Saturday, 29 October 2016

Implantation of three pieces inflatable penile prosthesis in patients with refractory erectile dysfunction

At present, patients with erectile dysfunction non responsive to oral medications and intracavernosal injection therapy are best served with penile prosthesis implantation.  
Among the various types of penile prosthesis available, the best results are achieved after the implantation of three pieces inflatable penile prosthesis as they guarantee a more natural erection and better girth and rigidity than their semirigid counterpart. 
Three pieces inflatable penile prosthesis are formed by 2 cylinders, which will be placed inside the corpora cavernosa of the penis, a pump, usually located in the scrotum between the testicles, and an intra-abdominal reservoir.  The components of the implant are connected by small tubing and all the system is filled with sterile water.
In most cases the device can be inserted though a 3 cm long incision at the root of the scrotum. This approach guarantees enough exposure to allow the surgeon to place the cylinders, the pump and the reservoir.
Classically the reservoir is positioned in proximity to the urinary bladder in the pelvis, but more recently an ectopic placement under the external oblique muscle of the abdomen has been described in patients who have previously undergone pelvic surgery.
Ectopic placement of the reservoir now represents the solution of choice in patients who have undergone previous extensive pelvic surgery as the classical placement in the pelvis would be associated with a significant risk of injury of the intra-abdominal organs. In the past these patients were managed with insertion of the reservoir under direct vision though a second abdominal incision. Ectopic placement of the reservoir is safe, as the device is positioned above the fascia transversalis, well away from the intra-abdominal organs, and avoids the inconvenience of performing a second abdominal incision.
Penile prosthesis implantation is usually performed under general anaesthetic and the procedure takes less than one hour. Patients are discharged the day after and usually are able to engage in penetrative sexual intercourse after six weeks.
In the hands of experienced high volume surgeons, this procedure is very safe with patients' and partners' satisfaction rates well above 95%.
Mechanical reliability of the device is also extremely high and in most patients the implant is still perfectly working after 10 years. Furthermore, if the device stops working, it can be easily replaced.

Wednesday, 26 October 2016

Penile shortening due to Peyronie's Disease: a solution is possible?

Peyronie's Disease is associated with the formation of anelastic scars on the tunica albuginea of the penis. As the scar does not stretch as the surrounding tunical tissue, during erections it can cause deformity and a degree of penile shortening. A degree of erectile dysfunction is also a common finding in patients with Peyronie's Disease.
Classically, patients with Peyronie's Disease and refractory erectile dysfunction are managed with penile prosthesis implantation in order to obtain the straightening and the rigidity necessary to engage in penetrative sexual intercourse.
Although successful in correcting the deformity and the erectile dysfunction, penile prosthesis implantation alone is not able to restore the length lost due to Peyronie's Disease, and this is why postoperative satisfaction rates in this subgroup of patients is not as high as in the other subgroups of implant patients, where no preoperative loss of length is present.
In order to address the loss of length, a very selective group of patients with Peyronie's Disease and severe shortening can now be offered penile length and girth restoration in combination with penile prosthesis implantation. This is a very complex procedure that should be performed only by high volume experienced implant surgeons. Once the penis is disassembled into the urethra, the neurovascular bundle and the corpora cavernosa, the length and girth are restored by incising circumferentially the tunica albuginea and filling the defect with a graft. In experienced hands, results can be very encouraging, with an average gain of 3.5 cm in length.
Complication rates following this procedure is however higher that after penile prosthesis implantation alone and should therefore be offered only to carefully selected and highly motivated patients.

Further reading:
  • Rolle L, Ceruti C, Timpano M, Sedigh O, Destefanis P, Galletto E, Falcone M, Fontana D. A new, innovative, lengthening surgical procedure for Peyronie’s disease by penile prosthesis implantation with double dorsal-ventral patch graft: the “sliding technique”. J Sex Med. 2012 Sep;9(9):2389-95. doi: 10.1111/ 1743-6109.2012.02675.x. Epub 2012 Mar 16. PubMed PMID: 22429331.
  • Rolle L, Falcone M, Ceruti C, Timpano M, Sedigh O, Ralph DJ, Kuehhas F, Oderda M, Preto M, Sibona M, Gillo A, Garaffa G, Gontero P, Frea B. A prospective multicentric international study on the surgical outcomes and patients’ satisfaction rates of the ‘sliding’ technique for end-stage Peyronie’s disease with severe shortening of the penis and erectile dysfunction. BJU Int. 2016 May;117(5):814-20. doi: 10.1111/bju.13371. Epub 2015 Dec 21. PubMed PMID 26688436.

Surgery for Peyronie's Disease. Which is the perfect procedure?

Surgery still represents the best solution in patients with stable Peyronie's Disease. The aim of surgery in Peyronie's Disease is to guarantee a penis straight and rigid enough to allow the patient to resume sexual activity with confidence. 
At present, more than 50 different types of procedures have been described in the literature and the question "is one technique better than another?" is perfectly legitimate. However, unfortunately the answer is "no".
The reason why there are many type of procedures is not only that different techniques are indicated according to the type of the deformity, the degree of penile shortening and the quality of the erections, but also that a perfect type of procedure still does not exist, as none of the procedures can bring back the exact pre Peyronie's Disease size and shape of the penis.
Surgical procedures available at present can be subdivided in 3 main cathegories: 1) Simple plication procedures; 2) Complex corporoplasty with plaque incision and grafting; and 3) Penile prosthesis implantation with additional straightening procedures. Each one of these categoris has its own indications, advantages and disadvantages. 
Penile prosthesis implantation is indicated in patients with refractory erectile dysfunction or with a degree of erectile dysfunction and complex deformity and/or severe penile shortening. This procedure guarantees adequate correction of the deformity and the rigidity necessary to engage in penetrative sexual intercourse.
Simple corporoplasties (such as Nesbit, Yahia and Tunica Albuginea Plication or TAP) are indicated if the curvature is less than 60 degrees, if penile shortening is not excessive and if there is no waist deformity. These procedures are not associated with postoperative worsening of the quality of the erections and are reasonalbly simple to perform. These procedure induce straightening by shortening the longer side of the shaft (the one ont affected by Peyronie's Disease). It is estimated that a shortening of 1 cm is necessary to correct 20 degrees of curvature and therefore these procedures are not indicated for curvatures of more that 60 degrees, as this would require a shortening of 3 cm at least to produce adequate straightening.
Complex corporoplasties involving plaque incision and grafting (such as the Lue procedure) are nieche procedures due to their complexity and therefore need to be performed only by experienced large volume surgeons in order to achieve adequate results. 
Patients with good quality erections and complex deformity, waist, severe shortening and curvatures of more than 60 degrees are the only candidates for this type of procedure. As plaque incision and grafing can worsen the quality of the erection in around 15% of cases, patients with a preexistent degree of erectile dysfunction are not candidates for this procedure, as they are likely to become fully impotent afterwards, and should be offered penile prosthesis implantation instead.
Finally, when discussing Peyronie's Disease surgery, it is very important to adequately counsel the patient and manage patient's expectation. Once the patient is fully counselled about the risks and benefits of each procedure, he can make an informed decision of the procedure he wants to undergo. In order to achieve higher patient's satisfaction levels, patient's expectations need to be realistic. In particular, the patient needs to accept that surgery will not remove Peyronie's Disease or restore fully the shape and size of the penis before the onset of the disease, but it will render the penis straight and rigid enough to engage in penetrative sexual intercourse with confidence.

Saturday, 22 October 2016

State of the art in female to male transsexual surgery

Female to male sex reassignment surgery remains a very challenging and long process. Patients should be followed by a multidisciplinary team of dedicated experts including psychiatrists, endocrinologists, plastic surgeons, gynaecologists and reconstructive urologists in order to achieve the best possible outcome from the transformation. 
At present, the radial artery phalloplasty represents the best choice for penile construction in these patients. This technique allows the creation of a very realistic phallus with tactile and erogenous sensation and with an incorporated neourethra to allow patients to void from the tip of the phallus while standing. After the implantation of an erectile device patients are also able to engage in penetrative sexual activity with confidence. 
This procedure, when performed by large volume surgeons, is very reliable and safe. Currently Mr Garaffa, who is a Consultant Uro-Andrologist at the University College London Hospitals is the reconstructive surgeon who currently performs the largest number of total penile reconstructions in the world and this has been the topic of the uT@lks at the 2016 SIU Congress in Buenos Aires, Argentina.
More information can be found on this link:

Thursday, 6 October 2016

Erectile dysfunction can help the physician to identify early cardiovascular risk factor and prevent cardiac events

This interesting review confirms how erectile dysfunction and major cardiovascular events such as heart attacks and strokes are caused by the same underlying problem, which is diffuse cardiovascular disease.
Sedentary lifestyle, obesity, high cholesterol levels, diabetes, hypertension and cigarette smoke are well known cardiovascular risk factors, which in the long term can cause obstruction of the arteries and vascular disease. 
When an artery gets progressively blocked the blood flow progressively reduces. If this happens in the arteries of the penis, the patient will notice a progressive worsening of the quality of the erections, while if the blockage occurs in the arteries of the heart or of the brain, the patient will experience respectively a heart attack or a stroke.
Since the vessels who are smaller are the one that will show the sign of a blockage first and since the vessels in the penis are smaller than the ones in the heart and in the brain, patients will develop signs of erectile dysfunction a few years before experiencing heart attacks or strokes.
It is therefore very important that patients seek immediate medical attention when they develop the first signs of erectile dysfunction. 
A thorough medical evaluation can not only help the patient to restore an adequate erectile function but also identify and treat potential cardiovascular risk factors that may cause fatal events a few years later. 
This will prevent the patient from suffering from a cardiovascular event and guarantee him a much longer life expectancy.
This article should therefore represent a strong invitation to patients not to be ashamed of their erectile dysfunction and to seek medical attention not only because effective treatments are now available in almost all cases but also to prevent the development of serious cardiovascular events in the near future.

For further reading please click on the following link

Wednesday, 5 October 2016

total penile reconstruction following traumatic amputation of the penis

An innovative article describing total penile reconstruction with the use of the forearm free flap in patients who have previously experienced traumatic amputation of the penis has been recently published on "The Journal of Sexual Medicine", the most prestigious international journal in andrology.

This represents the largest series of patients who have undergone total penile reconstruction with the use of a forearm free flap ever described in the literature. All the procedures have been carried out at the University College London Hospital by an equipe led by Mr Garaffa and Mr Ralph, who are the world leading experts in total penile reconstruction. 

After a very complex surgical procedure, reconstruction of a neophallus has been possible in all patients. This operation has allowed the creation of a cosmetically acceptable phallus with both cutaneous and erogenous sensation. Patients were therefore able to resume a normal sexual and urinary function.

These series confirms the encouraging results of the forearm free flap phalloplasty previously described by Mr Garaffa and Mr Ralph in patients who have undergone penile amputation for penile cancer, in these with micropenis and in female to male transsexuals.

The forearm free flap phalloplasty represents the best option in patients who require total penile (re)construction as it guarantees superior results in terms of sensation, function and cosmetic appearance. 

So we can now say that penile reconstruction is now possible and that results an be excellent..