UNLABELLED Study Type - Diagnostic (case series) Level of Evidence 4 What's known on the subject? and What does the study add? It is known that magnetic resonance imaging (MRI) is safe and effective for imaging patients with inflatable penile prostheses (IPPs). Previous series have reported results of MRI for imaging series of patients with IPPs. The impact on management in particular with regard to salvage procedures is not well defined. This study represents the largest known experience with MRI evaluation of IPPs. This also provides an algorithm that assists with decisions regarding utilization of MRI and treatment planning based on results. OBJECTIVE • In some patients who undergo placement of an inflatable penile prosthesis (IPP) the device may function inadequately. We describe the use of magnetic resonance imaging (MRI) for anatomical localization and detection of prosthesis malrotation, angulation, displacement and erosion in IPPs with equivocal clinical examination. PATIENTS AND METHODS • We prospectively performed MRI by a defined protocol including T1-weighted imaging, and transaxial, sagittal and coronal fat-saturated fast spin-echo T2-weighted imaging in both deflated and inflated states to evaluate patients seen at our referral centre for IPP-related complaints. • We retrospectively reviewed 32 such MRI studies performed as a supplement to clinical examination between 2000 and 2008. RESULTS • Of 32 cases, 75%(24/32) underwent surgical intervention. Of these, 45%(11/24) underwent device salvage procedures including cylinder revision in 33%(8/24), cylinder replacement in 8%(2/24) and pump replacement in 4%(1/24). • MRI was most useful for determination of surgical approach in those with abnormal physical examination, and for justification of either surgical or expectant management in those with indeterminate physical examination. CONCLUSIONS • MRI is safe and effective for imaging genitourinary prostheses. • We found MRI to be a valuable adjunct for evaluation of IPP-related complaints when clinical examination is equivocal as it detected a variety of prosthetic and corporal abnormalities and impacted management decisions regarding observation, replacement or device salvage procedures. • We provide technique, results and an algorithm that can be beneficial in this complex subset of patients.

INTRODUCTION Within a study evaluating the redesigned AMS 700MS inflatable penile prosthesis (IPP)(American Medical Systems, Minnetonka, MN, USA), one site used new length measurement technique (NLMT), a more aggressive dilation and measurement of the corpora cavernosa on a stretched penis, to address penile shortening. AIM To compare cylinder size and patient satisfaction, between a NLMT and traditional sizing for IPP implantation. METHODS Fourteen men received IPPs using NLMT, and 55 with traditional sizing. Nationwide sales data from 2005 to 2008 for AMS 700 IPPs was obtained from AMS for comparison; additional surveys captured patient satisfaction. MAIN OUTCOME MEASURE Demographic data, cylinder sizes, and patient satisfaction were compared between the NLMT and standard techniques. RESULTS The Fisher's exact test (P<0.001) showed a significant difference between the cylinder sizes with NLMT as compared with standard techniques. Of the 14 NLMT patients, 71.4%(10) received cylinders>21 cm long and 28.6%(4) received cylinders<21 cm long, as compared with 12.7%(7) and 87.3%(48), respectively, for patients implanted by traditional techniques. There were ethnic differences between the samples: 42.9%(6) NLMT patients were of African-American descent, as compared with 10.9%(6) in the standard technique group. However, longer cylinders were utilized more often, with 83.3%(5) of African-Americans treated using the NLMT; as compared with 33.3%(2) of the standard technique group. Nationwide data reveal 12.3% of patients routinely receive 21 cm cylinders. At 6 months postimplantation, patient satisfaction with NLMT was no different than standard techniques. There were no distal erosions, complications, infections, or pain concerns reported through 24 months among the NLMT patients. CONCLUSIONS The NLMT resulted in a larger number of subjects implanted with larger cylinders. Satisfaction with performance and complication rates for NLMT patients was comparable to those implanted using standard techniques.

INTRODUCTION The interrelationship between male and female sexual function suggests that partner outcomes after inflatable penile prosthesis (IPP) implantation must be assessed. AIM We examined predictors of patient and partner satisfaction, and the relationship between patient satisfaction and female sexual function, after IPP implantation. METHODS We designed a questionnaire (scored 1-5) assessing satisfaction with various domains related to the IPP (e.g., overall satisfaction and satisfaction related to: length, width, ease of use, and partner perception). Scores ≥3 were classified as satisfied. The Female Sexual Function Index (FSFI) was administered to the female partners of patients that underwent an IPP. MAIN OUTCOME MEASURES Independent samples Students' t-test was used to compare various FSFI domain scores in relation to male and female satisfaction. Analysis of variance test was used to assess linear regression correlation between various continuous variables. RESULTS 45 men and 32 partners with a mean follow-up of 2.2 years were contacted. Overall satisfaction for men and women was 3.60 and 3.62 (out of 5), respectively. Partner FSFI scores were higher, respectively, in men with higher implant satisfaction than those with lower implant satisfaction (25.09 ± 6.79 vs. 13.67 ± 12.70, P < 0.001). Regression analysis suggests a direct correlation between FSFI scores and the degree of patient (r = 0.50, r(2)= 0.23; P = 0.001) and partner (r = 0.70 r(2)= 0.50; P < 0.001) satisfaction with the IPP. CONCLUSION Patient satisfaction after IPP implantation implies favorable partner sexual function compared to that of unsatisfied patients. The correlation observed suggests that patients not satisfied with their IPP are likely to have female partners at high risk for female sexual dysfunction. Further interventions may be needed to improve patient and partner sexual function, particularly unsatisfied men and their female partners.

Inflatable penile prostheses are the definitive therapy for erectile dysfunction refractory to medical therapy. For years mechanical malfunction was the most common cause of device failure, but recent advances in design have largely eliminated this, and now infection is the most significant problem with these implants. Antibiotic-coated medical devices, such as central venous and bladder catheters, have proven effective in reducing bacterial colonization and biofilm formation, leading to decreased rates of infection. In 2001, American Medical Systems (AMS) released its AMS 700 series penile prosthesis impregnated with a proprietary combination of the antibiotics rifampin and minocycline, called InhibiZone. Multiple studies have found that this device significantly reduces infection rates in men receiving penile prostheses. In July 2009, the US FDA approved the AMS 700 with InhibiZone as the only inflatable penile prosthesis with clinical evidence showing significant reduction in the rate of revision surgery due to infection.

ABSTRACT Introduction. AMS 700CX/CXM inflatable penile prosthesis is increasingly applied for the treatment of erectile dysfunction (ED). However, there are a few long-term survival data of the inflatable penile prosthesis (IPP) over 10 years. Aim. To determine the long-term mechanical reliability of AMS 700CX/CXM inflatable penile prosthesis in patients with ED. Methods. A total of 438 consecutive patients with ED received implantation of an AMS 700CX/CXM penile prosthesis at our institution from January 1991 to April 2009. In 397 patients (90.7%), the medical records were available and current status of penile prosthesis could be obtained by a direct telephone interview. The overall and mechanical survival rates of penile prosthesis were evaluated using Kaplan-Meier method. Main Outcome Measures. Assessing the mechanical and overall survival rates of the AMS 700CX/CXM penile prosthesis using Kaplan-Meier analysis, and looking for clinical factors related to survival of the CX/CXM using log-rank test. Results. Mean age of 397 patients was 63.1 years (range, 24-93) and follow-up duration was 113 months (range 1-219). Eighty-two patients (20.6%) experienced mechanical failure at a median follow-up of 82 months. Mechanical survival rate of the penile prosthesis was 97.6%, 93.2% and 78.2% at 3, 5, and 10 years after implantation, respectively. 12 patients (3.0%) experienced nonmechanical failure including infections, tissue erosion resulting in cylinder protrusion at the meatus and chronic discomfort. Overall survival rate of the penile prosthesis was 95.0%, 91.0% and 75.5% at 3, 5, and 10 years after implantation, respectively. Patients with neurogenic cause for ED showed lower median overall survival of penile prosthesis compared with patients with non-neurogenic cause. Patient age, obesity, and diabetes mellitus had no association with overall survival of penile prosthesis after implantation. Conclusions. The AMS 700CX/CXM could be accepted and applied in more patients as a reliable treatment alternative of ED. Kim DS, Yang KM, Chung HJ, Choi HM, Choi YD, and Choi HK. AMS 700CX/CXM inflatable penile prosthesis has high mechanical reliability at long-term follow-up. J Sex Med **;**:**-**.

CONTEXT: Erectile dysfunction (ED) and premature ejaculation (PE) are the two most prevalent male sexual dysfunctions. OBJECTIVE: To present the updated version of 2009 European Association of Urology (EAU) guidelines on ED and PE. EVIDENCE ACQUISITION: A systematic review of the recent literature on the epidemiology, diagnosis, and treatment of ED and PE was performed. Levels of evidence and grades of recommendation were assigned. EVIDENCE SYNTHESIS: ED is highly prevalent, and 5-20% of men have moderate to severe ED. ED shares common risk factors with cardiovascular disease. Diagnosis is based on medical and sexual history, including validated questionnaires. Physical examination and laboratory testing must be tailored to the patient's complaints and risk factors. Treatment is based on phosphodiesterase type 5 inhibitors (PDE5-Is), including sildenafil, tadalafil, and vardenafil. PDE5-Is have high efficacy and safety rates, even in difficult-to-treat populations such as patients with diabetes mellitus. Treatment options for patients who do not respond to PDE5-Is or for whom PDE5-Is are contraindicated include intracavernous injections, intraurethral alprostadil, vacuum constriction devices, or implantation of a penile prosthesis. PE has prevalence rates of 20-30%. PE may be classified as lifelong (primary) or acquired (secondary). Diagnosis is based on medical and sexual history assessing intravaginal ejaculatory latency time, perceived control, distress, and interpersonal difficulty related to the ejaculatory dysfunction. Physical examination and laboratory testing may be needed in selected patients only. Pharmacotherapy is the basis of treatment in lifelong PE, including daily dosing of selective serotonin reuptake inhibitors and topical anaesthetics. Dapoxetine is the only drug approved for the on-demand treatment of PE in Europe. Behavioural techniques may be efficacious as a monotherapy or in combination with pharmacotherapy. Recurrence is likely to occur after treatment withdrawal. CONCLUSIONS: These EAU guidelines summarise the present information on ED and PE. The extended version of the guidelines is available at the EAU Web site (http://www.uroweb.org/nc/professional-resources/guidelines/online/).

ABSTRACT Introduction. The field of erectile dysfunction (ED) is evolving and there is a need for state-of-the-art information in the area of treatment. Aim. To develop an evidence-based, state-of-the-art consensus report on the treatment of erectile dysfunction by implants, mechanical devices, and vascular surgery. Methods. To provide state-of-the-art knowledge concerning treatment of erectile dysfunction by implant, mechanical device, and vascular surgery, representing the opinions of 7 experts from 5 countries developed in a consensus process over a 2-year period. Main Outcome Measure. Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. Results. The inflatable penile prosthesis (IPP) is indicated for the treatment of organic erectile dysfunction after failure or rejection of other treatment options. Comparisons between the IPP and other forms of ED therapy generally reveal a higher satisfaction rate in men with ED who chose the prosthesis. Organic ED responds well to vacuum erection device (VED) therapy, especially among men with a suboptimal response to intracavernosal pharmacotherapy. After radical prostatectomy, VED therapy combined with phosphodiesterase type 5 therapy improved sexual satisfaction in patients dissatisfied with VED alone. Penile revascularization surgery seems most successful in young men with absence of venous leakage and isolated stenosis of the internal pudendal artery following perineal or pelvic trauma. Currently, surgery to limit venous leakage is not recommended. Conclusions. It is important for the future of the field that patients be made aware of all treatment options for erectile dysfunction in order to make an informed decision. The treating physician should be aware of the patient's medical and sexual history in helping to guide the decision. More research is needed in the area of revascularization surgery, in particular, venous outflow surgery. Hellstrom WJG, Montague DK, Moncada I, Carson C, Minhas S, Faria G, and Krishnamurti S. Implants, mechanical devices, and vascular surgery for erectile dysfunction. J Sex Med 2010;7:501-523.

INTRODUCTION The implantation of penile prostheses is an effective option for treating erectile dysfunction (ED), and nowadays it is used to treat those cases where pharmacological agents have not provided a useful result. AIMS The primary aim of the present study was to verify the patient and their partner's satisfaction, in 80 patients who underwent AMS CX 700 prostheses implant in a single center, by the same surgeon, in the period between 2004 and 2008. METHODS In the period between March 2004 and May 2008, 80 penile prostheses implantations have been performed. Any information regarding patients has been retrospectively collected consulting their case histories stored in our archive. Each patient was followed postoperatively, and surgical complications were recorded. MAIN OUTCOME MEASURE All the patients entered in this study were contacted by phone by a single operator who asked for their consent to collect information regarding their operation, the use of the prostheses, and the couple satisfaction. Once the consent was obtained, a nine-point questionnaire was administered. RESULTS Seventy-six patients (97%) affirmed to use penile prostheses frequently. Fifty-four patients (69%) and 70 partners (90%) affirmed that they never had problems with the use of the prosthesis and they considered themselves satisfied. Sixty-two patients (79%) answered that this therapeutic method has led to evident improvements in their sexual life. Sixty-two patients (79%) gave a score equal or major than seven and sixty-four partners (82%) gave a score equal or major than seven. All but two patients (97%) reported they would suggest this treatment to other people. CONCLUSIONS Penile prosthetic surgery constitutes a valid therapeutic alternative, capable of modifying the prognosis and the course of ED. This consideration is emphasized by the high rate of patients and partner's satisfaction emerged in our series and in literature.

OBJECTIVES: 1). To evaluate the satisfaction and clinical outcome in patients with penile prosthesis implant as a treatment to Severe Biogenic Erectile Dysfunction. 2). To identify the most frequent complications associated with the surgical intervention. 3). To compare the behaviour of sexual satisfaction in partners and patients with penile prosthesis implant before and after the application of the treatment. METHODS: A descriptive,(longitudinal) study with quantitative and qualitative methodology was done, where 25 men with penile prosthesis implants, performed at Faustino Perez Hospital, were evaluated. RESULTS: The complications presented in the procedures were perforation of the tunica albuginea, postoperatory pain, thin penis and the expulsion of one or two cylinders, this latter case in a patient who presented periprosthetic sepsis. CONCLUSIONS: The penile prosthetic implant constitutes an option of effective treatment which achieves an 88 % of sexual satisfaction in patients. Both partners and patients treated with penile prosthetic implantation referred increase in erotism, satisfactory sexual activity, improvement of self-esteem, quality of communication with their partner, better labour results, interpersonal and social relationships and strengthening of couple's bonds.

Penile prosthesis surgery is a recommended treatment option for a subset of patients who present with erectile dysfunction (ED). Although treatment outcome research indicates that patients are generally satisfied with this intervention, it remains an invasive procedure with risk for complications. A review of the literature reveals general agreement for the importance of a thorough preoperative evaluation to determine appropriateness for a penile implant; however, there are no known descriptions of such an evaluation in the literature. This article provides an introduction to the domains that are most relevant to assess in a patient who is considering penile implant surgery: sexual history (including organic and psychogenic causes of ED), success and utilization of other treatment interventions, relationship functioning, and patient expectations for and knowledge of the procedure. The advantages to this approach are presented, particularly in enhancing patient satisfaction with treatment outcomes.

OBJECTIVES: This study was aimed to demonstrate the feasibility of laparoscopic conservative surgery of the adrenal gland in the treatment of adrenal cysts. METHODS: Two cases of laparoscopic decortication of symptomatic adrenal cysts with preservation of the adrenal parenchyma are presented. RESULTS: Surgery was uneventful in both cases and patients returned to preoperative activity within 10 days from the operation. At the 3-month follow-up, computerized tomography demonstrated the absence of any cystic recurrence and adrenal endocrine function was normal. These findings were confirmed at the 1-year follow-up by ultrasonography. CONCLUSIONS: Symptomatic adrenal cysts can be effectively and safely treated by laparoscopic unroofing, a minimally invasive procedure which leaves the nondiseased adrenal parenchyma intact.

This study was designed to clarify the functional results, morbidity and the patient-partner satisfaction observed with, the American Medical System 700 CX three-piece inflatable prosthesis in the treatment of impotence associated with Peyronie's disease. Thirty-three patients were treated and additional plaque surgery was performed in 13 cases (40%). Within 10 days of surgery, four patients (12%) developed a wound infection which was treated conservatively and one patient (3%) experienced glandular ischemia. At the 6-week follow-up, complete penile straightening was achieved in 23 patients (70%), while penile rigidity was considered optimal by all patients. On the contrary, the penis was considered short by 10 patients (30%). Five diabetic patients (15%) complained of severe scrotal and penile pain during full activation of the implant and in one of these patients (3%) the implant had to be removed. Due to spontaneous erections occurring after implant activation one patient (3%) required replacement of the reservoir from the Retzius space into the peritoneum. At the long-term follow-up (mean +/- SE: 17 +/- 2.2 months), 23 patients were evaluated and all found to be engaging in intercourse with the prosthesis. However, five patients (21%) and three of the 13 partners (25%) assessed were not yet completely satisfied. The American Medical System CX700 inflatable penile prosthesis obtains complete penile straightening in 70% and rigidity in 100% of impotent patients with Peyronie's disease. Patients should be fully informed about possible surgical morbidity and actual post-operative penile length.

Due to the heterogeneity of prostate cancer (PCa) outcomes, there is a need for individualized treatment plans based on clinical and cancer characteristics. Recent advances in sophisticated imaging modalities have improved the ability to stratify patients according to their risk of PCa diagnosis and progression. This, in turn, has positively influenced the clinical decision making process. However, there is also an overuse of diagnostic imaging in the evaluation of PCa patients. Baseline diagnostic and re-staging evaluations need to be indeed personalized, in order to maximize the results and reduce unnecessary, lengthy and costly procedures. The aim of this review was to critically evaluate current international guidelines in order to identify clinical and diagnostic markers that might help clinicians in the selection of the most appropriate imaging approach. For this aim, different imaging modalities were analyzed in patients with newly diagnosed PCa, focusing on local, nodal and distant staging. Every step of staging was taken into consideration based on patient individualized risk, as defined by routinely available clinical variables. Second, different imaging techniques were also reviewed in the context of relapse after primary treatment, highlighting their utility and impact in the clinical decision making process. This review focuses mainly on conventional established imaging techniques, with an eye also to novel approaches that still need to be validated on large patient series.

This study was aimed at assessing presence and predictors of a trend towards more advanced paternal age at presentation in a cohort of 1283 Caucasian-European infertile couples with male factor infertility (MFI) over a short time frame. Multivariate linear regression analysis tested the association between predictors [namely, partners' age, length of infertility at first presentation, patients' comorbidities as scored with the Charlson Comorbidity Index (CCI) and educational status] and patient's age at presentation. Using anova, patient's age at presentation (F ratio: 2.43; p = 0.024) and patients' educational status (χ(2) trend: 142.38; p < 0.001) significantly increased over time. In contrast, length of infertility at first presentation, CCI and partners' age did not significantly change over time (all p ≥ 0.05). Linear regression analyses showed that CCI, educational status and year of presentation were not correlated with patients' age at presentation (all p ≥ 0.05), whereas partners' age (β = 0.170; p < 0.001) and length of infertility (β = 0.123; p = 0.004) were independent predictors of delayed fatherhood. These results showed a significant shift towards advanced paternal age, but a non-significant increase of maternal age at first presentation among Caucasian-European infertile couples with MFI over a short time frame.

The objective was to test the hypothesis that in patients with prostate cancer undergoing radical prostatectomy (RP), diabetic patients are at a higher risk of harboring a high-grade tumor than non-diabetic patients. We examined 2060 consecutive men who underwent RP between 2001 and 2009. Of them, 7.1% had type 2 diabetes mellitus (DM). A high-grade tumor was defined as having a Gleason score ≥ 8. Univariable and multivariable logistic regression analyses were used to test the relationship between type 2 DM and high-grade tumor. Mean patient age was 64 years (range: 45-85). Mean total PSA level was 9 ng ml(-1)(range: 1-89.5). A significantly higher percentage of diabetic patients had high-grade tumor on biopsy (16.3 vs 7.6%; P = 0.001) and on RP specimen (21.1 vs 11.7%; P = 0.001) in comparison with non-diabetic patients. In multivariable analyses, DM was an independent predictor of high-grade tumor on biopsy (odds ratio = 2.31, P = 0.001) and on final pathological specimen (odds ratio = 2.22, P = 0.002). In patients undergoing RP, those with type 2 DM had a higher risk of harboring a poorly differentiated tumor on final pathological examination.

The increasing incidence of prostate cancer is manly due to the improvement of systematic transrectal ultrasound-guided prostate biopsy techniques. The objective of this review is to analyze the different approaches and the most common schemes used to perform prostate biopsy, the role of the anesthetic procedures, of the complementary imaging methods and the histological evaluation of the biopsy results. The actual indications to perform prostate biopsy have been also critically reviewed. We performed a review of the literature by searching Medline Database with the following key words: prostate cancer, diagnosis, trans-rectal ultrasound (TRUS), prostate biopsy, anaesthesia and prognosis. Prostate biopsy is always performed under transrectal ultrasound guidance with both transrectal and transperineal approach, with a minimal core number of 10. The extended protocols include lateral peripheral zone cores and cores from lesions found on palpation or imaging. Saturation biopsies should be performed only in case of repeat biopsies. The refinement of effective local anesthesia has allowed to increase the number of biopsies without important side effects. Complementary imaging methods might be adopted in order to reduce the number of unnecessary procedures .The histological issues related to the number and the location of cores are still matter of debate as important prognostic factors. According to international guidelines, the factors most involved in performing prostate biopsy still include suspicious digital rectal examination and PSA. Both the transrectal and the transperineal approach in prostatic biopsy are valid in term of detection rate and low incidence of side effects. The initial biopsy scheme in mainly extended, saturation biopsy has to be considered only in the repeat setting, with the eventual help of the complementary imaging methods. The histological issues has to be considered about patient's prognosis.

Erectile dysfunction (ED) is one of the most challenging complications associated with radical prostatectomy (RP) for clinically localized prostate cancer. Currently, a broad spectrum of therapeutic options are available to improve sexual health after surgical treatment. Several basic science reports highlighted a potential role for phosphodiesterase type 5 inhibitors in the prevention of endothelial damage related to ischemia reperfusion and/or denervation following surgery. Recent studies have shown that pharmacological prophylaxis soon after RP can significantly improve the rate at which erectile function is recovered after surgery. Use of on-demand treatments for ED in patients who have undergone RP has been shown to be highly effective. In this context, pharmacological prophylaxis potentially may have a significantly expanded role in future strategies aimed at preserving postoperative erectile function. We analyzed the factors affecting erectile function after RP and evaluated the evidence suggesting the role of pharmacological prophylaxis and treatment of ED after surgery.

Trans-urethral resection of the prostate (TURP) and other minimally invasive therapies are the most common surgical procedures used to treat benign prostatic hyperplasia today. However, many patients with a markedly enlarged prostate are often not amenable to these treatment options. In these patients open prostatectomy has been representing a viable and preferred treatment. Despite the morbidity of open enucleation is substantial, until recently no other options were available when the size of the prostate approached 100 g and beyond. The use of holmium laser for the treatment of benign prostatic hyperplasia was first reported in 1996. Holmium laser enucleation of the prostate (HoLEP) has been proposed as an alternative to TURP and to open prostatectomy for patients with lower urinary tract symptoms (LUTS) due to large benign prostatic enlargement. In this manuscript, the development of HoLEP from the initial reports to the long-term follow-up data which demonstrate the effectiveness of the technique in treating patients affected by LUTS secondary to large adenomas has been reviewed. HoLEP seems to represent a valid alternative to both TURP and OP, with valid long-term functional results, a low rate of short-term and long-term complications, and very low rates of reintervention. In conclusion, HoLEP can be offered as the size-independent gold standard treatment of patients with LUTS due to benign prostatic enlargement.

Radiofrequency interstitial tumor ablation (RITA) is a thermal ablation method that uses needles and low radiofrequency (RF) energy. The aim of our study was to evaluate the histopathology of thermal lesions induced by RF energy delivered interstitially in prostate cancer patients who subsequently underwent prostatectomy, and to determine the feasibility, effectiveness and safety of this new method in a pilot study.

Introduction.  Implantation of a penile prosthesis in severely scarred corporal bodies represents a great challenge as fibrosis can compromise dilatation and subsequent closure of the corpora cavernosa and limit size, type, and function of the device. Aim.  The aim of this study is to report our experience of simultaneous corporeal reconstruction and penile prosthesis implantation in patients with severe penile contracture consequence of diffuse fibrosis. Methods.  Between March 2006 and February 2010, 18 patients with severe penile contracture and coporeal fibrosis underwent simultaneous corporeal reconstruction and placement of a 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 questionnaire. Results.  Although the dilatation of the corpora was extremely difficult due to the severe fibrosis, a penile prosthesis has been implanted in all patients. A malleable penile prosthesis has been inserted in four patients and a three-piece inflatable device in the remainder. After an average follow-up of 26 months (range 6-36), revision surgery was required in four patients (elective exchange to three-piece inflatable device in three patients and upsizing of the implant in one patient). Although all patients were able to achieve penetrative sexual intercourse, four patients were partially dissatisfied because of significant penile shortening. Conclusion.  In expert hands, simultaneous penile prosthesis implantation and corporal reconstruction of severely scarred corpora yield satisfactory results. Patients must be warned that complication rate in presence of severe fibrosis is significantly higher than in virgin cases and that downsized cylinders might be required due to the contracture of the tunica albuginea. Sansalone S, Garaffa G, Djinovic R, Antonini G, Vespasiani G, Ieria FP, Cimino S, Loreto C, and Ralph DJ. Simultaneous total corporal reconstruction and implantation of a penile prosthesis in patients with erectile dysfunction and severe fibrosis of the corpora cavernosa. J Sex Med **;**:**-**.

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.

OBJECTIVES To assess the etiology and the late effects of penile fractures treated by immediate surgical intervention. METHODS Between 1986 and 2008, a total of 155 patients with penile fracture were treated surgically in our center. The interval from injury to presentation was between 1 and 96 hours. Those patients were contacted by mail or phone and were re-evaluated. All patients were re-evaluated by questionnaire and local examination. Patients with erectile dysfunction were evaluated by color Doppler ultrasonography. RESULTS The most common cause of fracture of penis is sexual intercourse (51.5%). Unilateral and bilateral corporeal ruptures were present in 139 (89.7%) and 3 (1.9%) cases, respectively, whereas no tunical tear was found in 13 (8.4%) cases. Concomitant urethral injury was present in 14 (9%) cases. Long-term follow-up (>12 months) was available for 141 patients; among whom there was no complications in 108 (77%), painful erection in 2 (1.3%), penile deviation in 5 (3.2%), both in 1 (0.7%), erectile dysfunction in 11 (7.8%), and palpable scarring in 14 (10%). Scar formation was highly associated using nonabsorbable sutures (P <.001). CONCLUSIONS Vigorous sexual intercourse was found to be the most common cause of penile fracture. Immediate surgical intervention has low morbidity, short hospital stay, rapid functional recovery, and no serious long-term sequelae. Nonabsorbable sutures should be avoided as it has a higher incidence of scar formation.

BACKGROUND Ischaemic priapism (IP), which is refractory to conventional medical and surgical intervention, results in necrosis of the corpus cavernosum smooth muscle. These patients eventually develop a variable degree of corporal smooth muscle fibrosis that presents as erectile dysfunction and penile shortening. OBJECTIVES To evaluate the long-term outcome of patients who have undergone the immediate insertion of a penile prosthesis as a treatment for an acute episode of IP refractory to medical therapy or shunt surgery. DESIGN, SETTING, AND PARTICIPANTS A total of 50 patients presented with prolonged IP that was unresponsive to conventional treatment. Unsuccessful shunt surgery had been performed in 13 patients. All patients had evidence of cavernosal smooth muscle necrosis and, therefore, underwent an immediate insertion of a penile prosthesis in the acute setting. MEASUREMENTS Mean age, duration of priapism in hours, intraoperative and postoperative complications, the surgical outcome, and patients' satisfaction were recorded. RESULTS AND LIMITATIONS A malleable penile prosthesis was inserted in 43 patients and a three-piece inflatable implant in was inserted in 7 patients; a subsequent elective exchange of a malleable to an inflatable device was performed in 6 patients. After a median follow-up of 15.7 mo (4-60 mo), 42 patients had already resumed successful sexual intercourse. Prosthesis infection occurred in three patients (6%), which was managed by explantation and delayed reinsertion. A further six patients needed revision surgery. No patient complained of penile shortening, and the overall satisfaction rate was 96%. CONCLUSIONS The immediate insertion of a penile prosthesis for acute refractory ischaemic priapism is a simple and successful procedure that treats the acute episode as well as the inevitable erectile dysfunction that will occur with preservation of penile length.

Sexual dysfunction impairs the quality of life of patients undergoing hemodialysis (HD). The aim of this study was to evaluate the prevalence and the nature of sexual dysfunction in a Moroccan cohort of patients with chronic renal failure (CRF) on HD. This cross-sectional study was carried out with a questionnaire in 86 patients undergoing hemodialysis. Clinical and biological investigations were done. The mean age of our patients was 46.27 +/- 15.68 years old. 81.4% of the cases suffered from a decrease in sexual activity after the onset of HD. The decrease or the loss of libido was noted in 59.3% of the cases. Total impotence was present in 22.1% of the cases and 36% reported partial impotence. Ejaculation was present in 86% of the cases. The comparison between the group of patients who had no sexual dysfunction (group I) and the group of those who had this problem (group II) showed significant differences of age, social status and sexual life before HD. Other significant differences were found regarding frequency of intercourses and sexual satisfaction. Group II was divided into 2 subgroups: IIA included patients who had sexual dysfunction before HD and IIB: those who developed it after. The comparison of this subgroups showed that differences were significant regarding age, weight and vascular risk factors (diabetes mellitus, atherosclerosis). Sildenafil was more efficient in the patients of the subgroup IIB. This study suggested that HD was one of many factors causing sexual dysfunction in hemodialysed patients. After this clinical evaluation of sexual dysfunction, we emphasize the value of a global approach of this problem. The use of sildenafil seems to be more valuable in young patients with erectile dysfunction which appeared after long dialysis duration.

BACKGROUND Herein, we present the largest series of penile fracture ever published. We evaluate the clinical presentation, the outcome of the treatment and the prognosis. METHODS We retrospectively studied patients with penile fracture treated from 1975 to 2005. RESULTS Three hundred patients were included in this study. The mean patient age was 30 years (range, 18-68 years). Out of these patients, 57 (19%) patients were injured during sexual intercourse, whereas 180 (60%) patients were injured during masturbation. The mean time from injury to presentation was 26 hours. The diagnosis was clinical in all cases. No further investigation was needed for confirming the diagnosis. Five patients had urethral bleeding with urethral lesion. All patients were treated by immediate surgery. All of the patients had a tunica albuginea tear that was promptly repaired. At follow-up (mean time of 7 years), 14 patients presented mild curvature, which had not hindered intercourse in 10 patients. The Nesbit intervention was performed in four patients. Penile pain at intercourse developed in four patients (1.3%) and at erection in six patients (2%). Erectile dysfunction was observed in two cases (0.6%). CONCLUSION Penile fracture has typical clinical signs. Early surgical treatment is associated with a low incidence of late complications. The high frequency in our area is neither because of physical nor genetic particularities. It is probably because of sociocultural characteristics.

BACKGROUND AND OBJECTIVE Erectile dysfunction, which is common in men with hypertension, has been reported as a common adverse effect of many antihypertensive drug classes, including beta-blockers and diuretics. Atenolol and nebivolol are both beta(1)-selective blockers, but nebivolol is a new-generation compound with nitric oxide-mediated vasodilating activity. The aim of the study was to compare the effects of nebivolol and atenolol +/- chlorthalidone on the sexual function of hypertensive men. METHODS A total of 131 male patients (mean age 47.3 +/- 4.6 years) with newly diagnosed hypertension were included in the study. All the patients were married and had not previously experienced any erectile dysfunction. After a 4-week placebo run-in period, patients were randomised to receive 12 weeks' therapy with nebivolol 5 mg/day (n = 43), atenolol 50 mg/day (n = 44), or atenolol 50 mg/day + chlorthalidone 12.5 mg/day (n = 44), according to a double-blind design. After 4 weeks of treatment, drug dosage could be doubled in patients not responding to therapy. Erectile function (instances of successful intercourse/month) was assessed by means of a questionnaire at the end of the placebo run-in period (baseline) and at the end of double-blind treatment. Blood pressure was also assessed at these times. RESULTS At the end of the 12-week, double-blind treatment period, the mean number of episodes of satisfactory sexual intercourse per month was significantly decreased from baseline in the groups receiving atenolol (from 7.0 to 3.7; p < 0.01) and atenolol + chlorthalidone (from 6.4 to 2.8; p < 0.01). In contrast, the mean number of episodes of satisfactory sexual intercourse per month remained constant in the group of patients receiving nebivolol (6.4 during the baseline assessment and 6.0 during the last month of treatment). Blood pressure and heart rate were significantly decreased from baseline in all treatment groups. CONCLUSION Increased release of nitric oxide associated with nebivolol may counteract the detrimental effect of beta-blockade on penile erection, thereby allowing maintenance of sexual activity in previously untreated hypertensive men compared with a significant decrease observed in the sexual activity of men receiving atenolol-based treatment.

Introduction. Since the availability of oral type 5 phosphodiesterase (PDE5) inhibitors for the treatment of erectile dysfunction (ED), patients' views on the use of intracavernous injections (ICI) of prostaglandin E1 (PGE1) may have changed. Aim. To assess the satisfaction of patients with long-term ICI. Methods. Patients with ED (>18 years old) who had used ICI of PGE1 for at least 3 months were asked to complete the "EASY"(Evaluation de l'Acceptation des injectionS dans la dYsfonction érectile) questionnaire. Main Outcome Measures. Overall patient satisfaction with ICI, impact on quality of life, ease of use, satisfaction with the quality of erections, and perceived partner satisfaction. Results. Overall, 596 questionnaires met our inclusion criteria. Mean patient age was 62.1 years, mean duration of ED was 61 months, and mean duration of ICI treatment was 35 months. Before using ICI, 43% of patients had taken at least one PDE5 inhibitor; 81% discontinued PDE5 for want of efficacy. The overall satisfaction rate with ICI was 78.3%. ICI met expectations each time in 78.6% of patients and at least half the time in 90% of patients; 86% were ready to recommend ICI to friends. Patients noted improvements in their sex life (70.1%), relationship with their partner (50%), quality of life (44.8%), and confidence in attempting sexual intercourse (80.3%). The mean number of injections was 4.4 per month. Most patients (81.1%) found the injections easy to use. The mean score for pain on injection was 2.09/10 and for pain on erection was 2.15/10. Three-quarters of patients (73.1%) thought that their partners were satisfied with ICI. Conclusion. Patients on long-term ICI/PGE1 can recover a very satisfying sex life. ICI met patients' expectations in terms of efficacy, ease of use, tolerance, and improved sex life. These results should encourage physicians and patients to use ICI when PDE5 fails, is not well tolerated, or is contraindicated.

We report on 64 patients who did not achieve erections adequate for satisfactory sexual intercourse from among a total of 243 patients who were prescribed PDE5 inhibitors for erectile dysfunction (ED). Intracavernous injection (ICI) of PGE was performed in this non-responder group. An ICI of 20 or 40 mcg of PGE1 in 1 ml saline was performed and the responses evaluated. Forty-nine out of 64 (77 percent ) cases responded to 20 mcg of PGE1. Forty mcg of PGE was injected into the 15 non-responding cases, and 9 patients responded favorably. The overall effective rate was 58/64 (91 percent ). No major adverse effects were observed.

OBJECTIVE To study the effect and safety of the Chinese-made inflatable penile prosthesis in the treatment of erectile dysfunction (ED). METHODS According to the anatomy and physiology of Chinese men, an inflatable penile prosthesis was developed in China, consisting of an innovated pump, a reservoir, and a pair of penile cylinders, which were connected by tubes to form a complete system. It was authorized to be used clinically by State Food and Drug Administration (SFDA). Forty-five cases of organic ED were selected for penile prosthesis implantation. Penoscrotal approach was used to implant the cylinders into the corpus cavernosum, the pump into the scrotum and the reservoir into the prevesical space. RESULTS Surgical problems and mechanical failures were not found in the subjects. Post-operative complications occurred in 3 cases (6.6%), but did not affect the intercourse. Satisfactory intercourses were achieved 10-12 months later and the intercourse duration averaged about (20 +/- 6) min. CONCLUSION The Chinese-developed inflatable penile prosthesis was safe and effective for patients with ED, with low rate of mechanical failures. Its long term effect has yet to be further studied.