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Surgical management of Peyronies Disease - "Up to Date"
« on: November 09, 2010, 05:49:29 AM »

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Surgical management of Peyronie's disease
 
Authors
William O Brant, MD
Anthony J Bella, MD, FRCSC
Tom F Lue, MD, ScD (Hon), FACS Section Editor
Jerome P Richie, MD, FACS Deputy Editor
Kathryn A Collins, MD, PhD, FACS
 
Last literature review version 18.2: May 2010 | This topic last updated: March 17, 2010 


INTRODUCTION — Peyronie's disease, an acquired, localized fibrotic disorder of the tunica albuginea, can cause significant penile deformity and lead to sexual dysfunction and psychological trauma (figure 1). The nature and extent of Peyronie's plaque, and therefore severity or complexity of penile deformity, varies widely.

Early medical intervention is the first line of therapy and is likely to be more effective when the disease is evolving. Once Peyronie's disease has reached a stable phase, surgery may be offered but only for penile deformity that compromises sexual function.

This topic will review the indications for surgery in Peyronie's disease, approaches to surgical correction, and the complications of surgical management.

The diagnosis and medical management of Peyronie's disease are discussed elsewhere. (See "Peyronie's disease: Diagnosis and medical management".)

SURGICAL INDICATIONS — Surgical management is indicated for patients whose Peyronie's disease has persisted for more than 12 months and is associated with a penile deformity compromising sexual function. It is important to delay surgery until Peyronie's disease has been stable for at least three months because surgical results can be compromised by active disease [1,2].

Surgery is not indicated for plaque without curvature, or minimal degrees of curvature though "minimal degree" is a subjective measurement. The main determinant is whether sexual intercourse without pain is possible [3]. Curvature that does not preclude intercourse, does not warrant surgery. (See "Peyronie's disease: Diagnosis and medical management".)

Concurrent implantation of a penile prosthesis is indicated in men with Peyronie's disease and erectile dysfunction (Erectile Dysfunction) unresponsive to oral agents or intracavernous injection therapy. (See 'Penile prosthesis' below and "Surgical treatment of erectile dysfunction".)

PREOPERATIVE EVALUATION — A thorough review of the patient's medical and surgical history, and a physical examination are performed. (See "Preoperative medical evaluation of the healthy patient".)

Medications that prolong bleeding, such as aspirin, are generally discontinued 7 to 10 days prior to the procedure. (See "Perioperative medication management", section on 'Medications affecting hemostasis' and "Management of anticoagulation before and after elective surgery".)

The following elements of the preoperative evaluation are specific to penile reconstructive procedures.

Duplex evaluation of erectile capacity — A preoperative penile duplex ultrasound combined with intracavernous injection of a vasoactive agent is performed if distal flaccidity is present, or erectile function is in question. (See "Evaluation of male sexual dysfunction".)

Ultrasound assesses the nature and location of the Peyronie's plaque and penile vascular anatomy, identifying any arterial and/or venous components of erectile dysfunction, if present. This information is particularly useful if grafting is being considered.

Preoperative penile photographs/measurements — Preoperative penile photographs should be obtained of the erect penis to document penile length, nature (dorsal, ventral lateral), and degree of curvature for future reference and for medicolegal purposes. Photographs in multiple views can be taken by the patient at home, or in the office by inducing an artificial erection by injecting a vasodilating medication, such as alprostadil.

Choice of surgical approach — The most important factor determining surgical success is selection of the appropriate surgical procedure for a given patient. No one procedure is suitable for all cases of Peyronie's disease. Surgical options include tunical shortening (eg, plication), tunical lengthening (eg, grafting) or implantation of penile prostheses.

Important factors to consider in determining the best surgical approach include the length of the penis, configuration (eg, hourglass, curved) and severity of the deformity, erectile capacity, and patient expectations [2,4]. Most curvature deformities are dorsal although Peyronie's presentations are widely varied. A complete urologic examination is performed.


For a penis with a simple curvature <60º, adequate length, and intact erectile function, a tunical shortening procedure (ie, tunica wedge resection, plication) technique is appropriate. This procedure will not correct an hourglass deformity or hinge effect. When performed on appropriately selected men, simplified tunical shortening (ie, pure plication) offers satisfactory results and minimizes surgical morbidity. (See 'Plication' below.)
For a very short penis, the presence of a severe curvature (>60º), narrowing deformity (eg, hourglass, severe indentation), and good erectile function, tunical lengthening with plaque incision and graft placement may restore penile length, and/or girth. (See 'Grafting' below.)
For curvature associated with significant Erectile Dysfunction, a penile prosthesis can be placed and additional corrective procedures (plication or grafting) are performed if the prosthesis does not provide adequate straightening. (See 'Penile prosthesis' below.)

Patient counseling — A thorough preoperative discussion is essential and should review preparation, complications and realistic long-term outcomes associated with the planned surgery. Patients are informed of the risks of temporary or permanent penile hypoesthesia or anesthesia, future plaque formation, recurrent curvature, and risk of de novo or worsened Erectile Dysfunction. (See 'Complications' below.)

If erectile function is compromised preoperatively, the risk of further dysfunction is increased. Patients with a history of cardiovascular disease (ie, coronary artery disease [CAD] or peripheral arterial disease [PAD]), diabetes, or smoking also have an increased long-term risk for Erectile Dysfunction, independent of the surgery performed for Peyronie's disease [5]. (See "Overview of male sexual dysfunction", section on 'Association with cardiovascular disease' and "Overview of male sexual dysfunction", section on 'Chronic disease' and "Erectile dysfunction in diabetes mellitus".)

Patients with Erectile Dysfunction or significant risk factors for future Erectile Dysfunction should be counseled regarding the placement of a penile prosthesis at the time of surgery. A prosthesis may also be placed at a later date as the need arises. (See 'Penile prosthesis' below.)

Patient expectations about postoperative penile length should also be addressed. Penile shortening often accompanies Peyronie's disease and is dependent on direction and degree of curvature, and original penile length [6]. Patients, however, may have unrealistic recollections of their erect penile length prior to the onset of Peyronie's disease, and premorbid penile measurements are rarely available. The patient is informed that plication surgery may result in a straight erection but is not likely to restore any length, and in fact will likely reduce length. With tunical lengthening procedures (ie, grafting), only about 1/2 to 1 inch of additional length can be expected. It is important to document and review the preoperative stretched penile length with the patient.

Uncircumcised patients are informed that certain incisions may necessitate circumcision to prevent the postoperative complication of foreskin necrosis, which can be difficult to manage. The aesthetic and sensory ramifications of circumcision should be explained. (See "Circumcision: Risks and benefits".)

SURGICAL ANATOMY

Tunica albuginea — The tunica albuginea is a tough layer of fibrous connective tissue surrounding the bilateral corpora cavernosa of the penis (figure 2). The tunica is typically the target in Peyronie's disease surgery, with either plication of the side opposite the plaque, or incision/grafting the same side as the plaque.

Neurovascular bundle — The neurovascular bundle runs along the dorsal aspect of the penis in a groove between the corpora cavernosa (figure 2). The neurovascular bundle consists of the dorsal penile vein, and paired dorsal arteries and nerves. Preserving the neurovascular bundle is critical since injury may lead to glans hypoesthesia or even necrosis. The neurovascular bundle is often intimately adherent to the underlying Peyronie's plaque; releasing these structures is often the hardest component of reconstructive surgery.

GENERAL APPROACH — Reconstructive procedures for Peyronie's disease are typically performed as an ambulatory procedure, or with overnight observation either in an ambulatory or inpatient setting. Plication procedures can be performed with local anesthesia and monitored sedation; general or regional anesthesia may be more appropriate for more complicated procedures. (See "Overview of anesthesia and anesthetic choices".)

Prior to the incision, a single dose of first generation cephalosporin is given. The patient is positioned supine and the operative area depilated with a clipper. Bladder drainage is generally not required unless a penile prosthesis will be placed. If the saphenous vein will be used as a graft, the non-dominant lower extremity is slightly flexed and abducted and prepped separately [7]. (See "Placement and management of urinary bladder catheters".)

Following sterile preparation, an artificial erection is induced by injecting normal saline with 60 mg of papaverine into the corpus cavernosum; this aids in preprocedure planning and intraoperative assessment of surgical results. The site of greatest curvature and plaque is marked and the incision made in the skin, and the penis degloved to access the tunica albuginea; the choice of incision (circumferential below the glans, or longitudinal) depends upon the nature of the planned surgery.

An uncircumcised patient who receives a circumferential incision often requires a concomitant circumcision; profound lymphedema or even foreskin necrosis have been reported with prepuce-preserving techniques. Patients must be informed of the aesthetic and sensation ramifications of this. (See 'Patient counseling' above.)

A longitudinal incision may be advantageous in managing a dorsal curvature. This approach is also associated with improved healing, avoids lymphedema and the need for circumcision; however, visible scarring will result unless the incision is placed along the penile raphe.

TECHNIQUES — Complementary techniques employed in the surgical management of Peyronie's disease include plication, grafting, or placement of a penile prosthesis. Tailored approaches are often required to manage the variety of plaque-induced penile deformities associated with Peyronie's plaques.

Each of the techniques can be performed with or without plaque incision, which facilitates tunica mobility. An H-shaped incision in the exterior surface of the plaque is often all that is needed. Plaque excision involves complete removal of the plaque and is associated with higher rates of Erectile Dysfunction, graft contracture and late recurrence of curvature; however, plaque excision may be required if the plaque is heavily calcified [7].

Plication — Straightening the penis with plication is achieved by shortening the convex side of the penis (ie, opposite the plaque) and should only be performed in men with adequate penile length and curvature less than 60º (figure 3). All plication procedures result in loss of penile length as the tunica albuginea is shortened on the longer side to match the shorter side [6].

Soft, braided, permanent, or delayed absorbable sutures are used because they are the least noticeable under the skin.

Plication is performed with or without plaque incision. When the tunica albuginea is plicated without incision (ie, pure plication), normal anatomy is minimally disrupted. Since dorsal curvature is the most prevalent, plication of the ventral surface avoids the need to dissect the dorsal neurovascular bundle.

The most common plication techniques are:


Nesbit procedure - One or more ellipses of the tunica albuginea are excised from the convex side (ie, tunica wedge resection) and the tunica plicated at the most prominent portion of the curvature [8].
Yachia procedure - Longitudinal incisions in the tunica albuginea on the convex side are closed horizontally (eg, Heineke-Mikulicz) [9].
Lue procedure - The Lue procedure, also known as the "16 dot" minimal tension approach, is a pure plication procedure consisting of two or three pairs of plications on the convex side [10,11]. Paired, mattress sutures are placed in the tunica albuginea and tension adjusted to straighten the curvature prior to completing the ties.

Grafting — Men with Peyronie's disease who have a short penis, extensive plaque, severe (>60º), or complex deformities will require a grafting procedure. Grafting the concave side of the penis serves to lengthen that side and therefore straighten the penis (figure 4).

Dissection of the neurovascular bundle and/or corpus spongiosum may be required depending upon the location of the deformity; injury to the dorsal neural complex with loss of glans sensation may result.

Opening the tunica albuginea often worsens erectile function. Patients must be aware of this risk, and should be counseled regarding the option of penile prosthesis implantation [12]. (See 'Complications' below and 'Patient counseling' above.)

Graft materials — Following management of the plaque, a graft is placed. The choice of graft material depends upon several factors, including type of deformity, efficacy, and availability [13]. Grafting materials include:


Autologous tissue (eg, saphenous vein, fascia lata, rectus fascia, tunica vaginalis, dermis, buccal mucosa). Vein patch is the most commonly used autograft material and is harvested from the distal saphenous vein; if a larger graft is needed, the proximal saphenous vein can be used. Saphenous vein is spared in patients with significant cardiovascular disease (ie, CAD, PAD); these patients may need the saphenous vein for future bypass grafting.
Allograft or xenograft materials (eg, cadaveric or bovine pericardium, engineered dermal graft, porcine small intestinal submucosa [SIS]) [14-16]. These acellular matrices allow regenerative in-growth of native tissues. The main advantage of allograft tissues is elimination of the need for tissue harvesting.
Synthetic grafts (eg, PTFE). The use of synthetic materials is discouraged due to increased incidence of infection and postoperative inflammation leading to perigraft fibrosis [1,3,16]. (See 'Complications' below.)

Penile prosthesis — The treatment of choice for patients with Peyronie's disease and significant Erectile Dysfunction is placement of a penile prosthetic implant with or without manual modeling and with or without penile reconstruction.

Patient satisfaction is higher with inflatable penile prostheses than malleable devices [1,17]. Either a two-piece or three-piece (figure 5) prosthetic is used. (See "Surgical treatment of erectile dysfunction", section on 'Inflatable'.)

The correction of penile curvature can be accomplished solely by implantation of the penile prosthesis in patients with mild to moderate curvature. Manual modeling over the prosthesis may be required to correct more significant deformities (eg, >30º curvature) [18]. Penile reconstruction (plaque incision/grafting) can be performed before or after implant placement in patients with severe or complex deformities, or calcified Peyronie's plaque [19].

Manual modeling is a process by which the tunica plaque is fractured over the inflated prosthetic cylinder at the time of implantation. The penis is forcibly bent in a direction opposite the curvature [18]. Bending pressure is maintained on the penis for 90 seconds. When successful, the modeling procedure causes splitting and rupturing of the fibrotic plaques. The penile implant is left partially inflated for six weeks to prevent contraction of the tunica defect which could lead to recurrent curvature.

Dressing — Following the reconstructive procedure, a petrolatum gauze is placed on the incision and covered loosely with a gauze pad. A snug, self adhesive wrap (eg, Coban) is placed around the penis from distal to proximal and then squeezed gently to make it snug but not constrictive.

POSTOPERATIVE CARE — Depending upon the nature and length of the procedure and degree of postoperative pain, overnight observation may be indicated.

Pain management — Intravenous or oral pain medications are given, as needed. (See "Management of postoperative pain".)

An ice pack is applied intermittently to the penis for the first 24 hours to lessen pain and swelling.

Dressing — On the first postoperative day, patients are taught how to change their dressing, and are instructed to perform daily dressing changes for 5 to 10 days. The patient may shower, but should keep the dressing dry, which can be accomplished by applying a condom. Water immersion is avoided for five weeks.

Patient instructions — Patients are instructed to:


Resume activities as tolerated. If the patient has received a prosthesis, heavy lifting is avoided for four weeks.
Return to work in a few days depending upon speed of recovery.
Watch for signs of infection (ie, fever, redness, excess swelling, discharge, increasing pain), particularly if a prosthesis has been placed.
Arrange to be seen by the surgeon if infection develops, or if there are any other concerns.

Sexual activity — The patient is instructed not to engage in sexual intercourse or masturbation for four to eight weeks.

FOLLOW UP CARE — Follow up in the office varies depending upon the nature of the procedure and the patient's recovery. Following the placement of a prosthesis, the patient is scheduled to return to the clinic in approximately six weeks to learn how to use the device.

COMPLICATIONS — The complications associated with correction of Peyronie's disease deformities are dependent upon the technique used for reconstruction. General complications include surgical site infection, penile hematoma, penile narrowing or indentation, phimosis, sensory abnormalities and erectile dysfunction.

Erectile dysfunction, like sensory abnormalities, is more likely to occur in procedures that require dissection and mobilization of the neurovascular bundle.

Erectile dysfunctionErectile dysfunction (Erectile Dysfunction) is reported to occur in up to 20 percent of patients postoperatively. In retrospective reviews, pure plication (ie, Lue procedure) has been associated with the least risk of erectile dysfunction compared to standard plication (ie, Nesbit, Yachia) and grafting procedures [8,11,16]. Patients with preexisting Erectile Dysfunction are more likely to experience worsened sexual function, though Erectile Dysfunction can develop de novo. Up to 45 percent of patients with pre-existing Erectile Dysfunction will suffer a further decline [20,21]. Long term, additional deterioration in both erectile and orgasmic function has been observed [20]. Patients with preexisting Erectile Dysfunction should be counseled appropriately. (See 'Patient counseling' above.)

Graft complications — The use of grafting materials is associated with additional complications that include: persistent pain which may be due to neurological injury, graft bulging (ie, herniation), graft infection, or graft contracture leading to penile shortening or recurrent curvature [14,22]. Surgical site infection can also occur at the site of autogenous tissue harvest.

If the patient notices a bulging of the graft, which can occur two to three months postoperatively, a duplex ultrasound is performed. If a hematoma is identified, an aspiration procedure is performed. If no hematoma is identified, observation is continued. Reoperation may be required if the bulge is chronic and clinically significant (ie, causing difficulty with or precluding sexual intercourse).

Penile implant complications — The complications associated with penile implants are discussed elsewhere. (See "Surgical treatment of erectile dysfunction", section on 'Penile implants'.)

OUTCOMES — With appropriately chosen technique taking into consideration patient-specific characteristics, reconstruction for Peyronie's disease achieves satisfactory results in the majority of men [1,13,20,22]. Long term satisfaction with return to sexual activity was high for both patient (86 percent) and partner (77 percent) in a retrospective evaluation of 61 patients [23]. Curvature is corrected in most patients, however, minor residual and recurrent curvature is reported for all the techniques described.

Plication (Yachia, Nesbit, Lue) achieves penile straightening in 67 to 100 percent of patients with a low risk for postoperative sexual dysfunction [1,9,11,24,25]. The primary concern for these patients is the degree of penile shortening. While some degree of penile shortening occurs in all patients, few have difficulty with penetration [8]. Residual curvature rates vary from 7 to 21 percent, and may be due to suture absorption, slippage, or breakage [11]. (See 'Plication' above.)

For patients who undergo grafting procedures, patient satisfaction and curvature correction rates are the highest (>90 percent) with autogenous vein grafting (table 1) compared to other grafting materials in retrospective reviews [1,14,20,22,23,26,27]. Recurrent curvature occurs in 12 to 16 percent of patients following vein graft procedures [20,23]. Other grafting materials (ie, dermis, pericardium, SIS) have been evaluated but clinical outcomes are inconsistent and not superior to autogenous vein grafts [1,23,26].

The use of penile implants in the treatment of Peyronie's disease produces satisfactory correction of curvature with adequate erectile function in greater than 85 percent of patients in most large series [1,17,28]. (See "Surgical treatment of erectile dysfunction".)

SUMMARY AND RECOMMENDATIONS


Peyronie's disease is an acquired, localized fibrotic disorder of the tunica albuginea, which can cause significant penile deformity and lead to sexual dysfunction and psychological trauma. (See 'Introduction' above.)
Surgical management is indicated for patients whose Peyronie's disease has persisted for more than 12 months and is associated with a penile deformity compromising sexual function. (See 'Surgical indications' above.)
The length of the penis, nature (eg, hourglass, curved) and severity of the deformity, erectile capacity, and patient expectations are important factors to consider when determining the surgical approach. (See 'Choice of surgical approach' above.)
Surgical techniques used for penile reconstruction in Peyronie's disease include plication, grafting, or placement of a penile prosthesis. Plication shortens the convex side of the penis, whereas grafting techniques lengthen the concave side. Penile implants are used in patients with pre-existing erectile dysfunction. Plaque incision is often combined with these techniques to improve the mobility of the plaque. (See 'Techniques' above.)
Erectile dysfunction (Erectile Dysfunction) occurs in up 20 percent of patients following surgical reconstruction for Peyronie's disease and can occur without a prior history of Erectile Dysfunction; however, Erectile Dysfunction is more likely to complicate procedures requiring dissection of the neurovascular bundle, or in patients with pre-existing Erectile Dysfunction. (See 'General approach' above.)
For patients with a dorsal curvature less than 60 degrees, we suggest ventral plication as the initial surgical approach (Grade 2C). (See 'General approach' above.)
For patients with curvatures greater than 60 degrees, we suggest plaque excision and grafting (Grade 2C). (See 'General approach' above.)
In those patients with pre-existing Erectile Dysfunction, we suggest implantation of a penile prosthetic in conjunction with penile reconstruction (Grade 2B). (See 'Patient counseling' above and 'Complications' above.)



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REFERENCES

1 Kadioglu, A, Akman, T, Sanli, O, et al. Surgical Treatment of Peyronie's Disease: A Critical Analysis. Eur Urol 2006; 50:235. 
2 Dean, RC, Lue, TF. Peyronie's disease: advancements in recent surgical techniques. Curr Opin Urol 2004; 14:339. 
3 Ralph, DJ, Garaffa, G, Garcia, MA. Reconstructive surgery of the penis. Curr Opin Urol 2006; 16:396. 
4 Levine, LA, Lenting, EL. A surgical algorithm for the treatment of Peyronie's disease. J Urol 1997; 158:2149. 
5 Kadioglu, A, Tefekli, A, Erol, B, et al. A retrospective review of 307 men with Peyronie's disease. J Urol 2002; 168:1075. 
6 Greenfield, JM, Lucas, S, Levine, LA. Factors affecting the loss of length associated with tunica albuginea plication for correction of penile curvature. J Urol 2006; 175:238. 
7 Brant, WO, Bella, AJ, Garcia, MM, et al. Surgical Atlas. Correction of Peyronie's disease: plaque incision and grafting. BJU Int 2006; 97:1353.
8 Ralph, DJ, al-Akraa, M, Pryor, JP. The Nesbit operation for Peyronie's disease: 16-year experience. J Urol 1995; 154:1362. 
9 Yachia, D. Modified corporoplasty for the treatment of penile curvature. J Urol 1990; 143:80. 
10 Brant, WO, Bella, AJ, Lue, TF. 16-dot procedure for penile curvature. J Sex Med 2007; 4:277.
11 Gholami, SS, Lue, TF. Correction of penile curvature using the 16-dot plication technique: a review of 132 patients. J Urol 2002; 167:2066. 
12 Ralph, DJ. The Surgical Treatment of Peyronie's Disease. Eur Urol 2006; 50:196.
13 Kendirci, M, Hellstrom, WJ. Critical analysis of surgery for Peyronie's disease. Curr Opin Urol 2004; 14:381. 
14 Breyer, BN, Brant, WO, Garcia, MM, et al. Complications of porcine small intestine submucosa graft for Peyronie's disease. J Urol 2007; 177:589. 
15 Knoll, LD. Use of porcine small intestinal submucosal graft in the surgical management of Peyronie's disease. Urology 2001; 57:753. 
16 Kadioglu, A, Sanli, O, Akman, T, et al. Graft materials in Peyronie's disease surgery: a comprehensive review. J Sex Med 2007; 4:581. 
17 Montorsi, F, Guazzoni, G, Bergamaschi, F, Rigatti, P. Patient-partner satisfaction with semirigid penile prostheses for Peyronie's disease: a 5-year followup study. J Urol 1993; 150:1819. 
18 Wilson, SK, Delk JR, 2nd. A new treatment for Peyronie's disease: modeling the penis over an inflatable penile prosthesis. J Urol 1994; 152:1121. 
19 Rahman, NU, Carrion, RE, Bochinski, D, Lue, TF. Combined penile plication surgery and insertion of penile prosthesis for severe penile curvature and erectile dysfunction. J Urol 2004; 171:2346. 
20 Montorsi, F, Salonia. Five year follow-up of plaque incision and vein grafting for Peyronie's disease. Eur Urol 2004; 3(Suppl 2):33 Abstract 123.
21 Montorsi, F, Salonia, A, Maga, T, et al. Evidence based assessment of long-term results of plaque incision and vein grafting for Peyronie's disease. J Urol 2000; 163:1704. 
22 El-Sakka, AI, Rashwan, HM, Lue, TF. Venous patch graft for Peyronie's disease. Part II: outcome analysis. J Urol 1998; 160:2050. 
23 Usta, MF, Bivalacqua, TJ, Sanabria, J, et al. Patient and partner satisfaction and long-term results after surgical treatment for Peyronie's disease. Urology 2003; 62:105. 
24 Gholami, SS, Gonzalez-Cavadid, NF, Lin, CS, et al. Peyronie's disease: a review. J Urol 2003; 169:1234. 
25 Licht, MR, Lewis, RW. Modified Nesbit procedure for the treatment of Peyronie's disease: a comparative outcome analysis. J Urol 1997; 158:460. 
26 Levine, LA, Estrada, CR. Human cadaveric pericardial graft for the surgical correction of Peyronie's disease. J Urol 2003; 170:2359. 
27 Akkus, E, Ozkara, H, Alici, B, et al. Incision and venous patch graft in the surgical treatment of penile curvature in Peyronie's disease. Eur Urol 2001; 40:531. 
28 Wilson, SK, Cleaves, MA, Delk, JR. Long-term followup of treatment for Peyronie's disease: modeling the penis over an inflatable penile prosthesis. J Urol 2001; 165:825. 
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