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Erectile Dysfunction (ED) is defined as the inability to obtain or maintain an erection firm enough for satisfactory sexual performance and affects the quality of life of over 50% of men aged over 40 years. Venogenic ED is elucidated as a cause in a subgroup of patients. The study aims to investigate the clinical success, technical success, safety and durability of venous embolisation for management of venogenic ED.After providing informed consent, and subsequent to confirmation of venogenic ED by Doppler ultrasound (dUS) and cavernosography, 80 men referred for cavernosography and pelvic vein embolisation, will undergo randomisation by a computer system either to treatment or sham groups. Efficacy will be assessed using dUS and a validated questionnaire, the International Index of Erectile Function (IIEF). Pharmacologic agents used during the trial will be recorded. The primary outcome of PiVET-ED is to establish clinical success at 3 and 6 months post venous embolisation, as defined by end diastolic velocity in the cavernosal artery 5 cm/s with dUS and by a 4-point improvement in IIEF. Durability of the embolisation procedure will be assessed annually to 5 years. Quality of life will be assessed at all study time points using the 36-Item Short Form Survey (SF-36).The PiVET-ED trial is a prospective, randomised, single-blinded, single centre, sham controlled study, which aims to establish the safety, efficacy and durability of pelvic vein embolisation for the treatment of venogenic erectile dysfunction.Australian New Zealand Clinical Trials Registry ACTRN12620001023943, 08/10/2020.

Injection of exogenous material into the penis and scrotum has been performed for augmentation purposes. Complications include cosmetic dissatisfaction, penile necrosis and lymphoedema. We report the complications and outcomes from a single centre with an updated systematic review of the literature. A retrospective review of all cases presenting with foreign substance injection into the genitalia, over a 10-year period was performed. Thirty-five patients with a mean (standard deviation (SD); range) age of 36.9 (±9.1; 22–61) years at presentation were included. The mean (SD; range) time between injection and presentation was 7.8 (±5.8; 1 day–20 years) years. The most common injected substance was silicone (n = 16, 45.7%) and liquid paraffin (n = 8, 22.9%). The penile shaft (94.3%) was the most injected site. The most common presentations were cosmetic dissatisfaction (57.1%) and pain and/or swelling (45.7%). Surgery was required in 32 (91.4%) cases. Primary procedures included local excision and primary closure (n = 19, 59.4%), circumcision (n = 5, 15.6%), excision with a split skin graft or a scrotal flap reconstruction (n = 5, 15.6%). Three (8.6%) patients presented with necrosis and required acute debridement. Overall, 18 patients had more than 1 procedure, and 8 patients required 3 or more procedures. A systematic search of the literature identified 887 articles of which 68 studies were included for analysis. The most common substance injected was paraffin (47.7%), followed by silicone (15.8%). The majority of patients (77.9%) presented with pain, swelling or penile deformity. 78.8% of the patients underwent surgical treatment, which included excision and primary closure with or without the use of skin grafts (85.1% of all procedures), the use of flaps (12.3%) and penile amputation (n = 2). Complications of foreign body injection into the male genitalia can be serious resulting in necrosis and autoamputation. Surgical intervention is often required to excise abnormal tissue to manage pain and improve cosmesis.

Penile fractures are the traumatic rupture of the tunica albuginea encasing the corpora cavernosum. We reviewed long-term sexual and urinary outcomes following penile fracture repair. We performed a multicentre retrospective analysis with data from three metropolitan Australian hospital services over a 10-year period. Operative reports were reviewed and patients with intraoperatively confirmed fractures were included. Patients were contacted to complete a survey, composed of validated questionnaires including the International Index of Erectile Function-5 (IIEF-5) and International Prostate Symptom Score (IPSS). We analysed perioperative data against questionnaire responses. 55 patients were identified with penile fractures. 21 patients completed questionnaire follow-up. The median age was 44.8 years; the median time to follow-up was 4.0 years; 95.5% (20) of these cases occurred during sexual intercourse. The median IIEF-5 was 23 (no erectile dysfunction) and median IPSS was 5 (mildly symptomatic). Seven patients (33.3%) suffered bilateral cavernosal injury and eight (38.1%) suffered urethral injury. No significant relationships were found between injury factors and erectile or urinary function. We found promising outcomes for long-term erectile and urinary function. Study limitations include sample size and subjective outcome measurements. To completely define the relationship between injury factors and outcomes, larger cohorts will need to be analysed.

From 2012, the World Professional Association Transgender Health defined a structured therapeutic path and standards of care for transgender patients undergoing genital gender affirming surgery (GGAS). The main goal of GGAS in transgender males is to provide patients with an aesthetically appealing appearance of the neophallus that should allow standing micturition and enabling penetrative intercourse along with erogenous and tactile sensitivity. The optimal procedure should be safe, reproducible and performed in the fewest number of surgical stages. The ideal technique for total phallic construction (TPC) has not yet been demonstrated; TPC remains challenging and, from a functional point of view, it is also make more demanding as yet there are no perfect replacement materials for erectile and urethral tissues. Several procedures and different type of flaps (pedicled and free-flaps) have been proposed and investigated over time to address TPC with significant advances over the years especially after microsurgical procedures introduction. Due to its high complexity TPC is not free from complications. Local tissue ischaemic complications, complete and partial flap loss, donor site morbidity and urethral complications (fistulae and strictures) are reported. This narrative review aims to provide the readers with a contemporary overview of surgical procedures for TPC in transgender males focusing on key surgical steps, as well as surgical and functional outcomes.

Functional and surgical outcomes after surgical correction of adult acquired buried penis (AABP) are limited in the current literature. We retrospectively recruited patients underwent surgical treatment of AABP in a single institution from 2017 to 2021. Surgical repair was classified according to surgical complexity following Pariser-Santucci's classification. The primary endpoint of the study was the recurrence-free rate survival. The secondary endpoints were surgical, functional and patients' reported outcomes. Overall 28 patients were included in the study. Median follow-up was 27.5 (18.5-34.5). The most common complaints at presentation were sexual (53.6%) and voiding (39.3%) dysfunction. Surgical management steps ranged from circumcision to more complex procedures, such as suprapubic fat pad excision, abdominoplasty and/or penile shaft skin grafting. Overall postoperative complications were recorded in 32.1%. High-grade complications (Clavien≥3) occurred in 7.1%. One-year recurrence-free survival was 88.7%. Postoperatively IPSS and IIEF-15 questionnaires showed a significant improvement in urinary 8 (0-12) vs 2 (0-3), p = 0.03 and sexual function 37 (23-68) vs 68 (45-72), p = 0.001 respectively. Overall, patients reported functional improvement and 93.8% experienced a positive impact of QoL. AABP surgical repair, despite the high incidence of complications, seems to allow satisfactory outcomes and a significant improvement in patients' QoL.

To report surgical, functional and patient reported outcomes(PROs) of glansectomy(GS), and split-thickness skin graft(STSG) reconstruction in case of locally invasive penile cancer(PC) MATERIALS AND METHODS: A retrospective analysis from May 2015 to August 2019 was conducted. Inclusion criteria were age80, a "de novo" malignancy, clinically confined PC (≤T2) with histologic confirmation. Complications, recurrence-free(RFS), cancer-free(CFS) and overall survival(OS) were described. Functional outcomes and PROs were explored using validated questionnaires and "ad hoc" created questionnaire respectively. Kaplan-Meier analysis, t-Student and the Mann-Whitney U test were used to estimate survival and postsurgical functional changes respectively.34 patients were enrolled. Median follow-up was 12(IQR:12-41) months. Positive surgical margins were detected in 2.9% of cases, requiring salvage surgery. Postoperative complications occurred in 29.4%, most commonly being a graft partial loss (17.6%), meatal stenosis (5.8%) or genital wound infection (5.8%). Disease recurrence occurred in 17.6% of cases with a median elapsed time of 16 months (12-41). 12-month RFS was 88.2%, whilst CSS and OS were 91% at the same time point. Glans sensation was preserved in 91.2% of cases. 88.2% of patients reported to be fully satisfied with the postoperative aesthetic appearance of the penis, 91.2% of patients would recommend the same procedure to someone else. Limitations include retrospective design and the lack of a control group CONCLUSION: GS with STSG minimizes the impact on urinary and sexual functions without jeopardizing oncological control in locally advanced PC.

Background Nesbit corporoplasty was proposed to address penile curvature (PC), both congenital (CPC) and acquired (APC). Aim To evaluate surgical, functional, and patient reported outcomes (PROs) of a modified corporoplasty. Methods From May 2005 to January 2017, a consecutive series of patients underwent a modified corporoplasty. Data were retrospectively extrapolated. Intra and postoperative complications and hospital stay were recorded as surgical outcomes. 2 validated international questionnaires were administered preoperatively and at 12 months after surgery: International Index of Erectile Function and Sexual Encounter Profile (items 2–3). An “ad hoc” questionnaire was utilized to assess PROs. Outcomes Postoperative surgical and functional outcomes and PROs were the primary outcomes assessed in this study. Results 87 out of 145 patients had complete data available and were included in the study. CPC was noted in 61 patients whilst APC, secondary to Peyronie's disease, was present in 26 patients. Median preoperative PC was 60° (interquartile range [IQR] 45–70). Functional and PROs were evaluated 12 months after surgery for all enrolled patients. Considering surgical outcomes, the median follow-up time was 110 months (IQR 27–132.5). Median operative time was 130 minutes for CPC (IQR 115–150) and 120 minutes for APC (IQR 95–140). Median hospital stay was 2 days for both groups (IQR 1–2). After the median follow-up time of 110 months (IQR 27–132.5), a recurrent curvature was observed in 9.2% of cases. Minor residual curvature (35 years), and postoperative complications represented independent risk factors for the development of postoperative erectile dysfunction. Postoperative complications, in terms of bleeding, infection, or poor esthetic wound healing, occurred in 12.6% of patients. No Clavien-Dindo grade III–IV intraoperative complications were reported. Postoperative hematoma was more frequent in CPC when compared to APC (P = .003). In relation to PROs, 26.4% of patients responded as being dissatisfied with postoperative penile length, with a higher incidence in the APC group (P = .001). Overall, a significant improvement in everyday and sexual life quality was observed in both categories. Clinical Implications The modified corporoplasty described showed better residual curvature rates, whilst maintaining similar PROs even if APC patients reported less favorable outcomes when compared to CPC. Strengths & Limitations The primary limitations of this study are its retrospective nature, no objective evaluation of postoperative curvature, and no penile length assessment. Conclusion The aforementioned corporoplasty may represent an excellent option for PC correction, with low complication rate and high patient satisfaction.

There is limited scientific literature regarding the management outcomes for end-stage erectile dysfunction (ED) following radical cystoprostatectomy (RCP). This study aims to evaluate the surgical outcomes of penile prosthesis (PP) implantation. A retrospective analysis over 17 years (2004-2017) was performed from the clinical records of patients in four tertiary referral centres, whom previously had undergone RCP, followed by PP implantation for end-stage ED. Outcome measures include both intra and postoperative complications, operative duration, a 5-point Likert hematoma scale as well as length of hospital stay. Additionally, a matched-pair cohort analysis was performed, dividing patients in 2 groups according to the type of urinary diversion (neobladder versus ileal conduit/cutaneous ureterostomy). The median time elapsed between RCP and PP implantation was 38 months (IQR 20-56). The median follow-up was 18 months (IQR 12-156). A 3-piece inflatable PP was implanted in 43 patients (91.5%) whereas a semirigid device was implanted in the remainder. Reservoir position was extra-peritoneal (utilising a separate abdominal incision) in 24 patients (54.8%), while an ectopic high-submuscular placement was preferred in the remainder. PP infection and mechanical failure occurred in 1 (2.1%) and 3 cases (6.3%) respectively. The comparative analysis of surgical outcomes did not show any statistically significant difference between the two groups. Our evidence suggests that PP implantation in patients with refractory ED following RCP may represent a safe and effective procedure associated with a low incidence of complications. The main limitation of this study is represented by the non-randomised, retrospective nature as well as the lack of patients' functional outcomes and the limited follow-up.

Significant developments have enabled the transformation of phalloplasty to a functional organ. Differences exist in the surgical placement of a prosthesis when within a phallus, such as the lack of corpora, pubic fixation requirement, distal sock placement, and the consideration of a vascular pedicle. Increased complications compared with nonphalloplasty cohorts remain one of the biggest challenges, including rates of infection, erosion, mechanical malfunction, and malposition. Nonetheless, the placement of penile prosthesis within a phalloplasty enables trans men to achieve a once near-impossible goal of penetrative sexual intercourse without an external device.

INTRODUCTION AND OBJECTIVES:Total penile reconstruction (TPC) is challenging, with surgical goals including an acceptable cosmetic and functional phallus, with restoration of sufficient penile leng...

INTRODUCTION AND OBJECTIVES:The function of the penile suspensory ligament (PSL) is to provide support to the erect penis to and maintain an appropriate angle for sexual intercourse, This paper des...

Objective To review the mechanisms and patient outcomes for men presenting with abnormalities of the penile suspensory ligament (PSL) and their correction. Patients and methods We conducted a retrospective review of a total of 118 patients who presented with a variety of PSL abnormalities that necessitated surgical repair from 1993 to 2018. The patients mean (range) age at presentation was 29 (12-60) years with a mean (range) follow up of 8 months (3 months-12 years). The diagnosis was made clinically, often with a history of penile instability, pain or curvature/torsion, which was confirmed on artificial erection testing. Nocturnal tumescent testing and magnetic resonance imaging were used where necessary. The surgical repair was performed by placing non-absorbable sutures between the tunica albuginea of the penis and the symphysis pubis. Postoperative outcomes were reported in the clinic by direct questioning and a repeat of the investigations above when patients were unsatisfied with the result. Results The aetiologies and surgical indications in the 118 patients included: abnormality subsequent to sexual trauma (n = 66); congenital curvature of penis and/or congenital absence/laxity of the ligament (n = 37); Peyronie's disease (n = 8); and venogenic erectile dysfunction (ED; n = 7). A good surgical result, as defined by stabilization and straightening of the penis and a return to normal sexual function, was achieved in 85% of the patients and 82% were very satisfied with the outcome. Complications included long-term ED in four patients. Conclusion Abnormalities of the PSL are uncommon and often subtle, but with the appropriate diagnosis, a good cosmetic and functional result is usually achievable.

Penile dimensions and related dissatisfaction, may have significant impact upon patients whom undergo andrological surgeries. Whilst penile dimension assessment is performed as part of the andrological evaluation, little is known regarding the surgeons' opinions nor contemporary practices. This study was designed to gain further insights into the opinions and practices of clinicians regarding penile measurement and is the first paper in the literature of its kind. The study was performed by inviting clinicians at andrological/urological conferences to participate in a voluntary 10 point survey concerning penile dimensions. Of 126 responses recorded, 56% (71/126) were andrologists. Of the responders, 45% (56/122) did not routinely perform penile measurement prior to treatment nor were they aware of the standardised method (93/123). The majority 64%(81/126) would measure the penile length from the pubic bone to the tip (79/123) with the penis in a stretched position (99/125). A goniometer was the most common way of assessing penile curvature (37/73) and the length would be measured mostly on the convex side (46/119). Responders felt that, from the patients perspective, a combination of length, girth and shape (51/123), or length only (50/123), were the more important aspects of penile dimensions. As responders were recruited based on their interest in andrological aspects of urology, it may not be representative of the general urological community. In conclusion, attitudes and methods of penile measurement are quite varied amongst surgeons, thus further discussion and investigation of this aspect of andrological care ought to occur.

Much has changed over the past few decades in the management of benign prostatic enlargement. The most exciting aspect however, is in the future—there undoubtedly will arise medical and surgical options which boast vastly improved efficacy and safety compared with current treatments. From humble beginnings of blind incision, much has changed and will continue to do so—medical options including more specific subtypes of alpha blockers, and potential newer hormonal agents are around the corner. A variety of pro-apoptotic agents are also being investigated. Lasers, hydro-dissectors, steam ablation and high intensity ultrasound are just a few of the newer technologies emerging onto the market. Whilst various mechanical stents have been developed, many more will arise. Robotics and excitingly, nano-robotics, provide another frontier awaiting exploration. Regardless of your vantage point, new treatments will arise and we are tasked with the responsibility of applying them appropriately and safely, to facilitate the best improvement for our patients.

With over 4,000 da Vinci robotic systems in operation throughout the world performing mainly prostate and gynaecological surgery there seems to be plenty of capacity and opportunity to expand robotic indications even further. Whilst robotic partial nephrectomy (RPN) has become an established technique in many centres there remains some reluctance to use this technology across the wider spectrum of upper renal tract disease. The enhanced 3-dimensional optics, tremor elimination, precise dissection and suturing ease permitted with the robotic system lends itself to the delicate complexities of upper renal tract surgery. Those aspects of upper tract surgery that require reconstruction are particularly suitable for robotic assistance. Since the first RPN by Gettman et al. [1] in 2005, it has become increasingly obvious that use of the robotic approach has significant benefits in terms of a reduction in warm ischaemia times when compared to laparoscopic surgery [2]. It may also allow a quicker procedure, a reduction in intra-operative complications such as vascular injuries due improved suturing dexterity, and the ability for more surgeons to perform procedures of higher complexity. The recent British Association of Urological Surgeons audit in the United Kingdom [3], where all urologists performing nephrectomies are mandated to submit their personal data each year, shows significant advantages to a robotic approach when compared with the open or laparoscopic counterparts. This audit looked at over 1,400 partial nephrectomies over 3 years across the country and showed improvements in positive margin rates, intra and postoperative complications, and length of hospital stay. There was no recording of warm ischaemic times or tumour complexity in the initial audit so case selection will have had an impact on these results for the different approaches. Despite this the data represents a national perspective rather than just the highest volume centres and seems to clearly indicate that if a minimally invasive partial nephrectomy is indicated, it may be optimally performed robotically. Thus for the vast majority of tumours we feel that RPN represents the current Gold standard. With regards to laparoscopic radical nephrectomy most urologists would not routinely use the robot for this relatively routine task. However we feel there are several potential advantages to its use. For instance the procedure may well be quicker than the standard laparoscopic approach enabling more cases (3 or 4) to be carried out in an all-day operating list. If the robot and maintenance contract are already in place in the hospital it may be cost neutral as many laparoscopic disposables are eliminated such as a Harmonic Scalpel or Ligasure device and disposable ports [4]. Robotic radical nephrectomy uses the same port placement and set-up as partial nephrectomy so is ideal for training within a fellowship programme. Small improvements in the quality of the robotic case may permit increased confidence allowing surgery without using a wound drain or even a urethral catheter. Perhaps the key advantage of robotic radical nephrectomy is the potential to expand the indications for minimally invasive renal surgery to include patients with tumours who would otherwise be deemed too complex for laparoscopic surgery. Most larger tumours >10 cm, those invading adjacent organs, those carried out for cytoreductive indications, or those with clear venous invasion are avoided by laparoscopic nephrectomists. The additional control and dexterity provided by robotics brings many of these cases into the remit of the robotic surgeon. There are now case series of tumours with significant renal vein, levels I–III thrombii successfully managed robotically [5]. The challenge of nephro-ureterectomy for upper tract transitional cell carcinoma (TCC) is often not the nephrectomy component but the ureterectomy component where precise dissection of the distal ureter and accurate closure of the cystotomy defect are paramount. There is no doubt from our perspective, having performed many with both approaches, that compared with laparoscopic surgery the robotic approach adds an increase in quality to this step and also makes lymphadenectomy more feasible. Although costs have been shown to be higher, postoperative complications seem reduced [6]. The optimal bladder closure with a robotic approach permits early removal of catheter, the ability to safely instill intravesical chemotherapy and hence can decrease length of stay. With regards to the less common retroperitoneal procedures the robotic system can usually add some technical quality to the operations. Whilst adrenalectomy is a very established laparoscopic technique, dissection around the great vessels and particularly the inferior vena cava can be fraught with danger. In the event of a major vascular injury use of the enhanced suturing permitted by the da Vinci system may make the difference between conversion to open surgery or salvaging the situation. Less stressful reconstructive procedures such a dismembered pyeloplasty, ureteric reimplantation and ureterolysis for retroperitoneal fibrosis may all benefit from robotic dexterity [7]. There are however many potential disadvantages of using the robot over a pure laparoscopic approach. The main downside stated is clearly cost as the system still costs almost $1.5 million to purchase and comes with an expensive maintenance contract. If the robot has already been purchased for pelvic surgery (prostate/gynaecology) then these costs are far less, and extending indications to the upper tract becomes more appealing. From a practical perspective there are also disadvantages in terms of robotic specific complications due to untrained and inexperienced use of the system. The distance between the console surgeon and the assistant can lead to misunderstanding and poor communication whilst operating in an area where significant bleeding can occur without warning with dramatic consequences. Judging tension when elevating structures takes experience and although suturing is easier it still requires training and practice. Assistant instruments can occasionally become inadvertently lodged beneath robotic arms due to lack of tactile feedback and diathermy arcing can occur from robotic scissors into adjacent structures causing damage and potential haemorrhage. Like all complex surgical tools dedication to training and ongoing audit and assessment of one's performance are vital. Despite these potential problems overall we feel that units with an established robotic programme should try and get the most out of their costly equipment. Expanding the upper tract programme has many potential advantages in terms of health economics and clinical delivery. When compared to laparoscopic procedures it is often possible to perform a whole range of operations more quickly, more safely and with additional quality in an integrated robotic renal tract programme. When it comes to the upper urinary tract we feel the sky's the limit.