An outcomes analysis of penile prosthesis implantation following radical cystoprostatectomy and urinary diversion: a multicentric retrospective cohort study.

There is limited scientific literature regarding the management outcomes for end-stage erectile dysfunction (ED) following radical cystoprostatectomy (RCP). This study aims to evaluate the surgical outcomes of penile prosthesis (PP) implantation. A retrospective analysis over 17 years (2004-2017) was performed from the clinical records of patients in four tertiary referral centres, whom previously had undergone RCP, followed by PP implantation for end-stage ED. Outcome measures include both intra and postoperative complications, operative duration, a 5-point Likert hematoma scale as well as length of hospital stay. Additionally, a matched-pair cohort analysis was performed, dividing patients in 2 groups according to the type of urinary diversion (neobladder versus ileal conduit/cutaneous ureterostomy). The median time elapsed between RCP and PP implantation was 38 months (IQR 20-56). The median follow-up was 18 months (IQR 12-156). A 3-piece inflatable PP was implanted in 43 patients (91.5%) whereas a semirigid device was implanted in the remainder. Reservoir position was extra-peritoneal (utilising a separate abdominal incision) in 24 patients (54.8%), while an ectopic high-submuscular placement was preferred in the remainder. PP infection and mechanical failure occurred in 1 (2.1%) and 3 cases (6.3%) respectively. The comparative analysis of surgical outcomes did not show any statistically significant difference between the two groups. Our evidence suggests that PP implantation in patients with refractory ED following RCP may represent a safe and effective procedure associated with a low incidence of complications. The main limitation of this study is represented by the non-randomised, retrospective nature as well as the lack of patients' functional outcomes and the limited follow-up.

Outcomes of inflatable penile prosthesis insertion in 247 patients completing female to male gender reassignment surgery.

OBJECTIVES: To assess the oucomes of penile prosthesis (PP) implantation after total phallic reconstruction secondary to gender dysphoria. PATIENTS AND METHODS: We conducted a retrospective single-centre analysis of 247 consecutive patients. The recruitment period was January 2001 to October 2015. A total of 328 inflatable PPs were implanted. A two-staged inflatable PP implantation was carried out. As a first step, an extraperitoneal reservoir placement was performed simultaneously with the glans sculpture and the insertion of a single large testicular prosthesis into the labia majora. Subsequently, cylinder(s) and pump placement was performed. A Dacron envelope was fitted around the proximal and distal aspect of the cylinder(s) to anchor the device to the pubic bone and to prevent apical protrusion. The outcomes measured were postoperative complications, eventual need for revision surgery, and long-term survival of the implants. Patient and partner satisfaction rates were extrapolated from the administered non-validated questionnaires. The data were analysed using non-parametric tests, multivariate logistic regression analysis, and a Kaplan-Meier survival curve. RESULTS: The mean follow-up was 20 months. In all, 88% of patients were satisfied with the result, although only 77% used their device for sexual intercourse. The overall 5-year device survival was 78%, with no one device being superior. Device infection occurred in 8.5% of patients with an overall revision rate of 43%. According to the multivariate logistic regression analysis, only type of phalloplasty significantly affected the infection risk (P = 0.013). CONCLUSIONS: Implantation of a PP into a neophallus is a complex procedure but yields high satisfaction rates. Nevertheless, complication rates are high and patients must be warned that multiple revisions will be necessary throughout their lifetime.

Management of refractory ischemic priapism: current perspectives.

OBJECTIVES: The aim of the present manuscript is to review the current literature on priapism, focusing on the state-of-the-art knowledge of both the diagnosis and the treatment of the refractory ischemic priapism (IP). METHODS: Pubmed and EMBASE search engines were used to search for words "priapism", "refractory priapism", "penile prosthesis", "diagnosis priapism", "priapism treatment", "penile fibrosis", "priapism therapy". All the studies were carefully examined by the authors and then included in the review. RESULTS: First-line treatment involves ejaculation, physical exercise and cold shower followed by corporal blood aspiration and injection of α-adrenoceptor agonists. Subsequently, a distal or proximal shunt may be considered. If none of the treatment is effective or the priapism episode lasts >48 hours penile prosthesis implantation could be the only option to solve the priapism and treat the ongoing erectile dysfunction. CONCLUSION: The management of IP is to achieve detumescence of persistent penile erection and to preserve erectile function after resolution of the priapic episode. On the other hand, penile fibrosis and following shortening should be prevented. Early penile prosthesis implantation in patients with refractory IP is able to solve both the priapic episode and prevent the otherwise certain penile shortening. Penile prosthesis implantation is the actual gold standard of care in cases of refractory IP.

A Single-center Analysis on the Learning Curve of Male-to-Female Penoscrotal Vaginoplasty by Multiple Surgical Measures.

OBJECTIVE: To asses and quantify the learning curve (LC) of the penoscrotal inversion flap vaginoplasty (PSV). PATIENTS AND METHODS: We retrospectively reviewed clinical records of 69 patients who underwent PSV from January 2005 to January 2015. Two validated methods were used: a scatterplot representation and a splitting group. We selected as primary outcomes the operative time and vaginal depth. Surgical outcomes including blood losses, hospital stay, and postoperative complications such as vaginal stenosis or atresia or urethral meatus stenosis were also evaluated. RESULTS: The overall median operative time was 245 minutes. Severe intraoperative complications were not reported. The overall incidence of postoperative major complications was 21.7 %, most of them being urethral issues. The splitting group analysis revealed a statistically remarkable difference between groups for the operative time (P < .01), the vaginal depth (P = .01), the hospital stay (P < .01), and the intraoperative complication rate (P = .01). On the contrary, no differences were evidenced between the cohorts for the amount of blood loss (P = .08). The scatterplot logarithmic analysis demonstrated a clear visible LC for most parameters. The operative time showed a sharp decrease within the first 20-30 cases, reaching a plateau after 40 cases. Considering the analysis of the vaginal depth, the logarithmic scatterplot curve evidenced a slight increase within the first 10 cases, reaching a clear stabilization after nearly 30-40 cases. CONCLUSION: An evident LC for PSV is detectable, consisting of at least 40 cases needed to the surgical team to develop adequate skills to guarantee a safe and high-quality procedure.

A prospective multicentric international study on the surgical outcomes and patients' satisfaction rates of the 'sliding' technique for end-stage Peyronie's disease with severe shortening of the penis and erectile dysfunction.

OBJECTIVES: To report the results from a prospective multicentric study of patients with Peyronie's disease (PD) treated with the 'sliding' technique (ST). PATIENTS AND METHODS: From June 2010 to January 2014, 28 consecutive patients affected by stable PD with severe penile shortening and end-stage erectile dysfunction (ED) were enrolled in three European PD tertiary referral centres. The validated International Index of Erectile Function (IIEF) questionnaire, the Sexual Encounter Profile (SEP) Questions 2 and 3, and the Peyronie's disease questionnaire (PDQ) were completed preoperatively by all patients. At the follow-up visits (at 3, 6 and 12 months), the IIEF, the SEP Questions 2 and 3, the PDQ, and the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) were completed. The outcome analysis was focused on penile length restoration, and intra- and postoperative complications classified according the Clavien-Dindo Classification. RESULTS: The mean (range) follow-up was 37 (9-60) months. A malleable penile prosthesis (PP) was implanted in seven patients, while an inflatable three-pieces PP was placed in the remainder. In the case of inflatable PP implantation, porcine small intestinal submucosa and acellular porcine dermal matrix were used to cover the tunical defects. While in patients undergoing malleable PP implantation, collagen-fibrin sponge was used. The mean operative time was 145 min in the inflatable PP group and 115 min in the malleable PP group. There were no intraoperative complications. Postoperative complications included profuse bleeding requiring a blood transfusion in one patient (3.5%) on anticoagulation therapy for a mechanical heart valve (Grade II) and PP infection requiring the removal of the device (7%) (Grade III). There were no late recurrences of the shaft deformation. The postoperative functional data showed a progressive improvement in the score of all questionnaires, peaking at 12 months postoperatively. The mean (range) penile lengthening was 3.2 (2.5-4) cm and no patient reported recurrence of the curvature. CONCLUSIONS: The present series suggests that, in the hands of experienced high-volume surgeons, penile length restoration with the use of the ST represents an effective option for end-stage PD associated with ED and severe shortening of the shaft. Larger series and longer follow-up will be required to fully establish the efficacy of this procedure.

Sexual function after surgical treatment for penile cancer: Which organ-sparing approach gives the best results?

INTRODUCTION: We compared the postoperative sexual function of patients who underwent wide local excision (WLE) and glansectomy with urethral glanduloplasty for penile cancer. METHODS: We retrospectively reviewed clinical data of 41 patients affected by superficial, localized penile cancer (≤cT2a) between 2006 and 2013. Patients with severe erectile dysfunction and not interested in resuming an active sexual life were selected for penile partial amputation. Patients with preoperative satisfying erectile function and concerned about the preservation of their sexual potency were scheduled for WLE (Group A) or glansectomy with urethral glanduloplasty (Group B). Sexual function was assessed with the International Index of Erectile Function (IIEF) questionnaire and the Sex Encounter Profile (SEP). At 1 year, patients were asked to complete the questionnaires again and were questioned about their genital sensibility and ejaculatory reflex persistence. Postoperative complications were reported according to the Clavien-Dindo classification. Statistical analysis was performed by two-tailed test: Student t-test and chi-square. RESULTS: Among the 41 patients enrolled, 12 underwent WLE (29.2%), 23 glansectomy with urethral glanduloplasty (56%) and 6 with penile partial amputation (14.6%). A decrease in postoperative IIEF was recorded in both groups, but was statistically significant only in Group B (p = 0.003). As for the SEP, while no significant changes were recorded postoperatively in Group A, a marked reduction was reported for Group B, with a statistically significant decrease in the possibility of achieving penetrative intercourse (p = 0.006) and in the perceived satisfaction during sexual activity (p = 0.004). CONCLUSIONS: WLE lead to better sexual outcomes and less postoperative complications as compared to glansectomy with urethral glanduloplasty.

Prognostic factors of 'high-grade' Ta bladder cancers according to the WHO 2004 classification: are these equivalent to 'high-risk' non-muscle-invasive bladder cancer?

OBJECTIVE: To determine the impact of prognostic factors of a series of high-grade Ta non-muscle-invasive bladder cancers (NMIBCs) according to the new International Society of Urological Pathology (ISUP) 1998/WHO 2004 grading system (previously classified as either TaG2 or TaG3). METHODS: One hundred and thirty-one high-grade Ta (105 G2 and 26 G3) cases were identified after independent review by two pathologists. Univariable and multivariable Cox regression models addressed recurrence and progression-free survival. Progression was defined as appearance of any T ≥1 recurrence after complete TUR (type 1) or occurrence of T ≥2 (type 2). RESULTS: Ten-year recurrence, type-1 and type-2 progression-free survival were 60, 75 and 95%, respectively. The previous grading system (G3 vs. G2) significantly predicted type 1 progression in the univariate model only. In the multivariate model, Ki67 was the only independent predictor of progression according to both definitions (HR = 5.25, p = 0.002 and HR = 6.16, p = 0.03, respectively). CONCLUSIONS: High-grade Ta NMIBC as defined by the WHO 2004 grading system cannot be equated with high-risk NMIBC. The risk of progression to muscle-invasive disease (type 2) is low, more in keeping with an intermediate-risk category of NMIBC. The previous WHO 1973 subcategorization into G2 and G3 is of little help in the prediction of outcome. Ki67 is a strong independent predictor of progression worthy of consideration for a clinical setting.

Robotic nephropexy in case of symptomatic nephroptosis.

We found only a recent report of robotic-assisted nephropexy, in a young female with associated dismembered pyeloplasty. Herein we present the first case of isolated robotic nephropexy. A 34-year old female was referred to our Urological Division history of right flank pain and evidence at intravenous urography of a 5-6 cm descent of right kidney moving from supine to erect position. The robotic nephropexy was performed with a transperitoneal approach and 4 trocars. The kidney was wrapped up with a Parietex Composite (PCO) mesh (Tyco Healthcare), previously precut in an hockey stick shape to obtain a "spoon effect" to push up the lower pole of kidney. Despite the laparoscopic or retroperitoneoscopic procedures, the robotic-assisted nephropexy appears easier, with the particular advantages of the intracorporeal suturing and a better intraoperative view. The use of mesh, in our opinion, is preferable respect the decapsulation of the kidney, to avoid unnecessary blood loss and possible scarring.

Fatal haematuria in a patient with an orthotopic neobladder and chronic liver failure.

Haematuria in orthotopic neobladder can be due to upper urinary tract recurrence of the primary bladder tumour, the rare occurrence of a primary bowel tumour or benign conditions such as stones and infections. We report the case of a 60-year-old man with chronic hepatopathy who suffered severe bleeding from neobladder varices, which ultimately led to his death.