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Restoring penis sensation in patients with low spinal cord lesions: The role of the remaining function of the dorsal nerve in a unilateral or bilateral TOMAX procedure


  • Max L.E. Overgoor,

    Corresponding author
    1. Department of Plastic, Reconstructive and Hand Surgery, Isala Clinics, Zwolle, The Netherlands
    • Correspondence to: Max L.E. Overgoor, M.D., Department of Plastic, Reconstructive and Hand Surgery, Isala Clinics, Sophia Site, P.O. Box 10400, 8000 GK Zwolle, The Netherlands. E-mail:

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  • Jan P. Braakhekke,

    1. Department of Neurology and Clinical Neurophysiology, Isala Clinics, Zwolle, The Netherlands
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  • Moshe Kon,

    1. Division of Plastic, Reconstructive and Hand Surgery, University Medical Centre, Utrecht, The Netherlands
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  • Tom P.V.M. De Jong

    1. Paediatric Renal Centre, Department of Paediatric Urology, University Children's Hospital, UMC Utrecht and AMC Amsterdam, The Netherlands
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  • Conflict of interest: none.
  • Mickey Karram led the peer-review process as the Associate Editor responsible for the paper.


Aims: The recently developed TOMAX-procedure restores unilateral genital sensation, improving sexual health in men with a low spinal lesion (LSL). It connects one dorsal nerve of the penis (DNP) to the intact ipsilateral ilioinguinal nerve. We proposed bilateral neurotization for full sensation of the glans but this entails cutting both DNPs, risking patients' erection/ejaculation ability.

The objective was to select patients for a bilateral TOMAX-procedure by measuring remaining DNP function, and perform the first bilateral cases.


In 30 LSL patients with no penile- but normal groin sensation selected for a unilateral TOMAX-procedure the integrity of the sacral-reflex-arc and DNP function was tested pre-operatively using bilateral needle electromyography (EMG)–bulbocavernosus reflex (BCR) measurements, and an interview about reflex erections (RE) ability.


In 13 spina bifida- and 17 spinal cord injury patients [median age 29.5 years (range 13–59 years), spinal lesion T12 (incomplete) to sacral], seven (23%) patients reported RE, four (57%) with intact BCR, and of nine (30%) patients with intact BCR, four reported RE (44%).


Even patients with a LSL and no penile sensation can have signs of remaining DNP function, but cutting both DNPs to restore full glans sensation in a bilateral TOMAX-procedure might interfere with their RE/ejaculation. To avoid this risk, we propose a selecting-protocol for a unilateral- or bilateral procedure using RE and BCR measurements.

Using this protocol, three patients were bilaterally operated with promising preliminary results. Full sensation of the glans could lead to further improvement in sexual function. Neurourol. Urodynam. 34:343–348, 2015. © 2014 Wiley Periodicals, Inc.

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