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Re: Reconstruction of the Fossa Navicularis, by G. H. Jordan, J. Urol., 138: 102–104, 1987.
385
LETTERS TO THE ED1TOJR
Reply by Authors. Diabetic neuropathic changes in somatic nerve pathways are common. These changes are frequent in the dorsal nerve of the penis as well as the peroneal nerve. However, it is important to document neuropathic change specifically in the dorsal nerve of the penis for several reasons. Although neuropathic changes in diabetes are frequently comparable in all somatic nerves, such as the peroneal and dorsal nerve of the penis, there are occasionally surprising differences in the individual patient. The dorsal nerve of the penis has a significant role in all 3 aspects of male sexual expression (libido, erection and ejaculation/ orgasm). If the evaluation of the impotent patient is to include measurement of bulbocavernosus reflex latency and latency of the cortical pudenda[ evoked response, then it is necessary to measure the conduction velocity of the dorsal nerve of the penis. Only in this manner will the clinician be aware of the site of impairment of conduction. RE: RECONSTRUCTIVE SURGERY FOR VASCULOGENIC IMPOTENCE
A H Bennett, D. J. Rivard, R. P Blanc and M. Moran
J. UroL, 136: 599-601, 1986 To the Editor. Since 1981 we have operated on 60 patients with erectile impotence owing to venocavernous leakage. 1 We have performed ligation of the deep penile veins with or without pericavernoplasty and cavernoplasty without serious complications. Only 25 patients (41 per cent) had good results after an average of 24 months. The best results were noted when venous leakage was fairly significant and when it was isolated or associated with Peyronie's disease. Our experience shows that there is no specific venous leakage syndrome. The influence of posture or presence of associated venous pathological conditions seems not to be truly typical of venocavernous leakage. The diagnosis actually is made by cavemosography with a passive erection test.' Venous leakage is evoked when the flow rate necessary to maintain erection exceeds 120 mL per minute. However, this criterion is arbitrary and it seems to be insufficient because potent men may have a high flow rate. The criteria of venocavernous leakage must be defined better. Intracavernous injection of vasoactive drugs, and measurement of erectile compliance and intracavemous pressure may be helpfuL The complexity of the mechanisms of venous blockade implies a physiopathological diversity, including impairment of the active mechanisms of venous regulation, lack of imperviousness of the tunica albuginea and, mainly, a decrease in compliance of the cavernous bodies by alteration of the tunica albuginea and elastic properties of the erectile tissue by fibrosis." These physiopathological doubts explain the difficulty in the choice of therapy and surgical techniques. In case of extensive fibrosis, a penile prosthesis seems to be preferable. Despite some failures for which no precise cause could be determined and the ever present possibility of subjective improvement, reconstruction may be a good treatment for some cases of venocavernous leakage, which still is difficult to distinguish. However, the success rate probably will improve with experience and mainly better knowledge of venous blockade mechanisms. Respectfully,
P Bondi/ and J. L Nguyen Qui 282 Bd Foe Salon de Provence 13300 France and T Schauvliege 27 rue Henri Dunant Bethune 62400, France L Bondi!, P., Schauvliege, T. and Nguyen Qui, J. L.: Impuissance par fuite veineuse: reflexions a propos de 60 cas operes. Acta UroL Belg., in press. 2. Virag, R., Spencer, P. P. and Frydman, D.: Artificial erection in diagnosis and treatment of impotence. Urology, 24: 157, 1984. 3. Bondi!, P., Rigot, J. M. and Nguyen Qui, J. L.: Hemodynamique penienne: mecanismes probables. Cahiers Sexol. Clin., 12: 18, 1986.
Reply by Authors. We agree on the complexity of the mechanisms of venous drainage of the penis as well as the discrepancy in the literature concerning the definition of corporovenous leakage or venous incom-
petence. The criteria used in our study for the diagnosis of corporovenous leakage were anything greater than a flow requirement of 60 cc per minute after the corporeal bodies were primed with vasoactive drugs. The assessment of a normal response could be either subjective or by measurement of intracavernous pressure. The 41 per cent success rate reported by Bondi! and associates does not vary greatly from the 60 per cent success rate noted in our article. Our personal experience currently numbers 40 patients and 2-year followup studies on these patients indicate an approximately 50 per cent success rate from an operation alone, which can be improved to approximately 65 per cent with the addition of a pharmacological erection program. The success of surgery also may be related to the degree of corporovenous leakage in that patients with a poor response during the cavemometric study or who require greater than 150 cc per minute to maintain flow appear not to benefit as much from an operation. It also is important to differentiate the operation that includes pericavernoplasty from wide resection of the deep dorsal vein alone. None of the operations in our series has included a procedure on the corporeal bodies or corporeal tips, which may be detrimental with potential injury to either vascular or nerve structures. We agree that the field of venous incompetence still is in a developmental stage and that one must be able to define the condition better so that one can choose more appropriately which patients will benefit from an operation. RE: RECONSTRUCTION OF THE FOSSA NA VICULARIS G. H Jordan J. UroL, 138: 102-104, 1987
To the Editor. The author mentions that our technique for reconstruction of the meatus and fossa navicularis uses a midline flap with a narrow vascular pedicle. This is not true. Indeed, the midline flap, which will become the roof of the anterior urethra, is created by 2 superficial longitudinal skin incisions that preserve the subcutaneous tissue and the vascular pedicle coming from both sides. The vascular pedicle is dissected further downwards and laterally far enough to allow sufficient mobilization of the skin flap. In these circumstances the flap certainly is vascularized as well as in the technique described by the author. We currently have up to 20 cases of meatal stricture, some extending even farther than the fossa navicularis. We never use urinary diversion. The aesthetic results are perfect and no complications were noted. We believe that use of a ventral or, rather, a dorsal transverse island flap will complicate the inte1°vention and oblige one to perform diversion or use a urethral splint. This does not allow one to consider it a 1-day procedure as we do. Respectfully, WA. De Sy
Kliniek voor Urologie Universitair Ziekenhuis De Pintelaan 185 9000 Gent, Belgium Reply by Author. The technique I described clearly is a ventral transverse penile skin-preputial island flap. The dorsal flap is not used, although the Duckett onlay procedure with a dorsal flap could well be applied. As mentioned in the article, I have tried Doctor De Sy's procedure and was not happy with the results. Because of this I attempted to explain the bad results on the basis of flaws in the principle of tissue transfer. As Doctor De Sy' s flap is described, the vascular pedicle indeed appears to be narrow in that he describes longitudinal incisions placed adjacent to a strip that is de-epithelialized. Perhaps what is described is not actually what Doctor De Sy is doing but, certainly, it is the way that it is understood in the article. In addition, Doctor De Sy's flap is transferred by an advancement. One of the greatest advantages to an island flap is that it can be transferred by rotation, transposition and inversion, and, thus, one is not limited by the rules of advancement only. It appeared to me that Doctor De Sy had to advance the tip of the flap by almost 4 cm. This advancement then must come from some place and I believed that it was unduly advancing the ventral skin on the penile shaft. The flap I described is transposed and inverted. While the pedicle is advanced minimally, it is advanced only by the width of the flap, that
LETTERS TO THE ED1TOJR
Reply by Authors. Diabetic neuropathic changes in somatic nerve pathways are common. These changes are frequent in the dorsal nerve of the penis as well as the peroneal nerve. However, it is important to document neuropathic change specifically in the dorsal nerve of the penis for several reasons. Although neuropathic changes in diabetes are frequently comparable in all somatic nerves, such as the peroneal and dorsal nerve of the penis, there are occasionally surprising differences in the individual patient. The dorsal nerve of the penis has a significant role in all 3 aspects of male sexual expression (libido, erection and ejaculation/ orgasm). If the evaluation of the impotent patient is to include measurement of bulbocavernosus reflex latency and latency of the cortical pudenda[ evoked response, then it is necessary to measure the conduction velocity of the dorsal nerve of the penis. Only in this manner will the clinician be aware of the site of impairment of conduction. RE: RECONSTRUCTIVE SURGERY FOR VASCULOGENIC IMPOTENCE
A H Bennett, D. J. Rivard, R. P Blanc and M. Moran
J. UroL, 136: 599-601, 1986 To the Editor. Since 1981 we have operated on 60 patients with erectile impotence owing to venocavernous leakage. 1 We have performed ligation of the deep penile veins with or without pericavernoplasty and cavernoplasty without serious complications. Only 25 patients (41 per cent) had good results after an average of 24 months. The best results were noted when venous leakage was fairly significant and when it was isolated or associated with Peyronie's disease. Our experience shows that there is no specific venous leakage syndrome. The influence of posture or presence of associated venous pathological conditions seems not to be truly typical of venocavernous leakage. The diagnosis actually is made by cavemosography with a passive erection test.' Venous leakage is evoked when the flow rate necessary to maintain erection exceeds 120 mL per minute. However, this criterion is arbitrary and it seems to be insufficient because potent men may have a high flow rate. The criteria of venocavernous leakage must be defined better. Intracavernous injection of vasoactive drugs, and measurement of erectile compliance and intracavemous pressure may be helpfuL The complexity of the mechanisms of venous blockade implies a physiopathological diversity, including impairment of the active mechanisms of venous regulation, lack of imperviousness of the tunica albuginea and, mainly, a decrease in compliance of the cavernous bodies by alteration of the tunica albuginea and elastic properties of the erectile tissue by fibrosis." These physiopathological doubts explain the difficulty in the choice of therapy and surgical techniques. In case of extensive fibrosis, a penile prosthesis seems to be preferable. Despite some failures for which no precise cause could be determined and the ever present possibility of subjective improvement, reconstruction may be a good treatment for some cases of venocavernous leakage, which still is difficult to distinguish. However, the success rate probably will improve with experience and mainly better knowledge of venous blockade mechanisms. Respectfully,
P Bondi/ and J. L Nguyen Qui 282 Bd Foe Salon de Provence 13300 France and T Schauvliege 27 rue Henri Dunant Bethune 62400, France L Bondi!, P., Schauvliege, T. and Nguyen Qui, J. L.: Impuissance par fuite veineuse: reflexions a propos de 60 cas operes. Acta UroL Belg., in press. 2. Virag, R., Spencer, P. P. and Frydman, D.: Artificial erection in diagnosis and treatment of impotence. Urology, 24: 157, 1984. 3. Bondi!, P., Rigot, J. M. and Nguyen Qui, J. L.: Hemodynamique penienne: mecanismes probables. Cahiers Sexol. Clin., 12: 18, 1986.
Reply by Authors. We agree on the complexity of the mechanisms of venous drainage of the penis as well as the discrepancy in the literature concerning the definition of corporovenous leakage or venous incom-
petence. The criteria used in our study for the diagnosis of corporovenous leakage were anything greater than a flow requirement of 60 cc per minute after the corporeal bodies were primed with vasoactive drugs. The assessment of a normal response could be either subjective or by measurement of intracavernous pressure. The 41 per cent success rate reported by Bondi! and associates does not vary greatly from the 60 per cent success rate noted in our article. Our personal experience currently numbers 40 patients and 2-year followup studies on these patients indicate an approximately 50 per cent success rate from an operation alone, which can be improved to approximately 65 per cent with the addition of a pharmacological erection program. The success of surgery also may be related to the degree of corporovenous leakage in that patients with a poor response during the cavemometric study or who require greater than 150 cc per minute to maintain flow appear not to benefit as much from an operation. It also is important to differentiate the operation that includes pericavernoplasty from wide resection of the deep dorsal vein alone. None of the operations in our series has included a procedure on the corporeal bodies or corporeal tips, which may be detrimental with potential injury to either vascular or nerve structures. We agree that the field of venous incompetence still is in a developmental stage and that one must be able to define the condition better so that one can choose more appropriately which patients will benefit from an operation. RE: RECONSTRUCTION OF THE FOSSA NA VICULARIS G. H Jordan J. UroL, 138: 102-104, 1987
To the Editor. The author mentions that our technique for reconstruction of the meatus and fossa navicularis uses a midline flap with a narrow vascular pedicle. This is not true. Indeed, the midline flap, which will become the roof of the anterior urethra, is created by 2 superficial longitudinal skin incisions that preserve the subcutaneous tissue and the vascular pedicle coming from both sides. The vascular pedicle is dissected further downwards and laterally far enough to allow sufficient mobilization of the skin flap. In these circumstances the flap certainly is vascularized as well as in the technique described by the author. We currently have up to 20 cases of meatal stricture, some extending even farther than the fossa navicularis. We never use urinary diversion. The aesthetic results are perfect and no complications were noted. We believe that use of a ventral or, rather, a dorsal transverse island flap will complicate the inte1°vention and oblige one to perform diversion or use a urethral splint. This does not allow one to consider it a 1-day procedure as we do. Respectfully, WA. De Sy
Kliniek voor Urologie Universitair Ziekenhuis De Pintelaan 185 9000 Gent, Belgium Reply by Author. The technique I described clearly is a ventral transverse penile skin-preputial island flap. The dorsal flap is not used, although the Duckett onlay procedure with a dorsal flap could well be applied. As mentioned in the article, I have tried Doctor De Sy's procedure and was not happy with the results. Because of this I attempted to explain the bad results on the basis of flaws in the principle of tissue transfer. As Doctor De Sy' s flap is described, the vascular pedicle indeed appears to be narrow in that he describes longitudinal incisions placed adjacent to a strip that is de-epithelialized. Perhaps what is described is not actually what Doctor De Sy is doing but, certainly, it is the way that it is understood in the article. In addition, Doctor De Sy's flap is transferred by an advancement. One of the greatest advantages to an island flap is that it can be transferred by rotation, transposition and inversion, and, thus, one is not limited by the rules of advancement only. It appeared to me that Doctor De Sy had to advance the tip of the flap by almost 4 cm. This advancement then must come from some place and I believed that it was unduly advancing the ventral skin on the penile shaft. The flap I described is transposed and inverted. While the pedicle is advanced minimally, it is advanced only by the width of the flap, that