Evolution of techniques for aesthetic penile enlargement during prosthesis placement: a chronicle of the Egydio non-grafting strategy.

Since penile prostheses only provide axial rigidity, correction of penile deformity and enlargement of the visible penis during implant surgery may be desired. Evolving techniques of tunica expansion have made it possible to avoid grafting and preservation of the cylindrical appearance without bulges and indentations. After two decades of devising individualized solutions for patients and continuous enhancements of existing surgical solutions, Dr. Paulo Egydio has arrived at his Tunica Expansion Procedure (TEP). This strategy is his newest iteration of a lengthening techniques without grafting accompanied by penile prosthesis implantation. The TEP Strategy permits surgeons to use their own intuitive reasoning to determine the best pattern of multiple, small, staggered incisions to promote length and girth enlargement.

Inflatable penile prosthesis reservoir placement—Are we ready for a paradigm change? / Colocación de reservorio para prótesis de pene inflables: ¿estamos preparados para un cambio de paradigma?

In 2002, Steve Wilson pioneered new procedures for alternative placement of reservoirs for inflatable prostheses in patients who have suffered damage to the space of Retzius following pelvic surgery or obliteration of the transversalis fascia by mesh hernia repair. Since then, surgical techniques and tools for ectopic reservoir placement have gradually gained acceptance to minimize palpability, and the risk of visceral and vascular lesions for high risk patients has been all but eliminated. Lockout valves and high submuscular placement techniques are now recommended, and reports of vascular, bowel or bladder injuries are uncommonly rare. While surgeons continue their search for safer and more effective placement methods, new skills and instruments are constantly being introduced to make recommendations to minimize complications and provide safety and functionality. Additional studies and comparisons of techniques are needed to achieve a consensus of best practice for reservoir placement solutions. (AU)

En 2002, Steve Wilson fue el precursor de nuevos procedimientos para la colocación alternativa de reservorios para prótesis inflables en los pacientes que habían sufrido daños en el espacio de Retzius tras cirugía pélvica u obliteración de la fascia transversalis por reparación de hernia con malla. Desde entonces, han ido ganando aceptación las técnicas y herramientas quirúrgicas para colocación de reservorio ectópico, a fin de minimizar la palpabilidad, habiéndose eliminado prácticamente el riesgo de lesiones viscerales y vasculares para pacientes de alto riesgo. Hoy en día se recomiendan las válvulas de bloqueo y las técnicas de colocación submuscular alta, siendo excepcionalmente raros los informes sobre lesiones a nivel vascular, intestinal o en la vejiga. A pesar de que los cirujanos siguen investigando en busca de métodos de colocación más seguros y efectivos, se están introduciendo constantemente nuevas competencias e instrumentos en aras de realizar recomendaciones para minimizar las complicaciones y aportar seguridad y funcionalidad. Son necesarios más estudios y comparaciones sobre técnicas para lograr un consenso acerca de la mejor práctica sobre soluciones de colocación de reservorios. (AU)

The International Penile Prosthesis Implant Consensus Forum: clinical recommendations and surgical principles on the inflatable 3-piece penile prosthesis implant.

Despite significant scientific advances in the modern three-piece inflatable penile prosthesis implant surgery, it is not without surgical risks and can carry additional cosmetic and psychosocial consequences in poorly selected and consented individuals. To address this problem, an international group of key opinion leaders and high-volume prosthetic surgeons reviewed the current guidelines and clinical evidence, discussed their experiences, and formed a consensus regarding inflatable penile prosthesis surgery. The findings of this consensus panel were presented at the 17th biennial Asia Pacific Society of Sexual Medicine scientific meeting. The experts concluded that proper patient selection, informed consent and strict adherence to safe surgical principles are important to optimize clinical outcomes. Furthermore, most intraoperative complications, if recognized, can be addressed intraoperatively to enable placement of the device at the time of initial surgery. Men with significant corporal fibrosis due to Peyronie's disease, prior prosthesis explantation and priapism, and men who have undergone construction of a neophallus, as well as men who receive concurrent continence surgery, are complex cases requiring additional care and advanced techniques to obtain optimal surgical outcomes. Variability in patient care - in terms of postoperative antibiotic use, pain management, scrotal care, and cycling of the penile prosthesis implant - must be reduced to enable optimization and assessment of outcomes across patient groups.

Inflatable penile prosthesis reservoir placement-Are we ready for a paradigm change?

In 2002, Steve Wilson pioneered new procedures for alternative placement of reservoirs for inflatable prostheses in patients who have suffered damage to the space of Retzius following pelvic surgery or obliteration of the transversalis fascia by mesh hernia repair. Since then, surgical techniques and tools for ectopic reservoir placement have gradually gained acceptance to minimize palpability, and the risk of visceral and vascular lesions for high risk patients has been all but eliminated. Lockout valves and high submuscular placement techniques are now recommended, and reports of vascular, bowel or bladder injuries are uncommonly rare. While surgeons continue their search for safer and more effective placement methods, new skills and instruments are constantly being introduced to make recommendations to minimize complications and provide safety and functionality. Additional studies and comparisons of techniques are needed to achieve a consensus of best practice for reservoir placement solutions.

Surgical outcomes after collagenase Clostridium histolyticum failure in patients with Peyronie's disease in a multicenter clinical study.

In the present study we aimed to investigate the surgical outcomes of patients with persistent penile curvature (PC) after Collagenase Clostridium histolyticum (CCH) intraplaque injections. Data from 90 patients with persistent PC after CCH in a multicentre study from 6 andrological centres were retrospectively reviewed. Three standardized surgical techniques were performed. Group 1: plaque incision grafting (PIG) with penile prosthesis implant (PPI); Group 2: PIG without PPI; Group 3: Nesbit technique. Hospital stay, operative time, postoperative complications and PC persistency/recurrence (> 20°) were evaluated. Overall satisfaction and functional outcomes were assessed through International Index of Erectile Function-Erectile Function (IIEF-EF), Peyronie's Disease Questionnaire (PDQ), Female Sexual Function Index (FSFI) administered pre and 3 months postoperatively. Of all, 25 (27.8%) patients received grafting procedure + PPI (Group 1), 18 (20.0%) patients belonged to Group 2, and 47 (52.2%) to Group 3. Bovine pericardium graft and collagen fleece have been used in in 22 (51.2%) and 21 (48.8%) patients, respectively. Median penile length after surgery was 13.0 cm (IQR 12.0-15.0). After surgery, Group 1 showed higher increase in penile length after surgery and better improvements in terms of PDQ-PS. In contrast, both IIEF-EF and FSFI scores did not differ among groups. Overall, 86 (95.6%) did not report any complication. 4 (4.4%) patients had PC recurrence; of those, 2 (8.0%), 1 (5.6%) and 1 (2.1%) cases were observed in Group 1, Group 2 and Group 3, respectively. In case of persistent PC after CCH, surgical correction by grafting with or without concomitant PPI or Nesbit technique emerged as a technically feasible, effective and safe procedure, with no significant postoperative complications.

An Innovative Strategy for Non-Grafting Penile Enlargement: A Novel Paradigm for Tunica Expansion Procedures.

BACKGROUND: Peyronie's disease, diabetes, trauma, pelvic surgeries, and aging are conditions that promote penile fibrosis and trigger erectile dysfunction associated with penile reduction. These pathologies require an objective preoperative diagnosis and intraoperative management of penile shrinkage. AIM: The goal is to develop a non-grafting procedure to promote lengthening using geometric patterns of multiple staggered small cuts on the tunica albuginea with an optimal ratio between tissue expansion and resistance to confine the cylinders inside the corpora cavernosa. METHODS: Between February 2016 and February 2019, 416 patients suffering penile shortening with or without Peyronie's disease received implants using the tunica expansion procedures (TEP). Incisions were distributed in respective areas of the tunica to allow maximum expansion while maintaining strength to confine prosthetic cylinders within the corpora cavernosa to prevent bulges and denting. OUTCOMES: In accordance with these principles, surgical objectives and patient satisfaction were achieved in length and girth restoration regardless of the type of implant used to obtain adequate axial rigidity. RESULTS: The sample of 416 patients included 287 cases of Peyronie's disease having a mean axial deviation of 51° (0-90°) whose curvature was corrected in surgery, with pressure from the cylinders maintaining straightness for malleable and inflatable devices. Tunica constriction in 40.86% of cases was corrected with vertical relaxing incisions. Ventral glanspexy was performed intraoperatively in 92.8% of patients to prevent hypermobility. A penile gain of 3.3 cm (2-6) was measured intraoperatively. CLINICAL IMPLICATIONS: Diagnosis of penile shortening was performed by a stretch length test and pharmacologically induced erection together with the patient's subjective opinion of penile loss. Lengthening procedure depends on the limit of the dissected neurovascular bundle. The patient and surgeon select the type of implant in accordance with his individual anatomic characteristics. STRENGTHS AND LIMITATIONS: The TEP strategy is a non-grafting procedure based on tissue restitution by expansion instead of substitution, which provides surgeons a solution for penile enlargement to the limit of the dissected neurovascular bundle. CONCLUSIONS: The TEP strategy has been demonstrated to be safe and effective to resolve problems of penile size reduction independently of penile curvature. It eliminates grafting and improves penile lengthening techniques using small, staggered cuts on the tunica albuginea, while maintaining tunica structural resistance to contain cylinders inside the corpora, preventing bulges and denting, facilitating tissue regeneration, and improving axial rigidity. Paulo H. Egydio, An Innovative Strategy for Non-Grafting Penile Enlargement: A Novel Paradigm for Tunica Expansion Procedures. J Sex Med 2020;17:2093-2103.

The Multiple-Slit Technique (MUST) for Penile Length and Girth Restoration.

BACKGROUND: Patients with severe erectile dysfunction (ED) and penile size issues, especially seen in Peyronie's disease (PD), are candidates for more invasive penile prosthesis insertion techniques that aim for penile length and girth reconstruction. AIM: To present the feasibility and safety of penile length and girth restoration based on the so-called multiple-slit technique (MUST) for patients with severe ED and significant penile shortening with or without PD. METHODS: From July 2013 through January 2016, 138 patients underwent the MUST. The International Index of Erectile Function (IIEF) and the Erectile Dysfunction Inventory of Treatment Satisfaction were completed. OUTCOMES: Outcome analysis was focused on penile length restoration, penile curvature correction, intra- and postoperative complications, and patient satisfaction. RESULTS: 138 patients underwent the procedure (103 malleable and 35 inflatable devices). Etiologies of penile shortening and narrowing were PD, severe ED, post-radical prostatectomy, and androgen-deprivation therapy with or without brachytherapy or external radiotherapy for prostate cancer, and post-penile fracture in 60.1%, 24.6%, 10.1%, 3.6%, and 2.2%, respectively. In PD cases, the mean deviation of the penile axis was 55° (range = 0-90°). Mean subjective penile length loss reported was 3.2 cm (range = 1-5 cm), and shaft constriction was present in 44.9%. Median follow-up was 15.2 months (range = 6-36 months). Mean penile length gain was 3.1 cm (range = 2-5 cm). No penile prosthesis infection caused device explantation. One glans necrosis was encountered. The average IIEF score increased from 22 points at baseline to 66 points at 6-month follow-up. CLINICAL IMPLICATIONS: The MUST helps address penile size issues in cases of severe ED with concomitant conditions that impair penile length or girth. STRENGTHS AND LIMITATIONS: The strength of the study is its applicability to provide surgeons with a solution for cases in which patients have severe ED and penile size impairment owing to underlying conditions such as PD. The study is limited by the relatively short follow-up. CONCLUSIONS: The MUST is an effective, safe, and viable treatment option for a selected patient cohort. Because of the potential complications, proper counseling should take place and only experienced surgeons should perform this type of surgery. Egydio PH, Kuehhas FE. The Multiple-Slit Technique (MUST) for Penile Length and Girth Restoration. J Sex Med 2018;15:261-269.

Glans Necrosis Following Penile Prosthesis Implantation: Prevention and Treatment Suggestions.

OBJECTIVE: To examine possible etiology and treatment outcomes in 21 patients with glans necrosis following penile prosthesis implantation. METHODS: Glans necrosis typically presented with a dusky glans on the first postoperative day following prosthesis implantation. RESULTS: The blood supply to the glans penis consists of the dorsal arteries and the terminal branches of the spongiosal arteries. Using the cohort in our study, we compiled preoperative comorbidities and adjunctive surgical maneuvers that might compromise glans vascularity, leading to glans necrosis. Preoperative risk factors were arteriosclerotic cardiovascular disease (90%), diabetes mellitus (81%), smoking (81%), previous prosthesis explantation (57%), and previous radiation therapy (48%). The most prevalent intraoperative and postoperative factor was subcoronal incision for reasons as simple as coincident circumcision or as complex as for penile degloving (86%). Other factors detected were penile wrapping with an occlusive elastic bandage (62%), use of a sliding technique for penile lengthening (33%), and coincident distal urethral injury repair (29%). Seventeen patients (81%) managed expectantly with preservation of implanted prosthesis sustained significant glandular loss. Four patients managed with immediate prosthesis removal healed without sequelae. CONCLUSION: Patients with preoperative risk factors undergoing penile prosthesis implantation should avoid high-risk adjunctive surgical maneuvers. Upon development of signs of glans necrosis postoperatively, in the setting of these high-risk factors, immediate implant removal may prevent subsequent glans necrosis.

Lengthening strategies for Peyronie's disease.

Loss of penile length is a common complaint of men with Peyronie's disease (PD), both before and after corrective intervention, which has a significant negative effect on patient quality of life. We sought to identify and describe the methods by which penile length can be preserved or increased. We conducted an extensive, systematic literature review, based on a search of the PUBMED database for articles published between 1990 and 2015. Articles with the key words "Peyronie's disease", "penile length" and/or "penile lengthening" were reviewed if they contained subjective or objective penile length outcomes. Only English-language articles that were related to PD and penile size were included. We found no evidence in the literature that medical therapy alone increases penile length. Classic inflatable penile prosthesis (IPP) placement, plication procedures, and the Nesbit procedure appear likely to maintain or decrease penile length. Plaque incision (PI) and grafting appears likely to maintain or increase penile length, but is complicated by risk of post-operative erectile dysfunction (ED). There are several surgical procedures performed concomitantly with IPP placement that may be suitable treatment options for men with comorbid ED, and consistently increase penile length with otherwise good outcomes concerning sexual function. These include the subcoronal penile prosthesis (scIPP), Egydio circumferential technique, the sliding technique, the modified sliding technique (MoST), and the multiple slice technique (MuST). In addition, adjuvant therapies such as penile traction therapy (PTT), post-operative inflation protocols, suspensory ligament relaxation, lipectomy, and adjuvant medical therapy for glans engorgement appear to increase subjective and/or objective penile length for men at high risk of decreased penile length after PD surgery. Considering the psychological burden of length loss in men with PD, providers with adequate volume and expertise should attempt, if possible, to maintain or increase penile length for men undergoing surgical intervention. There are several evidence-based, safe, and effective ways to increase penile length for these men and multiple emerging adjuvant therapies that may help ensure adequate length.

Penile lengthening and widening without grafting according to a modified 'sliding' technique.

OBJECTIVE: To present the feasibility and safety of penile length and girth restoration based on a modified 'sliding' technique for patients with severe erectile dysfunction (ED) and significant penile shortening, with or without Peyronie's disease (PD). PATIENTS AND METHODS: Between January 2013 and January 2014, 143 patients underwent our modified 'sliding' technique for penile length and girth restoration and concomitant penile prosthesis implantation. It is based on three key elements: (i) the sliding manoeuvre for penile length restoration; (ii) potential complementary longitudinal ventral and/or dorsal tunical incisions for girth restoration; and (iii) closure of the newly created rectangular bow-shaped tunical defects with Buck's fascia only. RESULTS: In all, 143 patients underwent the procedure. The causes of penile shortening and narrowing were: PD in 53.8%; severe ED with unsuccessful intracavernosal injection therapy in 21%; post-radical prostatectomy 14.7%; androgen-deprivation therapy, with or without brachytherapy or external radiotherapy, for prostate cancer in 7%; post-penile fracture in 2.1%; post-redo-hypospadias repair in 0.7%; and post-priapism in 0.7%. In patients with ED and PD, the mean (range) deviation of the penile axis was 45 (0-100)°. The mean (range) subjective penile shortening reported by patients was 3.4 (1-7) cm and shaft constriction was present in 53.8%. Malleable penile prostheses were used in 133 patients and inflatable penile prostheses were inserted in 10 patients. The median (range) follow-up was 9.7 (6-18) months. The mean (range) penile length gain was 3.1 (2-7) cm. No penile prosthesis infection caused device explantation. The average International Index of Erectile Function (IIEF) score increased from 24 points at baseline to 60 points at the 6-month follow-up. CONCLUSION: Penile length and girth restoration based on our modified sliding technique is a safe and effective procedure. The elimination of grafting saves operative time and, consequently, decreases the infection risk and costs associated with surgery.

International multicentre psychometric evaluation of patient-reported outcome data for the treatment of Peyronie's disease.

OBJECTIVE: To compare patient-reported outcomes (PROs) of surgical correction of Peyronie's disease (PD) with the Nesbit procedure, plaque incision and grafting, and the insertion of a malleable penile implant after surgical correction of penile curvature. PATIENTS AND METHODS: We performed a retrospective review of men who underwent surgical correction of PD between January 2010 and December 2012 at six international centres. Treatment-related PROs and satisfaction were evaluated with a non-validated questionnaire. RESULTS: The response rate to the questionnaire was 70.9%, resulting in a study cohort of 206 patients. The Nesbit procedure, plaque incision with grafting, or implantation of a malleable penile prosthesis was performed in 50, 48, and 108 patients, respectively. Overall, 79.1% reported a subjective loss of penile length due to PD preoperatively (range 2.1-3.2 cm). Those patients treated with a malleable penile implant reported the greatest subjective penile length loss, due to PD. A subjective loss of penile length of >2.5 cm resulted in reduced preoperative sex ability. Postoperatively, 78.0%, 29.2% and 24.1% patients in the Nesbit, grafting, and implant groups reported a postoperative, subjective loss of penile length (range 0.4-1.2 cm), with 86.3%, 78.6%, and 82.1% of the patients in each group, respectively, being bothered by the loss of length. CONCLUSIONS: Penile length loss due to PD affects most patients. Further penile length loss due to the surgical correction leads to bother among the affected patients, irrespective of the magnitude of the loss. The Nesbit procedure was associated with the highest losses in penile length. In patients with PD and severe erectile dysfunction, a concomitant lengthening procedure may be offered to patients to help overcome the psychological burden caused by the loss of penile length.

The STAGE technique (superficial tunica albuginea geometric-based excision) for the correction of biplanar congenital penile curvature.

INTRODUCTION: Congenital penile curvature can present with both uniplanar and biplanar defects, the latter of which entails more technically demanding surgery. AIM: The study aims to demonstrate the efficacy and safety of our novel superficial tunica albuginea geometric-based excision (STAGE) technique based on multiple, small, superficial elliptical tunica albuginea excisions and geometrical principles for correcting biplanar congenital penile curvature. METHODS: The study represents a retrospective analysis of 145 patients with disabling congenital biplanar ventrolateral (n = 131; 90.3%) or dorsolateral (n = 14; 9.7%) curvature of the penis, which underwent stepwise STAGEs between June 2006 and March 2012. Multiple 3-mm elliptical excisions of the superficial tunica albuginea were performed without compromising the inner layer of the tunica albuginea, thus resulting in a stepwise correction of the curvature and improved distribution of the bending force of the curvature. MAIN OUTCOME MEASURES: Functional outcome regarding penile straightening, erectile function, and patient satisfaction were evaluated. Furthermore, clinical data concerning the early postoperative outcome were analyzed retrospectively. RESULTS: The mean follow-up period was 21 months (range 6-62 months). Mean age at surgery was 23.8 years (range 15-47 years). Mean degree of curvature was 65° (range 45-90°). There was no recurrent curvature. Complete correction of the penile axis was obtained in 98.6% (n = 143). No change in erectile function according to International Index of Erectile Function-5 score was visible (P = 0.748). The mean loss of penile length was 0.7 cm (range 0.3-0.9 cm). The excellent functional outcomes resulted in a high level of patient satisfaction, including improved self-esteem, libido, sexual intercourse, and psychosexual relief. Two patients had a residual curvature of up to 30° requiring a reoperation. No intra- or postoperative complications were encountered. CONCLUSIONS: We recommend the STAGE technique as the optimal surgical intervention for correcting both uniplanar and biplanar congenital deviations.

Distal penile shaft reconstruction and reinforcement: the "double-windsocks" technique.

INTRODUCTION: The management of penile prosthesis protrusion and the implantation of a prosthesis in fibrotic penile corporal bodies represents a challenging task even for experienced surgeons. AIM: To demonstrate the long-term efficacy and safety of a new technique for distal shaft reconstruction and reinforcement in cases of penile prosthesis protrusion or cases of penile prosthesis implantation in corporal fibrosis. METHODS: Between August 2007 and August 2012, 69 patients underwent surgery for penile prosthesis protrusion (45 patients) or severe distal corporal fibrosis (24 patients). The mean age at the time of surgery was 56 years (range 38-69). All patients underwent distal shaft reconstruction using our technique, involving the creation of two neocorpora ("double windsocks"). MAIN OUTCOME MEASURES: Functional outcome and patient satisfaction were evaluated with item numbers 1 and 7 of the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire. Furthermore, clinical data concerning the early postoperative outcome were analyzed retrospectively. RESULTS: Mean follow-up time was 22.5 months (range 6-48). Based on answers to EDITS questionnaire item 1, 42 patients (60.9%) were very satisfied and 19 patients (27.5%) were somewhat satisfied with the outcome of the procedure. Furthermore, answers to the self-confidence domain question (EDITS item 7) revealed that 63 patients (91.3%) felt that the treatment had a positive effect with respect to their ability to engage in sexual activity. No patient exhibited device extrusion, postoperative infection, or skin dehiscence, and glans sensation as well as orgasmic ability were also preserved in all cases. Neuropraxia was reported in five cases (3.4%) immediately after the operation. The recovery of orgasmic ability was delayed in 17 (24.6%) patients. All patients were able to perform sexual intercourse postoperatively. CONCLUSION: The "double-windsocks" technique is an effective option for difficult cases of distal penile shaft reconstruction and reinforcement.

Penile length and girth restoration in severe Peyronie's disease using circular and longitudinal grafting.

OBJECTIVE: To report patient outcomes and satisfaction with our technique for penile length and girth restoration in severe Peyronie's disease (PD). PATIENTS AND METHODS: Between November 2006 and November 2011, 105 men with severe PD and erectile dysfunction (ED) underwent surgical correction using our new approach. The technique consists of penile prosthesis implantation with concomitant penile lengthening and girth restoration through circular and longitudinal incisions in the tunica albuginea according to geometric principles. RESULTS: The overall patient satisfaction rate was 89.4%. The mean (sd; range) functional penile length gain was 3.6 (0.7; 2-5) cm. Patient satisfaction with penile length gain was 95.2%. Three patients (2.9%) developed retraction with residual curvature of up to 30°, but no re-operation was necessary. In one (1%) patient, the prosthesis had to be removed because of wound infection. At a mean (sd; range) follow-up of 18.2 (5.9; 6-46) months, 104 patients (99%) were able to have sexual intercourse. CONCLUSIONS: Our surgical approach for penile length and girth restoration leads to high patient satisfaction rates and excellent functional outcomes. Our surgical approach is a safe and valid therapeutic method for the treatment of severe PD associated with ED.

Treatments for fibrosis of the corpora cavernosa.

INTRODUCTION: Corporal fibrosis usually occurs after explantation of an infected penile prosthesis, severe penile trauma, refractory low-flow priapism, Peyronie's disease, or the chronic intracavernous injection of vasoactive drugs. METHODS: We analysed current treatmentss for penile fibrosis. We searched PubMed using the keywords 'penile corporal fibrosis', 'treatment' and 'penile fibrosis', resulting in 63 matches, of which 19 articles met the inclusion criteria. RESULTS AND CONCLUSIONS: This review covers conservative medical therapy for corporal fibrosis and surgical therapeutic methods. The roles of phosphodiesterase- 5 inhibitors and pentoxifylline are analysed. Surgical therapy includes implantation of a penile prosthesis and corporal reconstruction, and these are reviewed. Corporal fibrosis is a major problem for patients, and is associated with severe erectile dysfunction. Conservative treatment options can be applicable in the early phase, but simultaneous corporal reconstruction procedures with concomitant implantation of a penile prosthesis should be attempted in severe cases of corporal fibrosis.

Superficial tunica albuginea excision, using geometric principles, for the correction of congenital penile curvature.

UNLABELLED: Study Type--Therapy (practise pattern survey) Level of Evidence 3b. What's known on the subject? and What does the study add? Congenital penile deviation has become a relatively frequent finding due to a greater awareness of the problem among patients and physicians. Since the first surgical correction for congenital penile curvature was performed, many modifications have been implemented to overcome the disadvantages of the standard procedure and to improve functional results. Among the possible side effects of the original technique are postoperative erectile dysfunction, the development of painful nodules at the suture sites ('dog ears'), alteration of cutaneous sensibility and significant penile shortening. This study presents a novel approach for the correction of congenital penile curvature. We modified the conventional Nesbit technique by applying superficial tunica albuginea excisions, according to the geometric principles of the Egydio technique. OBJECTIVE: • To report our experience with a new technique for the correction of congenital penile curvature based on geometric principles. PATIENTS AND METHODS: • Between January 2006 and March 2011, 211 men with congenital penile curvature underwent our modified Nesbit technique. • The technique consists of an objectivation of the degree of curvature and distribution of the bending force by multiple, small, superficial, elliptical excisions of the tunica albuginea. RESULTS: • The overall success rate was 99.1%. • A residual curvature of less than 20° was reported in 5% (n = 11) of the cases; none of these patients opted for further surgical correction. • Residual curvature of up to 30° was observed in 0.9% (n = 2); these patients underwent a reoperation. • Acquiring or regaining the ability to perform sexual intercourse brought major relief and high rates of satisfaction and self-esteem. • No recurrence of a ventral curvature occurred. CONCLUSIONS: • Our modified Nesbit technique, consisting of superficial tunica albuginea excision according to the geometric principles of the Egydio technique, leads to rapid and excellent results due to an objectivation of the curvature. • It is a safe and valid alternative for the treatment of congenital ventral or ventro-lateral penile deviation.

Simultaneous penile lengthening and penile prosthesis implantation in patients with Peyronie's disease, refractory erectile dysfunction, and severe penile shortening.

INTRODUCTION: Due to loss of length, patients who had penile prosthesis implantation for Peyronie's disease (PD) show a statistically significant reduction in their levels of satisfaction when compared with the general implant population. AIM: The aim of this study is to report our experience of penile lengthening with circumferential graft during penile prosthesis implantation in patients with PD and severe penile shortening. METHODS: Between March 2006 and February 2008, 23 patients with PD, refractory erectile dysfunction, and severe penile shortening underwent penile lengthening with circumferential graft and concomitant implantation of an inflatable penile prosthesis. MAIN OUTCOME MEASURES: Surgical outcome and complications have been recorded during postoperative follow-up. Patients' satisfaction has been assessed 6 months postoperatively with the administration of the modified Erectile Dysfunction Index of Treatment Satisfaction (EDITS) questionnaire. RESULTS: After an average follow-up of 22 months (range 6-36), 20 patients attended all the postoperative follow-up visits and returned the EDITS questionnaire. An average length gain of 2.8 cm (range 2.2-4.5) was recorded, and all patients were able to cycle the device and engage in penetrative sexual intercourse. Patient recorded complications included diminished glans sensitivity in four (20%) and persistent dorsal curvature of less than 15° in three (15%). Overall, 18 patients (90%) were satisfied with the cosmetic and functional result of surgery. CONCLUSION: Penile lengthening with circumferential graft during penile prosthesis implantation in patients with PD represents a safe and reproducible technique that yields higher satisfaction rates than penile prosthesis implantation alone in patients with severe penile shortening.

Peyronie's reconstruction for maximum length and girth gain: geometrical principles.

Peyronie's disease has been associated with penile shortening and some degree of erectile dysfunction. Surgical reconstruction should be based on giving a functional penis, that is, rectifying the penis with rigidity enough to make the sexual intercourse. The procedure should be discussed preoperatively in terms of length and girth reconstruction in order to improve patient satisfaction. The tunical reconstruction for maximum penile length and girth restoration should be based on the maximum length of the dissected neurovascular bundle possible and the application of geometrical principles to define the precise site and size of tunical incision and grafting procedure. As penile rectification and rigidity are required to achieve complete functional restoration of the penis and 20 to 54% of patients experience associated erectile dysfunction, penile straightening alone may not be enough to provide complete functional restoration. Therefore, phosphodiesterase inhibitors, self-injection, or penile prosthesis may need to be added in some cases.