The inferior epigastric artery (IEA) is commonly used as a recipient vessel in microsurgical phalloplasty but its use can be associated with abdominal parietal complications (hernia, bulging). To ...preclude such complications and avoid involvement of the femoral artery, we assessed an external pudendal artery (EPA) as a recipient vessel. We studied the disposition of the external pudendal system and its general anatomy. Then we compared the external diameter of the EPA to that of the first branches of the femoral artery. The most important point was to determine the location of the EPA through a reference line to facilitate a surgical approach. We then illustrated this preliminary study with a clinical case to check the reliability of the identified landmarks. Ten adult cadavers were dissected. The arteries of interest were part of a system consisting of either a common trunk or a duplicated system. The branches of the pudendal system arose from either the femoral artery or the deep femoral artery. On a horizontal reference line passing through the two pubic tubercles, we observed that 83% of EPAs arose between the reference line and 3 cm below it, at the level of a vertical axis centered on the femoral artery. The EPA could be suitable as recipient vessel in phalloplasty owing to its location, size, and ease of dissection. Using it instead of the IEA precludes abdominal parietal complications and reduces scarring in the recipient area.
To perform a systematic review and meta-analysis of endoscopic procedures for treating vesico-urethral anastomotic stenosis (VUAS) after prostatectomy, as initial VUAS management remains unclear.
A ...search of the MEDLINE database, the Cochrane database, and clinicaltrials.gov was performed (last search February 2023) using the following query: ('bladder neck' OR 'vesicourethral anastomotic' OR 'anastomotic' AND 'stricture' OR 'stenosis' OR 'contracture' AND 'prostatectomy'). The primary outcome was the success rate of VUAS treatment, defined by the proportion (%) of patients without VUAS recurrence at the end of follow-up.
The literature search identified 420 studies. After the screening, 78 reports were assessed for eligibility, and 40 studies were included in the review. The pooled characteristics of the 40 studies provided a total of 1452 patients, with a median (interquartile range IQR) follow-up of 23.7 (13-32) months and age of 66 (64-68) years. The overall success rate (95% confidence interval CI) of all endoscopic procedures for VUAS treatment was 72.8% (64.4%-79.9%). Meta-regression models showed a negative influence of radiotherapy on the overall success rate (P = 0.012). After trim-and-fill (addition of 10 studies), the corrected overall success rate (95% CI) was 62.9% (53.6%-71.4%).
This first meta-analysis of endoscopic treatment success rate after VUAS reported an overall success rate of 72.8%, lowered to 62.9% after correcting for significant publication bias. This study also highlighted the need for a more thorough reporting of post-prostatectomy VUAS data to understand the treatment pathway and provide higher-quality evidence-based care.
Objective
To evaluate the surgical and functional outcomes of urethral reconstruction associated with phalloplasty, depending on the surgical techniques and patient history.
Materials and Methods
We ...conducted a single‐centre retrospective study including 89 patients who underwent phalloplasty with urethral reconstruction between 2007 and 2018. Patients included were trans‐male patients undergoing gender‐affirming surgery and cis‐male patients undergoing penile reconstruction after trauma, congenital malformation, or cancer. Urethral reconstructions were performed by free flap or skin graft (total or thin). Secondary urethroplasty may include direct vision urethrotomy, excision‐anastomosis, or augmentation urethroplasty (skin graft, buccal mucosa graft). Patient demographics, medical history, peri‐ and postoperative data were collected from patient files. Functional results were evaluated using individual questionnaires.
Results
The mean (±sd) follow‐up duration was 5.5 (±3.7) years. No significant difference was found for total urethral complication rate (fistula and/or stricture) according to type of urethral construction (70.9% for free flap urethra vs 73.5% for skin graft urethra; P = 0.911), nor according to the patient's grounds for surgery (72.7% for cis‐male vs 71.8% for trans‐male patients; P = 1). A total of 36 patients (40.5%) answered the functional questionnaire, of whom 80.5% reported usually voiding while standing and 47.5% were comfortable with urinating in public.
Conclusions
Urethral construction in phalloplasty is associated with a high complication and revision rate regardless of the type of urethral reconstruction. Voiding in a standing position is generally possible but should not conceal feeble functional results.
Many techniques, specifically forearm free flap phalloplasty, are used in penile reconstructive surgery. Although satisfying, a major disadvantage is the large, stigmatizing scar on the donor site, ...which leads many patients to explore alternatives.
The aim of this study is to assess the outcomes and satisfaction of patients offered the choice between metaidioplasty, forearm free flap, and suprapubic phalloplasty.
Medical outcomes from the three-stage surgery were collected from the hospital files of 24 patients, who were also interviewed to assess their satisfaction, sexual function, and psychosexual well-being.
Medical complications, anthropometric measures, and interviewing questionnaire on satisfaction with appearance, sexual function, and psychological variables.
Duration of surgery and of hospital stay was relatively short in the first (1 hour 30 minutes; 3 days) and last (1 hour 40 minutes; 3 days) stage of surgery involving tissue expansion and neophallus release. These two stages were associated with few complications (17% and 4% minor complications respectively, 12% additional complications with hospitalization for the first stage). The second stage involving tubing was associated with longer surgery and hospital stay (2 hour 15 minutes; 5 days) and had more complications (54% minor complications and 29% requiring hospitalization) although fewer than one-step surgery. No loss of neophallus was reported. Overall, 95% of patients were satisfied with their choice of phalloplasty, 95% with the appearance, 81% with the length (Mean = 12.83 cm), and 71% with the circumference (Mean = 10.83 cm) of their neophallus. Satisfactory appearance was significantly correlated (P < 0.01) with penile length (r = 0.69) and diameter (r = 0.77). Sexual satisfaction was significantly correlated with penile diameter (r = 0.758), frequency of orgasm (r = 0.71), perceived importance of voiding while standing (r = 0.56), presurgery satisfaction with sexuality (r = 0.58), current masculine–feminine scale (r = 0.58), attractive–unattractive scale (r = 0.69), and happy–depressed scale (r = 0.63).
Suprapubic phalloplasty, despite the lack of urethroplasty, offers an interesting alternative for patients concerned with the stigmatizing scar on the donor site. Terrier J-É, Courtois F, Ruffion A, and Morel Journel N. Surgical outcomes and patients satisfaction with suprapubic phalloplasty. J Sex Med 2014;11:288–298.
The control of male sexual responses Courtois, Frédérique; Carrier, Serge; Charvier, Kathleen ...
Current pharmaceutical design,
2013, Letnik:
19, Številka:
24
Journal Article
Recenzirano
Male sexual responses are reflexes mediated by the spinal cord and modulated by neural circuitries involving both the peripheral and central nervous system. While the brain interact with the reflexes ...to allow perception of sexual sensations and to exert excitatory or inhibitory influences, penile reflexes can occur despite complete transections of the spinal cord, as demonstrated by the reviewed animal studies on spinalization and human studies on spinal cord injury. Neurophysiological and neuropharmacological substrates of the male sexual responses will be discussed in this review, starting with the spinal mediation of erection and its underlying mechanism with nitric oxide (NO), followed by the description of the ejaculation process, its neural mediation and its coordination by the spinal generator of ejaculation (SGE), followed by the occurrence of climax as a multisegmental sympathetic reflex discharge. Brain modulation of these reflexes will be discussed through neurophysiological evidence involving structures such as the medial preoptic area of hypothalamus (MPOA), the paraventricular nucleus (PVN), the periaqueductal gray (PAG), and the nucleus para-gigantocellularis (nPGI), and through neuropharmacological evidence involving neurotransmitters such as serotonin (5-HT), dopamine and oxytocin. The pharmacological developments based on these mechanisms to treat male sexual dysfunctions will complete this review, including phosphodiesterase (PDE-5) inhibitors and intracavernous injections (ICI) for the treatment of erectile dysfunctions (ED), selective serotonin reuptake inhibitor (SSRI) for the treatment of premature ejaculation, and cholinesterase inhibitors as well as alpha adrenergic drugs for the treatment of anejaculation and retrograde ejaculation. Evidence from spinal cord injured studies will be highlighted upon each step.
OBJECTIVE
To assess the long‐term outcome of forearm free‐flap phalloplasty in transsexuals, as obtaining a satisfying neophallus in female‐to‐male transsexuals is a surgical challenge.
PATIENTS AND ...METHODS
We analysed retrospectively 56 transsexuals who had a phalloplasty using a radial forearm free‐flap in our department from 1986 to 2002. The complication rate was assessed by regular examination. Patient satisfaction was evaluated by a questionnaire about cosmetic aspects, sexual life and overall satisfaction.
RESULTS
The mean follow up was 110 months; 53 of the 56 patients (95%) currently have a neophallus, after a mean of six surgical procedures. Satisfaction was assessed in 53 patients using a specific questionnaire: 51 (93%) of the patients reported that the phalloplasty allowed them to accord their physical appearance with their feeling of masculinity. There were flap complications in 14 patients (25%); three (5%) flaps were lost, with one each due to early haematoma, cellulitis and late arterial thrombosis. The other 11 flap complications were all transitory, e.g. infection, haematomas and vascular thrombosis. There were prosthesis complications in 11 of 38 patients (29%). Moreover, seven of 19 patients (37%) who had a urethroplasty presented with complex strictures and fistulae that led to perineal urethrostomy.
CONCLUSION
Our study shows that phalloplasty with a forearm free‐flap leads to good results in term of flap survival and patient satisfaction. However, there was a high rate of complications. Patients must be clearly informed that the procedure can seldom be achieved in one stage.
The objective of this study is to make an inventory of surgical practices and their consequences in the short and medium term on sexuality and micturition comfort.
It is a retrospective multicenter ...study over ten years on 63 men who had an operation for a fracture of the corpora cavernosa associated or not with a urethral lesion. Patient history, clinical presentation, surgical management as well as postoperative data were collected from operative reports. Residual penis curvature, IIEF5 score, IPSS score and residual pain were collected during a telephone interview during data collection.
No statistically significant difference was demonstrated for IIEF5, IPSS, sequelae curvature, pain during intercourse, time to resumption of sexual life, rate of surgical resumption between use of absorbable or non-absorbable threads and between the realization of an overlock or a separate point. We found a significant difference in the time taken to resume sexual activity, between surgical exploration by degloving compared to elective surgical exploration.
Our study shows great variability in the surgical management of penile fractures, with no influence in the short and medium term on sexuality and urination comfort. Medium-term complications such as erectile dysfunction, curvature of the penis and pain during sexual intercourse seem frequent and insufficiently diagnosed, but decrease during urological follow-up.
L’objectif principal de cette étude est de faire un état des lieux de la prise en charge chirurgicale des fractures de verge et leurs conséquences sur le court et moyen terme sur la sexualité et le confort mictionnel.
Étude rétrospective sur dix ans multicentrique sur 63 hommes pris en charge pour une fracture des corps caverneux. Les antécédents, la présentation clinique, la prise en charge chirurgicale ainsi que les données postopératoires ont étés récupérées dans les comptes rendus opératoires. La courbure de verge résiduelle, l’IIEF5, l’IPSS et les douleurs résiduelles ont étés récupérées lors d’un entretien téléphonique.
Il n’a pas été mis en évidence de différence statistiquement significative sur l’IIEF5, l’IPSS, la courbure séquellaire, les douleurs lors des rapports, le délai de reprise de la vie sexuelle, le taux de reprise chirurgicale entre l’utilisation de fils résorbables ou non résorbables et entre la réalisation de surjet ou de point séparés, avec l’utilisation de médicaments inhibiteurs de l’érection et sur les différents types de pansements. On retrouve une différence significative sur les délais de reprise d’activité sexuelle, entre l’abord par dégantage et l’abord électif.
Notre étude montre une grande variabilité de la prise en charge chirurgicale des fractures de verge, sans influence sur le court et moyen terme sur la sexualité et le confort mictionnel. Les complications à moyen terme tels que la dysfonction érectile, la courbure de verge et les douleurs lors des rapports sexuels semblent fréquentes et insuffisamment diagnostiquées, mais diminuent au cours du suivi urologique.
Study Type – Aetiology (individual cohort)
Level of Evidence 2b
What’s known on the subject? and What does the study add?
This study provides the first questionnaire on the specific bodily sensations ...that can be perceived at orgasm thereby complementing the subjective phenomenological experience of orgasm.
OBJECTIVES
•
To provide a questionnaire for assessing the sensations characterizing orgasm.
•
To test the hypothesis that orgasm is related to autonomic hyperreflexia (AHR) in individuals with a spinal cord injury (SCI).
SUBJECTS AND METHODS
•
A total of 97 men with SCI, of whom 50 showed AHR at ejaculation and 39 showed no AHR, were compared.
•
Ejaculation was obtained through natural stimulation, vibrostimulation or vibrostimulation combined with midodrine (5–25 mg).
•
Cardiovascular measures were recorded before, at, and after each test.
•
Responses to the questionnaire were divided into four categories: cardiovascular, muscular, autonomic and dysreflexic sensations.
RESULTS
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Significantly more sensations were described at ejaculation than with sexual stimulation alone.
•
Men with SCI who experienced AHR at ejaculation reported significantly more cardiovascular, muscular, autonomic and dysreflexic responses than those who did not.
•
There was no difference between men with complete and those with incomplete lesions.
CONCLUSIONS
•
The findings show that the questionnaire is a useful tool to assess orgasm and to guide patients in identifying the bodily sensations that accompany or build up to orgasm.
•
The findings also support the hypothesis that orgasm may be related to the presence of AHR in individuals with SCI. Data from able‐bodied men also suggest that AHR could be related to orgasm, as increases in blood pressure are observed at ejaculation along with cardiovascular, autonomic and muscular sensations.
The aim of this study was to assess long-term efficacity of botulinum neurotoxin A (BoNT-A) in the treatment of neurogenic detrusor overactivity (NDO).
This was a retrospective monocentric study in a ...reference center. We included patients who received intradetrusor BoNT-A for NDO between 2001 and 2015. The focus of our analysis was on patients defined as "good responders" (≥ 5 injections of intradetrusor BoNT-A over a period of ≥5 years). The primary endpoint was the evaluation of long-term efficacity of BoNT-A. Recurrent NDO was monitored by the use of cystomanometry before the first injection and 1 month after each injection. The secondary objective was to assess the influence of NDO's etiology, age, and sex on the long-term efficacity of the treatment.
A total of 107 patients were included (60.7% with spinal cord injury SCI and 36.4% with multiple sclerosis MS). The mean follow-up period was 83.7 months (66; 120). The mean number of injections was of 8.9 (5; 21). A total of 67.3% (n = 72) of patients were still controlled by treatment at the end of their follow-up period. Therapeutic failure occurred in 30 patients (26.1%) with a cessation of BoNT-A treatment at 76 months on average (median: 82.5 months). There was no significant impact of age (P = .42), sex (P = .35), or NDO's etiology (MS vs SCI; P = .54) on long-term efficacy of BoNT-A treatment.
The results of our study indicate that the application of BoNT-A seems to be an effective and durable treatment in a large number of neurogenic patients after more than 10 years of follow-up. However, botulinum toxin tolerance occurred in approximately 25% of patients.
