Name: microscopic electric rotary grinding of plaques combined with graft repair in the management of peyronie's disease
Uploaded: 2024-03-15T14:10:00.000+00:00
Duration: 2 min 21 s
Description: Read this Scientific Article Protocol about Microscopic Electric Rotary Grinding of Plaques Combined with Graft Repair in the Management of Peyronie's Disease at JoVE.com

The protocol was carried out in accordance with the principles of the Helsinki Declaration, and all the methods described here have been approved by the ethics committee of Daping Hospital (IRB: 2023168). Written consent was obtained from the patients.
1. Instruments for operation
<ol>
	<li>Conduct all the procedures under a surgical microscope. Ensure the availability of sterilized instruments and other equipment mentioned in the Table of Materials. Set the magnification between 3x-6x during the surgery, which is enough for dissection.</li>
</ol>
2. Inclusion and exclusion criteria
<ol>
	<li>Inclusion criteria: Include patients who are in a stable stage, have severe penile curvature and deformity, and are unable to finish sexual activity.</li>
	<li>Exclusion criteria: Do not include patients during the active stage or having a slight curvature of the penis, erection dysfunction, or no sexual desire.</li>
</ol>
3. Preparation for surgery
<ol>
	<li>Anesthetize before the procedure by combined spinal-epidural anesthesia (0.5% Ropivacaine, 2.5 mL) and then place the patient in a supine position.</li>
	<li>Use a rubber band as a tourniquet to tie the base of the penis, and inject normal saline into the corpus cavernosum of the penis to induce artificial erection. Assess the localization and degree of penile curvature using the ruler and the protractor.</li>
</ol>
4. Procedure
<ol>
	<li>Make a circular incision under the coronal sulcus, perform circumferential degloving of the foreskin along with the superficial fascia(dartos), and expose the Buck&#39;s fascia.</li>
	<li>Make a longitudinal incision along both sides of the penis shaft by a small circular blade adjacent to the urethra, at the Buck&#39;s fascia level, with a length of approximately 4-6 cm. Ensure that it fully exposes the plaque area on the dorsal side of the penis without damaging the nerves and blood vessels on the dorsal side of the penis</li>
	<li>Dissect Buck&#39;s fascia and meticulously separate it from either side toward the midline area on the dorsal side. Use precise dissection techniques, employing microscissors or a fine needle electrode (Disposable Radiofrequency Ablation Electrode) for cauterization to minimize possible injury to neurovascular bundles.</li>
	<li>Mark the extent of the plaque after complete exposure of the plaques on the dorsal area of the tunica albuginea.</li>
	<li>Utilize an electric grinding drill to ablate the fibrotic plaques. 
	NOTE: There is no need to remove all the rigid plaque tissue; the endpoint is to fully release the fibrotic plaques, allowing the corpus cavernosum and tunica albuginea to extend normally.</li>
	<li>Use unilateral or bilateral tunica vaginalis grafts or bovine pericardium to repair the defects of tunica albuginea based on the size of the defect. 
	NOTE: Ensure that the size of the repair material is significantly larger than the defect area.</li>
	<li>Make sure maximal penis stretching during suturing, allowing the tunica vaginalis or bovine pericardium loosely cover the defect without tension, providing adequate extension potential for erection.</li>
	<li>Reposition the neurovascular bundles and Buck&#39;s fascia.</li>
	<li>Re-induce artificial erection for the assessment of penile curvature. Make a minor plication of tunica albuginea to achieve complete rectification of curvature if needed. 
	NOTE: The suture material is 2-0 non-absorbable thread.</li>
	<li>Meticulously restore and suture the retracted dartos fascia and foreskin, respectively.</li>
</ol>
5. Postoperative care
<ol>
	<li>Moderately compress and bandage the penis, keeping it in an upright position for at least 2 weeks to prevent early inflammatory swelling of the foreskin and penis.</li>
	<li>Maintain postoperative intravenous antibiotic treatment every 12 h for 2-3 days and change to oral treatment for 5-7 days (Cefuroxime sodium, 1.5 g every 12 h).</li>
	<li>Use the vacuum device to assist the functional recovery of the corpus cavernosum for at least 8 weeks from 4 weeks after surgery.</li>
	<li>Advise the patient to take low-dose tadalafil (5 mg/day) orally once a day for 2-3 months 2 weeks after the surgery.</li>
	<li>Advise the patient to attempt sexual intercourse from 8 weeks after surgery.</li>
</ol>

<ol>
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E., Tal, R., Nelson, C. J., Mulhall, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Penile+sensory+changes+after+plaque+incision+and+grafting+surgery+for+Peyronie's+disease.">Penile sensory changes after plaque incision and grafting surgery for Peyronie's disease.</a> J Sex Med. 15 (10), 1491-1497 (2018).</li><li>Levine, L. 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The authors have nothing to disclose.

In this study, we developed a new surgical strategy combining microscopic electric rotary grinding of plaques with graft repair to manage PD. The preliminary results showed that the corrective effect is satisfactory. To the best of our knowledge, this is the first study on the combined application of microscopic technology and an electric grinding drill for the surgical correction of PD. 
Currently, various treatment options are recommended for PD patients, ranging from oral medications and intralesional injection to surgical intervention, depending on the stages and the severity of the deformity9. However, the overall effectiveness of nonsurgical therapies remains limited, especially for those with severe deformity1,10,11. Under such conditions, surgical intervention becomes the ultimate way, with three main approaches existing: convex side shortening (plication or tunical shortening procedures), concave side lengthening(grafting or tunical lengthening techniques), and penile prosthesis implantation3,10. 
The choice of specific surgical procedures is based on both penile morphology and patient preference10. However, current surgical methods are challenged by penile shortening12,13, postoperatively irregular plaque indurations7, and sensory or rigidity loss14. Additionally, techniques involving rectangular or elliptical incisions to remove sections of plaque tissue are challenging in terms of controlling depth and scope during excision, which can potentially lead to excessive damage to the corpus cavernosum7. 
In light of these challenges, we have explored the use of electric rotary grinding in plaque management under microscopy. This approach offers a significant advantage: it not only prevents the large-scale defects associated with traditional excision methods but also minimizes the extent of the hardened plaque, thereby improving local tactile satisfaction. Besides, surgery under microscopy can provide accuracy and reliability during the process of neurovascular bundle mobilization, which can prevent postoperative sensory loss and erectile dysfunction (ED). 
Currently, the complete or partial plaque excision method is not widely accepted and is rarely employed because the larger defect could result in higher postoperative ED risk7,8. The general consensus is that it is sufficient to excise only the most severely affected area of plaque tissue responsible for penile deformity without the need for complete plaque removal. Alternatively, some advocate for loosening the tunica albuginea in the plaque region to correct the curvature. 
In the literature, several techniques have been employed worldwide for plaque management15,16. In a recent systematic analysis encompassing various surgical methods, the overall incidence of ED can reach as high as 24.1%, loss of sensation can be as pronounced as 36%, and satisfaction levels can dip as low as 62%3. In contrast, our method's initial results demonstrate optimal outcomes compared to the reported data. 
In this study, we described the surgical procedure for treating Peyronie's Disease (PD) using electric rotary grinding of plaques and repairing tunica albuginea or bovine pericardium grafts and discussed its promising outcomes. Compared to previous surgical methods, this protocol has been refined and improved in various clinical aspects. Precise microscopic techniques are employed throughout the entire surgical procedure with 3x-6x magnification. When addressing Buck's fascia, the emphasis is on initiating the lifting and sharp separation at locations as distant as possible from the dorsal neurovascular bundle. This minimizes the risk of damaging the neurovascular system and avoids excessive tension on the Buck's fascia and its neurovascular bundle. An electric grinding drill and a combination of "moving" and "scattered point" grinding techniques are used to transform the plaque area into a grid-like pattern. This enables normal expansion and stretching of the corpus cavernosum. The testicular tunica vaginalis is completely removed and loosely overlaid on the grid-like defect area, followed by tight suturing using 5-0 absorbable Polyglactin thread. Buck's fascia is replaced and sutured using 5-0 absorbable Polyglactin thread to prevent excessive expansion of the repaired testicular tunica vaginalis during erection. After the full restoration and suturing of Buck's fascia, an artificial erection is induced to assess penile straightness recovery. If necessary, limited plication of the tunica albuginea may be performed. To facilitate penile erection function recovery and reduce the risk of penile shortening due to scar healing, patients are routinely prescribed 5 mg of tadalafil for oral administration once daily after surgery. Additionally, vacuum devices are used for rehabilitation training, involving daily sessions of 15-20 min each, starting 4 weeks after surgery and continuing for 2-3 months.
Despite the strengths mentioned above, the limitations should also be noted. The small number of cases is the main limitation of this study. A long-term follow-up is required to achieve definitive conclusions. A direct comparison with other surgical techniques is required for further study. The use of a tourniquet may, to some extent, affect the accurate measurement of penile erection abnormalities in PD patients. The application of vasoactive drugs to induce erections may be more beneficial for accurate evaluation of penile deformities. Due to the limited number of cases, this study did not observe the differences in efficacy between tunica vaginalis and bovine pericardium as graft materials. More cases and longer follow-ups are still needed to reach a conclusive result. The histological types and characteristics of the tunica vaginalis and the tunica albuginea are different. Therefore, as a repair material, the tunica vaginalis still needs long-term follow-up observation to evaluate its impact on penile erection and the effectiveness of correcting deformities. Nevertheless, this study is the first to visually demonstrate technical details using microscopic electric rotary grinding combined with tunica albuginea or bovine pericardium graft repairing for the management of PD. In conclusion, microscopic electric rotary grinding combined with graft repairing is an effective and safe method for patients with severe PD in terms of overall satisfaction, cosmetic shape, and sexual ability.

Peyronie's disease (PD) is a chronic fibrotic condition that contributes to penile deformity, curvature, pain, sexual disability, and even leading to psychological distress1. PD likely represents a heterogeneous condition, with both heritable and environmentally-driven epigenetic factors contributing to its development and progression2. 
The reported epidemiology of PD varies and may be under-reported because of embarrassment and misconceptions about the available treatment options, with 0.4%-20.3% among different ethnicities and cohorts2,3. The treatment for PD includes conservative therapy or surgical intervention, depending on symptom severity and stability. Conservative therapy is the most common recommendation during the active phase, while more invasive treatments are reserved for the passive phase4. A recent randomized, controlled trial evaluating the efficacy of Collagenase Clostridium Histolyticum (CCH) + RestoreX penile traction vs. Surgery + RestoreX penile traction in Peyronie's disease management demonstrated comparable results between these two strategies5.
Although penile traction therapy and intralesional injections result in modest improvements for many patients, surgical intervention remains the final solution for this disease, especially for those with severe curvature and hourglass or hinge deformities1. Currently, penile straightening, such as penile plication and plaque incision or partial excision and grafting, represents the most reliable approach to correct penile curvature or deformity6. However, the reported methods have a high rate of sensory loss, erection function loss, or cosmetic dissatisfaction5,7,8. 
An electric grinder is commonly used in neurosurgery and orthopedics as an effective tool for bone shaping. It exhibits high efficiency in grinding hard tissues, like bones, while causing minimal damage to soft tissues. This characteristic gives it a unique advantage in the treatment of hard plaques.
In this study, we developed a new management strategy involving microscopic electric rotary grinding of the fibrous plaques and the use of tunica vaginalis or bovine pericardium as graft materials in the treatment of PD, which delivered high levels of patient satisfaction. This protocol is applicable for patients with severe curvature or other deformities that limit their ability to engage in satisfactory penetrative intercourse.

<table><tbody><tr><td>Bovine pericardium</td><td>Guanhao Biotech, Guangzhou, Co.</td><td>TB-S6050/TB-S3050</td><td></td></tr><tr><td>Cefuroxime sodium</td><td>Yiyi Saite, Co., Ltd</td><td>N/A</td><td>0.75 g</td></tr><tr><td>Disposable Radiofrequency Ablation Electrode (Multifunctional Surgical Dissector)</td><td>Chongqing Andiyingge Techology Developement Co.,Ltd</td><td>SZ02068</td><td></td></tr><tr><td>Operating microscope system</td><td>Carl Zeiss Co., Ltd</td><td>OPMI VARIO 700</td><td></td></tr><tr><td>Polyglactin thread</td><td>Ethicon, LLC</td><td>Vicryl, W9981</td><td></td></tr><tr><td>Ropivacaine</td><td>Yiyi Saite, Co., Ltd</td><td>N/A</td><td>0.5%,2.5 mL</td></tr><tr><td>Vacuum device</td><td>Shenzhen Chunyu Biotech Co.</td><td>CY078</td><td></td></tr></tbody></table>

microscopic electric rotary grinding of plaques combined with graft repair in the management of peyronie's disease

Peyronie's Disease (PD) is clinically characterized by the development of localized fibrous plaques, primarily on the tunica albuginea, especially on the dorsal area of the penis. These plaques are the hallmark feature of this condition, resulting in penile curvature, deformity, and painful erections for affected individuals. Although various nonsurgical treatment options exist, their overall effectiveness is limited. As a result, surgical intervention has become the ultimate choice for patients with severe penile curvature deformities and associated erectile dysfunction. Our research team has successfully employed a combined approach involving microscopic electric rotary grinding of the fibrous plaques and the use of tunica vaginalis or bovine pericardium as graft materials for the repairing of the defects of tunica albuginea in the treatment of PD. This approach has consistently yielded highly satisfactory results regarding the restoration of penile shape, with excellent cosmetic results and significantly improved sexual satisfaction. 
This protocol aims to present a comprehensive surgical management strategy utilizing electric rotary grinding of the plaques and repairing the defects of tunica albuginea by using the tunica vaginalis, which represents an optimal surgical strategy for treating PD.

A total of 21 patients were included from January 2021 to May 2023. The patient's age ranges from 34 to 68 years, with an average of 51.5 ± 9.4 years old. Of the total number of patients, 8 (38.1%) had diabetes. A total of 16 patients (76.2%) showed significant simple dorsal curvature of the penis, with a curvature angle of 60-90° and 5 patients (23.8%) presented with complex hourglass-like deformities with both dorsiflexion and lateral curvature, or accompanied by constriction like deformities, with bending angles ranging from 45-60° degrees. The demographic information is presented in Table 1.
Table 2 demonstrates the intra- and postoperative results. The average plaque area was 4.3 ± 2.6 cm2. Two types of repair materials were adopted during the surgery: the tunica vaginalis of the testis and the bovine pericardium. The average surgical duration is around 4.5 h. After surgery, 9 (42.9%) patients experienced numbness at penile glans and self-resolved within an average of 3.2 months. The majority of patients (17 cases, 81%) reported total straightened penile, while the rest of which reported a &lt;10° of curve. As for overall satisfaction, almost all the patients reported satisfaction.
In a typical example, a 54-year-old patient presented to the urology clinic with a penile deformity that had persisted for over 1 year. Physical examination revealed a painless, approximately 2 cm x 4 cm uneven plaque on the dorsal side of the penis. The patient reported that after achieving an erection, his penis bent backward at an angle greater than 60°, accompanied by complex deformity, making sexual intercourse impossible. Subsequently, the patient underwent a procedure involving microscopic electric rotary grinding of the plaque and an autologous tunica vaginalis graft to repair the defect of the tunica albuginea (Figure 1). No postoperative complications or severe adverse events were noted. The patient did not experience numbness at the penile glans and resumed sexual intercourse 3 months after surgery. At the 12-month follow-up, the penile morphology was completely straightened. The plaque disappeared. The hardness of penile erection was rated as 4. There is no loss of penile sensation and length, and the follow-up showed that the patient was very satisfied with the treatment results.
<img alt="Surgical technique series showing steps in reconstructive penile surgery procedure." class="xfigimg" src="/files/ftp_upload/66305/66305fig01.jpg" data-altupdatedat="1747911167000" data-alt="Figure 1"> 
Figure 1: The main surgical steps and corrective effects of curvature deformity in patients with Peyronie's disease. (A) Artificial erection is induced to observe and record the degree and location of penile curvature and deformity. (B) Buck's fascia is isolated following routine foreskin degloving. Buck's fascia is meticulously separated from both sides towards the midline area on the dorsal surface. (C) The plaque area on the dorsal surface of the tunica albuginea is marked. (D) The fibrotic plaque is ablated using an electric grinding drill until a grid-like defect appears in the tunica albuginea, allowing full, normal stretching of the corpus cavernosum. (E) One side of the tunica vaginalis was excised completely. (F) The defect of the tunica albuginea and the edge of the tunica vaginalis are covered with the excised side of the tunica vaginalis, and the edge of the defect is tightly sutured using a 5-0 absorbable polyglactin thread. (G) Due to the large area of the defect on the dorsal side of the patient, the coverage of the defect with one side of the tunica vaginalis is not sufficient; the tunica vaginalis from the other side is taken to cover the remaining defect. (H) Both sides of the tunica vaginalis completely repair the defect in the tunica albuginea, ensuring adequate room for expansion. (I) Buck's fascia is meticulously repositioned and sutured using 5-0 absorbable polyglactin thread. (J) Artificial erection is induced again to observe the correction of penile curvature deformity. The original dorsal, lateral, and narrowing deformities disappear, and the penis returns to a normal straight state. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66305/66305fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="2">Variables</td>
			<td>n (%)</td>
			<td>Mean ± SD</td>
			<td>Median(minimum, maximum)</td>
		</tr>
		<tr>
			<td colspan="2">Age(y/s)</td>
			<td>-</td>
			<td>51.5 ± 9.4</td>
			<td>55 (34, 68)</td>
		</tr>
		<tr>
			<td colspan="2">Smoking length(year)</td>
			<td>-</td>
			<td>20 ± 10</td>
			<td>18 (0, 35)</td>
		</tr>
		<tr>
			<td colspan="2">Onset to surgery(month)</td>
			<td>-</td>
			<td>26.4 ± 24.0</td>
			<td>15 (12, 84)</td>
		</tr>
		<tr>
			<td colspan="2">Diabetes</td>
			<td>8 (38.1)</td>
			<td>-</td>
			<td>-</td>
		</tr>
		<tr>
			<td colspan="2">Hinge/sandglass deformity</td>
			<td>5 (23.8)</td>
			<td>-</td>
			<td>-</td>
		</tr>
	</tbody>
</table>
Table 1: Demographic features of 21 patients. The patients with PD underwent microscopic electric rotary grinding of plaques combined with graft repairing of the defect of the tunica albuginea. PD: Peyronie's Disease; SD: standard deviation.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="2">Variables</td>
			<td>n (%)</td>
			<td>Mean ± SD</td>
			<td>Median (minimum, maximum)</td>
		</tr>
		<tr>
			<td colspan="2">Surgery time (min)</td>
			<td>-</td>
			<td>272 ± 69</td>
			<td>268 (170, 385)</td>
		</tr>
		<tr>
			<td colspan="2">Surface area of plaque (cm3)</td>
			<td>-</td>
			<td>4.3 ± 2.6</td>
			<td>4.0 (2.0, 12.0)</td>
		</tr>
		<tr>
			<td colspan="2">Graft type</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">Autologous unilateral Tunica Albuginea</td>
			<td>12 (57.1)</td>
			<td>-</td>
			<td>-</td>
		</tr>
		<tr>
			<td colspan="2">Autologous bilateral Tunica Albuginea</td>
			<td>3 (14.3)</td>
			<td>-</td>
			<td>-</td>
		</tr>
		<tr>
			<td colspan="2">Bovine pericardium</td>
			<td>6 (28.6)</td>
			<td>-</td>
			<td>-</td>
		</tr>
		<tr>
			<td colspan="2">Slight plication</td>
			<td>5 (23.8)</td>
			<td>-</td>
			<td>-</td>
		</tr>
		<tr>
			<td colspan="2">Follow-up time(month)</td>
			<td>-</td>
			<td>12.1 ± 7.2</td>
			<td>12 (3, 24)</td>
		</tr>
		<tr>
			<td colspan="2">Numbness at glans</td>
			<td>9 (42.9)</td>
			<td>-</td>
			<td>-</td>
		</tr>
		<tr>
			<td colspan="2">Persist time of numbness (month)</td>
			<td>-</td>
			<td>3.2 ± 1.9</td>
			<td>3 (1, 6)</td>
		</tr>
		<tr>
			<td colspan="2">Shortening#</td>
			<td>13 (61.9)</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">Shortening length (cm)</td>
			<td>-</td>
			<td>1.1 ± 0.7</td>
			<td>0.5 (0.5, 2.0)</td>
		</tr>
		<tr>
			<td colspan="2">Completely Strengthening(%)</td>
			<td>17 (81.0)</td>
			<td>-</td>
			<td>-</td>
		</tr>
		<tr>
			<td colspan="2">Curvature &lt;10 degree(%)</td>
			<td>4 (19.0)</td>
			<td>-</td>
			<td>-</td>
		</tr>
		<tr>
			<td colspan="2">Penile hardness after erection</td>
			<td>-</td>
			<td>3.8 ± 0.4</td>
			<td>4 (3, 4)</td>
		</tr>
		<tr>
			<td colspan="2">Gap between surgery and sexual activity(month)</td>
			<td>-</td>
			<td>2.9 ± 1.4</td>
			<td>3 (1, 12)</td>
		</tr>
		<tr>
			<td colspan="2">Self-reported overall satisfaction*</td>
			<td>-</td>
			<td>4.4 ± 0.7</td>
			<td>4.5 (3, 5)</td>
		</tr>
	</tbody>
</table>
Table 2: Intraoperative information and follow-up results among 21 patients with PD. #Self-reported. *Score from 1-5, from very dissatisfactory, dissatisfactory, medium, satisfactory, to very satisfactory.

Read this Scientific Article Protocol about Microscopic Electric Rotary Grinding of Plaques Combined with Graft Repair in the Management of Peyronie's Disease at JoVE.com

Microscopic Electric Rotary Grinding of Plaques Combined with Graft Repair in the Management of Peyronie's Disease

The presented protocol describes a microscopic surgical method for the treatment of Peyronie's disease by using electric rotary grinding of the plaques followed by using the tunica vaginalis or bovine pericardium as a graft for the repairing of the defects of the tunica albuginea.

Peyronie's Disease (PD) is clinically characterized by the development of localized fibrous plaques, primarily on the tunica albuginea, especially on the ...

microscopic-electric-rotary-grinding-plaques-combined-with-graft

Nanyang Technological University

Research

JoVE Journal

Medicine

534 Views.  Army Medical University. The presented protocol describes a microscopic surgical method for the treatment of Peyronie's disease by using electric rotary grinding of the plaques followed by using the tunica vaginalis or bovine pericardium as a graft for the repairing of the defects of the tunica albuginea. 

Video: Microscopic Electric Rotary Grinding of Plaques Combined with Graft Repair in the Management of Peyronie's Disease

Vessel-sparing Excision and Primary Anastomosis

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short bulbar or posterior urethral strictures, urethroplasty by excision and primary anastomosis (EPA) is recommended. As EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full-thickness transection of the corpus spongiosum, as performed in the traditional transecting EPA (tEPA), is usually unnecessary. Jordan et al. introduced the idea of a vessel-sparing approach in 2007, aiming to reduce surgical trauma, especially to the dual arterial blood supply of the urethra, and, thus, potentially reducing the risk of postoperative erectile dysfunction or glans ischemia. This approach could also be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking. Moreover, vessel-sparing EPA (vsEPA) should at least be able to provide similar surgical outcomes as tEPA. The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main objective of this manuscript is to outline the surgical technique and to report the representative surgical outcome. A total of 117 patients were managed according to the described protocol. The analysis was performed on the entire patient cohort and on the bulbar (n = 91) and posterior (n = 26) vsEPA group separately. Success rates were 93.4% and 88.5% for the bulbar and posterior vsEPA, respectively. To conclude, vsEPA, as outlined in the protocol, provides excellent success rates with low complication rates for isolated short bulbar and posterior urethral strictures.

Here, we present an elaborate and efficient protocol to treat isolated short bulbar or posterior urethral strictures with vessel-sparing excision and primary anastomosis.

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short ...

Isolation of Adipose Derived Regenerative Cells for the Treatment of Erectile Dysfunction Following Radical Prostatectomy

Stem cells are used in many research areas within regenerative medicine in part because these treatments can be curative rather than symptomatic. Stem cells can be obtained from different tissues and several methods for isolation have been described. The presented method for the isolation of adipose-derived regenerative cells (ADRCs) can be used within many therapeutic areas because the method is a general procedure and, therefore, not limited to erectile dysfunction (ED) therapy. ED is a common and serious side effect to radical prostatectomy (RP) since ED often is not well treated with conventional therapy. Using ADRC&#8217;s as treatment for ED has attracted great interest due to the initial positive results after a single injection of cells into the corpora cavernosum. The method used for the isolation of ADRC&#8217;s is a simple, automated process, that is reproducible and ensures a uniform product. Furthermore, the sterility of the isolated product is ensured because the entire process takes place in a closed system. It is important to minimize the risk of contamination and infection since the stem cells are used for injection in humans. The whole procedure can be done within 2.5-3.5 hours and does not require a classified laboratory which eliminates the need for shipping tissue to an off-site. However, the procedure has some limitations since the minimum amount of drained lipoaspirate for the isolation device to function is 100 g.

Precise disclosure of methods and protocols is crucial for large scale uptake of stem cell therapies. Here, we present a protocol to isolate adipose-derived regenerative cells, used for a single intracavernous injection as treatment of erectile dysfunction (ED) following radical prostatectomy (RP).

Stem cells are used in many research areas within regenerative medicine in part because these treatments can be curative rather than symptomatic. Stem ...

Microscopic Replantation of Penile Glans Amputation Due to Circumcision

Circumcision using a disposable stapler is becoming quite popular in China. However, improper surgical procedures also bring the risk of penile glans amputation, which is a very rare iatrogenic genital injury. Such complication is conventionally treated by simple hemostasis to achieve self-healing, early gross replantation, or delayed plastic surgery. However, these may lead to obvious unfavorable outcomes such as amputated glans loss, necrosis, malformation healing, or urethral orifice stenosis. In the present study, we adopted microscopic replantation as an emergency approach to achieve the precise anastomoses and anatomic reconstruction of penile glans. The goal of this protocol is to present a detailed emergency management strategy with meticulous surgical skills for the penile glans amputation. The postoperative results showed that the original shape of the glans was perfectly restored with satisfactory cosmetic appearance. The micturition function was completely restored to normal without any obvious complications. There was also no significant reduction in the sensation of amputated glans area. Hence, early meticulous microscopic replantation as soon as possible is an ideal emergency management strategy for the penile glans amputation due to circumcision.

The present protocol describes the emergency management of microscopic replantation of penile glans amputation due to circumcision.

Circumcision using a disposable stapler is becoming quite popular in China. However, improper surgical procedures also bring the risk of penile glans ...

Microvascular Doppler Assisted Microsurgical Denervation of the Spermatic Cord in Treating Chronic Orchialgia

Chronic orchialgia is a common disease in department of urology and andrology. The etiology is complex, and the treatment is difficult. In severe cases, orchiectomy is even necessary. In recent years, microsurgical denervation of the spermatic cord (MDSC) is a minimally invasive and effective surgical method for the treatment of chronic orchialgia. Its greatest advantage is to preserve the testis and epididymis, avoid the possible organ resection. The key of the operation is to dissect all the fibrous tissues in the spermatic cord, while protecting the arteries (especially the testicular arteries) and several lymphatic vessels. Combined with the use of microvascular doppler in the operation, when separating the structure of spermatic cord under the microscope, the testicular arteries can be objectively and accurately protected (pulse &#8220;whistle&#8221; sound can be heard when the microvascular doppler probes the arterial surface), while artery injury and venous missed ligation can be avoided. The postoperative blood supply of the testis is also maximumly safeguarded. At the same time, we can be more fearless to cut the cremaster muscle, fatty and connective tissues surrounding the spermatic cord blood vessels and vas deferens after the arteries and lymphatic vessels being accurately protected under the microscope, finally achieve the spermatic cord completely &#34;skeletonized&#34; (only the testicular arteries, lymphatic vessels and vas deferens remained after the surgery). Thus we can better ensure the clinical curative effect (denervation thoroughly), avoid serious complications (testicular atrophy), and achieve better surgical results.

Here, we present a protocol to treat chronic orchialgia by microsurgical denervation of the spermatic cord. Combined with the use of a microvascular doppler, the procedures can be more easily implemented.

Chronic orchialgia is a common disease in department of urology and andrology. The etiology is complex, and the treatment is difficult. In severe cases, ...

An Electrophysiological Technique to Accurately Diagnose and Treat Erectile Dysfunction

Erectile dysfunction (ED) is a common disease in males. In the past, the first-line treatment of ED was mainly noninvasive-psychotherapy and oral phosphodiesterase 5 (PDE5) inhibitors. Oral PDE5 inhibitors often need to be used before sexual intercourse and do not repair the pathological damage; hence, the therapeutic effect for secondary ED caused by neurological or endocrine disorders is poor. Second-line treatments mainly include penile corpus cavernosum injection of alprostadil, transurethral administration, vacuum negative pressure devices, and other methods, with obvious side effects such as local pain. 
The third-line treatment mainly refers to penile prosthesis implantation. Indications of this treatment are strict, complications such as mechanical failure and infection may occur after operation, and it is expensive. Other treatments such as stem cell therapy and gene therapy are still in the experimental research stage and have not been used in clinics. A new treatment based on an electrophysiological technique combines a medical infrared thermal imager with low-frequency (20-50 Hz) neuromuscular electrical stimulation, which has achieved good results in the prevention and treatment of female pelvic floor dysfunction. 
Male generative organs are located in the pelvic floor area, and their normal function not only depends on the integrity of the structure and function of the male generative organs, but is also closely related to the blood vessels, nerves, muscles, and other pelvic floor organs. Therefore, this electrophysiological technique was applied to male ED, focusing on the observation of the penis, groin, and hypogastrium for accurate diagnosis and treatment. This demonstrated effective improvement in the conscious erectile status and erectile function scores of patients suffering from ED.

Here we describe an appropriate electrophysiological technique to diagnose and treat patients with erectile dysfunction.

Erectile dysfunction (ED) is a common disease in males. In the past, the first-line treatment of ED was mainly noninvasive-psychotherapy and oral ...

A Modified Bilateral Scrotal Flap for Penile Skin Defect Repair

Skin shortages and scar contractures are common complications following penile trauma and tumor surgery, resulting in significant pain and erectile dysfunction. Currently, skin grafts and scrotal flaps are widely used to reconstruct skin shortages. However, various limitations still exist; for instance, the skin graft may cause severe scarring in patients, and the traditional scrotal flap usually requires a two-stage procedure due to the large skin defect. 
To treat the shortage of foreskin, a modified bilateral scrotal pedicled flap is used. In this procedure, flaps located on each side of the midline of the scrotum, which was pedicled from the anterior scrotal artery, are harvested. Subsequently, these bilateral scrotal flaps, like a butterfly, can successfully cover the foreskin defect. In this study, seven patients underwent this procedure, and satisfactory outcomes were obtained. Only two patients developed necrosis in some small areas of the flaps, which were recovered after wound care. Postoperative penile length significantly increased compared to the preoperative status in both flaccid and erectile states. We believe that modified bilateral scrotal flaps are a simple and effective solution to penile skin shortages and scar contractures.

This study presents an application of the modified bilateral scrotal flap for the reconstruction of penile skin shortages and scar contractures.

Skin shortages and scar contractures are common complications following penile trauma and tumor surgery, resulting in significant pain and erectile ...

Intracavernosal Pressure Recording to Evaluate Erectile Function in Rodents

Erectile dysfunction (ED) is defined as the inability to attain or keep an erection of the penis, and this has become a prevalent male sexual disorder. Rodents are employed by many studies to research the physiology/pathology of erectile function. Erectile function in rodents can be evaluated by measuring the intracavernosal pressure (ICP). In practice, ICP can be monitored following electrical stimulation of the cavernous nerves (CNs). The arterial pressure of the carotid artery (the mean arterial pressure) is used as the reference for ICP. Using ICP recording protocols, many key parameters of erectile function can be measured from the ICP response curve. The ICP measurement provides more information than the apomorphine-induced penile erection test, and is cheaper than telemetric monitoring of the corpus spongiosum penis, making this method the most popular one to evaluate erectile function. However, compared to the easily-performed APO-induced erectile function test, successful ICP recordings require attention to detail, practice, and adherence to the operation method. In this work, an introduction to ICP recording in rats is provided to complement the procedure efficiently.

Intracavernosal pressure recording (ICP) is an important method to evaluate the erectile function of experimental animals. Here, a detailed protocol is demonstrated for the recording procedure of ICP by catheterizing the crura penis and then electrically stimulating the cavernous nerves in rats.

Erectile dysfunction (ED) is defined as the inability to attain or keep an erection of the penis, and this has become a prevalent male sexual disorder. ...

Biology

Urethral Stricture Induction Followed by Buccal Mucosa Graft Urethroplasty in a Rat Model

Urethral reconstruction is an important area of expertise for urologists. The buccal mucosa is considered the best option when urethral grafting is necessary, although in some cases, it is inappropriate or needs to be optimized to repair a given stricture. Therefore, developing innovative procedures and evaluating their putative success in experimental models is crucial to fit the clinical need. With this goal, this study describes a protocol in which urethral stricture was induced by electrocautery in Wistar rats. Urethral reconstruction was performed 1 week later with a buccal mucosa graft, harvested from the lower lip, and placed in a ventral onlay fashion. A retrograde urethrogram showed a significant improvement in urethral diameter after urethroplasty compared to the respective value after stricture induction. Additionally, the graft placement was assessed by blood perfusion analysis using laser Doppler. As expected, a dark blue area corresponded to the non-vascularized buccal mucosa graft. This procedure can successfully simulate the normal pathophysiological process of urethral injury and tissue modulation, as well as urethral reconstruction using a buccal mucosa graft in a reproducible manner, and serve as the basis for future research based on tissue engineering or urethral grafts.

In the present protocol, a urethral stricture induction was developed in Wistar rats, followed by urethral reconstruction with a buccal mucosa graft. A retrograde urethrogram and laser Doppler assessment were performed, validating urethral reconstruction (after stricture formation) and graft placement.

Urethral reconstruction is an important area of expertise for urologists. The buccal mucosa is considered the best option when urethral grafting is ...

Intracavernous Pressure Recording in a Cavernous Nerve Injury Rat Model

The bilateral cavernous nerve (CN) injury rat model has been extensively used to simulate clinical cavernous nerve injury associated with erectile dysfunction (ED) for evaluating the effect of clinical therapeutic methods. However, the methods of CN injury model construction are flawed and varied in the ED research field. It is CN crush injury that is the most commonly used method in recent years. This study aims to provide a detailed description of the procedure of bilateral CN injury rat model construction and measurement of intracavernous pressure (ICP) recording, providing a reliable and reproducible CN injury rat model. This work successfully developed the CN injury method of hemostat crush injury using a syringe needle as hard support and a hemostat with a rubber sleeve. Also, this method concludes that a voltage of 1.0 V, frequency of 20 Hz, and pulse-width of 5 ms are the optimized stimulation parameters for ICP recording in a bilateral CN injury rat model.

This protocol describes developing a stable bilateral cavernous nerve injury rat model of radical prostatectomy associated with erectile dysfunction and intracavernous pressure measurement.

The bilateral cavernous nerve (CN) injury rat model has been extensively used to simulate clinical cavernous nerve injury associated with erectile ...

Efficient Rat Model for Urethral Stricture: Electric Knife Method

Iatrogenic Injury Recapitulated: Electroexcision Technique for Urethral Stricture Modeling in Rats

Urethral stricture (US) is a common clinical condition in urology, characterized by high prevalence and morbidity across all ages. Current treatments for US, such as urethral dilatation and internal urethrotomy, fail to fully resolve the condition and are associated with high rates of recurrence and complications. 
Additionally, the pathogenesis of US is not well understood. To explore the pathogenesis of US and develop new therapeutic strategies, it is crucial to establish a standardized rat model that accurately reflects the clinical manifestations. This study outlines a straightforward and repeatable method for inducing US in rats using a high-frequency electric knife. The method involves making a longitudinal incision with the electric knife set to a unipolar mixed cutting mode at 4 W, which inflicts significant urethral damage. Histopathological analysis shows thickening of the urothelium, inflammatory infiltration, and disorganized collagen fibers. This model effectively replicates iatrogenic injury through electroexcision in the rat urethra. In summary, this study successfully establishes a new, efficient, and stable rat model of US that closely mimics the clinical scenario, providing a valuable tool for further research into the mechanisms and novel treatments for US.

In this study, we present a novel, efficient, and stable rat model of urethral stricture created through electroexcision of the rat urethra, which effectively simulates iatrogenic injury observed in clinical settings.

Urethral stricture (US) is a common clinical condition in urology, characterized by high prevalence and morbidity across all ages. Current treatments for ...