Sava V. Perovic

The Management of Peyronie's Disease: Evidence‐based 2010 Guidelines

INTRODUCTION The field of Peyronies disease is evolving and there is need for a state-of-the-art information in this area. AIM To develop an evidence-based state-of-the-art consensus report on the management of Peyronies disease. METHODS To provide state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical management of Peyronies Disease, representing the opinion of leading experts developed in a consensus process over a 2-year period. MAIN OUTCOME MEASURES Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. CONCLUSIONS The real etiology of Peyronies disease and the mechanisms of formation of the plaque still remain obscure. Although conservative management is obtaining a progressively larger consensus among the experts, surgical correction still remains the mainstay treatment for this condition.

Vaginoplasty in male transsexuals using penile skin and a urethral flap

Objectives To describe and present the results of a one‐stage vaginoplasty in male‐to‐female sex reassignment surgery.

Phalloplasty in Children and Adolescents Using the Extended Pedicle Island Groin Flap

An operative procedure for phalloplasty is reported that uses an extended pedicle island groin flap. Forming a combined groin and lower abdominal flap based on the superficial iliac and epigastric vessels is the main characteristic of this technique. The flap consists of 3 parts: 1) the lateral narrow hairless part for the neourethra, 2) the medial wide part for neophallus shaft reconstruction and 3) the base of the flap on which a flap pedicle is formed and lengthened by de-epithelializing the skin. The pedicle includes subcutaneous tissue with blood and lymph vessels. The neourethra and neophallus shaft are reconstructed using a tube-within-tube technique. The size of the flap depends on patient build. The flap is transferred to the recipient area, that is to the level of the lower margin of symphysis. Anastomosis of the new and native urethra may be done simultaneously or during the second stage of the procedure. The donor site skin defect is closed by direct approximation. During 3 years (1991 to 1993) this flap technique was performed on 24 patients (age 12 to 18 years). There were 2 main indications for treatment: 1) complete absence of the penis, and so total reconstruction of the phallus was done and 2) small dimensions of the penis or just a penile stump, and so augmentation of the penis was done. Specific indications were female transsexualism in 4 patients, penile amputation in 2 and a small disabled penis in 18 (the exstrophy-epispadias complex, intersex and micropenis). Followup ranged from 6 to 42 months (average 29). A new phallus of satisfactory dimensions was achieved in all cases. Complications included partial necrosis of the flap in 2 patients, fistulas in 2 and stenosis of the urethral anastomosis in 1. These complications were successfully resolved by corrective surgery. The method is simple and timesaving with a minor complication rate. This technique is the available alternative to the most commonly used procedure, that is microsurgical free tissue phalloplasty.

Retrospective Descriptive Analysis of 1,176 Patients With Failed Hypospadias Repair

PURPOSE To our knowledge epidemiological data on the incidence of failed hypospadias repair and the number of patients seeking further surgical treatment remain unknown. We report an observational, descriptive survey of patients who were evaluated and treated for urethral stricture disease and/or penile defects after primary hypospadias repair. MATERIALS AND METHODS We performed a retrospective observational chart analysis of patients evaluated and treated for urethral stricture disease and/or penile defects at 2 tertiary European centers from January 1998 to December 2007. In each case we investigated the primary abnormal meatal site, the number of operations needed to repair primary hypospadias and complications of this primary repair. Patients were offered surgical repair for previous failed hypospadias treatment. After surgery evaluation was scheduled at 3, 6 and 9 months. Success was defined as a functional urethra without fistula, stricture or residual chordee and a cosmetically acceptable glanular meatus after the completion of all secondary procedures. RESULTS A total of 1,176 patients with a mean age of 31 years were evaluated and treated. To treat failed hypospadias repair 760 (64.6%) and 416 patients (35.4%) underwent 1-stage and staged repair, respectively. Mean followup was 60.4 months. Of 1,176 cases 1,036 (88.1%) were classified as successful and 140 (11.9%) were considered failures. CONCLUSIONS Failed hypospadias repair may be corrected by multiple and complex surgeries. Its effects are experienced during the lifetime of the patient and parents.

Onlay Island Flap Urethroplasty for Severe Hypospadias: A Variant of the Technique

A variant of the onlay island flap urethroplasty in severe hypospadias repair is described. The principles of the technique include mobilization of the urethral plate without dividing it, release of chordee, creation of a pedicle island flap on the dorsal penile skin with redundant vascularized tissue that is transposed to the ventral side of the penis by a buttonhole maneuver, and onlay of the flap to the mobilized urethral plate, covering all suture lines with a wide pedicle of flap. During the last 3 years this operation was performed in 92 patients 12 months to 19 years old with severe hypospadias. The complication rate was 5%.

Trauma, Gender Reassignment, and Penile Augmentation

INTRODUCTION Penile trauma is common with standard management options. Gender reassignment techniques are rapidly changing and penile augmentation remains a controversial topic. Consequently, there is need for a state-of-the-art information in this area. AIM This study aims to develop an evidence-based state-of-the-art consensus report on the management of penile trauma, gender, reassignment and penile augmentation. METHODS The study provides state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical management of penile trauma, gender reassignment and penile augmentation, representing the opinion of leading experts developed in a consensus process over a 2-year period. MAIN OUTCOME MEASURES Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. CONCLUSIONS Penile fracture should be managed surgically. Information should be readily available to patients to help them decide the surgical technique desired for gender reassignment and to justify any form of penile augmentation.

Is it Reasonable to Treat Refractory Voiding Dysfunction in Children With Botulinum-A Toxin?

PURPOSE We present our results with botulinum-A toxin transperineal pelvic floor/external sphincter injection combined with behavioral and biofeedback reeducation in children with voiding dysfunction who had been resistant to previously applied therapies. MATERIAL AND METHODS Eight boys and 12 girls between 7 and 12 years old (mean age 9) with recurrent urinary tract infection, an interrupted or fractional voiding pattern and high post-void residual urine in whom behavioral, short biofeedback and alpha-blocker therapies had failed were included in the study. They were treated with botulinum-A toxin at a dose of 50 to 100 U. Botulinum-A toxin was injected transperineally into the pelvic floor and/or external sphincter in all patients. In boys the sphincter was localized endoscopically before injection (endoscopically assisted transperineal approach). Behavioral and biofeedback reeducation started 15 days after injection. RESULTS Followup was between 9 and 14 months. All patients were without urinary tract infection and fever, while 5 were still on chemoprophylaxis. Six months after treatment residual urine decreased in 17 of 20 patients by 0 to 130 ml (mean +/- SD 45.75 +/- 32.17 ml, t = 6.360, p <0.001). Nine patients reestablished a normal voiding curve and 8 showed improvement. Three did not manifest any significant improvement. In 1 girl transitory incontinence resolved spontaneously within 48 hours. There were no other complications. CONCLUSIONS The effect of botulinum is transitory. However, it can break the circle of detrusor-sphincter dyssynergia and the period when it is sustained can be used for retraining the patient in normal voiding. At this moment botulinum-A toxin is one of last options in refractory cases of voiding dysfunction.

Total phalloplasty using a musculocutaneous latissimus dorsi flap

Authors from Serbia describe their experience of total phalloplasty in children and adults using a musculocutaneous latissimus dorsi free flap, finding that this method successfully allowed the creation of a neophallus, facilitating subsequent urethroplasty and the safe insertion of a penile prosthesis.

Dorsal dartos flap for preventing fistula in the Snodgrass hypospadias repair.

There are three different topics covered in the paediatric urology section in this issue. Authors from Belgrade describe how a dorsal dartos flap can be used to prevent fistula in the Snodgrass hypospadias repair. The use of extracorporeal pelvic floor magnetic stimulation in children with voiding dysfunction is described by authors from Seoul. And finally, authors from Antalya write about the impact of the location of the ureteric orifice on the efficacy of endoscopic injection to correct VUR.

A NEW APPROACH TO THE TREATMENT OF PENILE CURVATURE

PURPOSE Techniques for penile straightening generate the serious dilemma of which is most appropriate. We created and describe our penile disassembly technique to avoid penile shortening in curvature repair. MATERIALS AND METHODS From November 1995 to March 1997 we performed our penile disassembly technique in 87 patients 12 months to 47 years old (mean age 4.5 years). Indications for surgery were isolated penile curvature and chordee with or without hypospadias, curvature of the distal third of the corpora cavernosa and a small penis with curvature. Our method consists of separation of the penis into its entities, a glans cap with its neurovascular bundle dorsally, a nondivided or divided urethra, or urethral plate ventrally and corpora cavernosa that may be partially separated in the septal region. This maneuver achieves excellent correction of penile curvature. In addition, during this procedure a space is created between the glans cap and the tips of the corpora cavernosa into which various tissues may be inserted to avoid penile shortening due to corporoplasty or even to lengthen the penis. RESULTS Mean followup was 16 months (range 6 months to 2 years). There were no injuries to the neurovascular bundle or urethra. Complications developed only in relation to onlay or tubularized urethroplasty in 4 patients. CONCLUSIONS Our penile disassembly technique seems to be the most effective procedure in select cases of severe curvature of the distal penile shaft, marked glans tilt and a small penis with curvature. In addition, the procedure provides the possibility of penile lengthening.