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Penile augmentation and lengthening procedurewith partial minimal incision
142
V. VIDEO PRESENTATIONS ABSTRACTS
V1
Reduction Phalloplasty and Penile Prosthesis Implantation in a Case of Megalophallus as a Consequence of Neglected Priapism Kattan, S 1; Seyam, RM 1; Al-Ghamdi, D 1 1 : King Faisal Specialist Hospital and Research Center Objectives: Megalophallus is a rare complication of priapism and sickle cell disease. More commonly, priapism in those patients is recurrent, difficult to prevent and ends up in erectile dysfunction as a result of cavernous tissue fibrosis or surgical intervention. A 33 year old man presented to us with a history of neglected priapism for 12 days 2 years previously. He developed a permanent unusual enlargement of the penis and erectile dysfunction. The patient determined that his new penile size is nonfunctional and unacceptable. We evaluated the patient and set out to surgically fashion the penis into a usable size, with adequate rigidity and stable condition. Material and Methods: For 9 years the patient had frequent episodes of priapism which resolved spontaneously. The last episode was unsuccessfully treated conservatively and eventually the patient received a Winter shunt. The penis became enlarged and erections soft. Upon examination with intracavernous injection of 60 mg papaverine, the penis became mildly engorged and it measured 21 cm in circumference and 18 cm in length from the pubic pad of fat to the tip of the glans. MRI showed that the enlargement is mainly due to massive enlargement of corpora cavernosa. We based our goals on normative data for penile length and circumference. Under general anesthesia, we degloved the penis using a circumcision incision. The tunica albuginea was exposed laterally. A 3 cm wide strip was marked on the lateral side of each corpus cavernosum and excised along the long axis of the penis from 1 cm proximal to the coronal sulcus to the pubic bone. The cavernous tissue underneath was fibrotic and was excised to fit in the cylinders of an AMS 700 Ultrex penile prothesis. The tunica albuginea was run with an absorbable suture and the pump and reservoir were placed in the scrotum and retropubic space. Inflation of the prosthesis resulted in rupture of the suture line for 5 cm on the right side just proximal to the glans. Repeated removal of underlying cavernous tissue was not enough to accommodate the cylinder and a free tunica albuginea patch graft was sewn in. Results: At the end of surgery, the penile length was left intact, while the circumference was reduced to 15 cm. Conclusion: Reduction phalloplasty is feasible to manage the unusual cases of megalophallus. Extensive dissection and cavernous tissue removal necessitate penile prosthesis implantation. This is particularly justified in cases associated with erectile dysfunction complicating priapism. Disclosure: Was this work supported by industry? No.
V2
Penile augmentation and lengthening procedurewith partial minimal incision
with dissection of fundiform ligament. After dissection of ligament, multiple transverse sutures were done for approximation of prepubic dead space with 3-0 chromic cat gut. Results: Postoperative penile length after 3 months was 7.3 ± 1.6cm compared with preoperative length 4.5 ± 1.2. Postoperative complications were seroma and inflammatory change (3.0%). Graft failure was 2 cases (1.4%). Conclusion: For penile augmentation and lengthening procedure, partial minimal incision on circumcision incision was effective surgical procedure with minimal complications. Disclosure: Was this work supported by industry? No.
V3
Split plaque incisions and bovine pericardium grafts in severe Peyronie’s disease Gueglio, G 1; Piana, M 1; Giudice, CR1; Damia, O 1 : Hospital Italiano de Buenos Aires
1
Objective: surgical treatment for severe Peyronie’s disease is a challenge for urologists throughout the world. The aim of this video is to show the Gelbard’s technique of split plaque incisions and the use of bovine pericardium grafts in a patient with severe dorsal curvature (90o) and no hourglass deformity. Material and Methods: the video shows the operation of a 58 years old man who consulted for severe Peyronie’s disease and firm erections. First, the x-ray and the ultrasound studies are shown and so are the auto-photographs. Then the main steps of the surgery are displayed in a didactic way. A pair of split incisions are performed in the plaque after lifting the neuro-vascular bundle and measuring of the penis. After the incisions, 3 cms. are gained in the penile length. Then, 2 grafts of bovine pericardium are placed to cover the gaps, tailoring them 20% bigger than the gaps. No corporoplasty was added. After closure of Buck’s fascia, circumcision is routinely performed. Once the skin is closed, a Coban dressing is applied. Results: using this technique we have operated on 6 patients since September 2003. Mean follow-up is 6 months (9-2) and so far the results are very good in terms of straightness and firmness of the erections. As the problem is only the curvature, there is no need for an H shaped incision thus reducing the probability of post-op ED. In this small series, only one patient reported a slight decrease in the firmness of his post-op erections. Conclusion: although the number of patients is low and the followup is short, it seems that split plaque incisions and bovine pericardium grafts is a sound alternative in patients with severe dorsal curvature and no hourglass deformity. Disclosure: Was this work supported by industry? No.
V4
Lee, WH 1; Chang, SY 2 1 : LJ genitourinary surgery institute; 2: LJ Genitourinary Surgery Institute
Flap Cover is superior to Graft Cover everywhere, even in Peyronie’s Disease
Objectives: To perform penile augmentation and lengthening procedure (PALP) for micropenis with partial minimal circumcision incision. Material & Methods: From 1999 to 2004, 145 patients underwent PALP with partial minimal incision, dorsal one third of circumcision incision. PALP adopted dermofat graft from gluteal region. Graft length was 11cm and width was 4cm. Lengthening procedure was done
Objectives: The aim is to re-draw attention to the penile dermal flap (PDF) and present an update. A case is made for the more widespread use of this simple and effective technique. It is important to understand the difference between flaps and free grafts and recognize the clear superiority of the former over the latter.
J Sex Med 2004; Supplement 1
Krishnamurti, S 1 1 : Andromeda Andrology Center, India
143
V. Video Presentations Abstracts Materials and Methods: The PDF was first applied to close tunical defects in Peyronie’s disease in uncircumcised males with available foreskin, then modified for use in the circumcised, and adapted for use in congenital penile curvatures. Nearly 100 patients have undergone this operation. Results: Exact figures are not ready at the time of submission of this abstract. However, penile straightening occurred in nearly 100 % of patients, with very low post-operative rates of contracture or ED. Details will be presented. Discussion: It is elementary knowledge that flaps are of proven superiority to free grafts. Yet, urologists continue to be obsessed with free grafts for Peyronie’s disease. All free grafts: auto-, allo-, xeno-, synthetic—may get infected, and will contract sooner or later. This was painfully clear after 30 years’ experience with free dermal (and other) grafts, yet the lesson isn’t learnt. Vein grafts are no exception. The nitric oxide advantage of the vein intima is purely theoretical. It is wellknown that luminal blood cannot always nourish the media and adventitia layers in medium-sized and large veins by diffusion alone, and that vasa vasora are necessary. Vasa vasora get destroyed when the vein is cut.
Disclosure: Was this work supported by industry? No.
V5
New technique for hydraulic penile prosthesis insertion and corporotomy closure Andrianne, RM 1 1 : CHU Liège Belgium An original technique of insertion and corporotomy closure on the level proximal is described. Proximal angle of corporotomy is closed on the pipe of the hydraulic cylinder by a point of vicryl which was installed before the device implantation. This simple technique allows correct installation of proximal extremity of the prosthesis in the tail of the cavernous body and avoids damage and perforation to the prothesis. Disclosure: Was this work supported by industry? No.
J Sex Med 2004; Supplement 1
V. VIDEO PRESENTATIONS ABSTRACTS
V1
Reduction Phalloplasty and Penile Prosthesis Implantation in a Case of Megalophallus as a Consequence of Neglected Priapism Kattan, S 1; Seyam, RM 1; Al-Ghamdi, D 1 1 : King Faisal Specialist Hospital and Research Center Objectives: Megalophallus is a rare complication of priapism and sickle cell disease. More commonly, priapism in those patients is recurrent, difficult to prevent and ends up in erectile dysfunction as a result of cavernous tissue fibrosis or surgical intervention. A 33 year old man presented to us with a history of neglected priapism for 12 days 2 years previously. He developed a permanent unusual enlargement of the penis and erectile dysfunction. The patient determined that his new penile size is nonfunctional and unacceptable. We evaluated the patient and set out to surgically fashion the penis into a usable size, with adequate rigidity and stable condition. Material and Methods: For 9 years the patient had frequent episodes of priapism which resolved spontaneously. The last episode was unsuccessfully treated conservatively and eventually the patient received a Winter shunt. The penis became enlarged and erections soft. Upon examination with intracavernous injection of 60 mg papaverine, the penis became mildly engorged and it measured 21 cm in circumference and 18 cm in length from the pubic pad of fat to the tip of the glans. MRI showed that the enlargement is mainly due to massive enlargement of corpora cavernosa. We based our goals on normative data for penile length and circumference. Under general anesthesia, we degloved the penis using a circumcision incision. The tunica albuginea was exposed laterally. A 3 cm wide strip was marked on the lateral side of each corpus cavernosum and excised along the long axis of the penis from 1 cm proximal to the coronal sulcus to the pubic bone. The cavernous tissue underneath was fibrotic and was excised to fit in the cylinders of an AMS 700 Ultrex penile prothesis. The tunica albuginea was run with an absorbable suture and the pump and reservoir were placed in the scrotum and retropubic space. Inflation of the prosthesis resulted in rupture of the suture line for 5 cm on the right side just proximal to the glans. Repeated removal of underlying cavernous tissue was not enough to accommodate the cylinder and a free tunica albuginea patch graft was sewn in. Results: At the end of surgery, the penile length was left intact, while the circumference was reduced to 15 cm. Conclusion: Reduction phalloplasty is feasible to manage the unusual cases of megalophallus. Extensive dissection and cavernous tissue removal necessitate penile prosthesis implantation. This is particularly justified in cases associated with erectile dysfunction complicating priapism. Disclosure: Was this work supported by industry? No.
V2
Penile augmentation and lengthening procedurewith partial minimal incision
with dissection of fundiform ligament. After dissection of ligament, multiple transverse sutures were done for approximation of prepubic dead space with 3-0 chromic cat gut. Results: Postoperative penile length after 3 months was 7.3 ± 1.6cm compared with preoperative length 4.5 ± 1.2. Postoperative complications were seroma and inflammatory change (3.0%). Graft failure was 2 cases (1.4%). Conclusion: For penile augmentation and lengthening procedure, partial minimal incision on circumcision incision was effective surgical procedure with minimal complications. Disclosure: Was this work supported by industry? No.
V3
Split plaque incisions and bovine pericardium grafts in severe Peyronie’s disease Gueglio, G 1; Piana, M 1; Giudice, CR1; Damia, O 1 : Hospital Italiano de Buenos Aires
1
Objective: surgical treatment for severe Peyronie’s disease is a challenge for urologists throughout the world. The aim of this video is to show the Gelbard’s technique of split plaque incisions and the use of bovine pericardium grafts in a patient with severe dorsal curvature (90o) and no hourglass deformity. Material and Methods: the video shows the operation of a 58 years old man who consulted for severe Peyronie’s disease and firm erections. First, the x-ray and the ultrasound studies are shown and so are the auto-photographs. Then the main steps of the surgery are displayed in a didactic way. A pair of split incisions are performed in the plaque after lifting the neuro-vascular bundle and measuring of the penis. After the incisions, 3 cms. are gained in the penile length. Then, 2 grafts of bovine pericardium are placed to cover the gaps, tailoring them 20% bigger than the gaps. No corporoplasty was added. After closure of Buck’s fascia, circumcision is routinely performed. Once the skin is closed, a Coban dressing is applied. Results: using this technique we have operated on 6 patients since September 2003. Mean follow-up is 6 months (9-2) and so far the results are very good in terms of straightness and firmness of the erections. As the problem is only the curvature, there is no need for an H shaped incision thus reducing the probability of post-op ED. In this small series, only one patient reported a slight decrease in the firmness of his post-op erections. Conclusion: although the number of patients is low and the followup is short, it seems that split plaque incisions and bovine pericardium grafts is a sound alternative in patients with severe dorsal curvature and no hourglass deformity. Disclosure: Was this work supported by industry? No.
V4
Lee, WH 1; Chang, SY 2 1 : LJ genitourinary surgery institute; 2: LJ Genitourinary Surgery Institute
Flap Cover is superior to Graft Cover everywhere, even in Peyronie’s Disease
Objectives: To perform penile augmentation and lengthening procedure (PALP) for micropenis with partial minimal circumcision incision. Material & Methods: From 1999 to 2004, 145 patients underwent PALP with partial minimal incision, dorsal one third of circumcision incision. PALP adopted dermofat graft from gluteal region. Graft length was 11cm and width was 4cm. Lengthening procedure was done
Objectives: The aim is to re-draw attention to the penile dermal flap (PDF) and present an update. A case is made for the more widespread use of this simple and effective technique. It is important to understand the difference between flaps and free grafts and recognize the clear superiority of the former over the latter.
J Sex Med 2004; Supplement 1
Krishnamurti, S 1 1 : Andromeda Andrology Center, India
143
V. Video Presentations Abstracts Materials and Methods: The PDF was first applied to close tunical defects in Peyronie’s disease in uncircumcised males with available foreskin, then modified for use in the circumcised, and adapted for use in congenital penile curvatures. Nearly 100 patients have undergone this operation. Results: Exact figures are not ready at the time of submission of this abstract. However, penile straightening occurred in nearly 100 % of patients, with very low post-operative rates of contracture or ED. Details will be presented. Discussion: It is elementary knowledge that flaps are of proven superiority to free grafts. Yet, urologists continue to be obsessed with free grafts for Peyronie’s disease. All free grafts: auto-, allo-, xeno-, synthetic—may get infected, and will contract sooner or later. This was painfully clear after 30 years’ experience with free dermal (and other) grafts, yet the lesson isn’t learnt. Vein grafts are no exception. The nitric oxide advantage of the vein intima is purely theoretical. It is wellknown that luminal blood cannot always nourish the media and adventitia layers in medium-sized and large veins by diffusion alone, and that vasa vasora are necessary. Vasa vasora get destroyed when the vein is cut.
Disclosure: Was this work supported by industry? No.
V5
New technique for hydraulic penile prosthesis insertion and corporotomy closure Andrianne, RM 1 1 : CHU Liège Belgium An original technique of insertion and corporotomy closure on the level proximal is described. Proximal angle of corporotomy is closed on the pipe of the hydraulic cylinder by a point of vicryl which was installed before the device implantation. This simple technique allows correct installation of proximal extremity of the prosthesis in the tail of the cavernous body and avoids damage and perforation to the prothesis. Disclosure: Was this work supported by industry? No.
J Sex Med 2004; Supplement 1