Eugen Molodysky

Advances in understanding of mammalian penile evolution, human penile anatomy and human erection physiology: Clinical implications for physicians and surgeons

Summary Recent studies substantiate a model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat spanning from the bulbospongiosus and ischiocavernosus proximally and extending continuously into the distal ligament within the glans penis. The anatomical location and histology of the distal ligament invites convincing parallels with the quadrupedal os penis and therefore constitutes potential evidence of the evolutionary process. In the corpora cavernosa, a chamber design is responsible for facilitating rigid erections. For investigating its venous factors exclusively, hemodynamic studies have been performed on both fresh and defrosted human male cadavers. In each case, a rigid erection was unequivocally attainable following venous removal. This clearly has significant ramifications in relation to penile venous surgery and its role in treating impotent patients. One deep dorsal vein, 2 cavernosal veins and 2 pairs of para-arterial veins (as opposed to 1 single vein) are situated between Buck’s fascia and the tunica albuginea. These newfound insights into penile tunical, venous anatomy and erection physiology were inspired by and, in turn, enhance clinical applications routinely encountered by physicians and surgeons, such as penile morphological reconstruction, penile implantation and penile venous surgery.

Penile Veins Are the Principal Component in Erectile Rigidity: A Study of Penile Venous Stripping on Defrosted Human Cadavers

The human erectile mechanism is an intricate interplay of hormonal, vascular, neurological, sinusoidal, pharmacological, and psychological factors. However, the relative influence of each respective component remains somewhat unclear, and merits further study. We investigated the role of venous outflow in an attempt to isolate the key determinant of erectile function. Dynamic infusion cavernosometry and cavernosography was conducted on 15 defrosted human cadavers, both before and after the systematic removal and ligation of erection-related penile veins. Preoperatively, an infusion rate of more than 28.1 mL/min (from more than 14.0 to 85.0 mL/min) was required to induce a rigid erection (defined as intracavernosal pressure [ICP] exceeding 90 mmHg). Following surgery, we were able to obtain the same result at a rate of 7.3 mL/min (from 3.1 to 13.5 mL/min) across the entire sample. Thus, we witnessed statistically significant postoperative differences (all P ≤ .01), consistently elevated ICP, lower perfusion volumes, and a general reduction in time taken to attain rigidity. The cavernosograms provided further evidence substantiating the critical role played by erection-related veins, whereas histological samples confirmed the postoperative integrity of the corpora cavernosa. Given that our use of cadavers eliminated the influence of hormonal, arterial, neurological, sinusoidal, pharmacological, and psychological factors, we believe that our study demonstrates that the human erection is fundamentally a mechanical event contingent on venous competence.

Simple microwave and thermal cycler boiling methods for preparation of cervicovaginal lavage cell samples prior to PCR for human papillomavirus detection

Sample preparation is an important step in the detection of viral DNA by the polymerase chain reaction (PCR) technique. The method used should achieve release of cellular DNA with the minimum of manipulation steps so as to reduce the possibility of contamination. The present report demonstrates that either microwaving or 20 min of boiling in the heating block of a thermal cycler lead to satisfactory results in the detection by PCR of human papillomavirus in cervicovaginal epithelial cell specimens obtained by lavage. Since each of these methods uses only one step the possibility of contamination is greatly reduced compared to the widely used proteins K/nonionic detergent extraction procedure.

Penile vascular surgery for treating erectile dysfunction: Current role and future direction.

Abstract Penile vascular surgery for treating erectile dysfunction (ED) is still regarded cautiously. Thus we reviewed relevant publications from the last decade, summarising evidence-based reports consistent with the pessimistic consensus and, by contrast, the optimistically viable options for vascular reconstruction for ED published after 2003. Recent studies support a revised model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat. Additional studies show a more sophisticated venous drainage system than previously understood, and most significantly, that the emissary veins can be easily occluded by the shearing action elicited by the inner and outer layers of the tunica albuginea. Pascal’s law has been shown to be a significant, if not the major, factor in erectile mechanics, with recent haemodynamic studies on fresh and defrosted human cadavers showing rigid erections despite the lack of endothelial activity. Reports on revascularisation surgery support its utility in treating arterial trauma in young males, and with localised arterial occlusive disease in the older man. Penile venous stripping surgery has been shown to be beneficial in correcting veno-occlusive dysfunction, with outstanding results. The traditional complications of irreversible penile numbness and deformity have been virtually eliminated, with the venous ligation technique superseding venous cautery. Penile vascular reconstructive surgery is viable if, and only if, the surgical handling is appropriate using a sound method. It should be a promising option in the near future.

Reconstructive surgery for idealising penile shape and restoring erectile function in patients with penile dysmorphology and erectile dysfunction.

Abstract Objective: To report an innovative combination of two surgical procedures to treat patients with erectile dysfunction and penile deviation, arising from advances in penile anatomy. Patients and methods: From October 1998 to October 2011, 132 men (aged 23–39 years) underwent penile venous stripping and corporoplasty. Of these, 37 were allocated to a transverse and 95 to a longitudinal group, with an infrapubic transverse or pubic median longitudinal approach, respectively. The abridged five-item version of the International Index of Erectile Function (IIEF-5) and cavernosography were used for assessment, as necessary. Under acupuncture-aided local anaesthesia, and after a circumferential incision, the deep dorsal vein and cavernous veins were completely stripped, with 6-0 Nylon sutures for ligation, followed by tunical surgery for correcting the penile shape. Results: In the transverse and longitudinal groups the mean (SD) duration of surgery was 4.6 (0.2) and 4.8 (0.3) h, respectively. Before surgery the mean (SD) IIEF-5 score was 9.4 (2.3) and 9.6 (2.1), which increased to 20.6 (2.4) and 20.8 (2.7), respectively, after surgery. The penile shape (<15°) was deemed satisfactory in 92% (34/37) and 96% (91/95) of patients in the transverse and longitudinal groups, respectively. The cavernosograms consistently showed a good penile shape. There were significant differences in the mean (SD) duration of penile oedema, at 3.2 (1.6) vs. 11.9 (2.1) days, the overall satisfaction rate and the prevalence of hypertrophied scarring (all P < 0.001). Conclusion: This combination of unique penile venous stripping with a pubic median longitudinal approach and an anatomy-based corporoplasty is ideally suited to the simultaneous restoration of penile erectile function and morphological reconstruction.

The venous drainage of the corpora cavernosa in the human penis.

Abstract Objective: To study the drainage proportions from the corpora cavernosa in defrosted human cadavers, as the veins related to penile erection were recently depicted to comprise the deep dorsal vein (DDV), a pair of cavernous veins (CVs) and two pairs of para-arterial veins (PAVs), as opposed to a single DDV between Buck’s fascia and the tunica albuginea of the human penis. Materials and methods: With no formalin fixation, 10 defrosted male human cadavers were used for this study. After injecting a 10% solution of colloid, and with the intracavernous pressure (ICP) fixed at 90 mmHg, the perfusion rate was recorded before and after the DDV, CVs and PAVs were removed, respectively. Finally, measurements were again recorded after penile arterial ligation. Cavernosography was used if required. Results: The mean (range) perfusion rate for maintaining the ICP at 90 mmHg was 30.2 (15.5–90.8) mL/min, whereas the arterial perfusion rate was 2.8 (0.3–3.9) mL/min. The mean (range) drainage proportion of the corpora cavernosa was 60.5 (50.3–69.7)%, 11.9 (5.8–22.9)% and 11.4 (5.2–15.0)% via the DDV, CVs and PAVs, respectively. The remaining drainage proportion was 15.6 (14.1–18.1)%. This study shows the separate drainage contributions of the DDV, CVs and PAVs to the corpora cavernosa of the human penis. Conclusion: We conclude that the venous drainage system of the corpora cavernosa is much more complex than the previous depictions of it, and the consequent focus on a single DDV. This also shows the independent role of each venous system.

A Combination of Penile Venous Stripping, Tunical Surgery and Varicocelectomy for Patients with Erectile Dysfunction, Penile Dysmorphology and Varicocele under Acupuncture-aided Local Anesthesia on Ambulatory Basis

Background: Since 1986, we have refined our combination of penile venous stripping, corporoplasty and varicocelectomy which has proven to be efficacious to patients who suffer from the combination of Erectile Dysfunction (ED), Penile Deviation (PD) and varicocele. It has been developed in tandem with the advances in our understanding of the penile venous, tunical and related anatomy. Herein we sought to report on an approach utilizing the combination of three surgeries for reversing ED, restoring libido and revitalizing the age-related decline in sexual performance. Materials and methods: From June 2010 to March 2012, a total of 35 men, aged from 41 to 49 years, with ED resulting from Veno-Occlusive Dysfunction (VOD), penile deviation and a varicocele. Twenty three (the surgical group) underwent a combination of penile venous stripping, morphological reconstruction and varicocelectomy. Twelve were assigned to the control group. The abridged five-item version of the International Index of Erectile Function (IIEF-5) was used to score the patients. Furthermore, a dual cavernosogram, a prostaglandin E-1 test and a life quality rating were used to assess patients at 6 month intervals. Under an innovative method of acupuncture-aided local anesthesia, and following a circumferential incision, the Deep Dorsal Vein (DDV) and Cavernosal Veins (CVs) were completely stripped and ligated, followed by a pubic median longitudinal skin incision for completing the venous vasculature removal. Tunical surgery was then performed for correcting penile shape. Finally, along the longitudinal pubic wound, a unilateral or bilateral varicocelectomy was performed via a subcutaneous tunnel. Results: The follow-up period ranged from 0.5 to 2.5 years. In the surgical group the average operation time was 4.8 ± 0.3 h. There was no postoperative infection. The preoperative IIEF-5 and the life quality ratings were 9.6 ± 2.1 and 27.3 ± 4.5%, which was increased postoperatively to 20.6 ± 2.3 and 80.8 ± 6.4% respectively (both p<0.001). Whereas in the control group the corresponding preoperative IIEF-5 and life quality ratings were 9.8 ± 2.5 and 29.4 ± 4.4% respectively, in the equivalent postoperative period these changed to 8.8 ± 2.7 and 20.8 ± 6.5% respectively (both p<0.01). The difference between the two groups (p<0.001) and within the group (p<0.01) was significant. A satisfactory penile shape was achieved in 21 (91.3%) patients with 2 men (8.7%) complaining of mild residual deviation of the penis (<10°). Postoperative frenulum edema was limited (3.2 ± 1.6 days). Cavernosograms also demonstrated the ideal milieu of the corpus cavernosum for retaining intracorporeal fluid/blood. Conclusion: A combination of penile venous stripping, penile morphological reconstruction and varicocelectomy provides a novel solution for reestablishing satisfactory and satisfying sexual functioning and performance.