The use of iliac bone flap as a penile stiffener in a diabetic patient with erectile dysfunction.

A diabetic man with erectile dysfunction in whom two previous attempts at penile prosthesis implantation had failed was treated by using an iliac bone flap as a penile stiffener. The patient had satisfactory sexual function with his penis; it retained its size and stiffness during the 1-year follow-up period. We recommend this method for use in patients in whom multiple earlier attempts at penile prosthesis implantation were unsuccessful.     

Treatment modalities for hypospadias cripples

Hypospadias cripples can be defined as patients with remaining functional complications after previous hypospadias repair. A retrospective follow-up study was performed on the long-term results of a group of 94 patients disabled by hypospadias. The records of 94 patients showed that they presented with the following problems: 82 had a major meatal dystopia (87 percent), 43 (46 percent) had residual curvature of the penile body, 19 (20 percent) showed meatal stenosis, and only 5 (5 percent) had one or more fistulas. The techniques used to solve these problems were circumferential advancement of penile skin, dorsal transposition flap of preputial skin, distally based transposition flap of penile skin, and full-thickness skin graft. Between one and nine operations were needed to achieve the desired result (mean and median of two operations). The complications after these procedures were 11 fistulas in nine patients, meatal stenosis caused by tight scarring in six patients, and a residual curvature after an orthoplasty that had to be released once before a urethroplasty could be performed. Forty-three men were seen at long-term follow-up (range, 2 to 25 years; mean, 12 years). Functional complaints that were seen included spraying at micturition (5 patients, 12 percent), dribbling (6 patients, 14 percent), and deviation of urinary stream (7 patients, 16 percent). No patients complained of painful miction, hesitation, or straining. At physical examination, 4 patients had a residual curvature (three of which were mild without functional problems), 5 had a skin surplus, 1 presented with a fistula after an operation in another hospital, and 13 had a penile torsion. Only 6 patients had a penile torsion greater than 10 degrees, which was evenly distributed to the left and right. There was no correlation between any functional complaint and the presence of a physical abnormality.     

Erectile dysfunction and diabetes mellitus

Background: Erectile dysfunction (ED) is highly prevalent, affecting ≥50% of men with diabetes mellitus (DM) worldwide.Objective: This article reviews current knowledge on the epidemiology and underlying pathophysiology of ED in men with DM, diagnostic modalities, and treatment options.Methods: A MEDLINE literature search was conducted for articles published in English from inception of the database through November 2008, using the terms erectile dysfunction, diabetes, epidemiology, pathophysiology, phosphodiesterase inhibitors, intracavernosal injection, and penile prosthesis. Data on the epidemiology, diagnosis, and treatment of ED were extracted from all relevant articles.Results: The literature search revealed 685 original articles and reviews, 67 of which were selected for inclusion in this review. DM may cause ED through a number of pathophysiologic changes, including neuropathy, endothe-lial dysfunction, cavernosal smooth muscle structural/functional changes, hormonal changes, and psychological effects. The diagnosis of ED in men with DM is based on their sexual and medical histories and results of validated questionnaires such as the International Index of Erectile Function. Laboratory examinations are usually limited to testosterone and prolactin levels that may independently contribute to ED because specialized examinations are not necessary in most diabetic men with ED. The first step in the treatment of ED in men with DM includes glycemic control and treatment of diabetic comorbidities. The associated hypogonadism must also be treated; otherwise, pharmacologic treatment may be less efficacious or not efficacious at all. Phosphodiesterase type-5 (PDE-5) inhibitors have revolutionized the treatment of ED, and they are considered first-line treatment, with a mean efficacy rate of 50% and a favorable safety profile. Intracavernous administration of vasoactive drugs is the second-line medical treatment when PDE-5 inhibitors have failed. Alprostadil is the most widely used drug for this condition, but the combination of papaverine, phentolamine, and alprostadil represents the most efficacious pharmacologic treatment option for patients whose ED does not respond to monotherapy. Excellent functional and safety results have been reported for penile prosthesis implantation, and this approach, along with proper counseling, can be considered for selected patients with treatment-refractory ED.Conclusions: ED is common in men with DM, who represent one of the most difficult-to-treat subgroups of ED patients. PDE-5 inhibitors are the first-line treatment option, followed by intracavernosal injections and implantation of a penile prosthesis.     

Design of intramedullary prostheses to prevent bone loss: predictions based on damage-stimulated remodelling

The adaptation of bone around intramedullary fixated prostheses, such as the femoral component of the hip joint or the radial component of the elbow joint, is well documented in follow-up studies. Bone adaptation takes the form of proximal bone atrophy accompanied, in some cases, by distal bone hypertrophy. A mechanistic model has been formulated to predict bone adaptation based on the concept that the continuous processes of damage and repair regulate bone adaptation. We apply the model to investigate the significance of two features of intramedullary prosthesis design on bone adaptation: prosthesis Young's modulus and the presence of a prosthesis collar. Results, as well as indicating some characteristics of accumulative-damage stimulated bone adaptation, predict that a low Young's modulus stem will very much reduce the extent of bone loss whereas the presence of a collar will have no significant effect. The results predict that a collarless low stiffness prosthesis is one possible approach for improving the secondary stability of intramedullary-fixated orthopaedic implants.     

Follow-up visits as a measure of adaptation process to removable prostheses

Objectives: The paper was aimed to establish the influence of some general and local factors on adaptation process to removable prostheses (RPs). The adaptation process is a complex issue, which is often associated with painful reactions. Those complaints force patients to visit a dentist who makes alterations to reduce the patient's discomfort. Material and methods: The study involved analysis of 300 dental records of patients who visited our Department for RPs. The authors analysed the influence of gender, age, condition of general health, maintenance of the prosthetic base tissues and the kind of prostheses on the process of adaptation. It was measured by means of a number of follow‐up visits of the patients to our polyclinic. The findings were analysed statistically by means of chi‐squared test. The level of significance was assumed to be p < 0.05. Results and conclusions: Adaptation to RPs without any correction was revealed by about one‐fifth of patients. Men adapted to RPs better than women. The biggest problems with adaptation to RPs were observed in patients using a complete and partial prosthesis simultaneously. The number of follow‐up visits by patients who were treated with RPs for the first time or had been treated before was almost the same. Adaptation of RPs on an atrophic muco‐osseous ridge was associated with more multiple visits than in the case of a well‐preserved ridge. Healthy patients adapt to RPs better than patients with systemic disorders. Taking into account the limitations of the study, the number of follow‐up visits may be used as a helpful indicator of the adaptation process.     

Penile prosthesis implantation for end-stage erectile dysfunction after radical prostatectomy

When erectile dysfunction occurs after radical prostatectomy and phosphodiesterase-5 inhibitor therapy fails, second-line therapies such as vacuum constriction devices, intraurethral prostaglandins, and penile injection therapy should be offered. When second-line therapies are not effective or acceptable to the man and his partner, penile prosthesis implantation becomes the treatment of choice. Today's 3-piece inflatable devices offer flaccidity and erection that approach the natural state. Design improvements have resulted in devices that have freedom from mechanical failure ranging from 92% to 94%. Antibiotic and hydrophilic coatings have reduced infection rates.     

La place des protheses de verge dans le traitement de la maladie de La Peyronie

In Peyronie’s disease, a penile curvature makes sexual intercouse painful or impossible. Surgery is a treatment option after medical treatment failure. The aim of surgery is to restore an erection allowing sexual intercourse. Beside corpus cavernosus modeling procedures, penile prosthesis implantation (i.e.,semi-rigid, inflatable, orimplants) is rarely indicated. Such procedures should be based on erectile response to intracavernous injection and penile and corpus cavernosus anatomy.     

Long-term follow-up of total penile reconstruction with sensate osteocutaneous free fibula flap in 18 biological male patients

Surgical reconstruction of the penis is challenging because of the many cosmetic and functional (e.g., sexual intercourse and voiding) requirements that must be addressed. Since the free sensate osteocutaneous fibula flap was first described for total penile reconstruction in 1993 it has been widely accepted, with its advantages and minimal shortcomings. In this article, the authors present the longest follow-up of biologically male patients with free fibular phalloplasties. Since 1994, 18 biologically male patients with total penile losses for various reasons were treated with free sensate osteocutaneous fibula flaps. All patients were included in the study. The ages of the patients ranged between 20 and 26 years (mean, 22.2 years). The average follow-up period was 5.4 years (range, 1 to 9 years). Patient satisfaction was evaluated by a questionnaire regarding both quality of orgasm and daily activities. Conventional radiographic imaging, magnetic resonance imaging, and bone mineral densitometry were performed to evaluate the fate of the bony component of the flap. Also, sensibility was evaluated by bulbocavernous reflex and penile somatosensory evoked potentials testing in nine patients. Six patients married, and five of them had six children. Most patients and their partners reported pleasurable sexual intercourse and orgasm. Conventional radiographs of the fibular bone in neophalluses showed robust, calcified bone structure without any evidence of bone resorption or fracture. The magnetic resonance images showed the cortical substance and spongiosum of the bone marrow, which are characteristic signs of bone viability. After intravenous injection of gadolinium, the neophallus bone showed uptake of contrast medium. Viability of neophallus bone was shown even at 9-year follow-up (the longest follow-up in the literature). Dual energy x-ray absorptiometry measurements of the penile bone grafts showed that fibular components in the penis had bone mineral density values that were close to but lower than those of intact fibula in the same subjects. These results were considered as evidence of viability of bone grafts. Neural integrity was found between the nerves of the neophallus and the residual penile bodies by both bulbocavernous reflex and penile somatosensory evoked potentials tests. In conclusion, free sensate fibula flap phalloplasty provides the cosmetic and functional requirements that an ideal penis should have. All results put an end to the discussion that the fibular component of the neophallus could resorb. Constitution of neural integrity is important in terms of pleasurable sexual intercourse. The authors believe the free sensate osteocutaneous fibula flap should be considered as the standard in penile reconstruction.     

Nonpharmacologic treatment of erectile dysfunction

Nonpharmacologic treatment for erectile dysfunction (ED) includes sex therapy, the use of vacuum erection devices, penile prosthesis implantation, and penile vascular surgery. Sex therapy is indicated for psychogenic ED and is at times a useful adjunct for other treatments in men with mixed psychogenic and organic ED. Vacuum erection devices produce usable erections in over 90% of patients; however, patient and partner acceptability is an issue. Three-piece inflatable penile prostheses create flaccidity and an erection that comes close to that which occurs naturally. Penile vascular surgery has shown greatest efficacy in young men with vasculogenic ED resulting from pelvic or perineal trauma.     

Replantation versus Prosthetic Fitting in Traumatic Arm Amputations: A Systematic Review

Background

Traumatic arm amputations can be treated with replantation or surgical formalization of the stump with or without subsequent prosthetic fitting. In the literature, many authors suggest the superiority of replantation. This systematic review compared available literature to analyze whether replantation is functionally and psychologically more profitable than formalization and prosthetic fitting in patients with traumatic arm amputation.

Methods

Functional outcome and satisfaction levels were recorded of patients with amputation levels below elbow, through elbow, and above elbow.

Results

Functional outcomes of 301 replantation patients and 172 prosthesis patients were obtained. In the replantation group, good or excellent functional scores were reported in 39% of above elbow, 55% of through elbow, and 50% of below elbow amputation cases. Nearly 100% of patients were satisfied with the replanted limb. In the prosthesis group, full use of the prosthesis was attained in 48% of above elbow and in 89% of below elbow amputation patients. Here, 29% of patients elected not to use the prosthesis for reasons including pain and functional superfluity. In both replantation patients and prosthesis wearers, a below elbow amputation yielded better functional results than higher amputation levels.

Conclusions

Replantation of a traumatically amputated arm leads to good function and higher satisfaction rates than a prosthesis, regardless of the objective functional outcome. Sensation and psychological well-being seem the two major advantages of replantation over a prosthesis. The current review of the available literature shows that in carefully selected cases replantation could be the preferred option of treatment.     

A biomechanical model of Peyronie's disease

Peyronie's disease is a pathological condition of the penis which is characterized by localized ossification of the tunica albuginea. A common symptom of the chronic stage is penile deformity during erection, which is frequently associated with pain and erectile dysfunction. A two-dimensional biomechanical model of the penis was applied to study the development of Peyronie’s disease by simulating the mechanical stress distribution which would result from the interaction of the ossified tunical tissue with other penile soft tissues. The model was solved by using commercial finite element software for a characteristic erectile pressure. The results demonstrate that Peyronie’s plaques may induce intensified stresses around the penile nerves and blood vessels, up to double those in the normal penis. These elevated stresses may cause a painful sensation of neural origin or ischemia in regions of compressed vascular tissue. Severe penile deformities have been shown to develop if Peyronie’s plaques develop only around one of the corpora cavernosa due to the non-homogeneous resistance of the tunica to expansion during erection. The present model can be clinically applied as an aid in the planning process of reconstructive surgery or insertion of a prosthesis.     

Bone remodelling of the scapula after a total shoulder arthroplasty

According to Wolff’s law, the changes in stress after a prosthesis implantation may modify the shape and internal structure of bone, thus compromising the long-term prosthesis fixation and, consequently, be a significant factor for glenoid loosening. The aim of the present study is to evaluate the changes in the bone adaptation process of the scapula after an anatomical and reverse total shoulder arthroplasty. Five finite element models of the implanted scapula are developed considering the implantation of three anatomical, cemented, all-polyethylene components; an anatomical, cementless, metal-backed component; and a reverse, all-metal component. The methodology followed to simulate the bone adaptation of the scapula was previously validated for the intact model, prior to the prosthesis implantation. Additionally, the influence of the bone quality on the adaptation process is also investigated by considering an osteoporotic condition. The results show that the stress shielding phenomenon is more concerning in cementless, metal-based components than in cemented, all-polyethylene components, regardless of the bone quality. Consequently, as far as the bone adaptation process of the bone is concerned, cemented, all-polyethylene components are better suited for the treatment of the shoulder joint.     

PSYCHOSOMATIC PROBLEMS IN UROLOGY

The intimate relationship between the urinary and genital systems permits stimuli in one system to influence the other. At least 15 per cent of women with symptoms of cystitis have no organic basis for their complaints. In psychiatric studies it has been noted that sexual conflict is the primary etiological factor in these patients. In some cases, continuance of the disorder leads to irreversible organic change. Urinary symptoms such as frequency, urgency, burning or retention are most common in women and become an automatic response to anxiety-provoking or sexual stimuli.In men, functional urinary symptoms are relatively infrequent. Often they indicate problems of genital dysfunction. Complaints of impotence, penile pain, testicular pain, or non-specific urethritis stem back to difficulties in their sexual lives. Many of the patients have symptoms of a generalized anxiety tension state due to sexual problems.A purely organic consideration of genitourinary disorders will lead to erroneous conclusions and unsatisfactory therapeutic results. The psychosomatic approach—that is, considering both physical and psychological aspects—will explain many hitherto difficult cases.     

INTEGRATING EVOLUTIONARY AND FUNCTIONAL APPROACHES TO INFER ADAPTATION AT SPECIFIC LOCI

Inferences about adaptation at specific loci are often exclusively based on the static analysis of DNA sequence variation. Ideally, population‐genetic evidence for positive selection serves as a stepping‐off point for experimental studies to elucidate the functional significance of the putatively adaptive variation. We argue that inferences about adaptation at specific loci are best achieved by integrating the indirect, retrospective insights provided by population‐genetic analyses with the more direct, mechanistic insights provided by functional experiments. Integrative studies of adaptive genetic variation may sometimes be motivated by experimental insights into molecular function, which then provide the impetus to perform population genetic tests to evaluate whether the functional variation is of adaptive significance. In other cases, studies may be initiated by genome scans of DNA variation to identify candidate loci for recent adaptation. Results of such analyses can then motivate experimental efforts to test whether the identified candidate loci do in fact contribute to functional variation in some fitness‐related phenotype. Functional studies can provide corroborative evidence for positive selection at particular loci, and can potentially reveal specific molecular mechanisms of adaptation.     

Use of contoured and stabilized conchal cartilage grafts for lower eyelid support: a preliminary report

Lower lid stability can be affected by many conditions involving the lid directly, e.g. facial palsy, facial clefts, trauma, or tumors. Secondary stretching due to a poorly fitting orbital prosthesis can have the same effect. In 41 such eyelids, stability was obtained by inserting a large cartilage graft sutured to the tarsal plate and the infraorbital rim. Thirteen patients had tarsoconjunctival wedge resections, and 10 had lateral canthopexies performed at the same procedure. One graft was too small and was later replaced. There was one hematoma, which was evacuated. There were no other lid or visual problems. The follow-up is short, 21 months maximum, but so far the results are very satisfactory.     

Penile reconstruction: combined use of an innervated forearm osteocutaneous flap and big toe pulp

The use of a radial forearm flap has become the most popular method to reconstruct a phallus in recent years. This method of reconstruction, however, is plagued with problems such as urethral fistula and loss of phallic girth as a result of tissue atrophy, rendering a phallic contour that is cosmetically unsatisfactory. We had the opportunity of modifying the technique of penile reconstruction using a forearm osteocutaneous flap to minimize these problems. Specifically, a segment of the big toe pulp is used to reconstruct a glans penis. Sensory restoration in the "glans" and "penile shaft" is restored by coapting the digital and the antebrachial nerves to the penile nerve remnants. A segment of flexor carpi radialis muscle is included in the design of a forearm flap to reinforce the coaptation site of the urethral tract. An arteriovenous shunt is incorporated in the shaft as a mechanism to elicit erection of the penis by compressing the root of the neophallus. We had used these technical modifications in a 51-year-old man who had undergone penile amputation because of cancer. The cosmetic appearance and erotic and tactile sensation in the shaft and glans were proper and satisfactory at the end of fourth year after the surgery. The coital function was also satisfactory.     

Bilateral rhomboid flaps for reconstruction of the external genitalia in epispadias-exstrophy

In ten young males with the epispadias-exstrophy complex, a new technique of bilateral rhomboid flaps was used for penile elongation and genital reconstruction. This approach offers less chance of injury to the verumontanum and ejaculatory ducts and accurately defines the penopubic angle. Cosmetic and functional results were satisfactory in all patients.     

Neophalloplasty in female-to-male transsexuals with the island tensor fasciae latae flap

In the past 60 years, several different procedures have attempted to achieve a postoperative neophallus that is as aesthetic and as functional as possible after penile amputation or sex reassignment. Recently, with improvements in free tissue transfer and microvascular technique, many free flap procedures have been developed with the goal of an aesthetically acceptable neophallus of adequate bulk that enables urination in a standing position and sexual intercourse, with minimal functional and aesthetic donor-site defects. Most authors currently agree that the method of choice for penile reconstruction is microsurgical free tissue transfer, although it does not always fulfill all of the aforementioned goals in a predictable manner. In fact, complete urethroplasty, penile rigidity, and donor-site disfigurement remain challenges, thus making this operation one of the most difficult in plastic surgery. The vascular anatomy of the lateral circumflex femoral artery, which we studied in 1991 with the anatomic dissection of 27 cadavers, gave us the idea to use a long tensor fasciae latae neurovascular island flap as a donor source for neophalloplasty. Grounds for the procedure and its surgical planning have been carefully evaluated with 10 additional fresh cadaver dissections. Since 1991, we have performed five neophalloplasties using this procedure; all patients were female-to-male transsexuals. In four cases, the healing was uneventful; in one case, there was a marginal necrosis of the flap because of poor venous drainage, probably from a twisting of the pedicle. The island tensor fasciae latae provides a safe and sensate flap for phalloplastic procedure and leaves a less conspicuous donor scar.     

Assessment of training in psychosexual medicine.

The Institute of Psychosexual Medicine offers training in the treatment of psychosexual problems to medically qualified doctors. Training takes place in fortnightly seminars in which trainees present and discuss real cases. Assessment of cases presented at the beginning and end of the six term basic training showed appreciable improvement in doctors'' abilities. The proportion of doctors meeting each of the 14 predetermined clinical objectives rose. Factors which affected the amount of improvement were the initial score, the number of cases presented at the seminars, the occupation of the leader, and the duration of training. Accreditation by the Institute of Psychosexual Medicine was shown to be an appropriate outcome measure for the achievement of the required standards for practising psychosexual medicine.     

Nonmicrosurgical use of the radial forearm flap for penile reconstruction

Although the era of microsurgical techniques has greatly expanded the number of possible solutions for penile reconstruction, additional options are still needed for some unusual situations when microsurgery is not available or not desired. This article describes the first nonmicrosurgical use of the radial forearm flap for penile reconstruction. With this technique, an osteocutaneous radial forearm flap 15 x 20 cm in size is elevated as a reverse-flow island flap and used to create a neopenis in the classic "tube within a tube" fashion. The neopenis is then transferred to the recipient site as a distant flap, without dividing its vascular connection with the forearm. Once a complete healing is ensured after the following 2 to 3 weeks, the pedicle is cut and the penile reconstruction is completed. Since 1995, this technique was used for total penile reconstruction in four patients: two with congenital penile agenesis, one with penile amputation as a result of a high-voltage electrical injury, and one with total loss of the external genitalia as a result of a shotgun injury. The patients have been followed up for 1 to 4 years. Good results were achieved in all patients. In conclusion, non-microsurgical use of the radial forearm flap seems to be a useful alternative to create an innervated functionally and aesthetically acceptable neopenis when microsurgery is not available or not desired. Although it is a multistage procedure, it is easy to perform. Moreover, this technique provides all well-known advantages of the radial forearm flap in penile reconstruction but does not require the sophisticated equipment and expertise of microsurgery. This is a great advantage that enables surgeons without microsurgical skill to use the radial forearm flap for phallic reconstruction. The author believes that the described technique will be extremely useful in developing countries that have limited resources and where microsurgery is difficult to obtain.