTS: There was significant difference (P = 0.01) between the first (initial) and the third month (final) MIP in the control group and in the intervention group, but there was no difference (P = 0.45) between the groups. The RMS of the diaphragm was lower (P = 0.001) and the functional capacity was higher (P = 0.006) in the intervention group compared to the control. The general health and mental health domains received higher scores after three months in the control group (P = 0.01) and the intervention group (P = 0.004), but there was no significant difference between them. The comparison between the presence of initial ascites with the presence of ascites was performed after three months in the control group (P = 0.083) and intervention group (P = 0.31). There was no significant difference, in relation to the presence of ascites after three months between groups (P = 0.21). In the intervention group, patients with ascites at the end of the time period had decreased scores on the social aspects SF-36 domain (P = 0.023) compared to those who had no ascites. CONCLUSION: The proposed exercises provide an increase in the inspiratory muscle strength and improve functional capacity, consequently bettering the quality of life of liver disease patients.     

Mediolateral versus lateral episiotomy and their effect on postpartum coital activity and dyspareunia rate 3 and 6 months postpartum

ObjectivesComparison of the effects of two episiotomy types on sexual activity, dyspareunia and overall satisfaction after childbirth.Study designA prospective follow-up study of a randomized comparative trial evaluating peripartum outcome of a vaginal delivery after mediolateral (MLE) or lateral (LE) episiotomy.Main outcome measuresThe participants completed questionnaires regarding sexual activity, dyspareunia, perineal pain, aesthetic appearance and overall satisfaction 3 (3M) and 6 months (6M) postpartum.ResultsA total of 648 women were available for the analyses (306 MLE, 342 LE). The groups showed no difference regarding resumption and regularity of sex, timing of resumption, frequency and intensity of dyspareunia, perineal pain, aesthetic appearance or overall satisfaction 3M or 6M postpartum. 98.0% of women after MLE and 97.7% after LE resumed sexual intercourse within 6M after delivery (p = 0.74). In the same period 15.6% of women after MLE and 16.1% after LE suffered from considerable dyspareunia (p = 0.86).ConclusionsQuality of sexual life and perception of perineal pain after MLE is equivalent to LE.