Two-stage urethroplasty using buccal mucosa graft in patient with penile stricture and Lichen sclerosus

==inizio objective==

Lichen sclerosus (LS) is a disease of unknown etiology that affects the penile organ.
It is more common in young adults, but can affect any age.
It is characterized by atrophy of the epidermis.
LS affects especially the genital mucosa.
The disease can give: itching of the glans and penis, trauma during intercourse, difficulty in preputial mobility, erectile dysfunction, phimosis and paraphimosis and furthermore can lead to urethral stricture [1].

==fine objective==

==inizio methodsresults==

From January 2015 to February 2016 10 patients (pts) with LS and urethral stricture were enrolled for this study. Patient mean was age 45 years.
All of the patients underwent physical examination, uroflowmetry, retrograde and voiding urethrography in order to evaluate the stricture. The mean Qmax was 7 ml/sec. Mean stricture length was 3.7 cm.
All pts underwent two-stage urethroplasty with buccal/labial mucosa graft.
When the stricture affected the navicular urethra it was used a labial graft for its minor thickness.
A midline longitudinal incision was made along the penile skin ventrally. The penile urethra was exposed with minimal dissection. The urethra was opened along its ventral surface under the guidance of the guide wire, previously inserted. The urethra is spatulated up to 3 cm into normal caliber and pink urethral mucosa. The entire urethral plate affected by the LS was removed. Then the buccal mucosa graft was suteured on the urethral plate with two lateral running sutures and many single stiches on the whole graft in 5.0 Vicryl suture.
Second-stage procedure was carried out at 6 months from the first procedures in order to have a soft urethra and relaxed scar tissues. The neo-urethra is incised laterally and tubularized with 5.0 Vicryl suture.
The glans was reconstruct on the tubularized urethra. Dartos fascia and skin were closed. A sovrapubic catheter and a 10 Fr urethral stent were inserted and left for two weeks post-operatively.
Pts were discharged from the clinic 2 days after surgery. Pts were suggested to use anti-scar and moisturizing creams 3 times/day until the second-stage surgery.

==fine methodsresults==

==inizio results==

At 3 months follow-up after the second stage all pts underwent uroflowmetry in order to assess the voiding.
Two pts needed calibration with Nelaton catheter 16 Fr. One patient underwent surgery with buccal mucosa graft.
Mean Qmax was 21 ml/sec. All Pts were satisfied with the result of the surgery.

==fine results==

==inizio discussions==

In pts with penile strictures caused by LS, the penis is fully involved in the disease : glans, meatus, skin, fibrotic dartos. For these pts one-stage repair would be risky, having a poor chance of success. For this reason it is recommended the two-stage repair [2]. At moment buccal mucosa graft is the best tissue to replace the urethra

==fine discussions==

==inizio conclusion==

Penile urethroplasty is a complex procedure with high risk of insuccess so it should be perfomed only by surgeon specialized in genital reconstructive surgery. This procedure is the only technique that can treat LS and penile strictures.

==fine conclusion==

==inizio reference==

1) Kulkarni S, Kulkarni J, Surana S, Joshi PM. Management of Panurethral Stricture. Urol Clin North Am. 2017 Feb;44(1):67-75

2) Angulo JC, Arance I, Esquinas C, Nikolavsky D, Martins N, Martins F. Treatment of long anterior urethral stricture associated to lichen sclerosus. Actas Urol Esp. 2016 Nov 2. pii: S0210-4806(16)30131-0.

==fine reference==

case report: urthritis by syphilis

==inizio objective==

The continued and numerous migration flows in Europe to which we are subjected oblige us to confront now obsolete and no longer endemic diseases for some time.
Recognizing them can help in early diagnosis and appropriate therapy

==fine objective==

==inizio methodsresults==

It came under our observation for Urethrorrhagia: Man 20 years from gambia, normal white blood cells, hb reduced to 7.9 g / dl rbc3,01 Hct 25%.
alerted by the patient’s origin and asked to investigate the lack of cooperation, for idiomatic reasons, we contacted our colleagues in infectious diseases. they already knew the patient to a tertiary syphilis, positive to the relative test (TPPA). The patient was unhelpful to the previously recommended therapy.

==fine methodsresults==

==inizio results==

the patient is subjected to HCV,hbv e hiv tests, who test negative, Chest X-ray, CT abdomen-pelvis(to rule out any location of intraparenchymal disease). Chest X-ray is negative. diagnostics for system images nervous is in progress.
CT abdomen pelvis. shows inguinal lymph nodes of 3 cm, palpable on physical examination,And no other goal mark, and Minutes retroperitoneal lymph nodes. The patient has Brought to seven days urethral catheter (c up to interruption of Urethrorrhagia, then removal of the cu, shooting copious Urethrorrhagia hesitated in CV repositioning for Other 3 days, until complete interruption of ‘bleeding and then removed. The patient Meanwhile Treaty with the ceftriaxone 2 gr to day, it is transferred to the operative Unit of infectious diseases.

==fine results==

==inizio discussions==

Syphilis in clinical stage I, II, or III is called
“early syphilis” for the first year after the date of infection
and “late syphilis” at later times.
Painless lymphadenopathy develops regionally
Stage III syphilis causes a wide
variety of general medical, neurological, and
psychiatric morbidity and may be life-threatening if
untreated.Between this variety of symptoms acute urethritis with possible bleeding
This case represents an unusual complication of tertiary syphilis
It has been observed that urethral bleeding is more common
in patients with co-infection of syphilis and gonorrhoea,
suggesting that pathological changes to the urethral mucosa ,but it’s possible so in III stage ofsyphilis (1,2,3) All persons who have primary and secondary or tertiary syphilis should
be tested for HIV,hbv, hcv infection or for intraperenhimali injury ( with ct)
Patients with late latent syphilis should
receive doses of benzathine
penicillin Ceftriaxone (1–2 g daily) may be effective
for treating early syphilis. However, data are
limited, and the optimal dose and duration of
therapy are not defined ( 4.5)

==fine discussions==

==inizio conclusion==

The clinician should attempt to obtain objective
evidence of urethral inflammation for an adequate therapy

==fine conclusion==

==inizio reference==

1.The Presentation, Diagnosis, and Treatment
of Sexually Transmitted Infections
Florian M.E. Wagenlehner, Norbert H. Brockmeyer,
Thomas Discher, Klaus Friese, Thomas A. Wichelhaus
2.International Journal of STD & AIDS Volume 22 September 2011
J Penton MBBS BSc and P French FRCP

3.MMWR / June 5, 2015 / Vol. 64 / No. 3
Prepared by
Kimberly A. Workowski, MD1,2
Gail A. Bolan, MD1
1Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
2Emory University, Atlanta, Georgia

4.CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 81 • NUMBER 2 FEBRUARY 2014
NEBLETT FANFAIR AND WORKOWSKI

5.JAOA • Vol 104 • No 12 • December 2004
Nusbaum et al

==fine reference==

SURGICAL CORRECTION OF PEYRONIE’S DISEASE VIA TUNICA ALBUGINEA PLICATION- LONG TERM FOLLOW UP

==inizio objective==

Peyronie’s disease (PD) is an acquired connective tissue disorder of the tunica albuginea with fibrosis and inflammation that lead to palpable plaques, penile curvature and pain during erection, compromising quality of life. Patients report negative effects in four major domains: physically appearance and self-image, sexual function and performance, pain and social stigmatization. Aim of present study is to evaluate outcome in term of patient satisfaction, anatomical and functional correction at long term follow up after surgical plication of albuginea.

==fine objective==

==inizio methodsresults==

Between 1998 and 2006 a total of 204 patients with PD underwent surgical correction using albuginea plication technique. We obtained complete long term (at 5 and 10 years) follow up data in 187 cases.

==fine methodsresults==

==inizio results==

After an average of 141 months the most common postoperative complications are loss of length (150 patients had a minimal penile shortening ≤ 1,5 cm, 37 between 1,5 and 3 cm, none >3 cm), recurrent or residual penile curvature (in 15 without impairing sexual intercourse) erectile dysfunction (15 patients had IIEF-5 < 10 at 5 years follow up vs 28 patients at 10 years), change in penile sensation (37 lamented paresthesia of the glans 1 year after surgery, 28 at 5 years and 15 at 10 years); painful or palpable suture knots (in 20 cases) spontaneously revolved in 3 months. Overall 77% of the patients and partners were completely satisfied with the outcome of surgery, 14% partially satisfied and 9% unsatisfied. ==fine results== ==inizio discussions== Regardless of surgical approach, all patients should be informed about the risk of penis shortening, hypoesthesia and residual curvature prior to surgery, being imperative open and honest discussion to avoid false expectations. The most common postoperative complications of this approach are loss of length, recurrent or residual penile curvature, ED, change in penile sensation, and painful or palpable suture knots. Many of these outcomes can be quite distressing for the patient and they may impact the operative technique selection and overall satisfaction postoperatively. In our hands this approach obtained good success for the correction of curvature, maintenance of erectile function and patient-reported treatment satisfaction. The optimal surgical treatment for PD patients with erectile capacity is still controversial [1, 2]: lengthening procedures - mainly performed on the patients with severe penile curvatures and /or narrowing or hourglass deformities - and tunical shortening procedures including incisional/ excisional corporoplasty and non-incisional plication techniques. Penile prosthesis implantation is typically reserved for patients with PD and concurrent ED, especially non responders to medical management. The advantage of our technique is that it avoids incision or excision the tunica and yet achieved the desired result of straightening the deformity by shortening the longer side. It is simple to perform and there is no risk of excising too much of tunica. If after tying a suture the deformity appears over or under corrected, the suture can be cut or applied again as the case may be. The use of non-absorbable stitches reduced the risk of recurrence of the curvature by comparing the results to the data of those who useful absorbable stitches (Ebbehoj, Schroder-Essed[3,4]). The absorbable stitches probably cannot withstand the traction during replaced erections in the early postoperatively period. On the other hand, when nonabsorbable material is used, commonly problems are the formation of granuloma around the sutures and the unpleasant feeling of bumps under the skin. Very rarely the discomfort of the suture interfered with sexual intercourse with rates reported by Baskin and Hsieh as 0-10% [5, 6]. ==fine discussions== ==inizio conclusion== Plication procedure is safe and simpler to preform than the classical Nesbit’s procedure with shorter surgical time, lower costs and could be successfully performed also by less experienced surgeons. It has a minimal risk of de novo erectile dysfunction, a minimal risk of injury to the dorsal neurovascular bundle and may be used for a variety of angulation deformities, including multi-planar curvature and severe degrees of curvature obtaining good results in term of patient satisfaction for anatomical and functional correction. ==fine conclusion== ==inizio reference== 1. Iacono F, Prezioso D, Ruffo A, Illiano E, Romeo G, Amato G “Tunical plication in the management of penile curvature due La Peyronie’s disease. Our experience on 47 cases”. BMC Surgery 2012, 12 (Suppl 1):S25 2. Langston J.P. Carson C.C.” Peyronie's disease:plication or grafting” Urol Clin North Am (2011) 38:207-2016 3. Fried rich MG., Evans D., Noldus J.” The correction of penile curvature with the Essed-Schroder technique: a long term follow up assessing functional aspects and quality of life”. BJU Int. (2000) 86: 1034-1038 4. Baskin LS., Erol A., Li YW. “Anatomy of the neurovascular bundle: is safe mobilization possible?” J Urol 2000: 164:977-980 5. Hsieh Jt, Liu SP., Chen Y.” Correction of congenital penile curvature using modified tunic all plication with absorbable sutures the long-term outcome and patient satisfaction” Eur Urol,2007;52: 261-6 6. Makovey I, Higuchi TT, Montague DK, Angermeier KW, Wood HM. “Congenital penile curvature”. Curr Urol Rep (2012) 13: 290-297 ==fine reference==

Our surgical experience in bilateral benign testicular tumors. Is the conservative surgery an easy and safe approach?

==inizio objective==

Bilateral testicular tumors are a very rare event and represent the 2.7% of all testicular masses. 15% of the bilateral testicular tumors occurs simultaneously, but in 85% of cases the second tumor appears in the remaining testicles after a variable period. Epidermoid cysts of the testis are rare and benign lesions. The incidence of bilateral cysts is around 0,5%. Granulosa cell tumor of the testis is an infrequent stromal cell tumor and is a rare pathologic finding, accounting for 1.2%-3.9% of prepuberal testicular tumors. Although radical surgery was previously considered the treatment of choice, we evaluated the role of partial orchiectomy in presence of bilateral benign lesions in terms of preservation of testicular function (1). The aim of this study was to describe our experience in testicular tumors, focusing on their diagnosis and conservative surgical treatment.

==fine objective==

==inizio methodsresults==

231 patients with testicular tumors whose underwent testicular surgery for testicular masses at our department from January 2010 to June 2016 were retrospectively analysed. Baseline ultrasonography (US) and an hormone panel test were performed to all patients. Contrast-enhanced ultrasound (CEUS) was performed in the patients with no clear diagnosis of malignant lesion. Semen analysis was performed before of the testicular surgery and at the 6 month follow-up. Mean values with standard deviations (±SD) were computed and reported for all items. Statistical significance was achieved if p-value was ≤0.05 (two-sides).

==fine methodsresults==

==inizio results==

The patients with simultaneously occurring bilateral benign testicular tumors were 6 (2,6%). The average age is 23,8 years (range 16 – 34). Overall, 16 benign lesions are removed. 3 out of 16 patients had only 2 tumors (1 on the left testicle and 1 on the right), 2 out of 16 patients had 3 tumors (2 on the left testicle and 1 on the right) and only 1 patient had 4 tumors (2 on the left testicle and 2 on the right). The average diameter was 0,78cm (range 0,3 – 1,8cm). Preoperative average value of testosterone was 624,3±225,08 ng/dl (range 351 – 946 ng/dl). Preoperative average values of spermiogram were: global sperm cells count 45±17,34 millions (range 35 – 80 millions), sperm progressive motility 35,83±3,77% (range 29 – 40), normal forms 6±2,37% (range 3-9).
Postoperative average value of testosterone was 587,5 ± 188,16 ng/dl (range 400 – 861 ng/dl) (p=0,7648). Postoperative average values of spermiogram were: global sperm cells count 42,5 millions ± 21,14 (range 25 – 82 millions) (p=0,8273),sperm progressive motility 31,83±7,26% (range 23 – 45) (p=0,2582), normal forms 5,1±1,47% (range 3-7) (p=0,4476). No recurrences were seen at a median follow-up of 24,3 months. PGI-I (Patient Global Impression of Improvement) test average score was 2 (1 – 4).

==fine results==

==inizio discussions==

History, physical examination and tumor markers don’t always allow to distinguish between benign and malignant lesions.
Ultrasonography has a sensitivity of 96% and a specificity of 44% for the diagnosis of the testicular masses (2).
CEUS allows seeing the distribution of the microcirculation, which is homogeneous in benign lesions and anarchic in malignant lesions. We used histograms that enable to identify the anticipation of vascularization that is typical of malignant lesions.
In our experience, no significant differences were seen for serum testosterone levels and no significant differences were seen in global sperm cells count, sperm progressive motility and normal forms after the conservative surgery.
In addiction, PGI-I score indicates an higher degree of satisfaction of the patients treated with conservative technique.

==fine discussions==

==inizio conclusion==

Bilateral simultaneously occurring testicular masses are extremely rare. Some of these are benign and, in this case, the radical orchiectomy can represent an overtreatment. In these patients partial orchiectomy could be an option (in particular for young patients), allowing to maximize the advantages related to the maintenance of testicular parenchyma (3). The exocrine and the endocrine function are both preserved. In addiction, we should consider the psychological and cosmetic benefits of receiving a conservative treatment.
Despite the radical orchiectomy remains the gold standard for all testicular masses, the inclusion criteria are not clear and the discussion of informed consent with the patient is mandatory. We agree with EGCCCG (European Germ Cell Cancer Consensus Group) guidelines (4) that partial orchiectomy should be proposed for simultaneously occurring bilateral benign lesions.

==fine conclusion==

==inizio reference==

1-Tavolini IM, Oliva G, Nigro F, Dal Moro F, Zuliani G, Norcen M, Mazzariol C, Pagano F. Synchronous and metachronous bilateral tumors of the testis: a single institution experience of 11 cases and review of the literature. Arch Ital Urol Androl. 1999 Jun;71(3):155-64

2-Loberant N, Bhatt S, Messing E, Dogra VS. Bilateral testicular epidermoid cysts. J Clin Imaging Sci. 2011;1:4. doi: 10.4103/2156-7514.73502. Epub 2011 Jan 1.

3-Cosentino M1, Algaba F2, Saldaña L3, Bujons A4, Caffaratti J4, Garat JM4, Villavicencio H4. Juvenile granulosa cell tumor of the testis: a bilateral and synchronous case. Should testis-sparing surgery be mandatory? Urology. 2014 Sep;84(3):694-6.

4-Zuniga A, Lawrentschuk N, Jewett MA. Organ-sparing approaches for testicular masses. Nat Rev Urol. 2010 Aug;7(8):454-64.

==fine reference==

Can the testicular parenchyma fibrosis be a predictor of testicular failure in the patients with varicocele?

==inizio objective==

Diagnostic imaging plays a fundamental role in the diagnosis and staging of varicocele. In particular the European Association of Urology (EAU) recommends confirmation by color Doppler sonography after the diagnosis of varicocele is made by clinical examination. Color Doppler sonography was also be described like an useful tool for predicting the outcome of varicocelectomy (1). In the last years diffusion-weighted MRI of the testes was evaluated in order to detect fibrosis of the testicular parenchyma in the patients whose underwent varicocelectomy (2). The aim of this paper was to describe our preliminary experience in the use of the MRI for the patients with varicocele.

==fine objective==

==inizio methodsresults==

From January 2016 to July 2016 we recruited 10 consecutive patients with varicocele and 10 healthy control volunteers. The diagnosis of varicocele was confirmed by a physical examination and by color Doppler sonography. All patients exhibited unilateral varicocele and oligoastenozoospermia . All previous testicular pathologies (infections, trauma, torsion, tumor) were excluded in all patients. Infertile man using medications were also excluded. All patients and control volunteers underwent an MRI examination using a 1.5 T unit. The mean±DS ADC (Apparent Diffusion Coefficient) values were classified for testicles with varicocele (Group 1), testicles contralateral to varicocele (Group 2) and testicles of the control volunteers (Group 3). 5 out of 10 patient in the group 1 had a grade 2 of varicocele (Group 1a) and 5 out of 10 patient had a grade 3 or higher of varicocele (Group 1b). 4 out of 10 patient in the group 1 significantly improved their seminal parameters at six months follow-up without any medical therapy (group 1c) and 6 out of 10 patient in the group 1 did not significantly improved their seminal parameters (group 1d).

==fine methodsresults==

==inizio results==

There were no differences in the demographics and baseline characteristics between the two groups. The mean±DS ADC was 940.25±27.26 in the Group 1, 955.46±29.2 in the Group 2 and 1109.52±31.50 in the Group 3. A statistically significant difference was observed between the Group 1 and the Group 3. Moreover, a statistically significant difference was also observed between the Group 2 and the Group 3. No differences were seen between the Group 1 and the Group 2 (p=0,2442)
The mean±DS ADC was 918,6±8,65 in the Group 1a and 953,2±29,14 in the Group 1b (p=0,0344).
The mean±DS ADC was 914,2±4,91in the Group 1c and 957,6±21,69 in the Group 1d (p=0,0024).

==fine results==

==inizio discussions==

In this paper we confirmed that the mean ADC values significantly differed between patients with varicocele and healthy volunteer. Moreover also in the controlateral testis is possible to find signs of testiculare failure. The mean ADC also correlates with the grade of the varicocele and with the seminal parameters recovery at six months post-surgery. The decrease ADC values can be related to hypoxic and fibrotic change and the decrease ADC values in the contralateral testicles can be related to the heat stress or can be explained by hormonal and autoimmune factors. A limitation of this study is the small cohort of patients.

==fine discussions==

==inizio conclusion==

In conclusion, ADC values at MRI examination using a 1.5 T unit are a promising parameter in the detection of testicular fibrosis in patients with varicocele. It can be also used as a predictive parameter for determination of the degree of testicular damage and the ability to improve the seminal parameter after surgery.

==fine conclusion==

==inizio reference==

1- Hussein AF- The role of color Doppler ultrasound in prediction of the outcome of microsurgical subinguinal varicocelectomy. J Urol. 2006 Nov;176(5):2141-5.
2- Karakas E, Karakas O, Cullu N, Badem OF, Boyacı FN, Gulum M, Cece H.Diffusion-weighted MRI of the testes in patients with varicocele: a preliminary study. AJR Am J Roentgenol. 2014 Feb;202(2):324-8.

==fine reference==

Is the Vacuum Erection Device (VED) better than the ICI (Intra-Cavernous Injection) in preventing penile shortening after non nerve-sparing radical prostatectomy?

==inizio objective==

Penile length after radical prostatectomy has significant impact on patients and their partners. In addition, corporal fibrosis is associated with difficult penile prosthesis implantation (1). Vacuum erection device is a common device used for the treatment of the erection dysfunction (2). The aim of this study was to compare the penile shortening after non nerve-sparing radical prostatectomy, in the patients that underwent sexual rehabilitation with ICI and VED. In addiction, the study analyse the rate of significant penile fibrosis in the patients that underwent penile prosthesis implantation.

==fine objective==

==inizio methodsresults==

We enrolled 40 consecutive patients that underwent a non nerve-sparing laparoscopic radical prostatectomy (RP) at our department from June 2015 to June 2016. The patients were randomized into two groups (Group A=sexual rehabilitation with ICI and Group B= sexual rehabilitation with VED). Androbath Med VED was used in all patients of the Group B for 15-20 minutes daily. All patients underwent an early penile rehabilitation (initiated within 2-4 weeks after RP). The stretched flaccid penile length (SFPL) was evaluated before and after 6 months of rehabilitation. 18 out of 40 patients underwent a penile prosthesis implantation 12.83 months after the surgery. We considered “significant fibrosis” if during the surgery we needed the help of additional straightening procedures like incision or excision of the scar, multiple corporotomies with or without grafting, the use of the Rossello dilator, implant downsizing, and transcorporeal resection (1). Arduos dilatation has not been considered as a parameter of “significant fibrosis” because it can be related to the surgeon experience. Mean values with standard deviations (±SD) were computed and reported for all items.

==fine methodsresults==

==inizio results==

The mean±SD pre-operative SFPL was similar in the two groups (Group A= 8.42±1.82; Group B=8.21±1.74; p= 0.7112 ). After 6 months of treatment, we did not observed significant increase in SFPL in the Group A (post-operative SFPL=8.61±1.95; p=0.7518). After 6 months of treatment, we observed significant increase in SFPL in the Group B (post-operative SFPL=9.36±1.79; p=0.0463).
Significant fibrosis during the penile prosthesis implantation was found in 10 out 18 patients (8 patients of the Group A and 2 patients of the Group B.

==fine results==

==inizio discussions==

Nowadays there is no standard protocol or guideline for penile rehabilitation after RP. In our experience the use of VED Androbath Med achieved a median increase in SFPL of 1.15 centimeter after six month of therapy, while the use of ICI achieved a median increase in SFPL of 0.40 centimeter. The VED mechanism depends on its ability to increase arterial inflow and the oxygenation of the corpora. Moreover, VED increases NO release (3), reduces the hypoxia inducible factor-1 and transforming growth factor beta-1 and increases smooth muscle/collagen ratio (4). The ICI therapy also increases arterial inflow but the chronic intracavernous injection of vasoactive drugs can be associated to an increase of corporal fibrosis (5).

==fine discussions==

==inizio conclusion==

In conclusion, the penile rehabilitation after non nerve-sparing radical prostatectomy using a new vacuum erection device (Androbath Med) is related to a good increase in SFPL after six months of therapy. In addiction the patients whose underwent VED therapy before surgery had corpora that were more suitable for dilation during the penile prosthesis implantation.

==fine conclusion==

==inizio reference==

1. Yafi FA, Sangkum P, McCaslin IR, Hellstrom WJ.Strategies for penile prosthesis placement in Peyronie’s disease and corporal fibrosis. Curr Urol Rep. 2015 Apr;16(4):21.
2. Brison D, Seftel A, Sadeghi-Nejad H.The resurgence of the vacuum erection device (VED) for treatment of erectile dysfunction. J Sex Med. 2013 Apr;10(4):1124-35.
3. Li E, Hou J, Li D, Wang Y, He J, Zhang J.The mechanism of vacuum constriction devices in penile erection: the NO/cGMP signaling pathway? Med Hypotheses. 2010 Nov;75(5):422-4.
4. Yuan J, Lin H, Li P, Zhang R, Luo A, Berardinelli F, Dai Y, Wang R.Molecular mechanisms of vacuum therapy in penile rehabilitation: a novel animal study. Eur Urol. 2010 Nov;58(5):773-80.
5. Egydio PH, Kuehhas FE Treatments for fibrosis of the corpora cavernosa. Arab J Urol. 2013 Sep;11(3):294-8.

==fine reference==

Penile length preservation after prosthesis: is Ams Lgx more effective than Ams Cx? A prospectic, randomized study

==inizio objective==

Hydraulic penile prosthesis implantation (PPI) is almost unanimously considered the best solution for severe erectile dysfunction (ED); while patients and their partners commonly report high quality of life scores and satisfaction rates, a potential issue is postoperative reduced penile length. To verify if the AMS LGX prosthesis, with cylinders expanding in girth and length, can prevent penile shortening following surgery, and to compare its impact on penile length with the AMS CX device, which cylinders expand in girth only (1).

==fine objective==

==inizio methodsresults==

Thirty-two consecutive patients with severe ED scheduled for three-component hydraulic penile prosthesis placement were randomized in two groups: AMS LGX and AMS CX devices. Preoperatively a baseline stretched penile length (SPL) was obtained. In both groups our routine strategy for length preservation, consisting of cylinder oversizing (1 cm) and device kept activated for two weeks postoperatively, was used. Post-operatively penis length at fully inflated device was recorded at 1, 6 and 12 months. Participants completed the ”Quality of Life and Sexuality with Penile Prosthesis” (QoLSPP) questionnaire at one year follow-up.(2-3)

==fine methodsresults==

==inizio results==

Baseline mean SPL were: 14.7 cm (range:12.5 – 17) in the LGX group; 15.4 cm (range:12.5 – 17.5) in the CX group. At 1 month postoperatively no difference emerged between the two device groups in terms of fully inflated device penile length compared to baseline measurements. At 6 months follow-up the LGX group showed a mean significant length increase of 0.9 cm (p=0.008) compared to baseline, while the CX group did not (p= 0.556). At 1 year follow-up both LGX and CX groups exhibited a statistically significant mean increase in penile length compared to baseline (2.1 cm, p=0.001, and 0.8 cm, p=0.001, respectively). QoLSPP questionnaire showed high scores in all its domains (functional, relational, social and personal) in both groups, with no significant differences emerging between the two groups. (4)

==fine results==

==inizio discussions==

Both tested devices, with strategies of cylinder oversizing and prolonged postoperative activation, prevent penile shortening, promote penile length gain, and are associated with high satisfaction rates and QoL scores.

==fine discussions==

==inizio conclusion==

The LGX device provides a greater and faster penile length gain compared to the CX device. The 20% LGX cylinder in vitro length gain indicated by the Company translates in a in vivo penile length gain of 14.3% at one year follow-up.

==fine conclusion==

==inizio reference==

1. Carson CC, Mulcahy JJ, Govier FE, AMS 700 CX Study Group. Efficacy, safety and patient satisfaction outcomes of the AMS 700 CX inflatable penile prosthesis: results of a long term multicenter study. J Urol 2000;164:376–80
2. Montorsi F, Rigatti P, Carmignani G, Corbu C, Campo B, Ordesi G, Breda G, Silvestre P, Giammusso B., Morgia G, Graziottin A. AMS three-piece inflatable implants for erectile dysfunction: a long-term multi-institutional study in 200 consecutive patients. Eur Urol 2000;37:50–5
3. Caraceni E, Utizi L. A questionnaire for the evaluation of quality of life after penile prosthesis implant: quality of life and sexuality with penile prosthesis (QoLSPP): to what extent does the implant affect the patient’s life? J Sex Med. 2014 Apr;11(4):1005-12
4. Caraceni E, Utizi L, Angelozzi G. Pseudo-capsule “coffin effect”: how to prevent penile retraction after implant of three-piece inflatable prosthesis. Arch Ital Urol Androl 2014; 86(2): 135-137

==fine reference==

Use of a Non–cross-linked Xenograft (Xenform) in Surgical Treatment of Peyronie’s Disease

==inizio objective==

To evaluate the effectiveness in Peyronie’s disease surgical treatment using Xenform, a non–cross-linked graft derived from dermal bovine tissue, to close the defect obtained after plaque incision, without penile prosthesis implant. A further objective is to evaluate the satisfaction of patients. (1)

==fine objective==

==inizio methodsresults==

We treated with plaque incision 28 patients with a stable penile curvature ≥60° hindering penetration and with erectile function conserved. International Index of Erectile Function-15 and a not-validated questionnaire constituted of 7 questions about their satisfaction were administered after 1 year of follow-up. Furthermore, specific questions were relative about penile straightening, penile postoperative length, glandular sensitivity, and feeling palpability. (2)

==fine methodsresults==

==inizio results==

Sixteen patients were seen after at least 1 year of follow-up. Curvature improvement was obtained in all cases, with the complete straightening in 75%; we did not observe any retraction of the graft and any recurrence on the curvature.
Significant reduced glans sensibility and erectile dysfunction were the more frequent postoperative complications, resulting in 43.8% and 25%, respectively. All patients are satisfied with the straightening. Only 2 patients are dissatisfied about the overall result. (3-4)

==fine results==

==inizio discussions==

Graft is resulted compatible with albugineal features, like thickness, consistency, and elasticity; it is waterproof, allowing the visualization of complete correction of the curvature after the suture. No severe complications were observed except 1 hematoma requiring surgical revision.

==fine discussions==

==inizio conclusion==

Plaque incision corporoplasty with Xenform graft is an effective and safe surgical treatment. Xenform is a secure and a reliable albugineal substitute, comparable to other heterologous graft. We have not observed any retraction. Patient’s satisfaction is linked to the treatment result and to sexual life.

==fine conclusion==

==inizio reference==

1 Egydio PH, Lucon AM, Arap S. Treatment of Peyronie’s disease by incomplete circumferential incision of the tunica albuginea and placque with bovine pericardium graft. Urology 2002; 59(4): 570-4
2. Austoni E, Colombo F, Mantovani F. Radical surgery and conservation of erection in Peyronie’s disease. Arch Ital Urol Androl 1995; 67(5): 359-64
3. Carson CC, Levine L. Outcomes of surgical treatment of Peyronie’s disease. BJU Int. 2014; 113(5): 704-13
4. Levine LA, Burnett AL. Standard operating procedures for Peyronie’s disease. J Sex Med 2013; 10(1): 230-44.

==fine reference==

Different approaches in penile tri-component prosthesis surgery. A single Italian centre experience

==inizio objective==

Among different approaches proposed through time, peno-scrotal and infrapubic ones are the most common performed for penile prosthesis implantation. Those are generally shorter in dimension than that of the past and allows to implant the prosthesis with a single incision of few centimeter. In scientific literature works comparing both approaches are lacking. Aim of this study is to compare advantages and disadvantages of each peno-scrotal and infrapubic approach in order to assess whether there is one to prefer on the other.

==fine objective==

==inizio methodsresults==

This was a retrospective analysis on 69 consecutive patients who all have been implanted between 2010 and 2013. Among these 10 received and implantation via infrapubic incision and other 59 via peno-scrotal one. Quality of Life(QoL) was determined using the validated questionnaire QoLSPP. Data were analyzed using SPSS software for statistical analysis.

==fine methodsresults==

==inizio results==

Samples were homogeneous according to age ((60.3 A vs 67.1 B; p= 0.12).In Group A (peno-scrotal) 9 patients of 59 had concomitant IPP vs none in Group B (infrapubic). Mean of total implant length showed no difference, with differences in lenght of the extensor which is higher in group A. Operation time is 8 minutes shorter in group B (77.5 minutes A vs 85.2 minutes B; p<0,05). Penis length after surgery showed not significant difference (13.48 cm A vs 13.6 cm B; p=0,9). Few complications was observed all belonging to Dindo 1 with no significant difference between the groups. As well, QoLSPP scores showed no difference in the 4 domains: functional (3.9 A vs 4.0 B; p=0,32), relational (4,2 A vs 4,1 B; p=0.8), social (3.7 A vs 4,1 B; p=0.47) and personal (4.0 A vs 4.3 B; p=0.18). ==fine results== ==inizio discussions== The peno-scrotal approach was largely more frequently performed (6:1).Operation time was barely shorter with the infrapubic approach, although its effectiveness in reducing infections has been questioned (1). The peno-scrotal approach allows a better exposition of the corpora cavernosa and it should be preferred in complex cases (like concomitant IPP). Using one approach or another did not affect patients QoL after the implantation(2). ==fine discussions== ==inizio conclusion== Both approaches are safe, effective and should be considered minimally invasive if any ancillary procedure has been performed; the decision on which is to choice actually depends on surgeon or patient preference, evaluating every single case. In our centre, peno-scrotal approach is more frequently used as it is, in general, in Italy. (3) ==fine conclusion== ==inizio reference== (1) Garber , Markus. Urology 1998 Aug 52(2):291-3. (2) Caraceni, Utizi et al. J Sex Med 2014; 11:1005-1012 (3) INSIST-ED. Archivio italiano Urologia Andrologia 2016; 88-2 ==fine reference==

ANALYZING SATISFACTION RATE IN PATIENTS WITH PEYRONIE’S DISEASE UNDERWENT ALBUGINEAL GRAFTING AND PENILE IMPLANT

==inizio objective==

Peyronie’s disease (PD) is a benign, localized connective tissue disorder characterized by the abnormal deposition of collagen with the formation of fibrous, inelastic plaques in the tunica albuginea of the corpora cavernosa, which causes penile deformity during erection and Erectile Dysfunction (ED)[1].This disorder is frequently associated with anatomical alterations of the shaft and penile shortening and has a major impact on quality of life and significant psychological effects [2].The aim of this study is to analyze the satisfaction rate in patients underwent albugineal grafting and penile implant.

==fine objective==

==inizio methodsresults==

From March 2015 to April 2016 13 patients with PD were recruited. with stable disease at list for six months. 9 patients reported ED assessed by questionnaire IIEF – 5 (14 + – 2), degree of curvature> 50 ° in 9 patients, complex deformities in 3 patients and in one patient there was a penile shortening due cavernosal fibrosis.
The surgical procedure started with a sub coronal approach. The penis was degloved.  Buck’s fascia was dissected from the albuginea.With an artificial erection we identified the maximum curvature point, thanks to dermographic pen in order to asses the angle of curvature. A double Y incision is performed on the tunica albuginea.
The defect was musered and covered with a patch of porcine derma and sutured to the albuginea with a continuous suture in 4-0 polydioxanone.
Penile prosthesis (AMS 700 CX) was inserted using using a peno-scrotal incision and inflated at 80% of the maximum capacity for the next two weeks. The patients were discharged 2-3 days after surgery.
All patients were proposed therapy Vacuum[3] device for the next 6 months.
The assessment of patient satisfaction was measured with modified EDITS[4] questionnaire at 6 months after surgery.
This consists of 5 macro areas (overall satisfaction, self-confidence, loss of post-operative sensitivity, length of postoperative penile length loss of the post -operatoria penis); the patient could validate only one choice among the three proposals (satisfied, not very satisfied and not satisfied).

==fine methodsresults==

==inizio results==

The results at 6 months after surgery were:
84% (11 patients) of the patients was satisfied with the result of surgery.
2 patient (7.7%) was half satisfied with the result.
10 patients (76.9%) of patients had received greater security in the relationship with their partners after the surgery.
The third macro areas regard the loss of post-operative sensitivity of the 13 analyzed patients, 9 (69.2%) reported no loss of post – operative sensitivity, and only 4 (38.4%) reported minimal loss of sensitivity.
92.3% of patients, when asked about the length of the penis were satisfied, and only 1 patient (7.7%) not at all satisfied.
Finally, in no patient it was found loss of penile length.

==fine results==

==inizio discussions==

Surgery is the only effective tool in the management of severe PD. Unfortunately albugineal grafting results in a high rate of postoperative ED. Albugineal grafting and penile prosthesis implantation is the only technique able to restore penile size and guarantee pts’ satisfaction.

==fine discussions==

==inizio conclusion==

The psychological implications of Peyronie’s disease is a factor to be considered when setting the therapy with surgery.
In this study, we have shown that the ‘surgery and penile prosthesis implantation, associated with post-operative rehabilitation with vacuum device, leads to a high satisfaction rate and greater self-confidence.

==fine conclusion==

==inizio reference==

1. Pryor J., Akkus E., Alter G., Lebret T., Levine L., et. All. Peyronie’s disease. J Sex Med. 2004;Jul;1(1):110-5.
2. Egydio PH. Surgical treatment of Peyronie’s disease: Choos- ing the best approach to improve patient satisfaction. Asian J Androl 2008;10:158–66.
3. Raheem AA, et al. The role of vacuum pump therapy to mechanically straighten the penis in Peyronie’s disease. BJU Int 2010 p.1178-80
4. 1. Stanley E. Althof, Eric W: Edits: Development of Questionnaires for evaluating satisfaction with treatments for erectile dysfunction. Adult Urology 1999.

==fine reference==