Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis

Introduction

Many men suffering from erectile dysfunction are overweight with generous suprapubic fat pads, which often contribute to a decrease in visible exophytic phallic length.

Salvage and Extracapsular Implantation for Penile Prosthesis Infection or Extrusion

Introduction

When a penile prosthesis is implanted, a fibrous tissue capsule gradually forms around it. In case of penile prosthesis infection, salvage and immediate reimplantation into the same capsule that envelops the infected prosthesis is a trial to avoid the difficulty and shortening encountered with explantation and delayed reimplantation.

Extracorporeal Transseptal Penile Prosthesis Implantation for Extreme Cases of Corporeal Fibrosis: Shaeer Implantation Technique

Background

Penile prosthesis implantation into scarred corporeal bodies is one of the most challenging procedures in prosthetic urologic surgery, especially following infection and extrusion of a penile implant. Several instruments and techniques have been used for making dilatation of scarred corporeal bodies easier and safer in expert hands. Nevertheless, in some cases, implantation is not possible.

Distinguishing Failure to Cure From Complication After Penile Prosthesis Implantation

BackgroundA successful penile prosthesis implantation (PPI) surgery can be defined by outcomes beyond the absence of complications.AimTo introduce the concept of failure to cure (FTC) in the context of PPI to more accurately gauge postoperative outcomes after PPI.MethodsConsecutive patients from our sexual function registry who underwent PPI from January 2011 to December 2013 were analyzed. Demographics, previous treatment of erectile dysfunction, comorbidities, social history, postoperative problems (POPs), and surgical outcomes were tabulated. Patients completed the International Index of Erection Function (IIEF) and the Erectile Dysfunction Inventory of Treatment Satisfaction questionnaires. We defined a complication, according to the Clavien-Dindo classification, as any deviation from the ideal postoperative course that is not inherent in the procedure and does not constitute an FTC. FTC was defined as a POP that was not a complication. The χ² tests, t-tests, or Wilcoxon rank-sum tests were used.OutcomesPatient-reported and objective outcomes after PPI.ResultsOur enrollment consisted of 185 patients, and we contacted 124 (67%). Of these, 16 (12.9%) had a POP requiring reoperation. Eight patients developed surgical complications (three infections, four erosions, and one chronic pain). Eight patients had FTC (four malpositions and four malfunctions). Factors that correlated with POPs were previous PPI, body mass index higher than 30 kg/m², and previous treatment with intracorporal injections (P < .05 for all comparisons). Patients who had POPs scored significantly lower on the IIEF erectile function and intercourse satisfaction domains (P < .05 for the two comparisons), but not on the orgasmic function, sexual desire, and overall satisfaction domains (P > .05 for all comparisons).Clinical ImplicationsPOPs after PPI surgery can be more accurately categorized using the Clavien-Dindo classification of surgical complications to more clearly distinguish surgical complications from FTC.Strengths and LimitationsLimitations of our study include its retrospective approach. Our series included a large proportion of patients treated for prostate cancer, which limits the generalizability of our findings. We also had a relatively short median follow-up time of 27 months.ConclusionsPatient-reported outcome assessments can vary greatly from what physicians determine to be successful PPI. An assessment of POPs encompasses more than just complication rates; it also reflects FTC. Even when POPs occur, patients can still derive satisfaction if they are correctively managed. Factors that possibly predispose to POPs include previous PPI surgery, body mass index greater than 30 kg/m², and history of intracorporal injections.Pineda M, Burnett AL. Distinguishing Failure to Cure From Complication After Penile Prosthesis Implantation. J Sex Med 2017;14:731–737.     

Spontaneous Penile Tumescence by Sparing Cavernous Tissue in the Course of Malleable Penile Prosthesis Implantation

Introduction

Spontaneous penile tumescence after penile prosthesis implantation has been sporadically reported in the literature.

Survey on the Contemporary Management of Intraoperative Urethral Injuries During Penile Prosthesis Implantation

Background

Intraoperative urethral injury is an uncommon event during the placement of a penile prosthesis, and alternative management strategies have been proposed with continuation of implantation after urethral injury.

Technological Advances in Penile Implant Surgery

BackgroundDuring the last century, surgical management of erectile dysfunction has evolved from an experimental concept to a core treatment modality with widespread use among the men's health community. Over time, innovations in materials, mechanical design elements, device coatings, and surgical technique have provided patients with low-risk, reliable, and reproducible erectile function with high satisfaction rates.AimTo provide a foundation for future innovation by improving understanding of historical penile prosthetics and the rationale behind incremental technological improvements for the contemporary Men's Health physician.MethodsLiterature review was conducted to generate a comprehensive review of historical technological innovations in penile implant surgery. Companies with FDA approved penile prosthetics in use in the United States were contacted for information regarding technological innovations in the past and future devices in development. A separate literature review was performed to identify any significant future device design elements being tested, even in the ex vivo setting, which may have future clinical applications.OutcomesTechnological innovations in penile implant surgery were described.ResultsCurrent options for the prosthetic surgeon include malleable penile prostheses (MPP), self-contained (2-piece) inflatable penile prostheses, and multicomponent (3-piece) inflatable penile prostheses. Current MPPs consist of a synthetic coated solid core which allow for manipulation of the penis for concealability while maintaining sufficient axial rigidity to achieve penetration when desired. Multi-component (3-Piece) IPPs currently include the Coloplast Titan and Boston Scientific/AMS 700 which consist of a fluid reservoir, intrascrotal pump, and intracavernosal cylinders. The devices have undergone numerous design updates to the cylinders, pump, reservoir, tubing, and external coatings to increase reliability and decrease short- and long-term complications.Clinical ImplicationsFuture innovations in penile prosthetic surgery seek to broaden the indications and applicability to the transgender community and improve both safety and functionality for patient and partner.Strengths & LimitationsThe review is limited primarily to penile prosthetics approved for current or historical clinical use in the United States and may not be representative of the global prosthetic environment. Additionally, the research and development of future innovations, particularly those provided by device manufacturers, is likely limited by non-disclosure to maintain a competitive advantage.ConclusionsPenile prosthetic surgery will undoubtedly remain integral to the treatment of erectile dysfunction, and education regarding the current state of technological innovation will empower the prosthetic surgeon and biomedical engineering community to improve contemporary patient care and drive the development of the next generation of implantable penile prosthetics.Barnard JT, Cakir OO, Ralph D, et al. Technological Advances in Penile Implant Surgery. J Sex Med 2021;18:1158–1166.     

A Survey of Usage of Penile Prosthesis

BackgroundImplantation of an inflatable penile prosthesis (IPP) has high success and satisfaction rates, but there remains a paucity of evidence examining non-usage of IPP and reasons for discontinuation.AimTo identify how frequent patients use their prosthesis and their personal reasons for no longer using it.MethodsWe conducted a survey of all patients who underwent an IPP implantation by a single surgeon over a 6-year period, between 2012 and 2018. After application of inclusion and exclusion criteria, a total of 114 patients formed the final cohort. Patients were initially surveyed via mail with a questionnaire; those who did not respond were surveyed via telephone. The factors determining patient selection for IPP implantation included suitability for general anesthesia, manual dexterity to use the device by the patient or their partner on a demonstration device, and presence of refractory erectile dysfunction, HbA1C lower than 8.5, or need for a revision of a previously placed IPP. Universally, a 3-piece AMS 700 Series implant was placed via the penoscrotal approach. Data were analyzed with Pearson chi square test, and survivability of the device was assessed with Kaplan-Meier survival curve.OutcomesThe main outcomes of this study are the frequency of IPP usage and reasons for discontinuation.ResultsThe survey participation rate was 97%. The mean age of patient was 64 years (range 34–83 years), and the mean time between surgery and completion of survey was 2.98 years (range 0.25–7.4 years). Kaplan-Meier curve demonstrated that 68% of the patients were using the IPP at 5 years after implantation. Using the age 70 years as a cutoff, 18 (22%) patients younger than 70 years and 14 (42%) patients older than 70 years discontinued using the IPP (P = .029). The commonest reasons for discontinuation were poor health to engage in sexual activity (2.6%), loss of companion (19%), loss of interest in sex (2.6%), and device malfunction with no further interest in revision of prosthesis (14%).Clinical ImplicationsThe clinical implication of this study was improved patient selection for device implantation.Strengths and LimitationsTo our knowledge, no other study has investigated reasons for patients no longer using their prosthesis. Our study has several limitations including that it is a cross-sectional analysis, our survey is not validated, this is a single-surgeon experience, we have a small sample size, and we did not differentiate between virgin implant and reimplantation.ConclusionOur study shows a high rate (28%) of non-usage of IPP, more so in men older than the age of 70 years in the first 5 years of implantation.Knoll P, Rai S, Talluri S, et al. A Survey of Usage of Penile Prosthesis. J Sex Med 2020;17:2287–2290.     

Penile Prosthesis Implantation and Timing Disparities After Radical Prostatectomy: Results From a Statewide Claims Database

BackgroundMany patients with erectile dysfunction (ED) after radical prostatectomy (RP) improve with conservative therapy but some do not; penile prosthesis implantation rates have been sparsely reported, and have used nonrepresentative data sets.AimTo characterize rates and timing of penile prosthesis implantation after RP and to identify predictors of implantation using a more representative data set.MethodsThe Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery databases for Florida from 2006 to 2015 were used. Patients undergoing RP (2006–2012) were tracked longitudinally for penile prosthesis implantation. Patient and clinical data were analyzed using multivariable logistic regression.OutcomesThe primary outcome was risk-adjusted predictors of prosthesis implantation, and the secondary outcome was predictors of the highest quartile of time between RP and penile prosthesis.ResultsOf 29,288 men who had RP, 1,449 (4.9%) patients underwent subsequent prosthesis. The mean time from RP to prosthesis was 2.6 years (median: 2.1; interquartile range [IQR]: 1.2–3.5). Adjusted predictors of prosthesis implantation included open RP (odds ratio [OR]: 1.5, P < .01), African American race (OR: 1.7, P < .01) or Hispanic ethnicity (OR: 3.2, P < .01), and Medicare (OR: 1.4, P < .01) insurance. Oler patients (age >70 years; OR: 0.7, P < .01) and those from the highest income quartile relative to the lowest (OR: 0.8, P < .05) were less likely to be implanted. Adjusted predictors of longer RP-to-implantation time (highest quartile: median: 4.7 years; IQR: 3.9–6.0 years) included open RP (OR: 1.78, P < .01), laparoscopic RP (OR: 4.67, P < .01), Medicaid (OR: 3.03, P < .05), private insurance (OR: 2.57, P < .01), and being in the highest income quartile (OR: 2.52, P < .01).Clinical ImplicationsThese findings suggest ED treatment healthcare disparities meriting further investigation; upfront counseling on all ED treatment modalities and close monitoring for conservative treatment failure may reduce lost quality of life years.Strengths & LimitationsThis study is limited by its use of administrative data, which relies on accurate coding and lacks data on ED questionnaires/prior treatments, patient-level cost, and oncologic outcomes. Quartile-based analysis of income and time between RP and prosthesis limits the conclusions that can be drawn.ConclusionLess than 5% of post-RP patients undergo penile prosthesis implantation, with open RP, Medicare, African American race, and Hispanic ethnicity predicting post-RP implantation; living in the wealthiest residential areas predicts lower likelihood of implantation compared to the least wealthy areas. Patients with the longest time between RP and prosthesis are more likely to live in the wealthiest areas or have undergone open/laparoscopic RP relative to robotic RP.Bajic P, Patel PM, Nelson MH, et al. Penile Prosthesis Implantation and Timing Disparities After Radical Prostatectomy: Results From a Statewide Claims Database. J Sex Med 2020;17:1175–1181.     

Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis

IntroductionPenile prosthesis infections remain challenging despite advancements in surgical technique, device improvements, and adoption of antibiotic prophylaxis guidelines.AimTo investigate penile prosthesis infection microbiology to consider which changes in practice could decrease infection rates, to evaluate current antibiotic prophylaxis guidelines, and to develop a proposed algorithm for penile prosthesis infections.MethodsThis retrospective institutional review board–exempt multi-institutional study from 25 centers reviewed intraoperative cultures obtained at explantation or Mulcahy salvage of infected three-piece inflatable penile prostheses (IPPs). Antibiotic usage was recorded at implantation, admission for infection, and explantation or salvage surgery. Cultures were obtained from purulent material in the implant space and from the biofilm on the device.Main Outcome MeasuresIntraoperative culture data from infected IPPs.ResultsTwo hundred twenty-seven intraoperative cultures (2002–2016) were obtained at salvage or explantation. No culture growth occurred in 33% of cases and gram-positive and gram-negative organisms were found in 73% and 39% of positive cultures, respectively. Candida species (11.1%), anaerobes (10.5%) and methicillin-resistant Staphylococcus aureus (9.2%) constituted nearly one third of 153 positive cultures. Multi-organism infections occurred in 25% of positive cultures. Antibiotic regimens at initial implantation were generally consistent with American Urological Association (AUA) and European Association of Urology (EAU) guidelines. However, the micro-organisms identified in this study were covered by these guidelines in only 62% to 86% of cases. Antibiotic selection at admissions for infection and salvage or explantation varied widely compared with those at IPP implantation.ConclusionThis study documents a high incidence of anaerobic, Candida, and methicillin-resistant S aureus infections. In addition, approximately one third of infected penile prosthesis cases had negative cultures. Micro-organisms identified in this study were not covered by the AUA and EAU antibiotic guidelines in at least 14% to 38% of cases. These findings suggest broadening antibiotic prophylaxis guidelines and creating a management algorithm for IPP infections might lower infection rates and improve salvage success.Gross MS, Phillips EA, Carrasquillo RJ, et al. Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis. J Sex Med 2017;14:455–463.     

Penile Prosthesis Implantation in Patients With Peyronie's Disease: Results of the PROPPER Study Demonstrates a Decrease in Patient-Reported Depression

Background

Although there is a strong correlation between erectile dysfunction and Peyronie's disease (PD), there are limited data on the efficacy and satisfaction of inflatable penile prosthesis (IPP) placement in this population.

Trends in Penile Prosthetics: Influence of Patient Demographics,Surgeon Volume,and Hospital Volume on Type of Penile Prosthesis Inserted in New York State

Introduction

Penile prostheses (PPs) are a discrete, well-tolerated treatment option for men with medical refractory erectile dysfunction. Despite the increasing prevalence of erectile dysfunction, multiple series evaluating inpatient data have found a decrease in the frequency of PP surgery during the past decade.

Experience With Prophylactic Gentamicin During Penile Prosthesis Surgery: A Retrospective Comparison of Two Different Doses

BackgroundGentamicin has been determined to be active against a wide range of bacterial infections and has been commonly used as a preoperative antibiotic for inflatable penile prosthesis (IPP) implantation. However, the best dosing regimen to produce the safest optimal prophylactic effect remains to be determined.AimTo compare low- and high-dose gentamicin as prophylaxis during IPP implantation.MethodsWe retrospectively analyzed two groups of patients who underwent IPP placement from April 14, 2012 through April 13, 2016. Group 1 was composed of 490 patients who underwent IPP placement from April 14, 2012 through April 13, 2014 and received a low dose of preoperative gentamicin at 80 mg every 8 hours for 1 day. Group 2 was composed of 407 patients who underwent IPP placement from April 14, 2014 through April 13, 2016 and received a single high dose of preoperative gentamicin at 5 mg/kg. We compared the infection rates of IPP and any gentamicin-related toxicities. The same surgeon performed all procedures. All patients received additional vancomycin 1 g before incision and at 12 hours postoperatively.OutcomeDemographic data and IPP infection rate were compared and potential toxicities from the higher dose of gentamicin were closely monitored.ResultsThere were no significant differences in mean age, mean body mass index, and mean interval for IPP placement and IPP infection between the two groups. No toxicity was seen with the higher gentamicin dose. Six cases in group 1 (five de novo cases and one redo case, infection rate = 1.22%) and three cases in group 2 (two de novo cases and one redo case, infection rate = 0.74%) were found to have IPP infection. The infection rate in group 2 appeared to be lower than that in group 1, although a significant statistical difference was not achieved (P = .057).Clinical ImplicationsThese findings would help guide urologists in choosing an optimal preoperative gentamicin dose for IPP surgery.Strengths and LimitationsThis is the first study to report on the usage of high-dose preoperative gentamicin for IPP surgery but with limitations as a retrospective study.ConclusionsAlthough not achieving a statistical difference, there was a trend for patients receiving a higher dose of preoperative gentamicin to have a lower IPP infection rate. No toxicity was encountered from the 5-mg/kg gentamicin dose. We recommend following prophylactic high-dose gentamicin guidelines.Xie D, Gheiler V, Lopez I, et al. Experience With Prophylactic Gentamicin During Penile Prosthesis Surgery: A Retrospective Comparison of Two Different Doses. J Sex Med 2017;14:1160–1164.     

Impact of Index Surgical Care Setting on Perioperative Outcomes and Cost Following Penile Prosthesis Surgery

BackgroundPenile prosthesis surgery has witnessed a migration from the inpatient to ambulatory surgical care setting. However, little is known about the cost savings afforded by this change in care setting and whether or not these savings come at the expense of worse perioperative outcomes.AimThe aim of this study was to identify predictors of index penile prosthesis (PP) surgery care setting, and whether ambulatory vs inpatient surgery is associated with comparable perioperative outcomes and costs.MethodsThis was a retrospective cohort study using all-payer claims data from the 2014 Healthcare Cost and Utilization Project State Databases from Florida and New York. Patient demographics, regional data, total charges (converted to costs), and 30-day revisit rates were abstracted for all patients undergoing index placement of an inflatable or malleable PP. Multivariable logistic and linear regression adjusted for facility clustering was utilized.OutcomesThe outcomes were index surgical and 30-day postoperative costs, as well as 30-day revisit rates.ResultsOf the 1,790 patients undergoing an index surgery, 394 (22.0%) received care in the inpatient setting compared to 1,396 (78.0%) in the ambulatory setting. Adjusted index procedural ($9,319.66 vs $ 10,191.35; P < .001) and 30-day acute care costs ($9,461.74 vs $10,159.42; P < .001) were lower in the ambulatory setting. The underinsured experienced lower odds of receiving surgery in the ambulatory setting (Medicaid vs private: odds ratio [OR] 0.19; 95% CI 0.06?0.55; P < .001). There was no difference in risk-adjusted odds of experiencing a 30-day revisit between patients undergoing surgery in the ambulatory vs inpatient settings (OR 1.31; 95% CI 0.78?2.21; P = .3).Clinical TranslationAmbulatory PP surgery confers significant cost savings and is associated with comparable perioperative outcomes relative to inpatient-based surgery.ConclusionsBoth clinical and nonclinical factors predict the care setting of index PP surgery. Notably, underinsured patients experienced lower odds of undergoing ambulatory surgery. Ambulatory surgery was less costly with similar 30-day revisit rates relative to inpatient-based care.Berger A, Friedlander DF, Herzog P, et al. Impact of Index Surgical Care Setting on Perioperative Outcomes and Cost Following Penile Prosthesis Surgery. J Sex Med 2019;16:1451–1458.     

Rear Tip Extenders and Penile Prosthesis Rigidity: A Laboratory Study of Coloplast Prostheses

Background

Rear tip extenders (RTEs) are used commonly in penile prostheses, but their effect on erectile rigidity has not been extensively studied.

An Innovative Strategy for Non-Grafting Penile Enlargement: A Novel Paradigm for Tunica Expansion Procedures

BackgroundPeyronie’s disease, diabetes, trauma, pelvic surgeries, and aging are conditions that promote penile fibrosis and trigger erectile dysfunction associated with penile reduction. These pathologies require an objective preoperative diagnosis and intraoperative management of penile shrinkage.AimThe goal is to develop a non-grafting procedure to promote lengthening using geometric patterns of multiple staggered small cuts on the tunica albuginea with an optimal ratio between tissue expansion and resistance to confine the cylinders inside the corpora cavernosa.MethodsBetween February 2016 and February 2019, 416 patients suffering penile shortening with or without Peyronie’s disease received implants using the tunica expansion procedures (TEP). Incisions were distributed in respective areas of the tunica to allow maximum expansion while maintaining strength to confine prosthetic cylinders within the corpora cavernosa to prevent bulges and denting.OutcomesIn accordance with these principles, surgical objectives and patient satisfaction were achieved in length and girth restoration regardless of the type of implant used to obtain adequate axial rigidity.ResultsThe sample of 416 patients included 287 cases of Peyronie’s disease having a mean axial deviation of 51° (0–90°) whose curvature was corrected in surgery, with pressure from the cylinders maintaining straightness for malleable and inflatable devices. Tunica constriction in 40.86% of cases was corrected with vertical relaxing incisions. Ventral glanspexy was performed intraoperatively in 92.8% of patients to prevent hypermobility. A penile gain of 3.3 cm (2–6) was measured intraoperatively.Clinical ImplicationsDiagnosis of penile shortening was performed by a stretch length test and pharmacologically induced erection together with the patient’s subjective opinion of penile loss. Lengthening procedure depends on the limit of the dissected neurovascular bundle. The patient and surgeon select the type of implant in accordance with his individual anatomic characteristics.Strengths and LimitationsThe TEP strategy is a non-grafting procedure based on tissue restitution by expansion instead of substitution, which provides surgeons a solution for penile enlargement to the limit of the dissected neurovascular bundle.ConclusionsThe TEP strategy has been demonstrated to be safe and effective to resolve problems of penile size reduction independently of penile curvature. It eliminates grafting and improves penile lengthening techniques using small, staggered cuts on the tunica albuginea, while maintaining tunica structural resistance to contain cylinders inside the corpora, preventing bulges and denting, facilitating tissue regeneration, and improving axial rigidity.Paulo H. Egydio, An Innovative Strategy for Non-Grafting Penile Enlargement: A Novel Paradigm for Tunica Expansion Procedures. J Sex Med 2020;17:2093–2103.     

Impact of Pelvic Radiation Therapy on Inflatable Penile Prosthesis Reoperation Rates

Introduction

Considering that radiation therapy (RT) compromises soft tissue microvasculature, impairs wound healing, and causes cavernosal fibrosis, inflatable penile prosthesis (IPP) outcomes may be adversely affected in men treated with RT.