presentation of new operation - Alaa Aglan (9) - for treatment of premature ejaculation cases not responding to medical treatment or simple surgeries.

23 patients underwent surgery (2016/10/3 – 2017/3/17) at Alaa clinic hospital, Egypt. 
Criteria: hetro-sexual, age (23 – 44), ejaculation time less than 30 seconds no or inadequate response to medical treatment or previous unsatisfactory surgeries. 
Approach: right hypogastric nerve excisionFig1: modified Maylard in twenty patients and laparoscope in three patients Fig2. Muscle cutting and neurectomy: peno-scrotal incision. Frenular delta: simple excision.

After six months, follow up period:  one patient reported ejaculation time sixteen minutes, one patient reported thirteen minutes, one patient reported eleven minutes,two patients reported seven minutes,twelve patients reported ( 4 - 5 ) minutes,four patients reported two minutes, one patient reported one minute.
Neuroma reported in one patient treated medically, four patients were not satisfied.

frenular delta excision is safe as it is excised in many over circumcised persons without complications, muscle cutting ( bulbospongiosus )Fig3 is safe as we saw clinically in many of cases this underwent various types of Alaa Aglan operations, the muscle may be congenitally absent in normal persons or in cases of hypospedius or epispedius without effect. In neurectomy (around penis) we dissect the nerve a long penis shaft then we cut it at the penis root and pull the distal end away towards glans to prevent reunion and allow re-suturing if needed as the nerves diameter are obvious at root area, also we teach the patients to inject local anesthetics around chosen nerve/s and instruct them to practice sex or masturbate to predict any possible problems or erectile dysfunction. Theoretically, we can inject local anesthetics at right branch (intra operative) and stimulate the left branch electrically if ejaculation occurs that means it is safe to cut it and vice - versa, also we dissect the nerve then we pull its distal end towards pelvis to prevent reunion and allow re-suturing (we don’t cut a segment) if needed. Also, theoretically, we can use electrical devices like vagal inhibition devices at right or left hypogastric branches or even the trunk itself, but the cost is too much so we didn’t do this in our trials. The results were obvious in many cases in this study with satisfaction of the patients. After all some cases were not satisfied - four cases - by the results, so we may need to give medical treatment which a lone is of no value - Clinically seen - But may give synergistic action with the operation. This operation is preferred to be done laparoscopically, which is best for both doctors and patients.

Alaa Aglan (9) operation is recommended for cases not responding to medical treatment, more studies are needed to explore its efficacy and safety.