Reconstructive Technique for Partial Penile Amputation

Partial or total penile amputation with resection of the corpora cavernosa and the urethra is a common and effective surgical procedure used to treat squamous cell cancer infiltrating the deep tissues of the penis. We describe an original method that allows for an aesthetic and functional restoration of the partially or total amputated penis.

Surgical technique

We performe a reconstructive technique for partial penile amputation by releasing the scarring tissue adhesions with cavernosal lysis and by advancing the penile stump with dissection of the suspensory ligament; implantation of soft but axially firm endocavernosal elastomer prostheses to maintain the corpora cavernosa extended; placement of split-thickness skin grafts to cover the shaft skin defects and glanduloplasty with oral mucosa grafting. In cases of total penile amputation, the method begins with the reconstruction of a new phallus using a rectoabdominalis flap; the new penis is then covered with split-thickness skin grafts and finally, at a later date, soft but axially firm endocavernosal elastomer prostheses are implanted.

Results

The success rate as be excellent compared with other complex reconstructive and remodelling procedures for the penis and the glans after partial or total penectomy described by several authors.

Conclusions

In cases of total or subtotal penile amputation, the use of our techniques provides satisfactory aesthetic and functional results, thus we consider it to be a simple solution since it is not too invasive, it is quick and can be carried out by urologists without recourse to sophisticated microsurgery techniques.

Oxygenation Status of the Cavernosal Tissue after the Direct Action of the Vacuum Device

This study aims at comparing the oxygenation status of the cavernosal tissue after the direct action of the Vacuum device (VD) preceded or not by administration of Sildenafil. Patients and methods. We enrolled thirty patients who had undergone perineal radical prostatectomy. After four weeks from surgery we evaluated oxygen pressure (pO2), carbon dioxide pressure (pCO2) and O2 saturation in cavernosal blood. The pts were divided in 2 groups: 15 pts used only Vacuum device (first group), while the other 15 took Sildenafil 50 mg one hour before the exercise with VD (second group) for approximately 30 minutes without constriction band. Cavernous blood gas analyses pre- e post-exercising with the VD were repeated at the end of the complete 3-month rehabilitation program. The data obtained were processed by statistical analysis using the Student t test.

Results

During flaccidity at baseline, average levels of pO2, pCO2 and O2% saturation rates were respectively 30.07+/-2.91, 39.60+/-6.47, and 65.93+/-2.15 in the first group and 31.20+/-8.1, 42.64+/-7.64 and 52.87+/-8.95 in the second group. Mean values of pO2 rates increased after both treatments with higher oxygenation levels in the second group. At the end of the study pO2 and O2 saturation levels in the second group were found to be 68.5+/-6.87 (p>0.05) and 92.8+/- 2.66 (n.s.) versus levels of 63.8+/- 4.61 and 91.6+/-2.79 in the first group. No significant variations were found in partial CO2 pressure between the two groups (38.13+/-3.52 vs 38. 13+/-6.62).

Conclusions

In patients presenting with ED after radical prostatectomy, treatment with exercising of erectile tissue by means of an intermittent Vacuum device without constriction band can locally improve oxygenation levels. The addition of Sildenafil offers a further increase of oxygenation levels in the cavernosal tissue.

Nephron Sparing Surgery with the Ultrasonic Scalpel

Surgical resection remains the cornerstone of treatment renal cell carcinoma. In the last 15 years a better understanding of tumor biology and the early diagnosis permitted an evolution of the surgical treatment towards a minimal invasive approach by nephron-sparing surgery. Together with absolute and relative indications, nephron-sparing surgery is performed also as an elective indication, in patients with small, localized, often incidental tumors and a normal controlateral kidney. The oncological outcome in these cases is identical with that of radical nephrectomy. In order to achieve a complete tumor resection with the maximal preservation of unaffected renal parenchyma, tumor enucleation is the best technique when feasible. With the use of the harmonic scalpel, clamping of the renal pedicle and renal ischemia can be avoided in most of the cases during enucleation of small tumors, while the thermal damage in the remaing renal parenchyma is minimal.

A new technique for augmentation phalloplasty: albugineal surgery with bilateral saphenous grafts--three years of experience

OBJECTIVES

Penile augmentation surgery is a highly controversial issue due to the low level of standardisation of surgical techniques. The aim of the study is to illustrate a new technique to solve the problem of enlarging the penis by means of additive surgery on the albuginea of the corpora cavernosa, guaranteeing a real increase in size of the erect penis.

METHODS

Between 1995 and 1997, 39 patients who requested an increase in the diameter of their penises underwent augmentation phalloplasty with bilateral saphena grafts. The patients considered eligible for surgery were patients with either hypoplasia of the penis or functional penile dysmorphophobia. All the patients included in our study presented normal erection at screening. The average penis diameter in a flaccid state and during erection was found to be 2.1cm (1.6-2.7 cm) and 2.9 cm (2.2-3.7 cm), respectively. Before surgery the patients were informed of the experimental nature of the surgical procedure. The increase in volume of the corpora cavernosa was achieved by applying saphena grafts to longitudinal openings made bilaterally in the albuginea along the whole length of the penis.

RESULTS

No major complications and specifically no losses of sensitivity of the penis or erection deficiencies occurred during the post-operative follow-up period. All the patients resumed their sexual activity in 4 months. A measurement of the penile dimensions was carried out 9 months after surgery. No clinical meaningful increases in the diameter of the flaccid penis were documented. The average penis diameter during erection was found to be 4.2 cm (3.4-4.9) with post-surgery increases in diameter varying from 1.1 to 2.1cm (p<0.01).

CONCLUSIONS

The penile enlargement phalloplasty technique with albuginea surgery suggested by the authors definitely is indicated for increasing the volume of the corpora cavernosa during erection. Albuginea surgery with saphena grafts has been found to be free from aesthetic and functional complications with excellent patient satisfaction.

Relationship of flow rate with symptoms, quality of life and other clinical parameters in patients with LUTS suggestive of BPH

AIM

The uroflowmetry data of a selected number of patients who took part to the QUIBUS study (366 traces selected after quality control by a central panel of reviewer) were evaluated for their relationships with age, prostate volume, and IPSS and ICS-BPH scores. Waiting time, flow time, voided volume, maximum flow rate (Q(max)) and average flow rate (Q(ave)) were the flow variables considered for analysis. Only measurements with total voided volume exceeding 100 ml were included.

RESULTS

An increasing percentage of subjects with voided volume <200 ml was observed over 65 years of age. Age did not affect neither Q(ave) nor Q(max )(p = n.s. at correlation analysis). In particular, Q(max)was <15 ml/s in about 70% of patients independently of age. Prostate enlargement was inversely associated with voided volume, Q(max) and Q(ave), showing a worsening of urinary function for increasing values of prostate volume Q(max) was negatively correlated with IPSS total score and with most single items with the exception of two storage symptoms such as repeated urination and nocturia). Accordingly, Q(max) was inversely associated with the total score ICS-BPH for voiding symptoms to a higher extent (r = -0.31, p < 0.01) than with the one for storage symptoms (r = -0.22, p < 0.01). Flow variables were inversely correlated with IPSS-QoL.

CONCLUSION

Uroflowmetry and IPSS, although not allowing a definitive diagnosis of obstruction, may nonetheless satisfy the clinical need of a rapid, easy and accurate tool for the noninvasive screening of LUTS patients.

[Technical problems in achieving continence after perineal prostatectomy]

After radical perineal prostatectomy a 88% and 94% continence rate can be achieved respectively at 6 month and 12 month follow-up. Stress incontinence persists in 4.5% of cases, while in only 1.5% complete incontinence is observed during night and day without spontaneous voidings. In our experience of 176 consecutive perineal radical prostatectomies we observed that in order to obtain a complete recovery of urinary continence, in absence of signs of detrusor instability, a functional urethral length more than 16 mm and urethral closure pressure more than 42 cm H2O are needed.

Penile elongation and thickening--a myth? Is there a cosmetic or medical indication?

Penile lengthening and thickening techniques can be performed in different ways for treatment of congenital penile hypoplasia and dysmorphophobia in terms of aesthetics or function. Particularly for penile lengthening, a combination of surgery and stretcher device is suggested. Surgery for lengthening comprises three different stages: suture with plane alternating edges of the pubo-penile skin, infrapubic lipectomy, and section of the suspensory ligament. Our approach to penile thickening differs depending on whether dysmorphophobia is related to aesthetics or function. While pericavernosal apposition of autografts is suggested in the first case, a technique developed by the authors is performed in the latter, which comprises bilateral longitudinal incision of the corpora cavernosa and enlargement of the tunica albuginea by means of saphenous grafts. The endothelial lining, which constitutes the internal surface of the veins, is highly compatible with the endothelium of the corpora cavernosa; therefore, the incidence of postoperative subareolar fibrosis and occlusive vein pathology is lower than after surgery performed with techniques using grafts of other material. The described procedure did not cause postoperative complications in terms of infection, wound healing and cosmetic appearance. All subjects resumed regular sexual activity after 4 months without any disturbance or functional limitation. Diametrical measurements at the 9-month follow-up revealed an increase of 1.1-2.1 cm. The reliability and efficiency of these procedures are strongly influenced by factors other than technical problems; however, expert diagnosis and psychological consultation in the case of dysmorphophobia will confirm and specify the indications.

[Andrologic surgery]

The need of an economic and social low costs drive more and more surgeons towards the day surgery. The always growing diffusion of local anesthetic supports this trend. The drugs used as local anaesthetics are: carbocaine, procaine, lidocaine and bipivacaine. The Day Surgery can be largely employed in the therapy of andrological pathologies. In fact the anatomical placement of male genital apparatus allows easy possibilities of anaesthetical and surgical approach. It is so possible perform the following operations: meatotomy, section and plasty of fraenum, extirpation of Papovavirus lesions, circumcision, paraphymosis setting, corpora cavernosa drainage in priapism, section and ligation of deep dorsal vein, corporopexi, glandulopexi, cavernous crural plication, endocavernous penile prosthesis' implant, congenital or acquired penile recurvatum correction, blandulectomy, hepidydimis' cyst excision, testicle's biopsy, subcapsular orchiectomy sec. Higgins, testicular prosthesis' implant, resection and eversion of vaginal tunic of testicle in hydrocele's therapy, vasotomy and section and ligation of internal spermatic vein in varicocele's surgery. The Authors describe the anaesthetical and surgical techniques for bring forward these operations in Day Surgery.

[Varicocele and its repercussion on infertility. Indications and limitations of surgical intervention]

According to different Authors, varicocele incidence in unselected population fluctuates from 8 to 22% but in selected population affected by sterility incidence ranges from 21 to 39%. However other Authors have demonstrated that about 50% of patients suffering from varicocele have semen alterations. Various mechanisms have been suggested for testicular dysfunction associated with varicocele: intrascrotal hyperthermia, reflux of renal and adrenal metabolites from the renal vein and hypoxia. The most important semen alterations are observed in patients suffering from grade 2 and 3 varicocele and especially these patients must undergo surgical operation. According to recent findings, better results about the improvement of semen quality are obtained by operating children in puberal age. This clinical approach allows a prevention of testicular hypotrophy or, when this is already present, its reversibility. Varicocele surgical treatment makes use of traditional techniques microsurgical or not and mininvasive techniques. After renouncing of intrascrotal varicocelectomy, traditional techniques provide ligature and section of ectasic spermatic veins, after a surgical high (at level of the internal inguinal ring) or low (over inguinal canal) skin incision. Microsurgery allows recognition and protection of lymphatic and arterial vessels and execution of microsurgical anastomosis between venous spermatic and ileo-femoral circle vessels, when this is necessary. Internal spermatic vessels and vas deferens can be visualized through the laparoscope and so laparoscopic varicocele treatment was suggested. These new techniques and traditional operation are burdened with the same percentage of relapses but in laparoscopic procedure complications are more important. Recently radiographic occlusion techniques are also utilized (internal spermatic vein retrograde scleroembolization); the percentage of relapses is between 4 and 11%, with no risk of postvaricocelectomy hydrocele but with risk of loss of kidney (migration of the ballon or coil into the renal vein). Surgical treatment of varicocele produces a significant improvement in semen analysis in 60 to 80 per cent of patients affected by testicular dysfunction. Pregnancy rates after varicocelectomy are including from 20 to 60 per cent with most series averaging about 35 per cent.

[Surgical therapy of obstructive azoospermia: microsurgery]

Microscopic procedures for therapy of obstructive azoospermia or of vasectomy reversals have resulted in accurate reapproximation of ductal structures. The success of vasovasostomy appears to be influenced by the length of time that has passed since the vasectomy was performed or the obstruction become. Failures of vasovasostomy may be attributed to anastomotic stenosis, sperm antibodies, epididymal dysfunction, or an unrecognized epididymal tubule blowout with subsequent obstruction. The latter condition should by suspected when, at the time of the initial vasovasostomy, there is lack of fluid containing spermatozoa in the cut end of the testicular portion of the vas. Chronic intratubular pressure may cause an epididymal blowout, with subsequent spermatic granuloma and obstruction in the epididymal tubule, that may also be related to a congenital disorder or a postinflammatory condition. Spermatozoa gain maturation and the capacity for motility as they move from the caput to the cauda of the epididymis as possible. Microsurgery allows direct microtubular anastomosis between the epididymal tubule and the cut end of the vas. Some conditions are not amenable to conventional surgical techniques, such obstructed azoospermia due to congenital bilateral absence of the vas deferens or to severe damage to the reproductive ducts. To treat these patients surgeons have devised reservoirs (artificial spermatoceles) to collect spermatozoa to be used for artificial insemination. An alternative treatment method for obstructed azoospermia is to obtain sperm from the epididymis with the use of an operating microscope. Although sperm have been obtained the poor sperm motility requires either in vitro fertilization or GIFT. The technique looks promising, although improved techniques to enhance the motility of the collected sperm will ultimately yield better results.

[New trends in the surgical treatment of penile carcinoma]

With the current oncological emphasis on radical treatment allied to minimal invasiveness, choice of treatment relies on precise clinical staging. The corpora cavernosa of the penis represent a well defined anatomical structure distinct from the corpus spongiosum and the glans which are tightly connected to one another. In case of primary penile tumour the T.N.M. classification of the American Joint Committee on Cancer includes in the T2 stage both infiltration of the corpus spongiosum and of corpora cavernosa. Jackson's classification seems to be more pertinent as it limits to stage 1 cases involving the glans and corona and classifies as stage 2 cases limited to the corpora cavernosa. Partial penectomy can prove overly invasive, yet insufficiently radical, if the anatomical continuity of the spongious tissue is not considered. Carcinoma of the glandular corpus spongiosum without cavernosal involvement indicates glandulectomy with partial uretrectomy and apical cavernous-urethrostomy. Preserving the corpora cavernosa is an option of great relevance to the quality of life of the patient: erectile ability and stand-up micturition are not affected and the patient keeps complete sexual ability and orgasmic sensation. In case of scrotal or public involvement, emasculation with hemipelvectomy must be attempted; if indicated, it can be followed by radiotherapy. Perineo/abdominal reconstruction can be followed by urinary diversion with adjuvant chemotherapy. In selective cases neophallic reconstruction can be later attempted using the inferior abdominal rectum muscle.

[Revascularization: light and shadow]

Advances in the knowledge of penile haemodynamics make evidence of two fundamental mechanisms in the physiology of erection: 1) arterial vasodilatation; 2) blockage of venous outflow. Therefore peripheric vasculogenic erectile impotence presents two pathogenetic possibilities: 1) from insufficient arterial flow; 2) from increased venous outflow. It is therefore very important to make the correct diagnosis of the patient with erectile disturbances in order to determine an appropriate therapy. The following examinations are routine tests carried out at our Institution: NPT test, basal and dynamic Doppler-sonography, OOE-OME (evaluation of output obtaining and maintenance erection), basic and dynamic cavernosography, digital angiography, dynamic NMR. After an accurate diagnostic assessment medical treatment can begin, based essentially on the cavernous infusion of vasoactive drugs, in light forms; surgery is resorted to severe cases, or in cases of failure of medical therapy. Proposed operations may be divided into 3 groups: 1) arterio-cavernous by-pass; 2) arterio-arterial by-pass; 3) venous surgery. Since 1978 the successive experiences of the Authors in this field and the better knowledge of penile vascular structures have led to a standardization of the methods used, with partly original techniques (epigastro-dorsal antiflow and orthoflow double by-pass), which, with selective application, have raised the percentage of pulsing anastomoses at 18 months of 82%.

[Radical surgery and conservation of erection in Peyronie's disease]

The radical surgical option we propose for Peyronie's disease consists in removing the sclero-hyanolitic focus (plaque) and replacing it by an autologous dermal graft taken from the upper outer thigh area. Between 1981 and 1994, we operated 564 patients with Induration penis plastica (IPP), 418 of whom underwent plaque excision and dermal grafting. All could be assessed at two-year follow-up. Two main complications were observed: penile flexure relapse (71 Pts, 17% of cases), and erectile dysfunction with decreased corporal rigidity (84 Pts, 20% of cases). A mild deviation of the penis can occur some months after surgery and it is not due to disease progression (as it should have evolutive characteristics) but is mere scar retraction (44 Pts, 76% of examined relapsed flexures). The degree of this graft retraction is linked to the individual's histologic response and can be due to an idioptic tissular response or to an insufficient size of the patch. In some cases, the post-op penile flexure can result from a progression of disease (14 Pts, 24% of examined relapses flexures) and can be due either to a new "focus" or to an incomplete removal of the previous plaque. As the patient will date the onset of a possible postoperative erectile deficit from the time of the operation, it is advisable to assess preoperatively the real erectile ability of all patients. Furthermore, a post-op impaired erectile response (84 Pts, 20%) could result from a subalbuginear fibrosis of the erectile tissue that leads to a caverno-occlusive dysfunction (60%). In more than 35% of patients we found a psychogenic component, due to post-surgical stress, that involves an adrenergic hypertone with peripherical vasoconstriction. In few cases (4%) the post-op erectile dysfunction is the consequence of peroperative arterial damages that results in hypoaesthesia of the glans (injury of dorsal arteries) or in failure to obtaining corporal rigidity (damage of cavernosal arteries). A review of our experience involving plaque excision and dermal grafting led us to propose this option in case of mechanical disturbance during coitus and when the association of erectile dysfunction can be excluded.

Soft endocavernous prostheses and glandulopexy

Subrini's new prosthetic devices are two soft silicone cylinders, with good patient tolerance over time, that are easily insertable surgically and that make full use of the patient's remaining erectile ability (complementary erection). They have a dual function: reducing cavernosal volume and providing prosthetic support. Patients who retain even minimal erectile function make eligible candidates for this type of implant. Between 1991-1994 we performed surgery to insert such devices in 224 pts. aged 28 to 73 years. A sub-coronal access for exposure was used in ali cases. Operating time was 30 minutes and hospital stay 3 days on average. 33 patients had Peyronie's disease, 36 required only locai anaesthesia. 162 patients could be followed long-term (129 with uncomplicated erectile deficit; 33 with I.P.P.). Aesthetic and functional results were generally satisfactory, as ali patients were able to resumé full sexual activity. Post-implant glans displacement and its asymmetrical insertion over the cavernosal apices (ptosis - glandular asymmetry) were corrected by glandulopexy (partial glans mobilization on the corpora cavernosa and its symmetrical repositioning).

[Radical perineal and retropubic prostatectomy: comparison of technics]

Today we may consider radical perineal prostatectomy as an example of mild invasive surgery compared with the retropubic. Technique is found less traumatic account of the precision of the approach, the accuracy of hemostasis and urethral bladder suture and the speed of postoperative handling. The only disadvantage related with the impossibility of transperineal pathological lymph node staging can today be satisfactory overcome after the advent of laparoscopic lymph node methods which permits safe non invasive preoperative hystological examination. The authors show the technique of laparoscopic and surgical therapy, concluding that perineal prostatectomy is a better approach toward retropubic radical prostatectomy, if combined with preoperative laparoscopic pelvic lymphadenectomy.

Evaluation of corpora alterations and erectile dysfunction following radical surgery for Peyronie's disease and long-term follow-up on 152 operated patients

The radical surgical option we propose for Peyronie's disease consists in removing the sclerohyalinotic focus of disease and replacing it by an autologous dermal graft taken from the upper outer thigh area. Between 1981 and 1991, we operated on 335 patients with Peyronie's disease, 152 of whom underwent plaque excision and dermal graft. All could be assessed with a 2-year follow-up. Two main complications were observed: mild penile flexure due to scar retraction of the graft (35% of cases), and partial erectile deficit with decreased corporal rigidity (17% of cases). The degree of graft retraction is linked to the individual's histologic response. A mild deviation of the penis can occur some months after surgery and is not a relapse flexure due to disease progression, but is mere scar retraction and will spontaneously regress. Because the patient will date the onset of a postoperative erectile deficit from the time of the operation, it is advisable to assess preoperatively the erectile ability of all patients. Furthermore, an impaired erectile response could result from hypoaesthesia of the glans, postsurgical stress, and fibrosis of the erectile tissue. A retrospective assessment of radical surgery cases involving plaque excision and dermal graft led us to propose this option where precise indications apply, providing that other alterations of the erectile function are preoperatively assessed.

[Validity of superficial echography in the study of urethral pathology]

In male patients routine examination for urethral disease includes retrograde and anterograde urethrography and urethroscopy. In the patients underwent radical cystectomy, detection of cancerous cells in the urethral washing suggest cancer relapse. Nowadays we can achieve a sonographic study of the anterior male urethra, using a superficial high frequency ultrasound probe. Since September 1992 till July 1993, 12 patients underwent cystectomy at our Institution and 13 patients affected by urethral stricture, have been investigated by routine examination and sonographic urethrogram. In the first group of patients, out of 3 patients with urethral tumor, sonourethrography has confirmed the presence of tumor in 2 cases. In these second group of patients, sonourethrography has located the stricture, evaluated the length, calculated the diameter of the stricture and the depth of fibrosis. Sonourethrography is a non-invasive method that can provide valuable information about the urethral lumen and the urethral wall.

[Dynamic renal echography versus urography in the follow-up of patients who have undergone ureterosigmoidostomy]

The main post uretero-sigmoidostomy complications are stricture of the anastomosis, chronic infection and urolithiasis. In our institution the patients with ureterosigmodostomy undergo a follow-up protocol in which blood chemistry, ultrasonography, intravenous pyelography and C.T. are periodically performed. The aim of the present paper is to compare the accuracy of kidney sonography after diuretic stimulation with intravenous pyelography in the diagnosis of ureteral stenosis. Out of 91 patient with ureterosigmoidostomy 18 patients (34 kidneys) underwent intravenous pyelography, a basal U.S. and then a dynamic one at 5, 10, 15, 30, 45, 60, 90, 120 minutes after administration of furosemide 20 mg i.v. At basal U.S. 27 kidneys were normal and 7 showed a dilations. After diuretic stimulation we observed 16 normal kidneys, 16 dilated units and 2 intermittent hydronephrosis. Out of 16 dilated kidneys 6 became normal in 60 minutes. Out of 10 dilated units 3 were normal in 90 minutes (hipotonic), 2 were normal before 120 minutes (low grade obstruction) and 5 were dilated after 120 minutes (high grade obstruction). With intravenous pyelography we observed 27 normal kidneys and seven dilated units. Dynamic sonography have shown high sensibility (100%), specificity (88.8%) and accuracy (91%) in diagnosis of ureteral obstruction in to I.V.P. in the follow-up of this kind of divesion.

[The cavernosometry]

The recent clinical and experimental research innovations in Andrology make possible the following classification of impotence: "Failure to initiate" "Failure to store" "Failure to fill" The last aspect, including veno-occlusive dysfunction, is continuously reevaluated by andrologic studies. The main diagnostic procedure of this complex problem, in constant evolution, is represented by cavernometry. Recently, but with full success, we are utilizing direct radioisotopic penogram in video sexy stimulation: in preselection function but probably in future with substitutive function of the more invasive and traditional cavernometry. In spite of this methodologic progress the findings of cavernometry are in continuous discussion as in tumultuous evolution, in anatomo-physiological environment, is the intracavernous district that, for many aspects, necessity of ulterior histochemical, pharmacodynamic and neurophysiological acknowledgements.

[NPT: nocturnal penile tumescence test]

The recording of the variations of penile tumescence and rigidity during nocturnal unconscious erections that usually occur with the REM phases of sleep, has been considered the diagnostic tool of choice in the workup of erectile disturbances for a number of years. Such a success is partly due to its absence of invasiveness. Moreover this test was believed to allow to differentiate between the psychogenic and organic origin of impotence. As some authors have recently reported, anxiety state (common among patients who undergo invasive andrological procedure in the office) can at times influence the content of the dream state, thus negatively affecting the spontaneous nocturnal erections. Besides, sleep disturbances such as apnea and motor agitation can also induce erroneous interpretations of NPT graphs. Further, dysfunctions at the level of the cortex and the spine still allow the occurrence of nocturnal tumescence but determine an erectile deficit in the awake state. Clinically, all this poses new questions about the effectiveness of the NPT test in the study of the origin of impotence. The diagnostic methods, despite its world-wide diffusion, remains, under certain aspects, obscure: the operative details and, above all, its interpretative criteria. All this impedes the achievement of uniformity in the evaluation of the results obtained thanks to this test (e.g. the number and duration of erectile episodes, the interpretation of tumescence on its own, of the basal-apical dissociation, of the erectile episodes occurring immediately before waking, and of those of short duration).

Modified corporopexy as a new approach to the treatment of congenital rotation of the penis

Congenital anomalies of the penis expressed in various forms of flexures can be associated with a rotation of the shaft. An asymmetrical insertion of the suspensory ligament on the dorsal surface of the tunica albuginea often accounts for corporal rotation. This distorts the spatial relationship between the corpora cavernosa and the pubic bone. The two corpora may overlap and the shaft is partially rotated. For the surgical treatment of these defects we proposed (1989) a technique of contrarotation of the tunica albuginea which was later abandoned because it was too invasive. We developed a technique based on the ipsilateral re-suspension of the suspensory ligament of the penis between the tunica of the lower corpus and the pubic symphysis to restore the true axis. The neurovascular adnexa, the corpora cavernosa, and the corpus spongiosum remain untouched.

[Island flap in the surgical treatment of hypospadias]

Surgery of hypospadias represents an interesting field of innovatory ideas. Many methods may be suitable and many modifications can be performed. There is no one method for all kinds of hypospadias. It is necessary to find the right method for each patient. The result often depends upon the experience of the surgeon with a particular method. The choice between straightening and urethroplasty in one or two stages depends on cost-benefit ratio and evolution at distance of the straightening must be taken into account as well tissue consumption imposed by the urethroplasty, with one stage straightening that makes reintervention very difficult. In the latter case, a multi-stage operation will be necessary with flaps for urethroplasty after the straightening, or, in a more developed penis, a shortening operation according to Nesbit. With two-stage method, in case of relapsed curvature, this can easily be treated, if tissue is available. For a good result of urethroplasty the ability of surgeon, a constant calibration of the canal, plenty of elastic tissue for the neo-urethra, care not to suture on these planes, are highly important. In our opinion Duplay's method observes these requisites. Two-stages surgery allows easy correction of any eventual relapsing incurvature, with no problems for the following urethroplasty. One-stage surgery allows the problems to be resolved in a single surgical Step, but involves the risk of tissue consumption and proximal stricture.

[Realities and limitations of the diagnosis of erectile impotence: radical urethro-prostato-cystectomy as a human experimentalmodel]

Veno-occlusive dysfunction (formerly called "venous leakage") is a clinical-radiographic manifestation of a multi-aetiology syndrome, the pathogenesis of which is to be sought in intrinsic damage to the erectile tissue. It has been attributed to psycho-neurogenic, neurovascular and local--physical factors. The unsatisfactory results of the various surgical techniques proposed (venous ligatures, crural plication, corporopexy) can be explained by the formation of vicarious venous circles, a phenomenon which occurs regardless of the type of procedure adopted and which is the direct consequence of the alteration of the occlusive mechanisms intrinsic to the erectile tissue. At the Urological Institute of the University of Milan, a study has been carried out with the aim of experimentally assessing these aetiopathogenetic hypotheses. 48 sexually potent patients were selected from those scheduled for extensive surgical procedures on account of malignant pathologies of the pelvic cavity (urethro-prostato-cystectomy, radical prostatectomy). The protocol included a series of examinations before and after the operation (at three months): computerised recording of nocturnal erections (NPT test, three consecutive nights), dynamic penile Doppler velocimetry, dynamic cavernosometry/graphy, examination of bulbocavernosus reflex. The goal of the study was to evaluate the haemodynamic consequences of the massive venous ligatures effected during these operations (periprostatic plexus, deep dorsal vein, spongio-cavernous connections). There were 28 cases of radical prostatectomy and 20 cases of radical urethro-prostato-cystectomy. Among the cases of radical prostatectomy, the extrafascial retropubic technique was used for 14 patients, the monolateral nerve-sparing procedure was applied for 10 patients (stage B1) and the transperineal approach was used for 4 patients (the most recent).(ABSTRACT TRUNCATED AT 250 WORDS)

Anterior urethral reconstructions

In the surgical treatment of urethral strictures many techniques have been proposed in the last 30 years. Nowadays, only some of them are currently used, because of complications correlated to these surgical procedures. Of course, our School has also changed indications for surgical procedures in urethral strictures. We can use two different kinds of surgical technique; excision of the stricture with an end-to-end anastomosis or urethroplasty. At the Institute of Urology of the University of Milan, 84 patients underwent end-to-end anastomosis: the 12 months follow-up showed 6 relapsed strictures, 1 fistula and 5 penile ventral flexures. In the field of multi-stage urethroplasty our greatest experience is related to the scrotal inlay technique (144 patients: 36 relapsed strictures, 65 phlogoses, 44 stones), while 18 patients underwent the procedure by the use of free epidermal mesh graft (1 fistula, 2 penile flexures, 2 necrosis of the graft). Concerning the one-stage procedures, the bladder mucosa graft seems to be reliable, and the complications observed were the following: 2 relapsed strictures, 3 fistules, 1 penile flexure; the lip mucosa graft represents a possible alternative: using this technique in 8 patients we had 2 recurrent strictures and 1 fistula. Recently we proposed a modified technique using a tubularlzed penile skin flap for complex, recurrent, extended bulbo-membranous strictures. 24 pts. underwent this surgical procedure. Only two stricture relapses have been found. The first four operated pts. had urethrocystograms which revealed a neourethra exceeding the normal caliber and this was resolved in consecutive cases by reducing the size of the flap.

[Erectile complications after radical surgery for penile plastic induration]

The radical surgical option we propose for Peyronie's disease consists in removing the sclero-hyalinotic focus of disease and replacing it by an autologous dermal graft taken from the upper outer thigh area. Between 1981 and 1991, we operated 335 patients with IPP, 152 of whom underwent plaque excision and dermal graft. All could be assessed at two-year follow-up. Two main complications were observed: mild penile flexure due to scar retraction of the graft (35% of cases), and partial erectile deficit with decreased corporal rigidity (17% of cases). The degree of the graft retraction is linked to the individual's histologic response. A mild deviation of the penis can occur some months after surgery and is not a relapse flexure due to disease progression (as it should have evolutive characteristics) but is mere scar retraction and will spontaneously regress. As the patient will date the onset of a postoperative erectile deficit from the time of the operation, it is advisable to assess preoperatively the erectile ability of all patients. Furthermore, an impaired erectile response could result from hypoaesthesia of the glans, post-surgical stress, and fibrosis of the erectile tissue. A retrospective assessment of radical surgery cases involving plaque excision and dermal graft lead us to propose this option where precise indications apply, providing the presence of other alterations of the erectile function are pre-operatively assessed.

[Erectile function and ablative surgery of penile tumors]

The Authors try to show the possibility to combine radical excision with minimal invasiveness in the surgery of penile cancer. The focal point of every therapeutic decision is correct clinical staging. Unfortunately there's some confusion in the two international staging systems (TNM and Jackson's classification). In fact it's not clear the anatomical difference between epithelioma of the glans infiltrating corpus spongiosum and subcoronary epithelioma of the shaft infiltrating the corpora cavernosa. It's obvious that the infiltration of the corpora cavernosa is a far more aggressive oncological manifestation than that of tumour infiltrating the corpus spongiosum. So we consider Jackson's classification more congenial. In terms of surgery this anatomical independence makes it easy to consider the corpora cavernosa as a distinct entity, so they remain perfectly functional when separated from the glandulo-spongio-urethral unit with its vasculo-nervous bundle. This makes conservation of the erectile function, when clinical staging show us that the tumour is not infiltrating the corpora cavernosa. The Authors show their results, which seem to be rather good.

Extracorporeal shock-wave lithotripsy with MPL9000 for the treatment of urinary stones in pediatric patients

Extracorporeal shock-wave lithotripsy (ESWL) is now applied as the treatment of choice in most cases of urinary stones. Its acceptance in pediatry, however has been only gradual despite numerous positive studies. We report on fourteen young patients (mean age: 9.7 years) who were all treated by ESWL with the MPL9000 lithotriptor for renal stones. Each patient received an average of 1440 shocks with generator energy set at 14.4 Kv. Six of these patients required either analgosedation or anesthesia. No observable complications of treatment occurred. At one-month follow up, the kidneys of twelve patients were found to be stone-free, while two still presented fragments that could pass spontaneously. At three-month follow-up, thirteen patients were stone-free and a single patient retained some fragments. From this data we infer that ESWL with the MPL9000 lithotriptor may be used safety and efficiently to treat urolithiasis in younger patients.

Bulbocavernous myocutaneous flap: a new technique in repair of recurrent urethrovaginal fistula

This paper describes the case of a recurrent post-partum urethrovaginal fistula. The extent of the vaginal tissues loss and the perilesional scarring made the direct closure of the defect non practicable. After suturing the urethra, the anterior vaginal wall was reconstructed with an island bulbocavernous musculocutaneous flap raised from the left labium majus. Nineteen months after surgery the flap healed well without peri urethral suffusion.

Urological laparoscopy: our preliminary results

From the beginning of urological applications of laparoscopy, this technique has found many clinical indications. In our center, after an experimental training in animals, we performed 48 operations using laparoscopy: 18 pelvic lymphadenectomies (15 for prostate cancer, 2 for bladder tumor and 1 for penis carcinoma), 11 ligatures of the spermatic vein (3 bilateral), 4 orchidopexies, 10 excisions of renal cysts, 4 nephrectomies and 1 adrenalectomy. For cryptorchidism, laparoscopy is a less invasive alternative to surgical exploration; in case of prostate cancer, laparoscopic pelvic node dissection has a lower incidence of complications and requires few days of hospitalisation. The excision of renal cysts by laparoscopy, in case of large symptomatic pathology, is an efficacious operation with low morbidity. In case of nephrectomy for small wrinkled kidneys or severe hydronephrosis, long execution time makes cost/benefit ratio somewhat debatable; adrenalectomy, instead, is easier than nephrectomy and offers many advantages in comparison with traditional surgical approach. All indications will be better evaluated at a later date, with the indispensable learning period and the continuous progress of technical equipment.

Repair of a recurrent urethrovaginal fistula with an island bulbocavernous musculocutaneous flap

This paper describes a case of recurrent postpartum urethrovaginal fistula. The extent of the vaginal tissue loss and the perilesional scarring made direct closure of the defect not practicable. After suturing of the urethra, the anterior vaginal wall was reconstructed with an island bulbocavernous musculocutaneous flap raised from the left labium majus. Seven months after surgery, the flap healed well, and cystography showed a regular voiding without periurethral suffusions. Healing of thedonor site also was aesthetically satisfactory.

Our treatment of congenital complicated penile deviations

Congenital anomalies of the penis expressed in various forms of flexures can be associated to a rotation of the shaft. An asymmetrical insertion of the suspensory ligament on the dorsal surface of the tunica albuginea often accounts for corporal rotation. This distorts the spatial relationship between the corpora cavernosa and the pubic bone. The two corpora may overlap and the shaft is partially rotated. For the surgical treatment of these defects we proposed (1989) a technique of contrarotation of the tunica albuginea which was later abandoned because it was too invasive. We developed a technique based on the ipsilateral re-suspension of the suspensory ligament of the penis between the tunica of the lower corpus and the pubic symphysis to restore the true axis. The neurovascular adnexa, the corpora cavernosa, and the corpus spongiosum remain untouched.

[Andrologic problems in prostatic carcinoma]

In our opinion, the attempt to save the sexuality and the erectile ability in a patient with a prostate cancer, in the respect of an absolute oncological radicality, should be recommended since potency represents for the patient a primary aspect in the quality of residual life. At the Institute of Urology of the University of Milan a study to identify pathogenetic mechanisms leading to erectile failure in the various phases of a prostate cancer was performed. From January 1988 to December 1993, 36 patients (range 50-60 years old) suffering from prostate cancer B1 stage (14 pts), B2 (20 pts) and C (2 pts) underwent to radical prostatectomy. Out of 24 pts reporting erectile ability before surgery, 10 was in B1 stage and underwent monolateral nerve-sparing technique. Out of these, 6 pts (60%) maintained the erection after the operation. The treatment with LHRH analogues weighted on loss of libido and erectile and erectile potent due to central androgenic delete. At our Institute 87 pts in treatment with LHRH analogues reported loss of erection in 80% of cases. In this group 22 underwent to an andrological examination. The exams (Dynamic penile Doppler, Dynamic Cavernosometry and stimulating test with intracavernous vasoactive drugs) confirm the absence of peripherical damages in the pathogenesis of the erectile dysfunction. Patient underwent radiotherapy develop a secondary impotence due to an obliterant progressive angioitis in a percentage ranging from 30 to 80%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of prostatitis with a new laser probe with optic fiber]

The present treatment of the subacute abatteric prostatitis, prostatodinia, prostatosis (the most common prostatic flogistic diseases) is represented by the transrectal applications of infrared Laser. The concrete opportunity of applying such an energy directly to the prostate in cases of flogistic diseases--a very frequent pathology treated in many different and controversial ways--is a stimulating therapeutical method which we tested and that we presently use in our clinics. The thanks to the realization of an high technology equipment, easy to handle, cheap, safe, perfectly suitable, formed by a new infrared Laser probe, transrectal, atermical, made by a optical fibre, which we present. Micturition, ejaculation, fertility may draw a relevant improvement, provided that the same treatment is performed after a specific medical diagnosis and following a strict protocol.

[Treatment of urinary incontinence in the patient operated on for benign prostatic hyperplasia]

A potential complication of prostatic adenomectomy and TURP is urinary incontinence. The incidence of this problem ranges from 0.1 to 1%. we reviewed our experience with 15 patients who were incontinent between 10 to 24 months after prostatectomy. We treated these patients with bladder training. At first, patients were evaluated for the type and extent of incontinence. Perineal exercise were taught in detail, tested for their correct use via simultaneous and abdominal examination. Patients were evaluated weekly for compliance. No pharmaceutical agents were used. All the 15 patients improved in the number of incontinence episodes 5 patients achieved total continence, while only one showed a little change. We conclude that patients who are incontinent after prostatectomy can improve with a well-done behavioral training program.

[Changes in sexuality and fertility in the elderly: ejaculation]

After the remark of the own results on an epidemiological research about andropausal sexual problems, the Authors analyze the alterations of ejaculatory mechanism with elderly, focusing frequency and etiopathogenesis. They underline the need of prevention of ejaculatory disturbances deriving from chronic disease or of iatrogenic origin.

Complex Reconstructive Corporoplasty

Congenital and especially recurrent complex pathologies of the corpora cavernosa need an integrated surgical approach (urological and plastic surgery). The fields of application of these techniques are: a) correction of congenital pathologies of the male genitalia; b) genital reconstruction after radical pelvic surgery; c) genital reconstruction after trauma. An adequate experience in surgery of flaps, the knowledge of their vascularisation and biology, the observance of particular intraoperative procedures and an accurate postoperative management are mandatory. This is also the case of surgery in female to male transsexuals. Different techniques have been proposed but few of them give aesthetically and functionally satisfactory results. In our experience clitoridal enlargement and urethral transfer, in anatomically selected patients and after substitutive hormonal therapy, give sufficient guarrantee of conservation of sensitivity and erectile capacity and have a positive psychological impact on the patient. When cosmetic dimensional emphasis is required as regards the neophalius the transfer of a rectal abdominal muscle flap with epidermal graft has given, in our experience, satisfactory results.

[Laparoscopic cystectomy: an experimental model of urinary diversion]

During our experimental trial we achieved laparoscopic cistectomies with urinary diversion to prove our manual capability with the reconstructive surgery. We executed, on male pigs, 10 cistectomies with urinary diversion using laparoscopic technique. We performed 5 ureterocutaneostomies on 5 pigs and, in the other ones, 5 ureterosigmoidostomies. During UCS the pigs laid in lateral position, and during USS in supine position. The average time of the operation is going to reduce in consideration of the overcoming of the initial techno-instrumental difficulties and is 60 minutes for cistectomy, 30 minutes for ureterocutaneostomy and 120 minutes for ureterosigmoidostomy.

[Section of the spermatic vein]

Surgical treatment of varicocele can be carried out using different techniques. The laparoscopic approach [1-2] represent a new trend that we used to ligate and dissect the spermatic vein in 10 patients, 8 with monolateral left varicocele and 2 with bilateral varicocele. The average time for laparoscopic surgery has been 45 minutes for monolateral varicocele and 65 minutes in the bilateral one. The absence of important complications during and after the operation has allowed to dismiss all patients 48 hours after the surgical treatment. The preferential direction of laparoscopic approach to varicocele is represented by the bilateral form.

[Renal cysts resection]

Six patients with inferior and middle polar renal cysts of 8-15 centimeters of diameter, underwent the resection of the cyst by laparoscopic technique. The operation required an average time of execution of two hours and the positioning of four trochars to consent an adequate access. The absence of important complications during and after the operation has allowed a quick dismission of the patients. The laparoscopic treatment of renal cysts represent a valid choice to traditional surgery and percutaneous needle aspiration.

[Laparoscopic lymphadenectomy]

7 patients, suffering by prostatic adenocarcinoma in clinical stage B, were undergone to laparoscopic pelvic lymphadenectomy, to obtain a complete staging. The average time of execution of the operation was 180 minutes. The absence of important complications during and after surgical time, within low surgical trauma, has allowed the dismission of patients 48 hours after the operation. The low morbility demonstrated for this technique has allowed the dissection of a number of lymph node to consent an adequate staging.

[Orchiopexy]

The Authors illustrate their experience in the treatment of a case of left criptorchidism using laparoscopic technique associated with traditional surgery (Fowler-Stephens technique) without important complications during and after the procedure. The non palpable testis was located in the peritoneal cavity. The first step consists in a laparoscopic clip ligation of the spermatic vessels with the intent of improve the vasal collateral blood flow. After a 6 months interval, the patient underwent laparoscopic orchidopexy.

[Seminal changes of inflammatory origin]

Presence of bacteria in the sperm is often associated to a reduction of fertility in relationship with a decrease in number and motility of spermatozoa and with an augmentation of the abnormal spermatic cells. Clinical features of seminal phlogosis are extremely variable both in acute and chronic evolutions. In every case the first diagnostical step is sperm count and seminal complete analysis which can give evidence of phlogistic alteration in quantity and quality of spermatic cells with a typical presence of an excess in white blood cells (leucospermia) as consequence of infection. The great variety in clinical and bacteriological aspects and the particular biological features of the organs involved, as the prostate, make treatment a difficult problem to solve with particular regard to the choice of an effective antibiotic which pharmacokinetic has to result suitable for the microorganism as well as for the tissue of the infection site. All those efforts are indispensable to reduce the too frequent therapeutical failures in the management of seminal phlogistic pathology with complications of organic but also pathological relevancy for the patient and the partner too.