Glans Ischemia Research Articles

(340) A CASE OF GLANS NECROSIS STATUS POST PLACEMENT OF AN INFLATABLE PENILE IMPLANTATION IN A 35-YO PATIENT WITH TYPE I MUSCULAR DYSTROPHY

Abstract Introduction We present the case report a 35-year-old patient with type-I muscular dystrophy (DM1) and no known pre-operative or intra-operative risk factors who experienced acute glans necrosis following insertion of an inflatable penile prosthesis (IPP). Objective Our aim was to review what factors may have contributed to acute glans necrosis in a patient with type I muscular dystrophy and to document our outcome to add to the limited literature on this topic. Methods We reviewed the PUBMED literature for current recommendations regarding acute glans necrosis management, present our own case presentation, and discuss why DM1 may pose a risk for this post-operative complication. Results This 35-year-old male with a history notable for genetically-confirmed DM1 and first-degree heart block, obstructive sleep apnea and testicular detorsion at age 12 without known sequelae. He had no significant medical or surgical history. The patient was followed over a course of five years and found to have gradually worsening erectile dysfunction poorly responsive to medical therapy. The patient elected to undergo placement of an inflatable penile prosthesis. There were no intra-operative complications or adjunctive surgical procedures performed. Foley was removed at end of case and a drain was left in place. Implant was inflated to 70% and a non-occlusive Kerlex wrap was applied. Post-operatively, the patient was monitored in ICU due to risk of apnea. On three-hour post-operative check, he was found to have a concerning exam with dusky appearance of glans. The implant was fully deflated, and he was started on aspirin 81 mg, Sildenafil, topical nitropaste to glans, and supplemental oxygen. The exam continued to worsen, and he underwent uncomplicated explantation 12 hours post-initial implantation with immediate signs of glans recovery. The known risk factors for glans necrosis post-IPP placement include atherosclerosis, diabetes, smoking, pelvic irradiation, concomitant circumcision, and use of vasoconstrictive agents [1]. A confounder we explore is muscular dystrophy type I (DM1). DM1 is a multisystem disease that affects gene splicing and expression [2], with individually documented evidence showing involvement of the cardiac, vascular, and coagulation systems amongst others. DM1 is associated with cardiomyopathy and fatal arrythmias [3]. Furthermore, certain muscular dystrophies, especially DM1, have increased venous thromboembolism risk [4]. Early reports showed hypersensitive platelet response in myotonic patients [5, 6], but literature is conflicting with some showing normal response [7]. DM1 is linked to multiple ophthalmic vascular pathologies. [8-10]. As a complex multi-system disorder affecting gene function, DM1 may pose a risk for glandular necrosis. In hindsight, early device removal was likely optimal, as expectant management risks significant tissue loss [1], whereas timely explantation has been documented to allow for full tissue recovery. [11, 12]. Conclusions This case report describes acute glans ischemia post-IPP placement in a patient with type I muscular dystrophy and identifies a new potential risk factor for this complication. It adds to the dearth of data for the treatment of this complication and reinforces that prompt removal of IPP can lead to good tissue recovery. Disclosure No.

Multi-Institutional Bladder Exstrophy Consortium After 8 Years: The Short- and Intermediate-Term Outcomes.

Bladder exstrophy (BE) poses challenges both during the surgical repair and throughout follow-up. In 2013, a multi-institutional BE consortium was initiated, which included utilization of unified surgical principles for the complete primary repair of exstrophy (CPRE), real-time coaching, ongoing video capture and review of video footage, prospective data collection, and routine patient data analysis, with the goal of optimizing the surgical procedure to minimize devastating complications such as glans ischemia and bladder dehiscence while maximizing the rate of volitional voiding with continence and long-term protection of the upper tracts. This study reports on our short-term complications and intermediate-term continence outcomes. A single prospective database for all patients undergoing surgery with a BE epispadias complex diagnosis at 3 institutions since February 2013 was used. For this study, data for children with a diagnosis of classic BE who underwent primary CPRE from February 2013 to February 2021 were collected. Data recorded included sex, age at CPRE, adjunct surgeries including ureteral reimplantations and hernia repairs at the time of CPRE, osteotomies, and immobilization techniques, and subsequent surgeries. Data on short-term postoperative outcomes, defined as those occurring within the first 90 days after surgery, were abstracted. In addition, intermediate-term outcomes were obtained for patients operated on between February 2013 and February 2017 to maintain a minimum follow-up of 4 years. Outcomes included upper tract dilation on renal and bladder ultrasound, presence of vesicoureteral reflux, cortical defects on nuclear scintigraphy, and continence status. Bladder emptying was assessed with respect to spontaneous voiding ability, need for clean intermittent catheterization, and duration of dry intervals. All operating room encounters that occurred subsequent to initial CPRE were recorded. CPRE was performed in 92 classic BE patients in the first 8 years of the collaboration (62 boys), including 46 (29 boys) during the first 4 years. In the complete cohort, the median (interquartile range) age at CPRE was 79 (50.3) days. Bilateral iliac osteotomies were performed in 89 (97%) patients (42 anterior and 47 posterior). Of those undergoing osteotomies 84 were immobilized in a spica cast (including the 3 patients who did not have an osteotomy), 6 in modified Bryant's traction, and 2 in external fixation with Buck's traction. Sixteen (17%) patients underwent bilateral ureteral reimplantations at the time of CPRE. Nineteen (21%) underwent hernia repair at the time of CPRE, 6 of which were associated with orchiopexy. Short-term complications within 90 days occurred in 31 (34%), and there were 13 subsequent surgeries within the first 90 days. Intermediate-term outcomes were available for 40 of the 46 patients, who have between 4 and 8 years of follow-up, at a median of 5.7 year old. Thirty-three patients void volitionally, with variable dry intervals. Cumulative efforts of prospective data collection have provided granular data for evaluation. Short-term outcomes demonstrate no devastating complications, that is, penile injury or bladder dehiscence, but there were other significant complications requiring further surgeries. Intermediate-term data show that boys in particular show encouraging spontaneous voiding and continence status post CPRE, while girls have required modification of the surgical technique over time to address concerns with urinary retention. Overall, 40% of children with at least 4 years of follow-up are voiding with dry intervals of > 1 hour.

Maximizing outcomes in penile prosthetic surgery: exploring strategies to prevent and manage infectious and non-infectious complications.

Inflatable Penile Prostheses (IPP) implantation is a surgical treatment for patients desiring definitive treatment for erectile dysfunction. While this procedure has proven to be effective, it also carries its own set of unique risks that need to be carefully considered. The article reviews the current understanding of complications associated with penile prosthetic surgery and provides strategies to mitigate these adverse events. This article covers various aspects of IPP implantation, including the risks of infection, bleeding, injury to nearby structures, glans ischemia, and device malfunction. It also discusses the importance of careful preoperative screening to identify risk factors and the implementation of infection reduction strategies such as antimicrobial prophylaxis, skin prep, and operative techniques. In addition, it emphasizes the need for postoperative vigilance and prompt management of any complications that may arise. Overall, the article provides a comprehensive overview of the risks and strategies for mitigating complications associated with IPP implantation. Our recommendations are given based on the current consensus in the field and highlight the importance of careful planning, attention to detail, and effective communication between healthcare providers and patients. Despite the potential risks, this review underscores the fact that complications following penile prosthesis implantation are relatively rare.

Severe Acute Ischemia of Glans Penis after Achieving Treatment with Only Hyperbaric Oxygen Therapy: A Rare Case Report and Systematic Literature Review.

Acute ischemia of the glands is a severe complication after circumcision. We outline the challenging case of a seventeen-year-old boy with glandular ischemia (GI) that appeared shortly after circumcision. Methods: We present a case report and literature review related to glans ischemia, and the complications of circumcision are reviewed. We note that there are very few cases described in the literature. Our patient was successfully treated with hyperbaric oxygen therapy (HBOT) after four days of no positive effect after all medical and surgical treatments written in the literature: Subcutaneous enoxaparin, local application of a glyceryl trinitrate, continuous epidural perfusion, intravenous pentoxifylline, alprostadil, intraoperative drainage, and aspiration with saline solution and epinephrine. Clinical improvement was noted at the first session of HBOT. A number of days after the operation, the penis looked normal and was healing. Complete healing of the penile glans was successfully realized one month after surgery. Conclusion: Based on the review and the case presented, we conclude that HBOT is the treatment of choice for acute ischemia of the penile glans, especially when other treatments do not work.

Subcoronal Incision for Inflatable Penile Prosthesis Does Not Risk Glans Necrosis.

Glans vascular compromise had previously been considered a rare but devastating complication of the subcoronal incision for inflatable penile prosthesis surgery. Here, we describe the largest series of subcoronal implants to date to assess contemporary complication rates. A retrospective review of subcoronal prosthesis placements by a single surgeon from Seoul, South Korea, was performed. Patients were randomly assigned either Coloplast Titan or AMS 700 device per institutional practice. A total of 898 patients who underwent subcoronal implants from May 2015 to March 2022 were analyzed. Median follow-up was 41 months (IQR 40). Preoperative patient comorbidities included diabetes (36.6%) and Peyronie's disease (4%). The most common complication was transient distal penile edema (74.7%). Transient incisional paresthesia (20.6%) was more common in patients with diabetes (31.9% vs 13.9%, P < .01). Five cases (0.5%) of distal penile skin necrosis were reported in patients who had previously been circumcised. Of these, 3 were managed successfully with wet-to-dry dressing, 1 required skin grafting, and 1 required device explant. Device infection without incisional compromise occurred in 2 cases (0.2%). There were no instances of glans necrosis or ischemia observed in this cohort. Of the first-time implants (817, 90.9%), most (62.3%) were successfully completed under local anesthetic alone, with the remainder of surgeries completed with the addition of adjunctive conscious sedation. Subcoronal incision for first-time or revision penile implant surgery is not a risk factor for glans ischemia or necrosis and can be safely completed under local anesthetic with or without conscious sedation.

(452) Glans Necrosis is Not a Risk for Simple Inflatable Penile Prosthesis Insertion Performed via Subcoronal Incision

Abstract Introduction Some studies have questioned subcoronal incision via IPP as a risk factor for glans ischemia or necrosis. We analyzed the largest ever reported series of IPP via subcoronal incision. Objective To report complications related with subcoronal incision for IPP placement Methods We studied 898 men who had subcoronal IPP placement from 5/2015-3/2022 by single surgeon. 817 were first-time patients under local anesthesia, with 81 revisions under spinal anesthesia including 707 circumcised and 181 uncircumcised subjects. Most (76%) uncircumcised men underwent coincident circumcision; the remainder refused. Implants were Coloplast Titan (489) and AMS 700 (329) in 329 (36.6%) diabetics and 38 (4%) Peyronie’s. We report postoperative occurrence of device infections and glans/penile skin problems. Results Mean follow up was 47.3 months (3-81 months). Modeling (64%) and corporal relaxing incisions (36%) straightened the Peyronie’s patients. Transient distal penile skin edema which resolved within 2 to 4 months was noted in 673 cases (74.9%). Edema developed in 68.3% previously circumcised patients, 100% of concomitant circumcised patients and 96.2% of patients who had refused circumcision. One previously circumcised patient experienced prolonged edema of 7 months. Five previously circumcised patients (0.5%) developed partial distal penile skin necrosis on the proximal side of the subcoronal incision (Figure-1) with all but one healing without grafting. The other patient sustained necrotic wound dehiscence which led to device infection and removal. There were zero cases of glans ischemia or necrosis. Only 2 patients became infected (0.2%). Conclusions Subcoronal incision for simple IPP placement or revision is not an independent risk factor for glans ischemia or necrosis. Most postoperative patients do experience transient distal penile skin edema without glans involvement which heals without sequelae regardless of circumcision status. Very rarely (0.5%) penile skin loss may occur. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, International Medical Devices, Rigicon, Uramix.

MP62-09 GLANS NECROSIS IS NOT A RISK FOR SIMPLE INFLATABLE PENILE PROSTHESIS INSERTION PERFORMED VIA SUBCORONAL INCISION

You have accessJournal of UrologyCME1 Apr 2023MP62-09 GLANS NECROSIS IS NOT A RISK FOR SIMPLE INFLATABLE PENILE PROSTHESIS INSERTION PERFORMED VIA SUBCORONAL INCISION Sung Hun Park and Steven Wilson Sung Hun ParkSung Hun Park More articles by this author and Steven WilsonSteven Wilson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Some studies have questioned subcoronal incision for IPP as a risk factor for glans ischemia or necrosis.1 We analyzed the largest ever reported series of IPP via subcoronal incision. METHODS: We studied 898 men who had subcoronal IPP placement from 5/2015-3/2022 by single surgeon after ethical committee approval. 817 were first-time patients, with 81 revisions including 707 circumcised and 181 uncircumcised subjects. Most (76%) uncircumcised men underwent coincident circumcision; the remainder refused. Implants were Coloplast Titan (489) and AMS 700 (329) under local anesthesia in 329(36.6%) diabetics and 38(4%) Peyronie’s. We report postoperative occurrence of device infections and glans/penile skin problems. RESULTS: Mean follow up was 47.3 months (3-81 months). Modeling (64%) and corporal relaxing incisions (36%) straightened the Peyronie’s patients. Transient distal penile skin edema which resolved within 2 to 4 months was noted in 673 cases (74.9%). Edema developed in 68.3% previously circumcised patients, 100% of concomitant circumcised patients and 96.2% of patients who had refused circumcision. One previously circumcised patient experienced prolonged edema of 7 months. Five previously circumcised patients (0.5%) developed partial distal penile skin necrosis on the proximal side of the subcoronal incision with all but one healing without grafting. (see below) The other patient sustained necrotic wound dehiscence which led to device infection and removal. There were zero cases of glans ischemia or necrosis. Only 2 patients became infected (0.2%). CONCLUSIONS: Subcoronal incision for simple IPP placement or revision is not an independent risk factor for glans ischemia or necrosis. Most postoperative patients do experience transient distal penile skin edema without glans involvement which heals without sequelae regardless of circumcision status. Very rarely (0.5%) penile skin loss may occur. Reference: 1. Wilson SK et al. Glans Necrosis Following Penile Prosthesis Implantation: Prevention and Treatment Suggestions. Urology 2017; 107:144-148. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e864 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sung Hun Park More articles by this author Steven Wilson More articles by this author Expand All Advertisement PDF downloadLoading ...

An Unexpected Complication: Glans Ischemia After Urethractomy

Necrosis of the glans is a rare and unexpected complication of urethractomy. The literature is poorly documented regarding this complication. We report here the case of a 49 year old patient with a history of chronic smoking, followed for bladder tumour initially without muscle infiltration. Lost to follow-up for 3 years, his re-evaluation revealed a muscle-infiltrating bladder tumour with localization in the prostatic urethra without other secondary localizations.

An Unexpected Complication: Glans Ischemia After Urethractomy

Necrosis of the glans is a rare and unexpected complication of urethractomy. T

Sliding technique through a non-degloving approach for Peyronie's Disease: 2-surgeon experience

ABSTRACT Introduction The sliding technique (ST) has been used to restore penile size in patients with penile atrophy secondary to severe Peyronie's Disease (PD) and erectile dysfunction (ED). When combined with degloving, this procedure carries a potential risk of causing ischemia or necrosis to the glans penis. Objective We hereby present a detailed surgical technique of the non-degloving approach for the ST and penile prosthesis (PP) placement. Methods Retrospective review of databases from 2 surgeons and report patient outcomes after PP placement with sliding technique for the correction and size restoration of severe PD and ED from January 2015 to September 2019. Results A total of 39 patients had significant penile atrophy and/or curvature &amp;gt;60 degrees and underwent PP placement with grafting procedures between 2 surgeons. 11 of those patients underwent ST of which 9 had the procedure performed through a non-degloving ventral incision. Mean degree of curvature prior to ST was 62 degrees (45 to 90 degrees) Mean penile length gain was 2.47 cm (2.0 to 3.0 cm). At a mean follow up of 12.4 months (3 to 31 months) only 1 patient had residual curvature, which was minimal at 15 degrees. There were no infections or vascular complications in our series. Conclusion There are reports of ischemic injury in PD patients undergoing penile prothesis placement in addition to the ST with a circumcision and penile degloving. The non-degloving technique with a ventral incision provides for an alternative method to perform the ST in patients with penile atrophy secondary to severe PD and ED. This approach could theoretically minimize the risk of glans ischemia by maintaining dartos and skin continuity to the glans penis while still allowing for adequate surgical exposure. Disclosure Work supported by industry: no. A consultant, employee (part time or full time) or shareholder is among the authors (Jonathan Clavell Hernandez: Consultant for Coloplast and Boston Scientific, Run Wang is consultant for Boston scientific and Coloplast ).

A Novel Algorithm for Peyronie's Management At the Time of Penile Prosthesis to Maximize Length Without Elevation of the Neurovascular Bundle

ABSTRACT Introduction Peyronie's disease (PD) is a fibrous transformation of the tunica albuginea within the corpora cavernosa causing curvature of the penis while erect. This can not only be painful but can also cause narrowing, shortening, an hourglass deformity and problems with penetrative intercourse. Objective There are many means of management of Peyronie's disease at the time of penile implant. Modelling is a commonly used approach but leaves the penis without increased length. Multi-incisional techniques enhance length restoration, but risk significant vascular and neurologic compromise. Herein, we present our experience with a novel algorithm to approach Peyronie's disease with an effort to enhance and restore length without elevation of the neurovascular bundle. Methods A retrospective review was performed of an institutional review board approved database. Patients treated for Peyronie's disease and erectile dysfunction with penile implant from 8/16/18 to 8/20/2020 were evaluated. Results In our cohort of 33 patients there is an average of 1.9 cm average stretch difference in stretch penile length. There was a 2.15 cm difference in the cohort subset that utilized the Brock technique. We had no loss of sensation or glans ischemia. There was one patient with autoinflation. All patient had less than 10 degrees of residual curvature. Conclusions In conclusion with the proposed algorithm we are able to safely maximize length restoration without elevation of the neurovascular bundle. We do require more patients with longer follow-up however to ensure the safety of this algorithm. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific, Olympus

Glans Ischemia Treatment with Pentoxifylline Following Circumcision in a Neonate

Introduction: Circumcision is the most common surgery in male infants in Islamic countries. Therefore, knowledge of its side effects and appropriate therapies is essential. Case Presentation: In this case report, we describe a 12-day neonate with glans ischemia, two days after circumcision. We admitted the neonate and treated him with oral pentoxifylline and antibiotic for three days. Conclusions: Thus, pentoxifylline can be implemented as a treatment in post-circumcision ischemia of the glans penis in neonates.

Ишемия головки полового члена после циркумцизии на фоне блокады дросального нерва полового члена: клинический случай

Introduction. Circumcisio is a fairly simple, often performed surgical procedure in childhood, which is fraught with a small number of complications (1-5-5%). One of the most rare and dangerous is necrosis of the glans penis. The low incidence of complications determines the lack of a single standardized approach to the treatment of this pathology. The clinical case. In this article, we present a case of glans ischemia after circumcisio with pineal block, corrected with the help of therapy aimed at improving the rheological properties of the blood. A review of the literature and various treatment methods described by other authors was conducted. The exact etiology of ischemia and necrosis of the head in most cases remains unclear. However, numerous possible causes have been described, including spasm of the veins / arteries in the glans penis, thrombosis, hematoma at the injection site, burn during electrocoagulation, perforation of a vein or artery leading to endothelial damage and delayed necrosis. Results. After a course of conservative therapy, local signs of ischemia associated with surgery were stopped without side effects. Discussion.The standard of choice of treatment method for ischemia and necrosis of the glans penis after circumcisio has not yet been established. We have not found an analysis of such clinical cases in children in the domestic literature. A number of foreign colleagues have reported several therapies that have been used with successful results. The ultimate goal of all of these studies was vasodilation to increase arterial inflow and improve venous outflow, which allowed for revascularization of ischemic tissues. Conclusions. Despite the fact that ischemia or necrosis of the glans penis after circumcision is extremely rare, surgeons, urologists need to be wary if patients complain of acute pain or darkening of the color of the glans penis after circumcision of the foreskin.

A Modified Pressure Dressing to Avoid Severe Bleeding After Circumcision With a Disposable Circumcision Suture Device and a Discussion on the Mechanism of Bleeding With the Disposable Circumcision Suture Device.

IntroductionA novel type of a disposable circumcision suture device (DCSD) has been proved to be effective and safe; however, a few cases of severe bleeding took place after circumcisions.AimTo evaluate the effectiveness of a modified double-layer pressure dressing to avoid severe bleeding after circumcision with the DCSD, in our department in a prospective randomized controlled study, and discuss the mechanism of bleeding with DCSD.MethodsPatients with redundant foreskin or phimosis were included between September 2018 and November 2019 and divided into 2 groups: In group A, the conventional pressure dressing was performed; in group B, an modified double-layer pressure dressing was performed.Main Outcome MeasureThe main outcomes and complications (surgical time, incidence of glans ischemia, severe bleeding rate, infection rate, pain level, total cost, and overall satisfaction) were collected and analyzed.ResultsA total of 624 patients were recruited for this study. There was no difference in the average age and body mass index between 2 groups. No patient suffered obvious glans ischemia. In group B, lower pain level, lower incidences of severe bleeding, and better satisfaction were recorded.ConclusionThe mechanism of bleeding with the DCSD was discussed in this study, and the modified pressure dressing was proved effective, safe, and easy to perform.W Jiang, J-li Fu, W-l Guo, et al. A Modified Pressure Dressing to Avoid Severe Bleeding After Circumcision With a Disposable Circumcision Suture Device and a Discussion on the Mechanism of Bleeding With the Disposable Circumcision Suture Device. Sex Med 2021;9:100288.

Hyperbaric Oxygen as Salvage Therapy for Neonates Suffering From Critical Ischemia of the Glans Penis After Circumcision

Ischemic complications of glans penis following circumcision are rare, and if occurs can culminate in irreversible necrosis with severe long-term consequences. Here we present 2 challenging cases of neonates suffering from acute severe glans penis ischemia after circumcision that were treated by hyperbaric oxygen treatment (HBOT). In addition to case presentations, the literature related to complications of circumcision and the physiological effects of HBOT are being reviewed. Based on the review and the case presented, we conclude that HBOT can be used as salvage treatment for circumcision induced glans ischemia as early as possible before full necrosis develops.

Surgical Technique for Complex Cases of Peyronie’s Disease With Implantation of Penile Prosthesis, Multiple Corporeal Incisions, and Grafting With Collagen Fleece

IntroductionPatients with Peyronie’s disease (PD) and erectile dysfunction (ED) concomitant with shortening or other malformations benefit from prosthesis implantation and penile lengthening procedures. AimTo evaluate the safety and efficacy of a multi-incisional technique with penile prosthesis implantation with multiple corporeal incisions and collagen grafting for the surgical management of complex cases of PD with ED and severe penile shortening. MethodsFrom February 2015–May 2018, 43 consecutive patients with complex PD were treated using this technique. Implantation of a penile prosthesis (malleable or inflatable [IPP]) together with multiple relaxing tunica albuginea incisions and grafting with a self-adhesive collagen-fibrin fleece (TachoSil, Baxter Healthcare) was performed in all patients by a single surgeon (J.I.M.S.). Main Outcome MeasurePenile length and curvature correction, operative time, and incidence of postoperative complications were recorded as outcome measures. Functional outcomes were measured with questionnaires (International Index of Erectile Function-5, Erection Hardness Score, modified Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire, PD Questionnaire) before and 3 and 6 months after surgery. ResultsWith a median follow-up of 21 months (range 10–31), mean postsurgical penile lengthening was 2.5 (range 1–5) cm, with an improvement in the Bother domain of the PD Questionnaire of 4.4 (range 2–5) points. The average operative time was 86.7 and 71.6 minutes for the IPP and malleable penile prosthesis procedure, respectively. No glans ischemia was recorded; however, 1 IPP infection and 1 delayed distal corporeal erosion were recorded. Hematoma or bruising was observed in 23.2% of patients. The modified Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire was completed by 39 (90.7%) patients. Overall, 89.7% would recommend this surgery. Patient satisfaction with straightness and length was 94.9% and 82.1%, respectively. Clinical ImplicationsThe described technique helps restoration of penile length and erectile function in patients with complex PD. Strengths & LimitationsThe strength of the study is that it offers a simple, easy-to-apply technique for surgeons to correct shortening and other malformations in patients with ED and complex PD. The study is limited by the small number of patients, the short follow-up period and the performance of the technique by a single high-volume implanter. ConclusionThe implantation of a penile prosthesis (malleable or inflatable) together with multiple incisions of the plaque/tunica albuginea and grafting with a collagen fleece is a safe and efficient treatment for patients with complex PD in addition to ED and significant shortening.Fernández-Pascual E, Gonzalez-García FJ, Rodríguez-Monsalve M, et al. Surgical Technique for Complex Cases of Peyronie’s Disease With Implantation of Penile Prosthesis, Multiple Corporeal Incisions, and Grafting With Collagen Fleece. J Sex Med 2019;16:323–332.

Vessel-sparing Excision and Primary Anastomosis.

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short bulbar or posterior urethral strictures, urethroplasty by excision and primary anastomosis (EPA) is recommended. As EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full-thickness transection of the corpus spongiosum, as performed in the traditional transecting EPA (tEPA), is usually unnecessary. Jordan et al. introduced the idea of a vessel-sparing approach in 2007, aiming to reduce surgical trauma, especially to the dual arterial blood supply of the urethra, and, thus, potentially reducing the risk of postoperative erectile dysfunction or glans ischemia. This approach could also be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking. Moreover, vessel-sparing EPA (vsEPA) should at least be able to provide similar surgical outcomes as tEPA. The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main objective of this manuscript is to outline the surgical technique and to report the representative surgical outcome. A total of 117 patients were managed according to the described protocol. The analysis was performed on the entire patient cohort and on the bulbar (n = 91) and posterior (n = 26) vsEPA group separately. Success rates were 93.4% and 88.5% for the bulbar and posterior vsEPA, respectively. To conclude, vsEPA, as outlined in the protocol, provides excellent success rates with low complication rates for isolated short bulbar and posterior urethral strictures.

Acute Post-Inflatable Penile Prosthesis Glans Ischemia: Review of Incidence, Pathophysiology, and Management Recommendations

Acute Post-Inflatable Penile Prosthesis Glans Ischemia: Review of Incidence, Pathophysiology, and Management Recommendations

Penile Prosthesis Complications: Planning, Prevention, and Decision Making.

Inflatable penile prosthesis (IPP) is an established treatment option for men with erectile dysfunction (ED) refractory to medical therapy. Standardization of surgical technique and improvements in device construction have reduced all-cause complication rates to less than 5% in recent reports. Nonetheless, complications do exist, and can strongly impact morbidity and the quality of life of patients. Prosthetic urologists must be aware of the constellation of complications that can arise during or after IPP placement. To provide a comprehensive review of penile prosthesis complications and discuss preventative strategies, as well as proper preoperative, intraoperative, and postoperative decision making. A review of the available literature from 1973 to 2018 was performed using PubMed with regard to IPP complications. We reviewed publications that outlined preoperative planning strategies and the following IPP complications: hematoma, floppy glans, corporal fibrosis, corporal perforation and crossover, urethral injury, infection, impending erosion, and glandular ischemia. Careful patient and device selection, setting realistic expectations of postsurgical outcomes, and adherence to a perioperative checklist is essential in the preoperative period. Intraoperatively, anticipate corporal fibrosis situations and always dilate laterally during corporal passage to reduce the risk of crossover and urethral injury. Limit perioperative antiplatelet therapy, apply compressive dressing, use a closed suction drain if indicated, and leave the device partially inflated postoperatively to reduce risk of hematoma. After surgery, monitor patients for potential complications that may warrant device explantation or salvage: IPP infection, glans ischemia, and impending erosion. By using evidence and expert opinion-based decision-making strategies in the preoperative, intraoperative, and postoperative period of IPP placement, surgeons can reduce the risk of complications and dissatisfaction, even in ED patients with multiple comorbid conditions. Scherzer ND, Dick B, Gabrielson AT, etal. Penile Prosthesis Complications: Planning, Prevention, and Decision Making. Sex Med Rev 2019;7:349-359.

130 Surgical Technique for Complex Cases of Peyronie’s Disease: Penile Prosthesis Implantation, Modified Neurovascular Bundle Release and Single or Multiple Corporeal Incisions and Grafting with Collagen Fleece

Surgery is the mainstay of treatment for Peyronie’s disease (PD), but multiple surgical approaches may be considered. We present specific surgical techniques for each individual case. We aim to demonstrate its safety and effectivity for penile curvature correction and restoring erectile dysfunction with limited complications. Data were collected from a prospective cohort of 23 consecutive patients treated in our institution with complex PD and ED, between February 2015 and May 2017. The surgical procedure consists of an implantation of penile prosthesis (malleable or inflatable) associated with single or multiple incisions of the plaque/tunica albuginea and grafting with a self-adhesive collagen fleece, and previously modified neurovascular bundle release. All patients provided informed consent and the protocol was approved by Institution Review Board (IRB). In the video attached, we described each technique, step by step. With a median follow-up of 15.3 months, the mean postsurgical penile lengthening was 2.7(1-5) cm, with an improvement of PDQ PD bother score of 4.3(2-5) points. No glans ischemia or infectious complications were recorded, but hematoma was observed in 26% patients, and the overall satisfaction was 92%.