Outcomes of Surgical Management of Men With Peyronie's Disease With Hourglass Deformity

OBJECTIVE

To investigate the outcomes of two surgical interventions for Peyronie's disease (PD) with hourglass deformity: partial excision and grafting (PEG) or inflatable penile prosthesis (IPP) implantation.

MATERIALS AND METHODS

Retrospective data were collected from two centers: Technical University of Munich (PEG) and Tulane University Medical Center (IPP). Collected variables included patient demographics, sexual function, penile vascular measurements, and treatment outcomes.

RESULTS

A total of 50 PD patients with hourglass deformity (26 PEG [group 1] and 24 IPP [group 2]) were included in this study. Patients in group 1 had higher mean preoperative Sexual Health Inventory for Men scores (22.2 vs 10.3, P < 0001), required less erectile dysfunction treatment (35% vs 79%, P = .005), and had more nonvascular etiology (77% vs 21%, P < .0001). There were no intraoperative complications, 2 patients in group 1 had postoperative glans hypoesthesia, and 1 patient in group 2 required surgical revision. All patients in both groups had significant ≥20% improvements in penile curvature with mean changes of 68.1 degrees (12.7) in group 1 and 49.6 degrees (13.5) in group 2, P < .0001. Resolution of hourglass deformity was achieved in 85% of patients in group 1 and 100% of patients in group 2, P = .045. The mean postoperative change in Sexual Health Inventory for Men score was -0.3 (1.3) in group 1 and 16.7 (4.7) in group 2, P < .0001.

CONCLUSION

Both options provide excellent outcomes for well-selected patients with PD and an hourglass deformity. PEG can be offered to patients with good erectile function, whereas the IPP remains the preferred option for patients with poor erections.

Surgical management of Peyronie's disease

Peyronie's disease (PD) has a significant impact on the quality of life of both patients and their partners due to the compromised sexual function and physical deformation resulting from the condition. PD is a connective tissue disorder marked by fibrotic healing of the tunica albuginea, leading to penile deformities including curvature, shortening, loss of girth, hourglass appearance, and hinging. Despite the multiple medical therapies available, surgery is the gold standard of treatment once the plaque has stabilized. We present a review of the disease process, preoperative evaluation, operative planning, surgical treatments with outcomes and complications, and nascent developments in surgical management and graft development. Options include tunical lengthening procedures, tunical shortening procedures, and penile prosthesis. Decision-making is governed by degree of curvature, erectile function, and associated penile deformities. In cases with curvature of less than 60-70 degrees, adequate penile length, and no hourglass deformity, patients are candidates for tunical shortening procedures. Patients with curvature greater than 60-70 degrees, penile hourglass or hinge-destabilizing deformities, and adequate erectile function should be counseled with regard to tunical lengthening procedures. Patients with poor preoperative erectile function should undergo inflatable penile prosthesis placement, with possible secondary straightening procedures. Technique selection should be based upon surgeon preference, expertise, and experience, as evidence does not necessarily support one procedure over another.

Impact of sexual activity on glycated hemoglobin levels in patients with type 2 diabetes mellitus after penile prosthesis implantation

PURPOSE

To examine the benefits of sexual activity on glycated hemoglobin (HbA1c)in penile prosthesis implanted patients with type 2 diabetes mellitus (DM).

MATERIALS AND METHODS

Sixty-seven male subjects who had HbA1c levels of ≥ 6.5% before and could perform regular sexual activity after the implantations were enrolled. The contribution of sexual activity on glycemic control assessed by HbA1c level as well as age, duration of DM and frequency of sexual activity were evaluated.

RESULTS

Mean age and mean time from the surgery of the study patients was 59.9 years (range,30-82) and 22.6 months (range, 10-63), respectively. The average of penile prosthesis usage for sexual activity was 9.9 times per month (range, 2-28). Compared with the preimplantation, the absolute mean change in HbA1c after penile prosthesis implantation was found as - 0.2% (P > .05). This study also revealed that more sexual activity was associated with more reduction in HbA1c.

CONCLUSION

The present study demonstrated that sexual activity is associated with HbA1c reduction, which is clinically important in patients with type 2 DM after penile prosthesis implantation.

[Medico legal considerations on prosthesis surgery of the erectile dysfunction in a La Peyronie disease case]

Peyronie's disease is characterized by the presence of an inelastic fibrous plaque of the penile tunica albuginea affecting 3-10% of the male population. The fibrous scar causes the curvature of the erect penis, which prevents the penetration. In the stabilization phase the plaque can cause a variable degree of erectile dysfunction (20-54%). In the treatment of the chronic disease, surgery is the gold standard and in case of concomitant erectile dysfunction the placement of a penile prosthesis is indicated. This surgery is loaded with an increase of the variables which can affect the outcome, such as individual clinical features and functionality of the device. The present case concerns a patient suffering from erectile dysfunction associated with Peyronie's disease who underwent surgery for implantation of hydraulic three-component penile prosthesis. After surgery a malfunction of the prosthesis was detected, which required unloading measures under sedation and a surgical revision of the scrotal pump. The latter was followed by the displacement of the prosthesis' cylinder and by a new surgical treatment for the reintegration of the prosthesis and the repair of the left corpus cavernosum. After two months a wrong positioning of the two cylinders inserted into the corpora cavernosa, with the left cranial extreme positioned 2 cm below the contralateral, was detected. In this case the failure of surgical treatment highlights a negligent behavior and the responsibility of the doctors by failing to examine adequately the variables, both clinical and not clinical, that might affect the outcome of the intervention.

[Clinical efficacy and patient satisfaction with penile prosthesis implantation for the treatment of severe erectile dysfunction]

OBJECTIVE

To investigate the clinical efficacy and patient and partner's satisfaction with penile prosthesis implantation (PPI) for treating Chinese patients with severe erectile dysfunction (SED).

METHODS

One hundred and sixty-eight SED patients were successfully treated by PPI from July 2000 to June 2010. Of the 146 (86.9%) patients who had been followed up over 6 months post-operation, 36 (24.7%) had been implanted with one piece malleable prosthesis (AMS650) and 110 (75.3%) with three piece inflatable prosthesis (AMS700CXM).All the patients had been followed up by using international index of erectile dysfunction (IIEF5), Quality of Life Score (QOL) for evaluating clinical efficacy and using Visual Analogue Scale (VAS) for evaluating patient and partner's satisfaction and the duration of the follow-up was 6 to 119 months.

RESULTS

The mean age of patients was 35.9+/-12.1 years(20 to 75 years), All the operations were successful and sexual intercourse with PPI was performed post 4 to 6 weeks without severe complications like infection and erosion. The prosthesis survive rate and frequent sexual intercourse rate were 98.6% and 87.7% respectively. IIEF5 scores pre and post PPI were 6.3+/- 1.7 and 21.3+/-1.6 respectively,the QOL scores pre and post PPI were 5.1+/-0.9 and 1.5+/-0.5 respectively, and both of them showed significant improvement (P<0.01). As for VAS, the patient and partner's overall satisfaction rates were 92.5% and 90.4% respectively. Moreover, better satisfaction was showed with AMS700CXM as compared with AMS650 (P<0.05) in patients with SED.

CONCLUSION

PPI is the safe and effective treatment option for Chinese patients with SED. The AMS700CXM penile prosthesis is better than AMS650 for patients' overall satisfaction.

Treatment of diabetic impotence with umbilical cord blood stem cell intracavernosal transplant: preliminary report of 7 cases

OBJECTIVES

Stem cells are characterized by self renewal and multipotent differentiation.We report the effects of intracavernosal transplant of human umbilical cord blood stem cells on diabetic erectile dysfunction.

MATERIALS AND METHODS

Seven type 2 diabetics who had failed to achieve an erection for at least 6 months despite medications, and who are currently awaiting penile prostheses, participated. All laboratory results were normal, except for impotence and diabetes mellitus. A total of 1.5 x 10(7) human umbilical cord blood stem cells were infused into the corpus cavernosum. No immunosuppressive measures were taken in any of the patients. International index of erectile function-5, SEP, GAQ, erection diary, blood glucose diary, and medication dosage were followed for 9 months.

RESULTS

The mean age was 69.5 years (range, 57-87 years). Morning erections were regained in 3 participants within 1 month, and for all except 1 by the third month, and maintained for more than 6 months. Rigidity increased as the result of stem cell therapy alone, but was insufficient for penetration. With the addition of PDE5 inhibitor before coitus, 2 achieved penetration and experienced orgasm, and maintained for more than 6 months; however, 1 participant could not achieved penetration at ninth month. All but 1 reported increased desire. During follow-up, 2 returned for prosthesis, 4 returned to a nonerectile condition at 9 months, and 1 maintained erection sufficient for coitus with medication until the 11th month. Blood glucose levels decreased by 2 weeks, and medication dosages were reduced in all but 1 subject for 4 to 7 months. Glycosylated hemoglobin levels improved after treatment for up to 3 to 4 months.

CONCLUSIONS

Human umbilical cord blood stem cell therapy has positive effects on erectile dysfunction and diabetes mellitus. Stem cells and unknown humoral factors of human umbilical cord blood stem cells mediate mechanism may contribute to these positive effects.

[Repair and functional reconstruction of the penis (a report of 62 cases)]

OBJECTIVE

To investigate the effects of surgery treatment on serious penile lesions and malformation.

METHODS

Sixty-two patients, aged from 19 to 63 years old (mean 35 ys), were included in the study. Among them, 4 patients suffered from penis partial defection were respectively treated with restoring defective penis, penis lengthening and urethroplasty; three patients with penis completely missing were treated with penis reconstruction surgery; 22 cases with serious penile curvature were treated with the 16-dot plication technique (Lue's procedure); 15 cases with penile fracture were treated with conservative treatment for 1 case and with patch penis, corpus spongiosum, and deep penile dorsal vein ligation for 14 cases; 5 cases with post-operative complications of 3-pieces of penile prosthesis, including the prosthesis perforating to the urethra, water pump failure, broken connection tube, erection angle < 60 degrees and failure to expansion the corpus cavernosum, were treated by taking out prostheses, urethral repair cracks, replacement of the prostheses, excision of fibrosis scar and re-implantation prostheses respectively. Four cases with penis complete amputation were treated with the penis replantation; three cases of avulsion injury were treated with the replantation and free flap skin; 6 with Paget's disease of penises were treated with the lesion free skin buried in the scrotum and penis.

RESULTS

All these patients were followed up for 3 months to 4 years, with the average of 9 months. Among the 4 cases of penis partial defection, 2 patients were satisfied with the penile appearance and sexual function; 1 got some satisfactory and 1 was unsatisfied. Three cases with the loss of the penis completely were satisfied with both the postoperative appearance and urination, and 1 was not satisfied. Twenty-two cases of penile curvature deformities were corrected, and one case was recurrence. Fourteen of the 15 patients with penile fracture were followed, and all got the restoration of sexual function. Among them, 5 cases with post-operative complications, including mild bending, algopareunia, subcutaneous induration, poor hardness and poor sexual pleasure, were not further treated, and another case lost; Five cases with post-operative complications of three-pieces penile prosthesis were treated successfully, and 4 of their spouses were satisfied with their sexual function after operation, only 1 of their spouse not satisfied. Among four cases with complete amputation of penis, two cases of penis were replanted successfully while two necrosis. Three cases with avulsion were treated with skin grafting successfully. All 6 cases with penile Paget's disease were followed for 2 -4 years, and free skin grafts were all survival. One patient died of brain metastases 18 months after operation and five cases were disease-free survival.

CONCLUSION

The patients should be treated based on the procedure of andrological and urological surgery, together with microsurgical, flap or skin graft technique. The urologist should design personalized surgical procedure. Most of the patient's penis shape and erectile dysfunction can be reconstructed by our procedures, but some patients can not achieve the desired appearance or function of penis. New approaches of the treatment ought to be developed to restore both of the shape and function for those severe injury of the penis.

Patient and partner satisfaction with the mentor alpha-1 inflatable penile prosthesis

OBJECTIVE

To evaluate the satisfaction level of patients and partners after implantation of a Mentor Alpha-1 inflatable penile prosthesis (IPP) for the treatment of erectile dysfunction (ED).

MATERIAL AND METHODS

A questionnaire was sent to 46 patients who had been operated on for ED with implantation of a Mentor Alpha-1 IPP. The investigation was designed to evaluate patient and partner satisfaction.

RESULTS

Eighty-five percent of the questionnaires were returned. Sexual desire had not changed but the quality of sexual activity had significantly improved. Acceptance by the partner was good. Overall satisfaction among both patients and partners was high. In total, 95% of patients said that they would recommend the procedure to other patients in the same situation.

CONCLUSIONS

Patient and partner satisfaction with the Mentor Alpha-1 IPP was high, with the exception of the minority of patients who experienced unacceptable complications. Infection and mechanical failure are important risks which patients should be informed of before agreeing to implantation surgery.

Surgical treatment of Peyronie's disease: a single center experience with 145 patients

OBJECTIVES

To assess the outcomes of the surgical techniques used in Peyronie's disease (PD) surgery.

PATIENTS AND METHODS

One hundred fifty patients received surgical treatment for PD. Fifteen and 75 patients underwent simple corporoplasties and incision of the plaque, and venous (IV) grafting, respectively, whereas 60 patients with erectile dysfunction underwent penile prosthesis implantation. At follow-up, the erectile function and penile deformity were assessed at 3 and 12 mo postoperatively, and every 6 mo thereafter.

RESULTS

Postoperative results were satisfactory in 14 of 15 patients with simple corporoplasties, with a mean angle of deformity and follow-up of 51.0 degrees +/-14.9 degrees and 21.0+/-9.7 mo, respectively. Among patients undergoing IV grafting with sapheneous vein (mean curvature angle: 61.6 degrees +/-19.5 degrees ), 70 were regularly seen with a mean follow-up of 41.7+/-35.1 mo. Penile curvature was completely straightened in 53 (75.7%) patients, whereas 12.8% and 11.4% had residual curvature less than 20 degrees and more than 20 degrees , respectively. The mean degree of penile curvature of patients with penile prosthesis was 46.9 degrees +/-20.1 degrees . Straightening of the penis was accomplished with implantation of the prosthesis only, manual modeling, plaque incision and grafting (autologous rectus fascia in the majority), incision of the plaque, and penile plication in 35%, 30%, 33.3%, 1.6%, and 1.6%, respectively. In the prosthesis group, two patients had recurrent curvatures.

CONCLUSIONS

IV grafting is a good option with satisfactory mid- and long-term outcome. Insertion of the prosthesis only and manual modeling correct the curvature in the majority of the patients. For the remaining patients, autologous rectus fascia is an appropriate graft material.

Complete genital prosthetization in patients treated with bilateral orchiectomy for metachronous testicular cancer

Testicular malignant tumours represent 1% of neoplasms. The probability of developing a contralateral tumour is between 3% and 7%. We report two cases of complete genital prosthetization in two patients treated with bilateral orchiectomy for metachronous testicular cancer. In our knowledge no previous case is reported in literature.

CASE REPORTS

A 46-year-old patient and a 49-year-old patient underwent bilateral radical orchiectomy for metachronous cancers of the testis. The first patient complained the complete loss of libido and complete impotence. For this reason he began a substitutive hormonal therapy with testosterone esters obtaining re-establishment of the masculine phenotype. With the reappearance of the libido and physical efficiency, the patient showed the intention to recover sexual activity and he was treated first by phosphodiesterase type 5 (PDE-5) inhibitors and then he began a cycle of prostaglandin El1(PGE1) but unfortunately without a satisfactory sexual performance. The second man maintained libido, lost sexual efficiency and showed hypogonadism. Substitutive therapy with testosterone enanthate obtained normalization of testosterone values. A psychosexual assessment highlighted a depressive state related to the absence of sexual performance due to an erectile deficit, that was treated first by PDE-5 inhibitors and then by intracavernous injections of PGEI without benefits. After individual and couple counselling both of the patients submitted both semirigid mono component penile prosthesis and bilateral testicular prostheses implantation by means of a single penile-scrotal incision. Both the patients regained sexual activity and were satisfied with the cosmetic appearance.

CONCLUSION

We underline the importance of the collaboration between the andrologist and the psycho-sexologist and the on-going collaboration with the patient. This allows the clinician to appraise the situation completely and to work out a common solution built around the patient to obtain a full recovery of his identity.

[Experimental study of augmentation phalloplasty using tunica vaginalis grafts in bilateral albuginea of penile corpus]

OBJECTIVE

To study the effect and complications of augmentation phalloplasty by implanting autogenous tunica vaginalis grafts into the bilateral albuginea of the penile corpus.

METHODS

Five mongrel dogs underwent augmentation phalloplasty with bilateral autogenous tunica vaginalis grafts. The increase in the volume of the corpora cavernosa was achieved by applying autogenous tunica vaginalis grafts to longitudinal openings made bilaterally in the albuginea along the whole length of the penile cavernous corpora. The perimeter of the penile cavernous corpora was measured in the flaccid state and during erection and dynamic infusion cavernosometry (DIC) was conducted for each dog before and after the operation. Histology of the penis was examined using hematoxylin and eosin stains.

RESULTS

The average increase in the perimeter of the penile cavernous corpora was 21. 1% in the erectile state but unobvious in the flaccid state 3 months after surgery. There were no statistically significant differences in cavernosometric parameters before and after the operation, and neither were there any other severe postoperative complications. The grafts had mild inflammatory reaction and fibrosis with apparent reformation of the tunica albuginea over the patch site.

CONCLUSION

The augmentation phalloplasty technique with bilateral autogenous tunica vaginalis grafts was proved to be effective and reliable with few complications, particularly conspicuous in increasing the volume of the erectile tissues during erection.

Management of sildenafil treatment failures

PURPOSE OF REVIEW

Although oral type 5 phosphodiesterase inhibitors are considered as first-line therapy for the majority of causes of erectile dysfunction, because of their high efficacy, ease of use, and acceptable safety profile, there are some who fail to respond, mainly because of end-organ failure. This communication reviews the management of sildenafil failures in light of recent advances.

RECENT FINDINGS

Sildenafil failures can be attributed to either lack of efficacy or side effects; issues may involve the physician, patient, and his partner. Physicians may contribute to sildenafil failure and discontinuation because of inadequate instructions, lack of adequate follow-up, suboptimal dosing, lack of adequate trial, and insufficient clarification about safety issues. Studies have demonstrated that progression of endothelial dysfunction and diminished cavernosal smooth-muscle content are recognized organic factors which cause end-organ dysfunction and ultimately treatment failure.

SUMMARY

Proper counseling, medication optimization, and modifying associated risk factors can provide success in men who had initially failed sildenafil therapy for erectile dysfunction. Other treatment modalities that may be considered when sildenafil failure occurs include vacuum devices, intraurethral, and intracavernosal administration of vasoactive drugs alone or combined with sildenafil. Penile prosthesis implantation is considered as a last resort, if all first-line and second-line therapies fail.

Alternatives for non-PDE5-I responders in erectile dysfunction patients

The management of a patient presenting with erectile dysfunction encompasses the classical complete history, physical examination, blood work-up, and radiographic or sonographic studies. Often the history directs the treatment toward counseling and psychosexual therapy with use of PDE5 inhibitors as the first-line approach. When the latter fails, other oral erectogenic drugs, vasoactive injectables, creams, or hormone treatment is given based on the work-up. In certain cases of vasculogenic etiology, ligation of venous leakers or revascularization of the penis may be appropriate. The port of last call is the penile prosthetic implant. The implant, however, is an all or none option, requiring surgical destruction of the corporal tissue before implantation, and once inserted, it the implant must function forever. Explantation because of infection or for other reasons renders the patient impotent unless another implant is inserted. The Brindley penile drug delivery implant provides a solution that, when no longer needed, can be removed and returns the penis to its preimplant status. If a vasoactive drug like prostaglandin works, the candidate is deemed suitable. The device uses sodium nitroprusside. Through minimal access (day) surgery, the magnitude of which is only a stage slightly higher than integumentary surgery and done within 20-30 minutes, this is an advance that is presented herewith with a full account of the components, preoperative preparation, drug filling and refilling, and a step by step account of the surgery.

Evaluation of post-operative residual function of corpora cavernosa after soft penile prosthesis implant for Peyronie's disease

OBJECTIVE

The aim of this study is to evaluate the results of surgical implant with a new soft penile prosthesis, called SSDA, without plaque surgery in the treatment of impotence associated with Peyronie's disease.

MATERIALS AND METHODS

This study included 64 men with Peyronie's disease who underwent placement of a penile prosthesis. All the patients were followed for at least one year.

RESULTS

The implant of this kind of prosthesis straightened the penile shaft in all cases, restoring sexual satisfaction to the couple, as described in a clinical interview. No operative or postoperative complications occurred and no further operations were needed. Ten patients underwent a further examination with basal and duplex dynamic color Doppler ultrasound to establish the residual function of the corpora cavernosa.

DISCUSSION

The outcome is very positive: the penis preserves the ability to enhance the tumescence and the penile girth. We conclude that SSDA penile prosthesis are safe and effective in the treatment of Peyronie's disease associated with impotence.

Early experience with the American Medical Systems new tactile pump: results of a multicenter study

INTRODUCTION

A new Tactile Pump for the American Medical Systems (AMS) 700 Inflatable Penile Prosthesis (IPP) had been developed in an effort to improve usability for the patient. Aim. To assess the ease of use of the new Tactile Pump.

METHODS

A prospective, multicenter study was conducted at four investigative sites. Preoperatively, patients completed an evaluation of the new Tactile Pump vs. the current design 700 pump placed in scrotal models. Patients compared the ease of inflation and deflation of each model. All patients were implanted with the AMS 700 IPP including the new Tactile Pump. Patients returned at 6 weeks for activation of the device and for follow-up evaluation at 3 and 6 months.

MAIN OUTCOME MEASURES

Preoperatively patients compared ease of use of the Tactile Pump vs. the current design. Postoperatively both physicians and patients assessed device functionality for inflation and deflation, ease of use of the pump, and time required to learn device operation.

RESULTS

Thirty patients were implanted with the AMS 700 IPP and Tactile Pump. Thirty patients completed an activation visit, 20 patients completed the 3-month evaluation, and 9 patients completed the 6-month evaluation. The average age was 62.1 years. Primary erectile dysfunction etiologies included organic, nonspecific 10 (33.3%), vasculogenic 6 (20.0%), prostatectomy 6 (20.0%), diabetes mellitus 4 (13.3%), Peyronie's disease 3 (10.0%), and spinal cord injury 1 (3.3%). Preoperatively 93.3% (P < 0.001) of patients favored the Tactile Pump over the current pump on locating and working the inflation mechanism in the scrotal model. Patients also found the Tactile Pump deflation mechanism easier to find 100% (P < 0.001) and deflate 96.7% (P < 0.001). Most patients (86.7%) were trained to use their devices within 3 minutes.

CONCLUSIONS

The AMS Tactile Pump provides benefit to patients and physicians by improving ease of use and training over the current IPP 700 pump.

Clinical experience with the Mentor Alpha-1 inflatable penile prosthesis: report on 65 patients

OBJECTIVE

To evaluate the complications and prosthesis survival associated with implantation of the Mentor Alpha-1 inflatable penile prosthesis (IPP) for the treatment of erectile dysfunction (ED).

MATERIAL AND METHODS

Between August 1995 and March 2003, 65 patients underwent implantation of a Mentor Alpha-1 IPP at the Urological Departments of Skejby or Aalborg University Hospitals. Patient data were obtained retrospectively from medical files.

RESULTS

The follow-up period ranged from 1 to 96 months (median 48.5 months). Twenty-one patients (32%) experienced complications that required revision. The majority of complications consisted of mechanical problems, but infection was also a large contributor to the complication rate. Seven patients (11%) had the prosthesis permanently removed due to infection. Kaplan-Meier estimates of the 5-year prosthesis survival rates with and without successful revisions due to complications were 88% and 63%, respectively.

CONCLUSIONS

The Mentor Alpha-1 IPP is an efficient treatment for ED in situations where less invasive therapy has failed. The risk of infection or mechanical failure must not be ignored. Patients should be informed of this risk before agreeing to implantation surgery.

TREATMENT OF ERECTILE DYSFUNCTION FOLLOWING THERAPY FOR CLINICALLY LOCALIZED PROSTATE CANCER: PATIENT REPORTED USE AND OUTCOMES FROM THE SURVEILLANCE, EPIDEMIOLOGY, AND END RESULTS PROSTATE CANCER OUTCOMES STUDY

PURPOSE

Erectile dysfunction (ED) persists for years following curative therapies for clinically localized prostate cancer. We report use and treatment outcomes in a 5-year interval in a population based cohort from the Surveillance, Epidemiology, and End Results Prostate Cancer Outcomes Study.

MATERIALS AND METHODS

A sample of 1,977 men with localized prostate cancer who received external beam radiation therapy or radical prostatectomy in 1994 to 1995 were surveyed for 5 outcome measures of ED treatment, namely treatment, perceived helpfulness, erectile sufficiency, sexual activity frequency and erection maintenance. Subjects were surveyed 6, 12, 24 and 60 months after prostate cancer diagnosis.

RESULTS

Overall 50.5% of men ever used ED treatment. The use of ED treatments increased during the study course. Subject age, regular sexual partner and baseline sexual activity were factors positively associated with ED treatments. While it was used uncommonly (1.9%), a penile prosthesis was perceived as the most helpful ED treatment (helped a lot in 52% of respondents). Sildenafil helped a lot in 12% of respondents. Erectile fullness, erection maintenance and sexual activity frequency were modestly improved in men using ED treatment compared with those in men not using ED treatment.

CONCLUSIONS

Approximately half of the patients in this population based cohort of men used ED treatment during the 5 years following prostate cancer diagnosis. Men using ED treatments had modest improvement in sexual function compared with men that in who did not receive ED treatment at 60 months. More effective treatments for ED following local therapy for prostate cancer are needed.

[Prevention and treatment of the complications of inflatable penile prosthesis implantation]

OBJECTIVE

To report the amelioration of the three-piece inflatable penile prosthesis (IPP) implantation and the prevention of its complications.

METHODS

Thirty-two patients with moderate to severe erectile dysfunction (ED) irresponsive to conservative treatments received the implantation of the three-piece IPP. The surgical techniques were ameliorated in the course of operation. The patients were guided in using the IPP after operation. The effects and complications of the implantation were observed based on IIEF of the patients before and after operation.

RESULTS

Sexual life was resumed and no complication was found in 28 of the patients. The complications that developed in the other 4 were pump failure (2 cases), urethral perforation (1 case), and penis contraction (1 case). The former 3 achieved normal sexual intercourse after the second operation. Comparison between the IIEF scores before and after operation showed a very remarkable difference (P < 0.01). The occurrence rate of complications was 12.5%. The satisfaction rate of sexual intercourse was 87.5% and the total satisfaction rate of sexual life was 84.4%.

CONCLUSION

The complications of the three-piece IPP implantation were obviously reduced by ameliorating operation techniques. The implantation of the three piece-IPP is safe and effective for advanced ED patients.

TECHNIQUE FOR CONCOMITANT IMPLANTATION OF THE PENILE PROSTHESIS WITH THE MALE SLING

PURPOSE

We describe an initial experience with a technique for concomitant implantation of inflatable and semirigid penile prostheses with the synthetic male sling. In 4 cases the simultaneous procedures for erectile dysfunction and urinary incontinence were achieved successfully.

MATERIALS AND METHODS

Four patients presented with post-prostatectomy urinary incontinence and erectile dysfunction. They underwent treatment with placement of a synthetic (silicone coated polypropylene) perineal male sling with concomitant placement of a penile prosthesis, as performed by a single surgeon. The patients underwent the male sling procedure using 6 bone screws drilled into the descending pelvic rami bilaterally and a 4 x 7 cm silicone coated polymer mesh. Patients simultaneously also underwent placement of a semirigid or inflatable penile implant. Clinical outcome was determined via physician and patient assessment of continence and a continence questionnaire.

RESULTS

No perioperative complications occurred. All patients were discharged home within 24 hours of the procedures and postoperative pain was controlled with oral medications. One-year followup showed complete satisfaction in all 4 patients with continent status and erectile function.

CONCLUSIONS

Our initial experience shows that concomitant placement of the male sling and a semirigid or inflatable penile implant can be successfully accomplished with high satisfaction.

[Primary artery erectile dysfunction: one case report]

OBJECTIVE

To evaluate the relationship between the deformation of penile artery and the primary artery erectile dysfunction, and to improve the treatment and diagnosis of primary artery erectile dysfunction.

METHODS

One case of primary artery erectile dysfunction was presented with its primary clinic data.

RESULTS

The dorsal artery of the penis was thin and the bilateral penile arteries were lacking by arteriography. The implantation of a penile prosthesis significantly improved the patient's erectile function.

CONCLUSION

The primary artery erectile dysfunction is a relatively rare disease. The possibility of primary artery erectile dysfunction should be kept in mind. Penile prosthesis implantation is an effective means for the treatment of primary artery erectile dysfunction.

[Development and clinical application of the Chinese-made inflatable penile prosthesis]

OBJECTIVE

To study the effect and safety of the Chinese-made inflatable penile prosthesis in the treatment of erectile dysfunction (ED).

METHODS

According to the anatomy and physiology of Chinese men, an inflatable penile prosthesis was developed in China, consisting of an innovated pump, a reservoir, and a pair of penile cylinders, which were connected by tubes to form a complete system. It was authorized to be used clinically by State Food and Drug Administration (SFDA). Forty-five cases of organic ED were selected for penile prosthesis implantation. Penoscrotal approach was used to implant the cylinders into the corpus cavernosum, the pump into the scrotum and the reservoir into the prevesical space.

RESULTS

Surgical problems and mechanical failures were not found in the subjects. Post-operative complications occurred in 3 cases (6.6%), but did not affect the intercourse. Satisfactory intercourses were achieved 10-12 months later and the intercourse duration averaged about (20 +/- 6) min.

CONCLUSION

The Chinese-developed inflatable penile prosthesis was safe and effective for patients with ED, with low rate of mechanical failures. Its long term effect has yet to be further studied.

Penile prosthesis coating and the reduction of postoperative infection

Despite the recent development of effective oral agents for the treatment of erectile dysfunction, penile prosthesis implantation remains an effective and acceptable treatment for the significant number of men who fail to respond to nonsurgical therapy. The most serious complication that can affect the use of most prosthetic devices is infection. In penile prostheses, this can be devastating and frequently results in removal of the device despite aggressive antibiotic therapy. In recent years, new strategies have been developed in an attempt to minimize this risk. This review focuses on one such method, namely the use of an antibiotic coating on the device. It reviews recent published data regarding the effectiveness of such devices at decreasing infection rates.

Combined penile plication surgery and insertion of penile prosthesis for severe penile curvature and erectile dysfunction

PURPOSE

For persistent penile curvature after corporeal dilation and prosthesis placement other maneuvers, such as plaque incision with or without grafting, or penile modeling, must be used to complete penile straightening. However, each of these techniques is associated with increased morbidity, which includes higher rates of infection and urethral injury. We describe a new technique for correcting severe penile curvature and erectile dysfunction using combined penile plication and placement of a 3 piece inflatable penile prosthesis.

MATERIALS AND METHODS

Between February 2000 and June 2003, 5 patients with erectile dysfunction and severe curvature for which other treatment modalities had failed were treated with combined inflatable penile prosthesis and additional plication to correct the severe malformation. Detailed medical and sexual history was obtained as well as preoperative duplex ultrasound prior to surgery.

RESULTS

The age range of our patient population was 22 to 55 years. In each case penile prosthesis placement was insufficient to correct the malformation and the addition of multiple plication sutures was required. The malformation in all patients was corrected with this technique. To date no patients have reported any complications with followup (range 3 to 36 months).

CONCLUSIONS

In cases of severe penile deformity and curvature with erectile dysfunction the combination of penile plication and inflatable penile prosthesis placement is a method of repair that is well tolerated.

Peyronie's Disease

INTRODUCTION

Peyronie's disease is a sexual medicine condition that may adversely affect male sexual function.

AIM

To provide expert opinions/recommendations concerning state-of-the-art knowledge for the pathophysiology, diagnosis and treatment of Peyronie's disease.

METHODS

An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a scientific and debate process. Concerning the Peyronnie's disease committee, there were 10 experts from six countries.

MAIN OUTCOME MEASURE

Expert opinions/recommendations are based on grading of evidence-based medical literature, extensive internal committee discussion over 2 years, public presentation and deliberation.

RESULTS

Peyronie's disease is characterized by an inflammatory response beneath the tunica albuginea with fibroblast proliferation forming a thickened fibrous plaque that may cause penile pain, penile curvature and erectile dysfunction. Medical treatments have been described but few prospective controlled trials have revealed significant clinical benefits. Surgical treatments (penile plication, Nesbit excision, plaque incision and grafting and penile prosthesis insertion) should be considered after Peyronie's disease has stabilized. Surgical outcome studies reveal that a stable deformity is best corrected with the least postoperative ED by a Nesbit procedure. Plaque incision and grafting should be reserved for men with good erectile function and marked penile shortening although there is a higher prevalence of postoperative ED. Implantation of a penile prosthesis is an excellent option for men with an accompanying erectile deficit.

CONCLUSIONS

Safe and effective treatments for Peyronie's disease examined by prospective, placebo-controlled, multi-institutional clinical trials are needed.

The Penile Implant for Erectile Dysfunction

INTRODUCTION

Penile prostheses, introduced as the first effective organic treatment for erectile dysfunction over three decades ago, have an important role in the treatment of erectile dysfunction when other nonprosthetic treatment options have proven unsatisfactory. Although they are the least chosen and most invasive treatment option, they have the highest satisfaction rate of all available ED options and provide a predictable and reliable result.

AIM

To provide recommendations/guidelines concerning state-of-the-art knowledge for utilization of the penile prosthesis in the management of men with erectile dysfunction.

METHODS

An International Consultation in collaboration with the major sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. There were 10 experts from seven countries concerning the Penile Implant for Erectile Dysfunction.

MAIN OUTCOME MEASURE

Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate.

RESULTS

Recommendations/guidelines for penile prosthesis (hydraulic, semi-rigid and soft silicone) insertion for management of men with erectile dysfunction were updated. Consensed issues included: criteria for patient selection, informed consent procedures, strategies for preoperative preparation, operative incisions/technical considerations and outcome results in terms of patient satisfaction and device survival. Updated information was reviewed concerning therapies for device failures, device insertion in scarred corporal bodies and strategies for managing implant infections.

CONCLUSIONS

There is a need for more research in developing management strategies for insertion of penile prostheses in men with ED.

Tissue ingrowth in penile implants and its effect on repeat penile surgery

Penile implant malfunction is usually treated by removal of the original malfunctioning implant followed by replacement with a new device. During replacement, the original implant can be explanted without any difficulty, as it is not adherent to the surrounding tissue. Herein, we describe two cases of tissue ingrowth into the implant that produced difficulty during explantation and suggest ways in which this condition can be managed.

Surgical management of erectile dysfunction

Since the introduction of sildenafil citrate, oral systemic therapy has become the first line of therapy for men with erectile dysfunction (ED). Men who are not candidates for or who fail treatment with an oral agent may choose second-line therapies such as intraurethral prostaglandins, penile injection therapy, sex therapy, or a vacuum erection device. These secondline therapies may be unpalatable or inadequate for some men, and these men constitute the candidates for surgical intervention for ED. This article reviews surgical management of vascular ED, surgical management of Peyronie's disease, and penile prosthesis implantation. At the current time, the appropriate candidate for penile revascularization is a young man with proven arterial insufficiency resulting from pelvic trauma. Results in other populations are disappointing. Peyronie's disease with curvature significant enough to interfere with intercourse may be managed with tunical lengthening or shortening procedures in potent men and with prosthetic implantation in men with ED. Modern three-piece penile prostheses are associated with excellent device reliability, high rates of patient satisfaction, and acceptably low complication rates.

[Treatment of the paraplegic patient with erectile dysfunction by implantation of China-made three-piece inflatable penile prosthesis]

OBJECTIVE

To evaluate the effect of the treatment on paraplegic patients with erectile dysfunction (ED) by implantation of China-made three-piece inflatable penile prosthesis.

METHODS

Eighteen paraplegic patients with ED refractory to non-operative treatment were implanted with three-piece inflatable penile prosthesis through an incision at the border of penis and scrotum. The rate of maintained coitus and the satisfactory coitus of spouse were obtained by inquiring and letter visiting.

RESULTS

Operations were successfully performed upon all 18 patients. Follow-ups after operations ranged from 3 months to 36 months, mean follow-up being 18 months. Fluid exudation from penile prosthesis and localized infection occurred in one patient and mechanic complication occurred in two. Maintained coitus rate was 17/18. Ejaculation reflection occurred in three patients.

CONCLUSIONS

Treatment of paraplegic patient with ED refractory to non-operative treatment by implantation of China-made three-piece inflatable penile prosthesis has good concealment and rehabilitative effect, with similar mechanical troubles to imported products. With excellent covertness, implantation of three-piece inflatable penile prosthesis is well accepted by ED patients.

Patient and partner satisfaction and long-term results after surgical treatment for Peyronie's disease

OBJECTIVES

To assess the long-term functional outcome, patient and partner satisfaction, and predictive factors for unfavorable results in men treated with a surgical approach for severe Peyronie's disease.

METHODS

Sixty-one patients underwent surgical treatment for Peyronie's disease between 1997 and 2001 and were retrospectively evaluated. All patients were assessed preoperatively with a detailed sexual and medical history, focused physical examination, and penile duplex ultrasonography. Nineteen patients underwent penile plaque excision/incision and grafting with Tutoplast cadaveric pericardial grafting material (group 1). Penile prosthesis implantation and manual modeling was performed in 31 patients (group 2a), and 11 men were treated with penile prosthesis implantation and pericardial grafting (group 2b).

RESULTS

The mean follow-up of the patients was 21.9 +/- 13.6 months (range 12 to 48). Complete penile straightening was achieved in 15 patients (78.9%) in the excision/incision and grafting group. In the 42 men who underwent reconstruction using penile prosthesis implantation (group 2a,b), penile curvature resolved completely in 37 patients (88%). Long-term postoperative residual curvatures greater than 30 degrees occurred in 3 patients (15.7%) and 2 patients (4.8%) in groups 1 and 2a,b, respectively. One penile prosthesis (2.3%) was explanted in the second group for erosion. Patient responses to our questionnaire showed that overall 83.6% of the patients and 76.9% of the partners were satisfied with the surgical result.

CONCLUSIONS

According to the results of this long-term, retrospective study, pericardial grafting can be used successfully after plaque excision/incision procedures in men undergoing surgical treatment for severe Peyronie's disease. In patients with Peyronie's disease and erectile dysfunction, implantation of a penile prosthesis and correction of the curvature with a graft can provide an acceptable, functionally straight penis without any increased risk of complications compared with penile prosthesis implantation alone.

[Three-piece inflatable penile prosthesis implantation for the treatment of penile erectile dysfunction]

OBJECTIVES

To introduce the method and experience of three-piece inflatable penile prosthesis for treatment of erectile dysfunction (ED).

METHODS

Both AMS700CX/CXM and MENTOR ALPHA I three-piece inflatable prosthesis were used for 48 cases of ED.

RESULTS

There were no rejection, mechanical problems, urethral injury and penile skin necrosis after surgery. All patients had satisfaction of sexual life. Only one case had trauma of tunica albuginea (2.08%) and the implantation had to be cancelled. There were 2 cases of post-operative infection (4.17%), 10 cases of prepuce edema(20.8%), 8 cases of penile pain(16.67%). The effective rate was 97.9% and satisfaction rate was almost 100%.

CONCLUSIONS

Three-piece inflatable penile prosthesis was more compatible to human physiology. It is natural, easy to hide and use, and it caused little trauma in surgery with high rate of successful implantation and patient satisfaction. It was indicated for all kinds of ED, especially suitable for refractory and drug incurable ED patients.

New surgical technique for sphincter urinary control system using upper transverse scrotal incision

PURPOSE

Traditional implantation of the AMS Sphincter 800 Urinary Control System (American Medical Systems, Minnetonka, Minnesota) requires 2 incisions. The cuff is placed via a perineal incision, and the pressure regulating balloon and pump are placed through a separate suprapubic incision. We describe a novel implantation of all the artificial urinary sphincter components using a single upper scrotal incision. The scrotal incision allows excellent access to the proximal bulbar urethra and retropubic and subdartos spaces, and leaves the bulbocavernosus muscle intact.

MATERIALS AND METHODS

A total of 37 patients have undergone artificial urinary sphincter implantation using the new operative technique for revisions or reimplantations of a sphincter previously removed for infection/erosion (12) or as an initial procedure (25). In 9 of the 25 patients and 2 of the 12 dual implantation of a 3-piece penile prosthesis through the same incision was performed.

RESULTS

All patients are using the devices. Of the patients 66% are completely dry with no pad use and the remainder use 1 pad for accident prevention. Operative time was reduced due to easier exposure of the urethra and a second incision for placement of the pressure regulating balloon was not necessary. Followup at 1 year shows no difference in complication rate with the single incision technique compared to the traditional method.

CONCLUSIONS

Artificial urinary sphincter implantation through a single scrotal incision is easier and faster than the traditional 2-incision technique. Success in achieving continence is similar to traditional methods. Long-term followup is necessary to ensure that complications remain low.

Implantation of penile prosthesis in a patient with severe corporeal fibrosis induced by cavernosal injection therapy

Implantation of a penile prosthesis in men with complicated fibrosis of corpus cavernosum is very difficult and even impossible. Cavernosal dilation requires sharp intracavernosal dissection to implant prosthesis, however complete removal of the fibrotic tissue is often impossible. We introduce a new technique using electric resection and electrovaporization of fibrotic tissue for implantation of penile prosthesis in a patient with severe corporeal fibrosis.

Management of Peyronie's disease with penile prostheses

Peyronie's disease is a common malady affecting men mostly between the ages of 40 and 60. When penile curvature and erectile softening are present and the erectile dysfunction does not respond to Viagra a penile implant will strengthen and usually straighten the penis. If curvature persists after implant placement 'modeling' the erect penis will successfully achieve straightening in most patients. Plaque incision and grafting or a Nesbit procedure are rarely necessary to straighten the penis but will afford excellent results when employed. A thorough explanation of the pathogenesis of Peyronie's disease and effects of the disease and treatment on penile size will help avoid some of the disappointment seen when a shorter erection occurs.