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Introduction: Multiple modifications have been made to the inflatable penile prosthesis (IPP) since its inception in the 1970s. These modifications have made reservoir-related mechanical malfunctions highly unlikely in current IPP models. Although these complications are rare, it would be incumbent upon the implanting surgeon to be aware of these potential complications, how they present, how they are best treated, and how to prevent them from occurring., Aims: The aim of this article was to present our experience with complications associated with penile prosthesis reservoirs, perform a review of the literature regarding reservoir-related complications, and present our modified technique to place the reservoir into the space of Retzius., Main Outcome Measures: Reservoir-related complications including inguinal herniation, erosion into bladder or bowel, intraperitoneal reservoir placement with subsequent visceral injury, vascular injury, autoinflation, and infection., Methods: We retrospectively reviewed our experience with penile prosthesis reservoir complications or procedures requiring an alternative implantation approach at our center over the past 10 years where over 400 devices were implanted. We also review reservoir-related complications published in the English literature since the 1980s., Results: While exceedingly rare, reservoir complications do occur. Six cases from our institution are presented including one reservoir herniation, one postoperative direct inguinal hernia, one bladder laceration during revision surgery, one ectopic reservoir placement due to morbid obesity, one iliac vein compression syndrome, and one vascular laceration during reservoir revision. Reported reservoir complications include inguinal herniation, erosion into the bladder or bowel, intraperitoneal reservoir placement with subsequent injury to the ureter or bowel, vascular injury, autoinflation, and infection., Conclusion: Penile prosthesis reservoirs rarely fail mechanically but are associated with a variety of complications or may require alternate implantation technique. In our experience, the Jorgensen scissors technique allows safe entry into the space of Retzius with diminished risk of hernia as well as vascular, bladder, or bowel injury., (© 2012 International Society for Sexual Medicine.)

Purpose: Collagenase Clostridium histolyticum is an investigational nonsurgical treatment for Peyronie disease. In this phase 2b, double-blind, randomized, placebo controlled study we determined the safety and efficacy of collagenase C. histolyticum and assessed a patient reported outcome questionnaire., Materials and Methods: A total of 147 subjects were randomized into 4 groups to receive collagenase C. histolyticum or placebo (3:1) with or without penile plaque modeling (1:1). Per treatment cycle 2 injections of collagenase C. histolyticum (0.58 mg) were given 24 to 72 hours apart. Subjects received up to 3 cycles at 6-week intervals. When designated, investigator modeling was done 24 to 72 hours after the second injection of each cycle. We evaluated penile curvature by goniometer measurement, patient reported outcomes and adverse event profiles., Results: After collagenase C. histolyticum treatment significant improvements in penile curvature (29.7% vs 11.0%, p=0.001) and patient reported outcome symptom bother scores (p=0.05) were observed compared to placebo. In modeled subjects 32.4% improvement in penile curvature was observed in those on collagenase C. histolyticum compared to 2.5% worsening of curvature in those on placebo (p<0.001). Those treated with collagenase C. histolyticum who underwent modeling also showed improved Peyronie disease symptom bother scores (p=0.004). In subjects without modeling there were minimal differences between the active and placebo cohorts. Most adverse events in the collagenase C. histolyticum group occurred at the injection site and were mild or moderate in severity. No treatment related serious adverse events were reported., Conclusions: Collagenase C. histolyticum treatment was well tolerated. We noted significant improvement in penile curvature and patient reported outcome symptom bother scores, suggesting that this may be a safe, nonsurgical alternative for Peyronie disease., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: Implantable testosterone pellets were approved by the Food and Drug Administration in 1972 for the treatment of testosterone deficiency syndrome (TDS). Clinical use of this testosterone delivery modality has been limited until its recent reintroduction (Testopel(®) , Slate Pharmaceuticals, Durham, NC, USA). Six academic institutions collaborated and combined their databases to more fully characterize serum testosterone levels after the pellet implantations., Aims: To assess the time-dependent serum testosterone levels after subcutaneous testosterone pellets in clinical practice for the treatment of TDS., Methods: Data were retrospectively pooled and analyzed from data in six academic institutions. Variables included patient age, total testosterone concentrations before and after implantation, the number of testosterone pellets implanted, and the time from implantation to measurement of serum testosterone concentrations. Three hundred eighty men undergoing 702 insertions were included for analysis using JMP (version 4.0.4; SAS Institute, Cary, NC, USA)., Main Outcome Measures: Main outcome measures were postimplantation total testosterone levels and investigator-reported adverse events. Testosterone levels as a function of the number of pellets implanted and time from implantation were assessed., Results: Implantation of six to ≥10 testosterone pellets (450 to ≥750 mg) increased total testosterone into the therapeutic range at 1 month postimplantation and sustained therapeutic levels (>300) for 4-6 months. Higher pellet numbers (10-12 pellets) were associated with higher, more consistent, and longer maintenance of testosterone levels within the therapeutic range. Four extrusions and three hematomas were reported early in our experience; other investigator-reported adverse events were generally mild to moderate in nature and transient in duration. No subjects required analgesics., Conclusions: Testosterone pellets (Testopel(®) , Slate Pharmaceuticals) provide sustained levels of testosterone for at least 4 months and up to 6 months in men with TDS. Implantation of ≥8 pellets achieved optimal results with respect to peak mean testosterone level and duration of effect. Testosterone pellets were generally well tolerated., (© 2012 International Society for Sexual Medicine.)

Phosphodiesterase-5 inhibitors (PDE5Is) improve erectile function by enhancing nitric oxide availability in the penis and its supplying vasculature, resulting in vasodilation and increased blood flow. PDE5Is might benefit cardiovascular diseases because phosphodiesterase-5 is also located elsewhere in the body, including the pulmonary and systemic vasculature and in hypertrophied myocardium. PDE5Is are approved for pulmonary arterial hypertension, given that they improved several hemodynamic and clinical parameters in large randomized trials. Initial evidence suggests that PDE5Is benefit patients with congestive heart failure and secondary pulmonary hypertension. PDE5Is seem to improve hemodynamic and clinical parameters in patients with high-altitude pulmonary edema (HAPE) and high-altitude pulmonary hypertension. In climbers with prior episodes of HAPE, PDE5Is prevented HAPE in 2 small randomized trials. In small randomized trials of PDE5Is, patients with Raynaud's phenomenon demonstrated improved blood flow, fewer symptoms and frequency of attacks, and resolution of digital ulcers. In addition to enhancing vasodilation, PDE5Is seem to protect the myocardium through complex pathways that involve nitric oxide, cyclic guanosine monophosphate, protein kinase G, extracellular-signal-regulated kinase, B-cell lymphoma protein-2, and Rho kinase inhibition. In animal models of acute myocardial infarction, PDE5Is consistently reduced infarct size indicating cardioprotection and PDE5Is also promote reverse remodeling and reduce myocardial apoptosis, fibrosis, and hypertrophy. PDE5Is might also benefit patients with treatment-resistant hypertension, preeclampsia, or peripheral arterial disease. This review presents the pathophysiology and trial data with regard to the use of PDE5Is for cardiac diseases., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction. There is no current consensus as to the most effective non-surgical therapy for Peyronie's disease (PD).Aim. To assess the benefit of penile traction therapy (PTT) when added to intralesional verapamil injections (IVI) combined with oral L-arginine 1g bid and pentoxifylline 400 mg tid in men with PD.Methods. 74 men with PD completed 12 IVI. Patients electing to add PTT were advised to wear the device for 2-8 hours daily, and no longer than 2 hours per session. Subjective responses were measured using patient questionnaires. Stretched penile length (SPL) and erect penile curvature (EPC) using penile duplex ultrasound (DU) were measured. Response to therapy was defined as at least a 10 degree reduction in EPC.Main Outcome Measures. Change in SPL (cm), change in EPC (degrees).Results. 39 patients in the PTT group (I) vs. 35 patients in group (II) completed the protocol. 54% of men in group I responded to therapy vs. 46% in group II (p = 0.75). Responders had a mean EPC improvement of 26.9 degrees in group I vs. 20.9 in group II (p = 0.22). Mean PTT use was 3.3 hours per day, and men with >3 hours per day use gained 0.6 cm in SPL vs 0.07 cm using less than or equal to 3 hours per day (p= 0.09), while men in group I on lost 0.74 cm of SPL on average. Multivariate analysis revealed that duration of PTT use significantly predicts length gain (0.38 cm gain for every additional hour per day of PTT use, p = 0.007).Conclusion. There was a trend toward measured curvature improvement, and a significant gain in SPL in men using the combination therapy protocol. Length improvement is related to duration of use of the traction device [corrected]., (© 2011 International Society for Sexual Medicine.)

Non-surgical treatment of Peyronie's disease (PD) has come a long way since it was first described in 1743. A myriad of treatment options are currently available, including oral, intralesional and external energy therapies. The purpose of this article is to review the contemporary literature on non-surgical therapies for PD, and where possible, focus on randomized, placebo-controlled trials, as well as review the latest guidelines for the management of PD from the International Committee on Sexual Medicine, which conveyed its findings in July 2009. At this time, it appears that a combination of oral agents and/or intralesional injection with traction therapy may provide a synergy between the chemical effects of the drugs and the mechanical effects of traction. Until a reliable treatment emerges, it does appear that some of the non-surgical treatments discussed can be used to stabilize the scarring process and may result in some reduction of deformity with improved sexual function.

Introduction: Surgical therapy remains the gold standard treatment for Peyronie's Disease (PD). Surgical options include plication, grafting, and placement of inflatable penile prosthesis (IPP). Postoperative erectile dysfunction (ED) is a potential complication for PD surgery without IPP. We present our large series follow-up to evaluate preoperative risk factors for postoperative ED., Aims: The aim of this study is to evaluate preoperative risk factors for the development of ED following surgical correction of PD taking into account the degree of curvature, graft size, surgical approach, hypertension, hyperlipidemia, diabetes, smoking history, preoperative use of phosphodiesterase 5 inhibitors (PDE5), and preoperative duplex ultrasound findings including peak systolic and end diastolic velocities and resistive index., Methods: We identified 218 men undergoing either tunica albuginea plication (TAP) or partial plaque excision with pericardial grafting for PD following a previously published algorithm between November 1992 and April 2007. Preoperative and postoperative erectile function, curvature characteristics, presence of vascular risk factors, and duplex ultrasound findings were available on 109 patients., Main Outcome Measures: Our primary outcome measure is the development of ED after surgery for PD., Results: Ten percent of TAP and 21% of plaque excision with grafting patients developed postoperative ED. Neither curve direction (P = 0.76), graft area (P = 0.78), surgical approach (P = 0.12), chronic hypertension (P = 0.51), hyperlipidemia (P = 0.87), diabetes (P = 0.69), nor smoking history (P = 0.99) were significant predictors of postoperative ED. No combination of risk factors was found to be predictive of postoperative ED. Preoperative use of PDE5 was not a significant predictor of postoperative ED (P = 0.33). Neither peak systolic, end diastolic, nor resistive index were significant predictors of ED (P = 0.28, 0.28, and 0.25, respectively)., Conclusion: This long-term follow-up of a large published series suggests that neither preoperative risk factors nor preoperative duplex ultrasound findings are predictive of postoperative ED, thus reinforcing the use of previously published preoperative treatment algorithms., (© 2011 International Society for Sexual Medicine.)

Introduction: At the present time, inhibitors of phosphodiesterase type 5 (PDE5) have Food and Drug Administration approval only for the treatment of erectile dysfunction and pulmonary artery hypertension, for which their mechanism of action is vasodilation and augmentation of blood flow by impeding PDE5-mediated breakdown of cyclic guanosine monophosphate. However, these agents are also being investigated in a wide range of other potential medical and surgical applications for which current treatment options are limited and in which their mechanism of action may be the same as or different from their effects in the two approved indications. Even if only some of these potential applications prove useful, the effect on clinical practice could be far reaching., Areas Covered: This literature review summarizes potential noncardiovascular uses of PDE5 inhibitors, with emphasis on clinical research. Topics include a variety of male genitourinary disorders other than erectile dysfunction: cutaneous ulcerations, tissue protection, neurological conditions, diabetes, cancer, transplant and reconstructive surgery, female sexual dysfunction and disorders of pregnancy., Expert Opinion: The exceptionally wide range of research taking place with PDE5 inhibitors holds promise not only for improved therapeutic options but also for an improved understanding of the basic biological mechanisms that underlie scientific medicine.

Introduction: Loss of penile length after penile prosthesis implantation is one of the most common complaints. There is no recognized reliable technique to gain length once the device is placed., Aims: This noncontrolled pilot study was designed to evaluate the efficacy and safety of external penile traction therapy in men with a shortened penis used before inflatable prosthesis implantation., Methods: Ten men with drug refractory erectile dysfunction and a complaint of a shorter penis as a result of radical prostatectomy in four, prior prosthesis explantation in four, and Peyronie's disease in two were entered into this trial. External penile traction was applied for 2-4 hours daily for 2-4 months prior to prosthesis surgery., Main Outcome Measures: Baseline stretched penile length (SPL) was compared with post-traction SPL and postimplant inflated erect length. A non-validated questionnaire assessed patient satisfaction., Results: All men completed the protocol. Daily average device use was 2-4 hours and for up to 4 months. No man had measured or perceived length loss after inflatable penile prosthesis placement. Seventy percent had measured erect length gain compared with baseline pre-traction SPL up to 1.5 cm. There were no adverse events., Conclusion: External traction therapy appears to result in a preservation of penile length, as no man had measured or perceived length loss following prosthesis placement, but in fact, a small length gain was noted in 70% of the subjects with no adverse events. The protocol is tedious and requires compliance to be effective. External traction therapy prior to inflatable penile prosthesis placement appears to preserve and possibly result in increased post-prosthesis implant erect length., (© 2011 International Society for Sexual Medicine.)

The purpose of this article is to review the contemporary literature on nonsurgical therapies for Peyronie's disease (PD); focus on randomized, placebo-controlled trials; and review the latest guidelines for the management of PD from the International Consultation on Sexual Medicine. A combination of oral agents or intralesional injection with traction therapy may provide a synergy between the chemical effects of the drugs and the mechanical effects of traction. Until a reliable treatment emerges, some of the nonsurgical treatments discussed can be used to stabilize the scarring process and may result in some reduction of deformity with improved sexual function., (2011 Elsevier Inc. All rights reserved.)

Introduction: Erectile dysfunction (ED) frequently accompanies Peyronie's disease (PD) and changes the therapeutic approach., Aim: To evaluate a single-center experience with inflatable penile prostheses (IPP) in men with medication refractory ED and PD., Methods: Ninety men underwent placement of an IPP with straightening maneuvers as necessary to address their deformity and ED., Main Outcome Measures: Preoperative assessment included International Index of Erectile Function-erectile function domain (IIEF-EF) and duplex ultrasound to confirm ED and measure erect deformity. Postoperative assessment included a modified Erectile Dysfunction Index of Treatment Satisfaction (EDITS) questionnaire, as well as office visits at 1, 6, and every 12 months thereafter., Results: Complete chart review was performed with mean follow-up of 49 months. Mean preoperative IIEF-EF score was 11. Full rigidity was not obtained in any patient during duplex ultrasound. Mean curvature at maximum erection was 53°. There were seven mechanical failures requiring device replacement, two revision surgeries for pump or reservoir malposition, one infected device, and two corporoplasties for distal tunica erosion. Postoperative office assessment revealed a functionally straight (i.e., <20°) erect penis and a properly positioned as well as operational device in all patients. The modified EDITS questionnaire was returned by 56 (62%). Overall, 84% of patients were satisfied with their outcome, yet only 73% were satisfied with their straightness. Patient perceived postoperative curvature correction stabilized quickly and was complete by 3 months in 84% of patients. Satisfaction with ease of inflation, deflation, and concealability was 84%, 71%, and 91%, respectively. Coital activity was reported by 91% of men in this group., Conclusion: In men with PD and ED, IPP placement allowed reliable and satisfactory coitus for the great majority of men. Mechanical failure was 7%. Men with PD undergoing IPP placement should be counseled regarding potential penile length loss and residual curvature, neither of which appeared to interfere with coitus but may reduce satisfaction., (© 2010 International Society for Sexual Medicine.)

Two artificial dipeptides containing both a pendant monodentate (pyridine (py)) and tridentate (terpyridine (tpy) or phenyl terpyridine (varphi-tpy)) ligand on an aminoethylglycine (aeg) backbone have been synthesized. These oligopeptides are fully characterized by one and two-dimensional NMR spectroscopy, mass spectrometry, and elemental analysis. The ligands were chosen because they coordinate Cu(2+) to form [Cu(py)(tpy)](2+) complexes; when bound to the dipeptide scaffold, Cu(2+) chelation cross-links the strands to form double-stranded duplex structures with an antiparallel arrangement. Using spectrophotometric titrations, we observe coordination of one Cu(2+) metal per dipeptide strand. Mass spectrometry, NMR spectroscopy, vapor pressure osmometry, and HPLC confirm that the resulting structures are the dipeptide duplex cross-linked by two metal centers.

Moyamoya disease (MMD) is a rare cerebral vasculopathy with limited information on the associated cognitive and emotional sequelae, particularly presenting in a psychiatric setting. We present the case of a 25-year-old female with a history of MMD and depressive disorder. She underwent revascularization surgery following an ischemic stroke at age 15 years. Magnetic resonance imaging at the time of the current assessment revealed markedly abnormal appearance in the anterior cerebral circulation with extensive periventricular collateral vasculature involvement. Neuropsychological assessment data revealed deficits in inhibition and problem-solving, consistent with frontal lobe dysfunction. We discuss the importance of further research on the neuropsychological sequelae of MMD.

Supramolecular structures modeled after biological systems (DNA and enzymes) are being developed to simultaneously mimic natural biological functions including catalysis, information storage, and self-assembly and to engineer novel electronic and magnetic properties. Structural mimics of nucleic acids containing multiple metal-coordinating ligands, and comprising natural and artificial bases or completely synthetic systems, create stable double-stranded structures with new electronic, spectroscopic, and magnetic properties. Supramolecular inorganic mimics of enzymatic function, including metallonucleases and metalloproteases, have begun to be constructed. Alternatively, metal-organic-frameworks have potential as artificial catalysts with substrate-specificity and size-selectivity analogous to biological processes. This review describes some of the recent themes in inorganic supramolecular systems that aim to mimic and exploit nature's ability to self-assemble polyfunctional architectures for new materials and biological applications.

Penile shortening following radical prostatectomy and straightening procedures for Peyronie's disease can be a devastating and unwelcome side effect of these operations. The majority of men undergoing radical prostatectomy for prostate cancer have a measured loss of penile length, which also can occur in men with Peyronie's disease and may be exacerbated by surgery. Recent studies have investigated the mechanisms resulting in penile shortening, and various treatments have emerged to prevent and treat postoperative penile shortening. This article reviews the recent literature on penile length loss after radical prostatectomy and following correction of penile deformity for Peyronie's disease.

Purpose: To our knowledge no standard therapy exists for the prevention of recurrent ischemic priapism. We used ketoconazole and prednisone with dosing titrated according to serum testosterone levels to suppress sleep related erections in an attempt to prevent recurrent episodes., Materials and Methods: Eight patients with recurrent ischemic priapism were treated with ketoconazole and prednisone. Two patients had sickle cell anemia and 6 had idiopathic recurrent ischemic priapism. Testosterone was measured on initial presentation, and ketoconazole and prednisone dosing was titrated to approximately 200 ng/dl testosterone and based on the presence or absence of recurrent ischemic priapism episodes. The International Index of Erectile Function-5 questionnaire was administered to evaluate for erectile dysfunction. Patients were seen monthly and therapy was withdrawn after 6 months., Results: Mean testosterone before and after treatment was 468 and 275 ng/dl, respectively. Mean followup was approximately 1.5 years. One patient had 2 recurrent ischemic priapism episodes while on ketoconazole and prednisone treatment. Another patient experienced an increase in testosterone from 361 to 432 ng/dl after initiation of therapy, and 3 recurrent ischemic priapism episodes requiring emergency corporal irrigation. After dose titration testosterone was 184 ng/dl and the patient has had no subsequent episodes. Mean International Index of Erectile Function-5 score was 24.8 points. There were no recurrent ischemic priapism episodes after withdrawal of ketoconazole and prednisone, and no reported symptoms of hypogonadism., Conclusions: Ketoconazole and prednisone therapy was well tolerated in these 8 patients with recurrent ischemic priapism, and with testosterone monitoring and dose titration it was successful in preventing recurrent episodes while preserving sexual function.

The purpose of our study was to outline the evaluation of the Peyronie's disease (PD) patient and review the available nonsurgical treatments. A review of the literature on oral, intralesional, external energy, iontophoresis, and mechanical therapies for PD was performed. PubMed was utilized to find all published articles, and several meeting abstracts were reviewed for data ahead of publication. Our medical evaluation of the PD patient is described. The published results of available treatment options are reviewed, with recommendation by the authors for appropriate nonsurgical management of PD. There are no available validated questionnaires for PD, but a thorough history and focused physical examination, including measurement of erect penile deformity, will help the clinician make the diagnosis and guide treatment options. Although there are many published reports that show efficacy of nonsurgical therapies for PD, there is a lack of large-scale, multicenter, controlled clinical trials, which makes treatment recommendations difficult. Careful review of the literature does suggest that there are treatment options that make scientific sense and appear to stabilize the disease process, reduce deformity, and improve function. Offering no treatment at all will encourage our patients to pursue alternative treatments that may do harm, and misses the opportunity to do some good. Clearly, further work is necessary to develop safe and effective nonsurgical treatments for PD.

Introduction: Peyronie's disease (PD) is a relatively common disorder affecting middle aged men. Conservative nonsurgical treatments include oral, topical, and intra-lesional pharmacotherapies, vacuum stretching, and mechanical traction., Methods: Four people with expertise and/or interest in the area of PD were asked to contribute their opinions with regard to the safety and efficacy of nonsurgical conservative treatments., Main Outcome Measure: To provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine., Results: Of the four experts writing on the topic, one believes a combination of medical therapy and penile traction has positive potential for curvature. Another feels that although medical therapies have potential to alleviate pain, there is little evidence to show that they help with curvature or that penile traction helps. A third expert proposes dividing the disease into phases, where patients in the acute phase may benefit from conservative therapy, whereas patients whose disease is stable require surgical intervention. The last expert agrees that the therapy should depend on the stage of the disease, but believes like the first expert that there is a role for traction therapy for patients with stable disease., Conclusion: There is a need for guidelines for nonsurgical therapies for patients with PD, but there is a paucity of evidence as to their efficacy.

Introduction: Limited publications exist regarding long-term outcomes of surgical correction for Peyronie's Disease (PD)., Aim: To report on long-term postoperative parameters including rigidity, curvature, length, sensation, function, and patient satisfaction in men with PD treated surgically via Tunica Albuginea Plication (TAP) or Partial Plaque Excision with Tutoplast Human Pericardial Grafting (PEG)., Main Outcome Measures: Objective and subjective data regarding patients who underwent either TAP or PEG., Methods: We report on 142 patients (61 TAP and 81 PEG) with both objective data and subjective patient reports on their postoperative experience. Patients underwent either TAP or PEG following our previously published algorithm. Data was collected via chart review and an internally generated survey, in which patients were asked about their rigidity, straightness, penile length, sensation, sexual function and satisfaction., Results: Average follow up for TAP patients was 72 months (range 8-147) and 58 months (range 6-185) for PEG patients. At survey time, 93% of TAP and 91% of PEG patients reported curvatures of less than 30o. Rigidity was reportedly as good as or better than preoperative in 81% of TAP and 68% of PEG patients, and was adequate for coitus in 90% of TAP and 79% of PEG patients with or without the use of PDE5i. Objective flaccid stretched penile length measurements obtained pre and postoperatively show an average overall length gain of 0.6 cm (range -3.5-3.5) for TAP and 0.2 cm (range -1.5-2.0) for PEG patients. Sensation was reportedly as good as or better than preoperative in 69% of both TAP and PEG patients; 98% of TAP patients and 90% of PEG are able to achieve orgasm. 82% of TAP patients and 75% of PEG patients were either very satisfied or satisfied., Conclusion: Our long-term results support both TAP and PEG as durable surgical therapy for men with clinically significant PD.

Four weeks after bilateral nerve-sparing radical retropubic prostatectomy, men with normal erectile function before surgery were randomized to double-blind sildenafil (50 or 100 mg) or placebo nightly for 36 weeks, followed by an 8-week drug-free period before assessment of erectile function. Enrollment was prematurely ceased and only 76 men completed because, assuming a placebo response rate similar to the published literature (for example, 34% in meta-analysis), the 25% response at blinded interim review suggested a lack of treatment effect. On the contrary, spontaneous erectile function (a combined score of >or=8 for questions 3 and 4 of the International Index of Erectile Function and a positive response to 'Were erections good enough for satisfactory sexual activity?') occurred in only 4% of the placebo group (n=1 of 25) versus 27% (n=14 of 51, P=0.0156, Fisher's exact test) of the sildenafil group. Nightly sildenafil administration for 36 weeks after surgery markedly increased the return of normal spontaneous erections.

Purpose: We assessed the long-term efficacy, complications and patient perceptions of microsurgical denervation of the spermatic cord in the treatment of chronic orchialgia., Materials and Methods: Microsurgical denervation of the spermatic cord was performed on 95 testicular units in 79 men (mean age 40.3 years, mean duration of pain 62 months, 16 bilateral) for chronic orchialgia. Conservative management failed in all, and patients were evaluated with an extensive medical history and physical examination. To be a candidate for microsurgical denervation of the spermatic cord each man would have responded either completely or partially to spermatic cord block (greater than 50% decrease in pain) and had no identifiable reversible etiology. Postoperative pain rating scales (0 to 10) were used to determine efficacy., Results: Mean followup was 20.3 months (range 1 to 102 months) and complete, durable relief was noted in 67 (71%) testicular units, partial relief in 17 (17%), and unchanged in 11 (12%). No patients reported worse pain. Complications included testicular atrophy without hypogonadism in 2 patients, superficial wound infection in 2, hydrocele in 2 and an incisional hematoma in 1., Conclusions: Microsurgical denervation of the spermatic cord is a minimally invasive, effective and durable management option for treatment of chronic orchialgia refractory to medical management, preserving the physiological function and psychological role of the testes.

Purpose: Peyronie's disease is a fibrotic disorder of the tunica albuginea characterized by the localized formation of an inelastic plaque. We characterized matrix metalloproteinases and TIMPs (tissue inhibitors of matrix metalloproteinase) in Peyronie's disease tissue., Materials and Methods: Matrix metalloproteinases and TIMPs were investigated in Peyronie's disease plaque tunica removed from patients with stable Peyronie's disease. Immunological methods were used to characterize the matrix metalloproteinases and TIMPs produced by cell cultures stimulated with transforming growth factor-beta or interleukin-1beta (PreproTech, Rocky Hill, New Jersey). Enzyme activity was quantified with a fluorescent substrate and correlated with mRNA levels using real-time polymerase chain reaction., Results: Interleukin-1beta significantly induced (p <0.01) matrix metalloproteinase-1, 3, 10 and 13 protein production, endogenous matrix metalloproteinase-13 activity (12-fold) and matrix metalloproteinase-13 mRNA expression (11.2-fold) through a Ca(2+) independent mechanism in cultured fibroblasts. Transforming growth factor-beta stimulation failed to induce any detectable matrix metalloproteinase protein production or activity and conditioned culture medium even had the capacity to inhibit (p <0.01) the activity of purified recombinant human matrix metalloproteinase-13. Intact Peyronie's disease plaques were highly enriched with TIMP-1 to 4 compared to donor matched perilesional tunica., Conclusions: These data show that, while interleukin-1beta strongly induces matrix metalloproteinase expression, transforming growth factor-beta strongly induces TIMP expression without any effect on matrix metalloproteinases and may represent an important downstream biochemical mechanism that leads to the progression of Peyronie's disease. The localized accumulation of TIMPs together with decreased matrix metalloproteinase activity in the Peyronie's disease lesion may be the biochemical consequence of the transforming growth factor-beta over expression that has been reported in many fibrotic disorders, including Peyronie's disease.

Introduction: Peyronie's disease (PD) is a fibrotic disorder of the penis whose etiopathophysiology remains unclear. At this time, there is no known reliable nonsurgical treatment. This study reviews our experience with external penile traction therapy to correct the deformity associated with this disorder., Aim: To evaluate prolonged external penile traction as a nonsurgical treatment for PD., Methods: Ten men with PD completed this noncontrolled pilot study of traction therapy using the FastSize Penile Extender. Nearly all (90%) had failed prior medical therapy. Traction was applied as the only treatment for 2-8 hours/day for 6 months. All subjects underwent pre- and post-treatment physical examination including measurement of stretched flaccid penile length (SPL) and biothesiometry., Main Outcome Measures: Curvature and girth were measured during erection before and after treatment with dynamic duplex ultrasound. Assessment of erectile and sexual function was further assessed with the International Index of Erectile Function and Quality of Life Specific to Male Erection Difficulties (QOL-MED) questionnaires. At 3 and 6 months post-treatment, SPL was measured and subjective assessment of deformity by the patient was recorded., Results: Subjectively all men noted reduced curvature estimated at 10-40 degrees, increased penile length (1-2.5 cm) and enhanced girth in areas of indentation or narrowing. Objective measures demonstrated reduced curvature in all men from 10-45 degrees; average reduction for the group was 33% (51-34 degrees). SPL increased 0.5-2.0 cm and erect girth increased 0.5-1.0 cm with correction of hinge effect in four out of four men. International Index of Erectile Function-erectile function domain increased from 18.3-23.6 for the group. Changes in quality of life by QOL-MED were not found to be statistically significant in this small series. There were no adverse events including skin changes, ulcerations, hypoesthesia or diminished rigidity., Conclusion: Prolonged daily external penile traction therapy is a new approach for the nonsurgical treatment of PD. Further study appears warranted given the response noted in this pilot study.

This paper reports on the scientific principles, treatment protocol and initial trial results of the FastSize Medical Extender, a new medical device developed for the treatment of Peyronie's disease and phalloplasty utilizing controlled periodic stretching of the penis; other uses of the device are also mentioned. Initial Institutional Review Boards monitored clinical trials of the device indicate that significant (10-45 degrees ) improvement in curvatures are achievable and that larger scale trials are therefore justified. The device appears to meet a previously unmet need within the population of Peyronie's disease sufferers for a noninvasive, nonsurgical first-option treatment modality. The device works by holding the penis in a cradle and subjecting it to gentle stretching, the tension being provided by small metal extensions that are added to the cradle frame to provide traction against internal springs. Patient education is minimal for the device, but patient compliance with the extended daily treatment procedure is critical for significant curvature change. While a review of appropriate reimbursement codes has not been conducted, the pricing of the device makes it easily affordable. Although it has not yet been formally studied, the device also appears to have applications beyond Peyronie's disease; such as offering potential for offsetting penile shortening prior to implant surgery, preventing shortening following PD penile reconstruction and after radical prostatectomy where loss of penile length is commonly reported. The recent trial noted that, over a 6-month period, patients reported increases in penile length of 1-2.0 cm, with an accompanying increase in girth. There are no alternative devices available that have proven efficacy as a result of a clinical trial and, given reproducible results, the device will begin to play an important role in treatments that require penile tissue remodeling. Future developments should include larger scale, multicenter trials aimed at reproducing the results of the initial study on Peyronie's disease, also trials in conjunction with pharmacological treatment involving plaque remodeling agents such as verapamil and interferon, and trials that will investigate the possible benefits of the device for penile enlargement that may help pre- and postsurgical candidates for penile implants and penile reconstruction following prostatectomy.

Introduction: After bilateral nerve-sparing radical retropubic prostatectomy (BNSRRP), nocturnal and sexually mediated erections may help to preserve normal erectile function (EF)., Aim: To investigate nocturnal penile tumescence and rigidity (NPTR) in a subset (N = 54 men) from a randomized, double-blind trial (N = 76) of nightly sildenafil after BNSRRP., Methods: Inclusion required preoperative "normal" EF (defined as a combined score of >/=8 for International Index of Erectile Function questions 3 (penetration) and 4 (maintained erection after penetration) and NPTR testing (>/=10 continuous minutes of >/=55% rigidity [R >/= 55%] at the base). Postoperative assessments were at weeks 4 (pretreatment), 16, 28, 40 (during 36 weeks of nightly prophylaxis: sildenafil 50 mg [N = 17], 100 mg [N = 18] or placebo [N = 19]), and 48 (after 8 weeks of no erectile dysfunction therapy, when "responders" were delineated by the defined normal EF and a "yes" response to "Over the past 4 weeks, have your erections been good enough for satisfactory sexual activity?"). Base and tip rigidity and tumescence were measured using penile plethysmography., Main Outcome Measures: Duration of R >/= 55% and area under the curves for rigidity and tumescence., Results: Postoperatively, rapid profound reduction in nocturnal EF was noted in all groups. There was a gradual dose-dependent improvement in base and tip rigidity in the sildenafil groups but little improvement in the placebo group. Eight weeks after treatment termination (48 weeks postoperatively), 24% (4/17) of 50-mg sildenafil recipients, 33% (6/18) of 100-mg sildenafil recipients, and 5% (1/19) of placebo recipients were responders. Tip R >/= 55% was the most discriminating NPTR measure between nonresponders and responders to sildenafil, in whom it regained baseline (preoperative) levels (whereas base R >/= 55% did not). It was most prolonged in responders to sildenafil 100 mg., Conclusions: In our subset analysis, nightly sildenafil for 9 months post-BNSRRP objectively improved nocturnal erections and pharmaceutically unassisted EF.

The present paper provides a review of the available non-surgical treatments for Peyronie's disease (PD). A review of published literature on oral, intralesional, external energy and iontophoresis therapies for PD was performed, and the published results of available treatment options reviewed. The authors recommendations for appropriate non-surgical management of PD are provided. Although there are many published reports that show the efficacy of non-surgical therapies for PD, there is a lack of large scale, multicenter controlled clinical trials, which makes treatment recommendations difficult. Careful review of the literature does suggest that there are treatment options that make scientific sense and appear to stabilize the disease process, reduce deformity, and improve function. Offering no treatment at all will encourage our patients to pursue alternative treatments, which might do harm, and misses the opportunity to do some good. Clearly further work is necessary to develop safe and effective non-surgical treatments for PD.

Peyronie's disease is a psychologically and physically devastating disorder that is manifest by a fibrous inelastic scar of the tunica albuginea, resulting in palpable penile scar in the flaccid condition and causing penile deformity, including penile curvature, hinging, narrowing, shortening, and painful erections. Peyronie's disease remains a considerable therapeutic dilemma even to today's practicing physicians.

Purpose: We report our experience with buccal mucosa grafts for anterior urethral strictures. We compared outcomes in the pendulous and bulbar urethra as well as the impact of lichen sclerosus on success., Materials and Methods: A total of 53 men underwent buccal mucosa graft urethroplasty from 1997 to 2004 for strictures of all etiologies, including lichen sclerosis in 13. Of the patients 46 underwent 1-stage repair and 7 with full-thickness circumferential disease underwent multistage repair. For 1-stage repair strictures were limited to the bulb in 33 cases and they involved the pendulous urethra in 13. A dorsal onlay was used in 24 cases and a ventral onlay was used in 22. For multistage urethroplasty 2 strictures were in the bulbar urethra and 5 were in the pendulous urethra. Success was defined as no postoperative procedures or complications., Results: The success rate of all urethroplasties was 81% (43 of 53 cases) at a mean followup of 52 months. For bulbar vs pendulous urethroplasty the success rate was 86% (30 of 35 cases) vs 72% (13 of 18, p = 0.23). For 1-stage urethroplasty by graft location success was achieved in 20 of 24 cases (83%) for dorsal onlay vs 17 of 22 (77%) for ventral onlay (p = 0.61), in 18 of 21 (86%) for bulbar-dorsal onlay, in 10 of 12 (83%) for bulbar-ventral onlay, in 2 of 3 (66%) for pendulous-dorsal onlay and in 7 of 10 (70%) for pendulous-ventral onlay. For multistage urethroplasty success was achieved in 2 of 2 cases (100%) for bulbar repair vs 4 of 5 (80%) for pendulous repair. In the 13 patients with lichen sclerosus success was achieved in 4 of 8 (50%) with 1-stage repair vs 4 of 5 (80%) with multistage repair (p = 0.28). Complications developed in 10 of 53 cases (19%), including fistula in 1, urinary tract infection in 1 and stricture in 8 that required treatment, including dilation in 3, internal urethrotomy in 4 and perineal urethrostomy in 1. Five of these 8 recurrent strictures (63%) developed in patients with lichen sclerosus, including 4 in urethras in which 1-stage repair was done for lichen sclerosus. There were no donor site complications, postoperative erectile dysfunction or chordee., Conclusions: A buccal mucosa graft placed dorsally or ventrally remains an excellent graft material in the bulbar and pendulous urethra. When lichen sclerosus is present, careful consideration should be given to complete excision of the diseased urethra with multistage repair vs accepting a higher rate of stricture recurrence with 1-stage repair.

Introduction: Peyronie's disease (PD) is a connective tissue disorder with an uncertain etiology that causes penile deformity. The interest in PD and our understanding of the disorder has grown significantly in recent years. Data have shown that several previous beliefs regarding the prevalence, natural history, and treatment of PD were incorrect. The prevalence is significantly higher than the previously reported 1%, and most cases of PD do not spontaneously resolve., Aim: To determine the extent to which newer information about PD has reached physicians who are likely to encounter men with PD and to determine practice patterns regarding this disorder., Methods: We created a survey of 20 questions and mailed it to primary-care physicians (PCPs) and urologists (UROs) in Illinois and Wisconsin., Main Outcome Measures: Responses to individual survey items were totaled., Results: We received 152 responses from PCPs and 98 from UROs for response rates of 43% and 44%, respectively. Survey results revealed the following: 63% of PCPs and 41% of UROs thought the prevalence is less than 1%; 17% of PCPs and 38% of UROs believed PD spontaneously resolves in greater than 50% of cases; 17% of PCPs and 9% of UROs did not think PD occurs in men younger than 40 years of age; 48% of PCPs and 37% of UROs did not believe that PD is frequently associated with ED; 51% of PCPs and 1% of UROs were unsure if any effective medical or surgical treatment for PD existed., Conclusion: These data suggest that many physicians who are very likely to encounter men with PD have incorrect assumptions about the disease, and this can negatively affect diagnosis and treatment of men with PD.

Purpose: While surgery remains the gold standard of therapy to correct the acquired curvature of Peyronie's disease, the search for a less invasive therapy continues. Transdermal drug delivery was proposed to be superior to oral or injection therapy because it bypasses hepatic metabolism and minimizes the pain of injection. After electromotive drug administration with verapamil tunica albuginea specimens were demonstrated to contain detectable levels of the drug. Due to varying success with verapamil as injectable therapy for Peyronie's disease we performed a double-blind, placebo controlled trial to determine the effectiveness of verapamil delivered through electromotive drug administration., Materials and Methods: A total of 42 men with Peyronie's disease volunteered to participate in this study, which was approved by our institutional review board. A genitourinary examination was performed on all patients, including plaque location, stretched penile length, objective measurement of curvature after papaverine injection and duplex ultrasound. Each subject was randomized to receive 10 mg verapamil in 4 cc saline or 4 cc saline via electromotive drug administration. A Mini-Physionizer (Physion, Mirandola, Italy) device was used at a power of 2.4 mA for 20 minutes. Treatments were performed 2 times weekly for 3 months. After 3 months each patient was reevaluated with physical examination and duplex ultrasound by a technician blinded to the treatment received. A modified erectile dysfunction index of treatment satisfaction questionnaire was also completed by each patient., Results: A total of 23 patients were randomized to the verapamil treatment group (group 1) and 19 were randomized to the saline group (group 2). There were no significant differences between patient groups with respect to patient age, disease duration or pretreatment curvature. In group 1, 15 patients (65%) had measured improvement (mean 9.1 degrees, range 5 to 30), 5 (22%) had no change and in 3 (13%) the condition worsened. In group 2, 11 patients (58%) had measured improvement (mean 7.6 degrees, range 5 to 30), 7 (37%) showed no change and in 1 (5%) the condition worsened. To better evaluate effectiveness the total number of patients experiencing significant improvement (20 degrees or greater) was calculated and compared. Seven patients (30%) in group 1 and 4 (21%) in group 2 achieved this criterion. Although a greater percent of patients treated with verapamil had improved curvature, the results were not statistically significant., Conclusions: Although a greater percent of patients treated with verapamil in our electromotive drug administration protocol had a measured decrease in curvature, the results were not statistically significant. Further research is necessary to determine whether electric current may have a role in the treatment of Peyronie's disease as well as if verapamil delivered via electromotive drug administration may have a role as effective treatment. Electromotive drug administration is a treatment option in the patient whose major complaint is pain or in the patient with mild curvature who does not wish to undergo intralesional therapy or surgical correction.

Purpose: We evaluated long-term viability, quality of life and satisfaction with the redesigned 2 piece Ambicor inflatable penile prosthesis. This device underwent revision of the rear tip extender and reinforcement of the pump tubing connection to decrease fluid leak failure in 1998., Materials and Methods: In this retrospective analysis we evaluated 146 men with erectile dysfunction at 2 centers who underwent device implantation between June 1999 and October 2004 with the redesigned prosthesis. Patient information forms were completed, including patient history, surgical information and revision data. Patients were mailed a modified Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire, a modified Erectile Dysfunction Inventory of Treatment Satisfaction Partner survey and a questionnaire regarding pertinent inflatable penile prosthesis questions., Results: A total of 146 men with a mean age of 58.7 years (range 25 to 78) were evaluated after inflatable penile prosthesis placement. Time from implant to followup was 3 to 73 months (mean 38). Only 1 device (0.7%) was removed due to infection. One implant (0.7%) was replaced due to fluid loss and 1 (0.7%) was revised due to improper sizing. Kaplan-Meier life table analysis indicated that the percent of patients free from reoperation was 99.2% at 12 months, 99.2% at 36 months and 91% at 48 months or greater. Of the 101 subjects completing the survey the average patient used the prosthesis 5 times monthly and 88.9% reported continued use. Of the patients 91% said that it was easy to use and 95% had little to no trouble learning to use it, while 84% stated that the inflatable penile prosthesis provided good to excellent rigidity for coitus. Overall patient and partner satisfaction was 85% and 76%, respectively. Of the patients 86% said that they would recommend the prosthesis to friends or if need be undergo the procedure again., Conclusions: The redesigned Ambicor 2-piece penile prosthesis appears to be safe and effective. It is associated with a low rate of revision as well as high patient and partner satisfaction.

Purpose: We evaluated the efficacy and mechanism of failure in a small case series of VasClip vasectomies., Materials and Methods: Between September 2003 and March 2004, 8 patients underwent elective vasectomy using the VasClip ligation band. Microscopic semen analysis was done a minimum of 4 weeks postoperatively and after at least 15 ejaculations. The number of sperm and motility were quantified in 15 or more high power fields. Successful vasectomy was defined as 2 consecutive postoperative unspun semen analyses containing no sperm. Patients with failed vasectomy underwent bilateral surgical removal of the vas deferens segments containing the ligation band for gross and histological analysis., Results: Six of 8 patients (75%) were deemed azoospermic after 2 semen analyses at a mean followup of 7 and 11 weeks postoperatively, respectively. Two of 8 patients (25%) had semen analyses containing multiple motile sperm after vasectomy. In the 2 failed cases 1 side was patent, as demonstrated by vasal cannulation and irrigation with dilute methylene blue despite a well positioned, intact and secure ligation band. Histological analysis showed extravasation and sperm granuloma on the patent side., Conclusions: The VasClip was found to fail at an unexpectedly high rate. Pathological analysis suggests sperm extravasation and fistula tract formation as the mechanism. One failure resulted in an unwanted pregnancy, which demonstrates the need for patient counseling regarding postoperative followup.

The extensive sildenafil citrate erectile dysfunction (ED) database of double-blind, placebo-controlled clinical trials was examined to determine the relation between erection hardness graded on the Erectile Hardness Grading Scale (EHGS) and (1) erectile function (EF), as assessed by the EF domain of the International Index of Erectile Function (IIEF); (2) frequency of erections hard enough for penetration, as assessed by IIEF Q2; and (3) the percentage of successful sexual intercourse attempts according to patient event logs. Pooled data from 6549 men with ED provided strong proof and improved characterization of the response to sildenafil. Almost half of men with ED and a baseline IIEF EF domain score classified as "severe ED" (< or = 10) shifted to a score classified as "no ED" (> or = 26). Sildenafil recipients showed greater mean improvement from baseline to end point in IIEF Q2 scores versus placebo, regardless of baseline ED severity, and a higher mean percentage of successful sexual intercourse attempts occurred during the last 4 weeks of treatment versus placebo (5.4-fold vs 2.0-fold increase from baseline). At end point, 95% of men who scored "no ED" on the IIEF EF domain and 92% of men who reported "almost always/always" achieving an erection hard enough for penetration (IIEF Q2) had graded their erections hard (rigid) enough for penetration (grade 3) or completely hard and fully rigid (grade 4) during the last 4 weeks of treatment, suggesting that the IIEF EF domain and IIEF Q2 may be good surrogate end points for erection hardness. Furthermore, during the last 4 weeks of treatment, the percentage of grade 3 and/or 4 erections correlated positively with the percentage of successful sexual intercourse attempts. Hence, hard erections may be considered a unifying factor that defines response to ED treatment. Completely hard and fully rigid erections (grade 4) should be recognized as the optimal goal of an ED therapy. Evidence presented here demonstrates that sildenafil significantly improved EF as assessed by the IIEF EF domain and assessments of erection hardness in patients with ED; a dose-response relation was observed in the proportions of men with ED who graded their erections hard (rigid) enough for sexual penetration or completely hard and fully rigid.

Background: Erectile dysfunction (ED) may be one manifestation of a generalized vascular disorder characterized by endothelial dysfunction. Statin drugs may improve endothelial function, even before altering the lipid profile., Objective: We sought to determine whether the addition of a statin with sildenafil would improve ED in men who initially responded poorly to sildenafil., Methods: Men with moderate-to-severe ED despite an adequate sildenafil trial were enrolled in this randomized, double-blind, placebo-controlled pilot study. ED was defined using a validated self-administered questionnaire as a score of

Purpose: Loss of length is a common postoperative complaint of the patient who undergoes surgical correction of penile curvature. We investigate the factors influencing complications in patients who have undergone TAP for PD and chordee., Materials and Methods: A total of 102 patients underwent TAP for PD (68) or chordee (34) between 1997 and 2004. Data were gathered on each patient's preoperative complaints, physical examination, Doppler ultrasound, operative data and postoperative complaints. For the purposes of this study penile length was measured from pubis to corona along the dorsal surface of the stretched phallus., Results: Mean ages at surgery for men with PD and chordee were 53 and 24, respectively. A range of 1 to 6 plications were performed on each patient (mean 3) with an acceptably straight penis (curve less than 20 degrees) being achieved in 99% of patients. Mean followup for our patient population was 29 months and revealed only 1 patient with residual curvature. The mean loss in length after TAP was 0.36 +/- 0.5 cm with a range of 0 to 2.5 cm. When calculated as a percent of length lost from preoperative length, the postoperative percent length lost was 2.4%. When stratified into groups based on direction of curvature, the patients with ventral or ventrolateral curve had the highest percent loss of length. A 1-way ANOVA of these groups proved the differences between each group to be statistically significant (p = 0.04). Length change also significantly correlated with preoperative stretched penile length and the severity of curvature as measured in degrees in the operating room at time of surgery. Parameters that did not demonstrate a statistically significant impact on penile shortening included patient age, number of plications performed, plaque size, and hinge/narrowing effect due to a PD plaque., Conclusions: The TAP procedure is a safe and effective means of correcting penile curvature, with similar overall outcomes between patients with PD and chordee. Shortening of the penis does commonly occur but is dependent on direction and degree of curvature, as well as the length of the phallus.

This paper reports the binding of an artificial tetrapeptide to which are tethered four Pt(II) complexes (i.e., [Pt(tpy)(py)]48+) with a 12 base pair duplex DNA oligonucleotide. Isothermal Titration Calorimetry reveals that two tetrametallic peptides stoichiometrically bind to each DNA duplex with a binding constant, KB, of 1.7 x 106 M-1, with a change in free energy of -8.5 kcal/mol. This KB represents an affinity 2 orders of magnitude greater than that of the monometallic analogue [Pt(tpy)(pic)]2+ for the same dsDNA sequence. The metalated peptides bind by intercalation into the DNA, partially unwinding the helix while stabilizing the structure, causing an increase in the dsDNA melting temperature of 25 degrees C.

The investigation of medical options for the treatment of Peyronie's disease is lacking controlled clinical trials with uniform standardized assessments and objective measures of deformity, including curvature and circumference. A key to defining the beneficial effects of various medical therapies lies in standardizing the evaluation of the Peyronie's patient across various studies so that the proposed benefits can be confirmed and applied to all populations. Furthermore, basic science research into the pathophysiology of this disorder is likely to yield new insights into potential treatment options and direct future therapies.

Introduction: Peyronie's disease (PD) is correctable by several surgical approaches including plaque incision with grafting. While the best choice of graft material remains controversial, the risk of postoperative erectile dysfunction (ED) is apparent across previous reports., Aim: We attempt to provide guidelines as to which patients may be at increased risk for developing postoperative ED after this procedure, as well as examine the role of sildenafil citrate (SC) in the postoperative period for prevention of this complication., Materials and Methods: A retrospective review was performed on 37 patients who underwent surgical correction of PD with pericardial grafting after plaque incision. Mean follow-up was 24 months. We evaluated patient age, duration of disease, defect size, plaque location, degree of curvature, shaft narrowing, preoperative coital activity, vascular risk factors for ED, as well as preoperative erection grade and duplex ultrasound parameters. Twenty-six of these patients underwent a postoperative rehabilitation protocol of SC to enhance recovery of unassisted erections., Results: Overall, 11 patients (29%) noted diminished postoperative rigidity, that compromised unassisted coitus, compared to preoperative status. Comparison of rates of ED among those with or without vascular risk factors yielded no statistically significant results. Peyronie's disease duration, patient age, defect size, plaque location, degree of curvature, and narrowing were also insignificant predictors of which patients developed ED. An increased percentage of patients who developed ED were not sexually active preoperatively compared to those that did not develop ED (58% vs. 80%). When patients were compared based on preoperative erection grade, those patients with compromised erectile function were more likely to develop postoperative ED vs. those with full erections (P < 0.05). No significant differences were found in preoperative duplex ultrasound parameters between both sets of patients. For those undergoing SC rehabilitation, 7 out of 26 (26%) developed ED in comparison to 4 out of 11 patients (36%) developing diminished rigidity when not subjected to the protocol., Conclusions: No single parameter was found that predicted the occurrence of postoperative ED with the exception of preoperative erectile status. The surgeon must carefully assess and consult each patient when considering grafting as well as consider the possible role of SC in attempting to prevent this complication.

Treatment of erectile dysfunction may now be approached in a variety of ways. The hope is to provide a treatment that is reliable, safe, and effective as well as acceptable to the patient. Many men are not candidates for surgery and may fail or have contraindications to medical therapy. This article addresses the oldest available form of noninvasive device therapy for the restoration of erectile function., (Copyright 2004 Humana Press Inc.)

Purpose: In patients with stable penile deformity secondary to Peyronie's disease (PD) penile straightening can be achieved with plaque incision or partial excision and grafting. We present our experience with human cadaveric pericardium for tunica albuginea grafting for men undergoing penile reconstruction for Peyronie's disease., Materials and Methods: We retrospectively reviewed our experience with 40 men with PD who underwent penile straightening with partial plaque excision and grafting using human cadaveric pericardium from January 1999 to January 2003., Results: All 40 men were evaluable for preoperative, operative and postoperative characteristics. Mean postoperative followup was 22.0 months. Mean preoperative penile curvature was 69.1 degrees. Subjectively 36 of the 40 patients (90%) graded preoperative erection as sufficiently rigid for coitus and 100% had sufficiently rigid erection for coitus following intracorporeal papaverine injection. Mean pericardial graft size was 4.9 x 4.8 cm. Postoperatively 39 of the 40 patients (98%) had successful penile straightening, 38 (95%) achieved coitus, 28 (70%) achieved full, unaided erection and 12 (30%) had some degree of erectile dysfunction (ED) requiring pharmacological assistance for intercourse. There were no significant differences in ED risk factors, plaque location, graft size or complications in men who did and did not have ED postoperatively (p >0.05). There were no major complications or graft related adverse events., Conclusions: Human cadaveric pericardium is a safe, readily available and pliable tissue for tunica albuginea grafting following PD plaque incision or partial excision. Careful patient selection must be emphasized and particular attention must be given to deformity stability and preoperative erectile function to maximize surgical outcome.

The current nonsurgical treatment options for men with Peyronie's disease is reviewed. The treatments currently employed and published in the English literature are discussed. A wide variety of nonsurgical treatment options are available to the practicing physician, including oral and topical medications, intralesional injection therapy, as well as employing external energy sources to drive medicine into the tunica albuginea by iontophoresis or direct stimulation of plaque change by shock wave therapy. Nonsurgical treatment of Peyronie's disease clearly has a place in the armamentarium of the practicing urologist. Oral therapy appears to have little therapeutic benefit. Injection and topical approaches deserve further attention. Yet, no single treatment stands out as the most effective remedy for all men with Peyronie's disease. Further controlled, large-scale studies are necessary to establish the benefits of these nonsurgical approaches. In the meantime, combination therapy appears to make sense in the nonsurgical treatment of men with Peyronie's disease.