Increased sexual health after restored genital sensation in male patients with spina bifida or a spinal cord injury: the TOMAX procedure.

PURPOSE: In this study we prospectively investigated the contribution of restored penile sensation to sexual health in patients with low spinal lesions. MATERIALS AND METHODS: In 30 patients (18 with spina bifida, 12 with spinal cord injury, age range 13 to 55 years) with no penile sensation but good groin sensation the new TOMAX (TO MAX-imize sensation, sexuality and quality of life) procedure was performed. This involves microsurgical connection of the sensory ilioinguinal nerve to the dorsal nerve of the penis unilaterally. Extensive preoperative and postoperative neurological and psychological evaluations were made. RESULTS: A total of 24 patients (80%) gained unilateral glans penis sensation. This was initially felt as groin sensation but transformed into real glans sensation in 11 patients (33%). These patients had better overall sexual function (p = 0.022) and increased satisfaction (p = 0.004). Although 13 patients (43%) maintained groin sensation, their satisfaction with sexuality was only slightly less than that of those with glans sensation. Improved sensations helped them manage urinary incontinence, thereby improving personal hygiene and independence. Most patients felt more complete and less handicapped with their penis now part of their body image. They also reported having more open and meaningful sexual relationships with their partners. CONCLUSIONS: Tactile and erogenous sensitivity was restored in the glans penis in patients with a low spinal lesion. This new sensation enhanced the quality of sexual functioning and satisfaction. The TOMAX procedure should become standard treatment for such patients.

Microcirculatory changes following different temperature washouts in a free flap model.

In spite of the extensive experimental work on vascular washout in free flap surgery, an optimal temperature for the washout solution has not been established. This study was designed to determine the effect of the washout solution temperature on the degree to which the microcirculation is cleared of blood. The cremaster muscle flap in the rat was used, in which the microcirculation can be directly viewed and the presence of blood and perfusion parameters within various vessels can be measured during and after washout. Washout was started with a single, high-pressure infusion and continued at 130 mmHg for 15 minutes. The temperature of the washout solution was either 2-3, 20-22, or 35 degrees C. In all three groups, washout cleared the microcirculation almost completely within the first minute. However, we observed that a cold or room temperature washout cleared the microcirculation more completely than a warm washout did. The temperature of the washout solution did not effect post washout capillary perfusion and/or arterial diameters.

Acute ischemic preconditioning of skeletal muscle prior to flap elevation augments muscle-flap survival.

Ischemic preconditioning of the myocardium with repeated brief periods of ischemia and reperfusion prior to prolonged ischemia significantly reduces subsequent myocardial infarction. Following ischemic preconditioning, two "windows of opportunity" (early and late) exist, during which time prolonged ischemia can occur with reduced infarction size. The early window occurs at approximately 4 hours and the late window at 24 hours following ischemic preconditioning of the myocardium. We investigated if ischemic preconditioning of skeletal muscle prior to flap creation improved subsequent flap survival and perfusion immediately or 24 hours following ischemic preconditioning. Currently, no data exist on the utilization of ischemic preconditioning in this fashion. The animal model used was the latissimus dorsi muscle of adult male Sprague-Dawley rats. Animals were assigned to three groups, and the right or left latissimus dorsi muscle was chosen randomly in each animal. Group 1 (n = 12) was the control group, in which the entire latissimus dorsi muscle was elevated acutely without ischemic preconditioning. Group 2 (n = 8) investigated the effects of ischemic preconditioning in the early window. In this group, the latissimus dorsi muscle was elevated immediately following preconditioning. Group 3 (n = 8) investigated the effects of ischemic preconditioning in the late window, with elevation of the latissimus dorsi muscle 24 hours following ischemic preconditioning. The preconditioning regimen used in groups 2 and 3 was two 30-minute episodes of normothermic global ischemia with intervening 10-minute episodes of reperfusion. Latissimus dorsi muscle ischemia was created by occlusion of the thoracodorsal artery and vein and the intercostal perforators, after isolation of the muscle on these vessels. Muscle perfusion was assessed by a laser-Doppler perfusion imager. One week after flap elevation, muscle necrosis was quantified in all groups by means of computer-assisted digital planimetry. Our results show that ischemic preconditioning resulted in a significant reduction (p < 0.05) in muscle-flap necrosis immediately and 24 hours following ischemic preconditioning. Perfusion changes after flap elevation were similar among the three groups. Ischemic preconditioning of skeletal muscle prior to flap creation significantly reduces subsequent muscle-flap necrosis caused by the ischemia of flap creation immediately and 24 hours following ischemic preconditioning. Further elaboration of the mechanisms of ischemic preconditioning may allow pharmacologic preconditioning to be used in the augmentation of skeletal muscle-flap survival in the clinical setting.

Cold (0 degree C) ischaemic tolerance of latissimus dorsi free flaps in rats: a macroscopic and morphological study.

The purpose of this study was to define the cold (0 degree C) ischaemic tolerance (CIT) of the latissimus dorsi free flap in inbred rats. Flaps were isolated, stored at 0 degree C for periods of time ranging from 0 to 120 hr and then revascularised and reperfused for 14 days. Thereafter the CIT was assessed macroscopically, and by light microscopy. Electron microscopy was performed in flaps after 0 and 24 hr of reperfusion following a cold ischaemic interval ranging from 0 to 120 hr. From this preliminary study, it was concluded that the CIT was 48-72 hr.

The benefit of a single-passage perfusion with a hypertonic citrate solution on the cold ischemia tolerance of epigastric free flaps in Dark-Agouty rats.

In this study the effectiveness of a single-passage perfusion with hypertonic citrate solution on the cold ischemia tolerance in epigastric free flaps in Dark-Agouty rats was investigated. In the control group a significant decline in survival percentage was observed when the storage time was extended from 72 hours to 96 hours. A single (pressure controlled) passage perfusion with hypertonic citrate solution was able to prevent this decline.

Neither desferrioxamine nor lipoic acid enhances the cold ischaemic tolerance of epigastric free flaps in rats.

This study was designed to test the ability of pre- and postischaemic administration of desferrioxamine (DFX), a combination of a preischaemic single passage perfusion with hypertonic citrate solution (HCA) and postischaemic administration of DFX, and pre- and postischaemic administration of lipoic acid (LA) to enhance the cold (0 degree C) ischaemia tolerance in epigastric free flaps in inbred rats. The ischaemic intervals varied between 0 and 120 hr. The area of flap survival 2 weeks after revascularisation as a percentage of original flap size was recorded as an exponent of ischaemic tolerance. None of the treatment regimens was able to increase flap area survival. Histologically, there were no major differences between the different treatment regimens.

Non-revascularized epigastric free flap: no all-or-none survival pattern.

We have previously shown that the epigastric flap in Dark Agouty rats, measuring approximately 6 x 4 cm with borders related to well-defined anatomical structures, does not exhibit an all-or-none survival pattern. This study was designed to investigate the survival pattern of non-revascularized epigastric flaps in three other rat strains (Sprague-Dawley, Brown-Norway, and Lewis). In concordance with our earlier observations, but in contrast to reports by many other groups, in none of the used strains was an all-or-none survival pattern observed. Survival varying from 2 to 30% (mean, 12%) of the original flap, without significant differences between the strains, was found. The locations of survival exhibited a clear pattern, probably owing to the fat pad in the subcutis and revascularisation from the recipient wound edges.

Survival characteristics of the epigastric free flap in DA-rats.

Epigastic flaps measuring approximately 6 x 4 cm with borders related to well-defined anatomical structures were isografted (Dark Agouty to Dark Agouty inbred rats) with or without anastomosing their epigastric pedicle, after various periods of ischaemia, ranging from 0 to 120 h. During the ischaemic insult the flaps were stored at 0 degrees C in a hypertonic citrate solution. The non-revascularized flaps exhibited survival percentages varying from 2 to 34% (mean, 16%) of the original flap,. independent of the storage interval. The flaps that were revascularized after ischaemia had a 100% survival when transplanted immediately after isolation and following 48 h of cold storage. Mean survival percentages of 78% after 72 h of ischaemia, 32% after 96 h, and 4% after 120 h of ischaemia were found. It is concluded that the model described in this study is suitable for free flap research, because of its delineated borders. However, when the area of flap survival is lower than 30% in revascularized flaps there is a distinct likelihood that the flaps have survived regardless of the pedicle as simple Wolfe or composite grafts. Results must therefore be interpreted with great care.