Topographic and Structural Anatomy of the Suspensory Ligament of the Penis: Implications for Phalloplasty.

BACKGROUND: The suspensory ligamentous system of the penis supports the penis when erect and plays a key role during coitus. These ligaments, which are prone to injury during coitus, are clinically important in penile reconstruction procedures. OBJECTIVES: The current study investigated the macro- and microanatomy of the suspensory ligamentous system of the penis to determine the origin, course, insertion, dimensions, and tissue composition of these ligaments, knowledge of which is vital for successful penile reconstruction procedures. METHODS: The study utilized a total of 49 cadavers. Gross anatomy dissection, MRI, and histological staining were performed to elucidate the topography, dimensions, and tissue composition of the suspensory ligaments of the penis. RESULTS: Three ligaments were observed to form the suspensory ligamentous system of the penis. The most superficial is the fundiform ligament, which consists of superficial bundles and deep median bundles, with the former arising from the Scarpa's fascia and the latter arising from the linea alba of the anterior abdominal wall; both inserted into the superficial fascia of the penis. The suspensory ligament of the penis arose from the pubic symphysis and inserted into the deep fascia (Buck's fascia) of the penis. The arcuate ligament arose from the body of the pubis and pubic symphysis and inserted into the Buck's fascia. The ligaments were determined to consist of adipose tissue, collagen fibers, elastic fibers and reticular fibers, in varying proportions. CONCLUSIONS: The suspensory ligaments of the penis exhibit a fan-like structure on the penis that allows the forward movement of the penis as a result of engorgement of the erectile bodies while simultaneously offering support.

Erectile device insertion following phalloplasty in transgender and non-binary individuals assigned female at birth: a narrative review.

Genital gender affirmation surgery (gGAS) for individuals assigned female at birth (AFAB) is complex and requires the staged insertion of an erectile device to permit penetrative intercourse. This final stage of gGAS is challenging, owing to the variable anatomy and lack of supportive structures within the neophallus when compared with erectile device insertion for individuals assigned male at birth. There is a paucity in the literature at present regarding erectile device insertion in trans-sex AFAB patients. Hence, a narrative review following a literature review and supplemented by expert opinion from a high-volume centre of expertise is presented. The choices available for erectile device in this patient cohort are discussed. Principle surgical steps required for this complex surgery is outlined along with the recommended postoperative management of the patient. Postoperative outcomes and complications are also summarised in this fast-developing surgical procedure.

Urogenital development and sexual differentiation in males of the species Dasyprocta fuliginosa.

Thirteen black agouti (Dasyprocta fuliginosa) male fetuses, acquired in two areas of the Amazon Forest, were used for the purpose of morphologically describing the fetal male urogenital organs with a focus on addressing histological and macroscopic aspects. The organs of interest were dissected and photographed in situ and ex situ. Fragments were collected and subjected to routine histological processing for inclusion in paraffin, which was cut and stained by haematoxylin and eosin and Gomori's Trichrome methods and subsequently analysed in a light microscope. The results showed that the urinary tract is like that of domestic animals and is composed of smooth unilobed kidneys covered by a dense capsule of connective tissue and divided into two well-defined regions, cortical and medullary. Ureters, urethra and urinary bladder also showed macroscopic and microscopic characteristics similar to those of domestic animals. The penis of these animals has fibroelastic characteristics, with numerous keratinized structures at its apex. In the middle third of the penis, a "U" shaped penile flexure was seen; the glans penis is covered by a keratinized epidermis containing horny spicules. The presence of a penile bone in an endochondral ossification process was observed, being more developed in gestational ages greater than 76 days. The annex glands were not observed, probably because they were fetuses; only the ampulla of the ductus deferens was identified.

Cirugía de alargamiento y engrosamiento de pene. Técnica NEF: resultados en 750 pacientes / Penis enlargement and thickening surgery. NEF technique: results in 750 patients

Introducción y objetivo: La cirugía de alargamiento y engrosamiento de pene supone un reto técnico para el cirujano, puesto que las técnicas clásicas han demostrado resultados insuficientes para los pacientes. Nuestro objetivo es presentar nuestra experiencia con una técnica reproducible que permite evitar el empleo de extensores y las complicaciones de la infiltración de grasa. Material y método: Analizamos de forma retrospectiva 750 casos de alargamiento y engrosamiento de pene primarios realizados con la técnica NEF (No Extenders No Fat) - No Extensores No Grasa), analizando la técnica quirúrgica, sus resultados y complicaciones. Esta técnica se basa en la creación de un colgajo de avance cutáneo junto con un colgajo de fascia de Scarpa y un nanofat infiltrado en las fascias profundas del pene. Resultados: La ganancia media en longitud en el grupo de pacientes estudiados fue de 4.8cm en reposo, con un espectro de 2 hasta 8.1cm. En el engrosamiento, se alcanzó un incremento medio de 1.17 cm (mínimo de 0.5 y máximo de 1.8 cm). Conclusiones: La tasa de satisfacción de pacientes, de complicaciones y retoques en nuestro grupo de estudio nos hablan de una cirugía que mejora las técnicas previas, más invasivas y con mayor tasa de complicaciones. El apoyo psicológico y la ayuda profesional preoperatoria es imperativa, y se debe ofrecer especialmente en casos de dismorfofobia. El trabajo pre y postoperatorio es esencial en estos pacientes. Conseguir pacientes con expectativas reales es la primera barrera que debemos franquear. Solo cuando el paciente haya entendido la cirugía y sus resultados, debemos avanzar hacia ella. (AU)

Background and objective: Penis lengthening and thickening surgery is a technical challenge for the surgeon, since classical techniques have shown insufficient results for patients. Our objective is to present our experience in the develop of a a reproducible technique that avoids the use of extensors and the complications of fat infiltration. Methods: Retrospectiv análisis of 750 cases of primary penis enlargement and thickening performed with the NEF (No Extenders No Fat) technique, analyzing the surgical technique, its results and complications. This technique is based on the creation of a skin advancement flap, together with a Scarpa fascia flap and a nanofat infiltrated at the deep fascia of the penis. Results: Mean gain in length in the group of patients studied was 4.8 cm at rest with a spectrum from 2 to 8.1 cm. In thickening, the measurement reached an average increase of 1.17 cm (minimum of 0.5 and a maximum of 1.8 cm). Conclusions: Rates of patient satisfaction, complications and retouching in our group tell us about a surgery that improves previous more invasive techniques with a higher rate of complications. Psychological support and professional pre-surgery help is imperative and should be offered especially in those cases of dysmorphophobia. Pre and postoperative work is essential in these patients. Getting patients with real expectations is the first barrier we must overcome. Only when the patient has understood the surgery and its results, should we move towards it. (AU)

Accuracy of telemedicine for diagnosis and pre-operative assessment of pediatric penile conditions.

INTRODUCTION: Patients with penile conditions comprise a significant proportion of any pediatric urology practice, and physical examination is the mainstay of diagnosis for such conditions. While the rapid adoption of telemedicine (TM) facilitated access to pediatric urology care during the pandemic, the accuracy of TM-based diagnosis for pediatric penile anatomy and pathology has not been studied. Our aim was to characterize the diagnostic accuracy of TM-based evaluation of pediatric penile conditions by comparing diagnosis during the initial virtual visit (VV) with a subsequent in-person visit (IPV). We also sought to assess the agreement between scheduled and actual surgical procedure performed. METHODS: A single-institution prospective database of male patients less than 21 years of age who presented for evaluation of penile conditions between August 2020 and December 2021 was analyzed. Patients were included if they had an IPV with the same pediatric urologist within 12 months of the initial VV. Diagnostic concordance was based on a surgeon-reported survey of specific penile diagnoses, completed at both initial VV and follow-up IPV. Surgical concordance was assessed based on the proposed versus billed CPT code(s). RESULTS: Median age among 158 patients was 10.6 months. The most frequent VV diagnoses were penile adhesions (n = 37), phimosis (n = 26), "other" (n = 24), post-circumcision redundancy (n = 18), and buried penis (n = 14). Initial VV and subsequent IPV diagnoses were concordant in 40.5% (64/158); 40/158 (25%) had partial concordance (at least one diagnosis matched). There was no difference in age, race, ethnicity, median time between visits, or device type between patients with concordant vs. discordant diagnoses. Of 102 patients who underwent surgery, 44 had VV only while 58 had IPV prior to surgery. Concordance of scheduled versus actual penile surgery was 90.9% in those patients who only had a VV prior to surgery. Overall, surgery concordance was lower among those with hypospadias repairs vs. non-hypospadias surgery (79.4% vs. 92.6%, p = 0.05). CONCLUSION: Among pediatric patients being evaluated by TM for penile conditions, there was poor agreement between VV-based and IPV-based diagnoses. However, besides hypospadias repairs, agreement between planned and actual surgical procedures performed was high, suggesting that TM-based assessment is generally adequate for surgical planning in this population. These findings leave open the possibility that, among patients not scheduled for surgery or IPV, certain conditions might be misdiagnosed or missed entirely.

Baculum shape complexity correlates to metrics of post-copulatory sexual selection in Musteloidea.

The penis bone, or baculum, is present in many orders of mammals, although its function is still relatively unknown, mainly due to the challenges with studying the baculum in vivo. Suggested functions include increasing vaginal friction, prolonging intromission and inducing ovulation. Since it is difficult to study baculum function directly, functional morphology can give important insights. Shape complexity techniques, in particular, are likely to offer a useful metric of baculum morphology, especially since finding homologous landmarks on such a structure is challenging. This study focuses on measuring baculum shape complexity in the Musteloidea-a large superfamily spanning a range of body sizes with well-developed, qualitatively diverse bacula. We compared two shape complexity metrics-alpha shapes and ariaDNE and conducted analyses over a range of six different coefficients, or bandwidths, in 32 species of Musteloidea. Overall, we found that shape complexity, especially at the baculum distal tip, is associated with intromission duration using both metrics. These complexities can include hooks, bifurcations and other additional projections. In addition, alpha shapes complexity was also associated with relative testes mass. These results suggest that post-copulatory mechanisms of sexual selection are probably driving the evolution of more complex-shaped bacula tips in Musteloidea and are likely to be especially involved in increasing intromission duration during copulation.

Detailed anatomy of the corpora-glans ligament via the P45 plastination method / Anatomía detallada de los ligamentos cuerpo cavernoso-glande mediante el método de plastinación P45

SUMMARY: The corporo-glans ligament is the ligament connecting the corpus cavernosum and the glans of the penis. The anatomical description of the corporo-glans ligaments shape is still uncertain, this knowledge affects penile reconstructive procedures. The anatomy of the corporo-glans ligament was analyzed and recorded via observing sagittal sections of 10 different penile P45 plastination sections. According to the P45 plastination sections, the corporo-glans junction displayed a fibrous tissue band connecting the distal ends of the two corpus cavernous (CC) with the glans penis (GP). The fibrous band was a round-obtuse shape and ran deep into the glans of the penis and occupied about 2/3 of the whole GP. The original end was laid in a socket embedded in the GP. The density of the fibers of the ligament at the original end close to the tunica albuginea was less than that of the other parts. The fibers originating from the tunica albuginea, directly extended to the blind end of the two CC, covering the distal end of the two CC.

El ligamento cuerpo cavernoso-glande es el ligamento que conecta el cuerpo cavernoso y el glande del pene. La descripción anatómica de la forma de los ligamentos cuerpo cavernoso -glande aún es incierta; este conocimiento afecta los procedimientos reconstructivos del pene. La anatomía del ligamento cuerpo cavernoso-glande se analizó y registró mediante la observación de 10 secciones sagitales diferentes del pene a través de plastinación P45. Según las secciones de plastinación, la unión cuerpo-glande mostraba una banda de tejido fibroso que conectaba los extremos distales de los dos cuerpos cavernosos con el glande del pene. La banda fibrosa tenía una forma redonda y obtusa y se adentraba profundamente en el glande del pene ocupando alrededor de 2/3 de él. En su origen se coloca en un espacio profundo en el glande del pene. La densidad de las fibras del ligamento cuerpo cavernoso-glande en su origen cercano a la túnica albugínea era menor que el de las otras partes. Las fibras que se originan en la túnica albugínea, se extienden directamente hasta el extremo ciego de los dos cuerpos cavernosos, cubriendo el extremo distal de estos.

Male genital organs of the black-crowned dwarf marmoset (Callibella humilis).

This study provides the first morphological description of the male genital organs of black-crowned dwarf marmoset (Callibella humilis). Internal and external genital organs were similar to other species of non-human primates. However, some shape and size differences were noted. The penile shaft was laterally flattened and comprised of two corpus cavernosus. These were split by a septum up to the level of the glans and then merged to form a single structure. The glans penis had small, keratinized spicules arising from epidermal or dermal projections. The small, fully ossified and well-mineralized penile bone, located at the distal end of the penis, consisted of a bone matrix surrounded by sparse osteoblasts and well-developed internal osteocytes. The penile urethra was lined with columnar pseudostratified epithelium, with areas of simple cuboidal epithelium. The testes were small relative to the body compared to other primate species. The findings of this work may support comparative studies of primate reproductive ecology.

Penile lenghthening original technique using a pubo-cavernous spacer. Long term results from a series of over 200 patients.

INTRODUCTION: We report our long experience in the surgical treatment of patients requesting penile lengthening by suspensory ligament release and placement of a custom-made soft silicone pubo-cavernous spacer. The aim was to show that with this surgical technique the results obtained are maintained over time. It is crucial to achieve postoperative satisfaction of these patients who show fragility and self-esteem problems. METHODS: From 1999 to 2020, we treated 245 patients with congenital or acquired penile brevity. We carefully analysed the preoperative and postoperative (at 6, 12, 24 and 48 months) penile size of the patients to evaluate whether this technique could allow the long-term maintenance of aesthetic results. We also assessed preoperative erectile function and we focused on the psychological aspects to avoid surgery in patients with dysmorphophobia. This original technique involves the section of the suspensory ligament and the implantation of a silicone spacer between the pubic symphysis and the corpora cavernosa. This spacer is conformed to the patient anatomy and maintains the relationship between the anatomical structures unchanged over time. Sexual self-esteem and patient satisfaction were assessed with the APPSSI questionnaire. RESULTS: The mean increase in penile length was about 2.5 cm in flaccid state and 1.9 cm in stretched state. There were no injuries of the neurovascular bundle or urethra, and no erectile dysfunction was noted. These results persisted at 6, 12, 24 and 48 months without significant differences. Over 80% of patients stated that they were completely satisfied with the results obtained. This satisfaction remained stable along follow up. CONCLUSION: The section of the suspensory ligament and the implant of the soft silicone spacer provide real penis elongation with satisfactory results that persist over time. This technique avoids the frequent complication of short-term shortening due to the scar adhesions of the edges of the dissected ligament. The high aesthetic satisfaction of patients is stable at controls at 6, 12, 24 and 48 months.

Morphology of the male reproductive tract of Eira barbara.

Eira barbara, popularly known as irara, is a medium-sized carnivore member of the Mustelidae family. Despite its important role in the ecosystems in which its lives, data on the internal morphology of E. barbara remains scarce. Therefore, this study aimed to provide knowledge regarding the anatomy of the male reproductive system of this species to improve understanding of its reproduction to inform its conservation. We studied seven specimens who had died after being run over. The specimens were dissected for the evaluation of the reproductive system, which comprised a globular scrotum; a small pendulum covered with light-coloured hair; a pair of testicles of firm consistency and ellipsoid shape and suspended in the scrotum by the spermatic cord; a paired duct system; an ampoule of the deferens duct and prostate constituting the set of attached glands; a urethra divided into pelvic and penile portions; a penis with a baculum having a novel "C" shaped apex; and a prepuce. Microscopically, the testicular parenchyma consisted of seminiferous tubules separated by intertubular spaces formed by loose connective tissue, fibrocytes, Leydig cells, and blood and lymph vessels. The epididymis was surrounded by a capsule of dense connective tissue and extended to form septa. The baculum was microscopically classified as a compact bone containing several bony lamellae with osteocytes and osteoblasts. The macro and microscopic findings were generally similar to those of domestic carnivores, with some notable differences.

Glans penis augmentation: when, how, and why?

The growing demand for glans penis augmentation (GPA) makes it a hot topic in the field of andrological surgery, albeit still widely debated. The lack of high supporting evidence and its technically challenging aspects are the main concerns. The aim of this study was to review the current literature about GPA in order to provide an easy and comprehensive overview of the topic. GPA is suitable for managing both cosmetic and functional issues. Counseling should be the cornerstone of the decision-making process. A thorough understanding of the glans anatomy and treatment strategies remain essential to safely and effectively address the patient's needs. GPA can be performed using injectable fillers or surgical grafting. Glans-shaft penis asymmetries, small glans size, and loss of glans tumescence can be managed by both injectable fillers and surgery. On the other hand, patients with lifelong premature ejaculation can mainly benefit from using injectable fillers. Currently, available studies show promising results but are limited by small sample's size and non-randomized design. Furthermore, treatment-related complications are poorly reported. The long-term efficacy and safety profiles of GPA techniques should be further investigated.

Multidisciplinary approach and management of patients who seek medical advice for penile size concerns: a narrative review.

We aimed to provide an overview of the strategies available to manage patients concerned about their penile size and to provide useful surgical hints regarding the most common penile enlargement approaches, based on our surgical expertise in this field. A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning penile enlargement issues. The search strategy included a range of keywords; e.g. penis, penile, enlargement, augmentation, lengthening, girth. Management of penile size-related concerns represents a real challenge for the urologist, especially when dealing with patients suffering from penile dysmorphophobic disorder (PDD). A multidisciplinary preoperative assessment, including a psychiatric/psychological evaluation, may help in discerning those patients who would benefit the most from counselling/conservative management from those who would benefit from surgery instead. Conservative approaches include the use of vacuum-based and penile-stretching devices, which have shown encouraging levels of efficacy and safety. Over the last decades, different surgical strategies have been developed, aimed at either increasing flaccid penile length or improving penile girth. Penile lengthening procedures are more established, and satisfactory results can be achieved by experienced, large referrals' volume, surgeons. To date, there is lack of consensus regarding the penile girth enhancing techniques, and therefore these should be regarded as experimental. A multidisciplinary approach is necessary to identify patients with PDD, who should not be offered surgical intervention and should be referred for psychiatric/psychological counselling instead. The surgical approach should be tailored to the subject's unique anatomy and underlying conditions.

Penile length of men attending urology outpatient clinic in Southwest Nigeria.

Penile length varies worldwide. It is necessary to determine penile length in our region to enable adequate counselling on normal length and reduce avoidable anxiety. Two hundred and seventy-one men were recruited with 97 men in group I and 174 men in group II. Mean ages were 38.4 ± 6.9 (21-50) years and 68 ± 9.1 (51-98) years. In group I, the mean flaccid penile length (FPL)-I and stretched penile length (SPL)-I were 9.8± 2.7 and 10.6± 2.2, mean height 1.7±0.07m and body mass index (BMI) 24.1±3.1 kg/m2. While in group II, mean FPL-II and SPL-II were 13.0± 2.9 and 14.1 ± 2.1, mean height was 1.69± 0.07m and BMI 24.3± 3.2 kg/m2. There were positive correlations between the SPL-I and heights in group I; (r=0.305, p<0.002); height and FPL-I (r = 0.218, P<0.032). Similarly, in group II positive correlations of FPL-II and SPL-II with height; r = 0.166 P<0.028 and r = 0.183, P<0.015. There was negative correlation SPL-II and BMI-II r-0.224, p<0.003. FLR-II and BMI-II, -0.157, p<0.039. In conclusion, Flaccid and stretched penile length of men < 50 years was smaller than those > 50 years. In both age groups, flaccid and stretched penile lengths correlated with height. In group II, penile lengths correlated negatively with BMI.

Stretched penile length at birth: a systematic review.

BACKGROUND: Micropenis is an endocrinological condition that is habitually observed at birth. Diagnosis is made by measuring the stretched penile length, a method established 80 years ago. Discrepancies in the normative data from recent studies raise the need for a current revision of the methodology. OBJECTIVES: The aims of this systematic review were to compare the different normative data of SPL at birth, to examine the methodological aspects of the technique and to evaluate the independent variables that may be involved. METHODS: Searches were performed using MEDLINE, EMBASE, Scielo, the Cochrane Library and Web of Science. A combination of the relevant medical terms, keywords and word variants for "stretched penile length", "penile length", "penile size", "newborn" and "birth" were used. Eligibility criteria included normative studies that used the stretched penile length (SPL) measurement on a population of healthy, full-term newborns during the first month of life. The outcomes studied included characteristics of the studies, methodological aspects and independent variables. RESULTS: We identified 49 studies comprising 21,399 children. Significant discrepancies are observed between the different studies. Methodological aspects seem to be consistent and similar. The main independent variables appear to be ethnic group and gestational age. Main limitations were the absence of studies of entire world regions such as Europe or South America, and the heterogeneity of the ethnic background that complicates the analysis. CONCLUSIONS: It seems advisable to suggest the creation of customized reference charts for each specific population instead of resorting to the classic cut-off points.

Intra-horn Penile Intromission in the Alpaca Vicugna pacos and Consequences to Genital Morphology.

Copulatory behavior and genital morphology interact to deliver sperm more effectively during mating, but the nature of this interaction has not been explored in depth in most vertebrates. Alpacas have unusually long copulations lasting 15-20 min, and a unique copulatory behavior, where the penis intromits all the way past the cervix, into the uterine horns. Here we describe the morphology of male and female genitalia and report unique morphological characteristics that may be associated with this unusual insemination mode. Vaginal shape is highly variable, and seemingly not associated with age or parity. The cranial vagina varies between bulbous and cylindrical, while the caudal vagina is typically narrower and always cylindrical. The cervix consists of a series of two to three spirals or rings, and it is often found in a relaxed state that may prevent damage caused by the cartilaginous penis tip as it pushes through the cervix to reach the uterine horns. The uterus and uterine horns have a complex shape with multiple constrictions. The cartilaginous penis tip has a sharp urethral process that may help to push against these constrictions. The diameter of the vaginal lumen is much greater than the diameter of the penis suggesting that there is little direct interaction between them, and that female vaginal shape is not under strong copulatory selection. In effect, the entire female reproductive tract of the female is interacting with the penis during copulation.