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Penile Resensibilisation in 73 Low Spinal Cord Lesion Patients: Long-Term Results of the Ilioinguinal to Dorsal Penile Nerve Transfer (The TOMAX-Procedure)
Max L.E. Overgoor, MD PhD1; Annette J.C. van der Weide, MD2; Jasja T. Hoffman, MD1; Mireille A. Edens, PhD1
1Isala Clinics, Zwolle, Netherlands; 2Elisabeth - Twee Steden Hospital Tilburg, Tilburg, Netherlands

Introduction: Male patients with a low spinal lesion due to spina-bifida, spinal cord injury or cauda equine syndrome often have erections and ejaculations but no penile sensation. The TOMAX-procedure (ilioinguinal to dorsal penile nerve transfer) was developed to restore penile sensation and improve sexual health in these patients. We report long-term results of this nerve transfer.
Materials & Methods: A retrospective cohort study on 73 low spinal lesion patients with no penile but normal groin sensation, eligible to perform a TOMAX-procedure at our clinic between 2005 and 2017. Data were acquired using patients’ hospital records and questionnaires based on the International Index of Erectile Function and Groninger Arousablitity Scale. Main outcome was penile-glans sensation after (soft/pin-prick/cold 4.0C) touching (median follow-up 2.61 years [1.29 - 9.0]). Secondary outcomes: patient reported erectile function, ejaculations, orgasms, urine continence, satisfaction and complications (median follow-up 4.2 years [2.2 – 10.7]).Prognostic variables of success were explored using logistic regression analysis.
Results: In 66 patients (median age 31 [21 – 45]) a technically successful TOMAX-procedure was performed. In 51 glans-penis sensation was gained. Forty-five (median age at surgery 30 [19-43]) responded to the questionnaires. Patients with erections (38), ejaculations (31) or orgasm (27) all preserved this quality. Two gained erectile functioning and 8 developed a reflex-erection pathway. Seventeen achieved erections more easily and 3 more difficult. Maintaining erection increased in 11 but decreased in 5 and penile rigidity increased in 11 and decreased in 2. Three patients gained ability to ejaculate and 5 to have orgasm. The ease of ejaculation increased in 13 and decreased in 2. The ease of achieving orgasm was increased in 11 and decreased in 2. The intensity of orgasm increased in 12. Fifteen patients acquired urethral sensation. One patient could empty his bladder spontaneously, with no further need for intermitted catheterization. Overall satisfaction on erection, orgasm, sexual functioning and sex-life in general was increased in 58% of respondents and decreased in 8%. 98% recommends the TOMAX procedure to fellow sufferers. Younger age at surgery was significantly associated with gained sensation (p=0.033). Few complications like cystitis, decubitus, groin-scar neuroma and hematoma resolved conservatively.
Conclusions: The TOMAX-procedure can successfully restore genital sensation in male patients with a low spinal cord lesion and was associated with increased (sexual) satisfaction rates and minor complications. This nerve transfer should be considered when treating patients with a low spinal cord lesion


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