Syrian crises effect on specialty choice and the decision to work in the country among residents of six major hospitals in Syria, Damascus.

Assessing the impact of war on medical residents' specialty choices and migration decisions is critical to ensure the sustainability of healthcare systems worldwide. This study aimed to evaluate the effect of the Syrian crisis on specialty choices, related factors, and decisions to work in Syria among residents of six major university hospitals in Damascus. A cross-sectional study was conducted using a validated questionnaire from 20/4/2022 to 20/5/2022, including all eligible residents with no missing data. The questionnaire was comprised of 68 items, and residents were divided into two groups: group 1 included residents who made their specialty choice after the end of the military war in Damascus 2018, while group 2 included residents who made their specialty choice (the point of submitting their lists and applying for residency) during the war. A total of 370 residents were included, with 38.4% females and 61.6% males. Our findings revealed that 30% of residents preferred working in Syria, while 43.5% preferred working abroad. The factor of a "safer and more stable life" was significantly higher in Group 1 than in Group 2 (3.86>3.5, p-value = 0.026). Additionally, Group 1 residents were more likely to choose radiology, pathology, laboratory, and psychiatry specialization as their specialties, while choosing surgical specializations and hematology decreased compared to Group 2 (p-value<0.05). Factors related to social life were rated higher by group 1 (mean = 3.31) than by group 2 (mean = 2.27, Standard deviation = 0.19, p-value = 0.002). Moreover, the factor of "a specialization to facilitate traveling abroad" was significantly higher in Group 1 (2.69>2.21, Standard deviation = 0.22, p-value = 0.033). The Syrian crisis and its economic aftermath have influenced residents' specialty choices and practice locations. Even after the war's end, the high level of migration intentions could negatively affect the quality of provided healthcare services.

Scrotal arteriovenous malformation (AVM) successfully resected without angioembolization: A case report.

INTRODUCTION AND IMPORTANCE: The main types of scrotal vascular lesions are varicocele, hemangioma, lymphangioma and arteriovenous malformation (AVM). AVM consists of network between arteries and veins without capillaries. It is the rarest type especially when in scrotum. CASE PRESENTATION: A 24-year-old male patient presented with a skin deformity and painless swelling in the left scrotum. Physical examination revealed this swelling that extended to the inguinal region. Duplex Ultrasound (DUS) followed by Multi-slice Computed Tomography (MSCT) were performed to establish the diagnosis. Management depended on surgical excision without angioembolization. Preoperative sperm analysis showed oligoasthenozoospermia that improves significantly after treatment and 1 year of follow-up. CLINICAL DISCUSSION: Surgical resection of scrotal AVM without embolization has been used in very few cases and has resulted in a satisfactory outcome with no signs of recurrence throughout the follow-up period. CONCLUSION: Based on our experience, surgical excision without embolization is a reasonable alternative approach to treat scrotal AVM in low-income countries alongside avoiding the negative consequences of radiation therapy. Treatment should be considered when fertility is affected.

Dietary and smoking habits during the exam period and their effect on the academic achievement among Syrian medical students.

BACKGROUND: Dietary habits are crucial for maintaining overall health and have been shown to impact academic performance. However, little research has been conducted on the specific eating, drinking, and smoking habits during the exam period and their effect on academic performance. Therefore, this study aimed to investigate dietary and smoking habits and their relationship with academic performance among medical students at Damascus University. Findings from this study can inform interventions to improve both dietary habits and academic performance. METHODS: A cross-sectional design was used to investigate the association between dietary habits during the exam period and academic performance among 608 medical students. Data were collected using a self-administered paper-based questionnaire that was randomly distributed across multiple classes. The statistical analysis employed Spearman's rank correlation and multiple linear regression to examine the relationship between the different amounts of diet behaviour during the exams and the reported average students' grades from the last two semesters. The regression model was adjusted for age, sex, residency type, and residency partners. RESULTS: In both Spearman's rank correlation and multiple linear regression analyses, we observed consistent negative associations between specific dietary habits and self-reported average grades. These included daily consumption of tea (B = -0.334, p = 0.022), instant coffee (B = -0.682, p = 0.001), and weekly fast food consumption (B = -0.583, p = 0.038). Notably, traditional coffee was found to be significant in the Spearman analysis but did not exhibit significance in the regression analysis. Furthermore, the regression analysis revealed a negative association between water pipe consumption and academic performance (B = -0.700, p = 0.049). No significant association was observed between other dietary habits, cigarette smoking, and academic performance. CONCLUSIONS: The study highlights a negative, but weak, association between academic achievement and specific dietary habits during the exam period. However, further longitudinal studies are needed to establish causal relationships. Additionally, the study suggests exploring the impact of other habits such as study and sleeping habits, which may have a more significant impact on academic achievement.

A rare case of unconnection between the celiac trunk and the abdominal aorta and a large anastomosis with the inferior mesenteric artery with a literature review.

PURPOSE: Direct connection between the celiac trunk (CT) and inferior mesenteric artery (IMA) is very rare, knowledge of this anomaly is of great importance to surgeons and anatomists. INTRODUCTION: Splanchnic arteries arise from the abdominal aorta (AA). Unusual development of these arteries can lead to considerable variations. Historically there were a lot of classification of the variation in the CT and IMA, none of the classifications describes a direct connection from IMA to CT. MATERIALS AND METHODS: We report a rare case in which the connection between the CT and AA was lost and replaced by a direct anastomosis with IMA. RESULTS: 60 year old male presented to the hospital to undergo a computed tomography scan. Which showed that there was no CT arising from the AA, but there was a large anastomosis arises from the IMA and ended with a short axis and Left gastric artery (LGA), Splenic artery (SA), Common hepatic artery (CHA) arise from this axis, these arteries continued to the stomach and spleen and liver normally. The anastomosis provides the total supply to the CT. The CT branches are normal. CONCLUSION: Knowledge of the arterial anomalies provides an important help in clinical surgical implications especially in organs transplant.

Double right coronary artery with fistula to the right atrium and mitral insufficiency: A case report.

INTRODUCTION AND IMPORTANCE: Coronary artery abnormalities are uncommon and mostly asymptomatic. The combination of double right coronary artery (RCA) with a fistula and valvar deformity is very rarely reported in the literature. However, it is important to identify these deformities as they have relatively high complication rates. PRESENTATIONS OF CASE: A 47-year-old male came with chest pain that radiated to the lower jaw. ECG showed equivalent changes. Blood tests including troponin were within normal range. However, echocardiogram showed a severe mitral valve regurgitation with anterior leaflet prolapse and hypokinesia of the ventricular wall. Coronary angiogram showed a double RCA with a complete block in the main RCA and a fistula to the right atrium (RA). The left coronary system showed atherosclerosis in left anterior descending artery (LAD) and circumflex artery (CX). Surgical treatment, including the repair of the RCA-RA fistula, replacement of mitral valve and coronary artery bypass grafting (CABG) were performed. The patient had no complications in the follow-ups. DISCUSSION: Coronary fistulas may be congenital or acquired malformations. Their treatment depends on the symptoms, origin, size and the receiving chamber. Furthermore, double RCA is debatable whether the rate of atherosclerosis and other cardiac abnormalities are increased with this anomaly. The surgeon must keep in mind these rare anomalies before cardiac operations. CONCLUSION: Double RCA might accompany other deformities which are important to detect before intervention. More studies are required to decrease complications and have better outcomes.

Laparotomy Due to War-Related Penetrating Abdominal Trauma in Civilians: Experience From Syria 2011-2017.

OBJECTIVES: Penetrating abdominal trauma is one of the injuries that could affect civilians in wartime. This retrospective study investigates the commonly injured abdominal organs, and the impact of multiple injured organs on mortality. METHODS: We reviewed the operating room (OR) logs of patients who presented to the surgical emergency department (SED) at Al-Mouwasat University Hospital with war-related abdominal penetrating trauma requiring exploratory laparotomy between April 1, 2011 and December 31, 2017. RESULTS: Of 7826 patients with traumatic injuries, 898 patients (11.5%) required exploratory laparotomy. Of all patients who had an exploratory laparotomy (n = 898), 58 patients (6.5%) died in the perioperative period. Regarding complete laparotomies (n = 873 patients), small intestines, large intestines, and liver were the most commonly affected organs (36.4%, 33%, 22.9%, respectively). A total of 92 patients (10.2%) had negative laparotomy in which all the abdominal organs were not injured. The perioperative mortality rate (POMR) increased when more organs/organ systems were injured per patient reaching a peak at 3 organs/organ systems injuries with a POMR of 8.3%. POMR was highest in patients with musculoskeletal injuries (18.2%), followed by vascular injuries (11.8%), and liver injuries (7%). CONCLUSIONS: The management of civilians' abdominal injuries remains a challenge for general and trauma surgeons, especially the civilian trauma team. The number and type of injured organs and their correlation with mortality should be considered during surgical management of penetrating abdominal injuries.

A case report combining Dunbar syndrome and pancreatic neuroendocrine tumor.

BACKGROUND: Dunbar syndrome or median arcuate ligament syndrome is a rare disorder. In this disorder, a malposition of the arcuate ligament compresses the celiac trunk and causes nonspecific symptoms including postprandial pain, abdominal bruit and weight loss. Surgical management is the primary treatment.Pancreatic neuroendocrine tumors (PNETS) are also rare. It comprises about 1-3% of pancreatic neoplasm. The patient could be symptomatic or asymptomatic depends on the tumor being functional or nonfunctional. In addition, surgical therapy is the choice. CASE PRESENTATION: In this paper, we report a case of 28 old female patient complaining from a long term of recurrent abdominal pain that doesn't releive on any kind of treatment, the multislices computerised tomography scan showed compress of the median arcuate ligament with an incidental mass in the tail of pancreas turned out to be a pancreatic neuroendocrine tumor. CONCLUSIONS: The Dunbar syndrome and the Pancreatic neuroendocrine tumors must be kept in mind of phyciciens while the differential diagnosis of any recurrent abdominal pain.

Free large sized intra-abdominal endometrioma in a postmenopausal woman: a case report.

BACKGROUND: Endometriosis is an estrogen-dependent disease defined by the presence of endometrial glands and stroma out of the uterine cavity. Its prevalence is estimated to be 2-10% in reproductive aged women. Endometriosis occurrence is estimated to be 2.55% in postmenopausal patients due to the decreased levels of estrogen. Endometriosis can present in three different forms: superficial peritoneal implants, ovarian endometriomas, and deep infiltrating endometriosis. Ovarian endometriomas are the most common form of endometriosis. Even though endometriomas have been encountered in various localizations, a free abdominal endometrioma was only reported once in a premenopausal patient. Here, we are reporting the first case of a free large endometrioma in a postmenopausal patient. CASE PRESENTATION: A 67-year-old woman presented to the emergency department at our university hospital complaining of constipation and right flank pain. She suffered from uncontrolled primary hypertension and type 2 diabetes mellitus. On presentation, she was afebrile, hypertensive, and tachycardic. An abdominal CT scan revealed a large cystic mass measuring 17 × 26 cm in the anterior-posterior and transverse diameters respectively. The cyst caused bowel obstruction and right sided hydronephrosis. The patient underwent laparotomy and during the surgical exploration a large abdominal cyst adhered to the greater omentum was found. The cyst received plenteous blood supply from the greater omentum. The uterus and both ovaries were completely normal and didn't have any connection to the cyst. An en-bloc cystectomy was performed successfully. The final histopathology report confirmed an abdominal endometrioma. The patient had an uneventful postoperative recovery. CONCLUSIONS: Endometriomas might reach large sizes regardless of their location or the patient's age. The close relation of free abdominal endometriomas with the greater omentum suggests that these were developed from endometriotic omental implants. Endometrioma is rare in postmenopausal women. However, it should be considered as a possible differential diagnosis at any age.

A huge extrarenal cell carcinoma developing from a heterotopic renal anlage with distant metastases: case report and literature review.

Renal cell carcinoma (RCC) is the most common type of renal tumor arising from the proximal renal tubules. Extrarenal RCC is a rare case in which a tumor is found outside the kidney with no primary kidney tumor. Some theories suggest that these tumors arise from mesoderm remnant. Here, we present a unique case, the fourth in literature, of peri-renal, Extrarenal RCC case and the first case with a huge mass with distant metastases and aggressive progression.

Angioembolization of Scrotal Arteriovenous Malformations: A Case Report and Literature Review.

Arteriovenous malformations (AVMs) of the scrotum are rare lesions, usually diagnosed incidentally during the evaluation of scrotal masses or infertility. It could be presented with acute bleeding or acute pain. We are presenting a case of painless bilateral infiltrated scrotal mass (more advanced in the left side) developed dramatically over a year, no other symptoms existed. The diagnosis was made using duplex ultrasound (DUS), computed tomography arteriography (CTA), and digital subtraction angiography (DSA). Three sessions of angioembolization were performed and followed by surgical resection of the left side of the scrotum.

Language of written medical educational materials for non-English speaking populations: an evaluation of a simplified bi-lingual approach.

BACKGROUND: Debates have arisen in various non-English speaking countries over the chosen language of instruction in medical education, whether it has to be the English language or the mother tongue. English-based education supporters argue that English is the leading international language of medicine and research, and a crucial tool for Continuing Medical Education (CME), as well as for students who seek practice abroad. On the other hand, mother-tongue-based medical education supporters present it as a way to endorse communication and comprehension between medical practitioners and health care system users, to bridge the gap between practitioners and the paramedical staff, and to overcome linguistic dualism and the language thinking disparity while studying in another. This study aimed to evaluate one of the simplified bi-lingual approaches in terms of medical-educational-written texts for a non-English speaking population: Arabic speaking medical students in specific. METHODS: 1546 Arabic-speaking-medical students from different countries participated in a one-step-interactive-experimental-online test. The test assessed participants' scientific comprehension of three distinct written paragraphs: The first paragraph used conventional mother tongue (Arabic), the second combined English terminology and simplified mother tongue (hybrid), and the third used an English excerpt (English). Two multiple-choice questions (First question in Arabic, second in English) followed each paragraph. Response time was communicated for each paragraph. Participants were asked to select their favorable method. Repeated Measures ANOVA models and Paired Samples t-Test were used for statistical analysis. RESULTS: Participants scored a mean of [0.10] for the Arabic paragraph, [0.72] for the hybrid paragraph, and [0.24] for the English paragraph (P <  0.001). Results showed a significantly higher mean of points and correct answers within the fastest time for the hybrid paragraph [0.68] compared to the Arabic [0.08] and English [0.18] paragraphs (P <  0.001). Moreover, 50% of participants preferred the hybrid paragraph over the other two paragraphs. CONCLUSIONS: Taking into consideration the large number of participants and the statistically significant results, authors propose that simplified Arabic combined with English terminology may present a viable alternative method for medical-educational-written texts in Arabic-speaking population.

A rare presentation and recurrence of a retroperitoneal Müllerian cyst in a male patient: A case report.

INTRODUCTION: The retroperitoneal Müllerian cysts are extremely rare lesions seen mostly in female patients but their occurrence in males is quite possible. Their exact etiology stills unknown, its histological and immunohistochemical characteristics may serve as an evidence that reflects its origin. CASE PRESENTATION: We present a case of a resected retroperitoneal Müllerian cyst that reoccurred severely after 3 months of the first laparotomy in a male patient with a significant history of testicular teratocarcinoma. Due to the cyst's localization and its proximity to vital retroperitoneal structures, total surgical resection couldn't be made and the recurrence was minimized by post-operative oral chemotherapy. DISCUSSION: The retroperitoneal Müllerian cyst is a benign cystadenoma that could be confused with other retroperitoneal lesions, which makes the pathological examination with the immunohistochemical study of the cyst's wall essential to make the diagnosis. The immunopositivity to Cytokeratin 7 and the immunonegativity to Cytokeratin 20 is a key feature that confirm the diagnosis whenever the retroperitoneal Müllerian cyst is suspected. Due to its high vascularity, we highly recommend the administration of chemotherapy which targets the proliferative cyst's cells. CONCLUSION: The RMCs are rare benign lesions that tend to reoccur if total surgical resection isn't made, when the total resection couldn't be achieved, the-unspecific anti-mitotic drugs may help in minimizing the recurrence and improve the life quality of the patient.

Multiple Hepatic and Renal Hydatid Cysts Managed with Laparoscopic Surgery.

Cystic echinococcosis is a parasitic disease caused by Echinococcus granulosus. The liver and lungs are the most commonly infected organs. We present the first-of-a-kind case of laparoscopic excision of 8 hydatid cysts, of which seven were in the liver and one was in the kidney of a 40-year-old patient. The patient presented with fatigue and fever and a one-year history of vague abdominal pain. Albendazole was administered before surgical intervention. The postoperative follow-up period was notable for a renal fistula. The patient subsequently underwent CT-guided percutaneous removal of a central hepatic hydatid cyst that was inaccessible using laparoscopic techniques. Cystic echinococcosis is endemic in the Mediterranean region. The growing number of immigrants and refugees from endemic areas could increase the prevalence of the disease in nonendemic countries. Therefore, it is important for physicians worldwide to be familiar with the diagnostic modalities and possible treatment options for hydatid disease.

Pancreatic Hydatid Cyst Causing Acute Pancreatitis: A Case Report and Literature Review.

Hydatidosis is a public health problem in endemic countries. Hydatid cysts are located usually in the liver and the lungs. Primary pancreatic hydatid cyst is in unusual location and rarely causes acute pancreatitis. In this paper, we report a case of a 34-year-old man who admitted with recurrent acute pancreatitis. Following the preoperation investigations, the primary impression was a pancreatic pseudocyst. During surgery, a primary hydatid cyst was detected in the pancreas measuring 35 × 20 × 15 cm. The treatment consisted of evacuation and external draining of the cyst. In addition, we summarized 14 cases of primary hydatid cyst of the pancreas associated with acute pancreatitis reported in the literature.

Esophageal Cancer Metastases to Unexpected Sites: A Systematic Review.

The most common pattern of esophageal cancer metastases (ECM) is to the lymph nodes, lung, liver, bones, adrenal glands, and brain. On the other hand, unexpected metastasis (UM) spread to uncommon sites has increasingly reported and consequently affected the pathway of diagnosis, staging, and management. Using the PubMed database, a systematic search of the following headings "Esophageal" and "Metastasis" or "Metastases" was performed, 10049 articles were identified, and the articles were included if they demonstrated unexpected ECM. 84% of cases were men with an average age of 60.7 years. EC was located in the lower third in 65%. Two-thirds of the UM originated from the lower esophagus, and the two major histological types were adenocarcinoma 40% and squamous cell carcinoma 60%. Metastases were disseminated toward five main anatomical sites: the head and neck (42%), thoracic (17%), abdomen and pelvis (25%), extremities (9%), and multiple skin and muscle metastases (7%). The EC metastases were found to be synchronous 42% and metachronous 58%, isolated in 53.5% and multiple in 46.5%. The overall survival rate was 10.2 months. Since distant metastases are responsible for most EC-related deaths, understanding of ECM dissemination patterns needs more extensive studies. These critical data are the cornerstone of optimal cancer approach and treatment.

Origin and nature of pelvic ureter innervation.

AIMS: Innervation of the pelvic ureter traditionally comes from the pelvic plexus. This innervation is independent: adrenergic and cholinergic. The purpose of this study was to describe more precisely the origin and nature of its innervation (adrenergic, cholinergic, nitrergic, and somatic). METHODS: Six specimens of normal human fetal pelvis (four male and two female) from 20 to 30 weeks gestation were studied. The sections of these fetuses, carried out every 5 µm without interval, were treated with Hematoxylin Eosin (HE), with Masson's trichrome (TriM), immunolabeling of smooth muscle cells with smooth anti-actin, of nerves with anti-S100 protein, anti-tyrosine hydroxylase, anti-VAChT, anti-nNOS, and with anti- peripheral myelin protein 22 (PMP 22). The slides were scanned and two-dimensional images reconstructed in 3D, and analyzed. RESULTS: The terminal pelvic ureter travels above and inside the inferior hypogastric plexus (IHP). The nerve fibers that innervate the ureterovesical junction come mainly from the superior hypogastric plexus (SHP) which gives off the hypogastric nerves and pelvic branches of the sacral plexus that form the IHP. Most nerve fibers meet below the ureter, behind the bladder to form an ascending bundle, which innervates the pelvic ureter. Immunohistochemical analysis shows that the nerves of the pelvic ureter consist of adrenergic, cholinergic, and nitrergic fibers. CONCLUSION: The innervation of the distal ureter depends mainly on the SHP. This innervation is adrenergic, cholinergic, and nitrergic. It innervates the pelvic ureter in an ascending manner. This anatomical information can change rectal resection and ureteral reimplantation techniques and drug treatments for pelvic ureter stones. Neurourol. Urodynam. 36:271-279, 2017. © 2015 Wiley Periodicals, Inc.

Pelvic Myxoid Leiomyoma Mass between Vagina and Rectum.

Leiomyomas are the most common pelvic tumors in women. About 20-30% of women older than 35 are affected. Rare conditions of leiomyomas have extrauterine locations. Myxoid degeneration is a rare type of leiomyoma degeneration. We report a case of solid-cystic myxoid leiomyoma in a 53-year-old woman complained of constipation, urinary hesitation, and malodorous vaginal discharge with palpable 17 × 12 cm mass between vagina and rectum. Regarding the inferior location of the mass, a perineal approach was used to enucleate it. This rare location has not been mentioned before. The woman was finally diagnosed by pathologists which was myxoid leiomyoma.

Duplication Cyst in the Third Part of the Duodenum Presenting with Gastric Outlet Obstruction and Severe Weight Loss.

Duodenal duplication is a rare developmental abnormality which is usually diagnosed in infancy and childhood, but less frequently in adulthood. We report a case of a 16-year-old female with a duplication cyst in the third part of the duodenum. The patient presented with symptoms of gastric outlet obstruction, including severe anorexia and weight loss. The diagnosis was made preoperatively by CT scan and upper endoscopy. The cyst was successfully treated by marsupialization on the duodenum using a GIA stapler. Duodenal duplication presents with a wide variety of symptoms. Although illusive, many cases can be properly diagnosed preoperatively by using the appropriate imaging modalities. Treatment choices are tailored according to the size and location of the cyst, in addition to its relation to adjacent structures. The outcomes are favorable in the majority of patients.

The visceromotor and somatic afferent nerves of the penis.

INTRODUCTION: Innervation of the penis supports erectile and sensory functions. AIM: This article aims to study the efferent autonomic (visceromotor) and afferent somatic (sensory) nervous systems of the penis and to investigate how these systems relate to vascular pathways. METHODS: Penises obtained from five adult cadavers were studied via computer-assisted anatomic dissection (CAAD). MAIN OUTCOME MEASURES: The number of autonomic and somatic nerve fibers was compared using the Kruskal-Wallis test. RESULTS: Proximally, penile innervation was mainly somatic in the extra-albugineal sector and mainly autonomic in the intracavernosal sector. Distally, both sectors were almost exclusively supplied by somatic nerve fibers, except the intrapenile vascular anastomoses that accompanied both somatic and autonomic (nitrergic) fibers. From this point, the neural immunolabeling within perivascular nerve fibers was mixed (somatic labeling and autonomic labeling). Accessory afferent, extra-albugineal pathways supplied the outer layers of the penis. CONCLUSIONS: There is a major change in the functional type of innervation between the proximal and distal parts of the intracavernosal sector of the penis. In addition to the pelvis and the hilum of the penis, the intrapenile neurovascular routes are the third level where the efferent autonomic (visceromotor) and the afferent somatic (sensory) penile nerve fibers are close. Intrapenile neurovascular pathways define a proximal penile segment, which guarantees erectile rigidity, and a sensory distal segment.

What is the origin of the arterial vascularization of the corpora cavernosa? A computer-assisted anatomic dissection study.

The purpose of this study was to identify the microscopic arterial vascularization of the corpora cavernosa (CC) of the penis using computer-assisted anatomic dissection (CAAD), determine the contribution of the different penile arteries towards this vascularization, detail the nature of cavernospongiosum shunts, and locate the anastomoses between these different arteries. Tissue specimens were taken from five donors who donated their bodies to science. The specimens were fixed in 10% formalin and sliced into a series of five 5-µm sections at intervals of 200 µm. The first section was stained with hematoxylin-eosin or Masson's trichrome and the second with anti-protein S100. The cavernous artery of the penis is not the only source of arterial vascularization of the CC. In four of the five cases studied, we found two to four perforating branches arising from the dorsal arteries of the penis that join up with the cavernous artery of the penis or that are solely responsible for the vascularization of the distal third of the penis. The bulbo-urethral and urethral arteries are situated outside of the tunica albuginea of the corpus spongiosum on their lateral and dorsal sides. The anastomoses do not occur between the cavernous artery of the penis and the corpus spongiosum but between the cavernous artery of the penis and the urethral artery on the surface of the tunica albuginea. All of these arteries are accompanied by nerve branches. The CC were found to be vascularized by both cavernous and dorsal arteries of the penis. Intrapenile vascularization is organized around four arterial axes, which are anastomosed by multiple neurovascular shunts.