Use of Soft Penile Prosthesis in Grafting Surgery for Peyronie's Disease and Mild Erectile Dysfunction: Still an Option?

BACKGROUND: Plaque incision and grafting (PEG) is a primary surgical therapy for severe penile curvature in Peyronie's disease (PD); However, it can increase the risk of erectile dysfunction (ED), particularly in patients with pre-operative mild ED. Soft penile prosthesis (SPP) implantation is a viable treatment option in such cases. This study aims to compare the outcomes of PEG-only approach to PEG plus SPP implantation. METHODS: Between 2010 and 2019, 32 patients with PD and mild ED (5-item version of the International Index of Erectile Function scores: 17-21) underwent PEG surgery. Two groups were defined based on the surgery type: PEG-only and PEG plus SPP. The long-term outcomes included correction of penile bending, erection quality, intercourse ability, penile length and sensitivity. The overall satisfaction and impact of surgery on sexual activity and quality of life were also assessed. RESULTS: Of the 32 patients, 13 (40.6%) underwent PEG-only surgery, whereas 19 (59.4%) underwent PEG plus SPP. No significant differences were noted between the groups regarding pre-operative characteristics (all p > 0.1) or intra- and post-operative complication rates (all p > 0.2). The median patch area was larger in the PEG-only group (28 cm2 vs. 16.2 cm2; p = 0.001), whereas patients in the PEG plus SPP group were more likely to receive a single patch implant (100% vs. 53.8%; p < 0.001). The penile length increased in 18 patients (61.6%), with significant differences between the two groups (30% vs. 81.2%; p = 0.03). Overall, 14 patients (53.8%) reported greater satisfaction with their sexual life post-operatively, with comparable rates between the groups (p = 0.2). No significant differences were found in the post-operative 5-item version of the International Index of Erectile Function scores or severe post-operative ED (all p > 0.5). CONCLUSIONS: SPP placement during corporoplasty in patients with mild ED is safe and feasible, and it may be a suitable option for patients uncertain about inflatable prosthesis placement. The use of SPP resulted in longer penile lengths and necessitated smaller grafts. However, further data are required to understand the long-term clinical implications of this approach.

Sexual Function After Surgical Treatment for Benign Anorectal Disorders.

Benign anorectal diseases such as hemorrhoidal disease, anal fissure, anal pruritus, perianal abscess, and fistula are the most common ones. The aim of this study was to assess sexual function in patients after surgery for benign anorectal diseases. Sixty-one male patients with perianal fistulas, operated on at Department of General Surgery, Faculty of Medicine, completed a self-administered questionnaire including the International Index of Erectile Function (IIEF) score. The median IIEF score of the postoperative patients was significantly higher (24, range [10-25]) than that of preoperative patients (22, range [5-25]), p < .0001. Sexual function is significantly influenced by surgery for benign anorectal diseases.

Microscopic Electric Rotary Grinding of Plaques Combined with Graft Repair in the Management of Peyronie's Disease.

Peyronie's Disease (PD) is clinically characterized by the development of localized fibrous plaques, primarily on the tunica albuginea, especially on the dorsal area of the penis. These plaques are the hallmark feature of this condition, resulting in penile curvature, deformity, and painful erections for affected individuals. Although various nonsurgical treatment options exist, their overall effectiveness is limited. As a result, surgical intervention has become the ultimate choice for patients with severe penile curvature deformities and associated erectile dysfunction. Our research team has successfully employed a combined approach involving microscopic electric rotary grinding of the fibrous plaques and the use of tunica vaginalis or bovine pericardium as graft materials for the repairing of the defects of tunica albuginea in the treatment of PD. This approach has consistently yielded highly satisfactory results regarding the restoration of penile shape, with excellent cosmetic results and significantly improved sexual satisfaction. This protocol aims to present a comprehensive surgical management strategy utilizing electric rotary grinding of the plaques and repairing the defects of tunica albuginea by using the tunica vaginalis, which represents an optimal surgical strategy for treating PD.

Functional and oncologic outcomes of prostate capsule-sparing radical cystectomy: A systematic review and meta-analysis.

Radical cystectomy (RC) is the gold standard treatment for patients with organ-confined bladder cancer. However, despite the success of this treatment, many men who undergo orthotopic neobladder substitution develop significant erectile dysfunction and urinary symptoms, including daytime and nighttime urinary incontinence. Prostate-capsule-sparing radical cystectomy (PCS-RC) with orthotopic neobladder (ONB) has been described in the literature as a surgical technique to improve functional outcomes in appropriately selected patients. We performed a systematic review and meta-analysis of manuscripts on PCS-RC with ONB published after 2000. We included retrospective and prospective studies with more than 25 patients and compared PCS-RC with nerve-sparing or conventional RC. Studies in which the entire prostate was spared (including the transitional zone) were excluded. Comparative studies were analyzed to assess rates of daytime continence, nighttime continence, and satisfactory erectile function in patients undergoing PCS-RC compared with those undergoing conventional RC. Fourteen reports were included in the final review. Our data identify high rates of daytime (83%-97%) and nighttime continence (60%-80%) in patients undergoing PCS-RC with ONB. In comparative studies, meta-analysis results demonstrate no difference in daytime continence (RR:1.12; 95% CI: 0.72-1.73) in those undergoing PCS-RC compared to those undergoing conventional RC. Similarly, nighttime continence was similar between the 2 groups (RR:1.85; 95% CI: 0.57-6.00. Erectile function was improved in those undergoing PCS-RC (RR 5.35; 95% CI: 1.82-15.74) in the PCS-RC series. Bladder cancer margin positivity and recurrence rates were similar to those reported in the literature with conventional RC with an average weighted follow-up of 52.2 months. While several studies utilized different prostate cancer (CaP) screening techniques, the rates of CaP were low (incidence 0.02; 95% CI:0.01-0.04), and oncologic outcomes were similar to standard RC. PCS-RC is associated with improved nighttime continence and erectile function compared to conventional RC techniques. Further work is needed to standardize CaP screening before surgery, but the data suggest low rates of CaP with similar oncologic outcomes when compared to RC.

Urinary Symptoms Change and Quality of Life After Robotic Radical Prostatectomy: A Secondary Analysis of a Randomized Controlled Trial.

OBJECTIVE: To present the patient-reported quality of life (QoL) outcomes from a prospective, randomized controlled trial comparing the use of pelvic floor muscle training (PFMT) and duloxetine after robot-assisted radical prostatectomy (RARP). METHODS: We identified 213 men with organ-confined disease having post-RARP urinary incontinence who were randomly assigned to received PFMT, duloxetine, combined PFMT-duloxetine and pelvic floor muscle home exercises. Urinary symptoms burden was measured by marked clinical important difference improvement (MCID) defined by using the International Prostate Symptom Score (IPSS) difference of - 8 points (ΔIPSS ≤-8). QoL was assessed according to Visual Analog Scale (VAS), King's Health Questionnaire (KQH), and International Index of Erectile Function (IIEF-5). Multivariable regression analyses aimed to predict MCID, burden of urinary symptoms (IPSS ≥8), and patients reporting to be satisfied (IPSS QoL ≤2) or comfortable (VAS ≤1) post-RARP. RESULTS: Moderate to severe urinary symptoms decreased from 48% preoperatively to 40%, 34%, and 23% at 3, 6, and 12months post-RARP. After surgery, MCID improvement was observed in 19% of patients, and deterioration in 3.3%. Large prostate was the only factor associated to MCID (OR 1.03 [95%CI 1.01-1.05], P = .005). At 6months, patients reached the same degree of preoperative satisfaction. Neurovascular bundle preservation was the only predictor of being comfortable regarding urinary symptoms postoperatively (OR 12.8 [CI95% 1.47-111.7], P = .02 at 3months) and was also associated to higher median postoperative IIEF-5. CONCLUSION: Despite urinary incontinence following RARP, patients with larger prostates experience a reduction of lower urinary tract symptoms within a year, which subsequently elevates QoL. Furthermore, nerve-sparing surgery augments erectile function and urinary outcomes, shaping postoperative QoL.

Patient-reported prostate cancer treatment regret following primary partial gland cryoablation.

BACKGROUND: Prostate cancer treatment-related regret (TRR) incorporates the myriad effects of diagnosis and treatment with associated behavioral, emotional, and interpersonal changes within the context of patient values and expectations. We aimed to investigate TRR following primary partial gland cryoablation (PPGCA). METHODS: Men with prostate cancer undergoing PPGCA since 3/2017 enrolled in a prospective outcome registry. Between June and August 2022, a validated prostate cancer related TRR decision scale was distributed. TRR score ≥40 was considered significant TRR. Men were considered potent if they reported ability to have penetration at least half the time sexual intercourse was initiated. Associations between significant TRR and baseline characteristics and longitudinal outcomes were assessed using logistic regressions. RESULTS: Of 245 men who met inclusion criteria, 163 (67%) completed the survey with median time since cryoablation 2.3 years (IQR: 1.3, 3.6). Overall, the mean composite TRR score was 12.4/100. Significant TRR was expressed by 14% of men. Among those who were potent/had erectile function at baseline, loss of potency and erectile function were associated with higher probability of significant TRR, respectively. No associations were identified between TRR and recurrence of clinically significant prostate cancer or salvage treatment. CONCLUSIONS: The overwhelming majority of men do not express TRR following PPGCA. The loss of potency or development of erectile dysfunction predisposes to TRR. It is imperative to elucidate short-, intermediate- and long-term functional and oncological outcomes in order to define factors associated with TRR to improve counseling and reduce patient regret.

Low risk of erectile dysfunction after nontransecting bulbar urethroplasty for urethral stricture: a systematic review and meta-analysis.

BACKGROUND: Sexual function after urethroplasty may be a concern for patients, but there are still some controversies regarding the consequences of nontransecting bulbar urethroplasty (ntBU) in terms of erectile dysfunction (ED). AIM: This meta-analysis aimed to compare the efficacy and safety of ntBU with that of transecting bulbar urethroplasty (tBU). METHODS: The PubMed, Web of Science, Cochrane, and Embase databases were searched and reviewed up to October 31, 2022. Quality evaluation was performed using the Newcastle-Ottawa scale system and Cochrane tools for the nonrandomized and randomized studies, respectively. Baseline characteristics, preoperative information, and postoperative outcomes were collected. OUTCOMES: Outcomes included success rate, ED, overall complication, and maximum urinary flow. RESULTS: Thirteen studies comprising 1683 patients met the inclusion criteria, with 596 and 1087 patients undergoing ntBU and tBU, respectively. The results revealed that compared with the tBU group, the patients who underwent ntBU had a significantly lower incidence of ED, while there were no significant differences in the other perioperative outcomes. In subgroup analysis, the nontransecting anastomotic urethroplasty group had a lower incidence of ED than excision and primary anastomosis, and other perioperative outcomes were similar between the 2 groups. CLINICAL IMPLICATIONS: The results of the study may help clinicians choose procedures that protect sexual function in the treatment of urethral stricture. STRENGTHS AND LIMITATIONS: The strength of this study is that it is, to our knowledge, the first meta-analysis to evaluate the efficacy and safety of ntBU. A limitation is that most of the included studies were retrospective cohort studies. CONCLUSION: ntBU preserves the high efficacy of its transecting counterpart while reducing postoperative ED.

Patients' attitude with surgery for Peyronie's disease: results from a multicentric European study.

BACKGROUND: Despite the existence of conservative therapies for Peyronie's disease (PD), surgery is commonly utilized for the treatment of bothersome curvatures due to its potential effectiveness, although it carries intrinsic risks and may not universally lead to satisfactory outcomes. AIM: To explore the rate and factors influencing patients' willingness to undergo surgery for PD. METHODS: Data were prospectively collected in 5 European academic centers between 2016 and 2020. Data included age, time from PD onset, penile pain, curvature degree, difficulty at penetration, hourglass deformity, erectile dysfunction (ED), and previous treatments. All patients were offered conservative treatments, either medications or injections. Tunical shortening or lengthening procedures were offered as an alternative to conservative treatments, when indicated. Penile prosthesis was offered to those with concomitant ED. Patients' attitudes with surgery were recorded. Logistic regression analyses tested the profile of patients who were more likely to be willing to undergo surgery. OUTCOMES: Patients' willingness to undergo surgery for PD. RESULTS: This study included 343 patients with a median age of 57.3 years (IQR, 49.8-63.6) and a median penile curvature of 40.0° (IQR, 30.0°-65.0°). Overall, 161 (47%) experienced penetration difficulties and 134 (39%) reported ED. Additionally, hourglass deformity and penile shortening were reported by 48 (14%) and 157 (46%), respectively. As for previous treatments, 128 (37%) received tadalafil once daily; 54 (16%) and 44 (13%), intraplaque verapamil and collagenase injections; and 30 (9%), low-intensity shock wave therapy. Significant curvature reduction (≥20°) was observed in 69 (20%) cases. Only 126 (37%) patients were open to surgery for PD when suggested. At logistic regression analysis after adjusting for confounders, younger age (odds ratio [OR], 0.97; 95% CI, 0.95-1.00; P = .02), more severe curvatures (OR, 1.04; 95% CI, 1.03-1.06; P < .0001), and difficulty in penetration (OR, 1.88; 95% CI, 1.04-3.41; P = .03) were associated with a greater attitude to consider surgical treatment. CLINICAL IMPLICATIONS: The need for effective nonsurgical treatments for PD is crucial, as is comprehensive patient counseling regarding surgical risks and benefits, particularly to younger males with severe curvatures. STRENGTHS AND LIMITATIONS: Main limitations are the cross-sectional design and the potential neglect of confounding factors. CONCLUSIONS: Patients with PD, having a lower inclination toward surgery, emphasize the need for effective nonsurgical alternatives and accurate counseling on the risks and benefits of PD surgery, particularly for younger men with severe curvatures.

Evaluation of patient satisfaction using the validated French version of the SSIPI questionnaire after inflatable penile implantation.

BACKGROUND: Penile prothesis (PP) is a recommended treatment for erectile dysfunction that is refractory to less invasive treatments, but there are few validated tools to assess patient satisfaction. AIM: The aim of this study was to assess patient satisfaction after PP implantation using the French Satisfaction Survey for Inflatable Penile Implant (SSIPI) questionnaire. METHODS: Demographic, clinical, and perioperative data were collected from all consecutive patients who underwent PP implantation in our center between 2016 and 2021. The French SSIPI questionnaire was completed during a telephone call with each patient by an independent investigator. OUTCOMES: A good functional result was considered when the total SSIPI score was >48, corresponding to a score of >3 for each item. RESULTS: The median global SSIPI score for the cohort was 66 (interquartile range [IQR], 60-73), and 53 (89.8%) patients were satisfied. The appearance of the penis with the PP was the item that had the lowest score for satisfaction (median score 23 [IQR, 19-26]), while the patients reported almost no pain (median score 10 [IQR, 9-10]). When patients with a total score of ≤64 were compared with those with a score of >64, PP size was significantly greater in the group with better functional results (P = .03). CLINICAL IMPLICATIONS: Assessment of patient satisfaction with a PP is important because this is the main criterion used to judge the success of surgery. STRENGTHS AND LIMITATIONS: To our knowledge, this is the first study to evaluate the satisfaction of patients with a PP using the French-validated version of SSIPI questionnaire. However, patients came from a single center and the population size was small. CONCLUSION: Almost 90% of patients with a PP were satisfied with the device when satisfaction was assessed using the SSIPI questionnaire.

[PKEP with complete preservation of the urethral mucosa in the 11－1 o'clock position improves urinary continence and protects erectile function in BPH patients].

OBJECTIVE: To evaluate the effect of transurethral plasmakinetic enucleation of the prostate (PKEP) with complete preservation of the urethral mucosa in the 11－1 o'clock position on urinary continence and erectile function in BPH patients. METHODS: We retrospectively analyzed the clinical data on 84 cases of BPH treated by traditional PKEP (group A, n = 48) or modified PKEP with complete preservation of the urethral mucosa in the 11－1 o'clock position (group B, n = 36) from January 2017 to December 2021. All the patients had sexual activities within three months preoperatively. We followed up the patients for 12 months after surgery and compared the baseline, surgery-related and follow-up data between the two groups of patients. RESULTS: There were no statistically significant differences between the two groups of patients in age, disease duration, prostate volume, preoperative postvoid residual urine (PVR), preoperative maximum urinary flow rate (Qmax), IPSS, PSA level, QOL scores or IIEF-5 scores, nor in the operation time, intraoperative hemoglobin decrease, volume of resected tissue, bladder flushing time, postoperative hospital stay, or postoperative improvement of Qmax and IPSS. The rate of urinary continence was significantly higher in group B than in A at 1 month postoperatively (66.67% ï¼»24/36ï¼½ vs 43.25% ï¼»20/48ï¼½, P = 0.025) and so were IIEF-5 scores at 6 months (16.69 ± 3.21 vs 15.27 ± 2.74, P = 0.032) and 12 months (18.04 ± 2.04 vs 16.96 ± 2.54, P = 0.039), while the incidence rate of retrograde ejaculation markedly lower in the former than in the latter group at 6 months (33.33% ï¼»12/36ï¼½ vs 56.25% ï¼»28/48ï¼½, P = 0.018) and 12 months (25% ï¼»9/36ï¼½ vs 47.92% ï¼»23/48ï¼½, P = 0.027). At 1, 3, 6 and 12 months after surgery, the patients in group B also showed remarkably higher QOL scores than those in group B (2.61 ± 0.81 vs 2.12 ± 0.69, P = 0.005; 2.24 ± 0.66 vs 1.94 ± 0.51,P = 0.026; 2.12 ± 0.83 vs 1.80 ± 0.53,P = 0.047; and 1.94 ± 0.65 vs 1.72 ± 0.58, P = 0.038). CONCLUSION: Modified PKEP with complete preservation of the urethral mucosa in the 11－1 o'clock position can improve urinary continence, protect erectile function and ameliorate QOL in patients with BPH.

[Clinical effects of autologous split-thickness skin grafting for prefabricating urethra combined with scrotal flap in repairing middle urethral defect with penile defect].

Objective: To investigate the clinical effects of autologous split-thickness skin grafting for prefabricating urethra combined with scrotal flap in repairing middle urethral defect with penile defect. Methods: The retrospective observational study was conducted. Eight male patients (aged 14 to 58 years) with middle urethral defect and penile defect caused by various injuries who met the inclusion criteria were admitted to the First Affiliated Hospital of Air Force Medical University from January 2015 to January 2022. The length of urethral defect was 3 to 5 cm, and the wound area of penile defect after debridement was 5.0 cm×2.5 cm to 7.0 cm×5.5 cm. All the patients underwent autologous split-thickness skin grafting for prefabricating defect urethra in stage Ⅰ, and urethral anastomosis was performed and unilateral scrotal flap was transferred to reconstruct urethra and penis in stage Ⅱ. The area of scrotal flap was 6.0 cm×3.0 cm to 8.0 cm×6.0 cm. The wound in the donor area of skin graft was covered by oil gauze, and the wound of flap donor area was sutured directly. On the 7th day after the operation of stage Ⅱ, the survival of the flap was observed. In 3 weeks after the operation of stage Ⅱ, the urinary flow rate was measured by the urinary flow rate detector (urinary flow rate >15 mL/s was regarded as unobstructed urination), the urinary fistula and erectile function were observed, and the self-made therapeutic satisfaction questionnaire was used to investigate the therapeutic satisfaction degree of patients. During follow-up, the appearance of the flap recipient area was observed, the Vancouver scar scale (VSS) was used to evaluate the scar situation in the donor areas of skin graft and flap, the urinary flow rate was detected as before, the urethral stricture, urinary fistula, and erectile function were observed, and the therapeutic satisfaction degree of patients was investigated. Results: On the 7th day after the operation of stage Ⅱ, the flaps survived completely in 8 patients. In 3 weeks after the operation of stage Ⅱ, the urinary flow rate was 25.3 (18.0, 38.5) mL/s, with unobstructed urination, without urinary fistula and with erectile function, and the score of therapeutic satisfaction degree was 14.3 (14.0, 15.0). During follow-up of 1 to 7 years, the flap recipient area of 8 patients was full in appearance and not swollen, with similar color to the surrounding tissue; the VSS scores of the donor areas of skin graft and flap were 11.5 (10.0, 13.0) and 10.5 (9.3, 12.0), respectively, the urinary flow rate was 24.6 (17.7, 34.1) mL/s, with no urethral stricture, urinary fistula, and erectile dysfunction, and the score of therapeutic satisfaction degree was 13.5 (13.3, 14.8). Conclusions: Autologous split-thickness skin grafting for prefabricating urethra combined with scrotal flap in repairing the urethral and penile defects not only reconstructs the structure of urethra and the shape of penis, but also restores the sensation and erectile function of penis, with few postoperative complications, no obvious scar hyperplasia, and high satisfaction degree of patients, which is worthy of clinical promotion.

Maximizing outcomes in penile prosthetic surgery: exploring strategies to prevent and manage infectious and non-infectious complications.

Inflatable Penile Prostheses (IPP) implantation is a surgical treatment for patients desiring definitive treatment for erectile dysfunction. While this procedure has proven to be effective, it also carries its own set of unique risks that need to be carefully considered. The article reviews the current understanding of complications associated with penile prosthetic surgery and provides strategies to mitigate these adverse events. This article covers various aspects of IPP implantation, including the risks of infection, bleeding, injury to nearby structures, glans ischemia, and device malfunction. It also discusses the importance of careful preoperative screening to identify risk factors and the implementation of infection reduction strategies such as antimicrobial prophylaxis, skin prep, and operative techniques. In addition, it emphasizes the need for postoperative vigilance and prompt management of any complications that may arise. Overall, the article provides a comprehensive overview of the risks and strategies for mitigating complications associated with IPP implantation. Our recommendations are given based on the current consensus in the field and highlight the importance of careful planning, attention to detail, and effective communication between healthcare providers and patients. Despite the potential risks, this review underscores the fact that complications following penile prosthesis implantation are relatively rare.

Penile implants in low flow priapism.

Priapism is a persistent or prolonged erection, in the absence of sexual stimulation, that fails to subside. Prolonged ischaemic or low flow priapism is defined as a full or partial erection persisting for more than 4 h and unrelated to sexual interest or stimulation, characterised by little or no cavernous blood flow. Low flow priapism leads to progressive corporal fibrosis, which could, in turn, lead to long-lasting erectile dysfunction if left untreated. Penile prosthesis implantation is recognised as a management option in refractory and delayed low flow priapism for restoring erectile function with high patient satisfaction rates. However, the ensuing corporal fibrotic scarring poses a surgical challenge to clinicians, given the higher complication rates in this patient subset. Postoperative patient satisfaction has been closely linked to preoperative expectations and perceived loss of penile length. Therefore, thorough patient counselling concerning the risk and benefits of penile implants should be a priority for all clinicians. Moreover, there is a lack of consensus on the ideal prosthesis choice and procedural timing in refractory low flow priapism. In this review, we will examine the existing literature on penile implants in patients with priapism and discuss the options for managing complications associated with penile prosthesis surgery.

A narrative review on malleable and inflatable penile implants: choosing the right implant for the right patient.

A penile prosthesis/implant is an excellent option for men with erectile dysfunction refractory to medical treatment or with contraindications to medical management. In this narrative review, we discuss the different types of penile prostheses and the considerations for patient and device selection to maximize satisfaction. There are three main prosthesis types to choose from: three-piece inflatable devices, two-piece inflatable devices, and malleable/semirigid devices. The three-piece devices are the gold standard in advanced economy countries but require reservoir placement and manual dexterity, which can be limiting to some patients. The two-piece inflatable devices are a good option for patients who have standard-sized penises, lack significant penile pathology, have limited dexterity issues, or should avoid reservoir placement due to potential complications. The malleable devices are popular in countries where insurance coverage is limited but are increasingly used in advanced economy countries for length conservation in specific patient populations. Finally, not every patient needs an implant, and assessing partner sexual function is an important consideration for patient-partner satisfaction. Surgeons need to be familiar with the strengths and limitations of each device and the patient characteristics that will yield the best outcome from penile prosthesis surgery.

Suprapubic Lipectomy and Placement of a Three-piece Inflatable Penile Prosthesis.

BACKGROUND: Penile length loss is often observed in patients with erectile dysfunction and obesity. In patients with a prominent infrapubic fat pad, the excess fat can further reduce perceived penile length.1 As others have reported, concurrent suprapubic lipectomy and placement of a penile implant has been shown to be an effective way of exposing phallic length in this challenging patient population.2,3 OBJECTIVE: In this video, we present surgical technique and initial outcomes of concurrent suprapubic lipectomy and 3-piece inflatable penile prosthesis (IPP) placement in patients that have erectile dysfunction and lipodystrophy of the mons pubis. MATERIALS AND METHODS: We retrospectively reviewed an institutional review board-approved prosthetic database of male patients that underwent placement of a 3-piece IPP and concurrent suprapubic lipectomy from 2020 to 2023. Intraoperative complications and postoperative outcomes were collated and analyzed. To perform this operation, an elliptical incision is made around the suprapubic fat pad that extends to the base of the penis inferiorly. Laterally the incision is carried just medial to the inferior margin of the iliac crest. Sharp dissection and electrocautery are used to dissect the fat pad free. A layer of areolar tissue is preserved above the layer of the fascia to prevent seroma formation. For larger blood vessels, vascular clips are used to ensure adequate hemostasis. After removal of the fat pad, placement of the penile prosthesis can proceed as one would through an infrapubic approach. After the device is placed, the tissue flaps based on the external pudendal vessels are inspected for adequate vascularity. Penetrating towel clamps are used to approximate the skin edges from lateral to medial so that the midline closure can be approximated accurately. 0-PDS is used to anchor the flap superiorly into the lower edge of the abdominal fold. The incision is then closed in multiple layers of absorbable suture from lateral to medial. A skin stapler or suture is then used to approximate the skin and the penis is wrapped with a compressive dressing. RESULTS: Nine patients underwent the combined surgery. There were no intraoperative complications. In follow-up, 1 patient developed an infection-related complication that required device removal and immediate replacement. The remaining 8 did well postoperatively with improved dorsal phallic length with no infection or device-related complications. CONCLUSION: Concurrent suprapubic lipectomy and placement of a 3-piece IPP is a safe and reproducible technique for the treatment of suprapubic lipodystrophy, buried penis, and refractory ED.

Functional recovery of injured cavernous nerves achieved through endogenous nerve growth factor-containing bioactive fibrous membrane.

Radical prostatectomy is a highly successful treatment for prostate cancer, among the most prevalent manifestations of the illness. Damage of the cavernous nerve (CN) during prostatectomy is the main cause of postoperative erectile dysfunction (ED). In this study, the capability of a personalized bioactive fibrous membrane to regenerate injured CN was investigated. The fibrous membrane bioactivity is conferred by the selectively bound nerve growth factor (NGF) present in the rat urine. In a rat model of bilateral CN crush, the implanted bioactive fibrous membrane induces CN regeneration and restoration of erectile function, showing a significantly increased number of smooth muscle cells and content of endothelial and neuronal nitric oxide synthases (eNOS; nNOS). In addition, the bioactive fibrous membrane promotes nerve regeneration by increasing the number of myelinated axons and nNOS-positive cells, therefore reversing the CN fibrosis found in untreated rats or rats treated with a bare fibrous membrane. Therefore, this personalized regenerative strategy could overcome the recognized drawbacks of currently available treatments for CN injuries. It may constitute an effective treatment for prostate cancer patients suffering from ED after being subject to radical prostatectomy. STATEMENT OF SIGNIFICANCE: The present work introduces a unique strategy to address post-surgical ED resulting from CN injury during pelvic surgery (e.g., radical prostatectomy, radical cystoprostatectomy, abdominoperineal resection). It comprises a bioactive and cell-free fibrous implant, customized to enhance CN recovery. Pre-clinical results in a rat model of bilateral CN crush demonstrated that the bioactive fibrous implant can effectively heal injured CN, and restore penile structure and function. This implant selectively binds NGF from patient fluids (i.e. urine) due to its functionalized surface and high surface area. Moreover, its local implantation reduces adverse side effects. This tailored regenerative approach has the potential to revolutionize the treatment of ED in prostate cancer patients following radical prostatectomy, overcoming current treatment limitations.

Intermediate-term results of TachoSil grafting to correct residual curvature during inflatable penile prosthesis implantation in patients with Peyronie's disease.

Grafting techniques may be mandatory to improve residual penile curvature during inflatable penile prosthesis (IPP) implantation in Peyronie's disease patients. We aimed to report the intermediate-term outcomes of grafting with TachoSil (Corza Health, San Diego, USA) in patients with severe erectile dysfunction and concomitant complex Peyronie's disease through a prospective cohort study. We included 25 patients that underwent the PICS (penile implant in combination with Sealing) technique from 2017 to 2020 and were evaluated 24 months after surgery. Their mean age was 61.8 ± 8.7 years. Total straightness of the penis was achieved in 21 cases, while 4 (16%) patients presented a residual penile curvature of less than 15°. The mean penile length increased significantly (15 ± 1.2 to 16.4 ± 1.6 cm, p < 0.001). No intraoperative complications occurred, while, postoperatively, two patients developed fever and three scrotal hematoma, which resolved spontaneously. At three and six weeks, as well as at 24 months after surgery, no further complications occurred, and no cases of penile glans hyposensitivity were observed. At the 24-month follow-up evaluation, the 5-item score of the International Index of Erectile Function was 23.7 ± 1.4 (range: 20.5-25) and all patients responded positively to questions 2 and 3 of the sexual encounter profile questionnaire (p < 0.001 for all outcomes compared to baseline). Accordingly, the Erectile Dysfunction Inventory of Treatment Satisfaction score improved from 45.8 ± 6 at baseline to 25.6 ± 4.6 at 24 months, p < 0.001. Grafting with TachoSil to improve residual penile curvature during IPP is a safe and effective procedure. Nevertheless, careful patient selection and counseling, surgeon's experience with the technique, and strict postoperative penile rehabilitation are the main factors for treatment success and high satisfaction rates.