Alprostadil plus Vacuum (VITARUM) in severe erectile dysfunction (ED).

OBJECTIVES: Severe erectile dysfunction (ED) is not uncommon, as can be seen from the epidemiological literature, and there are several possible causes, which are not always known, or leastways evident. Having ascertained the ineffectiveness, intolerance to or rejection of pharmacological aids, the option of prosthetic surgery remains, but before this, it may be wise when feasible to use Alprostadil cream in association with Vacuum device. MATERIAL AND METHODS: 12 patients, aged between 55 and 65 years, with severe erectile dysfunction without palpable cavernous fibrosis, were instructed to self-insert into the urethral meatus, 3 mg of Alprostadil cream, sufficient to make it easy to place the Vacuum device over the penis. RESULTS: In the cases observed, the preliminary use of Alprostadil cream fast produced an erection with enough rigidity to place the Vacuum. A sufficient erection was maintained, obviously using an elastic ring at the base of the penis, to achieve penetration. The reproducibility of the use of Alprostadil cream with Vacuum device was then confirmed at home, to the satisfaction of the patients.

Pharmacological/dynamic rehabilitative behavioural therapy for premature ejaculation: Results of a pilot study.

OBJECTIVES: Premature ejaculation (PE) is a sexual disorder characterised by excessive rapidity of orgasm. It is defined as either primary (60%), present since the onset of sexual activity, or secondary (40%), manifesting later in life. To date, dapoxetine is the only preparation approved for the on-demand treatment of PE. However, side effects, costs associated with the treatment of chronic PE, drug dependence and its variable effectiveness leads to a not insignificant drop-out rate. Dynamic rehabilitative/behavioural therapy may be a viable therapeutic option, working alongside pharmacological treatment, as long as the participation and involvement of both the individual and the couple is optimal. MATERIALS AND METHODS: 18 patients were enrolled, aged between 25 and 55 (mean: 40), all with primary PE, free of comorbidities and with their partners involved. Six patients were prescribed 30 mg dapoxetine two hours before sexual relations for 3 months (group A); 6 patients began the dynamic rehabilitative treatment (group B); 6 other couples were assigned to pharmacological treatment in association with dynamic rehabilitative behavioural treatment for 3 months (group C). Division of subjects was carried out by simple randomisation, excluding patients with a short frenulum, phimosis, ED, chronic prostatitis or experiencing results from previous treatment. RESULTS: Outcomes of treatment were evaluated at the end of the 3 months of treatment and 3 months after discontinuing treatment. In Group A 75% of patients were cured at 3 months and 25% at 6 months. In Group B 25% patients were cured at 3 months and 25% at 6 months. In Group C 75% of patients were cured 3 months and 50% at 6 months. "Cured" means a Premature Ejaculation Diagnostic Tool (PEDT) score reduced from an average of 12 to an average of 6 and Intravaginal Ejaculation Latency Time (IELT) values from < 1 to > 6 minutes. CONCLUSIONS: the integration of pharmacological treatment with dynamic behavioural rehabilitation has the specific aim of optimising and stabilising the results, supporting a more efficient recovery of ejaculatory control. The close involvement of the partner is extremely useful for all results.

ReMeEx device (External Mechanical Regulator) for female stress urinary incontinence: a critical review of a single-operator, long-term experience on implants and readjustments.

OBJECTIVE: A single-operator, long-term (15 years) experience on a sling technique that allows a postoperative adjustment of its tension is presented to retrospectively report the objective and subjective outcomes in the treatment of female stress urinary incontinence (SUI). The readjustment option prevents the need of a reoperation in case of relapse with great compliance of the patients. MATERIALS AND METHODS: Indications for surgical tratment of SUI by ReMeEx included patients affected with not only true intrinsic sphyncteric deficency (ISD) and fixed urethra but also mild urethral hypermobility, previous incontinence surgery and relapsing conditions such as diabetes and obesity. Fifty-five female patients with severe SUI underwent ReMeEx system positioning between 1998 and 2013. Before surgery, patients were evaluated by physical examination, translabial ultrasonography, urodynamics, pad-test and compilation of a specific incontinence quality of life questionnaire. RESULTS: Out of 55 patients treated, 50 were cured with readjustment in 10; in one case, the device was removed for infection. Complications as one transitory retention, two de novo urgency and one sovrapubic varitensor seroma were easily treated. DISCUSSION: In our experience, the ReMeEx system produced remerkable long-term results that showed the effective role of this device in obtaining an adequate sling tension, also confirmed in a worse prognosis patient group, as reported in the present study. The limitation of this study, based on a retrospective and not comparative analysis, suggests the need for randomized prospective studies comparing the ReMeEx procedure with other similar anti-incontinence techniques. CONCLUSIONS: ReMeEx system offers the possibility to modify the sling support whenever needed during patients' life. By this device, we can improve the outcomes of these patients leaving them completely dry without reoperations. The system produced remarkable 15 years results with a low complication rate. These outcomes have also been confirmed in a worse prognosis patient group as reported in the present study.

Peyronie's disease: endocavernous plaque excision without substitutive graft: critical 5-year experience.

OBJECTIVE: In 2004, the Polish colleague Darewicz published his surgical experience of endocavernous plaque excision avoiding the use of any substitutive graft. Attracted by the extreme simplification in this new technique, we decided to verify such a surgical approach. MATERIALS AND METHODS: The separation of the plaque from the overlying albuginea is performed with scissors or scalpel. Once the plaque is removed, the cavernous incision is sutured and the correct straightening is verified. In 5 years, we selected 24 cases of stabilized disease and preserved erection geometrically disturbed by the severe deformity. RESULTS: We obtained substantial straightening in all cases, even if in 3 cases we added a complementary minimally invasive surgery in the form of a plication, and 2 cases were converted into a graft technique. CONCLUSIONS: Case studies and current controls allow us to say that the impression is quite good, without the need of autologous tissue or heterologous matrices to be inserted, allowing a more comfortable post-operative course and a faster and easier functional recovery.

[Reconstructive urethroplasty using porcine acellular matrix (SIS): evolution of the grafting technique and results of 10-year experience]. / Uretroplastica ricostruttiva con matrice acellularesuina (SIS): evoluzione della tecnica di impiantoe risultati di 10 anni di esperienza.

INTRODUCTION: Long tract urethral reconstruction still has no other resolution than two-stage techniques or graft and flap procedures, that are neither simple nor trouble-free. Tissue engineering simplifies this surgery using porcine acellular matrix, obtained from small intestine submucosa (SIS): thin but strong, ready for grafting, it is not immunogenic, being deprived of cells. It is a biological bridge for reconstruction, promoting the regeneration of surrounding tissue. We report our experience using SIS for urethroplasty. MATERIALS AND METHODS: After coronal or perineal-scrotal incision and penile degloving, the urethra is rotated of 180° and opened through the entire restricted tract. The graft is sutured dorsally and reinforced by the contact with the cavernous bodies to prevent pouching. From 1999 to 2005 we performed this grafting procedure in 36 men and 4 women. Afterwards, 16 more surgeries performed were with direct ventral graft procedure, without urethra isolation and rotation, with worthy simplification. RESULTS: A 10-year follow-up shows satisfactory urodynamic and subjective outcomes for both procedures, assessed by voiding urethrography, uroflowmetry, International Prostate Symptom Score, and Quality of Life perception. At urethroscopy the graft appears completely homogeneous to the native tissue, as confirmed by the histological examination. The ventral direct graft represents the more consistent innovation: we did not observe pouching and the results remained effective. For penile urethra, in a few patients, periodic dilatations were necessary. CONCLUSIONS: SIS can be considered as an alternative to more difficult grafting procedures, which are probably no more indispensable in urethral enlargement, even for critical strictures

Adjustable suburethral sling (male remeex system) in the treatment of male stress urinary incontinence: a multicentric European study.

OBJECTIVE: To evaluate the effectiveness of a readjustable sling for the treatment of male stress urinary incontinence (SUI). MATERIALS AND METHODS: Between October 2002 and August 2005, 51 male patients with mild to severe SUI were prospectively operated with the use of a readjustable sling (MRS) at seven different European hospitals: Spain (2), Italy (2), Greece (1), Germany (1), and Portugal (1). The origin of incontinence was radical prostatectomy in 43 cases, TUR in 4, and open prostatectomy in another 4. Duration of incontinence ranged from 1 to 10 yr with an average of 3.5 yr. RESULTS: All patients but 5 were regulated during the early postoperative period; 44 patients (including all 5 not regulated during the early period) required a second regulation under local anaesthesia between 1 to 4 mo after surgery, and 17 other patients required more than one delayed regulation. After that, 33 patients (64.7%) were considered cured (25 of them wore no pads at all, and 8 used small pads or sanitary napkins for security but normally remained dry); another 10 cases showed important improvement (19.6%); and only 8 patients remain unchanged (15.7%). The average follow-up time was 32 mo (range: 16-50). The mesh was removed in 1 case owing to urethral erosion and the varitensor in 2 cases owing to infection. There were five (9.8%) uneventful intraoperative bladder perforations at the postoperative period, and there were three mild perineal haematomas (5.9%). Most patients felt perineal discomfort or pain, which was easily treated with oral medications. CONCLUSIONS: The MRS((R)) allowed postoperative readjustment of the suburethral sling pressure at the immediate or midterm postoperative period, which allowed the achievement of good midterm results in almost 85% of patients without significant postoperative complications.

'Straightening-reinforcing' technique for congenital curvature and Peyronie's disease.

OBJECTIVES: We report an initial randomised study on surgical techniques with subsequent intensive application of our procedure. MATERIALS AND METHODS: We modified Ebbehoj-Metz technique by a 'straightening-reinforcing' (S-R) double stitch: the first performs the plication, the second tightens it, thus preventing tension during erection. This is different to the simple Ebbehoj-Metz stitch that only provides plication but, as it does not provide reinforcement, does not prevent recurrence. From 1995 to 2000 78 plications were performed: 60 for congenital curvatures (age range 18-32 years) and 18 for Peyronie's disease (PD; age range 36-58 years). During the first 3 years, i.e. between 1995 and 1998, patients were randomised to S-R plication (20 congenital and 5 PD) and Nesbit procedure (20 congenital and 5 PD), for a total number of 50 patients (40 congenital and 10 PD). The last 28 patients, operated between 1998 and 2000, were assigned exclusively to S-R plication. We delayed study publication in favour of an adequate follow-up. RESULTS: No patient reported a decrease in erectile function and all reported easy vaginal penetration within 3 months. In 60% of the patients undergoing the Nesbit technique, restoration of a fully satisfactory coital activity was delayed because of pain during erection; 35% of all patients had some problems with the coronal suture which disappeared 1 month after the operation, and 15% reported decreased sensibility of the glans. Recurrence rate was not significant for all patients of all groups, even if 3 PD patients of the S-R plication group and 1 PD patient of the Nesbit group received no benefit from the operation. CONCLUSION: S-R plication is not better than the Nesbit procedure. However, for low degrees of penile bending, both congenital and acquired, we do not think it strictly necessary to perform the more invasive Nesbit operation (requiring opening of Buck's fascia, detachment of the neurovascular dorsal bundle or urethra and albuginea excision). Modified plication may be a minimally invasive and effective treatment suitable for most curvatures treated in day clinics and under local anaesthesia.

ReMeEx device (External Mechanical Regulator) for incontinence: implantation and regulation procedure, complications and results at 3 years follow-up.

UNLABELLED: A new sling technique that allows a postoperative adjustment of the sling tension is presented with encouraging results in the treatment of female stress urinary incontinence. The readjustment prevents the need of a reoperation in case of relapse with great compliance of the patients. Indications for surgical treatment of female stress urinary incontinence by ReMeEx included patients with: fixed urethra, urethral hypermobility, intrinsic sphyncteric deficiency and previous incontinence surgical interventions. Out of 32 patients treated, 31 were cured with transitory urge in 2 and readjustment in 3. In one case the device was removed for infection. IN CONCLUSION: the ReMeEx system offers the possibility to modify the sling support level whenever needed during patient's life. Wiyh the ReMeEx system we can and should improve the outcome of these patients leaving them completely dry, without any urine leakage.

Reconstructive urethroplasty using porcine acellular matrix.

Long tract urethral reconstruction nowadays still has no other resolution than two-stage techniques or graft and flap procedures that are neither simple nor trouble-free both for the patient and the surgeon. Tissue engineering simplifies this surgery using "porcine acellular matrix", obtained from small intestine submucosa. It is thin but strong, just ready for grafting, without rejection, because it is not immunogenic, being deprivated of cells. It serves as biological bridging of the reconstruction, promoting the generation of surrounding tissue in which it is completely transformed. We report the first use of porcine intestine submucosa in urethroplastic surgery. The up to date follow up is sixteen months with satisfactory urodynamic and subjective outcome.

[Reconstructive urethroplasty using porcine acellular matrix: preliminary results]. / Uretroplastica ricostruttiva con matrice acellulare suina: risultati preliminari.

OBJECTIVE: The use of "porcine acellular matrix", obtained from small intestine submucosa, could simplify the repair of long urethral strictures, whereas single stage techniques can be carried out only by means of grafts, as buccal mucosa; or flaps, as prepucial skin. To our knowledge we report the first use of porcine intestine submucosa in urethroplastic surgery. MATERIALS AND METHODS: From May 2001 to December 2001, five urethral reconstructions were completed using "porcine acellular matrix". Four male patients had urethral strictures longer than 10 cm. After circumcision and penile degloving, we extended the surgical approach to the perineum-scrotal region by a midline longitudinal incision. The urethra was exposed, dissected from corpora cavernosa, then rotated of 180 degrees and on this side longitudinally incised throughout all the stenotic length. Urethroplasty was accomplished with matrix tissue modelled according to the length of the stenosis and grafted by a 5-0 polyglycolic acid running suture. The enlarged urethra was then derotated, laying the graft dorsally, closed to corpora cavernosa, to prevent pouching. A further graft was accomplished in a female patient with a 3 cm long urethral stricture. All urethroplasties were stented for 14 days. No complication developed. RESULTS: After 1 month urethral patency was satisfactory compared with preoperatory images and the urinary flow was normal. After 2 months the urethra was endoscopically verified: it was easy to appreciate the homogeneous transformation of the graft into the native tissue. At 6-month follow-up radiological and urodynamic outcome is still satisfactory in all patients. CONCLUSIONS: According to our preliminary experience "porcine acellular matrix" is a promising approach for the repair of long urethral strictures. Its safety and effectiveness encourage us to treat more cases in male and female patients.