A new, innovative, lengthening surgical procedure for Peyronie's disease by penile prosthesis implantation with double dorsal-ventral patch graft: the "sliding technique"

Penile prosthesis implantation: a bibliometric-based visualization study

The treatment of erectile dysfunction (ED) using penile prosthesis implantation (PPI) has recently garnered significant interest, but reports of bibliometric analyses of studies on PPI have yet to appear. Therefore, the purpose of this study is to use visualization techniques to statistically and qualitatively assess the state of knowledge, current research topics, and trends in this field. The Science Citation Index-Expanded (SCI-E) from the Web of Science Core Collection (WoSCC) was searched for publications about PPI from the inception of the database to 2023. VOSviewer (version 1.6.19), CiteSpace (version 6.2. R2), and Excel (version 2021) were used for the data analysis. The results show a total of 1015 original articles and reviews on PPI published over this nearly 50 years, with an increasing trend in the number of studies published each year. The United States is the country with the most published studies (n = 578). Mayo Clinic is the organization with the most publications overall (n = 46). The Journal of Sexual Medicine has the most publications (n = 184). The most prolific author is Wilson, Steven K (n = 31). The most commonly used terms were erectile dysfunction (n = 509), penile prosthesis (n = 332), implantation (n = 207), satisfaction (n = 201), surgery (n = 200), infection (n = 134), outcomes (n = 128), Peyronie's disease (n = 121), men (n = 115), and experience (n = 109). Current research focuses on four main areas: complications of PPI, the current status of inflatable penile prosthesis (IPP), the use of PPI in radical prostatectomy and Peyronie's disease populations, and patient satisfaction after PPI. Improving patient satisfaction with PPI through improved mechanical design and surgical techniques is a key concern for future research.

Cosmetic penile enhancement procedures: an SMSNA position statement

BACKGROUND

Penile cosmetic enhancement procedures have been performed for many years with varying success. However, they have historically been relegated to niche areas of sexual medicine, with limited data, and have not achieved mainstream adoption. More recently, the topic has been increasingly discussed within academic congresses due to availability of novel techniques, therapies, and procedures. Given their distinctive nature, the Sexual Medicine Society of North America (SMSNA) felt that it was pertinent to develop formal position statements to help guide both patients and sexual medicine providers on the current state of the scientific literature and to give recommendations for future research.

AIM

The study sought to provide an evidence-based set of recommendations for injection and surgical procedures designed to lengthen, augment, or otherwise cosmetically enhance the penis.

METHODS

A review was performed of all scientific literature listed in PubMed from inception through December 2023 relating to penile cosmetic enhancement procedures. Only invasive (injection/surgery) therapies were included due to their distinct risk-benefit profile compared with more conservative treatments (eg, vacuum erection devices, penile traction devices). Similar therapies were categorized, with pertinent data summarized and used to help create relevant position statements. All statements were expert opinion only and were based on analyses of the potential risks and benefits of the specific therapies.

OUTCOMES

A total of 6 position statements were issued relating to 5 distinct sexual medicine cosmetic enhancement procedures.

RESULTS

A consensus opinion was reached by SMSNA leadership on the state of injection/surgical penile cosmetic enhancement procedures as of 2024. Key topic areas addressed included injectable soft tissue fillers, suspensory ligament division, graft-and-flap procedures, silicone sleeve implants, and sliding/slicing techniques. Distinct recommendations were tailored to each therapy and were based solely on the current state of the literature. It is anticipated that future studies will further inform position statements and will lead to ongoing modifications.

CLINICAL IMPLICATIONS

The current position statements provide both patients and clinicians evidence-based, expert recommendations on best practices relating to penile cosmetic enhancement procedures.

STRENGTHS AND LIMITATIONS

Strengths include the use of an expert panel of sexual medicine clinicians, consensus design, and summary of existing literature. Limitations include expert opinion and limited research on the topic.

CONCLUSION

The current SMSNA position statements provide evidence-based, consensus opinions on the appropriate role for penile augmentation and cosmetic procedures in 2024.

Techniques for Penile Augmentation Surgery: A Systematic Review of Surgical Outcomes, Complications, and Quality of Life

The increase in practices related to enhancing penile size can be attributed to the belief that an improved genital appearance contributes to a man's virility, coupled with an altered self-perception of his body. It is crucial to tailor interventions to meet the genuine needs of patients by thoroughly assessing their history, psychological state, and potential surgical benefits, all while considering the associated risks of complications. This systematic review aims to summarize the available evidence on outcomes, complications, and quality of life after penile augmentation surgery, examining both minimally invasive and more radical techniques. A search of the PubMed and Scopus databases, focusing on English-language papers published in the last 15 years, was performed in December 2023. Papers discussing surgery in animal models and case reports were excluded from the present study unless further evaluated in a follow-up case series. The primary outcomes were changes in penile dimensions, specifically in terms of length and girth, as well as the incidence of surgical complications and the impact on quality of life. A total of 1670 articles were retrieved from the search and 46 were included for analysis. Procedures for penile length perceived enhancements include lipoplasty, skin reconstruction plasty, V-Y and Z plasty, flap reconstruction, scrotoplasty, ventral phalloplasty, and suspensory ligament release; techniques for increasing corporal penile length include penile disassembly, total phalloplasty, and sliding elongation. Finally, penile girth enhancement may be performed using soft tissue fillers, grafting procedures, biodegradable scaffolds, and Penuma®. In conclusion, while penile augmentation surgeries offer potential solutions for individuals concerned about genital size, the risks and complexities need to be accounted for.

The 100 most-cited publications on Peyronie's disease: a bibliometric analysis and visualization study

This study aimed to summarize the characteristics of the top 100 most-cited publications on Peyronie's disease (PD) research and to analyse past and current research hotspots and trends. The SCI-E database of the Web of Science Core Collection (WoSCC) provided us with the top 100 most-cited publications in PD research, from which we took the following information: general trend of publication, year of publication, nation/region, institution, journal, author, and keywords. VOSviewer (version 1.6.18) and Excel (version 2016) were used for information analysis. Through a standardized search, we ultimately found 1019 papers in the field of PD research, from which we extracted the 100 articles that had received the highest citations. The articles were published between 1949 and 2016. The United States is a major contributor to PD research (n = 67). The University of California, Los Angeles, was the institution with the largest number of articles (n = 11). These articles were published in 16 journals, with the largest number appearing in the Journal of Urology (n = 47). The author with the most articles was Levine LA (n = 9). Gelbard MK's articles had the highest citation frequency (n = 1158). Erectile dysfunction (n = 19) was the keyword with the highest frequency, indicating that PD-related erectile dysfunction was the leading focus of research in this field. Most of the keywords that have appeared in the past decade are related to the clinical treatment of PD. Therefore, we believe that improving patients' erectile function to the greatest extent in clinical treatment is the frontier and hot spot of future research.

Risk and benefits of penile length preservation techniques during penile prosthesis implantation: a systematic review by the young academic urologists sexual and reproductive health working group

Background

Penile shortening, frequently resulting from end-stage Peyronie's disease (PD), has a negative impact on patients' sexual activity and overall quality of life, especially when accompanied by Erectile dysfunction (ED). Various surgical techniques have been described to manage concomitant ED and penile shortening through penile prosthesis (PP) implantation.

Objectives

To evaluate the benefits and risks of different penile length preservation techniques during PP implantation.

Design

A systematic review of the available literature on the use of penile length preservation maneuvers in conjunction with PP implantation was conducted.

Data sources and methods

For this systematic review, three databases (Medline, Embase and Cochrane) and clinical trial.gov were queried for relevant publications from 1 January 1990 to 1 September 2022. The review process followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Results

The qualitative analysis included 15 relevant articles involving 1186 adult patients who underwent penile length preservation techniques during PP implantation. Penile lengthening of 1-7 cm was reported. Overall, postoperative complications were described in up to 21.7% of cases. Only five studies reported functional outcomes, showing a significant improvement in postoperative period based on the administered questionnaire (e.g. IIEF - International Index of Erectile Function, EDITS - Erectile Dysfunction Inventory of Treatment Satisfaction).

Conclusion

Penile length preservation procedures appear to offer a viable option for managing acquired penile shortening, particularly in cases of PD. However, they are associated with a significant risk of complications. Proper patient selection, thorough discussion of risks and benefits, and referral to high-volume centers are mandatory to achieve optimal outcomes and minimizing complications.

Trial registration

PROSPERO database registration CRD42022360758.

Surgical tips in difficult penile prosthetic surgery: a narrative review

Penile prosthesis implantation continues to represent a reliable solution to address erectile dysfunction when oral medications fail, are not tolerated or are contraindicated, and most typically is associated with excellent satisfaction rates and durable results. Despite the dramatic improvements in the prostheses' design, in the surgical instruments and techniques over the years, certain categories of patients still pose a significant surgical challenge. The aim of the current review is to provide a quick and useful practical guidance based on our expertise in the identification and management of the difficult penile prosthesis implantation cases. A narrative review design was here preferred to fulfil our purpose. The search strategy included a range of terms, e.g. penile prosthesis, corporal fibrosis, infection, ischaemic priapism, Peyronie's disease, radical prostatectomy, pelvic surgery. Extensive corporal fibrosis after explantation of an infected device or after prolonged ischaemic priapism may represent the most difficult situations to deal with in penile prosthesis implantation surgery. Penile prosthesis implantation in patients with Peyronie's disease and in those who previously underwent radical prostatectomy also presents with an increased risk of complications. Experienced surgeons need to be able to recognise promptly and manage urethral perforation, cylinder crossover, tunical perforation and erosion, as these complications are more common when dealing with difficult penile prosthesis implantation cases. Applying penile lengthening techniques and principles can be useful in selected cases to ensure better postoperative satisfaction rates, especially in those patients who have experienced a more significant degree of loss of length preoperatively. High-volume-implanting surgeons should always be involved in complex cases to minimise the risk of complications. A thorough preoperative counselling can set realistic patients' expectations in this context, further contributing to postoperative satisfaction.

European Association of Urology Guidelines on Penile Size Abnormalities and Dysmorphophobia: Summary of the 2023 Guidelines

CONTEXT

Recommendations regarding the management of penile size abnormalities and dysmorphophobia are important in guiding evidence-based clinical practice.

OBJECTIVE

To present a summary of the 2023 European Association of Urology sexual and reproductive health evidence-based recommendations for the management of penile size abnormalities and dysmorphophobia.

EVIDENCE ACQUISITION

A broad and comprehensive scoping exercise covering all areas of the guidelines was performed. Databases searched included Medline, EMBASE, and the Cochrane Libraries. A level of evidence and a strength of recommendation were assigned for each recommendation according to the evidence identified. The evidence cutoff date for the 2023 guidelines is June 1, 2022.

EVIDENCE SYNTHESIS

Well-structured studies reporting high level of evidence, with standardized PROMS were deficient on penile size abnormalities and dysmorphohobia. A shared definition for short penis/micropenis was also lacking. Categorisation of penile abnormalities according to congenital, acquired, and dysmorphophobic aetiology is deemed compulsory. A detailed medical and psychosexual history and precise measurements of penile size are essential in the diagnostic pathway. Patients with normal penile size who are seeking penile augmentation should be referred for psychological evaluation for potential dysmorphophobic disorders. Penile length and girth enhancements can be achieved via a multitude of treatments, but a personalised management plan is crucial for satisfactory results. Endocrinological therapies, when indicated, are effective in the prepubertal setting only. Vacuum therapy has a limited evidence base in treatment protocols, although acceptable outcomes have been reported for penile traction therapy. Surgical techniques to enhance penile length and girth have limited evidence and should only be proposed after extensive patient counselling.

CONCLUSIONS

Management of penile abnormalities and dysmorphophobia is a complex issue with considerable ethical concerns. The adoption of a structured diagnostic and therapeutic pathway is crucial, as recommended in the guidelines.

PATIENT SUMMARY

Requests for medical/surgical treatments to increase penis size have increased dramatically worldwide. Several conservative and surgical treatments are available. However, few patients receive clear information on the benefits and possible harms of these treatments. These guidelines aim to provide a structured path to guide both physicians and patients in the selection of appropriate treatment(s) to increase penis size.

The International Penile Prosthesis Implant Consensus Forum: clinical recommendations and surgical principles on the inflatable 3-piece penile prosthesis implant

Despite significant scientific advances in the modern three-piece inflatable penile prosthesis implant surgery, it is not without surgical risks and can carry additional cosmetic and psychosocial consequences in poorly selected and consented individuals. To address this problem, an international group of key opinion leaders and high-volume prosthetic surgeons reviewed the current guidelines and clinical evidence, discussed their experiences, and formed a consensus regarding inflatable penile prosthesis surgery. The findings of this consensus panel were presented at the 17th biennial Asia Pacific Society of Sexual Medicine scientific meeting. The experts concluded that proper patient selection, informed consent and strict adherence to safe surgical principles are important to optimize clinical outcomes. Furthermore, most intraoperative complications, if recognized, can be addressed intraoperatively to enable placement of the device at the time of initial surgery. Men with significant corporal fibrosis due to Peyronie's disease, prior prosthesis explantation and priapism, and men who have undergone construction of a neophallus, as well as men who receive concurrent continence surgery, are complex cases requiring additional care and advanced techniques to obtain optimal surgical outcomes. Variability in patient care - in terms of postoperative antibiotic use, pain management, scrotal care, and cycling of the penile prosthesis implant - must be reduced to enable optimization and assessment of outcomes across patient groups.

Multidisciplinary approach and management of patients who seek medical advice for penile size concerns: a narrative review

We aimed to provide an overview of the strategies available to manage patients concerned about their penile size and to provide useful surgical hints regarding the most common penile enlargement approaches, based on our surgical expertise in this field. A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning penile enlargement issues. The search strategy included a range of keywords; e.g. penis, penile, enlargement, augmentation, lengthening, girth. Management of penile size-related concerns represents a real challenge for the urologist, especially when dealing with patients suffering from penile dysmorphophobic disorder (PDD). A multidisciplinary preoperative assessment, including a psychiatric/psychological evaluation, may help in discerning those patients who would benefit the most from counselling/conservative management from those who would benefit from surgery instead. Conservative approaches include the use of vacuum-based and penile-stretching devices, which have shown encouraging levels of efficacy and safety. Over the last decades, different surgical strategies have been developed, aimed at either increasing flaccid penile length or improving penile girth. Penile lengthening procedures are more established, and satisfactory results can be achieved by experienced, large referrals' volume, surgeons. To date, there is lack of consensus regarding the penile girth enhancing techniques, and therefore these should be regarded as experimental. A multidisciplinary approach is necessary to identify patients with PDD, who should not be offered surgical intervention and should be referred for psychiatric/psychological counselling instead. The surgical approach should be tailored to the subject's unique anatomy and underlying conditions.

Male esthetic genital surgery: recommendations and gaps to be filled

The reason behind the spread of penis enlargement practices over time is rooted in the virility that the appearance of the genitals can give a man, as well as an altered perception of his own body. The approach should be to modulate the interventions on the real needs of patients, carefully evaluating the history, the psychological picture, and possible surgical advantages. The aim of this study was to shed light on cosmetic surgery of male genitalia through minimally invasive and more radical techniques, with the purpose of laying the foundation for possible indications and recommendations for the future. A non-systematic literature review using the PubMed and Scopus databases was conducted to retrieve papers written in English on cosmetic surgery of the penis published over the past 15 years. Papers discussing cosmetic surgery in patients with concomitant pathologies associated with sexual dysfunction were excluded. The main outcomes recorded were change in penile dimensions in term of length and girth and surgical complications.

Congenital Micropenis: Etiology And Management

In the newborn, penile length is determined by a number of androgen dependent and independent factors. The current literature suggests that there are interracial differences in stretched penile length in the newborn and although congenital micropenis should be defined as a stretched penile length of less than 2.5 SDS of the mean for the corresponding population and gestation, a pragmatic approach would be to evaluate all boys with a stretched penile length below 2 cm, as congenital micropenis can be a marker for a wide range of endocrine conditions. However, it remains unclear as to whether the state of micropenis, itself, is associated with any long-term consequences. There is a lack of systematic studies comparing the impact of different therapeutic options on long-term outcomes, in terms of genital appearance, quality of life, and sexual satisfaction. To date, research has been hampered by a small sample size and inclusion of a wide range of heterogeneous diagnoses; for these reasons, condition-specific outcomes have been difficult to compare between studies. Lastly, there is a need for a greater collaborative effort in collecting standardized data so that all real-world or experimental interventions performed at an early age can be studied systematically into adulthood.

ESSM Position Statement on Surgical Treatment of Peyronie's Disease

INTRODUCTION

Patients with Peyronie's disease may experience significat distress. The choice of treatment depends on a variety of factors, including the stage of the disease, the presence of pain, severity and direction of the curvature, penile length and the quality of erectile function.

AIM

To review the evidence associated with surgical treatment of Peyronie`s Disease and provide clinical recommendations on behalf of the European Society for Sexual Medicine. 131 peer-reviewed studies and systematic reviews, which were published from 2009 to 2019 in the English language, were included.

METHODS

MEDLINE, Google Scholar and EMBASE were searched for randomized clinical trials, meta-analyses, open-label prospective and retrospective studies.

MAIN OUTCOME MEASURE

The panel provided statements on clinically relevant questions including patient involvement in the decision process, indications for surgery, choice of the approach, and the management of patient expectations. A comparison of the different grafts used in patients who have undergone plaque incision/excision and grafting in order to identify an ideal graft, has been carried out. The prevalence of postoperative complications has been summarized. Levels of evidence were provided according to the Oxford 2011 criteria and Oxford Centre for Evidence-Based Medicine recommendations.

RESULTS

In order to allow shared decision making, a patient preoperative counselling regarding the pros and cons of each intervention is recommended. In particular, adverse effects of surgical treatments should be discussed to set realistic understanding and expectations of surgical outcomes and ultimately improve postoperative satisfaction rates. Surgical treatment should be only offered in the chronic phase of the condition, when the deformity and/or degree of erectile dysfunction, prevent patients from engaging in satisfying sexual interaction, or if the deformity is the cause of severe bother.

CONCLUSIONS

Current European Society for Sexual Medicine recommendations cover several aspects of Peyronie's disease treatment. These recommendations aim both to ensure patients and partners have accurate and realistic expectations of their treatment options, as well as to formulate algorithms to guide clinician management pathways. Osmonov D. et al., ESSM Position Statement on Surgical Treatment of Peyronie's Disease. Sex Med 2022;10:100459.

Use of grafting materials during penile prosthesis implantation in patients with Peyronie's disease-a systematic review

Severe Peyronie's disease (PD) and concomitant erectile dysfunction (ED) may require plaque incision/excision and grafting (PIG) as an adjunct to penile prosthesis implantation (IPP). Currently, there is no available consensus on the best graft material to use. Our aim was to systematically review graft materials used as patches following PIG + IPP. Literature search was performed in March 2021. Only original articles in English with a series of 10 or more patients were included. Overall, a total of 17 studies were included, corresponding to a cohort of 662 patients. The mean age ranged from 45 to 65 years and most patients had curvatures >45°. Average penile lengthening ranged from 1 to 3.5 cm, average residual curvatures from 0 to 20% and decreased glans sensitivity from 0 to 20%. Eighty to 100% of patients were satisfied with cosmetic and functional results. PIG + IPP with the use of various grafts offers promising results for the treatment of patients suffering from severe PD with concomitant ED. Unfortunately, the absence of high quality and comparative studies makes it difficult to establish the optimum graft. Therefore, the level of experience of the surgical team with one or more methods should guide their choice.

Penile implant surgery-managing complications

Penile prosthesis surgery represents the end-stage treatment for erectile dysfunction. It is conventionally used only in cases of erectile dysfunction refractory to pharmacological treatments or vacuum constriction devices. Contemporary literature suggests that penile prothesis surgery is associated with a high satisfaction rate and a low complication profile. However, it must be appreciated that the complications of surgery can have devastating consequences on a patient’s quality of life and satisfaction and include infection, prosthesis malfunction, penile corporal perforation and penile length loss. Several factors – such as appropriate patient selection, methodical preoperative assessment and patient optimization, specific intraoperative protocols and postoperative recommendations – can reduce the risk of surgical complications. This narrative review discusses the diagnosis and management of both intraoperative and postoperative complications of penile prosthesis surgery.

Penile Prosthesis Implantation Combined With Grafting Techniques in Patients With Peyronie's Disease and Erectile Dysfunction: A Systematic Review

INTRODUCTION

Penile prosthesis (PP) implantation combined with grafting techniques is indicated in patients with Peyronie's disease (PD) and erectile dysfunction (ED) nonresponsive to medical and conservative treatment that present with residual penile curvature greater than 30°, severe penile deformity or significant penile shortening.

OBJECTIVES

To address the preoperative evaluation, the surgical procedure and the functional outcomes of grafting techniques combined with PP implantation in patients with PD and concomitant ED and to provide future perspectives on the matter.

METHODS

We performed a systematic review of the literature based on the PRISMA statement (PROSPERO ID: CRD42021224517). Records were identified by searching Medline, Scopus, The Cochrane Library and Web of Science databases as well as sources of gray literature from inception to December 2020. The quality of all included records was assessed based on a modified version of the Newcastle-Ottawa Scale for cohort studies.

RESULTS

A total of 935 patients with a mean age of 59.6 ± 9.2 years from 23 studies were included in this systematic review. All studies reported excellent short- and long-term postoperative results, as well as high satisfaction rates ranging from 80 to 100%. A mean increase of 2.7 ± 1.4 cm in penile length was observed. Among different grafting materials and different types of PP, no significant differences in terms of preoperative, perioperative and postoperative functional outcomes or complications were demonstrated. Still, the operative time was shorter in studies applying the collagen fleece TachoSil.

CONCLUSIONS

PP implantation combined with grafting is a safe and highly effective surgical procedure in patients with PD and concomitant ED. All grafting materials provide similar beneficial outcomes, but TachoSil subsequently reduces the operative time and does not require suturing. Still, no definite conclusions can be drawn regarding the superiority of one grafting technique over the other, as randomized clinical trials are lacking. Sokolakis I, Pyrgidis N, Ziegelmann M, et al. Penile Prosthesis Implantation Combined With Grafting Techniques in Patients With Peyronie's Disease and Erectile Dysfunction: A Systematic Review. Sex Med Rev 2021;XX:XXX-XXX.

Penile shortening complaints in males with erectile dysfunction: a narrative review on penile lengthening procedures during penile prosthesis surgery

Patients complaining of short penile length pose a challenge in urology practice. Those men who present seeking penile lengthening surgery usually overestimate 'normal' penile length, and may in often cases relate their penile length with the degree of masculinity and self-esteem. Penile prosthetic devices are the gold standard treatment of erectile dysfunction (ED) after failure of conservative options. Penile shortening is the most prevalent long-term complaint after successful inflatable penile prosthesis (IPP) placement. This has a significant impact on patient’s overall satisfaction and quality of life. Using PubMed, we performed a thorough literature review of the current procedures of preservation or enhancement of penile length as well as reported perioperative protocols in patients undergoing penile prosthesis (PP) insertion. Keywords used were “penile lengthening”, “penile enhancement”, “penile girth”, “inflatable penile prosthesis” and “glans augmentation”. Several surgical techniques can be offered in the setting of penile shortening concurrently with PP insertion, e.g., sub-coronal approach of PP placement, sliding technique, modified sliding technique (MoST), multiple-slide technique (MuST), and tunica mesh expansion procedure (TMEP). Adjuvant techniques can also improve subjective penile length include, ventral phalloplasty, suprapubic lipectomy, suspensory ligament release and use of expanding penile implants. Preoperative protocols including use of a vacuum erectile device, traction therapy also seem to improve postoperative outcomes, minimizing postoperative pain, and encouraging the early device use. Currently, there is no consensus among experts on a particular lengthening procedure or when they can be performed to optimize outcomes. Furthermore, it is imperative to set proper expectations before surgery, with extensive patient and partner counseling. When used in the properly selected patient, penile lengthening procedures show promising results with minimal complication rates.

A comprehensive narrative review of residual curvature correction during penile prosthesis implantation in patients with severe erectile dysfunction and concomitant Peyronie's disease

Residual curvature correction during penile prosthesis implantation (PPI) is usually needed in patients with severe erectile dysfunction (ED) and concomitant Peyronie’s disease (PD). The aim of the study was to assess the different existing techniques for treating residual penile curvature during PPI in patients with severe PD and ED. We generated a comprehensive narrative review of the literature until August 2020 on the use of PPI in combination with straightening reconstruction techniques, in treating patients with severe PD and ED. We included studies published in English, assessing the PPI as primary intervention in patients with PD and ED. Secondary research studies and studies with insufficient data were excluded from final analyses. We included a total of 33 clinical articles with 1,612 patients that assessed the effects of PPI combined with straightening surgical techniques for the treatment of severe PD and ED. Based on the severity of penile curvature, the concomitance of additional penile deformities (i.e., hourglass deformity), the penile length, the presence of previous penile operations and the surgeon’s experience, four main categories of surgical techniques were identified: (I) PPI with plication of the penis on the convex side of the curvature, (II) transcorporeal plaque incision/excision, (III) PPI with plaque/tunical incision(s) on the concave side of the curvature and (IV) PPI with plaque incision/excision plus grafting. Patients with severe PD and ED can expect excellent outcomes with PPI and surgical correction of residual penile curvature and minimal side effects. Overall, all the above techniques seem to able to correct the residual penile curvature during prosthesis implantation. Grafting techniques seem to be favorable in patients with additional severe penile shortening. Still, no definite conclusions can be drawn regarding the superiority of one technique over the other.

The evolution in the surgical management of Peyronie's disease

Peyronie's disease (PD) is due to a fibrotic alteration of the tunica albuginea of the penis. It is responsible of penile pain, angulation, and possible erectile dysfunction (ED). Despite almost three centuries have passed since the first description of the disease, etiology still remains uncertain. This fact has led to the lack of a truly effective medical therapy and to date the surgical treatment, although not yet standardized, is the only one that offers acceptable outcomes in terms of function and overall patient's satisfaction. Since the beginning of the surgical experience in this field, two different currents of thought have developed: the first, involved the proposal of a number of different plication techniques, applied on the healthy side of the penis, opposite to the sick side, with the sole purpose of correcting the curvature; on the other side, efforts have focused on treating the "focus" of the disease, thus developing the so called "plaque surgery." If with the passing of the decades neither of the two "philosophical" currents has prevailed, this probably depends on the fact that is still not clear which is the lesser of evils: the frequent onset of ED which may follows the plaque surgery or rather the penis shortening that inevitably occurs if any technique of plication has been applied. Our contribution aims to offer an historical retrospective of the surgical treatment of this disease as well as to discuss the latest international guidelines on this topic. The reader will also find some notes about our personal experience in this field.

A Review on Penile Length and Girth Issues in Penile Prosthetic Surgery

PURPOSE OF REVIEW

The goal of this paper is to understand the reasons behind penile length and girth issues after penile prosthesis surgery and review the literature for current strategies employed to decrease these issues.

RECENT FINDINGS

Measurement inconsistencies triggering further studies have shown there is a real loss of penile length and girth after prosthesis surgery. There have been varying hypotheses of why this happens, and numerous approaches have been proposed to help combat this in the preoperative, intraoperative, and postoperative settings. Erectile dysfunction prevalence is expected to increase; therefore it is important for urologists to understand the treatment options, including prosthesis surgery. Numerous techniques have been hypothesized and studied in smaller settings in the preoperative, intraoperative, and postoperative settings with regard to prosthetics surgery. However, larger studies are still needed to confirm these findings in order to help to counsel and educate patients preoperatively in addition to employing tactics to help minimize penile shortening.

Management of residual penile curvature after penile prosthesis placement

Residual penile curvature is a common situation following the implantation of a penile prosthesis in patients with Peyronie's disease. Currently, there is a variety of options for the correction of residual curvature, including penile modeling, plication techniques, as well as tunical incision/excision with or without grafting. A literature search of PubMed and Medline databases was conducted from 1964 until 2020, using search terms for all articles in the English language. In this article, we provide a review of the techniques and the outcomes, according to the published literature.

Evolution of techniques for aesthetic penile enlargement during prosthesis placement: a chronicle of the Egydio non-grafting strategy

Since penile prostheses only provide axial rigidity, correction of penile deformity and enlargement of the visible penis during implant surgery may be desired. Evolving techniques of tunica expansion have made it possible to avoid grafting and preservation of the cylindrical appearance without bulges and indentations. After two decades of devising individualized solutions for patients and continuous enhancements of existing surgical solutions, Dr. Paulo Egydio has arrived at his Tunica Expansion Procedure (TEP). This strategy is his newest iteration of a lengthening techniques without grafting accompanied by penile prosthesis implantation. The TEP Strategy permits surgeons to use their own intuitive reasoning to determine the best pattern of multiple, small, staggered incisions to promote length and girth enlargement.

Modern treatment strategies for penile prosthetics in Peyronie's disease: a contemporary clinical review

Peyronie's disease is a common condition resulting in penile deformity, psychological bother, and sexual dysfunction. Erectile dysfunction is one common comorbid condition seen in men with Peyronie's disease, and its presence significantly impacts treatment considerations. In a man with Peyronie's disease and significant erectile dysfunction who desires the most reliable treatment, penile prosthesis placement should be strongly considered. In some instances, such as those patients with relatively mild curvature, prosthesis placement alone may result in adequate straightening. However, many patients will require additional straightening maneuvers such as manual modeling, penile plication, and tunica albuginea incision with or without grafting. For patients with severe penile shortening, penile length restoration techniques may also be considered. Herein, we provide a comprehensive clinical review of penile prosthesis placement in men with Peyronie's disease. Specifically, we discuss preoperative indications, intraoperative considerations, adjunctive straightening maneuvers, and postoperative outcomes.

Risk profiling in patients undergoing penile prosthesis implantation

Penile prosthesis implantation is the gold standard of surgical therapy for patients with medication-refractory erectile dysfunction. However, this umbrella definition includes significant heterogeneity and associated risk profiles that should be candidly discussed and addressed perioperatively. Factors associated with operative success and patient satisfaction are often surgery specific; however, risk profiling via patient selection, preoperative optimization, proper device selection, and intraoperative consideration are highly correlated. Some examples of common risk profiles include comorbidity(ies) such as cardiovascular disease, diabetes mellitus, prior abdominal surgery, Peyronie's disease, and psychological risk factors. Similarly, integration of surgeon- and patient-amenable characteristics is key to decreasing risk of infection, complication, and need for revision. Finally, patient risk profiling provides a unique context for proper device selection and evidence-based intraoperative considerations.

Intraoperative methods for residual curvature correction during penile prosthesis implantation in patients with Peyronie's disease and refractory erectile dysfunction

Peyronie's disease, or fibrous transformations of the tunica albuginea of the corpora cavernosa that cause penile curvature, is estimated to affect 3.2-8.9% of the male population. Treatment options for PD are based on the severity of the penile deformity and erectile function; of which surgical options include manual modeling during penile prosthesis implantation, plication, plaque incision, and grafting. Multiple approaches may be employed; each with its own advantages, limitations, and risk/benefit ratios. In this regard, we sought to review and highlight the current approaches for the management of residual curvature, optimal patient selection, and preoperative planning.

Strategies and current practices for penile lengthening in severe Peyronie's disease cases: a systematic review

Several strategies to optimize penile length in the presence of Peyronie's Disease (PD) have been described so far. In case of severe curvature and preserved erectile function, plaque incision/excision (PIG/PEG) are advisable in order to maximize penile length, despite the risk of postoperative erectile dysfunction (ED), recurrent curvature, or penile shortening. For men with PD deformities associated to a certain degree of ED several lengthening techniques associated to penile prosthesis (PPI) implantation can be considered. Because of the potential postoperative complications, the indication must be balanced between patient's risk factors and surgeon's experience. Furthermore, adjuvant surgeries, such as prepubic V-Y plasty, suspensory ligament release, suprapubic lipectomy, and ventral phalloplasty, can be performed simultaneously or in a staged fashion to maximize the outcomes. Restoration a decent penile length in the case of a severe PD represents a real challenge for reconstructive surgeons. We present a systematic review of the literature on the current practices for penile lengthening in severe PD, providing the reader with a practical overview on the existing surgical strategies and their surgical and functional outcomes.

Nondegloving technique for Peyronie's disease with penile prosthesis implantation and double dorsal-ventral patch graft

A circumcising incision to deglove the penis for penile prosthesis (PP) implantation can increase the risk of ischemic injury to the glans penis. In order to avoid vascular complications, we describe a novel technique utilizing a ventral incision to perform the PP implantation and a double-dorsal patch graft, or “sliding technique” (ST), in patients with severe Peyronie's disease (PD). Three patients with severe PD and erectile dysfunction at our institution underwent ST and PP implantation through a ventral incision. This new approach was not only successful in facilitating the ST and PP implantation in these patients but also allowed for adequate exposure of the penile shaft with no reported loss of sensation. We also conducted a review of current literature regarding the approaches for PD. While ischemic complications of PP implantation and ST are rare, there are reports of ischemic injury in patients undergoing a circumcising incision. The combination of a circumcising incision and a patient's underlying peripheral artery disease potentially raises a patient's risk of this rare complication. Our innovative ventral incision provides an alternative method for PP implantation and ST in order to avoid ischemia of the penis, while still allowing for adequate exposure.

[Adjuvant surgical maneuvers in penile prostheses implant to improve their aesthetic and functional outcomes]

Penile prosthetic surgery is the definitive treatment for those patients with erectile dysfunction refractory to medical treatment. Although it associates satisfaction rates>90%, it is known that men with Peyronie's disease, body mass index>30kg/m² or those previously operated on radical prostatectomy have lower satisfaction rates than the general population. The main reasons for dissatisfaction are the subjective loss of penile length and glans' flaccidity. Given such circumstance, several adjuvant surgical techniques have been described to improve aesthetic and functional outcomes after the implant. In our review, we wanted to investigate the different maneuvers used in patients with Peyronie's disease, those used to avoid the reduction of penile length and those used to avoid the floppy glans syndrome.

Recent advancements in penile prosthetics

Since the original inflatable penile prosthesis in the 1970s, several enhancements to penile prosthesis implant design, implant surgical technique, and post-operative care have been developed to increase overall patient (and partner) satisfaction rates. We, in this communication, seek to discuss these advancements and the overall impact in combating erectile dysfunction. As we continue to pursue avenues of effective and definitive treatment modalities for erectile dysfunction refractory to medical therapy, rates of infection and mechanical failure will hopefully continue to decline in the perioperative setting.

Additional procedures performed at time of penile prosthesis implantation: a review of current literature

Penile prosthesis implantation for treatment of medical refractory erectile dysfunction remains the gold standard. However, some men have additional pathology present such as Peyronie's Disease, penile shortening, penoscrotal webbing, buried penis or other penoscrotal anatomical abnormalities that may be addressed at the time of prosthesis implantation. Although several techniques are described, there remains a lack of data regarding the outcomes. We sought to identify the results of available literature regarding the additional procedures performed at the time of penile prosthesis implantation that provide defined surgical outcomes rather than merely describe surgical techniques. Surgical outcomes to procedures provide more realistic clinical outcome for readers than simply the description of novel techniques or expert opinions. We performed a review of the MEDLINE database to identify additional procedures performed in conjunction with penile prosthesis placement. Many procedures are described in review articles, however, with limited data regarding their outcomes. The included articles must describe additional procedures performed in conjunction with penile prosthesis placement. Perioperative office techniques and management were included if it changed the surgical technique. All abstracts obtained through search criteria were reviewed. Only articles written in English, on human subjects with documented surgical results and relevant articles were included in this study. After a thorough literature search, a total of 24 articles were identified. Penile lengthening procedures at the time of penile prosthesis comprise most of the literature on this subject. Lengthening procedures are as simple as Peyronie's plaque excision and grafting to complex sliding and lengthening procedures requiring complete neurovascular bundle and partial urethral mobilization. Additionally, aggressive cylinder sizing and prolonged postoperative cycling at home are also described. Glanulopexy may be necessary when malpositioning of the glans is present. Other options such as scrotoplasty are also available options for those patients with scrotal webs. Notably there is a paucity of published literature regarding girth enhancement, buried penis repair, hernia repair, and vasectomy at time of penile prosthesis placement. There are numerous procedures that can be performed in the same operative setting as penile prosthesis. Although the procedures do have a common goal to provide optimal postoperative natural appearance, length, straightness, girth and function, the techniques employed must be tailored to each patient as there is not a one-procedure fits all in this patient population.

Penile Reconstructive Surgery in Peyronie Disease: Challenges in Restoring Normal Penis Size, Shape, and Function

To provide an overview of current approaches to penile reconstructive surgery in Peyronie disease (PD), and to discuss the challenges in restoring normal penile size and function. A systematic literature search was conducted to identify the published literature relevant to PD and penile reconstructive surgery. A summary of the published guidelines from major organisations is included in this review paper. Penile plication is simple and minimally invasive, and tends to preserve potency in most patients. However, plication invariably results in penile length loss and may, in fact, worsen the existing hour-glass or hinge effect. In contrast, graft reconstructive surgery can address issues relating to the loss of penile length and complex penile deformities, but long-term data highlight the risks of altered glans sensation, recurrent curvature, and/or loss of penile length from graft contracture, as well as the development of erectile dysfunction. Complex penile reconstruction with the concurrent placement of a penile prosthesis and/or graft material is a demanding operation that should be performed by surgeons with extensive prosthetic and reconstructive experience, as the risk of sensory loss, glans ischemia/necrosis, prosthesis-related complications, and failure to gain any meaningful length are serious concerns and cannot be underestimated. While surgical approaches remain the standard of care, they pose considerable risks and require prolonged postoperative rehabilitation. Obtaining proper informed consent and establishing realistic outcome expectations are imperative for successful postoperative outcomes.

Glans Necrosis Following Penile Prosthesis Implantation: Prevention and Treatment Suggestions

OBJECTIVE

To examine possible etiology and treatment outcomes in 21 patients with glans necrosis following penile prosthesis implantation.

METHODS

Glans necrosis typically presented with a dusky glans on the first postoperative day following prosthesis implantation.

RESULTS

The blood supply to the glans penis consists of the dorsal arteries and the terminal branches of the spongiosal arteries. Using the cohort in our study, we compiled preoperative comorbidities and adjunctive surgical maneuvers that might compromise glans vascularity, leading to glans necrosis. Preoperative risk factors were arteriosclerotic cardiovascular disease (90%), diabetes mellitus (81%), smoking (81%), previous prosthesis explantation (57%), and previous radiation therapy (48%). The most prevalent intraoperative and postoperative factor was subcoronal incision for reasons as simple as coincident circumcision or as complex as for penile degloving (86%). Other factors detected were penile wrapping with an occlusive elastic bandage (62%), use of a sliding technique for penile lengthening (33%), and coincident distal urethral injury repair (29%). Seventeen patients (81%) managed expectantly with preservation of implanted prosthesis sustained significant glandular loss. Four patients managed with immediate prosthesis removal healed without sequelae.

CONCLUSION

Patients with preoperative risk factors undergoing penile prosthesis implantation should avoid high-risk adjunctive surgical maneuvers. Upon development of signs of glans necrosis postoperatively, in the setting of these high-risk factors, immediate implant removal may prevent subsequent glans necrosis.

A review of penile elongation surgery

Penile elongation surgery is less commonly performed in the public sector, but involves a collaborative approach between urology and plastic surgery. Congenital and acquired micropenis are the classic surgical indications for penile elongation surgery. The goal of intervention in these patients is to restore a functional penis size in order to allow normal standing micturition, enable satisfying sexual intercourse and improve patient quality of life. Many men seeking elongation actually have normal length penises, but perceive themselves to be small, a psychologic condition termed 'penile dysmorphophobia'. This paper will review the anatomy and embryology of congenital micropenis and discuss both conservative and surgical management options for men seeking penile elongation therapy.

Lengthening strategies for Peyronie's disease

Loss of penile length is a common complaint of men with Peyronie's disease (PD), both before and after corrective intervention, which has a significant negative effect on patient quality of life. We sought to identify and describe the methods by which penile length can be preserved or increased. We conducted an extensive, systematic literature review, based on a search of the PUBMED database for articles published between 1990 and 2015. Articles with the key words "Peyronie's disease", "penile length" and/or "penile lengthening" were reviewed if they contained subjective or objective penile length outcomes. Only English-language articles that were related to PD and penile size were included. We found no evidence in the literature that medical therapy alone increases penile length. Classic inflatable penile prosthesis (IPP) placement, plication procedures, and the Nesbit procedure appear likely to maintain or decrease penile length. Plaque incision (PI) and grafting appears likely to maintain or increase penile length, but is complicated by risk of post-operative erectile dysfunction (ED). There are several surgical procedures performed concomitantly with IPP placement that may be suitable treatment options for men with comorbid ED, and consistently increase penile length with otherwise good outcomes concerning sexual function. These include the subcoronal penile prosthesis (scIPP), Egydio circumferential technique, the sliding technique, the modified sliding technique (MoST), and the multiple slice technique (MuST). In addition, adjuvant therapies such as penile traction therapy (PTT), post-operative inflation protocols, suspensory ligament relaxation, lipectomy, and adjuvant medical therapy for glans engorgement appear to increase subjective and/or objective penile length for men at high risk of decreased penile length after PD surgery. Considering the psychological burden of length loss in men with PD, providers with adequate volume and expertise should attempt, if possible, to maintain or increase penile length for men undergoing surgical intervention. There are several evidence-based, safe, and effective ways to increase penile length for these men and multiple emerging adjuvant therapies that may help ensure adequate length.

A review of surgical strategies for penile prosthesis implantation in patients with Peyronie's disease

The introduction of the inflatable penile prosthesis (IPP) has revolutionized the treatment of patients with both Peyronie's disease (PD) and erectile dysfunction (ED). A thorough literature review was performed in order to review the surgical strategies used to treat PD, using the PubMed online database with the keywords "penile prosthesis", "surgical management" and "Peyronie's disease". Patient satisfaction rates of 72-100% and partner satisfaction rates of 89% have been reported in the literature, although strong preoperative education may be needed to prepare patients for risks such as penile shortening, seen in up to 54% of patients. Three-piece IPPs are most commonly used, and when comparing the two most popular models (AMS 700 CX vs. Coloplast Titan), no significant differences were seen in functional outcomes or patient satisfaction. Simple insertion of an IPP has been shown to resolve curvature in 33-90% of patients, but surgeons may often need to also utilize ancillary straightening procedures for residual curvatures. Manual modeling can correct residual curvature with an 86-100% success rate, but with a 4% risk of urethral injury. When the post-modeling residual curvature exceeds 30 degrees, a plaque-releasing incision or plication is recommended to further reduce curvature. Grafting is recommended if the resulting incisional defect is larger than two centimeters. Alternative straightening techniques such as plication prior to IPP insertion, endoscopic plaque resection, the "scratch technique" and bone saw plaque incision have also been described.

A review of the epidemiology and treatment of Peyronie's disease

Introduction

Peyronie’s disease (PD) has significant effect on patients and their partners. We provide a current review of the epidemiology as well as the nonsurgical and surgical treatment of PD.

Materials and methods

Review of literature pertaining to PD with focus on epidemiology and treatment options.

Conclusion

PD is common and likely underreported. The availability of new and highly effective treatment options will catalyze patient awareness and subsequently the prevalence of disease.

Penile curvature: an update for management from 20 years experience in a high volume centre

Our aim was to review the literature and discuss about penile curvature in order to have an update for management after 20 years experience in the field.Penile curvature may be congenital or acquired. Congenital penile curvature is a relatively uncommon condition that may present in late adolescent or early adult life. The incidence is estimated to be 0.6 %. On the other side, acquired penile curvature has an overall prevalence of 0.5-13%. Three main factors seem to increase the risk of developing an acquired penile curvature, often related to Peyronie's disease: penile traumatism, genetic and familiar conditions and a history of diseases of the genital tract. In treating Peyronie's disease, no medical therapy is fully effective, and surgery remains the gold standard in cases of severe deformity and/or erectile disfunction. Peyronie's disease is associated with significant psychological stress for patients and their partners. Appropriate treatment should be individualized and tailored to the patient's goals and expectations. There is not the 'best' surgical technique and outcomes are satisfactory when proper treatment decisions are made.

Peyronie's disease: What's around the bend?

INTRODUCTION

Peyronie's disease (PD) is a fibrotic diathesis of the tunica albuginea that results in penile plaque formation and penile deformity, negatively affecting sexual and psychosocial function of both patients and their partners. In this review, we discuss the PD literature and PD treatment options, with special emphasis on potential future therapies.

METHODS

The PD literature was reviewed, and articles of interest were identified using keyword search in PubMed. Articles evaluating investigational and novel PD treatments were emphasized.

RESULTS

Existing PD treatment modalities are diverse and include oral, topical, intralesional, mechanical, and surgical therapies. Surgical treatment has high success rates and is indicated in men with significant, stable deformity. The United States Food and Drug Administration-approved intralesional collagenase Clostridium histolyticum injection therapy is a minimally invasive option with demonstrated efficacy in PD. Other nonsurgical therapies have been reported, including Botox and stem cell therapy, but these currently have little or equivocal evidence to support their efficacy.

CONCLUSIONS

Further research is essential to develop novel, safe, and effective minimally invasive PD treatment options. This work is ongoing, with the promise of specific, targeted, and highly effective therapies on the horizon.

A prospective multicentric international study on the surgical outcomes and patients' satisfaction rates of the 'sliding' technique for end-stage Peyronie's disease with severe shortening of the penis and erectile dysfunction

OBJECTIVES

To report the results from a prospective multicentric study of patients with Peyronie's disease (PD) treated with the 'sliding' technique (ST).

PATIENTS AND METHODS

From June 2010 to January 2014, 28 consecutive patients affected by stable PD with severe penile shortening and end-stage erectile dysfunction (ED) were enrolled in three European PD tertiary referral centres. The validated International Index of Erectile Function (IIEF) questionnaire, the Sexual Encounter Profile (SEP) Questions 2 and 3, and the Peyronie's disease questionnaire (PDQ) were completed preoperatively by all patients. At the follow-up visits (at 3, 6 and 12 months), the IIEF, the SEP Questions 2 and 3, the PDQ, and the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) were completed. The outcome analysis was focused on penile length restoration, and intra- and postoperative complications classified according the Clavien-Dindo Classification.

RESULTS

The mean (range) follow-up was 37 (9-60) months. A malleable penile prosthesis (PP) was implanted in seven patients, while an inflatable three-pieces PP was placed in the remainder. In the case of inflatable PP implantation, porcine small intestinal submucosa and acellular porcine dermal matrix were used to cover the tunical defects. While in patients undergoing malleable PP implantation, collagen-fibrin sponge was used. The mean operative time was 145 min in the inflatable PP group and 115 min in the malleable PP group. There were no intraoperative complications. Postoperative complications included profuse bleeding requiring a blood transfusion in one patient (3.5%) on anticoagulation therapy for a mechanical heart valve (Grade II) and PP infection requiring the removal of the device (7%) (Grade III). There were no late recurrences of the shaft deformation. The postoperative functional data showed a progressive improvement in the score of all questionnaires, peaking at 12 months postoperatively. The mean (range) penile lengthening was 3.2 (2.5-4) cm and no patient reported recurrence of the curvature.

CONCLUSIONS

The present series suggests that, in the hands of experienced high-volume surgeons, penile length restoration with the use of the ST represents an effective option for end-stage PD associated with ED and severe shortening of the shaft. Larger series and longer follow-up will be required to fully establish the efficacy of this procedure.

A practical overview of considerations for penile prosthesis placement

Penile prostheses have remained the gold-standard therapy for medically refractory erectile dysfunction (ED) since their popularization. Advances in device design and surgical techniques have yielded improved rates of infection, satisfaction, and mechanical survival of devices. Operative techniques in penile prosthesis surgery include the use of adjunctive procedures (such as ventral phalloplasty and release of the suspensory ligament), management of penile fibrosis, and manoeuvres to correct Peyronie's-disease-related curvature. Complications include urethral and corporal perforation, crossover, infection, impending erosion, and/or supersonic transporter deformity. Long-term data regarding mechanical, overall, and infection-free survival demonstrate excellent results, and, given the consistently high satisfaction rates and limited alternatives for medically refractory ED, penile prostheses are likely to remain a relevant and important treatment strategy for the foreseeable future.

Strategies for penile prosthesis placement in Peyronie's disease and corporal fibrosis

Peyronie's disease (PD) is a wound healing disorder of the tunica albuginea of the penis. PD is generally categorized into two phases: the early acute inflammatory and late chronic fibrotic. Surgical reconstruction is only recommended during the latter established phase. There are a variety of options when erections are functional. However, when erectile dysfunction is present, the gold standard treatment is the placement of an inflatable penile prosthesis with or without additional straightening procedures. General recommendations include that after implanting and inflating the cylinders, if a clinically significant curvature is present, manual modeling is performed. If a residual curve >30° remains after modeling, then various techniques, including plaque releasing incision, is the next step. Grafting can be considered if tunical defects are >2.0 cm. Causes of corporal fibrosis include complications from an infected implant such as explantation, priapism, penile trauma, and prolonged use of an intracavernosal injection agent. Implant placement in the setting of corporal fibrosis can be technically challenging. Available strategies include incision or excision of the scar, corporotomies with or without grafting, the use of cavernotomes, or other specialized dilators, implant downsizing, and transcorporeal resection.