The first modern prosthetic reconstruction of a penis is attributed to NA Borgus, a German physician who performed the first surgical attempts in 1936 on soldiers with traumatic  amputations of the penis . He used  rib cartilages  as prosthetic material and reconstructed the genitals for both  micturition  and  intercourse  purposes. [ 3 ]  Willard E. Goodwin and William Wallace Scott were the first to describe the placement of synthetic penile implants using  acrylic  prosthesis in 1952. [ 4 ]   Silicone -based penile implants were developed by Harvey Lash and the first case series were published in 1964. [ 5 ]  The development of a high-grade silicone that is currently used in penile implants is credited to  NASA . [ 6 ]  The prototypes of the contemporary inflatable and malleable penile implants were presented in 1973 during the annual meeting of the  American Urological Association  by two groups of physicians from  Baylor University  (Gerald Timm, William E. Bradley and F. Brantley Scott) and  University of Miami  (Michael P. Small and Hernan M. Carrion). [ 3 ] [ 7 ] [ 8 ]  Small and Carrion pioneered the popularization of semi-rigid penile implants with the introduction of Small-Carrion prosthesis ( Mentor , USA) in 1975. Brantley Scott described the initial device as composed of two inflatable cylindrical bodies made up of silicone, a reservoir containing  radiopaque  fluid and two pumping units. [ 7 ]  The first generation products were marketed through American Medical Systems (AMS; currently  Boston Scientific ), with which Brantley Scott was associated. [ 6 ] [ 9 ]  Many device updates have been released by AMS since the first generation implants. In 1983, Mentor (currently  Coloplast ) joined the market. [ 6 ]  In 2017, there were more than ten manufacturers of penile implants in the world, however only a few now remain in the market. [ 10 ]  The latest additions to the market are  Zephyr Surgical Implants  and  Rigicon Innovative Urological Solutions . [ 11 ] [ 12 ]  Zephyr Surgical Implants, along with penile implants for biological men, introduced the first line of inflatable and malleable penile implants designed for  sex reassignment  for  trans men . In recent years, Rigicon Innovative Urological Solutions, a US-based company, has made significant advancements in the field of penile implants. In 2017, they released the 'Rigi10,' a malleable implant that expanded the market's options. Following this, in 2019, they introduced both the 'Infla10' series, which includes the Infla10 AX, Infla10 X, and Infla10 models, and the 'Rigi10 Hydrophilic.' These inflatable and hydrophilic-coated malleable models respectively were important additions to the range of penile implant technologies available. These advancements have contributed to the diversity and progress in the development of penile implants, offering patients more varied and tailored treatment solutions. [ 13 ]   [ 14 ]


According to analysis of the 5% Medicare Public Use Files from 2001 to 2010 approximately 3% of patients diagnosed with erectile dysfunction opt for penile implantation. [ 15 ]  Each year nearly 25,000 inflatable penile prostheses are implanted in the USA. [ 16 ]


The list shows penile implants available in the market in 2020.


The malleable (also known as non-inflatable or semi-rigid) penile  prosthesis  is a pair of rods implanted into the corpora of the penis. The rods are hard, but 'malleable' in the sense that they can be adjusted manually into the erect position. [ 18 ]  There are two types of malleable implants: one that is made of silicone and does not have a rod inside, also called soft implants, and another with a silver or steel spiral wire core inside coated with silicone. Some of the models have trimmable tails intended for length adjustment. [ 10 ]  Currently, a variety of malleable penile implants are available worldwide. [ 19 ]


The inflatable penile implant (IPP), more recently developed, is a set of inflatable cylinders and a pump system. Based on the differences in structure, there are two types of inflatable penile implants: two-piece and three-piece IPPs. Both types of inflatable devices are filled with sterile  saline solution  which is pumped into cylinders when in process. The cylinders are implanted into the  cavernous body of the penis . The pump system is attached to the cylinders and placed in the  scrotum . [ 10 ]  Three-piece implants have a separate large reservoir connected to the pump. The reservoir is commonly placed in the  retropubic space  (Retzius' space), however other locations have also been described, such as between the  transverse muscle  and  rectus muscle . Three-piece implants provide more desirable rigidity and girth of the penis resembling natural erection. Additionally, due to the presence of a large reservoir, three-piece implants provide full flaccidity of the penis when deflated, thus bringing more comfort than two-piece inflatable and malleable implants. [ 6 ]


The saline solution is pumped manually from the reservoir into bilateral chambers of cylinders implanted in the shaft of the penis, which replaces the non- or minimally-functioning erectile tissue. This produces an erection. The  glans of the penis , however, remains unaffected. Ninety to ninety-five percent of inflatable prostheses produce erections suitable for  sexual intercourse . In the United States, the inflatable prosthesis has largely replaced the malleable one, due to its lower rate of infections, high device survival rate and 80–90% satisfaction rate. [ 2 ]


The first IPP prototype presented in 1975 by Scott and colleagues was a three-piece prosthesis (two cylinders, two pumps and a fluid reservoir). Since then, the IPP has undergone multiple modifications and improvements for device reliability and durability, including change in the chemical material used in implant manufacturing, using hydrophilic and antibiotic eluting coatings to reduce the rates of infections, introducing one-touch release etc. [ 10 ]  Surgical techniques used for the implantation of penile prostheses have also improved along with evolution of the device. Inflatable penile implants were one of the first interventions in urology where the "no-touch" surgical technique was introduced. This has significantly reduced the rates of post-operative infections. [ 20 ]


In spite of recent rapid and extensive development of non-surgical management options for  erectile dysfunction , especially novel targeted medications and  gene therapy , the penile implants remain the mainstay and the gold standard choice for the treatment of erectile dysfunction refractory to oral medications and injectable therapy. [ 21 ] [ 6 ]  Additionally, penile implants can be a relevant option for those with erectile dysfunction who want to proceed with a permanent solution without medical therapy. Penile implants have been used for the treatment of erectile dysfunction with various etiologies, including vascular,  cavernosal , neurogenic, psychological and post-surgical (e.g.  prostatectomy ). The  American Urological Association  recommends informing all men with erectile dysfunction about penile implants as a choice of treatment and discussing the potential outcomes with them. [ 22 ]


Penile implants can help recover the natural shape of the penis in various conditions that have led to penile deformity. These can be traumatic injuries, penile surgeries, disfiguring and  fibrosing  diseases of the penis, such as  Peyronie's disease . [ 6 ]  In Peyronie's disease, the change in penile curvature affects normal sexual intercourse as well as causing  erectile dysfunction  due to disruption of blood flow in the  cavernous bodies  of the penis. [ 23 ]  Therefore, implantation of penile prosthesis in Peyronie's disease addresses several mechanisms involved in the pathophysiology of the disease.


Although different models of penile prostheses have been reported to be implanted after  phalloplasty  procedures, [ 24 ]  with the first case described in 1978 by Pucket and Montie, [ 25 ]  the first penile implants designed and produced specifically for  female-to-male gender reassignment surgery  for  trans men  were introduced in 2015 by  Zephyr Surgical Implants . [ 26 ]  Both malleable and inflatable models are available. These implants have more realistic shape with an ergonomic glans at the tip of the prosthesis. The inflatable model has an attached pump resembling a testicle. The prosthesis is implanted with a sturdy fixation on  pubic bone . Another, thinner malleable implant is intended for  metoidioplasty .


The overall satisfaction rate with penile implants reaches over 90%. [ 6 ]  Both self- and partner-reported satisfaction rates are evaluated to assess the outcomes. It has been shown that implantation of inflatable penile prosthesis brings more patient and partner satisfaction than medication therapy with  PDE5 inhibitors  or  intracavernosal injections . [ 21 ]  Satisfaction rates are reported to be higher with inflatable rather than malleable implants, but there are no differences between two-piece and three-piece devices. [ 27 ] [ 28 ]  The most frequent reasons for dissatisfaction are reduced penis length and girth, failed expectations and difficulties with device use. [ 21 ] [ 27 ]  Thus, it is vital to provide patients and their partners with detailed preoperative counselling and instructions. [ citation needed ]


33% to 90% of cases of patients with Peyronie's disease that have had an inflatable PI procedure have successfully corrected their penile deformity. [ 23 ]  The residual curvature after penile implant placement usually requires intraoperative surgical intervention.


Dilation of the corpora cavernosa, typically with Hegar sounds, before inserting the device has been a common part of implantation procedures. This dilation destroys erectile tissue. It has been shown that a tissue-sparing technique, i.e.  without  dilation, correlates with superior outcomes – some remaining natural erectile response can be preserved, and post-operative pain is reduced as well. [ 29 ] [ 30 ]


The most common complication associated with penile implant placement appears to be infections with reported rates of 1–3%. [ 27 ]  Both surgical site and device infections are reported. When the infection involves the penile implant itself, implant removal is required and irrigation of the cavities with  antiseptic  solutions. In this scenario, placement of a new implant is needed to avoid further tissue fibrosis and shortening of the penis. The rate of repeat surgeries or device replacements ranges from 6% to 13%. [ 23 ]  Other reported complications include perforation of the  corpus cavernosum  and  urethra  (0.1–3%), commonly occurring in patients with previous  fibrosis , prosthesis erosion or extrusion, change in  glans  shape,  hematoma , shortening of penis length, and device malfunction. Due to continuous improvement of surgical techniques and modifications of implants, complication rates have dramatically decreased over time. [ citation needed ]


To overcome post-operative penile shortening and to increase the perceived length of the penis and patient satisfaction, ventral and dorsal  phalloplasty  procedures in combination with penile implants have been described. [ 21 ]  Modified glanulopexy has been proposed to prevent supersonic transporter deformity and glandular hypermobility which are possible complications of penile implants. [ 31 ]


Sliding techniques in which the penis is cut and elongated with penile implants have been performed in cases of severe penile shortening. However, these techniques had higher rates of complications and are currently avoided. [ citation needed ]


Penis reduction  or  penis reduction surgery  refers to efforts or an assortment of techniques intended to decrease the girth or length of the  human penis , especially when erect. The motive behind such a procedure can range from complications such as  macropenis , [ 1 ] [ 2 ]  genital  lymphedema , [ 3 ]  or  sex reassignment . [ 4 ]  It may also be motivated by the shape or size of the extant penis being unviable for intercourse and the associated social liabilities of having macrophallic penile dimensions. [ 5 ]  The causes of macrophallism can range from  sickle cell disease  to  priapism . [ 6 ]  The age range of individuals who have undergone treatment or are purported to have considered it vary including a 17 year old, [ 7 ]  a 52 year old, [ 8 ]  a 20 year old [ 9 ]  and a 41 year old named Matt Barr. [ 10 ]  The procedure may involve the removal of tissue beneath the skin of the penis, [ 11 ]  amelioration through simple excision procedures, [ 12 ]  or antihypertensive medication. [ 13 ]  Such procedures have been considered by men with partners who have complained about discomfort of thrusts against the  cervix [ 14 ]  as well as those seeking additional stimulation of the  clitoris . [ 15 ]  In some ancient periods of history, the diminution of penile size was a desired appearance aesthetically, including those observable in surviving works of art, due to an association with unpretentiousness, reticence and timidity; [ 16 ]  artists also wanted to distance themselves from erotic art's obsession with over-sized genitals.


Penis removal  is the act of removing the  human penis . It is not to be confused with the related practice of  castration , in which the testicles are removed or deactivated, or emasculation, which removes both. Penis removal and castration have been used to create a class of servants or slaves called  eunuchs  in many different places and eras, having a notable presence in various societies such as  Imperial China .


In  Russia , men of a devout group of  Spiritual Christians  known as the  Skoptsy  were castrated, either undergoing "greater castration", which entailed removal of the penis, or "lesser castration", in which the penis remained in place, while Skoptsy women underwent  mastectomy . These procedures were performed in an effort to eliminate lust and to restore the Christian to a pristine state that existed prior to  original sin .


In the modern era, removing the human penis for any such activity is very rare (with some exceptions listed below), and references to removal of the penis are almost always symbolic. Castration is less rare, and is performed as a last resort in the treatment of  androgen -sensitive  prostate cancer . [ 1 ] [ 2 ] [ 3 ]


Some men have penile  amputations , known as  penectomies , for medical reasons.  Cancer , for example, sometimes necessitates removal of all or part of the penis. In some instances, botched childhood  circumcisions  have also resulted in full or partial penectomies. [ 4 ]


Genital surgical procedures for  transgender women  undergoing  sex reassignment surgery  do not usually involve the complete removal of the penis; part or all of the  glans  is usually kept and reshaped as a  clitoris , and the skin of the penile shaft may also be inverted to form the  vagina . When procedures such as this are not possible, other procedures such as  colovaginoplasty  are used which do involve the removal of the penis.


Issues related to the removal of the penis appear in psychology, for example in the condition known as  castration anxiety .


Some men have undergone penectomies as a voluntary  body modification , thus including it as part of a  body dysmorphic disorder .
Professional opinion is divided regarding the desire for penile amputation as a pathology, much as all other forms of treatment by amputation for body dysmorphic disorder. Voluntary  subincision , removal of the  glans penis , and bifurcation of the penis are related topics.


In ancient China, for crimes including adultery, "licentious" and "promiscuous" activity, males had their penises removed in addition to being  castrated . This was one of the  Five Punishments  that could be legally inflicted on criminals in China. [ 5 ]  The exact crime was called  gong , and referred to "immoral" sex between males and females. The punishment stated, "If a male and female engage in intercourse without morality, their punishments shall be castration and  sequestration  [respectively]." [ 6 ]  They were designed to permanently disfigure for life. [ 7 ]  "Castration", in China, meant the severing of the penis in addition to the testicles, after which male offenders were sentenced to work in the palace as  eunuchs . The punishment was called  gōngxíng  (宫刑), which meant "palace punishment", since castrated men would be enslaved to work in the harem of the palace. It was also called " fǔxíng "(腐刑). [ 8 ]  Husbands who committed  adultery  were punished with castration as required under this law. [ 9 ]


The removal of the penis was used as a punishment for men in the  Heian period  in Japan, where it replaced execution. It was called  rasetsu  羅切 (らせつ), and was separate from castration which was called  kyūkei  宮刑 (きゅうけい). [ 10 ] [ 11 ]   Rasetsu  was done voluntarily by some Japanese Buddhist priests to ensure celibacy. [ 12 ] [ 13 ]  Rasetsu was also known in  Edo period  Japan. [ 14 ]


The word  rasetsu  was made out of the components "ra" from " mara " which meant penis, and " setsu ", which meant cutting. [ 15 ] [ 16 ]


The word  rasetsu  was used in Japanese literature. [ 17 ]


Kyūkei  in Japanese law referred to the punishment of castration, which was used for male offenders, and confinement for females. [ 18 ] [ 19 ] [ 20 ] [ 21 ] [ 22 ] [ 23 ]


The  Arab slave trade  provided many eunuchs who were more highly prized, and priced. African boys were generally subject to penis removal, as well as castration. [ 24 ]


A study of penis reattachment in China found that in a group of 50 men, all but one reacquired functionality, even though some involved full reconstructive surgery using tissue and bone. Reportedly, some of these men later fathered children. [ 25 ]


If reattachment is not an option (such as the penis not being reattached long after 24 hours), [ 26 ] [ 27 ]  doctors can reconstruct a penis from muscle and skin grafted from another part of the body like the forearm. However, a penile implant is needed for an erection to be possible, as the reconstructed penis would look strange and would either not be able to ejaculate, [ 28 ] [ 29 ]  or ejaculate with less force. [ 26 ]  Patients are often dissatisfied with the reconstructed penis. [ 30 ]  Since 2015,  Zephyr Surgical Implants  produces malleable and inflatable penile implants particularly designed for phalloplasty surgeries. [ 31 ]  Standing during urination is an advantage offered by a reconstructed penis. [ 32 ]  If penis reconstruction is not done, the patient will have to squat in order to urinate since doctors reroute the entrance of the urethra to below the scrotum. [ 28 ]


In the 21st-century, successful  allographic  penis transplantation surgery began.


Phalloplasty  (also called  penoplasty ) [ 1 ]  is the construction or reconstruction of a  penis  or the artificial modification of the penis by  surgery . The term is also occasionally used to refer to  penis enlargement . [ 2 ]


Russian surgeon Nikolaj Bogoraz performed the first reconstruction of a total penis using rib cartilage in a reconstructed phallus made from a tubed abdominal flap in 1936. [ 3 ] [ 4 ] [ 5 ]
The first  gender-affirming surgery  for a  trans man  was performed in 1946 by Sir  Harold Gillies  on fellow physician  Michael Dillon , documented in  Pagan Kennedy 's book  The First Man-Made Man . [ citation needed ]  Gillies' technique remained the standard one for decades. Later improvements in  microsurgery  made more techniques available.


A complete construction or reconstruction of a penis can be performed on patients who: [ citation needed ]


There are different techniques for phalloplasty. Construction of a new penis (sometimes called a neophallus or neopenis) [ 6 ]  typically involves taking a tissue flap from a donor site (such as the forearm). Extending the  urethra  through the length of the neophallus is another goal of phalloplasty. [ 7 ]


Temporary lengthening can also be gained by a procedure that releases the suspensory ligament where it is attached to the pubic bone, thereby allowing the penis to be advanced toward the outside of the body. The procedure is performed through a discreet horizontal incision located in the pubic region where the pubic hair will help conceal the incision site. However, scar formation can cause the penis to retract. Therefore, the  American Urological Association  "considers the division of the suspensory ligament of the penis for increasing penile length in adults to be a procedure which has not been shown to be safe or efficacious." [ 8 ] [ 9 ]


Phalloplasty requires an implanted  penile prosthesis  to achieve an erection. Penile prostheses are implanted devices intended to restore the erectile rigidity in  cisgender  men and to build a neophallus (new penis) in  transgender  men. Penile implants have been used in phalloplasty surgeries both in cisgender and transgender patients since 1970s. [ 10 ]


There are two main types of penile implants – malleable (also known as non-inflatable or semi-rigid) and inflatable implants. Both types have a pair of cylinders implanted into the penis, replacing the non-erectile tissue in cisgender men and serving as the core for the neophallus in the phalloplasty procedure. The cylinder of the inflatable implant is filled with sterile  saline solution . Pumping saline into the chambers of this cylinder produces an erection. The glans of the penis, however, remains unaffected.


In  sex reassignment surgeries , a new penis is formed with the use of a penile implant surrounded with a tissue flap. [ 11 ]


The pump unit of inflatable penile implants resembles a human testicle and can serve as an artificial testicle for concomitant  scrotoplasty . [ 12 ]


Initially, standard penile implants were used in phalloplasty procedures. However, since there is no  corpus cavernosum  in the penis undergoing phalloplasty, and the fact that standard penile implants were designed to be implanted in corpus cavernosum, there were many adverse outcomes. [ 13 ]  Since 2015,  Zephyr Surgical Implants  proposes malleable and inflatable penile implants particularly designed for phalloplasty surgeries. [ 14 ]  Implantation procedures are usually done in a separate surgery to allow time for proper healing.


[ 15 ]  Sensation is retained through the  clitoral tissue  at the base of the neophallus. [ 15 ]  Nerves from the flap and the tissue it has been attached to may eventually connect. [ 16 ]


The disadvantages include:


This phalloplasty method is from  latissimus dorsi  musculocutaneous flap. [ 17 ]


This phalloplasty procedure involves the insertion of a subcutaneous soft silicone implant under the penile skin. [ 18 ] [ 19 ] [ 20 ] [ 21 ]


The no-touch surgical technique for  penile prosthesis  implantation is a surgical procedure developed by J. Francois Eid for the implantation of a  penile implant . [ 22 ]  Implantation through the use of the "No-Touch" technique minimizes the risk of infection.


As advancements in the design and manufacturing process of the IPP improved its mechanical survival, infection has emerged as the leading cause of implant failure. Although relatively infrequent (varying from .06% to 8.9%) infection of a penile prosthesis results in serious medical consequences for patients, requiring complete removal of the device and permanent loss of penile size and anatomy. [ 23 ] [ 24 ]  Bacterial contamination of the device can occur during the surgery, and is caused by allowing direct or indirect contact of the prosthesis with the patient's skin. Over 70% of infections occur due to the skin  microbiome 's microorganisms including  Staphylococcus epidermidis ,  Staphylococcus aureus ,  Streptococcus  and  Candida albicans . [ 25 ]


Traditional strategies to combat infections aim at decreasing skin colony count such as scrubbing skin preparation with alcohol and chlorhexidine or kill bacteria once the implant is contaminated by skin flora such as intravenous antibiotics, antibiotic irrigation and antibiotic-coated implants. The "No-Touch" technique is unique in that it aims to prevent bacterial contamination of the prosthesis by completely eliminating contact of the  device with the skin. [ 26 ]


Paired with the antibiotic-coated implant, the "No Touch" technique decreases infection to a rate of 0.46%, opposing the traditional method which has an infection rate of 5%. The use of an antibiotic-coated implant and a no-touch surgical technique with skin preparation measures and peri-operative antibiotic use has been found to be of high importance in the prevention of infection among penile implants. [ 27 ]  Eid developed the technique in 2006 on the hypothesis that eliminating any contact between the prosthesis and the skin, either directly or indirectly via surgical instruments or gloves, should reduce the incidence of contamination of the device with skin flora responsible for infection. [ 25 ] [ 28 ]


Three days prior to the procedure, a patient is placed on oral  fluoroquinolones , a grouping of antibacterial drugs. During this time, the patient scrubs the lower abdomen and genitals daily with  chlorhexidine  soap. On the day of the surgery,  vancomycin  and  gentamicin  are administered intravenously one to two hours prior to the procedure. The lower abdomen and genitals are shaved, scrubbed for five minutes with a chlorhexidine sponge and prepped with chorhexidine/alcohol applicator. The area is then draped with a  surgical drape  and a Vi Drape over the genitalia. Before the incision is made, a Foley catheter is inserted in the bladder through the urethra.


A 3 cm (1.2 in) scrotal incision is made on the penoscrotal raphe and carried down through the subcutaneous tissue to the  Buck's fascia . A Scott retractor, a flexible device that holds open the skin of the surgical site, is applied to the area.


Up until this stage of the surgery, the process has been consistent with the sanitary practices associated with standard surgical sterility. [ 29 ]  At this stage of the "No-Touch" technique, after the incision has been made, all instruments, including surgical gloves, that have touched skin are discarded. A loose drape is then deployed over the entire surgical field and secured at the periphery with adhesive strips. A small opening in the drape is then made overlying the incision and yellow hooks utilized to secure the edges of the opening to the edges of the incision, completely covering and isolating the patient's skin. At this point, new instruments and equipment are replaced and the entire prosthesis is inserted through the small opening of the loose drape. The loose drape allows for manipulation of the penis and scrotum required for this procedure without touching the skin.


Implantation of the device continues with an incision and dilation of corpora, sizing and placing the penile cylinders, and placement of the pump in the scrotum and the reservoir in the retropubic space. Saline is used throughout the implantation for irrigation. Once the corporotomies are closed and all of the tubing and components of the prosthesis covered with a layer of Buck's fascia, subcutaneous tissues are closed and the "No-Touch" drape is removed and the skin closed. [ 22 ]


Penis transplantation  could also become a standardized method. [ 30 ]


Preputioplasty  or  prepuce plasty , also known as  limited dorsal slit with transverse closure , is a plastic surgical operation on the prepuce or  foreskin  of the  penis , [ 1 ]  to widen a narrow non-retractile foreskin which cannot comfortably be drawn back off the head of the penis in erection because of a constriction ( stenosis ) which has not expanded after  adolescence .


Preputioplasty is a treatment for  phimosis  in the alternative to  circumcision  and radical  dorsal slit


Preputioplasty may be performed by  Z-plasty , also used in reconstructive surgery to loosen constricting scar tissue following traumatic burns.


However, Y-plasty and Z-plasty require a degree of surgical sophistication that physicians in general practice may lack.


More commonly it simply consists of one or more very short longitudinal incisions which release the stenosis–the constricting ring of tissue—in the foreskin and are closed transversely: [ | ] is closed and sutured as [ — ].


In the alternative to suturing, "[h]aemostasis [has been successfully] performed [in children] with a heated probe using the flame of an alcohol lamp or with bipolar electrodiathermy." [ 2 ]


Only one incision is shown in Figure 3; if two or more such incisions are made this will prevent a V-shaped indentation at the opening of the foreskin when the penis is not erect. If incisions are placed on the sides of the phimotic ring, the ultimate cosmetic result is better. It is also recommended that the subcutaneous tissue be  undermined  to ensure a better cosmetic result.


The opening of the foreskin is now normally wide enough for the foreskin to be easily retracted. The foreskin is also slightly shorter (by half the length of the longitudinal incisions which are now closed transversely) because the widening of the phimotic ring takes up some foreskin length.
Studies from a large cohort in the Indian Subcontinent show a good acceptance and an interest for foreskin preservation when there is no religious indication to remove the foreskin.


Prostate biopsy  is a procedure in which small hollow needle-core samples are removed from a man's  prostate gland  to be examined for the presence of  prostate cancer . It is typically performed when the result from a  PSA  blood test is high. [ 1 ]  It may also be considered advisable after a  digital rectal exam  (DRE) finds possible abnormality.  PSA screening is controversial  as PSA may become elevated due to non-cancerous conditions such as  benign prostatic hyperplasia  (BPH), by infection, or by manipulation of the prostate during surgery or  catheterization . Additionally many prostate cancers detected by screening develop so slowly that they would not cause problems during a man's lifetime, making the complications due to treatment unnecessary.


The most frequent side effect of the procedure is  blood in the urine  (31%). [ 2 ]  Other side effects may include infection (0.9%) and death (0.2%). [ 2 ]


The procedure may be performed transrectally, through the  urethra  or through the  perineum . The most common approach is transrectally, and historically this was done with tactile finger guidance. [ 3 ]  The most common method of prostate biopsy as of 2014 [update]  was transrectal  ultrasound -guided prostate (TRUS) biopsy. [ 4 ]


Extended biopsy schemes take 12 to 14 cores from the prostate gland through a thin needle in a systematic fashion from different regions of the prostate. [ 5 ]


A biopsy procedure with a higher rate of cancer detection is template prostate mapping (TPM) or transperineal template-guided mapping biopsy (TTMB), whereby typically 50 to 60 samples are taken of the prostate through the outer skin between the rectum and  scrotum , to thoroughly sample and map the entire prostate, through a template with holes every 5 mm, usually under a general or spinal  anaesthetic . [ 6 ] [ 7 ]


Antibiotics  are usually prescribed to minimize the risk of infection. [ 4 ] [ 8 ]  A healthcare provider may also prescribe an  enema  to be taken in the morning of the procedure. During the transrectal procedure, an ultrasound probe is inserted into the rectum to assist in guiding the biopsy needles. Following this, a  local anesthetic , such as  lidocaine , is administered into the tissue surrounding the prostate. Subsequently, a spring-loaded  biopsy needle  is inserted into the prostate, resulting in a clicking sound. When the local anesthetic is effective, any discomfort experienced is minimal.


Since the mid-1980s, TRUS biopsy has been used to diagnose prostate cancer in essentially a blind fashion because prostate cancer cannot be seen on ultrasound due to poor soft tissue resolution.  However, multi-parametric  magnetic resonance imaging  (mpMRI) has since about 2005 been used to better identify and characterize prostate cancer. [ 9 ]   A study correlating MRI and surgical pathology specimens demonstrated a  sensitivity  of 59% and  specificity  of 84% in identifying cancer when  T2-weighted ,  dynamic contrast enhanced , and  diffusion-weighted imaging  were used together. [ 10 ]   Many prostate cancers missed by conventional biopsy are detectable by MRI-guided targeted biopsy. [ 11 ]  In fact, a side-by-side comparison of TRUS versus MRI-guided targeted biopsy that was conducted as a prospective, investigator-blinded study demonstrated that MRI-guided biopsy improved detection of significant prostate cancer by 17.7%, and decreased the diagnosis of insignificant or low-risk disease by 89.4%. [ 12 ]


Two methods of MRI-guided, or "targeted" prostate biopsy, are available: (1) direct "in-bore" biopsy within the MRI tube, and (2) fusion biopsy using a device that fuses stored MRI with real-time ultrasound (MRI-US). Visual or cognitive MRI-US fusion have been described. [ 13 ]


When MRI is used alone to guide prostate biopsy, it is done by an  interventional radiologist . Correlation between biopsy and final pathology is improved between MRI-guided biopsy as compared to TRUS. [ 14 ]


In the fusion MRI-US prostate biopsy, a prostate MRI is performed before biopsy and then, at the time of biopsy, the MRI images are fused to the ultrasound images to guide the  urologist  to the suspicious targets. Fusion MRI-US biopsies can be achieved in an office setting with a variety of devices. [ 11 ]


MRI-guided prostate biopsy appears to be superior to standard TRUS-biopsy in prostate cancer detection. Several groups in the U.S., [ 15 ] [ 16 ]  and Europe, [ 17 ] [ 18 ]  have demonstrated that targeted biopsies obtained with fusion imaging are more likely to reveal cancer than blind systematic biopsies. In 2015, AdMeTech Foundation, American College of Radiology and European Society of Eurogenital Radiology developed Prostate Imaging Reporting and Data System (PI-RADS v2) for global standardization of image acquisition and interpretation, which similarly to BI-RADS standardization of breast imaging, is expected to improve patient selection for biopsies and precisely-targeted tissue sampling. [ 19 ] [ 20 ]   PI-RADS  v2 created standards for optimal mpMRI image reporting and graded the level of suspicion based on the score of one to five, with the goal to improve early detection (and exclusion) of clinically significant (or aggressive) prostate cancer. [ 21 ]  The higher suspicion on mpMRI and the higher PI-RADS v2 score, the greater the likelihood of aggressive prostate cancer on targeted biopsy. Considerable experience and training is required by the reader of prostate mpMRI studies.


Up to 2013, indications for targeted biopsy have included mainly patients for whom traditional TRUS biopsies have been negative despite concern for rising PSA, as well as for patients enrolling in a program of  active surveillance  who may benefit from a confirmatory biopsy and/or the added confidence of more accurate non-invasive monitoring. [ 15 ]  Increasingly, men undergoing initial biopsy are requesting targeted biopsy, and thus, the use of pre-biopsy MRI is growing rapidly.


Clinical trials of mpMRI and PI-RADS v2, including NIH-funded studies are underway to further clarify the benefits of targeted prostate biopsy. [ 22 ]


Side effects of a TRUS or TPM biopsy include: [ 23 ] [ 6 ] [ 24 ]


The tissue samples are examined under a microscope to determine whether cancer cells are present, and to evaluate the microscopic features (or  Gleason score ) of any cancer found. Gleason score, PSA, and digital rectal examination together determine clinical risk, which then dictates treatment options.


Tissue samples can be stained for the presence of PSA and other tumor markers in order to determine the origin of malignant cells that have metastasized. [ 25 ]


Prostate cancer screening  is the  screening  process used to detect undiagnosed  prostate cancer  in men without  signs  or  symptoms . [ 1 ] [ 2 ]  When abnormal prostate tissue or cancer is found early, it may be easier to treat and cure, but it is unclear if early detection reduces mortality rates. [ 2 ]


Screening precedes a diagnosis and subsequent treatment. The  digital rectal examination  (DRE) is one screening tool, during which the prostate is manually assessed through the wall of the rectum. The second screening tool is the measurement of  prostate-specific antigen  (PSA) in the  blood . The evidence remains insufficient to determine whether screening with PSA or DRE reduces mortality from prostate cancer. [ 1 ]  A 2013  Cochrane  review concluded PSA screening results in "no statistically significant difference in prostate cancer-specific mortality...". [ 3 ]  The American studies were determined to have a high bias. European studies included in this review were of low bias and one reported "a significant reduction in prostate cancer-specific mortality." PSA screening with DRE was not assessed in this review. DRE was not assessed separately. [ 3 ]


Most recent guidelines have recommended that the decision whether or not to screen should be based on  shared decision-making , [ 4 ]  so that men are informed of the risks and benefits of screening. [ 5 ] [ 6 ]  In 2012, the  American Society of Clinical Oncology  recommends screening be discouraged for those who are expected to live less than ten years, while for those with a longer life expectancy a decision should be made by the person in question. In general, they conclude that based on recent research, "it is uncertain whether the benefits associated with PSA testing for prostate cancer screening are worth the harms associated with screening and subsequent unnecessary treatment." [ 7 ]


Prostate biopsies  are used to diagnose prostate cancer but are not done on asymptomatic men and therefore are not used for screening. [ 8 ] [ 9 ]  Infection after prostate biopsy occurs in about 1%, while death occurs as a result of biopsy in 0.2%. [ 10 ] [ 11 ]  Prostate biopsy guided by  magnetic resonance imaging  has improved the diagnostic accuracy of the procedure. [ 12 ] [ 13 ]


Prostate-specific antigen  (PSA) is secreted by the  epithelial cells  of the  prostate  gland and can be detected in a sample of blood. [ 14 ]  PSA is present in small quantities in the  serum  of men with healthy prostates, but is often elevated in the presence of  prostate cancer  or other prostate disorders. [ 15 ]  PSA is not a unique indicator of prostate cancer, but may also detect  prostatitis  or  benign prostatic hyperplasia . [ 16 ]


A 2018  United States Preventive Services Task Force  (USPSTF) recommendation adjusted the prior opposition to PSA screening, [ 17 ]  suggesting shared decision-making regarding screening in healthy males 55 to 69 years of age. [ 17 ]  The recommendation for that age group states screening should only be done in those who wish it. [ 18 ]  In those 70 and over, screening remains not recommended. [ 18 ]


Screening with PSA has been associated with a number of harms including  over-diagnosis , increased  prostate biopsy  with associated harms, increased anxiety, and unneeded treatment. [ 19 ]  The evidence surrounding prostate cancer screening indicates that it may cause little to no difference in mortality. [ 3 ]


On the other hand, up to 25% of men diagnosed in their 70s or even 80s die of prostate cancer,  if  they have high-grade (i.e., aggressive) prostate cancer. [ 20 ]  Conversely, some argue against PSA testing for men who are too young, because too many men would have to be screened to find one cancer, and too many men would have treatment for cancer that would not progress. Low-risk prostate cancer does not always require immediate treatment, but may be amenable to active surveillance. [ 21 ]  A PSA test cannot 'prove' the existence of prostate cancer by itself; varying levels of the antigen can be due to other causes. [ 22 ]


During a digital  rectal examination  (DRE), a healthcare provider slides a gloved finger into the  rectum  and presses on the prostate, to check its size and to detect any lumps on the accessible side. If the examination suggests anomalies, a PSA test is performed. If an elevated PSA level is found, a follow-up test is then performed. [ 2 ]


A 2018 review recommended against primary care screening for prostate cancer with DRE due to the lack of evidence of the effectiveness of the practice. [ 23 ]


The USPSTF recommends against digital rectal examination as a screening tool due to lack of evidence of benefits. [ 24 ]  Although DRE has long been used to diagnose prostate cancer, no controlled studies have shown a reduction in the morbidity or mortality of prostate cancer when detected by DRE at any age. [ 25 ] [ 26 ]


The American Urological Association in 2018 stated that for men aged 55 to 69, they could find no evidence to support the continued use of DRE as a first-line screening test; however, in men referred for an elevated PSA, DRE may be a useful secondary test. [ 27 ]


A study by Krilaviciute et al. (2023) [ 28 ]  examined the effectiveness of the DRE as a standalone screening test for prostate cancer in >46,000 young men in Germany (age 45). It was found that DRE has a much lower detection rate for prostate cancer compared to PSA screening. Therefore, the authors recommend not to use DRE as a screening test for prostate cancer in young men, as it does not provide an improvement in detection compared to PSA screening.


Prostate biopsies  are considered the gold standard in detecting prostate cancer. [ 8 ] [ 9 ]  Infection after the biopsy procedure is a possible risk. [ 10 ]  MRI guided techniques have improved the diagnostic accuracy of the procedure. [ 12 ] [ 13 ]  Biopsies can be done through the  rectum  or  penis . [ 29 ]  The biopsy technique includes factors such as needle angle and prostate mapping method. [ 30 ]  People who have localized cancer and perineural invasion may benefit more from immediate treatment rather than adopting a watchful waiting approach. [ 30 ]


Transrectal ultrasonography  (TRUS) has the advantage of being fast and minimally invasive, and better than MRI for the evaluation of superficial tumor. [ 2 ]  It also gives details about the layers of the rectal wall, accurate and useful for staging primary rectal cancer. While MRI is better in visualization of locally advanced and stenosing cancers, for staging perirectal lymph nodes, both TRUS and MRI are capable. TRUS has a small field of view, but 3D TRUS can improve the diagnosis of anorectal diseases. [ 31 ]


MRI is used when screening suggests a malignancy. [ 32 ]  This model potentially minimizes unnecessary prostate biopsies while maximizing biopsy yield. [ 33 ] [ dubious  –  discuss ] [ citation needed ]  Despite concerns about the cost of MRI scans, compared to the long-term cost burden of the PSA/TRUS biopsy-based standard of care, the imaging model has been found to be cost-effective. [ dubious  –  discuss ] [ citation needed ]  MRI imaging can be used for patients who have had a previous negative biopsy but their PSA continues to increase. [ 34 ]  Consensus has not been determined as to which of the MRI-targeted biopsy techniques is more useful. [ 35 ]  In a study involving 400 men aged 50 – 69, MRI screening identified more men with prostate cancer than PSA tests or ultrasound and did not increase the number of men who needed a biopsy. [ 36 ] [ 37 ]  A large-scale trial of MRI screening, TRANSFORM, began in the UK in spring 2024. [ 38 ]


68 Ga -PSMA PET/CT imaging has become, in a relatively short period of time, the gold standard for restaging recurrent prostate cancer in clinical centers in which this imaging modality is available. [ 39 ]  It is likely to become the standard imaging modality in the staging of intermediate-to-high risk primary prostate cancer. [ 39 ]  The potential to guide therapy, and to facilitate more accurate prostatic biopsy is being explored. [ 39 ]  In the theranostic paradigm,  68 Ga-PSMA PET/CT imaging is critical for detecting prostate specific membrane antigen-avid disease which may then respond to targeted  177 Lu -PSMA or  225 Ac -PSMA therapies. [ 39 ]  For local recurrence,  68 Ga-PSMA PET/MR or PET/CT in combination with mpMR is most appropriate. [ 40 ]  PSMA PET/CT may be potentially helpful for locating the cancer when combined with multiparametric MRI (mpMRI) for primary prostate care. [ 41 ]  Prostate multiparametric MR imaging (mpMRI) is helpful in evaluating recurrence of primary prostate cancer following treatment. [ 42 ]


A number of  biomarkers  (blood, urine and tissue based tests) for screening, diagnosing and determining the prognosis of prostate cancer are supported by evidence and used widely. [ 43 ] [ 44 ]


Researchers at the Korea Institute of Science and Technology (KIST) developed a urinary multi marker sensor with the ability to measure trace amounts of biomarkers from naturally voided urine. [ 48 ]  The correlation of clinical state with the sensing signals form urinary multi markers was analyzed by two machine learning algorithms, random forest and neural network. Both algorithms provided a monotonic increase in screening performance as the number of biomarkers was increased. With the best combination of biomarkers, the algorithms were able to screen prostate cancer patients with more than 99% accuracy. [ 48 ]


Screening for prostate cancer continues to generate debate among clinicians and broader lay audiences. [ 53 ]  Publications authored by governmental, non-governmental and medical organizations continue the debate and publish recommendations for screening. [ 3 ]  One in six men will be diagnosed with prostate cancer during their lifetime but screening may result in the overdiagnosis and overtreatment of prostate cancer. [ 54 ] [ 55 ]  Though the death rates from prostate cancer continue to decline, 238,590 men were diagnosed with prostate cancer in the United States in 2013 while 29,720 died as a result. Death rates from prostate cancer have declined at a steady rate since 1992. Cancers of the prostate, lung and bronchus, and colorectum accounted for about 50% of all newly diagnosed cancers in American men in 2013, with prostate cancer constituting 28% of cases. Screening for prostate cancer varies by state and indicates differences in the use of screening for prostate cancer as well as variations between locales. Out of all cases of prostate cancer, African American men have an incidence of 62%. African American men are less likely to receive standard therapy for prostate cancer. This discrepancy may indicate that if they were to receive higher quality cancer treatment their survival rates would be similar to whites. [ 54 ]


Prostate cancer is also extremely heterogeneous: most prostate cancers are indolent and would never progress to a clinically meaningful stage if left undiagnosed and untreated during a man's lifetime. On the other hand, a subset are potentially lethal, and screening can identify some of these within a window of opportunity for cure. [ 56 ]  Thus, PSA screening is advocated by some as a means of detecting  high-risk , potentially lethal prostate cancer, with the understanding that lower-risk disease, if discovered, often does not need treatment and may be amenable to active surveillance. [ 21 ] [ 57 ]


Screening for prostate cancer is controversial because of cost and uncertain long-term benefits to patients. [ 58 ]  Horan echos that sentiment in his book. [ 59 ]  Private medical institutes, such as the  Mayo Clinic , likewise acknowledge that "organizations vary in their recommendations about who should – and who shouldn't – get a PSA screening test."  They conclude: "Ultimately, whether you should have a PSA test is something you'll have to decide after discussing it with your doctor, considering your risk factors and weighing your personal preferences." [ 60 ]


A 2009 study in Europe resulted in only a small decline in death rates and concluded that 48 men would need to be treated to save one life. But of the 47 men who were treated, most would be unable to ever again function sexually and would require more frequent trips to the bathroom. [ 59 ] [ page needed ]  Aggressive marketing of screening tests by drug companies has also generated controversy as has the advocacy of testing by the  American Urological Association . [ 59 ]


One commentator observed in 2011: “[I]t is prudent only to use a single PSA determination as a baseline, with biopsy and cancer treatment reserved for those with significant PSA changes over time, or for those with clinical manifestations mandating immediate therapy..... absolute levels of PSA are rarely meaningful; it is the relative change in PSA levels over time that provides insight, but not definitive proof of a cancerous condition necessitating therapy.“ [ 61 ]


Men report low levels of distress surrounding PSA screening. [ 62 ]  Men who present for PSA or have PSA levels at baseline scored low on cancer distress on numerous scales. [ 62 ]


Screening of PSA began in the 1990s. In the European Randomized Study of Screening for Prostate Cancer (ERSPC) initiated in the early 1990s, the researchers concluded that PSA-based screening did reduce the rate of death from prostate cancer but created a high risk of overdiagnosis, i.e., 1410 men would need to be screened and 48 additional cases of prostate cancer would need to be treated to prevent just one death from prostate cancer within 9 years. [ 63 ]


A study published in the European Journal of Cancer (October 2009) documented that prostate cancer screening reduced prostate cancer mortality by 37 percent. By utilizing a control group of men from Northern Ireland, where PSA screening is infrequent, the research showed this substantial reduction in prostate cancer deaths when compared to men who were PSA tested as part of the ERSPC study. [ 64 ]


A study published in the  New England Journal of Medicine  in 2009 found that over a 7 to 10-year period, "screening did not reduce the death rate in men 55 and over." [ 59 ]  Former screening proponents, including some from Stanford University, have come out against routine testing. In February 2010, the  American Cancer Society  urged "more caution in using the test." And the  American College of Preventive Medicine  concluded that "there was insufficient evidence to recommend routine screening." [ 59 ]


A further study, the  NHS  Comparison Arm for ProtecT (CAP), as part of the Prostate testing for cancer and Treatment (ProtecT) study, randomized  GP  practices with 460,000 men aged 50–69 at centers in 9 cities in Britain from 2001–2005 to usual care or prostate cancer screening with PSA (biopsy if PSA ≥ 3). [ 65 ]  The "Comparison Arm" has yet to report as of early 2018. [ 66 ]


Prostatectomy  (from the  Greek   προστάτης   prostátēs , "prostate" and  ἐκτομή   ektomē , "excision") is the  surgical  removal of all or part of the  prostate gland . This operation is done for  benign  conditions that cause urinary retention, as well as for  prostate cancer  and for other cancers of the  pelvis .


There are two main types of prostatectomies. A  simple prostatectomy  (also known as a subtotal prostatectomy) involves the removal of only part of the prostate. Surgeons typically carry out simple prostatectomies only for  benign  conditions. [ 1 ]  A  radical prostatectomy , the removal of the entire prostate gland, the  seminal vesicles  and the  vas deferens , is performed for cancer. [ 2 ]


There are multiple ways the operation can be done: with open surgery (via a large incision through the lower abdomen),  laparoscopically  with the help of a  robot  (a type of minimally invasive surgery), through the  urethra  or through the  perineum .


By laser prostatectomy (HoLEP - Holmium laser enucleation of the prostate), a laser is used to cut and remove the excess prostate tissue that is blocking the urethra. Another instrument is then used to cut the prostate tissue into small pieces that are easily removed. HoLEP can be an option for men who have a severely enlarged prostate. [ 3 ]


Other terms that can be used to describe a prostatectomy include:


Indications for removal of the prostate in a benign setting include acute urinary retention, recurrent urinary tract infections, uncontrollable  hematuria , bladder stones secondary to bladder outlet obstruction, significant symptoms from bladder outlet obstruction that are refractory to medical or minimally invasive therapy, and  chronic kidney disease  secondary to chronic bladder outlet obstruction. [ 5 ]


A radical prostatectomy is performed due to malignant cancer. For prostate cancer, the best treatment often depends on the risk level presented by the disease. For most prostate cancers classified as "very low risk" and "low risk", radical prostatectomy is one of several treatment options; others include radiation, watchful waiting, and active surveillance. For intermediate and high risk prostate cancers, radical prostatectomy is often recommended in addition to other treatment options. Radical prostatectomy is not recommended in the setting of known  metastases  when the cancer has spread through the prostate, to the lymph nodes or other parts of the body. [ 6 ]  Prior to deciding the best treatment option for higher risk cancers, imaging studies using CT, MRI or bone scans are done to make sure the cancer has not spread outside of the prostate.


These would be same as the contraindications for any other surgery. [ citation needed ]


There are several ways a prostatectomy can be done:


In an open prostatectomy, the prostate is accessed through a large single incision through either the lower abdomen or the perineum. Further descriptive terms describe how the prostate is accessed anatomically through this incision (retropubic vs. suprapubic vs. perineal). A retropubic prostatectomy describes a procedure that accesses the prostate by going through the lower abdomen and behind the pubic bone. A suprapubic prostatectomy describes a procedure cuts through the lower abdomen and through the bladder to access the prostate. A perineal prostatectomy is done by making an incision between the rectum and scrotum on the underside of the abdomen.


Robotic-assisted instruments are inserted through several small abdominal incisions and controlled by a surgeon. Some use the term 'robotic' for short, in place of the term 'computer-assisted'. However, procedures performed with a computer-assisted device are performed by a surgeon, not a robot. The computer-assisted device gives the surgeon more dexterity and better vision, but no tactile feedback compared to conventional laparoscopy.  When performed by a surgeon who is specifically trained and well experienced in  computer-assisted laparoscopy  (CALP), there can be similar advantages over open prostatectomy, including smaller incisions, less pain, less bleeding, less risk of infection, faster healing time, and shorter hospital stay. [ 7 ] [ 8 ]  The cost of this procedure is higher, while long-term functional and oncological superiority have yet to be established. [ 9 ] [ 10 ] [ 11 ]


Complications that occur in the period right after any surgical procedure, including a prostatectomy, include a risk of bleeding, a risk of infection at the site of incision or throughout the whole body, a risk of a blood clot occurring in the leg or lung, a risk of a heart attack or stroke, and a risk of death.


Severe irritation takes place if a latex  catheter  is inserted in the urinary tract of a person allergic to latex. That is especially severe in case of a radical prostatectomy due to the open wound there and the exposure lasting e.g. two weeks. Intense pain may indicate such situation. [ 12 ]


Men can experience changes in their sexual responses after radical prostatectomy, including impairments to sexual desire, penile morphology and orgasmic function. [ 13 ] [ 14 ]  A 2005 article in the medical journal  Reviews in Urology  listed the incidence of several complications following radical prostatectomy: mortality <0.3%, impotence >50%, ejaculatory dysfunction 100%, orgasmic dysfunction 50%, incontinence <5–30%, pulmonary embolism <1%, rectal injury <1%, urethral stricture <5%, and transfusion 20%. [ 15 ]


Surgical removal of the prostate contains an increased likelihood that patients will experience  erectile dysfunction . Radical prostatectomy is associated with greater decrease in sexual function than external beam radiotherapy. Nerve-sparing surgery reduces the risk that patients will experience erectile dysfunction. However, the experience and the skill of the nerve-sparing surgeon are critical determinants of the likelihood of positive erectile function of the patient. [ 16 ] [ better source needed ]


Following a prostatectomy, patients will not be able to ejaculate semen due to the nature of the procedure, resulting in the permanent necessity of assisted reproductive techniques in case of desires of future fertility. [ 17 ]  Preservation of normal ejaculation is possible after  transurethral resection of the prostate  (TURP), open or laser enucleation of adenoma and laser vaporisation of prostate. However, retrograde ejaculation is a common problem. Preservation of ejaculation is the aim of some new techniques. [ 18 ]  Once the prostate and vesicles are removed, even if partial erection is achieved, ejaculation is a very different experience, with little of the compulsive release that is common to ejaculation with those organs intact.


Prostatectomy patients have an increased risk of leaking small amounts of urine immediately after surgery, and for the long-term, often requiring  urinary incontinence  devices such as condom catheters or diaper pads. A large analysis of the incidence of urinary incontinence found that 12 months after surgery, 75% of patients needed no pad, while 9–16% did. Factors associated with increased risk of long-term urinary incontinence include older age, higher BMI, more comorbidities, larger prostates surgically excised, as well as experience and technique of the surgeon. [ 19 ]


Surgical management options for urinary incontinence secondary to prostatectomy include implantation of  perineal slings  and  artificial urinary sphincters . [ 20 ]  Although there are limited data on the long-term outcomes in males, perineal slings are offered for mild-to-moderate post-prostatectomy incontinence. [ 21 ] [ 22 ]  In a retrospective study the success rate of perineal  sling  placement in urinary incontinence following prostatectomy achieved 86% at a median follow-up of 22 months. [ 23 ]  Artificial urinary sphincters are offered for moderate-to-severe urinary incontinence in males and have shown good long-term efficacy and safety. [ 22 ] [ 21 ] [ 24 ] [ 25 ]  The use of artificial urinary sphincters for post-prostatectomy incontinence is supported by the recommendations of  European Association of Urology  and International Consultation on Incontinence. [ 21 ] [ 22 ]


Transurethral injection of bulking agents  have little role in the management of post-prostatectomy incontinence and there is weak evidence that these agents can offer any improvement. [ 21 ] [ 22 ]   Pelvic floor muscle training  can speed recovery of urinary incontinence following prostatectomy. [ 22 ]


Very few surgeons will claim that patients return to the erectile experience they had prior to surgery.  The rates of erectile recovery that surgeons often cite are qualified by the addition of  sildenafil  to the recovery regimen. [ 26 ]


Remedies to the problem of post-operative sexual dysfunction include: [ 27 ]


The use of radical prostatectomy as treatment for prostate cancer increased significantly from 1980 to 1990. [ 28 ]  As of 2000, the median age of men undergoing radical prostatectomy for localized prostate cancer was 62. [ 28 ]


Though a very common procedure, the experience level of the surgeon performing the operation is important in determining the outcomes, rate of complications, and side effects. The more prostatectomies performed by a surgeon, the better the outcomes. This is true for prostatectomies done as open procedures [ 29 ]  and those done using minimally invasive techniques. [ 30 ]


William Belfield , MD is generally credited for performing the first intentional prostatectomy via the suprapubic route in 1885, 1886 or 1887 at  Cook County Hospital  in Chicago. [ 31 ] [ 32 ]   Hugh H. Young  MD in collaboration with  William Stewart Halsted  MD developed the open, radical and perineal prostatectomies in 1904 at Johns Hopkins Brady Urological Institute, the first version of the procedure that became generally feasible. [ 33 ]  The Irish surgeon  Terence Millin , MD (1903–1980) developed the radical retropubic prostatectomy in 1945. [ 34 ]  American urologist Patrick C. Walsh, MD (1938—present) developed the modern nerve-sparing, retropubic prostatectomy with minimal blood loss. [ 35 ]  The first laparoscopic prostatectomy was performed in 1991 by William Schuessler, MD and colleagues in Texas. [ 36 ]


A 2014 survey of prostatectomy fees for uninsured patients at 70 United States hospitals found an average facility fee of $34,720 and average surgeon and anesthesiologist fees of $8,280. [ 37 ]


Radical perineal prostatectomy  is a  surgical procedure  wherein the entire  prostate  gland is removed through an incision in the area between the  anus  and the  scrotum  ( perineum ). [ 1 ] [ 2 ]


It is used to remove early  prostate cancer , in select people who have a small well defined cancer in the prostate. It is less commonly used than the alternative methods of the  retropubic route , or the robot assisted  laparoscopic  approach. [ 3 ] [ 4 ]


When the  cancer  is small and confined to the prostate, radical perineal prostatectomy achieves the same rate of cure as the retropubic approach but less  blood  is lost and recovery is faster. One downside to the perineal approach is an increased risk of  fecal incontinence . [ 2 ] [ 5 ]


The procedure was first performed in 1904 by  Hugh H. Young  and assisted by  William S. Halstead , as a way of removing the prostate in cancer treatment. [ citation needed ]


Radical perineal prostatectomy is used to remove early  prostate cancer , in select people who have a small well defined cancer in the prostate. [ 3 ]  It is less commonly used than the alternative methods of the  retropubic route , or the robot assisted  laparoscopic  approach. [ 1 ] [ 4 ]


It is more suited to younger men, age under 70 years, who have at least a ten-year life expectancy, few if any other medical problems, a  Gleason score  of less than 8 (4+4) and PSA of less than 10. [ 3 ]  It may be indicated where the man with prostate cancer is  obese , has had several abdominal operations before, previous pelvic arterial bypass grafts or has a delayed recurrence of prostate cancer after salvage prostatectomy and  radiotherapy . [ 3 ]


Before the operation, an assessment of  life expectancy  is made. Physical examination including a digital rectal examination and routine blood tests are carried out. At least six  transrectal ultrasound  guided  biopsies  taken from different zones of the prostate are usually obtained. Other considerations include bowel preparation the day before surgery and taking antibiotics. [ 3 ]


A radical perineal prostatectomy uses an incision in the area between the  anus  and the  scrotum  ( perineum ). [ 2 ] [ 6 ]  There is more than one way of performing the procedure. [ 7 ]  In men with normal erections, a small cancer which can not be felt and  Gleason scores  of 6 or less, it may be possible to preserve the nerves for erection. [ 7 ]  The procedure usually takes around one hour. [ 4 ]


Over the course of the first day or two after the procedure, many men require a gradual transfer from oral fluids to soft foods. Additionally, men are encouraged to maintain mobility and painkillers may be necessary initially but tapered off over time. The hospital stay is usually short and the  Foley catheter  can be removed usually at three weeks after surgery. Longer term followup with PSA monitoring is required. [ 3 ]


Lymph nodes  can be sampled through the same incision, although this procedure is not common place in the U.S. at this time. When the  cancer  is small and confined to the prostate, radical perineal prostatectomy achieves the same rate of cure as the retropubic approach but less  blood  is lost and recovery is faster. One downside to the perineal approach is an increased risk of  fecal incontinence . [ 2 ] [ 5 ]


The procedure was first performed on a 70-year old married preacher on 7 April 1904 by American surgeon  Hugh H. Young  and assisted by  William S. Halstead , as a way of removing the prostate in cancer treatment, after prostatic massage and an early type of  transurethral resection of the prostate  had failed to relieve him of pain in his urethra. [ 8 ]  By 1937, Young reported a five-year survival rate of 50%. However, by the time the diagnosis of prostate cancer was made, it was usually too late to perform the procedure. [ 2 ] [ 9 ]


Removing the prostate via the perineal route went out of favour in the 1970s. However, with the introduction the PSA test, better public awareness of options for treating localised disease, the ability to perform nerve-sparing surgery, and the advantage of there being potentially less post-operative complications using the perineal route, rekindled interest in the procedure. [ 3 ]


Radical retropubic prostatectomy  is a  surgical procedure  in which the  prostate  gland is removed through an incision in the  abdomen  (in comparison with  perineal prostatectomy , done through the perineum). It is most often used to treat individuals who have early  prostate cancer . Radical retropubic prostatectomy can be performed under  general ,  spinal , or  epidural anesthesia  and requires  blood transfusion  less than one-fifth of the time. Radical retropubic prostatectomy is associated with complications such as  urinary incontinence  and  impotence , but these outcomes are related to a combination of individual patient anatomy, surgical technique, and the experience and skill of the surgeon.


Radical retropubic prostatectomy was developed in 1945 by Terence Millin at the All Saints Hospital in London. The procedure was brought to the United States by one of Millin's students, Samuel Kenneth Bacon, M.D., adjunct professor of surgery,  University of Southern California , and was refined in 1982 by  Patrick C. Walsh [ 1 ]  at the James Buchanan Brady Urological Institute,  Johns Hopkins Medical School . It can be performed in several different ways with several possible associated procedures. [ 2 ]  The most common approach is to make an incision in the skin between the  umbilicus  and the top of the  pubic bone . Since initial description by Walsh, technical advancements have been made, and incisional length has decreased to 8–10 cm (well below the belt-line). The pelvis is then explored and the important structures such as the  urinary bladder , prostate,  urethra ,  blood vessels , and  nerves  are identified. [ citation needed ]


The prostate is removed from the urethra below and the bladder above, and the bladder and urethra are reconnected. The blood vessels leading to and from the prostate are divided and tied off. Recovery typically is rapid; individuals are usually able to walk and eat within 24 hours after surgery. A  catheter  running through the penis into the bladder is typically required for at least a week after surgery. A  surgical drain  is often left in the pelvis for several days to allow drainage of  blood  and other fluid. Additional components of the operation may include:


An intraoperative electrical stimulation  penile plethysmograph  may be applied to assist the surgeon in identifying the difficult to see nerves. [ citation needed ]


Radical retropubic prostatectomy is typically performed in men who have early stage prostate cancer. Early stage prostate cancer is confined to the prostate gland and has not yet spread beyond the prostate or to other parts of the body. Attempts are made prior to surgery, through  medical tests  such as  bone scans ,  computed tomography  (CT), and  magnetic resonance imaging  (MRI), to identify cancer outside of the prostate. Radical retropubic prostatectomy may also be used if prostate cancer has failed to respond to  radiation therapy , but the risk of urinary incontinence is substantial. [ citation needed ]


The most common serious complications of radical retropubic prostatectomy are loss of urinary control and impotence. As many as 40% of men undergoing prostatectomy may be left with some degree of  urinary incontinence , usually in the form of leakage with sneezing, etc. ( stress incontinence ) but this is highly surgeon-dependent. Continence and potency may improve depending on the amount of trauma and the patient's age at the time of the procedure, but progress is frequently slow. Doctors usually allow up to 1 year for recovery between offering medical or surgical treatment. Potency is greatly affected by the psychological attitude of the patient. [ citation needed ]


Even though the complications of prostate surgery can be bothersome, treatments are available, and patients should seek guidance from their physician instead of ignoring the problem.


Scrotoplasty , also known as  oscheoplasty , is a type of surgery to create or repair the  scrotum . Scientific research for male genital plastic surgery such as scrotoplasty began to develop in the early 1900s. [ 1 ]  The development of testicular implants began in 1940 made from materials outside of what is used today. Today, testicular implants are created from saline or gel filled silicone rubber. [ 2 ]  There are a variety of reasons why scrotoplasty is done. Some  transgender men  and intersex or non-binary people who were assigned female at birth may choose to have this surgery to create a scrotum, as part of their transition. [ 3 ]  Other reasons for this procedure include addressing issues with the scrotum due to birth defects, aging, or medical conditions such as infection. [ 4 ]  For newborn males with penoscrotal defects such as webbed penis, a condition in which the penile shaft is attached to the scrotum, scrotoplasty can be performed to restore normal appearance and function. [ 4 ]  For older male adults, the scrotum may extend with age. [ 4 ]  Scrotoplasty or scrotal lift can be performed to remove the loose, excess skin. Scrotoplasty can also be performed for males who undergo infection, necrosis, traumatic injury of the scrotum. [ 5 ]


Buried penis  is a condition when the penis is attached to the scrotum with an excess of skin. This condition can affect both newborn and adult males. Scrotoplasty can be performed to remove the extra skin in the scrotal area and reshape the scrotum. Penoscrotal webbing is another condition, where the skin connecting the penis to the scrotum extends along the underside of the penis shaft like a web. [ 6 ]  This condition is easily confused with buried penis. Both conditions affect newborn and adult males but they do not always require surgery. Scrotoplasty can be considered to remove excess skin in order to restore normal appearance of the scrotum and penis length, which can improve a man's confidence. In both conditions, the scrotoplasty procedure involves making an incision in the fused part between the penis and scrotum and then reconstructing the scrotum. [ 6 ]


Some trans men and intersex or non-binary people who were assigned female at birth may choose to have gender-affirming surgeries to create male genitals from existing tissue, as part of their female-to-male transition. [ 3 ]  There are two types of gender-affirming surgeries for the creation of a penis,  metoidioplasty  and  phalloplasty . In both of these surgeries, a scrotoplasty can be considered as an additional surgery to add testicular implants. [ 7 ]  Metoidioplasty involves modification of the clitoris into a penis. Generally, the clitoris is hormonally enlarged with  testosterone , making it possible for it to be straightened and lengthened into a penis. Outcomes of this surgery include the ability to urinate while standing and retain sexual stimulation. [ 7 ]  Phalloplasty is the other type of surgery to create a penis, but utilizes skin from other areas of the body besides existing genitals. The most common part of the body used in this surgery is the forearm and has the same outcomes as a metoidioplasty. [ 8 ]  The addition of a scrotoplasty with implants is an optional procedure for individuals to choose based on their goals with their transition. Deciding if a neoscrotum meets their needs in their transition is a consideration for adding a scrotoplasty procedure. [ 7 ] [ 8 ]


There are various categories of injuries to the scrotum that result in the loss of scrotal skin tissue. Scrotoplasty in these conditions is needed to remove necrotic skin and reconstruct the scrotum. Scrotal skin loss is not common among adult males who require scrotoplasty. [ 5 ]


The first category of scrotal injury includes  Fournier gangrene , which is a necrotic infection of the soft tissue around the genital. This infection is commonly caused by a poly microbic flora in the individuals who has co-morbidities such as immunocompromised conditions, diabetes mellitus, colorectal infection. To stop the  necrotizing fasciitis  from spreading, the treatment requires an aggressive surgical  debridement  which often results in the loss of the scrotal skin. After the patient is stable and cleared from the infection, scrotal reconstruction is needed to restore its function the scrotum. [ 4 ]


The second category of scrotal injury includes trauma to the scrotum, such as from burns, machinery accidents, traffic accidents, firearm accidents, and surgical accidents. [ 5 ]  People who experience these injuries may require scrotoplasty if they lose more than 50% of their skin. [ 6 ] [ 9 ]  Reconstructing scrotal skin can be accomplished by using skin grafts from other areas of the body. Tissue expansion, a procedure in which the skin is stretched to regenerate new cells, can also be an option in order to restore scrotal skin loss. In addition to surgically reconstructing the scrotum, antimicrobial medication and the tetanus vaccine should be given to prevent infection and reduce the risk of developing an infection. [ 5 ]


The third category of scrotal injury includes  Extramammary Paget  cancer that affects the scrotum. If the tissue is affected by cancer, scrotoplasty can be performed to remove the affected skin. [ 4 ] [ 6 ]  However, if the cancer affects the  testicles , other surgeries such as removal of the testicles and implantation of testicular prosthetics may be required. [ 6 ]


There are many reasons that can cause scrotal sagging such as natural aging,  varicocele , and  hydrocele . Naturally, as a person ages, skin loses elasticity and becomes less taut. The scrotum may start to sag due to the loss of elasticity in the skin as well as weakening of the cremaster muscles in the scrotum that pull the testicles toward the body. [ 10 ]  Many people develop scrotal sagging later in life, but it does not affect everyone. [ 10 ]  Scrotal sagging may also be due to the swelling of the testicles, a condition known as varicocele, which causes increased blood flow and temperature of the testicles. The body's response is to lower the testicles from the body, which causes sagging. [ 10 ]  Another reason for scrotal sagging is when the testicles swell and fill with fluid. This condition is known as a hydrocele which is very common among newborn males but can resolve itself within the first year. In adult males, hydrocele has many causes, including inflammation due to injury or infection. Similar to varicocele, the body lowers the testicles, causing scrotal sagging. [ 10 ]  The specific name for this type of scrotoplasty is commonly known as scrotal lift or scrotal rejuvenation, which is a procedure to remove excess loose scrotal skin, tighten, and reduce the size of the scrotum. [ 11 ]  Scrotal lift is done not just as a cosmetic surgery to improve the appearance of the scrotum, but also as a way to reduce discomfort. [ 4 ]  Scrotal sagging can cause discomfort due to chafing of the scrotum against the body during every day activities and during exercise. [ 12 ]


Candidates must avoid any nicotine products, which can potentially affect wound healings and perioperative complications, for 3 months prior to the surgery. [ 13 ]  People must also be screened for other contraindications, including obesity with specific adipose distribution. Diabetes can also lead to wound complications such as wound separation or wound disruption. [ 14 ]  Other contraindications exist for specific types of phalloplasty. For instance, a body mass index (BMI) of greater than 35 kg/m2 is contraindicated for radial forearm free flap (RFFF) phalloplasty. A metoidioplasty or anterolateral thigh (ALT) phalloplasty is only recommended for people with an ideal body weight. [ 13 ]


For gender-affirming scrotoplasty, people should have already been receiving hormone therapy for over 1 year with established mental and primary health care. Some transmasculine people have already undergone double mastectomy and hysterectomy. Scrotoplasty for transmasculine individuals is usually done with other gender-related genitourinary surgery (GRGUS), which consists of various procedures with variable personal desires for metoidioplasty, phalloplasty, vaginectomy, and urethroplasty. [ 13 ]   A comprehensive history and physical assessment of the physical sites are taken during consultation to identify the candidates' surgical goals, which then help determine which procedures are needed.


Depending on the purpose of scrotoplasty, whether the patients need to remove excess scrotal skin, reconstruct the scrotum due to scrotal skin loss, or create a new scrotum, the scrotoplasty types will vary.


There are various scrotoplasty techniques for the buried penis and penoscrotal web. The surgeon can perform the simplest technique by making a horizontal incision and closing along the longitudinal axis. However, the methods that give patients higher satisfaction are the single or double Z-plasty or V-Y advancement flap because they also can increase the penile length. [ 15 ]


The scrotoplasty procedure requires skin grafting to reconstruct the scrotum for scrotal skin loss. Full-thickness skin grafts (FTSGs) and split-thickness skin grafts STSG  [ 16 ]  are two types of skin graft can be used for reconstruction. [ 17 ]  The  suprapubic  skin and the anterior thigh are the most common donor sites.


The novo scrotoplasty is one stage of female-to-male transition, performed together with  phalloplasty , which creates the penis. When a trans man or  transmasculine  person has a scrotoplasty, the  labia majora  (the big lips of the  vulva ) are dissected to form hollow cavities and united into an approximation of a scrotal sack. [ 18 ]  If there is not enough skin to make a scrotum, then the surgeon may need to make tissue expansion before the operation by putting expanders under the skin. Over the course of a few months, more salt water ( saline ) will be occasionally added to the expanders through a port on the outside. This helps the skin expand and grow more skin. Each expansion procedure is done in an outpatient hospital visit. The patient does not have to stay overnight in the hospital, but will have to stay near the hospital, and return several times. [ 19 ] [ 20 ]


Most cases of gender-affirming scrotoplasty are done with Hoebeke's technique where the majority of people are satisfied with shape, size, and position of their newly constructed scrotum and consider getting prosthetic testicles and erectile inflatable devices . [ 18 ] [ 21 ]  Initially, a secondary surgery was carried out to insert 2 silicone prosthetic testicles into the newly constructed scrotum between 6–12 months following the initial scrotoplasty. An erectile inflatable device was then implanted during a tertiary surgery at least 12 months from the initial scrotoplasty. [ 18 ]  Later on, this technique was modified in which 1 silicone prosthetic testicle and an erectile inflatable device were implanted during the same surgery between 6–12 months after the initial scrotoplasty. [ 18 ]  These can be inserted through small cuts to fill the new scrotum. At this point, the new scrotum no longer needs expanders. Then the skin is closed up around the artificial testicles. [ 19 ] [ 20 ]  The artificial testicles only give a shape and do not create semen, sperm, or hormones.


In general, post-operative hospital stays for people undergoing scrotoplasty range from days to weeks, corresponding to the complexity of the procedure. [ 22 ]


Usually after the procedure, people may wear a support garment to limit the movement of the surgical sites to limit the risk of complications. In addition, a flexible tube for draining urine from the urinary bladder ( urinary catheter ) is placed and held in place until the genitals heal. Swelling of the scrotal areas is normal and can last up to months.


Individuals with buried penis undergoing a scrotal lift can be discharged on the same day as procedure, and are not allowed to engage in sexual activities for many weeks. [ 23 ]  People can ambulate or must rest in bed during recovery, depending on the surgeon's decision. A blood thinner ( anticoagulant ) is considered for people with risk factors for  deep vein thrombosis . [ 23 ]


People who are candidates for scrotoplasty need to be educated on the associated risks and complications before the procedure. There have been advancements in the surgical techniques. However, the risk of recurrent condition still exists. In addition, the cosmetic results might not be satisfactory to some people after surgery. [ 24 ]  Another factor to consider is the loss of sensation in the scrotal area due to the nature of the procedure which can involve removal of genital tissues. [ 24 ]  These sensation issues occur because the body's  nerve tissue  requires time to be reestablished with the body. In addition to the loss of sensation, individuals may experience other sensory problems including  hypersensitivity  and pain. Because of this, issues regarding sex and orgasms may arise post-operation, making it difficult to be sexually satisfied. Once nerve tissue is reestablished with the body after a few months post-operation, sexual function may return to its full capacity. [ 25 ]


Complications to scrotoplasty among transmasculine individuals primarily deal with testicular implants. If they are too big, there is chance that the implants could feel uncomfortable, or be a cause of  chronic pain . [ 26 ]  Another complication is that the implant could erode the skin of the scrotum. This can cause infection, or an abnormal connection between two body parts (a  fistula ) where the implant may work its way outside the body. [ 26 ]  People with a history of smoking are at increased risk of infections and prosthetic explantation. [ 21 ]


Other complications are those that are typical for any surgery, such as blood loss or problems with  anesthesia .


A scrotoplasty for a trans man or  transmasculine  person typically costs around US$3,000 to $5,000. [ 26 ]  These costs can be covered by  health insurance , though the person receiving care must communicate a great deal with their insurance in order to make certain that it will. In the United States, it is considered illegal for  Medicaid ,  Medicare , and private insurance plans to deny individuals transition-related care coverage. [ 27 ]  However, individuals may run into issues with their insurance plan coverage because insurance will only cover surgeries that are considered medically necessary. Insurance plans can deny coverage of a scrotoplasty if deemed to be an esthetic or  cosmetic surgery  instead of a reconstructive one. In this case, all of the costs will be covered by the individual under care. [ 28 ]


A  sperm granuloma  is a lump of leaked  sperm  that appears along the  vasa deferentia  or  epididymides  in  vasectomized  individuals.  While the majority of sperm granulomas are present along the vas deferens, the rest of them form at the epididymis. Sperm granulomas range in size, from one millimeter to one centimeter. They consist of a central mass of degenerating sperm surrounded by tissue containing blood vessels and immune system cells. [ 1 ]  Sperm granulomas may also have a yellow, white, or cream colored center when cut open. While some sperm granulomas can be painful, most of them are painless and asymptomatic. [ 2 ]  Sperm granulomas can appear as a result of surgery (such as a vasectomy), trauma, or an infection (such as sexually transmitted diseases). [ 3 ]  They can appear as early as four days after surgery and fully formed ones can appear as late as 208 days later. [ 4 ]


Sperm granulomas are a common complication of different types of vasectomy. In vasectomies, the vas deferens are cut and the two ends are tied to prevent sperm from passing. Sperm granuloma may then form at the point where the vas deferens were cut, due to the possibility of sperm leaking out at this site. History of trauma or inflammation of the epididymis can also lead to a sperm granuloma. [ 2 ]  Sperm granulomas are seen as the body's immune response to sperm being outside of their normal location, and are therefore seen as a protective mechanism.


Sperm granulomas are quite common after surgery, occurring in up to 40% of patients. On the contrary, sperm granulomas comprise only 2.5% of the general population. [ 5 ]  Amongst adolescents and pediatric patients, sperm granulomas are considered a rare phenomenon as this population does not undergo vasectomy often. The most common cause of sperm granuloma in pediatric and adolescent patients is often attributed to tumor obstruction, injury, or infection to the area. [ 5 ]


While sperm granuloma is considered a complication in most cases, it allows decompression of the vas deferens and epididymis at the vasectomy site. This allows for successful future reversal of vasectomy given the good quality sperm in the vas fluid. Any surgery in the genital area can lead to castration anxiety (fear of loss or damage to the genital organ.) [ 6 ]


Sperm granulomas are diagnosed using a microscope to examine tissues ( histology ) taken from the area, typically done with  fine needle aspiration  and occur within a few weeks of a vasectomy. [ 7 ]  An example of a histology based diagnosis supporting sperm granuloma would be a sperm core surrounded by inflammatory cells,  apoptotic cells , and fibrous tissue. Often, there will be empty tubes with cellular debris near the granuloma. [ 2 ]  Additionally, physicians might use  high frequency ultrasounds  to aid in properly diagnosing epididymal conditions such as sperm granulomas. [ 8 ]  Using these ultrasounds provide a better view of the anatomy of the epididymis, which could prevent misdiagnosis of conditions such as testicular tumors or supernumerary testis (the presence of more than two testes). [ 8 ]


Sperm granulomas appear as hard and firm nodules that do not exceed 1 cm in size. Sperm granulomas form in 20-50% of vasectomy procedures. [ 6 ]  An injury to the epididymal epithelium is caused by penetration of germ cells into the epididymal supportive tissue. This infiltration of germ cells allows for the pathogenesis of sperm granulomas. Moreover, the penetration of germ cells leads to inflammatory and autoimmune reactions that further increase the risk of sperm granuloma formation. [ 2 ]


Sperm granuloma can also mimic the presence of an abnormal number of testis on ultrasound. [ 9 ]


Sperm granulomas are mostly asymptomatic. [ 4 ]  However, they can cause pain and swelling of the epididymis, spermatic cord, and testis. The pain usually radiates to the groin, the junctional area between the abdominal wall and the thigh, and can imitate the feeling of kidney spasms. [ 10 ]


Sperm granuloma is a common complication of vasectomy. [ 2 ]  Vasectomies are a common, effective procedure for the sterilization of males. History of trauma or epididymitis can also lead to sperm granuloma. In vasectomies, the vas deferens are cut and the two ends are tied to prevent sperm from passing. Sperm granuloma may then grow at the point where the vas deferens were cut. [ 2 ]  This could happen two to three weeks post procedure. Sperm granuloma can also form from sperm leaking from the vas deferens into the surrounding interstitium. Leakage of sperm elicits an immune response which can lead to chronic inflammation. A histological examination can confirm a sperm granuloma by checking for inflammatory markers such as macrophages and lymphocytes surrounding the sperm core. [ 2 ]


Most sperm granulomas are asymptomatic and absorbed over time. However, in more severe cases, non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen may be used.


Surgery is very rarely performed. In cases where symptoms do not resolve in a reasonable amount of time and NSAID therapy is ineffective, the provider may choose to surgically resect the area where the pain is localized. Additionally, the stumps of the vas deferens can be burned and closed off in order to reduce the pain the patient is experiencing and prevent it from happening again. [ 11 ]


When sperm granulomas are occasionally mistaken for other conditions, such as testicular tumors, a more complicated treatment approach such as an  orchiectomy  may be accidentally used. [ 12 ]


Cauterization is a vasectomy method used to seal the vas deferens by utilizing heat or electricity to burn the lumen. Using thermal (heat) cautery instead of electrocautery can help prevent granulomas and nodular thickening. [ 2 ]


Refraining from ejaculation for 1 week can potentially reduce the risk of developing a sperm granuloma. [ 2 ]


There is also evidence that sperm granuloma formation may be linked to testosterone deficiency. Testosterone supplementation may reduce the inflammation related to sperm granulomas and potentially even prevent them from occurring. [ 2 ]  However, this evidence is only supported in animal models.


There have been complications involving sperm granuloma. A pediatric case documented a 13 year old boy who was admitted to the hospital with  edema  and redness on his left  hemiscrotum . [ 13 ]  Upon a physical examination, they found the scrotum to be enlarged, soft, red and painless. Initial sonographs detected possibility of inflammation of the testis and epididymis. The patient received anti-inflammatory and antibiotic treatment, and was examined again one week after treatment. [ 13 ]  The testis were still painless and now hardened. Upon a second reexamination five days later, low perfusion to the testis was detected. This testicular necrosis led the patient into an emergency operation. Histology determined there was a ruptured sperm granuloma that led to the testicular thrombosis and necrosis. [ 13 ]  Specifically, the walls of the vas deferens contained many growths of small ducts and gland-like structures, which came about as a response to the displacement of the sperm and fluid. The exact cause of his ruptured sperm granuloma was not determined, but it was found to be most likely a secondary response to inflammation and/or trauma. [ 13 ]


Another complication with sperm granulomas has been being mistaken for a tumor due to its tumor-like appearance. [ 14 ]  A 45 year old man presented with right testicular chronic pain. He had a vasectomy 7 years ago. Upon physical examination and an ultrasound, a solid nodule in the right epididymis was found, and medical staff suspected a tumor. After findings of sperm that had undergone phagocytosis, a final diagnosis of sperm granuloma was determined.  [ 14 ]


It is unknown whether sperm granulomas are definitively detrimental to sperm quality and fertility in humans. However, studies in donkeys have shown that sperm quality is only marginally affected. There was a lower percentage of sperm with intact plasma membranes; however, no effects on motility or morphology were observed. [ 15 ]  In some cases, the presence or absence of sperm granulomas may determine the success rate for vasectomy reversal.


It is believed that sperm granulomas may be protective because they can prevent the obstruction of the testicles and epididymis. [ 16 ]  Sperm granulomas are believed to reduce the pressure that is generated after vasectomy and prevent blockages of sperm output into the vas fluid during ejaculation. Therefore, there are no changes in the amount of sperm that are produced into the vas fluid. [ 16 ]


Additionally, sperm granulomas can exist in non-human species such as rats, dogs, horses, fish, etc. Non-human species exhibit the same causes for sperm granulomas, including infection, injury, and trauma to the epididymal region. For example, vasectomized rats were seen to also have a high prevalence of sperm granulomas post-operation while general populations of rats experienced a much lower prevalence of sperm granulomas. [ 17 ]  In the case of sperm granulomas within dogs, their presence is common amongst poorly performed vasectomies. [ 12 ]  This is consistent with the idea that these lesions form at the site where there is trauma or a chance for the sperm to leak outside of the vasa deferentia or epididymis. In multiple species, sperm granulomas have also been linked to the success rate of certain procedures such as vasectomy reversals, or  vasovasostomy . [ 12 ]  There is also an association between sperm granuloma and antibodies produced against sperm antigens. In a case study on sperm granuloma and anti-sperm antibody count in donkeys, it was found that sperm granuloma resulted in an increase in IgA- and IgG-bound sperm in donkeys. They also found donkeys with sperm granuloma had a reduction of sperm motility and a reduction of the percentage of sperm with an intact plasma membrane. However there was no significant damage found in total sperm motility compared to healthy control donkeys. The extent to which sperm granuloma and anti-sperm antibodies affect donkey fertility is still yet to be determined by further research studies.


A  spermatocelectomy  is a  surgical procedure  performed to remove a  spermatocele [ 1 ]  by separating it from the  epididymis . The patient is given an  anesthetic  in the groin and a small incision is made into the  scrotum .  The surgeon pulls the testicle and epididymis to the incision and separates the spermatocele by tying it off with a suture. The surgeon then removes it, and stitches up the area. [ citation needed ]


If medical treatment is not effective, surgery may need to be performed for  benign prostatic hyperplasia .


There are two invasive surgical procedures done for BPH:


There are two types of  transurethral resection of the prostate  (TURP): the standard monopolar and the newer bipolar procedure. A 2019 Cochrane review of 59 studies that included 8924 men with urinary symptoms due to  benign prostatic hyperplasia . [ 4 ]  This review found that bipolar and monopolar TURP probably results in comparable improvements in urinary symptoms, as well as a similar  erectile function , the incidence of urinary incontinence, and the need for retreatment. Bipolar surgery likely reduces the risk of  TUR syndrome  and the need for  blood transfusion . [ citation needed ]


Efforts to find newer surgical methods have resulted in newer approaches and different types of energies being used to treat the enlarged gland. However some of the newer methods for reducing the size of an enlarged prostate, have not been around long enough to fully establish their safety or side-effects. These include various methods to destroy or remove part of the excess tissue while trying to avoid damaging what remains. Transurethral electrovaporization of the prostate (TVP), laser TURP, visual laser ablation (VLAP), ethanol injection, and others are studied as alternatives. [ 5 ]


Minimally invasive therapies can offer faster recovery compared with traditional prostate surgery. [ 6 ]  They can further be divided into laser surgery (requiring  spinal anesthesia ) and other non-laser procedures.


Prostate laser surgery is used to relieve moderate to severe urinary symptoms caused by prostate enlargement. The surgeon inserts a scope through the penis tip into the urethra. A laser passed through the scope delivers energy to shrink or remove excess tissue that is preventing urine flow. [ 7 ]


Different types of prostate laser surgery include:


Both wavelengths, GreenLight and Holmium, ablate approximately one to two grams of tissue per minute. [ citation needed ]


Post-surgical care often involves placement of a  Foley catheter  or a temporary  prostatic stent  to permit healing and allow urine to drain from the bladder.


These procedures are typically performed with local anesthesia, and the patient returns home the same day. Some urologists have studied and published long-term data on the outcomes of these procedures, with data out to five years.


Transurethral microwave thermotherapy  (TUMT) was originally approved by the United States  Food and Drug Administration  (FDA) in 1996, with the first generation system by EDAP Technomed.  Since 1996, other companies have received FDA approval for TUMT devices, including Urologix, Dornier, Thermatrix, Celsion, and Prostalund. Multiple clinical studies have been published on TUMT.  The general principle underlying all the devices is that a microwave antenna that resides in a urethral catheter is placed in the intraprostatic area of the urethra.  The catheter is connected to a control box outside of the patient's body and is energized to emit microwave radiation into the prostate to heat the tissue and cause necrosis.  It is a one-time treatment that takes approximately 30 minutes to 1 hour, depending on the system used.  It takes approximately 4 to 6 weeks for the damaged tissue to be reabsorbed into the patient's body.


Transurethral needle ablation  (TUNA) operates with a different type of energy, radio frequency (RF) energy, but is designed along the same premise as TUMT devices, that the heat the device generates will cause necrosis of the prostatic tissue and shrink the prostate. The TUNA device is inserted into the urethra using a rigid scope much like a cystoscope. The energy is delivered into the prostate using two needles that emerge from the sides of the device, through the urethral wall and into the prostate. The needle-based ablation devices are very effective at heating a localized area to a high enough temperature to cause necrosis. The treatment is typically performed in one session, but may require multiple sticks of the needles depending on the size of the prostate. The most recent  American Urological Association  (AUA) Guidelines for the Treatment of BPH from 2018 stated that "TUNA is not recommended for the treatment of LUTS/BPH". [ 11 ]