Stesura Seveso Archivio Italiano di Urologia e Andrologia 2023; 95, 1 NOTE ON SURGICAL TECHNIQUE operative efficiency. We hereby describing our novel technique of penile tourniquet application using a sili- cone Penrose tube designed as a strap. This technique increases the operative efficiency and sim- plifies the application of a tourniquet for any type of penile surgery. Technique This technique was designed by an experienced penile reconstructive surgeon who performed and tested various tourniquet techniques. Our technique consists of the application of sterile Penrose silicone tube drain (Medline® Ref.DYND50427, Size: 45.72 cm x 0.64 cm). In this purpose, we utilize all Penrose length (45.72 cm) without shortening the tube. First, we create the tourni- quet part of the tube by using about 15 cm of the tube length as a loop. Then, we create a small 0.8 cm through and through hole in the 15 cm point using a surgical Mayo scissors. The extremity of the drain is then passed through this small window. We apply then the tourni- quet loops around the base of the penis and secure the loop by pulling away both extremities to create the desired compression on the corporal bodies. The tourni- quet will be self-retained, anti-slip through the silicone surface characteristics and the hole resistance. Additional clamping may be beneficial to increase or to maintain the exerted pressure. Lastly, releasing the tourniquet will be achieved by removing the clamp if present or simply by untightening both Penrose tube extremities. This maneu- ver can be repeated several times during the surgery with- out removing the tourniquet from the base of the penis. The tension exerted through the tourniquet is adjustable according to the pressure desired. In our experience, no complications, failures nor difficulties were encountered, and the application of this novel technique is repro- ducible and easy to perform (Figure 1). DISCUSSION To our knowledge, this is the first article describing this technique. There is a paucity of data regarding the vari- ous tourniquet types and safety use guidelines for penile surgery. Gupta et al. (6), studied the different type of penile tourniquet with an author’s design of silicone strip tourniquet secured by tubectomy ring. Introduction: Penile compression using a tourniquet is common with several materials and designs that have been previously described. The objective of the tourniquet is to induce an artificial erection through cor- poral occlusion for intra-operative penile curvature assessment or to obtain a clear visible bloodless surgical field. Objective: We sought to describe our novel step-by-step tech- nique of applying penile tourniquet using silicone Penrose drain tube designed as a strap by creating a small hole on the side of the tube to obtain a loop at the base of the penis Conclusions: This novel technique is simple, effective and requires no additional materials nor special equipment, and facilitates the application and release of a tourniquet during penile surgery. KEY WORDS: Penis; Penile surgery; Tourniquet; Penoplasty, Surgical technique. Submitted 21 January 2023; Accepted 17 February 2023 INTRODUCTION Penile surgery is common in general and reconstructive urology. Frequently, surgeons apply intra-operative penile compression called Tourniquet – derived from the French verb ‘’to turn’’ – at the base of the penis to induce an artificial arterial erection to assess penile curvature. Furthermore, tourniquet use allows a bloodless surgical field and an adequate hemostatic control in either emer- gency or elective settings. The aim of the tourniquet in penile surgery is to compress and constrict distal penile blood outflow by corporal body occlusion (1). Routine use of a tourniquet is safe respecting occlusion time and the exerted pressure to avoid complications (2). There is no standardized penile tourniquet design nor specific material recommendation. Several material types have been used (for example silicone, rubber, and latex) in numerous forms such as catheters, bands, rolled gloves and drains secured either by a simple knot tie or by a two-turn loop fashion by clamping in order to maintain the pressure inside both corpora cavernosa (3-5). In an attempt to respect the recommended occlusive compres- sion time of less than 30-40 minutes 2, surgeons may require to release and to reapply the tourniquet several times during the surgery. In contrast, repeating tourni- quet applications and releasing could decrease the intra- Novel penile compression technique of penile surgeries ‘’Penile strap’’ Abdulghani Khogeer 1, 2, Abdullah Alzahrani 1, 3, Ahmed Ibrahim 1, Melanie Aubé-Peterkin 1, Serge Carrier 1 1 Department of Surgery, Division of Urology, McGill University Health Center, Montreal QC, Canada; 2 Department of Surgery, Faculty of Medicine, Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia; 3 Department of Urology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. DOI: 10.4081/aiua.2023.11201 Summary Archivio Italiano di Urologia e Andrologia 2023; 95, 1 A. Khogeer, A. Alzahrani, A. Ibrahim, M. Aubé-Peterkin, S. Carrier In our center, we examined the application of silicone Penrose drain tube designed intra-operatively as a self- gripped strap with or without additional securing clamp to maintain the pressure. Furthermore, we found that this technique helps to maintain the tourniquet at the base of the penis all over the surgery in either released or tight- ened fashion. Tightening or un-tightening the tourniquet is achieved by simply pulling or releasing both extremi- ties respectively. This technique doesn’t require any addi- tional materials or resources and require exclusively a sil- icone Penrose tube and surgical Mayo scissors to create the small window. Penrose drain is widespread available and currently used by many urologists as a tourniquet in several forms. We modified the usage of silicone Penrose for this indication by inventing this strap-like tourniquet design. The aim of our study is to describe an effective technical surgical step that could interest current and future reconstructive urologist that we perceive as simple and easy to perform. However, our study is limited by its descriptive non-comparative design with no intention to prove superiority among other tourniquet techniques in terms of either facility or functional outcomes. We found this technique is easy with similar satisfactory operative objectives in terms of bleeding control and corporal occlusion. In addition, the use of tourniquet is advanta- geous during penile curvature surgery in order to achieve best results notably in cases of solitary saline infusion or vasoactive agents injection failure. Surgeon should con- sider that penile tourniquet could compromise precise assessment of penile curvature through penile geometri- cal alteration especially in the presence of penile deformi- ties at the base of the penis (hour-glass deformity, inden- tations). However, this technical field needs further studies to assess and to compare different tourniquet designs and to evaluate the exerted local mechanical pressure effects on the penile tissues and vascularity (dorsal penile arteries) and glandular supply. Our future suggestion is to create a penile tourniquet inspired by our design with either self- locked strap or buckle band (e.g., tongue/button and holes) with a pressure graduation measurement. CONCLUSIONS This novel technique of penile tourniquet is effective, reproducible and easy to perform to achieve complete corporal bodies occlusion for various penile surgery. Further studies are warranted to compare different tourniquet designs with penile mechanical pressure eval- uation. REFERENCES 1. Klenerman L. The tourniquet in surgery. J Bone Joint Surg Br. 1962; 44-B:937-943. 2. Parsons BA, Kalejaiye O, Mohammed M, Persad RA. The penile tourniquet. Asian J Androl. 2013; 15:364-367. Figure 1. Step-by-step technique (a-f). Measuring 15 cm from one extremity. Marking the hole window at the 15 cm Creating the hole using the Mayo point. Scissors. (a) (b) (c) Passing the extremity of the tube Applying pressure by pulling away both Securing the loop by using a surgical through the hole created. extremities. clamp. (d) (e) (f) Archivio Italiano di Urologia e Andrologia 2023; 95, 1 Penile strap for penile surgery 3. Redman JF. Tourniquet as hemostatic aid in repair of hypospadias. Urology. 1986; 28:241. 4. Barnett A, Pearl RM. Readily available, inexpensive finger tourni- quet. Plast Reconstr Surg. 1983; 71:134-135. 5. Obaidullah, Aslam M. Ten-year review of hypospadias surgery from a single centre. Br J Plast Surg. 2005; 58:780-789. 6. Gupta DK, Devendra S. A simple and safe penile tourniquet. Indian J Plast Surg. 2015; 48:93-95. Correspondence Abdulghani Khogeer, MD dr-abdulghani@hotmail.com Melanie Aubé-Peterkin, MD melanie.aube-peterkin@mcgill.ca Abdullah Alzahrani, MD abdullah.alzahrani2@mail.mcgill.ca Ahmed Ibrahim, MD eldemerdash90@gmail.com Department of Surgery, Division of Urology, McGill University Health Center, Montreal QC, Canada Serge Carrier, MD, FRCS (C), MMmgt, Professor of Urology (Corresponding Author) serge.carrier@mcgill.ca McGill University Health Centre 1001 Boul Decarie, Suite D05.5331, Montreal, Quebec H4A 3J1 Conflict of interest: The authors declare no potential conflict of interest.