Shaeer's infrapubic technique for penile prosthesis implantation through a single midline corporotomy: A single-center pilot study.

BACKGROUND: With the infrapubic approach (IPA) for penile prosthesis implantation, lateral corporotomies carry the risk of injury to the laterally coursing dorsal nerves. AIM: We sought to describe for the first time Shaeer's IPA, a modification of the IPA whereby malleable penile prosthesis cylinders are implanted through a single midline corporotomy in the bed of the deep dorsal vein, anatomically off the course of the dorsal nerves of the penis. METHODS: We compared semirigid penile prosthesis implantation via the single midline corporotomy IPA (IPA-S, n = 11) to the classic IPA with laterally placed dual corporotomies (IPA-D, n = 11) and to the penoscrotal approach (PSA; n = 13). Shaeer's IPA is performed through an infrapubic incision. A 3- to 5-cm length of the deep dorsal vein is stripped. A single 3- to 5-cm midline corporotomy is cut along the bed of the vein. Dilation, sizing, and implantation are performed through the single corporotomy on either side of the midline septum. Patients are discharged the same day and are allowed to bend the implant after 2 weeks and to commence intercourse after 3 weeks. OUTCOMES: Operative time, postoperative satisfaction, International Index of Erectile Function 5 (IIEF-5), and possible complications were recorded. RESULTS: There were no statistically significant differences in age, postimplantation IIEF-5, or satisfaction between the 3 groups. Average operative time for the IPA-S group was 21.8% shorter than that for the IPA-D group, and 34.5% shorter than for the PSA group. Those differences were statistically significant. No complications were recorded in the IPA-S group. Infection occurred in 1 PSA case, and partial hypoesthesia in 1 IPA-D case. CLINICAL IMPLICATIONS: The midline corporotomy confers an anatomical advantage that may help avoid nerve injury, thereby increasing the safety of the IPA. STRENGTHS AND LIMITATIONS: The main limitation of this study is the limited sample number, considering that this is a pilot study. CONCLUSION: The Shaeer's Midline-Corporotomy IPA is a minimally invasive technique for implantation of a semirigid penile prosthesis, with an anatomical advantage that may decrease the possibility of dorsal nerve injury.

Shaeer's corporal rotation IV: length-preserving correction of congenital ventral penile curvature.

BACKGROUND: For cases with severe penile curvature, the loss in length with shortening techniques or the loss in rigidity with incision grafting can compromise the results, hence the advent of Shaeer's corporal rotation III technique, which corrects the most severe degrees of ventral penile curvature without loss in length, though with a certain degree of narrowing. AIM: We sought to describe Shaeer's corporal rotation IV, aiming at correction of moderate-to-severe ventral penile curvature with minimal shortening, minimal narrowing, and minimal mobilization of the neurovascular bundle, among other improvements such as using thicker suture material to decease recurrence while inverting the surgical knots. METHODS: Forty-two patients with congenital ventral penile curvature were selected for the study with a curve ranging from 60° to 90°. Patients were randomized into 1 of the 2 groups: Shaeer's corporal rotation III (SCR-III) and SCR-IV. In SCR-IV, rotation is used to correct the main brunt of curvature, up to 70% to 80% of the curve. Plication is used to correct the residual curvature up to 100% straightness. This keeps the rotation points fewer and closer to the midline, thereby minimizing narrowing and mobilization of the neurovascular bundle. OUTCOMES: Both groups were compared with regard to intraoperative erection angle, length, and girth, before and after rotation, as well as subjectively reported postoperative recurrence, penile sensitivity, satisfaction, and IIEF. RESULTS: The postcorrection angle was zero for all cases in the 2 groups. Dorsal length decreased by 3% in the SCR-IV group compared with 0.5% in the SCR-III group (2.5% difference). The difference in circumference between the narrowest and widest points was 2% in the SCR-IV group vs 9.3% in the SCR-III group (7.3% difference). The average operative time was 19.2% shorter with SCR-IV. Girth asymmetry was reported in 1 (4.8%) of 21 patients in the SCR-IV group compared with 15 (71.4%) of 21 in the SCR-III group. Partial hyposensitivity of the penis was reported in 9.5% in the SCR-IV group compared with 19% in the SCR-III group. CLINICAL IMPLICATIONS: SCR-IV is an improvement over former versions of the technique, with higher patient satisfaction. STRENGTHS AND LIMITATIONS: A strength of the study is the long follow-up period. Limitations include being a single-center study and reliance on patient reporting to evaluate recurrence and satisfaction. CONCLUSION: The SCR-IV technique corrects moderate and severe degrees of congenital ventral penile curvature, with little or no compromise in penile length, girth, or sensitivity.

Effect of vas ligation on testicular sperm extraction results in nonobstructive azoospermic rats: Shaeer's lock-in technique.

This study evaluates the efficacy of vas ligation in enhancing sperm retrieval in nonobstructive azoospermia cases, by accumulating intratesticular spermatozoa. Fifty-six mature male rats with equally sized testes were included in this study. Forty-six were in the study group, and 10 were in the control group. Bilateral testicular fine needle aspiration was performed for all, to confirm presence of spermatozoa in all testes. Nonobstructive azoospermia was induced in all 56 rats, using Dienogest (40 mg/kg) + Testosterone Undecanoate (25 mg/kg) every month for three months. Monthly aspirations confirmed nonobstructive azoospermia from all rats, within the three months treatment. This was followed by unilateral vas ligation and was performed for 46 rats of the study group, with no ligation performed in the control group. After a further period of 90 days (2 spermatogenic cycles) with the same medical treatment maintained, bilateral testicular sperm extraction was performed. Sperm retrieval was evaluated, comparing the outcome of vas-ligated testicles to the nonligated. Upon evaluation, spermatozoa were found in 14/46 of the vas-ligated testes (30.4%), compared to none of the nonligated (0/66), p = .0005. Ligation of the vas deferens in rats with nonobstructive azoospermia may enhance the results of sperm retrieval via sperm accumulation.

Shaeer's Punch Technique: Transcorporeal Peyronie's Plaque Surgery and Penile Prosthesis Implantation.

BACKGROUND: Penile prosthesis implantation in cases of severe Peyronie's disease may require plaque excision/incision and grafting, which may require mobilization of the neurovascular bundle or urethra, posing the risks of penile hyposensitivity or urethral injury, and is time-consuming, possibly increasing infection risk. AIM: Evaluating transcorporeal debulking of Peyronie's plaques by "Shaeer's punch technique." METHODS: Penile prosthesis implantation and punch technique (PPI-Punch) was performed for 26 patients. After corporotomy and dilatation, Peyronie's plaques were punched out from within the corpora cavernosa using the punch forceps, and then a penile prosthesis was implanted. Comparison to a matching retrospective group of 18 patients operated upon by plaque excision-grafting and penile prosthesis implantation was performed. OUTCOMES: The study outcomes were straightness of the erect penis, complication, satisfaction with length on a 5-point scale, the International Index of Erectile Function-5, and the Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire. RESULTS: Average preoperative curvature angle was 58.1 ± 11.7 in the Punch group and 58 ± 14.8 in the excision-grafting group, p=0.99. After surgery, all patients had a straight penis. No tunical perforations, urethral injuries, or extrusions were noted. Average additional operative time for Punch technique ranged from 5 to 10 minutes (7.3 ± 1.7), in contrast to the excision-grafting group where plaque surgery duration was 50.8 minutes ± 11.1, an 85% difference, p < 0.0001. Septal plaques in the latter group could not be removed. In the PPI-Punch group, penile sensitivity was preserved in all patients, compared with the excision/grafting group, with 7 of 18 patients reporting hyposthesia of the glans. Infection occurred in 1 of 26 patients in the PPI-Punch group, compared with 2 of 18 patients in the excision/grafting group. Satisfaction with length on a 5-point scale was 3.8 ± 0.9 in the punch group, versus 3.1 ± 1.1 in the excision-grafting group, p=0.009. CLINICAL IMPLICATIONS: The proposed technique is minimally invasive and prompt, possibly decreasing the known complications of plaque surgery and PPI including sensory loss. STRENGTHS & LIMITATIONS: One limitation is the inability to accurately measure preoperative erect length in patients with erectile dysfunction with poor response to intracavernous injections. CONCLUSION: Shaeer's punch technique is a minimally invasive procedure for transcorporeal excavation of Peyronie's plaques before penile prosthesis implantation, omitting the need for mobilization of the neurovascular bundle or spongiosum, and hence, there is low or no risk for nerve or urethral injury and brief plaque surgery time. Shaeer O, Soliman Abdelrahman IF, Mansour M, et al. Shaeer's Punch Technique: Transcorporeal Peyronie's Plaque Surgery and Penile Prosthesis Implantation. J Sex Med 2020;17:1395-1399.

Female Orgasm and Overall Sexual Function and Habits: A Descriptive Study of a Cohort of U.S. Women.

INTRODUCTION: Few studies have investigated women's experiences with orgasm and the factors that they cite as important for their orgasmic function and sexual behavior related to foreplay and sexual stimulation. AIM: To investigate and describe overall sexual function in a cohort of North American women, with a special focus on orgasmic function, satisfaction, triggers, risk factors, and sexual behavior. METHODS: A total of 303 women aged 18-75 years completed a 100-questionnaire survey, which included the Female Sexual Function Index (FSFI) questionnaire and questions on orgasmic function, duration of sexual activity, sexual behaviors and relationship, and the partner's sexual function. Statistical analysis was performed using SPSS to illuminate factors affecting sexual function. OUTCOMES: The main outcome measures are FSFI score, satisfaction with sexual life, ability to reach orgasm, orgasm frequency, preferred sexual stimulation, and sexual habits. RESULTS: FSFI scores, which were calculated for the 230 women who reported having had a steady male sex partner in the preceding 6 months, showed that 41% of the 230 women were at risk for female sexual dysfunction (a cutoff less than 26.55) and 21% were dissatisfied with their overall sexual life. Almost 90% of the overall cohort reported good emotional contact with their partner, that their partner was willing to have sex, satisfaction with the partner's penis size (wherever applicable), and good erectile function and ejaculatory control of their partner (wherever applicable). 81% of the overall cohort claimed to be sexually active. Around 70% (70-72) did reach orgasm frequently, but around 10% never did so. Vaginal intercourse was reported by 62% of the overall cohort as the best trigger of orgasm, followed by external stimulation from the partner (48%) or themselves (37%). External stimulation was reported to be the fastest trigger to orgasm. CLINICAL IMPLICATIONS: The knowledge on how women reach orgasm and how it is related to the partners' willingness to have sex and other factors can be incorporated in the clinical work. STRENGTHS & LIMITATIONS: The use of a validated questionnaire and the relative large number of participants are strengths of the study. Limitations are the cross-sectional design, the lack of a sexual distress measure, and a possible selection bias. CONCLUSION: Most women in the overall cohort were satisfied overall with their sexual life and partner-related factors, even though 41% (of those who cited a steady sex male partner) were at risk for female sexual dysfunction. Most women did reach orgasm through different kinds of stimulation. Correlation was good between preferred and performed sexual activities and positions. Shaeer O, Skakke D, Giraldi A, et al. Female Orgasm and Overall Sexual Function and Habits: A Descriptive Study of a Cohort of U.S. Women. J Sex Med 2020;17:1133-1143.

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. AIM: We propose that, on salvage, the infected prosthesis be explanted, the capsule washed out and then abandoned, and the replacement prosthesis implanted in the extracapsular sinusoidal space, between the capsule and tunica albuginea. This aims at decreasing contact between the replacement implant and the pyogenic membrane in the capsule. METHODS: This study was performed in a tertiary implantation center, involving 20 prospective cases referred with either an infected implant or pump erosion. Through a penoscrotal incision, lateral corporotomies were performed by superficial cuts, in a trial to identify the extracapsular sinusoidal space before opening the capsule. The capsule was then opened. All components of the implant were explanted, and the capsules were washed out. The extracapsular space within the corpora cavernosa was developed between the capsule and the tunica albuginea by sharp dissection initially, then bluntly dilated with a Hegar dilator. A malleable penile prosthesis was implanted in the extracapsular space bilaterally. MAIN OUTCOME MEASURES: The reinfection rate was evaluated though 7-38 months after surgery. RESULTS: We were able to identify and dilate the extracapsular space in 18 of 20 cases. Reinfection occurred in 1 case (1 of 18, 5.6%). Development of the extracapsular space added approximately 10 minutes to the operative time. CLINICAL IMPLICATION: If salvage of an infected penile implant can be delayed until capsule maturation, extracapsular implantation may decrease the reinfection rate. STRENGTH & LIMITATIONS: The limitations are the lack of a control group of intra-capsular classic salvage and the relatively limited sample number. CONCLUSION: On penile prosthesis salvage surgery, whether for infection or extrusion, implantation of the replacement prosthesis in the extracapsular sinusoidal tissue is associated with low infection rates, because it bypasses the capsule, which may still harbor bacterial contamination despite the wash-out. Shaeer O, Shaeer K, AbdelRahman IFS. Salvage and Extracapsular Implantation for Penile Prosthesis Infection or Extrusion. J Sex Med 2019;16:755-759.

Extracorporeal Transseptal Penile Prosthesis Implantation for Extreme Cases of Corporeal Fibrosis: Shaeer Implantation Technique.

BACKGROUND: Penile prosthesis implantation into scarred corporeal bodies is one of the most challenging procedures in prosthetic urologic surgery, especially following infection and extrusion of a penile implant. Several instruments and techniques have been used for making dilatation of scarred corporeal bodies easier and safer in expert hands. Nevertheless, in some cases, implantation is not possible. AIM: This work presents extracorporeal transseptal implantation as a last resort in such cases. METHODS: In 39 patients with extensive corporeal fibrosis, penile prosthesis implantation is attempted. After failure of alternative techniques, extracorporeal implantation is resorted to in 10 patients. The corpus spongiosum is identified and protected. Diathermy knife is used to cut a longitudinal window into 1 corpus cavernosum, through the septum and into the contralateral corpus cavernosum. A single semirigid implant rod is inserted through the window at the base of the penis, halfway through. The 2 limbs of the rod are bent upward toward the glans, to assume a U shape. The limbs of the U are brought together at midshaft by a gathering suture passed through the corpora cavernosa and septum. The tips of the U are anchored under the glans. OUTCOMES: Achievement of acceptable coital relationship. RESULTS: The procedure allowed acceptable coital relationship and concealment in 9/10 cases. In 1 case, infection occurred. Reimplantation with the same method was performed 6 months later, and the implant survived adequately. Perforation, migration, and urethral injury were not encountered. CLINICAL IMPLICATIONS: This technique may help salvage abandoned cases with corporal fibrosis, particularly when the necessary expertise for alternative techniques is unavailable or when such techniques fail. STRENGTHS & LIMITATIONS: The technique presented is fairly straightforward and safe. However, the number of cases and duration of follow-up are limited. CONCLUSION: Extracorporeal transseptal penile prosthesis implantation can salvage cases with severe corporeal fibrosis when all alternatives fail. Shaeer O, Shaeer K. Extracorporeal Transseptal Penile Prosthesis Implantation for Extreme Cases of Corporeal Fibrosis: Shaeer Implantation Technique. J Sex Med 2018;15:1350-1356.

Simultaneous Suprapubic Lipectomy and Penile Prosthesis Implantation.

INTRODUCTION: A shorter penis is a frequent complaint following penile prosthesis implantation (PPI), and a large redundant suprapubic fat pad can conceal the penis and possibly compromise patient and partner satisfaction with length. AIM: To evaluate feasibility and outcome of same-session, same-incision, PPI and suprapubic lipectomy (SPL). METHODS: In 22 patients, SPL was performed through an abdominal crease incision. Through the same incision, the superficial perineal pouch was opened to gain access to the base of the penis. Penile prosthesis was implanted (semirigid in 16 patients and girth-expanding 3-piece inflatable in 6). Scarpa's fascia, subcutaneous fat, and the abdominal crease skin incision were closed. MAIN OUTCOME MEASURE: Evaluation was in terms of implant survival, preoperative vs postoperative patient and partner satisfaction with penile length on a 5-point rating scale, subjective opinion over penile length postoperatively, compared with recall of erect length before erectile dysfunction (ED) had set in (longer, same, or shorter), and penile length with the implant rigid, compared in the supine and standing positions postoperatively (pubic skin to tip, using a rigid ruler). RESULTS: No infections or extrusions or mechanical failures were encountered. There was a 53.3% increase in patient satisfaction with length comparing preoperative (2.55 ± 0.67) to postoperative (4.77 ± 0.43) ratings, P < .0001. Partner satisfaction showed a 40.2% increase, from 1.77 ± 0.61 to 4.41 ± 0.50, P < .0001. 19 of 22 patients reported that postoperative length was longer than their recall of erect length before ED had set in, and 3 patients reported that length was the same. With the implant rigid, there was no statistically significant difference in visible length between the supine and standing positions (14.1 cm ± 2.3 and 13.9 cm ± 2.3, respectively, P = .38). CLINICAL IMPLICATIONS: Patients with refractory ED and a concealed penis can be counseled as to the option of simultaneous SPL and PPI (SPL-PPI), a modification that may help avoid patient and partner dissatisfaction with length. STRENGTH & LIMITATIONS: Strengths include objective evaluation of the efficacy of the procedure by comparing supine and standing penile length. Limitations of the current study include inability to evaluate erect length preoperatively owing to refractory ED, and subjectivity of patient and partner opinion. CONCLUSION: Same-incision SPL-PPI appears to be a safe and effective procedure, with high patient and partner satisfaction rates. Shaeer O, Shaeer K, Abdel Rahman IF. Simultaneous suprapubic lipectomy and penile prosthesis implantation. J Sex Med 2018;15:1818-1823.

Priapism as a result of chronic myeloid leukemia: case report, pathology, and review of the literature.

INTRODUCTION: Priapism is rare-presenting feature in male patients with chronic myeloid leukemia (CML). Several hypotheses for pathogenesis have been described. Management has been controversial; some authors described resolution following priapism-specific interventions, and others recommended addition of CML-specific therapy or even CML-specific therapy alone. AIM: In this report, we describe presentation and management of a man with refractory priapism that was the first presenting manifestation of CML. We also report, for the first time, the pathology sections of the sinusoidal tissue in such cases. Literature is reviewed for similar cases and their outcome. METHODS: A 21-year-old male patient presented with painful priapism that started 6 days earlier and failed aspiration-irrigation. CBC revealed marked leucocytosis. Oncology care diagnosed CML, and treatment with Imatinib was commenced with prior semen cryopreservation. Following remission, a penile prosthesis was implanted, assisted by optical corporotomy. Sinusoidal tissue biopsy was stained by hematoxylin/eosin (H&E) and CD34. MAIN OUTCOME MEASURES: Pathology sections of cavernous tissue following CML-induced priapism. RESULTS: The penile implant survived without complications. H&E examination of the sinusoidal tissue biopsy revealed leukemic infiltration associated with vascular endothelial damage. CD34 staining showed the mixed picture of leukemic infiltrates, intact vascular endothelium with lumena showing leukemic cells, alternating with destroyed vessels, and no vascular lumena and ruminants of endothelial cells. CONCLUSION: Priapism can be the first manifestation of previously undetected CML. The pathological picture of sinusoidal tissue in such cases is presented. In the case at hand, a complete blood picture was helpful in early diagnosis of CML and early initiation of targeted chemotherapy along with the corporal irrigation/aspiration or shunt surgery. It is therefore recommended to have a CBC examined at presentation of any case of ischemic priapism of unknown etiology, early initiation of CML therapy along with aspiration/irrigation, preferably cryopreserving a semen sample before CML therapy.

Same-session dorsal vein ligation and testing by intracavernous injection prior to penile prosthesis implantation (DVL-ICI-PPI).

INTRODUCTION: Complications of penile prosthesis implantation (PPI) are rare, nevertheless can be grave. In cases with veno-occlusive dysfunction (VOD), alternative surgical techniques such as dorsal vein ligation (DVL) are controversial. Some patients may opt for trial at DVL to avoid the possible complications of PPI. However, this may be associated with disappointment if DVL fails and another procedure is required. AIM: The aim if this study is to evaluate the results of a combined approach involving DVL, same-session testing by intracavernous injection (ICI) of prostaglandin E1 (PGE1), and immediate implantation of a penile prosthesis (PPI) in case of poor response to DVL. MAIN OUTCOME MEASURES: Long-term erectile function in cases with favorable intraoperative response to DVL. METHODS: Twenty-six patients with refractory VOD were operated upon. Through a peno-pubic incision, DVL was performed, followed by ICI of 20 µg PGE1 in two divided doses, 10 µg each, 15 minutes apart. Group 1 exhibited full rigidity in response to the first dose. Group 2 exhibited full rigidity in response to the second dose. PPI was not performed for either. Group 3 exhibited suboptimal response to both doses, and PPI was performed through the same incision. Patients were followed up from 24 to 48 months using International Index of Erectile Function-5 scoring. RESULTS: For Group 1 (n = 8), six patients experienced normal erectile function following DVL throughout the whole follow-up period of 48 months (23.1% of all patients), and two patients relapsed. Group 2 (n = 6) (23.1%) reported normal erectile function for an average of 6 months, then relapsed. Group 3 (n = 12) had a penile prosthesis implanted in the same setting. CONCLUSION: Combined DVL-ICI-PPI can spare around 23.1% of young patients with VOD from PPI, at no additional risk. Full response to 10 µg PGE1 at intraoperative testing carries good prognosis to DVL on the long run. Investigation of a larger number of patients is necessary before reaching a final conclusion.

The Global Online Sexuality Survey (GOSS): male homosexuality among Arabic-speaking internet users in the Middle East--2010.

INTRODUCTION: The prevalence of male homosexuality is difficult to elicit considering the sensitivity of one's sexual orientation. The Global Online Sexuality Survey (GOSS) is an online epidemiologic study of male and female sexuality. The online nature of GOSS allows more confidentiality and wider geographic reach, particularly important in investigating sexual issues within the more conservative societies. AIM: This study aims to determine the prevalence of male homosexuality among Internet users in the Arabic-speaking Middle East and the unique characteristics of this subset of the population. MAIN OUTCOME MEASURES: Prevalence of male homosexuality. METHODS: In the year 2010, GOSS was offered to Arabic-speaking web surfers above 18 years of age in the Middle East. Potential participants were invited via advertising on Facebook®. Invitations were dispatched randomly with the exception of geographic region and age, regardless web surfing preferences. GOSS relied in part on validated questionnaires such as the International Index of Erectile Function, as well on other nonvalidated questions. RESULTS: 17.1% reported desire toward the same sex, of whom 5.6% had homosexual encounters, mostly in the form of external stimulation rather than intercourse, and exclusively undercover. An overwhelming majority was ego-dystonic (78.2%). CONCLUSION: This is--to our knowledge--the first online survey to address the prevalence of homosexual orientation and practice in the Middle East, discriminating desire from practice, ego-syntonic from ego-dystonic, and investigating the pattern of practice. Homosexual desire is present in the Middle East as it is around the world, and homosexual encounters are as prevalent. Yet, the undercover and ego-dystonic states prevail.

Sub-gluteal ligation of the internal pudendal vein for management of veno-occlusive erectile dysfunction (Shaeer's Vein Ligation-I): the cadaveric study.

Vein ligation for veno-occlusive erectile dysfunction is being abandoned due to the recurrence rate. Among the reasons for failure is inability to ligate the deep system of veins; the internal pudendal vein. The vein exits the pelvis in the gluteal region, from the lesser sciatic foramen to the greater sciatic foramen, coursing over the ischial spine and sacro-spinous ligament, under the gluteus maximus. This work aims to verify feasibility of the first surgical procedure to ligate the internal pudendal vein through the gluteal approach. This cadaveric study involved five formalin-fixed cadavers. A surface anatomical landmark was designed to identify the ischial spine, at the intersection of two lines: a vertical line from posterior superior iliac spine to ischial tuberosity, and a horizontal line extending from sacro-coccygeal joint, laterally. An incision is cut encompassing the target point. Subcutaneous fat is dissected down to the gluteus maximus, which is split along the direction of its fibers. The vein can be found crossing over the ischial spine. "Shaeer's Vein Ligation - I" appears to be surgically feasible. A protocol for a surgical study is registered at clinicaltrials.gov, and is open for participation.

Shaeer's Cavernotome for Penile Prosthesis Implantation in Scarred Corpora Cavernosa.

OBJECTIVE: Penile prosthesis implantation in scarred corporal bodies is one of the most challenging urologic procedures, with high risks of perforation and/or failure. We present Shaeer's Cavernotome (patent application number PCT/EG2021/050003). This is the forward-cutting cavernotome that relies on the principle of controlled coring and grinding rather than forward stabbing, with fibrous tissue accommodated into the hollow core, thereby ensuring high efficacy and low risk of perforation. MATERIALS AND METHODS: This is a prospective study involving 18 patients with severe corporal scarring. Surgery is performed through a peno-scrotal incision with an indwelling urethral catheter. Corporotomies are incised and a 2-cm-long core of fibrous tissue is excised with a scalpel. Shaeer's Cavernotome is introduced and lodged against the fibrous tissue. Coring proceeds with the stretched corpus or crus held between the thumb and index fingers of the non-dominant hand as a guide, ahead of the tip. Shaeer's cavernotome doubles as a sizer. Following coring, penile prosthesis implantation proceeds. RESULTS: Dilation of the corpora cavernosa was successful in 17 out of 18 patients. Average coring time was 8 ± 3.2 minutes. Dilation was up to girth 13 Hegar in 12 patients, and 11 in 5. No perforations or infections were encountered. CONCLUSION: Shaeer's cavernotome facilitates penile prosthesis implantation in scarred corporal bodies. Full excavation of both corpora cavernosa is achievable in less than 10 minutes, with a low risk for perforation.

The Global Online Sexuality Survey (GOSS): the United States of America in 2011. Chapter I: erectile dysfunction among English-speakers.

INTRODUCTION: The Global Online Sexuality Survey (GOSS) is a worldwide epidemiologic study of sexuality and sexual disorders, based on validated questionnaires and applying age adjustment to the World Standard Population (WSP) by the World Health Organization. In 2010, the first report of GOSS came from the Middle East, describing an erectile dysfunction (ED) prevalence rate of 47%. AIM: This report studies the prevalence rate of ED in the United States as of 2011-2012 and evaluates risk factors for ED. MAIN OUTCOME MEASURES: Prevalence of ED. METHODS: GOSS was randomly deployed to English-speaking male web surfers in the United States via paid advertising on Facebook, comprising 146 questions including the abbreviated 5-item International Index of Erectile Function. RESULTS: Two thousand twenty-two males participated; with a mean age was 52.38 years ± 14.5. Prevalence of ED was 37.7%, adjusted to 33.7% according to WSP, comparable across ethnic groups. The following risk factors were associated with higher risk for ED: diabetes mellitus, hypertension with and without antihypertensive treatment, coronary heart disease, obesity (defined by body mass index), difficult micturition, subjectively reported depression, interpersonal distress, subjectively reported impotence, in addition to novel factors such as subjectively reported premature ejaculation (PE) and concerns over genital size (not a smaller penis per se), low libido, and irregular coitus. Frequency of smoking and alcohol were not associated with higher prevalence of ED, although duration of smoking was. CONCLUSION: Adjusted to WSP, prevalence rate of ED in the United States of America is 33.7% in the year 2011, in contrast to the adjusted prevalence in the Middle East (47%). Most of the classical risk factors for ED play the same role in the United States and the World, including diabetes, hypertension, and aging. Concerns over genital size and PE are emerging risk factors for ED.

The Global Online Sexuality Survey (GOSS): ejaculatory function, penile anatomy, and contraceptive usage among Arabic-speaking Internet users in the Middle East.

INTRODUCTION: Sexuality is a sensitive issue that may be difficult to explore through surveys involving direct contact. Epidemiological studies in this domain are scarce. Online surveys may provide more anonymity and less direct contact encouraging participation. The Global Online Sexuality Survey (GOSS) reports on different aspects of male and female sexuality. The Global Online Sexuality Survey-Arabic-Males (GOSS-AR-M) is the Arabic version reporting on male sexuality. AIM: To evaluate male ejaculatory function, penile size and contraceptive trends among Arabic speakers in the Middle East. METHODS: The survey was randomly offered online to web surfers in the Middle East. MAIN OUTCOME MEASURES: Prevalence of premature ejaculation, ejaculatory latency, penile size and their correlation with erectile function. RESULTS: A total of 82.6% reported various degrees of premature ejaculation, associated with a statically significant decline in erectile function, despite a median intravaginal ejaculatory latency time (IELT) of 5 minutes, 95% confidence interval (CI) of 8.4-9.8. Adjusted to the World Standard Population by the World Health Organization, the collective prevalence was 83.7%. Local anesthetics gave better results and tolerance in delaying ejaculation. Self-measured erect penile length from symphysis pubis to glans was 15.6 cm ± 4.1, 95% CI = 15.4-15.9, yet, 30% were dissatisfied with size, mainly in the flaccid state, with dissatisfaction being inversely proportional with erectile function. Intrauterine device was the method mostly used by couples, and condoms had a high dissatisfaction rate. CONCLUSION: The prevalence of premature ejaculation appears to surpass that of erectile dysfunction, despite the possibility that it may be overreported considering the acceptable IELT of the population surveyed. Premature ejaculation and concerns over genital size may be considered as risk factors for ED. More male contraceptive measures should be introduced and popularized. Alleviating dissatisfaction with condom utility via health education should be a priority.

The Global Online Sexuality Survey (GOSS): female sexual dysfunction among Internet users in the reproductive age group in the Middle East.

INTRODUCTION: The exact prevalence of female sexual dysfunction (FSD) in the Middle East is exceptionally difficult to measure in light of its sensitive nature and the conservative tinge of the population. AIM: The Global Online Sexuality Survey-Arabic-Females (GOSS-AR-F) is a community-based study of female sexuality in the Middle East through an online survey. MAIN OUTCOME MEASURES: Prevalence of risk for female sexual dysfunction (rFSD) in the reproductive age group and its vulnerability to various risk factors. METHODS: GOSS-AR-F was offered via online advertising. The survey is comprised of the Female Sexual Function Index (FSFI) questionnaire among other questions. RESULTS: Out of 2,920 participants, 344 participants completed all survey questions. Average total FSFI score was 23 ± 6.5, with 59.1% of participants suffering rFSD. Age adjusted prevalence of rFSD was 59.5%, standardized to World Health Organization World Standard Population. There was a statistically significant higher prevalence of rFSD among cases with subjectively reported depression and male partner-related shortcomings such as erectile dysfunction and premature ejaculation as reported by the female participant, in addition to dissatisfaction with partner's penile size, insufficient foreplay, and practice of masturbation. This was not the case with advancing age, diabetes mellitus, hypertension, smoking, ongoing pregnancy, mode of previous child delivery, infertility, menstrual irregularities, dysmenorrhea, interpersonal distress, subjectively reported hirsutism, and female genital cutting. Participants were found to require longer duration of coitus and better ejaculatory control but not necessarily a higher coital frequency. CONCLUSION: Female sexual function in the reproductive age appears to be adversely affected by psychological factors and shortcomings in male sexual function more than anything. These findings point to the possibility that many cases of FSD can be managed with the focus on male partner's ailments and attitudes that are relatively easier to manage.

Impact of penile size on male sexual function and role of penile augmentation surgery.

Penile augmentation is an ongoing debate. Emerging evidence proves a relationship between dissatisfaction with penile size and sexual dysfunction. Despite a widespread belief of the value of penile size, and the prevalent complaint of a "small penis," penile augmentation still stands short of addressing the demand. This report highlights the studies added to medical literature on penile augmentation in 2011-2012, including data on normal penile dimensions and the expected dimensions for a normal person, determination of the prevalence of the dissatisfaction with penile size, its effect on erectile function, female partner's opinion of the value of penile size, as well as further experience with augmentation techniques.

The Global Online Sexuality Survey (GOSS): erectile dysfunction among Arabic-speaking internet users in the Middle East.

INTRODUCTION: Epidemiologic studies exploring sexuality across different cultures and geographic regions are scanty, particularly from the Middle East. The Global Online Sexuality Survey (GOSS) is an Internet-based survey investigating male and female sexual function. GOSS-Arabic-Males is the Arabic version targeting males in the Middle East, exploring prevalence rate of and factors affecting erectile dysfunction and its therapeutic trends, as well as premature ejaculation, attitudes toward genital size, and contraception. AIM: To explore epidemiologic aspects of male sexuality through an online survey. MAIN OUTCOME MEASURES: Prevalence rate of erectile dysfunction, its relationship to risk factors, and therapeutic trends. METHODS: The online survey was randomly offered to Web surfers in the Middle East. RESULTS: Eight hundred four subjects completed the survey. The overall prevalence of ED was 45.1%, strongly correlating with various risk factors studied, including age, diabetes, hypertension under treatment, depression, concerns over genital size, interpersonal distress, premature ejaculation, low libido, and subjective reports of penile deviation. Adjusted to the World Standard Population, the prevalence rate for ED was 47%. Phosphodiesterase (PDE) inhibitors gave a poor response among those with low libido and interpersonal distress, emphasizing the need for proper diagnosis and psychological counseling parallel to medical treatment. Furthermore, PDE inhibitors were stigmatized with unrealistic concerns that decreased their utility to a great extent. CONCLUSION: In the study population of Arab-speaking Internet users, prevalence of erectile dysfunction and effect of risk factors have proven similar to reports from different parts of the world, though not unanimously. Premature ejaculation, low desire, concerns over penile size, and penile curvature are factors to be considered in the evaluation of ED patients. PDE inhibitors are stigmatized with false beliefs that should be addressed through mass media and counseling if this population is to take full benefit from this therapeutic option.

Urethral instillation of chlorhexidine gel is an effective method of sterilisation.

Objective: To examine the effectiveness of preoperative urethral sterilisation with chlorhexidine gel in rendering the urethra as sterile as the skin of the genital area, with the skin sterilised as per the International Society for Sexual Medicine guidelines for penile prosthesis implantation. Patients and methods: A total of 111 male patients undergoing sterile andrological surgical procedures were divided into a control group (N = 61) and a chlorhexidine gel group (N = 50). Patients in the chlorhexidine group received urethral instillation with 6 mL of chlorhexidine preoperatively and on table. Patients from both groups received on-table skin preparation using povidone iodine and chlorhexidine povidone iodine. At the end of surgery, swabs were obtained from urethra and the penile skin. Skin and urethral swabs were compared for bacterial colonisation by culture and sensitivity. Results: Of the 111 patients, 16 had urethral colonisation and 10 had skin contamination, and they were all in the control group. The most common organism detected in both the urethral and skin samples was coagulase-negative Staphylococcus aureus. Urethral colonisation was significantly greater in the control group compared to the chlorhexidine group, at 16/61 vs 0/50 (P = 0.001). Similarly, skin colonisation was significantly greater in the control group compared to the chlorhexidine group, at 10/61 vs 0/50, (P = 0.002). Conclusion: Chlorhexidine gel is a powerful sterilising agent that will render the urethra sterile.

Delayed complications of gel injection for penile girth augmentation.

INTRODUCTION: Penile girth augmentation is a domain of extensive controversy and debate. A variety of methods is available for the choice of the surgeon including dermal-fat grafts and flaps. The need for a simple procedure with minimal donor site has lead to proposing injection therapy for penile augmentation, whether by fat or synthetic materials. AIM: This work reports on a male patient suffering a deforming subcutaneous mass in the penis following penile girth augmentation by injection therapy using synthetic material, and describes its management, and pathologic analysis of the extracted tissue. METHODS: The mass was excised through a circumferential subcoronal incision while maintaining skin vascularity and integrity of the corpora. The excised tissue was microscopically examined. MAIN OUTCOME MEASURES: Cosmetic and functional results of surgical correction. RESULTS: Cosmetic and functional outcome were acceptable. Pathology examination revealed features of foreign body granuloma. CONCLUSION: Injection of fillers for girth augmentation of the penile shaft may result in delayed complications including migration, granulomatous reaction, and resorption that may occur beyond the follow-up span of the currently available study that recommends its use.