2214 TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION

Long-Term Outcome of Surgical Treatment of Penile Fracture Complicated by

Urethral Rupture
A. El-Assmy, H. S. El-Tholoth, T. Mohsen and el-H. I. Ibrahiem
Department of Urology, Mansoura Urology and Nephrology Center, Mansoura, Egypt

J Sex Med 2010; 7: 3784 3788.

Introduction: The combination of lesions of the penile urethra and the corpus cavernosum is rare and
is likely to worsen the immediate and long-term prognosis. Aim: To assess the late effects of penile
fractures complicated by urethral rupture treated by immediate surgical intervention. Methods:
Fourteen patients with concomitant urethral rupture were treated surgically at our center. Those
patients were seen in the outpatient follow-up clinic and were re-evaluated. Main Outcome Measures:
Sexual Health Inventory for Men questionnaire, local examination, uroflowmetry and penile color
Doppler ultrasound. Results: The most common cause of penile fracture is sexual intercourse (50%).
The site of tunical tear was in the proximal shaft of the penis in 3 patients (21%) and in the mid of
the shaft in 11 patients (79%). Urethral injury was localized at the same level as the corpus
cavernosum tear in all cases; and it was partial in 11 cases and complete in 3. Long-term follow-up
(mean90 months) was available for 12 patients; among whom there was no complications in 4 (33%),
painful erection in 1 (8%), erectile dysfunction in 2 (17%), and palpable fibrous nodule in 5 (47%). All
patients had a normal urinary flow except one who developed relative urethral narrowing that
required regular dilatation for 1 month. Conclusions: The urethral injury complicating penile fracture
is often partial and localized at the level of the corpora cavenosa tear. Standard treatment consists of
immediate surgical repair of both urethral and corporal ruptures with no harmful long-term sequelae
on urethral and erectile function in most of patients.

Editorial Comment: This Egyptian report details an experience with immediate recon-
struction in 14 men who sustained combined urethral and penile rupture injuries (9% of
155 penile fracture cases presenting during a 20-year span). In all cases the urethral injury
was localized at the same level as the corpus cavernosum tear. For all urethral repairs a
direct, spatulated, end-to-end anastomosis was successfully achieved without tissue trans-
fer, despite the relatively distal urethral locationa site not usually amenable to primary
anastomosis. Amazingly only half of these injuries occurred as a result of sexual inter-
course, the rest being related to some form of self-manipulation. During 90 months of
followup the overwhelming majority of patients healed without development of erectile
dysfunction or urethral stricture. We have also found that additional tissue transfer
techniques have not been necessary for urethral repairs associated with penile rupture.

Allen F. Morey, M.D.

Re: Penile Fracture: Diagnosis, Treatment and Outcomes of 150 Patients

L. Koifman, R. Barros, R. A. Jnior, A. G. Cavalcanti and L. A. Favorito
Division of Urology, Souza, Aguiar Municipal Hospital, Rio de Janeiro, Brazil

Urology 2010; 76: 1488 1492.

Objective: To report the diagnosis, treatment options, and outcomes of 150 patients with suspicion of
penile fracture. Materials and Methods: We analyzed 150 patients with clinically suspected penile
fracture (PF). The patients were divided into two groups: group 1 (G1) with low suspicion of penile
fracture (n 25), and group 2 (G2) with high suspicion of penile fracture (n 125). Complementary
image methods were conducted on 59 patients (39.3%), with ultrasonography (USG) performed on 37
(24.6%) patients and magnetic resonance imaging on only one (0.6%). Retrograde urethrocystogram
was performed when urethral injury was suspected (21 patients, 14%). In G1, all patients underwent
USG to complement diagnosis. In G2, 12 patients underwent USG owing to a doubtful diagnosis.
Mean follow-up was 34.6 months. Results: All patients in G1 were able to achieve erection after the
initial traumatic event and immediate penile detumescence did not occur in any of the cases. Of the
 BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY 2215

125 patients evaluated in G2, 110 (92%) presented with disruption of the tunica albuginea and 15 (8%)
showed injury of the dorsal vein of the penis. Urethral injury was found in 20 (16%) patients and was
always associated with corpus cavernosum injury. Among 110 cases of PF, 95 (86.3%) presented with
unilateral and 15 (13.7%) presented with bilateral lesions. Conclusions: Patients with high suspicion
of PF should be treated surgically. However, in cases of low suspicion of corpora cavernosum injury,
based on clinical criteria and imaging methods, conservative treatment is a feasible and safe option.

Editorial Comment: This article from Rio de Janeiro describes an experience of 150 men
having clinically suspected penile fractures during a 12-year period. What is interesting
and novel about this article is the clinical distinction of selected patients into a low
suspicion group based on absence of immediate detumescence, minimal edema/bruising on
physical examination, absence of pain and persistence of normal erections after the
traumatic event. The 25 patients in the low suspicion group underwent ultrasonography
and were treated conservatively with analgesics on an outpatient basis. The other 125
patients were treated with standard surgical repair. All cases managed conservatively
were followed for 6 months and did not develop sexual complications.
The clinical diagnosis of penile fracture can be difficult. Injury to the superficial dorsal
vein of the penis (15 cases in this series), smaller vessels or soft tissues can create a picture
closely resembling that of penile fracture. As the authors indicate, several recent studies
reveal that dorsal vein rupture appears to be an injury that responds well to conservative
treatment alone. Ultrasound findings that confirmed absence of tunica albuginea disrup-
tion were associated with an excellent outcome without intervention. When ultrasound
was positive for tunical rupture or large hematoma, surgical intervention and repair were
undertaken. I congratulate these authors for developing and reporting a thoughtful ap-
proach to a difficult problem in an attempt to avoid unnecessary surgical interventions.

Allen F. Morey, M.D.

Bladder, Penis and Urethral

Cancer, and Basic Principles of Oncology

Robot-Assisted Intracorporeal Ileal Conduit: Marionette Technique and Initial

Experience at Roswell Park Cancer Institute
K. Guru, S. A. Seixas-Mikelus, A. Hussain, A. J. Blumenfeld, J. Nyquist,
R. Chandrasekhar and G. E. Wilding
Department of Urologic Oncology, Roswell Park Cancer Institute, Buffalo, New York

Urology 2010; 76: 866 871.

Objectives: To present our technique and initial experience with patients who underwent robot-
assisted intracorporeal creation of ileal conduit and to compare them with patients who underwent
extracorporeal ileal diversion after robot-assisted radical cystectomy. Methods: Twenty-six patients
diagnosed with invasive transitional cell carcinoma of the bladder underwent a robot-assisted radical
cystectomy with bilateral extended pelvic lymphadenectomy with ileal conduit diversion. Total
intracorporeal ileal conduit creation was performed in the last 13 patients. Operative data and
short-term outcomes between the 2 groups were assessed. The novel surgical technique for intracor-
poreal ileal conduit will be presented. Results: The intracorporeal group (IC) included 2 female and
11 male patients (mean age 71 years). The extracorporeal group (EC) included 4 female and 9 male
patients (mean age 66 years). No significant differences were noted between the groups in terms of
patient age, BMI, sex, prior surgery, or pathologic stage. Overall operative time and intraoperative
complications were similar. No significant differences were noted between the 2 groups in terms of