BACKGROUND: Erectile dysfunction (ED) is common in middle-aged and elderly men, affecting more than 100 million males worldwide. Most ED cases can be attributed to organic and/or psychological factors. Here we report an atypical ED case with no clear manifestation fitting the diagnosis for recognized types of ED.
METHODS: The 35-year-old male is unable to have normal erection since puberty, and unable to complete intercourse with his wife. He had no history of trauma, surgery or psychiatric/psychological disease. The patient has a normal male karyotype. There is no significant finding in physical examination, nocturnal penile tumescence test, and ultrasound measurement of penis vascular functions. The serum levels of major hormones are all in normal ranges.
METHODS: Atypical ED, psychogenic ED not excluded; infertility.
METHODS: Oral phosphodiesterase inhibitors Tadalafil (20 mg, BIW) or Sildenafil (50 mg, BIW) had no effect in this patient. Penile prosthesis implantation helped the patient to acquire normal sexual life, but did solve the ejaculation failure and infertility. Motile sperms were obtained by testicular epididymal sperm aspiration under the guidance of ultrasound, and intracytoplasmic sperm injection was performed with occytes retrieved from his wife.
RESULTS: The patient sexual life was significantly improved after penile prosthesis implantation; the patient wife is currently in the first trimester of pregnancy as the result of in vitro fertilization.
CONCLUSIONS: The no response to phosphodiesterase type 5 inhibitors (PDE5) treatment may suggest an impediment of PDE5-related pharmacological pathways or the presence of defect/injury in the neural system. This special case raises a question if some patients with persistent ED may have similar manifestations and can be treated with the same procedures.

Despite significant scientific advances in the modern three-piece inflatable penile prosthesis implant surgery, it is not without surgical risks and can carry additional cosmetic and psychosocial consequences in poorly selected and consented individuals. To address this problem, an international group of key opinion leaders and high-volume prosthetic surgeons reviewed the current guidelines and clinical evidence, discussed their experiences, and formed a consensus regarding inflatable penile prosthesis surgery. The findings of this consensus panel were presented at the 17th biennial Asia Pacific Society of Sexual Medicine scientific meeting. The experts concluded that proper patient selection, informed consent and strict adherence to safe surgical principles are important to optimize clinical outcomes. Furthermore, most intraoperative complications, if recognized, can be addressed intraoperatively to enable placement of the device at the time of initial surgery. Men with significant corporal fibrosis due to Peyronie\'s disease, prior prosthesis explantation and priapism, and men who have undergone construction of a neophallus, as well as men who receive concurrent continence surgery, are complex cases requiring additional care and advanced techniques to obtain optimal surgical outcomes. Variability in patient care - in terms of postoperative antibiotic use, pain management, scrotal care, and cycling of the penile prosthesis implant - must be reduced to enable optimization and assessment of outcomes across patient groups.

OBJECTIVE: To investigate the therapeutic effect of implanting a three-piece inflatable penile prosthesis (IPP) combined with the phosphodiesterase-5 inhibitor sildenafil in severe erectile dysfunction (ED) patients.
METHODS: This randomized controlled study included 123 ED patients. Sixty-two patients received the IPP implantation and 61 patients received the IPP implantation and the phosphodiesterase-5 inhibitor sildenafil. Erectile function and sexual life quality were evaluated using the five-item International Index of Erectile Function (IIEF) and modified Sexual Life Quality Questionnaire-Quality of Life domain (mSLQQ-QoL), respectively. Serum interleukin (IL)-6, IL-8, tumor necrosis factor (TNF)-α, vascular cell adhesion molecule (VCAM)-1, and intercellular adhesion molecule (ICAM)-1 levels were assessed. Kaplan-Meier curves were used to assess the overall IPP survival.
RESULTS: Implantation of the three-piece IPP with sildenafil improved erectile function and sexual life quality, alleviated the inflammatory response, reduced the complication rate, and improved overall IPP survival.
CONCLUSIONS: Implantation of the three-piece IPP combined with a phosphodiesterase-5 inhibitor significantly improved clinical outcomes and the prognosis in ED patients.

We retrospectively evaluated the clinical outcome of penile prosthesis implantation (PPI) in Chinese patients with severe erectile dysfunction (SED). From July 2000 to December 2011, 224 patients (mean age: 35.9±11.8 years, range: 20-75 years) with SED underwent PPI by experienced surgeon according to standard PPI procedure at our centre. A malleable prosthesis (AMS 650) was implanted in 45 cases (20.1%), and a three-piece inflatable prosthesis (AMS 700 CXM or AMS 700 CXR) was implanted in 179 cases (79.9%). Surgical outcomes, including postoperative complications, clinical efficacy and couple satisfaction, were evaluated over than 6 months postoperatively using medical record abstraction, IIEF-5, quality of life (QoL) scores, and the patient/partner sexual satisfaction score proposed by Bhojwani et al. Of the 224 patients eligible for the study, 201 subjects (89.7%) completed follow-up. All of patients could perform sexual intercourse post PPI with the mean postoperative IIEF-5 and QoL scores were 20.02±2.32 and 5.28±0.76, respectively, which were significantly improved compared with the preoperative scores (6.29±1.5 and 2.13±0.84, P<0.01). Of the 201 men, mechanical malfunction occurred in four cases (2.0%) and three cases were re-implanted new device, and two cases (1.0%) developed a mild curvature of the penis. Scrotal erosion with infection occurred in one case with diabetes mellitus (0.5%) and required complete removal of the implanted AMS 700 CXM. Satisfactory sexual intercourse at least twice per month was reported by 178 men (88.6%), and overall satisfaction with the PPI surgery was reported by 89.0% of men and 82.5% of partners. Patient satisfaction in the three-piece inflatable prosthesis group was higher than in the malleable prosthesis group (P<0.05). Satisfaction, however, between the types of prostheses, did not differ in the partner survey. PPI is a safe and effective treatment option for Chinese patients with SED and experienced surgeon perform PPI according to standard PPI procedure could reduce the postoperative complications of PPI and could improve patient satisfaction ratio and QoL.

OBJECTIVE: To investigate the clinical efficacy and patient and partner\'s satisfaction with penile prosthesis implantation (PPI) for treating Chinese patients with severe erectile dysfunction (SED).
METHODS: One hundred and sixty-eight SED patients were successfully treated by PPI from July 2000 to June 2010. Of the 146 (86.9%) patients who had been followed up over 6 months post-operation, 36 (24.7%) had been implanted with one piece malleable prosthesis (AMS650) and 110 (75.3%) with three piece inflatable prosthesis (AMS700CXM).All the patients had been followed up by using international index of erectile dysfunction (IIEF5), Quality of Life Score (QOL) for evaluating clinical efficacy and using Visual Analogue Scale (VAS) for evaluating patient and partner\'s satisfaction and the duration of the follow-up was 6 to 119 months.
RESULTS: The mean age of patients was 35.9+/-12.1 years(20 to 75 years), All the operations were successful and sexual intercourse with PPI was performed post 4 to 6 weeks without severe complications like infection and erosion. The prosthesis survive rate and frequent sexual intercourse rate were 98.6% and 87.7% respectively. IIEF5 scores pre and post PPI were 6.3+/- 1.7 and 21.3+/-1.6 respectively,the QOL scores pre and post PPI were 5.1+/-0.9 and 1.5+/-0.5 respectively, and both of them showed significant improvement (P<0.01). As for VAS, the patient and partner\'s overall satisfaction rates were 92.5% and 90.4% respectively. Moreover, better satisfaction was showed with AMS700CXM as compared with AMS650 (P<0.05) in patients with SED.
CONCLUSIONS: PPI is the safe and effective treatment option for Chinese patients with SED. The AMS700CXM penile prosthesis is better than AMS650 for patients\' overall satisfaction.

To investigate the efficacy and safety of the corpus cavernosum-corpus spongiosum shunt (Al-Ghorab Shunt) plus intracavernous tunneling (CC-CSS+ICT) for prolonged ischemic priapism (PIP). Twelve patients with PIP were enrolled in this study. The mean age of patients was 38.3 ± 9.2 years old and the mean duration of PIP was 2.8 ± 1.0 days (range, 1.5-4 days). All patients received CC-CSS+ICT for treating PIP. The penile hardness score (PHS) and pain visual analogue score (PVAS) were used to assess the efficacy of the surgery 1, 3, and 5 days after surgery. Color duplex Doppler ultrasonography, International Index of Erectile Function, and quality of life (QOL) were used for evaluating penile morphology, erectile function, QOL, and response to sildenafil treatment. The mean duration of follow up was 21.6 ± 10.1 months. Penile detumescence was successfully restored for all 12 patients postsurgery, with the mean PHS and PVAS significantly decreased compared with that presurgery at different time points (1, 3, 5 days postsurgery; P < .001). The cavernosal arterial blood flow observed with the mean PSV at 1, 3, and 5 days postoperation were 17.79 ± 2.04, 19.14 ± 1.58, and 7.73 ± 2.02 cm/s respectively. All patients suffered from corpus cavernosum fibrosis and erectile dysfunction postoperation; only 2 cases (16.7%) with a short duration of PIP (1.5 days) showed response to sildenafil treatment, and 3 cases (25.0%) with severe fibrosis were satisfied with sexual life after excision of penile corpus cavernosum scar and penile prosthesis implantation. The CC-CSS+ICT could quickly reduce penile rigidity and pain for improving the symptoms of PIP and suggests a safe and effective therapeutic method for PIP.

OBJECTIVE: To investigate the effects of surgery treatment on serious penile lesions and malformation.
METHODS: Sixty-two patients, aged from 19 to 63 years old (mean 35 ys), were included in the study. Among them, 4 patients suffered from penis partial defection were respectively treated with restoring defective penis, penis lengthening and urethroplasty; three patients with penis completely missing were treated with penis reconstruction surgery; 22 cases with serious penile curvature were treated with the 16-dot plication technique (Lue\'s procedure); 15 cases with penile fracture were treated with conservative treatment for 1 case and with patch penis, corpus spongiosum, and deep penile dorsal vein ligation for 14 cases; 5 cases with post-operative complications of 3-pieces of penile prosthesis, including the prosthesis perforating to the urethra, water pump failure, broken connection tube, erection angle < 60 degrees and failure to expansion the corpus cavernosum, were treated by taking out prostheses, urethral repair cracks, replacement of the prostheses, excision of fibrosis scar and re-implantation prostheses respectively. Four cases with penis complete amputation were treated with the penis replantation; three cases of avulsion injury were treated with the replantation and free flap skin; 6 with Paget\'s disease of penises were treated with the lesion free skin buried in the scrotum and penis.
RESULTS: All these patients were followed up for 3 months to 4 years, with the average of 9 months. Among the 4 cases of penis partial defection, 2 patients were satisfied with the penile appearance and sexual function; 1 got some satisfactory and 1 was unsatisfied. Three cases with the loss of the penis completely were satisfied with both the postoperative appearance and urination, and 1 was not satisfied. Twenty-two cases of penile curvature deformities were corrected, and one case was recurrence. Fourteen of the 15 patients with penile fracture were followed, and all got the restoration of sexual function. Among them, 5 cases with post-operative complications, including mild bending, algopareunia, subcutaneous induration, poor hardness and poor sexual pleasure, were not further treated, and another case lost; Five cases with post-operative complications of three-pieces penile prosthesis were treated successfully, and 4 of their spouses were satisfied with their sexual function after operation, only 1 of their spouse not satisfied. Among four cases with complete amputation of penis, two cases of penis were replanted successfully while two necrosis. Three cases with avulsion were treated with skin grafting successfully. All 6 cases with penile Paget\'s disease were followed for 2 -4 years, and free skin grafts were all survival. One patient died of brain metastases 18 months after operation and five cases were disease-free survival.
CONCLUSIONS: The patients should be treated based on the procedure of andrological and urological surgery, together with microsurgical, flap or skin graft technique. The urologist should design personalized surgical procedure. Most of the patient\'s penis shape and erectile dysfunction can be reconstructed by our procedures, but some patients can not achieve the desired appearance or function of penis. New approaches of the treatment ought to be developed to restore both of the shape and function for those severe injury of the penis.

OBJECTIVE: Penile augmentation surgery is still a controversial issue because of the uncertain indication, the possibility of severe complications and a variety of surgical techniques. The purpose of this study is to provide two surgical procedures of penile corpora cavernosa augmentation and to investigate its effect by implanting autogenous saphenous vein grafts or expanded polytetrafluoroethylene (ePTFE) vessel patches.
METHODS: Between January 2001 and December 2005, 20 patients underwent surgeries in which bilateral longitudinal incisions were placed on the tunica albuginea and the penile corpora cavernosa were extended by means of implantation of saphenous grafts or PTFE artificial vessel patches. The patients included in this study presented either with congenital idiopathic micropenis or normal penile length and perimeter (dysmorphophobia). Before the operation, the penile length and perimeter in the flaccid and erectile states were as follows: flaccid length 2.5-7.5 cm and flaccid perimeter 3.0-7.5 cm; erectile length 4.9-10.5 cm and erectile perimeter 4.5-10.0 cm.
RESULTS: Immediately after surgery, the penile corpus circumferential measurements (on table), showed remarkable increases which were 1.0-2.3 cm and 1.5-3.0 cm in the flaccid and erectile states, respectively; then, at 12 months to 5 years\' follow-up, these girth gains had reduced by 0.5-1 cm in some cases. All cases in the two groups obtained satisfactory surgical results with satisfactory erection and no serious complications, such as infection and fistula. In 20 cases, 17 married cases resumed regular and satisfactory sexual activities 1 month after the operation without any functional limitation.
CONCLUSIONS: The two kinds of surgical procedures for augmenting penile corpora cavernosa were proved to be effective and reliable, with few complications. Both saphenous grafts and ePTFE artificial vessel patches are excellent materials for reconstructing the tunica albuginea. These augmenting phalloplasties can not only be used for patients with micropenis, but also applied to satisfy the cosmetic and functional requests of patients with normal penile length and perimeter. However, the long-term outcomes of these surgical procedures need a further, detailed follow-up study.

OBJECTIVE: To study the effect and complications of augmentation phalloplasty by implanting autogenous tunica vaginalis grafts into the bilateral albuginea of the penile corpus.
METHODS: Five mongrel dogs underwent augmentation phalloplasty with bilateral autogenous tunica vaginalis grafts. The increase in the volume of the corpora cavernosa was achieved by applying autogenous tunica vaginalis grafts to longitudinal openings made bilaterally in the albuginea along the whole length of the penile cavernous corpora. The perimeter of the penile cavernous corpora was measured in the flaccid state and during erection and dynamic infusion cavernosometry (DIC) was conducted for each dog before and after the operation. Histology of the penis was examined using hematoxylin and eosin stains.
RESULTS: The average increase in the perimeter of the penile cavernous corpora was 21. 1% in the erectile state but unobvious in the flaccid state 3 months after surgery. There were no statistically significant differences in cavernosometric parameters before and after the operation, and neither were there any other severe postoperative complications. The grafts had mild inflammatory reaction and fibrosis with apparent reformation of the tunica albuginea over the patch site.
CONCLUSIONS: The augmentation phalloplasty technique with bilateral autogenous tunica vaginalis grafts was proved to be effective and reliable with few complications, particularly conspicuous in increasing the volume of the erectile tissues during erection.

OBJECTIVE: To report the amelioration of the three-piece inflatable penile prosthesis (IPP) implantation and the prevention of its complications.
METHODS: Thirty-two patients with moderate to severe erectile dysfunction (ED) irresponsive to conservative treatments received the implantation of the three-piece IPP. The surgical techniques were ameliorated in the course of operation. The patients were guided in using the IPP after operation. The effects and complications of the implantation were observed based on IIEF of the patients before and after operation.
RESULTS: Sexual life was resumed and no complication was found in 28 of the patients. The complications that developed in the other 4 were pump failure (2 cases), urethral perforation (1 case), and penis contraction (1 case). The former 3 achieved normal sexual intercourse after the second operation. Comparison between the IIEF scores before and after operation showed a very remarkable difference (P < 0.01). The occurrence rate of complications was 12.5%. The satisfaction rate of sexual intercourse was 87.5% and the total satisfaction rate of sexual life was 84.4%.
CONCLUSIONS: The complications of the three-piece IPP implantation were obviously reduced by ameliorating operation techniques. The implantation of the three piece-IPP is safe and effective for advanced ED patients.