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.     

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.     

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.     

Xanthogranulomatous inflammation of corpus cavernosum

IntroductionXanthogranulomatous inflammation is a rare, chronic destructive inflammatory lesion. The pathological finding is typically lymphocyte and plasma cell infiltration, surrounded by accumulating lipid-laden macrophages.MethodsA 65-year-old healthy man presented with a 3-week history of a painless palpable mass in the penis.ResultsThe patient underwent an excision of the mass with a tunica albuginea, and a graft from the tunica vaginaglis. Histopathological findings showed the diffuse xanthogranulomatous inflammation.ConclusionsXanthogranulomatous inflammation of corpus cavernosum in old men is a rare condition. The inflammatory mass should be treated by complete excision and graft. Seo IY, Jo HJ, and Rim JS. Xanthogranulomatous inflammation of corpus cavernosum.     

An Innovative Strategy for Non-Grafting Penile Enlargement: A Novel Paradigm for Tunica Expansion Procedures

BackgroundPeyronie’s disease, diabetes, trauma, pelvic surgeries, and aging are conditions that promote penile fibrosis and trigger erectile dysfunction associated with penile reduction. These pathologies require an objective preoperative diagnosis and intraoperative management of penile shrinkage.AimThe goal is to develop a non-grafting procedure to promote lengthening using geometric patterns of multiple staggered small cuts on the tunica albuginea with an optimal ratio between tissue expansion and resistance to confine the cylinders inside the corpora cavernosa.MethodsBetween February 2016 and February 2019, 416 patients suffering penile shortening with or without Peyronie’s disease received implants using the tunica expansion procedures (TEP). Incisions were distributed in respective areas of the tunica to allow maximum expansion while maintaining strength to confine prosthetic cylinders within the corpora cavernosa to prevent bulges and denting.OutcomesIn accordance with these principles, surgical objectives and patient satisfaction were achieved in length and girth restoration regardless of the type of implant used to obtain adequate axial rigidity.ResultsThe sample of 416 patients included 287 cases of Peyronie’s disease having a mean axial deviation of 51° (0–90°) whose curvature was corrected in surgery, with pressure from the cylinders maintaining straightness for malleable and inflatable devices. Tunica constriction in 40.86% of cases was corrected with vertical relaxing incisions. Ventral glanspexy was performed intraoperatively in 92.8% of patients to prevent hypermobility. A penile gain of 3.3 cm (2–6) was measured intraoperatively.Clinical ImplicationsDiagnosis of penile shortening was performed by a stretch length test and pharmacologically induced erection together with the patient’s subjective opinion of penile loss. Lengthening procedure depends on the limit of the dissected neurovascular bundle. The patient and surgeon select the type of implant in accordance with his individual anatomic characteristics.Strengths and LimitationsThe TEP strategy is a non-grafting procedure based on tissue restitution by expansion instead of substitution, which provides surgeons a solution for penile enlargement to the limit of the dissected neurovascular bundle.ConclusionsThe TEP strategy has been demonstrated to be safe and effective to resolve problems of penile size reduction independently of penile curvature. It eliminates grafting and improves penile lengthening techniques using small, staggered cuts on the tunica albuginea, while maintaining tunica structural resistance to contain cylinders inside the corpora, preventing bulges and denting, facilitating tissue regeneration, and improving axial rigidity.Paulo H. Egydio, An Innovative Strategy for Non-Grafting Penile Enlargement: A Novel Paradigm for Tunica Expansion Procedures. J Sex Med 2020;17:2093–2103.     

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.     

Tumor Necrosis Factor‐Related Apoptosis‐Inducing Ligand (TRAIL) and Its Death Receptor (DR5) in Peyronie's Disease. A Biomolecular Study of Apoptosis Activation

IntroductionPeyronie's disease (PD) is a connective tissue disorder of tunica albuginea (TA), a thick fibrous sheath surrounding the corpora cavernosa of the penis. Relatively, little is known about the disease itself.AimTo investigate whether the apoptosis cascade in degenerated and macroscopically deformed TA from men with PD is activated through the extrinsic pathway, by assessing the immunoexpression of tumor necrosis factor‐related apoptosis‐inducing ligand (TRAIL) and its death receptor, DR5.MethodsTA plaques from 15 men with PD and from four unaffected men were processed for TRAIL and DR5 immunohistochemistry and Western blot analysis.Main Outcome MeasuresA greater understanding of the pathophysiology of PD through a molecular approach, to gain insights that may lead to novel forms of treatment.ResultsActivation of the apoptosis mechanisms through the extrinsic pathway was demonstrated by TRAIL and DR5 overexpression in fibroblasts and myofibroblasts from affected TA.ConclusionThe finding that apoptosis activation in TA plaques occurs, at least in part, via the extrinsic pathway may help devise novel therapeutic options for these patients. Loreto C, Barbagli G, Djinovic R, Vespasiani G, Carnazza ML, Miano R, Musumeci G, Sansalone S. Tumor necrosis factor‐related apoptosis‐inducing ligand (TRAIL) and its death receptor (DR5) in Peyronie's disease. A biomolecular study of apoptosis activation. J Sex Med 2011;8:109–115.     

Trans-corporal incision of Peyronie's plaques

IntroductionPatients presenting with Peyronie's disease (PD) curvature and erectile dysfunction (ED) can achieve straightening and rigidity through penile prosthesis implantation and manual modeling and, if necessary, a relaxing tunical incision with or without grafting. Unfortunately, this maneuver will not correct PD‐induced shortening. In addition, incision and grafting after the prosthesis has already been implanted adds to operative time and risk, and may indicate mobilization of the neurovascular bundle and, possibly, a secondary skin incision.AimThis work describes trans‐corporal incision (TCI), a minimally invasive endoscopic approach for plaque incision from within the corpora cavernosa, restoring straightness and length to the penis, before calibration of the corpora cavernosa, allowing implantation of a longer prosthesis in a straight penis, with neither mobilizing the neurovascular bundle nor a secondary incision.MethodsSixteen patients with PD deformity and refractory ED were operated upon. Intra‐operative artificial erection demonstrated the deformity. Through a penoscrotal incision, the corpora were dilated. TCI was performed to incise Peyronie's plaques at the point of maximum deformity. Artificial erection was re‐induced and correction of curvature evaluated. Length was measured before and after TCI. Implantation proceeded as usual.Main Outcome MeasuresPenile straightness and length.ResultsFollowing implantation, the penis was straight in all cases. Pre‐TCI length of the corpora was unequal on either side. Post‐TCI, both corpora were of equal length with an average increase of 2.5 cm (11.9%) on the right side and 1.9 (9.1%) on the left.ConclusionTCI; corporoscopic incision of Peyronie's plaques upon implantation of penile prosthesis is a minimally invasive approach that restores both straightness and length to patients with PD and ED, with neither mobilization of the neurovascular bundle nor plaque incision and grafting. Shaeer O. Trans‐corporal incision of Peyronie's Plaques. J Sex Med 2011;8:589–593.     

A New,Innovative, Lengthening Surgical Procedure for Peyronie's Disease by Penile Prosthesis Implantation with Double Dorsal‐Ventral Patch Graft: The “Sliding Technique”

IntroductionPeyronie's disease is the result of the formation of fibrous plaques in the tunica albuginea of the penis; typical presentations of the disease are represented by pain during erection, erectile dysfunction, and penile deformities, such as curvature, narrowing, and penile shortening. The most complex treatment is related to penile shortening.AimTo find a safe procedure in penile shortening due to Peyronie's disease providing a satisfactory lengthening, allowing an early stabilization of the penis, and preventing axial tension on the neurovascular bundles during dilation.MethodsWe describe a new lengthening surgical procedure based on a ventro‐dorsal incision of the tunica albuginea, penile prosthesis implantation, and double dorsal‐ventral patch grafting with porcine small intestinal submucosa. Three patients, affected by Peyronie's disease with penile shortening and erectile dysfunction, underwent this procedure with approval of our local ethical committee.We evaluated the penis lengthening, intraoperative and postoperative complications, patient's preoperative and postoperative sexual life satisfaction (International Index of Erectile Function [IIEF] questionnaire).ResultsThe average operative time was 2 hours and 50 minutes. No major intraoperative nor postoperative complications occurred. No significant bleedings were recorded. Patients were discharged after 48–72 hours.The average increase in length obtained was 3.2 cm. All patients resumed sexual intercourses with satisfaction; no significant loss of sensitivity or any sign of vascular distress of the glans was recorded. The follow‐up is 13 months. The average IIEF score is 60.ConclusionsThe lengthening of the penis by a double dorsal‐ventral patch graft is an innovative procedure that is based on current techniques of plaque incision and grafting, and that can easily resolve severe shortening of the penis due to Peyronie's disease. In the cases presented, this procedure resulted easily, effectively, and safely. Nevertheless, the technique proposed in this article shall be validated through prospective studies with larger samples. Rolle L, Ceruti C, Timpano M, Sedigh O, Destefanis P, Galletto E, Falcone M, and Fontana D. A new, innovative, lengthening surgical procedure for Peyronie's disease by penile prosthesis implantation with double dorsal‐ventral patch graft: The “sliding technique.” J Sex Med 2012;9:2389–2395.     

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.     

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.     

Implantation of penile prosthesis in cases of corporeal fibrosis: modified Shaeer's excavation technique

IntroductionImplantation of penile prosthesis in case of corporeal fibrosis poses a greater risk of complications because of the blinded aggression involved. Penoscopic excavation and ultrasonography‐guided excavation can decrease these complications but still have limitations.AimThis work described the combination of penoscopy‐guided and ultrasound‐guided excavation in a trial to eliminate the limitations inherent to both.MethodsTwelve patients with penile fibrosis were operated upon. A guide wire was inserted under ultrasound monitoring, along which penoscopic corporotomy and resection was performed. Ultrasound was also used to monitor penoscopic excavation toward the tip of the corpus cavernosum and crus.Main Outcome MeasuresEase of the procedure, safety, extent of dilatation, and girth of prosthesis implanted.ResultsThe procedure was relatively easy. Ten cases were dilated up to size 13.5 Hegar, and two up to size 14. Size 13 prosthesis was implanted in all cases.ConclusionThe relative safety of the procedure, the low incidence of complications, the possibility of restoring length and girth to an extent, and the resultant generous dilatation of the corpora for accommodating a sizable unhindered inflatable penile prosthesis all make ultrasound‐guided penoscopic corporotomy and resection a valid option for prosthesis implantation in cases of penile fibrosis. Shaeer O. Implantation of penile prosthesis in cases of corporeal fibrosis: Modified Shaeer's excavation technique. J Sex Med 2008;5:2470–2476.     

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.     

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.

Continuing Medical Education: A Case of Mechanical Failure with Proximal Perforation at the Time of Revision Surgery (CME)

BackgroundImplantation of inflatable penile prosthesis (IPP) is a well-established treatment for medically refractory erectile dysfunction with proven long-term reliability. However, if an IPP fails, the subsequent surgery to fix the IPP can be more difficult with higher risks of complications than the primary implantation.AimsTo review and evaluate a case of a difficult IPP replacement surgery for ways to improve surgical techniques and outcomes.Materials & MethodsPerform a case report of a difficult IPP replacement surgery in which the patient had proximal perforation of the tunica albuginea with a review of the pertinent literature.ResultsThe rear tip sling is a successful way to repair proximal perforation of the tunica albuginea. Recent publications show new surgical techniques to lower infection rates in IPP revision surgery.DiscussionThe rear tip sling appears to have better outcomes than a synthetic windsock for repairs of proximal perforation of the tunica albuginea. Recent publications have shown that the revision washout decreases penile prosthesis infection rates in revision surgeries.ConclusionWhile revision surgery for IPPs have higher risks than primary implantation, newer surgical techniques are helping to reduce these risks. Zanoni M, and Henry GD. A case of mechanical failure with proximal perforation at the time of revision surgery. J Sex Med 2009;6:2629–2632.     

Penile Histomorphometrical Evaluation in Hypertensive Rats Treated with Sildenafil or Enalapril Alone or in Combination: A Comparison with Normotensive and Untreated Hypertensive Rats

IntroductionErectile dysfunction (ED) is frequently associated to hypertension and antihypertensive drugs; however, the penile morphological aspects on these situations are poorly known.AimEvaluate the penile morphology of untreated hypertensive rats and rats treated with enalapril or sildenafil alone or in combination to verify the hypothesis that morphological alterations promoted by hypertension on corpus cavernosum could be ameliorated by the use of angiotensin-converting enzyme inhibitors and/or phosphodiesterase type 5 inhibitors.MethodsFifty male rats were assigned into five groups: normotensive rats, untreated spontaneously hypertensive rats (SHRs), and SHR treated with enalapril or sildenafil alone or in combination. Blood pressure was measured weekly. At the conclusion of the study, the rats were euthanized, and their penises were collected for histomorphometrical analysis.Main Outcome MeasuresThe cross-sectional areas of the penis, tunica albuginea, and corpus cavernosum were measured. The density of the corpus cavernosum structures was quantified.ResultsBoth groups of SHR rats treated with enalapril became normotensive. Untreated SHR showed no difference in penile and cavernosal cross-sectional area compared with normotensive rats; however, those rats treated with enalapril or sildenafil alone demonstrated an increase in these parameters. Rats receiving combination therapy showed no cross-sectional area differences compared with normotensive rats. Cavernosal connective tissue density was increased, while the sinusoidal spaces were diminished in untreated SHR. All treatments were effective in maintaining connective tissue density in comparison with normotensive animals. Cavernosal smooth muscle density was similar in all groups, with the exception of the combination therapy group, which demonstrated a reduction in smooth muscle.ConclusionsHypertension promoted structural alterations in the corpus cavernosum that may be related to ED. Enalapril- and sildenafil-treated animals had preservation of normal corpus cavernosum structure and an increase in penile and cavernosal cross-sectional area. The combination of these drugs showed less benefit than individual use. Felix-Patrício B, Medeiros JL, Jr, De Souza DB, Costa WS, and Sampaio FJB. Penile histomorphometrical evaluation in hypertensive rats treated with sildenafil or enalapril alone or in combination: A comparison with normotensive and untreated hypertensive rats. J Sex Med 2015;12:39–47.     

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.