Penile fibrosis-still scarring urologists today: a narrative review.

Background and Objective: Implantation of penile prosthesis (PP) into scarred and fibrotic corpora can be a difficult challenge. In this review article, we provide a review of penile fibrosis, discuss current medical and surgical management and summarize preventative strategies. Methods: In this study, we searched PubMed between the years 2000-2023 for publications with search strategy: "penile fibrosis" OR "scarred corpora" OR "fibrosed corpora". Key Content and Findings: This search returned a total of 137 articles. We examine the evidence for preoperative patient evaluation and penile ultrasound (US), oral phosphodiesterase-5 inhibitors, pentoxifylline, and L-arginine, vacuum device therapy and the use of surgical approaches and tools in the context of complex penile fibrosis cases. Severe penile fibrosis is most associated with priapism and infection. Estimating the degree of fibrosis via preoperative US may help set realistic patient expectations. Phosphodiesterase inhibitors and L-arginine reduce fibrosis in animal models however their impact in humans remains unclear despite theoretical advantage for their use. Vacuum device therapy may preserve penile length following priapism and infected PP cases. The use of Coloplast Narrow-Based or AMS-700 CXR implants are used primarily for severe fibrosis. Various surgical excisional/incisional techniques, the Carrion-Rossello, Mooreville Uramix cavernotomes and reverse cutting scissors are all options, and their use varies from case to case. Finally, prevention of penile fibrosis in patients with history of penile implant infection and the safety of early implantation of a penile implant in patients with refractory priapism is encouraged. Conclusions: The management of penile fibrosis remains a challenge but there are multiple options to assist clinicians. Complex cases should be managed and studied at high volume centers.

Patient selection, counseling and preparation for penile prosthesis.

The penile prosthesis has revolutionized the management of erectile dysfunction and is a mainstay in the treatment of this clinical entity. The goal of proper patient selection and counseling is to achieve a satisfactory outcome for the patient. Most patients receiving a penile prosthesis are satisfied with their outcome, and while the penile prosthesis generally allows for high satisfaction rates, avenues for dissatisfaction can arise. Our aim is to aid the prosthetic urologist in identifying such avenues by discussing what factors can lead to a dissatisfied patient. Even a technically successful surgical outcome in the improperly counseled patient can have negative consequences for the patient and the patient-physician relationship. Satisfaction in the penile prosthesis arena can be variably defined and viewed from different perspectives. As such, establishing a personalized framework of expectation management, even in the patient who poses challenging factors, is paramount in preparation for penile prosthesis implantation.

Adnexal smooth muscle hyperplasia resulting in non-traumatic testicular dislocation: A case report.

Tumors of the para-testicular adnexa are very rare and are typically histologically diagnosed as adenomatoid neoplasms, leiomyomata, or smooth muscle hyperplasia. Though these masses are usually benign, the potential for malignancy and mass effect causing intrascrotal discomfort necessitate proper diagnosis and excision. Herein, we describe a unique case of gradual, atraumatic testicular dislocation in a 40-year-old male caused by smooth muscle hyperplasia of the testicular adnexa affecting the epididymis and vas deferens. This case highlights the diagnostic and surgical challenges associated with this presentation.

Penile Implant Instrument Innovations.

PURPOSE OF REVIEW: Numerous innovations have been made since the first inflatable penile prosthesis was introduced in 1973-not just of the implant apparatus itself, but crucially also in the surgical instruments used for prosthetic surgery. Starting with Dr. Furlow's revolutionary inserter tool, advancements were quickly made in dilators, retractors, and cavernotomes. RECENT FINDINGS: More recent innovations have been made in inserter tools, forceps, needle holders, clamps, and disposable instruments. Leading companies Boston Scientific and Coloplast have contributed significantly to the evolution of IPP surgical placement, and companies such as Uramix and Rigicon are developing a wide array of new specialized tools. We aim to summarize the instruments needed for IPP placement, with a focus on describing the variety of instrument innovations since Dr. Brantley Scott designed and placed the first IPP.

Current Status for Semirigid Penile Prosthetic Devices.

PURPOSE OF REVIEW: The goal of this paper was to evaluate the current use of semirigid penile prosthesis (SRPP), surgical techniques for insertion of SRPP, and how to prevent and approach surgical complications. RECENT FINDINGS: SRPP is a valid option for those who are refractory to medical therapy for erectile dysfunction (ED) and even more appropriate for specific subsets of patient populations. It is important for urologists to know which patient population SRPP is preferred for. Several studies have shown good patient outcomes and patient satisfaction with those who underwent SRPP.

Distortion of the implanted penis: SST and cylinder crossover.

In the previous workshop we described cylinders out of place due to flawed and unrecognized surgical movements piercing tissue planes that months later are subsequently exploited by the cylinders during sexual intercourse. This workshop completes the trilogy of cylinders out of place. The fourth workshop cataloged fixes of cylinders out of place intraoperatively and the fifth workshop showed the current surgical revision operations to address the cylinders once they have migrated. This sixth workshop will address correction of the implanted penis that is distorted by hypermobile glans, incorrectly measured or crossed over cylinders.

Out of place cylinders discovered in the postoperative period.

If the surgeon makes a flawed and unrecognized movement with an instrument during implantation surgery, the cylinder subsequently may migrate into an unexpected position with inflation and thrusting post operatively. The out of position cylinder is now evident to the patient or symptomatic with discomfort. This 5th Wilson's Workshop will describe our recommended surgeries for correction of out of place cylinders and illustrate the simplest, safest and least invasive.

Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis.

INTRODUCTION: Many men suffering from erectile dysfunction are overweight with generous suprapubic fat pads, which often contribute to a decrease in visible exophytic phallic length. AIM: To present a novel surgical concept of suprapubic fat pad excision with a concomitant placement of inflatable penile prosthesis. METHODS: A transverse incision begins slightly medial to the anterior superior iliac spine, with the superior edge crossing transversely to the contralateral anterior superior iliac spine. The inferior border is incised in a curvilinear fashion, with the medial apex being approximately 1 cm above the base of the penis. Dissection is carried down to the lower abdominal anterior fascia, which leads to excision of the suprapubic fat pad. Using this same exposure, the inflatable penile prosthesis (IPP) is placed via an infrapubic approach. The wound is reapproximated in multiple layers, and 2 drains are placed, 1 subcutaneous in the area of the fat pad excision and the other in the scrotum around the pump. MAIN OUTCOME MEASURES: Primary outcomes included penile implant functionality, ability to engage in sexual activity, and cosmetic satisfaction. RESULTS: A total of 8 patients have undergone suprapubic fat pad excision with simultaneous placement of IPP at our institution. Average body mass index of our patient cohort was 36.6. 1 patient developed prosthetic infection after inadvertent removal of his drains in the immediate postoperative period. At last follow-up, all other patients have excellent cosmetic and functional outcomes. CLINICAL IMPLICATIONS: This technique can lead to higher patient satisfaction with their penile implant, enhanced sexual performance, and improved quality of life for patients with concurrent erectile dysfunction and significant suprapubic fat pad. STRENGTHS & LIMITATIONS: This unique technique has never been previously described. It allows placement of IPP in the setting of fat pad excision without any additional incisions. Limitations include the small patient population and relatively short follow-up. CONCLUSIONS: Suprapubic fat pad excision is a safe and reproducible technique that can be performed simultaneously with the placement of an IPP in appropriately selected patients. Patients must be counseled appropriately on the expectations of surgeries and the theoretical increased risk of postoperative complications, such as infection. Baumgarten AS, Beilan JA, Shah BB, et al. Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis J Sex Med 2019;16:333-337.

Intralesional Injection of Collagenase Clostridium histolyticum May Increase the Risk of Late-Onset Penile Fracture.

INTRODUCTION: The use of intralesional injection of collagenase Clostridium histolyticum (CCH) has become a valid treatment option in the management of Peyronie's disease (PD). Multiple studies have shown the drug's safety and efficacy. However, sparse literature exists on the utility of the injection protocol's 14-day "observation period," in which patients are instructed to abstain from all sexual activity. AIM: To summarize the contemporary literature and report on our series of patients treated with CCH in an effort to explore the effectiveness of the postinjection observation period. METHODS: We retrospectively reviewed the clinical course of men treated with at least one CCH injection at our institution from April 2014 through February 2017. MAIN OUTCOME MEASURES: The main outcome measure for our cohort was complication rate (hematoma, fracture). Secondary outcomes included progression to corrective surgery. RESULTS: Of the 102 patients treated, 5 (4.9%) developed a corporal fracture. Four of these occurred outside the 14-day observation period. One fracture was managed conservatively and the rest underwent surgical exploration and repair. Twelve penile hematomas were reported; one of these patients was surgically explored because of suspicious magnetic resonance imaging findings. Seven patients (6.9%) progressed to corrective surgery. CONCLUSION: Penile hematoma and corporal fracture are serious complications that must be discussed with patients before initiation of intralesional CCH treatment. Little evidence exists to direct physicians on the proper management of post-CCH penile fractures; many caregivers and patients elect to treat these injuries conservatively and avoid surgical exploration. Further studies are warranted to generate discussion and reassessment regarding the safety and effectiveness of this 14-day observation period. Beilan JA, Wallen JJ, Baumgarten AS, Morgan KN, Parker JL, Carrion RE. Intralesional Injection of Collagenase Clostridium histolyticum May Increase the Risk of Late-Onset Penile Fracture. Sex Med Rev 2018;6:272-278.

Effectiveness of Two Moisturizers in the Treatment of Foot Xerosis A Randomized Clinical Trial.

BACKGROUND:: Xerosis (dryness) of the foot is commonly encountered in clinical care and can lead to discomfort, pain, and predisposition to infection. Many moisturizing products are available, with little definitive research to recommend any particular formulation. METHODS:: We compared two commonly prescribed moisturizing products from different ends of the price spectrum (sorbolene and 25% urea cream) for their effectiveness in reducing xerosis signs using the Specified Symptom Sum Score. A randomized clinical trial of parallel design was conducted over 28 days (February-May 2015) on 41 participants with simple xerosis. Participants, therapists, assessors, and data entry personnel were blinded to treatment, and allocation was determined via a randomization table. RESULTS:: Thirty-four participants completed the study (19 urea and 15 sorbolene), with one reporting minor adverse effects. There were statistically significant improvements in both groups after 28 days. Mean differences between pre and post scores were 3.50 (95% confidence interval [CI], 2.80 to 4.20) for the urea group and 2.90 (95% CI, 2.00 to 3.80) for the sorbolene group. There was a slightly lower mean posttreatment score in the urea group (1.16; 95% CI, 0.67 to 1.64) than in the sorbolene group (1.80; 95% CI, 1.25 to 2.35), but this difference was not significant ( P ≤ .09). Effect size of difference was -0.48 (95% CI, -1.16 to 0.22). CONCLUSIONS:: In this study, there was no difference between using sorbolene or 25% urea cream to treat symptoms of foot xerosis. A recommendation, therefore, cannot be made based on efficacy alone; however, sorbolene treatments are invariably cheaper than urea-based ones.

Translating interprofessional theory to interprofessional practice.

Although interprofessional collaborative activities for health professions students have demonstrated increased knowledge of professional roles, interprofessional attitudes and confidence, and team skills; traditional professional role patterns and lack of professional role understanding are still prevalent among health professions students and may continue into professional practice. Between 1 and 10years after they completed their undergraduate studies, practicing community/public health education professionals and registered nurses who participated in an interprofessional patient home-visiting curriculum as undergraduates were surveyed. Most reported current positive attitudes and perceived collaborative abilities regarding interprofessional collaboration. On their perceived interprofessional collaborative abilities, however, community/public health education participants scored significantly higher (t(143)=-2.53, p=0.01) than registered nurse participants. Although it is difficult to generalize the findings from this study to other interprofessional curriculum models, it seems that this curriculum that concentrated on teamwork behaviors and abilities may have contributed to participants' positive translation of interprofessional theory to interprofessional practice.

V-Neck Technique: A Novel Improvement to the Infra-Pubic Placement of an Inflatable Penile Implant.

BACKGROUND: Infra-pubic placement of an inflatable penile prosthesis (IPP) has a well-known configuration deformity from contralateral tubing that crosses the corporal bodies, resulting in tubing visibility and irritation under the penile skin. AIM: To present a novel step to eliminate this tubing crossover deformity. METHODS: The V-neck technique was applied to five patients, two of whom underwent suprapubic fat pad excision with simultaneous infra-pubic IPP placement and three patients who underwent only infra-pubic IPP placement. The technique added an additional 1 minute of procedure time. The reservoir was placed on one (ipsilateral) side into the space of Retzius. OUTCOMES: Primary outcome measurements were esthetic appeal at follow-up, immediate postoperative complications, and difficulty of implementation of the technique. RESULTS: The technique included the following steps. (i) The standard infra-pubic approach, as popularized by Perito (J Sex Med 2008;5:27-30), was used to place the reservoir and cylinders. The ipsilateral and contralateral cylinders and the reservoir were clamped and unconnected. (ii) Finger dissection was used to create a sub-phallic window and a U-shaped aortic clamp was used to pass the contralateral tubing. (iii) After passing the green tubing through the window, all connections were performed in the usual fashion. Tubing crossover was eliminated, as was passage of the right and left cylinder tubes down their respective gutters. Postoperative follow-up at 2 weeks showed no visible tubing. CLINICAL IMPLICATIONS: This simple maneuver could help prevent the discomfort of tubing crossover deformity commonly seen after infra-pubic placement of an IPP. STRENGTHS AND LIMITATIONS: This unique maneuver can be applied to all infra-pubically placed IPPs. Limitations include the small patient population and short follow-up. Whether this maneuver will make revision surgery more difficult is unclear. CONCLUSION: This technique is a novel step to infra-pubic IPP placement that adds minimal operative time and could eliminate visible tubing. Shah BB, Baumgarten AS, Morgan K, et al. V-Neck Technique: A Novel Improvement to the Infra-Pubic Placement of an Inflatable Penile Implant. J Sex Med 2017;14:870-875.

Moisturisers for the treatment of foot xerosis: a systematic review.

BACKGROUND: Xerosis, literally dryness of the skin, of the foot is a common condition encountered clinically, which can lead to discomfort and predisposition to infection. Currently, there are no evidence-based recommendations on which moisturiser formulations best alleviate xerotic symptoms. The aim of this review was to guide clinical practice in the treatment of primary and diabetes related foot xerosis, by identifying from the existing literature the most effective ingredient or formulation of topical treatments for symptoms of primary foot xerosis in the general population. METHODS: A systematic review of published experimental trials was undertaken. Only studies pertaining to primary xerosis, classified within levels II - IV of the NHRMC hierarchy were reviewed. EMBASE, AMED, Cochrane, MEDLINE, CINAHL, Ageline and SCOPUS were searched using relevant search terms and keywords and pearling of reference lists was undertaken. Studies were evaluated for methodological quality using a critical appraisal tool. Individual active ingredients were identified from all studies, along with observed reported outcomes. A narrative synthesis was then conducted. RESULTS: A total of 22 experimental studies were included, from which 12 different active ingredients were identified. Study literature consisted of mainly comparative studies against other active interventions or controls, or pre-post-tests and was of a poor-to-moderate methodological quality as assessed by the Epidemiological Appraisal Instrument. Urea was the most researched active ingredient (14 studies), with ammonium lactate being next (7 studies). CONCLUSIONS: No conclusive recommendations were possible due to wide variation in study quality, methodologies and outcome measures. A synthesis of available literature suggests that treatments containing urea as a primary active ingredient have been the most researched. The poor quality of literature generally, however, precludes recommendation of any active ingredient over another.

Floppy Glans Syndrome: Pathogenesis and Treatment.

INTRODUCTION: Floppy glans syndrome (FGS) is a potential complication of penile prosthesis placement in patients with erectile dysfunction. FGS affects a very small proportion of these patients, and it can manifest in a ventral, dorsal, or lateral droop of a hypermobile glans, which can cause affected patients to complain of painful, unsatisfying, or otherwise difficult attempts at sexual intercourse. Incorrect cylinder sizing can even result in extreme conditions such as flail penis or S-shaped deformity. AIM: The aim of this review is to outline the types, causes, and management options for FGS. METHODS: This review was conducted after a thorough literature search in addition to experience managing FGS at the authors' institution. MAIN OUTCOME MEASURES: Clarification of the nomenclature for FGS, supersonic transporter deformity, flail penis, and crossover to define, diagnose, and treat these conditions. RESULTS: In many cases of FGS, poor intraoperative prosthetic cylinder positioning and sizing can lead to insufficient compression of the deep dorsal and circumflex veins between the Buck fascia and the corpora cavernosa, even when cylinders are maximally inflated. When the adjacent tissue does not adequately restrict blood flow through these vessels, then glanular tumescence becomes increasingly difficult to achieve, particularly in patients with severe erectile dysfunction who have poor glanular blood flow at baseline. FGS also can be a result of poor underlying glanular structural support. Thus, droop is possible even when cylinders have an appropriate size and position. Treatment options range from medical management to surgical correction. Distal penoplasty and glanulopexy have been described as effective methods of correcting the FGS deformity and avoiding the more invasive option of prosthetic cylinder replacement. These options are especially valuable in patients who undergo adequate cylinder sizing intraoperatively. CONCLUSION: FGS is not monolithic, and careful diagnosis is essential to determining the appropriate treatment course.

A Rare Case of the Simultaneous, Multifocal, Metastatic Renal Cell Carcinoma to the Ipsilateral Left Testes, Bladder, and Stomach.

We describe the rare case of a 68-year-old gentleman with the history of a hand-assisted laparoscopic left radical nephrectomy for a T2bN0M1 clear cell renal cell carcinoma (RCC). Seven years after surgery and with clean surveillance imaging for metastasis/recurrence the patient presented with three separate tumors suspicious for malignancy. A bladder lesion was found during workup for hematuria, a stomach lesion during diagnostic endoscopy, and a testicular lesion during self-exam. He underwent transurethral resection of bladder tumor, left inguinal orchiectomy, and upper endoscopic ensnarement. All specimens surprisingly showed RCC by histology and immunostaining. These three sites are rare for RCC metastasis and simultaneous presentation is even rarer, further emphasizing the importance of continuous and careful follow-up in this patient population, despite what could appear as complete remission.

A Novel Approach for the Treatment of Radiation-Induced Hemorrhagic Cystitis with the GreenLightTM XPS Laser.

INTRODUCTION: The treatment of pelvic malignancies with radiotherapy can develop severe sequelae, especially radiation-induced hemorrhagic cystitis. It is a progressive disease that can lead to the need for blood transfusion, hospitalizations, and surgical interventions. This tends to affect the quality of life of these patients, and management can at times be difficult. We have evaluated the GreenLight Xcelerated Performance System (XPS) with TruCoag, although primarily used for management of benign prostatic hypertrophy (BPH), for the treatment of radiation-induced hemorrhagic cystitis. MATERIALS AND METHODS: After International Review Board (IRB) approval, a retrospectivechart review was performed in addition to a literature search. A series of four male patients, mean age of 81 years, with radiation-induced hemorrhagic cystitis secondary to radiotherapy for pelvic malignancies (3 prostate cancer, 1 rectal cancer) were successfully treated with the GreenLight laser after unsuccessful treatment with current therapies described in the literature. RESULTS: All four patients treated with the GreenLight laser had resolution of their hematuria after one treatment and were discharge from the hospital with clear urine. CONCLUSION: The GreenLight XPS laser shows promising results for the treatment of patients with radiation-induced hemorrhagic cystitis, and deserves further evaluation and validation, especially since there is limited data available in the literature regarding the use of this technology for the treatment of this devastating condition.