presentation of new operation for treatment of cases not responding to local anesthetics. In Alaa Aglan (7) operation we excise right hypogastric nerve (inhibits emission phase) Fig1. Also, we cut bulbospongiosus muscles bilaterally with frenular delta excision (inhibits expulsion phase)Fig2.

21 patients underwent surgery between 2016/4/15 – 2016 /9/19 at Alaa Clinic hospital, Egypt. 
Criteria: hetro sexual, age varies between (22 – 54) no response to local anesthetics or good response to alcohol, ejaculation time less than 30 seconds. 
Approach: modified maylard incision in 19 patients, mid line incision in one patient, laparoscope in one patient Fig3.

after six months follow up period, one patient reported ejaculation time 20 minutes, nineteen patients reported ( 4-5 ) minutes, one patient reported one minute, post – operative one patient reported partially wound dehesience ( treated medically ), one patient reported in ability to extend trunk completely ( works as waiter ) but he improved after three weeks. One patient we can`t identify the hypogastric (right branch) due to extensive adhesions from previous surgeries we didn’t excise it, so we cut bulbospongiosus muscles only – bilaterally with frenular delta excision but the result was not enough as improvement was only one minute (previously ejaculation was before entrance) the patient was advised to take medical treatment - Central acting drugs- but the time did not changed even after we tried different drugs.

The hypogastric nerve fibers shows crossing at bifurcation level and pelvic ganglia level, so cutting of the nerve at right side could be compensated this inhibits emission phase. If we cut the nerves, bilaterally retrograde ejaculation occurs but ejaculation is compensated, cutting bulbospongiosus muscles bilaterally with frenular delta excision inhibits expulsion phase. In One patient we can`t identify the hypogastric (right branch) due to extensive adhesions from previous surgeries, we didn’t excise it, so we cut bulbospongiosus muscles only - bilaterally - with frenular delta excision but the result was not enough as improvement was only one minute (previously ejaculation was before entrance) the patient was advised to take medical treatment - Central acting drugs- but the time did not change even after we tried different drugs. One patient reported low semen volume. Laparoscope offers easy and simple way to operate the patients, theoretically we can increase the safety of the operation by injection of local anesthetics at right hypogastric branch and stimulate the left branch electrically if ejaculation occurs this means it is safe to cut the right branch. After cutting the nerve we pull the distal end towards pelvis - we do not cut a segment- to prevent reunion and allow re-suturing if needed. Theoretically, we can use electrical devices like vagal inhibition devices as alternative to nerve cutting, the device may be used either unilaterally or bilaterally or even at the trunk itself but the cost is too much so we did not try to use it in this study.

Alaa Aglan (7) operation allow bi-phasic control of ejaculation, more studies are needed to demonstrate its efficacy and safety.