Could plaque excision surgery with sis graft induce a new fibrotic reaction in la Peyronie's disease patients?

OBJECTIVES: Peyronie's disease is an acquired disorder of tunica albuginea characterized by the formation of a fibrous plaque which may be associated with pain during erection, penile shortening and/or curvature, difficult vaginal penetration and erectile dysfunction. Severe deformity and/or intractable erectile dysfunction require surgical management. The plaque excision with grafting technique requires the complete excision of the fibrotic tissue and its replacement with an autologous or eterologous graft; among the latter, porcine small intestine submucosa graft is widely used. Nowadays, it is not known if the unsatisfactory results of this surgery caused by a fibrotic process are directly determined by the graft material. MATERIALS AND METHODS: A 50 year-old patient with a severe dorsal penile curvature (> 90 degrees) not allowing penetration, without erectile dysfunction underwent plaque excision surgery with porcine small intestine submucosa grafting. Soon after the surgical intervention a new and progressive penile shortening with a penile dorsal curvature and a erectile dysfunction appear, and thus, six months later, a new plaque excision surgery with saphenous vein graft and penile prosthesis implantation was performed. During the first intervention, plaque and peri-plaque tissue were excised and analyzed, whilst during the second intervention fibrotic tissue on the graft and tissue around it were excised and analyzed, too. RESULTS: In the tissues excised during the second intervention, fibrosis was present either in graft or in peri-graft tissue. Around the graft material, a gigantocellular reaction (foreing body-like) was present and ossification was present, too. DISCUSSION: This type of inflammatory cellular component is associated with foreign body reactions and was never described in Peyronie's disease. Our results suggest that plaque excision surgery with SIS graft could induce the formation of a new cicatritial plaque, not directly correlated to Peyronie's disease, causing the formation of a new plaque and a new penile curvature.

Microsurgical "testis-sparing" surgery for nonpalpable hypoechoic testicular lesions.

OBJECTIVES: With the increased use of trans-scrotal ultrasonography, the unexpected detection of nonpalpable hypoechoic testicular lesions has become more frequent. The different approaches vary from radical orchiectomy to simple ultrasound follow-up, but definitive guidelines do not yet exist about the management of these lesions. We report our series of patients with hypoechoic testicular lesions who underwent surgical exploration with the aid of an operating microscope. METHODS: A total of 7 patients were considered for microsurgical exploration of a nonpalpable hypoechoic testicular lesion from April 2003 to June 2005. The hospital records and ultrasound and operative reports were reviewed retrospectively. RESULTS: The side of the lesion was the left testis in 4 patients and the right testis in 3. The mean size of the hypoechoic area was 5.7 +/- 4.6 mm (range 2.5 to 16). The microsurgical technique allowed us to identify and successfully excise the lesion in all patients. Intraoperative frozen section examination revealed a benign lesion in 6 cases and testicular intraepithelial neoplasia in 1. The patient with testicular intraepithelial neoplasia underwent radical orchiectomy. The definitive histologic analysis always confirmed the frozen section examination report. The patients were evaluated clinically and by ultrasonography for a mean follow-up of 15 months. No complications occurred. CONCLUSIONS: Microsurgical exploration of the testis combined with frozen section examination represents a safe, effective, and reliable technique for evaluation of nonpalpable hypoechoic testicular lesions. This approach has significant advantages and should be considered in particular for patients with a solitary testis or presenting with bilateral lesions and wishing to father a child.

The Nesbit operation for penile curvature: an easy and effective technical modification.

PURPOSE: We report the results of an original technical modification to the Nesbit operation, designed to increase precision and simplify the correction of congenital or acquired penile curvature. MATERIALS AND METHODS: A total of 50 patients were considered candidates for surgical treatment of penile curvature and underwent a modified corporoplasty procedure involving plication suture on the convex aspect of the penis before tunica albuginea resection. Hospital records and followup data were retrospectively reviewed. RESULTS: A total of 32 patients had congenital penile curvature with a mean angle of 48 degrees (range 40 to 90) and difficult vaginal penetration. Another 18 patients had Peyronie's disease with penile deformity with a mean angle of 48 degrees (range 40 to 60) without hourglass deformity or hinge effects. All patients had spontaneous and full erections. Mean operative time +/- SD was 62 +/- 15 minutes. No intraoperative complications were recorded. In all cases penile curvature was completely corrected. Neither residual curvature nor hypercorrection were recorded. Regarding erectile function, which was evaluated in the Peyronie's disease group, preoperative average International Index of Erectile Function-5 score was 17.83 +/- 4.17, whereas postoperatively it was 19 +/- 4.63 (p = 0.036). Regarding overall satisfaction, 3 patients (6%) with Peyronie's disease were unsatisfied. CONCLUSIONS: Our modified corporoplasty procedure results in an improved straightening outcome due to the possibility of performing tunica albuginea excision only after the surgeon has made and verified the exact correction in real time. A slight but statistically significant improvement in erectile function was observed in patients with Peyronie's disease.