Molecular testing with next-generation sequencing appears to identify biofilm on penile prostheses better than traditional cultures: The new gold standard?

INTRODUCTION: Traditional culture is the current standard-of-care to determine therapeutic antibiotics for patients suffering from penile prostheses (PP) infections. However, approximately 50% of PPs removed for infection are culture negative. Next-generation sequencing (NGS) compares DNA sequences to reference sequences with known microbial taxonomies to identify isolates and report relative abundances. We aim to compare the ability for standard culture and NGS techniques to identify microorganisms and biofilm composition on PPs. MATERIALS AND METHODS: Ninety-one PPs explanted for mechanical malfunction were included in this study. Devices removed for infection or erosion were excluded. During revision surgery, two specimens were collected and sent for culture testing at institutional laboratory and for NGS testing (MicroGenDx, Lubbock, TX, USA). Species' relative abundances, sample diversity and richness, and compositional differences among samples were analyzed. RESULTS: NGS had a higher rate of microbial detection (n = 72, 79.1%) compared to culture results (n = 3, 3.3%). Some of the bacteria identified using both methods were known prosthetic infectious pathogens, with NGS producing more isolates (mean: 11) than culture (mean: 1). Escherichia coli was the most abundant and most frequently occurring bacteria detected on NGS. Coagulase-negative Staphylococci were the most common bacteria detected on traditional culture. CONCLUSIONS: NGS appears to be beneficial in its thorough analysis of PP biofilm composition when compared to culture methods. We hope that further research will be able to demonstrate a clinical benefit of NGS in characterizing distinct microbiomes and biofilms of infected PP, which can aid in tailoring antimicrobial therapy and improving patient outcomes.

Successful treatment of complicated benign prostatic hyperplasia in a diabetic patient with water vapor thermal therapy and urethral stenting.

Water Vapor Thermal Therapy is a novel, office-based procedure which has gained traction as first line therapy in specific therapeutic cases of benign prostatic hyperplasia. In this study, we present a case of a diabetic patient with complicated benign prostatic hyperplasia who presented with acute urinary retention along with bilateral hydronephrosis and acute kidney injury. He was treated with water vapor thermal therapy and subsequent urethral stenting, which alleviated his acute presentation and clinical symptoms. To the authors' knowledge, there are no reported cases which highlight the use of water vapor thermal therapy in complicated benign prostatic hyperplasia.

Biomechanical Studies of the Inflatable Penile Prosthesis: A Review.

INTRODUCTION: The penile prosthesis remains the primary surgical treatment for refractory erectile dysfunction. Over the decades, inflatable penile prostheses' mechanical reliability, patient satisfaction, safety, and functional erectile restoration have greatly improved. During this time, many studies of biomechanical properties of the prosthesis have been conducted to better understand their biomimicry to the erect human phallus. AIM: To review all current literature on the biomechanical properties of the penile prosthesis, including prosthesis biomechanical function, and variability in model-related performance. METHODS: A Medline PubMed search was used to identify all articles of interest related to subjects involving the penile prosthesis and its related biomechanical properties. The following were included in the search for articles of interest: "biomechanics," "mechanics," "mechanical properties," "axial rigidity," "penile implant," and "penile prosthesis." Articles were further screened for content and English language. MAIN OUTCOME MEASURE: Here we perform a literature review of the bio-mechenical function, performance, and patient satisfaction of penile implants. RESULTS: Axial rigidity helps determine the ability of an erect penis to complete vaginal intromission and pelvic thrusting without buckling. Recent cadaveric data show that at maximum inflation, Coloplast and American Medical Systems (AMS) implants had comparable performance. Variability was seen at various lower fill pressures, where more severe buckling was observed. Coloplast Titan showed a tendency toward better resistance to longitudinal and horizontal forces. The AMS CX device showed similar performance to the Titan, and the AMS LGX device was shown to be most sensitive to fill pressure variation. Additionally, rear tip extenders (RTEs) appear to negatively affect axial loading, especially in settings of larger implants. CONCLUSION: Current research suggests that circumferentially expanding devices, such as AMS CX and Coloplast Titan, show better resistance to longitudinal (penetration) and horizontal (gravity) forces and, unlike the AMS LGX device, are less sensitive to device fill pressure. Additionally, RTEs have been shown to negatively impact axial loading, especially in larger cylinder inflatable penile prostheses >20 cm in length. Madiraju SK, Wallen JJ, Rydelek SP, et al. Biomechanical Studies of the Inflatable Penile Prosthesis: A Review. Sex Med Rev 2019;7:369-375.

Placement of Inflatable Penile Implants in Patients With Prior Radical Pelvic Surgery: A Literature Review.

BACKGROUND: Penile prosthesis for erectile restoration remains the only surgical option for medical refractory erectile dysfunction. Many expert prosthetic surgeons recommend special care when placing a reservoir in a patient who has undergone prior radical pelvic surgery (PRPS) due to distortion of anatomy and obliteration of the dead space in the traditionally used space of Retzius. AIM: Review all the current literature on penile prosthesis implantation in patients with prior pelvic surgery, with an emphasis on tips and tricks for reservoir placement in this unique population. METHODS: A Medline PubMed search was used to identify articles of interest related to all topics surrounding pelvic surgery and penile prostheses. The following terms were included in the search for articles of interest: "bladder cancer," "prostate cancer," "rectal cancer," "colon cancer," "pelvic surgery," "penile implants," "penile implant reservoir," and "penile prosthesis." Articles were further screened for content and English language. MAIN OUTCOME MEASURE: Outcomes and adverse event rates in this population. Review of options for reservoir placement. RESULTS: The outcomes, satisfaction, and adverse event profiles are similar between patients in the PRPS group and those who are not, regardless of the cause for pelvic surgery. For surgeons uncomfortable with placing a reservoir in the compromised pelvis, a 2-piece inflatable penile implant (AMS Ambicor) is a viable option. For surgeons who recommend 3-piece implants in this patient population, alternative positions for the reservoir have been developed in the hope of avoiding catastrophic bowel, bladder, and vascular injuries. CONCLUSION: In patients with PRPS, placing an inflatable penile prosthesis is not only feasible, it is definitive therapy with excellent patient satisfaction. Reservoir placement outside the space of Retzius or placing a 2-piece inflatable device can be easily performed with equivalent safety and efficacy. Madiraju SK, Hakky TS, Perito PE, et al. Placement of Inflatable Penile Implants in Patients With Prior Radical Pelvic Surgery: A Literature Review. Sex Med Rev 2019;7:189-197.

Biomechanical Comparison of Inflatable Penile Implants: A Cadaveric Pilot Study.

BACKGROUND: Throughout the last decade there has been a growing interest in the biomechanical differences between inflatable penile prostheses (IPPs) and their significance with regard to the patient experience. AIM: To present our findings assessing the biomechanical properties of IPPs with and without rear tip extenders (RTEs). METHODS: This is a biomechanical study of the 3 most commonly used IPPs (AMS CX, AMS LGX, and Coloplast Titan) as assessed by column compression, modified cantilever deflection, and 3-point bending methods. The IPPs were surgically placed into 3 fresh cadavers via an infrapubic technique by a single large-volume implanter. A biomechanical evaluation of the properties of each IPP inside the fibroelastic tunica albuginea was assessed in blinded testing, and analyses were based on industry standard methods for assessment. OUTCOMES: Maximum axial load; kink formation; horizontal stiffness; and resistance to 3-point flexure testing were measured. RESULTS: At maximum inflation, all 3 implants had similar performance. Differences appear to be most affected by fill pressures. In fact, only the AMS LGX at less than maximum inflation (LTMI) was unable to consistently withstand the roughly 0.9 kg (2 lbs) of pressure for column load testing mimicking vaginal intromission. The Coloplast Titan showed slightly better rigidity than the AMS LGX and CX devices in horizontal load testing, and, with 3-point flexure testing, the CX showed the best rigidity in the shortest phallus (A). Overall, the Titan showed slightly better rigidity in the longest phallus (C) and the phallus with mild Peyronie's disease (B). CLINICAL TRANSLATIONS: Penile implants with circumferential expansion had higher rigidity on biomechanical testing and should be considered in a patient's decision during selection of a penile implant. STRENGTHS AND LIMITATIONS: Strengths include blinding of the biomechanical testing and analyses, surgical procedures performed by a highly experienced surgeon, and that this is the "closest to" in vivo evaluation (inside the tunica albuginea) of penile implant function and properties to date. Weaknesses are that this study was performed in cadavers and not in live patients. It also has a small sample size, including the use of only 3 cadavers, and there was no correlation of performance to patient satisfaction. CONCLUSION: The results of this study support the conclusion that all devices are capable of functionally restoring erectile capacity. However, we observed that, in general, the 2 circumferentially expanding penile prosthesis showed greater resistance in biomechanical testing when compared with longitudinal and circumferential expanding devices. This should be considered as a guide during device selection for a patient undergoing penile prosthesis. Wallen JJ, Barrera EV, Ge L, et al. Biomechanical Comparison of Inflatable Penile Implants: A Cadaveric Pilot Study. J Sex Med 2018;15:1034-1040.

Intralesional Injection of Collagenase Clostridium histolyticum May Increase the Risk of Late-Onset Penile Fracture.

INTRODUCTION: The use of intralesional injection of collagenase Clostridium histolyticum (CCH) has become a valid treatment option in the management of Peyronie's disease (PD). Multiple studies have shown the drug's safety and efficacy. However, sparse literature exists on the utility of the injection protocol's 14-day "observation period," in which patients are instructed to abstain from all sexual activity. AIM: To summarize the contemporary literature and report on our series of patients treated with CCH in an effort to explore the effectiveness of the postinjection observation period. METHODS: We retrospectively reviewed the clinical course of men treated with at least one CCH injection at our institution from April 2014 through February 2017. MAIN OUTCOME MEASURES: The main outcome measure for our cohort was complication rate (hematoma, fracture). Secondary outcomes included progression to corrective surgery. RESULTS: Of the 102 patients treated, 5 (4.9%) developed a corporal fracture. Four of these occurred outside the 14-day observation period. One fracture was managed conservatively and the rest underwent surgical exploration and repair. Twelve penile hematomas were reported; one of these patients was surgically explored because of suspicious magnetic resonance imaging findings. Seven patients (6.9%) progressed to corrective surgery. CONCLUSION: Penile hematoma and corporal fracture are serious complications that must be discussed with patients before initiation of intralesional CCH treatment. Little evidence exists to direct physicians on the proper management of post-CCH penile fractures; many caregivers and patients elect to treat these injuries conservatively and avoid surgical exploration. Further studies are warranted to generate discussion and reassessment regarding the safety and effectiveness of this 14-day observation period. Beilan JA, Wallen JJ, Baumgarten AS, Morgan KN, Parker JL, Carrion RE. Intralesional Injection of Collagenase Clostridium histolyticum May Increase the Risk of Late-Onset Penile Fracture. Sex Med Rev 2018;6:272-278.

Deflate-gate: Conservative Management of a Large Ruptured Hydrocele.

A hydrocele is a common cause of intrascrotal swelling that results when fluid accumulates between the parietal and visceral layers of the tunica vaginalis. Over time, fluid may collect to form a massive hydrocele and result in significant discomfort for the patient. In this case report, we present a rare event of a 28-year-old gentleman with a documented massive hydrocele measuring 14.1 × 8.9 cm who ruptured his hydrocele during sexual intercourse. We expectantly managed the patient's ruptured hydrocele and encountered no complications throughout the course of his recovery.

Optimizing penile length in patients undergoing partial penectomy for penile cancer: novel application of the ventral phalloplasty oncoplastic technique.

The ventral phalloplasty (VP) has been well described in modern day penile prosthesis surgery. The main objectives of this maneuver are to increase perceived length and patient satisfaction and to counteract the natural 1-2 cm average loss in length when performing implantation of an inflatable penile prosthesis. Similarly, this video represents a new adaptation for partial penectomy patients. One can only hope that the addition of the VP for partial penectomy patients with good erectile function will increase their quality of life. The patient in this video is a 56-year-old male who presented with a 4.0x3.5x1.0 cm, pathologic stage T2 squamous cell carcinoma of the glans penis. After partial penectomy with VP and inguinal lymph node dissection, pathological specimen revealed negative margins, 3/5 right superficial nodes and 1/5 left superficial nodes positive for malignancy. The patient has been recommended post-operative systemic chemotherapy (with external beam radiotherapy) based on the multiple node positivity and presence of extranodal extension. The patient's pre-operative penile length was 9.5 cm, and after partial penectomy with VP, penile length is 7 cm.