Could IVF replace reproductive surgery? No, reproductive surgery is still very much alive.

Could IVF replace reproductive surgery? The answer is no. Reproductive surgery still has a place, at least in some indications that will be explored in this contribution. While IVF can offer infertile couples the chance to have a healthy baby, it should be acknowledged that reproductive surgery can heal or harm the organs where reproduction takes place. This paper reviews different diseases and conditions with an impact on fertility, which may benefit from the technological innovations of recent decades, novel applications and the skill of reproductive surgeons. Reproductive surgery is certainly not dead. It lives on with the promise of restoring the functional anatomy to enhance the chances of pregnancy. It is our responsibility to train young residents adequately in this field to provide the right treatment at the right time.

What Do Patients and Parents Say About Parents' Ability to Choose Early Genital Surgery for Girls with Congenital Adrenal Hyperplasia?

PURPOSE: We assessed opinions of females with congenital adrenal hyperplasia and their parents about the parent's ability to choose early genital surgery for these patients. MATERIALS AND METHODS: We conducted an online survey of females with congenital adrenal hyperplasia (46XX,16+ years old) and independently recruited parents (2019-2020) diagnosed in first year of life in the United States. A multidisciplinary medical team, women with congenital adrenal hyperplasia and parents drafted the survey. Fisher exact test was used. RESULTS: Of 57 females with congenital adrenal hyperplasia (median age 39 years), 93.0% underwent genital surgery (median 1-2 years old). Most females (79.0%) believed legislation prohibiting surgery in childhood would cause harm. Most (64.9%) believed a ban "would have been harmful to me" (24.6% not harmful, 10.5% neutral). Most females (70.2%) believed a ban undermined parental rights to make medical decisions in their child's best interest. While 75.4% did not believe a ban was in the best interest of females with congenital adrenal hyperplasia, 14.0% did (10.5% neutral). For 132 parents of females with congenital adrenal hyperplasia (parent/child median age 40/11 years), 78.8% of children underwent surgery (median <1 year old). Most parents (93.9%) believed legislation prohibiting surgery in childhood would cause harm. Most (77.3%) believed a ban "would have harmed my daughter" (12.1% no harm, 5.3% neutral, 5.3% no answer). Parents were more likely than females with congenital adrenal hyperplasia to oppose a ban (p ≤0.02). Most parents (90.9%) believed a ban undermined parental rights. While 93.9% did not believe a ban was in the best interest of females with congenital adrenal hyperplasia, 3.8% did (2.3% neutral). CONCLUSIONS: The majority of females with congenital adrenal hyperplasia and their parents support the parents' ability to decide about potential genital surgery, opposing moratoria on surgery in childhood.

Non-invasive and surgical penile enhancement interventions for aesthetic or therapeutic purposes: a systematic review.

OBJECTIVE: To systematically review the literature in order to investigate the efficacy and safety of surgical and non-invasive penile enhancement procedures for aesthetic and therapeutic purposes. METHODS: A systematic search for papers investigating penile enhancement procedures was performed using the MEDLINE database. Articles published from January 2010 to December 2019, written in English, including >10 cases, and reporting objective length and/or girth outcomes, were included. Studies without primary data and conference abstracts were excluded. The main outcome measure was objective length and/or girth improvement. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS: Out of 220 unique records, a total of 57 were reviewed. Eighteen studies assessed interventions for penile enhancement in 1764 healthy men complaining of small penis. Thirty-nine studies investigated 2587 men with concomitant pathologies consisting mostly of Peyronie's disease and erectile dysfunction. Twenty-five studies evaluated non-invasive interventions and 32 studies assessed surgical interventions, for a total of 2192 and 2159 men, respectively. Non-invasive interventions, including traction therapies and injection of fillers, were safe and mostly efficacious, whereas surgical interventions were associated with minor complications and mostly increased penile dimensions and/or corrected penile curvature. Overall, the quality of studies was low, and standardized criteria to evaluate and report efficacy and safety of procedures, as well as patient satisfaction, were missing. CONCLUSION: The quality of the studies on penile enhancement procedures published in the last decade is still low. This prevents us from establishing recommendations based on scientific evidence regarding the efficacy and safety of interventions that are performed to increase the penis size for aesthetic or therapeutic indications.

Early Genital Surgery in Disorders/Differences of Sex Development: Patients' Perspectives.

Controversy continues over a proposed moratorium on elective genital surgery in childhood for disorders/differences of sex development (DSD). Empirical evidence on patient preference is needed to inform decision-making. We conducted a multicentre survey by cross-sectional questionnaire in 14 specialized clinics in six European countries. The sample comprised 459 individuals (≥ 16 years) with a DSD diagnosis, including individuals with congenital adrenal hyperplasia (CAH) (n = 192), XY DSD with prenatal androgen effect (A) (n = 150), and without (nA) (n = 117). Main outcome measures were level of agreement with given statements regarding genital surgery, including clitoris reduction, vaginoplasty, and hypospadias repair. A total of 66% of individuals with CAH and 60% of those with XY DSD-A thought that infancy or childhood were the appropriate age for genital surgery. Females with XY DSD were divided on this issue and tended to prefer vaginoplasty at a later age (XY DSD-A 39%, XY DSD-nA 32%). A total of 47% of males preferred early hypospadias surgery. Only 12% (CAH), 11% (XY DSD-A), and 21% (XY DSD-nA) thought they would have been better off without any surgery in childhood or adolescence. Individuals who had early genital surgery were more likely to approve of it. Outcome data failed to support a general moratorium on early elective genital surgery. Participant perspectives varied considerably by diagnostic category, gender, history of surgery, and contact with support groups. Case-by-case decision-making is better suited to grasping the ethical complexity of the issues at stake.Trial registration: German Clinical Trials Register DRKS00006072.

Robotic Low Anterior Resection and Partial Bladder Resection for Management of Locoregional Endometrial Cancer Recurrence.

OBJECTIVE: To demonstrate a robotic tumor debulking for management of locoregional endometrial cancer recurrence. DESIGN: Case report. SETTING: Tertiary referral center in New Haven, CT. INTERVENTIONS: A 70-year-old patient with a history of stage IB endometrioid endometrial cancer presented with rectal bleeding 3 years after the completion of treatment. A mass involving the distal sigmoid colon/upper rectum and bilateral distal periureteral masses were visualized on imaging. There was no distant metastatic disease. Colonoscopic biopsies were consistent with endometrial cancer recurrence. Because the patient was symptomatic with rectal bleeding and had no distant metastasis, it was recommended that she undergo surgical resection for management of this locoregional recurrence. The patient was placed in reverse Trendelenburg position with a rightward tilt to mobilize the splenic flexure. Once the cephalad aspect of the descending colon mobilization was completed, the patient was placed in Trendelenburg lithotomy position to expose the pelvis. A robot was docked at this point and the pelvic avascular spaces were delineated. A medial-to-lateral approach was used in mobilization of the sigmoid colon mesentery. The left ureter was identified and the sigmoid branches of inferior mesenteric artery were sealed. The descending/sigmoid colon junction was stapled. After complete mobilization of the sigmoid colon, the tumor-free upper rectum was delineated and stapled. Attention was then turned to the distal peri-ureteral masses. The 2-cm mass on the right, which was densely adherent to the distal right ureter, was completely resected after extensive ureterolysis. The resection of the 4-cm mass on the left which involved both the distal left ureter and the bladder dome required an intentional cystotomy and a partial cystectomy to attain negative margins (Supplemental Figure 1). The procedure was continued with the bowel anastomosis. The anvil was introduced through the vagina and was placed into the proximal limb through an antimesenteric incision. An end-to-end tension-free anastomosis was performed and adequate vascularization was confirmed with intravenous indocyanine green. CONCLUSION: Robotic low anterior resection and partial bladder resection were performed without any complications with negative margins. Robotic tumor debulking should be considered in appropriate patients when managing locoregional recurrence of endometrial cancer [1,2].

[Feminizing genitoplasty for prepubertal children and teenagers female]. / Génitoplastie féminisante dans les anomalies du développement sexuel de l'enfant pré-pubère et de l'adolescente au Cameroun. À propos de 9 cas.

OBJECTIVE: The aim of this study was to report our experience after 10 years of practice of feminizing genitoplasty in prepubertal and adolescent patients with disorders of sex development (DSD) assigned females as females in a developing country. METHODOLOGY: This was a cross-sectional, descriptive and retrospective study over a period of 9 years. All pre-pubertal (8-12 years) and adolescent patients female sex assigned with DSD who had willfully consented to the surgery with their guardians and underwent feminizing genital surgery were enrolled in the study. Data collection included: age at presentation, precise diagnosis, surgical procedures, complications, cosmetic result and duration of follow-up. Each patient had a precise diagnosis and the surgery was planned after discussion with the multidisciplinary team. Cosmetic results were assessed based on: appearance of the clitoris and separation of the vaginal and urethral openings. RESULTS: Nine patients raised as females with a median age of 8 years (IR: 10.75) were recorded. Surgery was performed at a median age of 11 years (IR: 9.5). In this series, 6 had a 46, XY karyotype with varying diagnoses: partial androgen insensitivity syndrome (n=2); 5-alphareductase insufficiency (n=2); 17-ketoreductase insufficiency (n=2); gonadal dysgenesis with a mutation in the NR5A1 gene (n=2), 2 had ovostesticular DSD, (karyotypes 46, XX), and 1 had mixed gonadal dysgenesis (karyotype 45, X/46, XY). Partial or total gonad(s) removal in accordance with assigned gender was the most common associated procedure. It was bilateral in 7 cases and unilateral in 2 cases. Follow-up ranged from 3 months to 4.5 years (median: 26 months, IR:18.25). One patient had acute urinary retention in the early follow-up. No other complication such as incision bleeding was recorded. The cosmetic appearance of the external genitalia was satisfactory in all patients. CONCLUSION: Feminizing genital surgery in Cameroon remains a major challenge and should seldom be realized without a precise diagnosis. Late age at presentation is peculiar to our setting; however, it gives room for the patients' participation and input to decisions that will have a life-long personal impact on their lives in terms of psychosocial development and fertility. LEVEL OF EVIDENCE: 3.

Immunologic impact of chemoradiation in cervical cancer and how immune cell infiltration could lead toward personalized treatment.

We investigated the potential of tumor-infiltrating immune cells (ICs) as predictive or prognostic biomarkers for cervical cancer patients. In total, 38 patients treated with (chemo)radiotherapy and subsequent surgery were included in the current study. This unique treatment schedule makes it possible to analyze IC markers in pretreatment and posttreatment tissue specimens and their changes during treatment. IC markers for T cells (CD3, CD4, CD8 and FoxP3), macrophages (CD68 and CD163) and B cells (CD20), as well as IL33 and PD-L1, were retrospectively analyzed via immunohistochemistry. Patients were grouped in the low score or high score group based on the amount of positive cells on immunohistochemistry. Correlations to pathological complete response (pCR), cause-specific survival (CSS) and metastasis development during follow-up were evaluated. In analysis of pretreatment biopsies, significantly more pCR was seen for patients with CD8 = CD3, CD8 ≥ CD4, positive IL33 tumor cell (TC) scores, IL33 IC < TC and PD-L1 TC ≥5%. Besides patients with high CD8 scores, also patients with CD8 ≥ CD4, CD163 ≥ CD68 or PD-L1 IC ≥5% had better CSS. In the analysis of posttreatment specimens, less pCR was observed for patients with high CD8 or CD163 scores. Patients with decreasing CD8 or CD163 scores between pretreatment and posttreatment samples showed more pCR, whereas those with increasing CD8 or decreasing IL33 IC scores showed a worse CSS. Meanwhile, patients with an increasing CD3 score or stable/increasing PD-L1 IC score showed more metastasis during follow-up. In this way, the intratumoral IC landscape is a promising tool for prediction of outcome and response to (chemo)radiotherapy.

Alpha-lipoic acid improves sperm motility in infertile men after varicocelectomy: a triple-blind randomized controlled trial.

RESEARCH QUESTION: Does supplementation with alpha-lipoic acid (ALA) enhance sperm parameters and/or the status of sperm lipid peroxidation and DNA fragmentation in men who have undergone microsurgical repair of a varicocele? DESIGN: Individuals with a varicocele who had undergone varicocelectomy were divided into two groups receiving either 600 mg of ALA or an identical placebo for 80 days. Semen samples obtained from the participants before surgery and after completion of the course of medication were analysed and compared. Participants, clinicians and data analysts were blinded to the randomization sequence. RESULTS: In the ALA group, total motility (P = 0.01) and progressive motility (P = 0.002) of the spermatozoa were significantly higher compared with the placebo group after surgery. Sperm lipid peroxidation and DNA damage (assessed by sperm chromatin structure assay) showed significant decreases in both the ALA and placebo groups (P ≤ 0.02) after treatment. CONCLUSIONS: An 80-day course of ALA medication after surgical repair improves total motility and progressive motility of the spermatozoa in individuals with a varicocele.

An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.

PURPOSE: To investigate the feasibility of conducting a rehabilitation program for patients following surgery for abdomino-pelvic cancer. METHODS: A non-randomised controlled before-and-after study. Patients who had undergone surgery for stage I-III abdomino-pelvic cancer (colorectal, gynaecological or prostate cancer) were recruited. The rehabilitation group (n = 84) received an 8-week, bi-weekly education and exercise program conducted by a physiotherapist, exercise physiologist, health psychologist and dietician, supplemented by exercise diaries and telephone coaching sessions. The comparator group (n = 104) completed postal questionnaires only. Feasibility measures, functional exercise capacity, muscle strength, physical activity levels, pelvic floor symptoms, anxiety and depression, health-related quality of life (HRQoL) and self-efficacy were measured at baseline (time 1), immediately post-intervention (time 2) and at 6 months post-baseline (time 3) and compared within- and between-groups. RESULTS: The consent rate to the rehabilitation program was 24%. Eighty-one percent of the rehabilitation group attended 85-100% of 16 scheduled sessions. Overall satisfaction with the program was 96%. Functional exercise capacity, handgrip strength in males, bowel symptoms, physical activity levels, depression and HRQoL were significantly improved in the rehabilitation group (p < 0.05) at time 2. The improvements in all these outcomes were sustained at time 3. The rehabilitation group had significantly improved physical activity levels, depression and HRQoL compared with the comparator group at times 2 and 3 (p < 0.05). CONCLUSION: Recruitment to this oncology rehabilitation program was more difficult than expected; however, attendance and patient satisfaction were high. This program had positive effects on several important clinical outcomes in patients following abdomino-pelvic cancer treatment. TRIAL REGISTRATION: ANZCTR 12614000580673.

Surgical treatment and outcome of complete unilateral urinary tract duplication in a dog.

OBJECTIVE: To report the surgical technique and outcome for correction of complete unilateral duplication of the left urinary tract in a dog. ANIMALS: One 7-month-old entire male Jack Russell terrier. STUDY DESIGN: Case report METHODS: A dog was referred for investigation because of urinary incontinence (UI), preputial irritation (pruritus), diphallia, and cryptorchidism. Computed tomography including urethrographic studies revealed a left duplex kidney, double ectopic left ureters, and a duplex urinary bladder comprising two halves separated by a median septum, each of which emptied into a separate urethra which coursed through separate penises. The left testis was abdominally retained. The right upper urinary tract was considered normal, and the right testis was within the scrotum. Left sided ureteronephrectomy was performed, the median bladder septum was ablated, and the left urethra was ligated. The left penis was partially amputated, and the dog was castrated. RESULTS: Urinary incontinence was improved but persisted after surgery. After repeat imaging, revision surgery was performed 3 months later in which the distal stumps of the (left) ectopic ureters were found to be filling with urine from the right urethra. Urinary incontinence resolved after resection of these ureteric stumps from the prostate and complete transection of the left urethra. CONCLUSION: Extensive surgery with resection and correction of urinary tract duplication was successful in resolving UI in this case. Urogenital duplication should be considered a rare cause of UI. The presence of external congenital deformity (eg, diphallia) should alert clinicians to the possibility of significant concurrent internal abnormalities.

Efficacy of prostatic urethral lift compared with transurethral resection of the prostate.

This article reviews the prostatic urethral lift (PUL) and its potential benefits and risks compared with transurethral resection of the prostate (TURP). TURP is the traditional procedure for benign prostatic hyperplasia (BPH), and is associated with ejaculatory and erectile dysfunction. PUL is a minimally invasive option, but its efficacy has not been well studied. A literature review indicates that both procedures should be afforded equal consideration, and both have limitations. Further long-term research is needed to establish if PUL is superior to TURP.

Psychological perspectives to early surgery in the management of disorders/differences of sex development.

PURPOSE OF REVIEW: The review focuses on genitoplasty, performed on young children with disorders/differences of sex development (DSD) to 'typify' ambiguous external genitalia and intended to result in either male or female-appearing genitals. Consensus on whether or not early genitoplasty is optimal or appropriate has yet to be achieved. This article reviews arguments in favor of early surgery as well as those disputing their justification. RECENT FINDINGS: Arguments supporting early genitoplasty include the assumption that a child's genital anatomy should match their gender of rearing for optimal psychosocial development and that outcomes are better physically and psychologically than when surgery is deferred. Those disputing their justification argue that they deny patients the right to participate in irreversible decisions related to anatomy and gender, revoke the possibility of an open future, and violate basic human rights. Clinical management includes recommendations for interdisciplinary care integrating psychologists, and shared decision-making processes to assist families in carefully considering options. SUMMARY: Early genital surgery in DSD care is controversial with compelling arguments put forth by both proponents and opponents. Relevant issues can be examined from ethical, psychological, cultural and medical perspectives - all of which need to be accounted for in both research and standard of care development.

Laparoscopic vesiculectomy for large seminal vesicle cystadenoma.

Cystadenomas of the seminal vesicles are extremely rare. Here, we report a large seminal vesicle cystadenoma. A 37-year-old man presented a 6-month history of haemospermia, 10 days of Lower Urinary Tract symptoms (LUTSs) and gross haematuria. Transabdominal ultrasonography, computed tomography and magnetic resonance imaging were performed and revealed a large solid-cystic pelvic mass morphometrically measured 7.0 cm × 11.9 cm × 8.6 cm on the right seminal vesicle, which caused hydronephrosis of the right kidney. The prostate-specific antigen of the patient was 27.860 ng/dl. Laparoscopic exploration found the capsule of tumour was complete and the tumour came from the right seminal vesicle, in addition, the mass had a certain space with the bladder and prostate, which could be separated. So a nerve-sparing Laparoscopic Vesiculectomy was performed at last, even though the intraoperative frozen section analysis could not make sure the nature of the tumour either. The postoperative pathology revealed cystadenoma of the seminal vesicle.

Assessment of the influence of transrectal and transperineal prostate biopsies on erectile function: A prospective observational single-center study.

OBJECTIVES: To assess the impact of transrectal versus transperineal prostate biopsy on erectile function. METHODS: This was a single-center, observational, prospective study of consecutive patients who underwent a prostate biopsy (transrectal or transperineal/fusion biopsy). Study participants completed the International Index of Erectile Function-5 questionnaire before the procedure, and 3 and 6 months after. Prostatic biopsies were carried out following the standard procedure for both techniques. RESULTS: The study included 135 male patients with a mean age of 63.5 years. At baseline, 28 patients (21%) presented normal erectile function, whereas 107 patients (82%) presented erectile dysfunction, which was severe in four (3%), moderate in 49 (36%) and mild in 54 (40%), with an overall mean International Index of Erectile Function-5 score of 17.70. After 3 months, the rates were 29%, 3%, 27% and 38%, respectively (mean International Index of Erectile Function-5 score 17.95). At 6 months, the rates were 30%, 6%, 28% and 34%, respectively (mean International Index of Erectile Function-5 score of 17.77). No significant differences between pre- and post-biopsy International Index of Erectile Function-5 scores at 3 and 6 months were observed, even when analyzing transrectal and transperineal separately. The number of biopsy cores and number of previous biopsies did not influence the International Index of Erectile Function-5 scores. CONCLUSIONS: Our findings suggest that prostate biopsy technique, number of biopsy cores and history of previous biopsy do not significantly impact erectile function in the medium term up to 6 months.

Urinary and Fecal Continence in 5-Year-Old Patients Who Underwent in utero Myelomeningocele Repair: A Prospective Study.

INTRODUCTION: After the successful results of in utero myelomeningocele (MMC) repair presented by the Management of Myelomeningocele Study, the concept of fetal surgery was introduced in our institution in 2011. Since then, we have been able to follow prospectively a group of patients with attention to urological care. In the present study, we were interested in estimating urinary and fecal continence in this new subset of patients. MATERIAL AND METHODS: We selected from our database patients aged 5 years or older for evaluation of urinary and fecal continence. We reviewed all charts and completed a questionnaire to study aspects of urinary and fecal continence. RESULTS: We identified 14 patients, i.e., 4 (28.6%) males and 10 (71.4%) females. The mean age at MMC surgery was 25.6 gestational weeks. The uro-dynamic class was high-risk in 6 (42.9%), incontinent in 4 (28.6%), hypocontractile in 1 (7.1%), and normal in 3 (21.4%) patients. Three patients had undergone surgery (2 augmentations, i.e., 1 in association with a left colon ACE Macedo-Malone procedure and 1 mini-sling urethroplasty). Twelve patients underwent clean intermittent catheterization (CIC) (85.7%). Only 3 (21.4%) patients had no urinary leakage. Eleven patients (78.6%) used diapers. Eight patients (57.2%) underwent retrograde rectal irrigation and 11 (78.6%) complained of fecal loss. Eleven patients (78.6%) did not report an impact on their self-esteem. CONCLUSION: Despite the use of CIC in 85.7% of the cases, the continence rate in MMC patients operated on in utero was low and 78.6% of the patients used diapers. This data can be used to educate parents about future conditions of their 5-year-old children and may stimulate the debate regarding further attempts (surgical or not) to improve fecal and urinary continence.

External-internal ureteral catheterization technique in treatment of ureteral injuries

Background/aim: It was aimed to describe the external-internal ureteral catheterization technique and evaluate its safety, efficacy, and reliability in iatrogenic and traumatic ureteral injuries. Materials and methods: A retrospective review was performed on patients with iatrogenic and traumatic ureteral injury, treated using the external-internal ureteral catheterization technique between May 2012 and January 2018 in our hospital. A total of 14 patients were investigated with clinical, postoperative, and follow-up findings, as well as technical outcomes. Results: The urology, gynecology, and general surgery departments referred patients for treatment at a rate of 57% (n = 8), 36% (n = 5), and 7% (n = 1), respectively. The causes were urological procedures for lithiasis (43%, n = 6), gynecological surgery (36%, n = 5), rectosigmoid surgery (7%, n = 1), penetrating injury (7%, n = 1), and partial nephrectomy (7%, n = 1). The most commonly affected segment was the distal third of the ureter, at a rate of 79% (n = 11). The mean duration of catheterization in all of the patients was 39 days. The overall technical success was 100% and no major complications occurred. Conclusion: The external-internal ureteral catheterization technique in patients with ureteral injury is easy to apply and effective not only in reducing costs but also complications that may result from recurrent percutaneous interventions.

Colpectomy Significantly Reduces the Risk of Urethral Fistula Formation after Urethral Lengthening in Transgender Men Undergoing Genital Gender Affirming Surgery.

PURPOSE: We assessed the effect of performing colpectomy before (primary) or after (secondary) gender affirming surgery with single stage urethral lengthening on the incidence of urethral fistula in transgender men. MATERIALS AND METHODS: We retrospectively reviewed the charts of all transgender men who underwent gender affirming surgery with urethral lengthening between January 1989 and November 2016 at VU University Medical Center. Patient demographics, surgical characteristics, fistulas and fistula management, and primary and secondary colpectomy were recorded. Descriptive statistics were calculated and incidence rates were compared. RESULTS: A total of 294 transgender men underwent gender affirming surgery with urethral lengthening. A urethral fistula developed in 111 of the 232 patients (48%) without colpectomy and in 13 of the 62 (21%) who underwent primary colpectomy (p <0.01). Secondary colpectomy resulted in 100% fistula closure when performed in 17 patients with recurrent urethral fistula at the proximal urethral anastomosis and the fixed part of the neourethra. CONCLUSIONS: Primary colpectomy decreases the incidence rate of urethral fistulas. Secondary colpectomy is also an effective treatment of fistulas at the proximal urethral anastomosis and the fixed part of the neourethra.

Complications of Genital Enlargement Surgery.

INTRODUCTION: The objective of genital enlargement surgery is to increase length and/or girth for cosmetic reasons; however, newer techniques have been recently reported to be associated with only minor complications in a small percentage of patients. AIM: We aim to report the severe complications of penile augmentation surgery seen at a referral center and describe their subsequent management. METHODS: Institutional review board approval was obtained. We reviewed our prospectively collected database for all patients who presented with complications of genital enlargement surgery from 2002-2016. MAIN OUTCOME MEASURE: Interventions following complications of genital enlargement surgery. RESULTS: 11 Patients were identified. Mean age was 47 (21-77) years. Prior procedures included subcutaneous injection of silicone outside a medical setting, girth enhancement procedures involving the subcutaneous placement or injection of substances including fat, other substances, or subcutaneous silicone implants. All patients who underwent subcutaneous penile implant underwent removal prior to presentation. Adverse changes included sexually disabling penile deformity and severe shortening, curvature, edema, subcutaneous masses, infection, non-healing wounds, and sexual dysfunction. 10 patients underwent corrective surgery, with 2 requiring multiple procedures and 3 requiring split-thickness skin grafting. All 10 patients had an improved cosmetic appearance and those who had disabling shortening had significantly improved functional length. CLINICAL IMPLICATIONS: Report of such adverse events should assist in appropriate perioperative counseling prior to genital enhancement surgery. STRENGTH & LIMITATIONS: Few reports of debilitating complications of penile enlargement exist in literature. However, without knowing the overall number of procedures performed, the true complication incidence is not known. CONCLUSION: Penile and scrotal enhancement surgery can be associated with major disabling complications, leading to deformity and functional compromise in men with prior normal anatomy and function. Patients should be aware of these risks. Furr J, Hebert K, Wisenbaugh E, et al. Complications of Genital Enlargement Surgery. J Sex Med 2018;15:1811-1817.

Long-term follow-up of anterior vaginal repair: A comparison among colporrhaphy, colporrhaphy with reinforcement by xenograft, and mesh.

AIMS: To assess the long-term complications and outcomes in patients treated for pelvic organ prolapse (POP) with transvaginal anterior colporrhaphy (AC) alone, transvaginal naterior AC with reinforcement by using porcine Xenograft (AC-P) (Pelvisoft® Biomesh), and transvaginal anterior repair with polypropylene mesh (AC-M). METHODS: This was a retrospective analysis of 109/123 consecutive patients, who underwent cystocele repair: 42 AC, 19 AC-P, and 48 AC-M. Subjective outcomes included validated questionnaires as well as questions that had not been previously validated. Objective outcomes have been evaluated considering failure the anterior vaginal wall recurrence >2 stage POP-Quantification. Statistical analysis included the chi-square or Fisher exact test. RESULTS: The mean follow-up was 94.80 ± 51.72 months (19-192 months). In all groups, the patient's personal satisfaction was high. There was no evidence of difference in outcome based on whether a biological graft was or was not performed, or whether synthetic mesh was used to reinforce the repair. Data showed a higher rate of complications in the AC-M group (P < 0.05) that could explain the lower subjective satisfaction of these patients. CONCLUSIONS: This study evaluated long-term outcomes to anterior vaginal repair over a period of more than 5 years in all the groups. Our data show that anterior vaginal repair with mesh and xenograft did not improve significantly objective and subjective outcomes. Rather, prosthetic device use leads to higher rate of complications.