[Trans-scrotal penile degloving, a new procedure for corporoplasties]. / Degloving penieno trans-scrotale, un nuovo approccio chirurgico per gli interventi di corporoplastica.

INTRODUCTION: The subcoronal approach is the most widely used skin degloving procedure for corporoplasty. Although it is relatively easy and it fully exposes the corpora cavernosa, it is not free from several complications (subcoronal lymphedema, decrease of glans sensitivity, paraphimosis, distal skin necrosis), which sometimes require a postoperative circumcision, or a preoperative prophylactic circumcision. AIM: To describe our own degloving approach, the "Trans-scrotal Penile Degloving (TPD)", that is suitable for most corporoplasties, and to present the outcomes. METHODS: This is a retrospective analysis conducted on 89 patients (pts) presenting with different penile diseases, and submitted to the TPD during Corporoplasty, from February 2008 to July 2010: Congenital curvature (26 pts); Peyronie's Disease (PD) with penile curvature (18 pts); PD with erectile dysfunction and curvature (25 pts); Redo surgery with complex tunica albuginea remodeling and prosthesis implant (20 pts). The TPD approach calls for a 5 cm incision to be placed ventrally on the scrotal raphe at the penile base: penile degloving is then easily carried out up to the coronal line. Subsequently, the dorsal neurovascular bundle is normally isolated and all types of different corporoplasties can be carried out. RESULTS: Any complication occurring during or after surgery has been registered. Patient follow-up controls were performed on day 7, month 1 and month 3 post-surgery: -No pre- or post-operative circumcision procedures were required; -There was no evidence of post-operative preputial edema or penile skin necrosis or loss of glans sensitivity; -In 6 patients, we noted a mild scrotal sub-dartos hematoma, which reabsorbed spontaneously. CONCLUSIONS: TPD, which represents an evolution of our previous combined subcoronal-trans-scrotal approach, may be advantageously performed in most corporoplasties with optimal aesthetic and functional outcomes, and may replace in many cases the subcoronal approach without its associated complications.

Small intestinal submucosa (SIS) graft urethroplasty: short-term results.

OBJECTIVE: We evaluated the use of small intestinal submucosa (SIS) graft in penile and bulbar urethroplasties. METHODS: From 2003 to 2004, 20 men (mean age, 41 yr) with anterior urethral strictures underwent urethroplasty using SIS (COOK) as an inlay or onlay patch graft. Stricture location was penile in 1 patient, bulbar in 16, and penile-bulbar in 3. Average stricture and graft lengths were 3 and 5.7 cm, respectively. A dorsal inlay graft was performed in 14 cases, ventral onlay graft in 1, and dorsal inlay plus ventral onlay in 5. Clinical outcome was considered successful if no postoperative procedure was needed. RESULTS: Mean follow-up period was 21 mo (range: 13-35 mo). Seventeen cases (85%) were successful and 3 (15%) were failures. No postoperative complications were related to the use of heterologous graft material, such as infection or rejection. Sixteen successes (94%) were bulbar repairs and one a penile-bulbar repair, with stricture and graft average lengths 2.6 and 5.35 cm, respectively. Cystoscopy at 3 mo revealed adequate calibre lumens, but SIS grafted areas were not completely replaced by urothelium. The three failures were penile and penile-bulbar urethral repairs with stricture and graft average lengths of 5.7 and 7.7 cm, respectively. Recurrences showed fibrous tissue involving the grafted area with extension into the penile and bulbar urethra. CONCLUSIONS: In our short-term results, SIS seems to be a versatile material that may have a role in select urethral reconstructions. Longer follow-up and further investigations in select patients are needed before widespread use is advocated.

Smoking as a risk factor for erectile dysfunction: data from the Andrology Prevention Weeks 2001-2002 a study of the Italian Society of Andrology (s.I.a.).

OBJECTIVE: To analyse the relationship between smoking and erectile dysfunction (ED). METHODS: To provide further data on this issue, we analysed information gathered from men attending a free andrologic consultation in 234 Italian medical centres, in the setting of a project focused on andrologic prevention. Men were asked about "their ability to achieve and maintain an erection sufficient for satisfactory sexual performance". If they were dissatisfied, they were defined as having ED. RESULTS: Out of 16724 subjects, ED was diagnosed in 4081 men (24.4%). After adjustment for age, marital status, education, alcohol consumption, physical activity and concomitant pathologies, in comparison with never smokers, men who currently smoked more than 10 cigarettes/day and former smokers showed significantly higher odds ratio (ORs 1.4 and 1.3, respectively) for ED. These results were confirmed performing analysis in strata of diabetes, hypertension, cardiovascular disease and hypercolesterolemia. COMMENTS: This transversal observational study shows that the risk of ED is influenced by smoking. A dose- and duration-response effect is present; changes in smoking habits do not seem to significantly affect the risk to develop ED.

The new transperineal-prerectal approach in posterior urethroplasty.

OBJECTIVE: A new posterior urethroplasty is suggested for patients with pelvic fracture urethral distraction defect (PFUDD). METHODS: 12 men, with PFUDD were treated with an anastomotic urethroplasty, using a transperineal-prerectal approach. All patients had a suprapubic tube in place and were impotent after pelvic trauma. The goal of this approach was to facilitate an extensive removal of the scar tissues around the prostatic apex to promote successful bulbo-prostatic anastomosis. RESULTS: No patients had intraoperative, perioperative or postoperative complications. Urinary incontinence or rectourethral fistula was never observed. In 11 patients the postoperative mean peak flow was 20 ml/sec. The recurrence of the stricture occurred in 1 patient. CONCLUSIONS: The transperineal-prerectal approach to the posterior urethra facilitated a free tension posterior end-to-end anastomosis, as an alternative to the transpubic anastomotic procedure.

Soft prosthesis implant and relaxing albugineal incision with saphenous grafting for surgical therapy of Peyronie's disease: a 5-year experience and long-term follow-up on 145 operated patients.

INTRODUCTION: Most surgical therapies used to date for Peyronie's disease produce good results but cause penis retraction. The authors propose a personal surgical technique that makes use of an intracavernous cylinder, soft but axially rigid in consistency, in association with tunical relaxing incisions and saphenous vein grafting, in this exact sequence. METHODS: Between March 1997 and March 2003, 145 patients presenting with Peyronie's disease underwent this 3-phase personal surgical procedure. Complete plaque excision was necessary only for 13 patients (8.9%); in the remaining 132, a single incision was placed in 113 cases (77.9%) and double incisions were used for 19 patients (13.1%). Penile length was measured intraoperatively, after drug-hydraulic erection, then at the later control visits. Distance follow-up ranged from a minimum of 6 months to a maximum period of 3 years (mean 13 months); the latter follow-up period was possible for 38 patients. All patients and partners with at least one year follow-up were asked to answer a questionnaire administered over the telephone at 12 months post-surgery. RESULTS: Average penile lengthening was approximately 1.5 cm. 80 patients answered the questionnaire (70.75%): 76 expressed complete satisfaction, while 4 patients reported glans paresthesia. No major complications were noted; for 8 patients circumcision was repeated because of preputial edema. In 6 cases there was a local, postoperative infection, that was treated conservatively with a prolonged antibiotic therapy. CONCLUSIONS: This technique allows to successfully solve penile retraction, caused by traditional surgery for Peyronie's disease. The technique is easy to carry out, has low risks of complications and ensures very high rates of patient satisfaction.

Efficacy and safety of tadalafil in a Western European population of men with erectile dysfunction.

OBJECTIVE: To evaluate, in a randomized, double-blind, placebo-controlled, multicentre trial, the safety and efficacy of on-demand tadalafil (an oral phosphodiesterase type-5 inhibitor approved in many countries for treating erectile dysfunction, ED) in a Western European population of men with mild-to-severe ED. PATIENTS AND METHODS: Patients were randomized according to baseline severity of ED in a ratio of 3 : 1 to receive either tadalafil 20 mg or placebo for 12 weeks. Primary efficacy endpoints were mean changes from baseline to endpoint (12 weeks) in the erectile function (EF) domain of the International Index of Erectile Function (IIEF) and percentages of 'Yes' responses to Sexual Encounter Profile (SEP) diary Question 2 ('Were you able to insert your penis into your partner's vagina?') and Question 3 ('Did your erection last long enough for you to have successful intercourse?'). Secondary endpoints included mean changes from baseline to endpoint in IIEF Intercourse Satisfaction and Overall Satisfaction domains, selected questions of the IIEF, and the percentage of 'Yes' responses to Global Assessment Questions (GAQ) at the last visit. Other analyses included the percentage of patients in each treatment group at endpoint with IIEF EF domain scores in the normal range (>26), the frequency of intercourse attempts and mean per-patient intercourse success rate at various times after dosing. RESULTS: The mean age of the patients was 53 years and 80% had a history of ED of > or = 1 year. The mean baseline EF domain score was 13.5, with 40.5% of patients in the severe category. Tadalafil improved mean EF domain scores by 11.1, vs 0.4 for placebo (P < 0.001). In addition, 73.9% of sexual intercourse attempts were successful (SEP-Q3) in tadalafil-treated patients, compared with 29.9% in placebo-treated patients during the period after baseline (P < 0.001). Tadalafil significantly improved the mean IIEF intercourse satisfaction (5.1, tadalafil; 1.1, placebo) and overall satisfaction domain scores (3.9, tadalafil; 0.5, placebo), P < 0.001. GAQs used to assess the overall effect of the treatment indicated that tadalafil was superior to placebo (P < 0.001) in improving erections (82.1%, tadalafil; 23.1%, placebo) and sexual activity (78.6% and 17.3%). The most common treatment-emergent adverse events more frequent (>2%) with tadalafil than placebo were headache, dyspepsia, flushing, back pain, pain in limb and myalgia. These adverse events were mostly mild to moderate. CONCLUSIONS: Tadalafil improved erectile function and was well tolerated when taken by men from Western Europe with mild-to-severe ED.

[Urethro-autoplasty: scrotal in-lay, mesh-graft, buccal on-lay]. / Uretro-autoplastiche: in-lay scrotale, mesh-graft, on-lay buccale.

The surgical therapy of the urethral strictures is still controversial as it interests the choice of an appropriate technique among many methods. In cases of complex urethral strictures, urethroplasties using genital or extragenital tissue for reconstruction are indicated. Scrotal in-lay was popular some years ago, but the complications rate was high. Nowdays, the two techniques with better outcome are the mesh graft urethroplasty and the buccal mucosa on-lay urethroplasty.