Mid-term outcomes of minimally invasive infrapubic approach for inflatable penile prosthesis implantation: A single-center study and literature review.

BACKGROUND: The minimally invasive infrapubic approach (MIIA) for inflatable penile prosthesis (IPP) placement has shown favorable peri-operative safety and efficacy profile, but scarce data exist on long-term follow-up. OBJECTIVES: We investigated the safety and efficacy of IPP implantation via the MIIA after a minimum 5-year follow-up. MATERIALS AND METHODS: We identified data of implanted patients prospectively included in our institutional database. Complications and functional outcomes were assessed by using validated tools. Specifically, quality of life and patient satisfaction were evaluated by the Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire. Kaplan-Meier method was used to analyze IPP survival (defined as a working IPP). RESULTS: Overall, 67 patients implanted by MIIA with a median (IQR) age of 64 years (61-70) were included. The median (IQR) follow-up duration was 71 months (63-80). Fifteen (22%) patients experienced complications: minor (Clavien ≤2) events included changes in penile sensitivity (n = 1; 1.5%), orgasmic dysfunction (n = 1; 1.5%), pain (n = 5; 7%), urinary tract infection (n = 2; 3%), and chronic discomfort (n = 1; 1.5%); major (Clavien 3) complications were represented by mechanical failure (n = 3; 4.5%), IPP infection (n = 1; 1.5%), and cylinder protrusion (n = 1; 1.5%). The estimated IPP survival was 94% (95% CI, 91.4-96.6), 92.5% (95% CI, 89.7-95.3), and 92.5% (95% CI, 89.7-95.3) at 3, 5, and 7 years after implantation, respectively. In patients using the device at follow-up (n = 61; 91%), median (IQR) scores for QoLSPP domains demonstrated favorable functional outcomes and patient satisfaction: functional 21 (19-23), personal 16 (15-18), relational 14 (12-15), and social 12 (11-14). DISCUSSION AND CONCLUSION: This study represents the longest follow-up using validated tools to assess the outcomes of IPP implantation via MIIA so far. IPP placement via MIIA confirms to be safe and to offer high satisfaction to both patients and partners at mid-term evaluation.

Shaeer's infrapubic technique for penile prosthesis implantation through a single midline corporotomy: A single-center pilot study.

BACKGROUND: With the infrapubic approach (IPA) for penile prosthesis implantation, lateral corporotomies carry the risk of injury to the laterally coursing dorsal nerves. AIM: We sought to describe for the first time Shaeer's IPA, a modification of the IPA whereby malleable penile prosthesis cylinders are implanted through a single midline corporotomy in the bed of the deep dorsal vein, anatomically off the course of the dorsal nerves of the penis. METHODS: We compared semirigid penile prosthesis implantation via the single midline corporotomy IPA (IPA-S, n = 11) to the classic IPA with laterally placed dual corporotomies (IPA-D, n = 11) and to the penoscrotal approach (PSA; n = 13). Shaeer's IPA is performed through an infrapubic incision. A 3- to 5-cm length of the deep dorsal vein is stripped. A single 3- to 5-cm midline corporotomy is cut along the bed of the vein. Dilation, sizing, and implantation are performed through the single corporotomy on either side of the midline septum. Patients are discharged the same day and are allowed to bend the implant after 2 weeks and to commence intercourse after 3 weeks. OUTCOMES: Operative time, postoperative satisfaction, International Index of Erectile Function 5 (IIEF-5), and possible complications were recorded. RESULTS: There were no statistically significant differences in age, postimplantation IIEF-5, or satisfaction between the 3 groups. Average operative time for the IPA-S group was 21.8% shorter than that for the IPA-D group, and 34.5% shorter than for the PSA group. Those differences were statistically significant. No complications were recorded in the IPA-S group. Infection occurred in 1 PSA case, and partial hypoesthesia in 1 IPA-D case. CLINICAL IMPLICATIONS: The midline corporotomy confers an anatomical advantage that may help avoid nerve injury, thereby increasing the safety of the IPA. STRENGTHS AND LIMITATIONS: The main limitation of this study is the limited sample number, considering that this is a pilot study. CONCLUSION: The Shaeer's Midline-Corporotomy IPA is a minimally invasive technique for implantation of a semirigid penile prosthesis, with an anatomical advantage that may decrease the possibility of dorsal nerve injury.

Infrapubic surgical approach for penile prosthesis surgery: Indications and technique. / Cirugía de prótesis peneana: indicaciones y técnica infrapúbica.

CONTEXT: Penile prosthesis surgery is currently the most effective treatment for erectile dysfunction when medical treatment is ineffective or contraindicated. Among the surgical approaches described in the literature, the scrotal, infrapubic and subcoronal are the most common in the daily clinical practice. OBJECTIVES: The main objectives were to describe the infrapubic surgical technique evaluating its indications and complications, as well as comparing its advantages and disadvantages with the penoscrotal approach. ACQUISITION AND SYNTHESIS OF THE EVIDENCE: A literature review from 1983 until current date was carried out in Medline (PubMed and Cochrane Library databases) following PRISMA standards. Sixteen studies were included: 4 prospective, 4 retrospective, one systematic review, one randomized trial, one original article, 5 expert opinion/surgical technique descriptive paper. DISCUSSION: According to the literature reviewed, although the penoscrotal approach is the most applied, the infrapubic approach showed a shorter operative time and a tendency for an earlier recovery of sexual activity after surgery. Complications are rare, having similar rates to the penoscrotal approach; no cases of glans hypoesthesia have been reported and peri-prosthetic infection rates were less than 3%. Satisfaction rates of infrapubic penile prosthesis were higher than 80%. CONCLUSIONS: Penile prosthesis implantation requires of a profound knowledge of the different surgical approaches in order to best adapt each technique based on each individualized case. The infrapubic approach, even if it is not the most used, is as feasible and reliable as the penoscrotal approach. The infrapubic approach is effective and safe, with high level of both, patients and partners' satisfaction.

Comparison of Infrapubic vs Penoscrotal Approaches for 3-Piece Inflatable Penile Prosthesis Placement: Do We Have a Winner?

BACKGROUND: The 3-piece inflatable penile prosthesis (IPP) is the gold standard treatment for male erectile dysfunction when other less invasive approaches are contra-indicated or unacceptable for the patient. There are currently 2 surgical approaches for IPP implantation: the penoscrotal (PS) and the infrapubic (IP) incision. AIM: To assess the most recent evidence on the impact of surgical approach for 3-piece IPP implantation in patients with erectile dysfunction. METHODS: A systematic literature review was performed using the MEDLINE (PubMed) and Cochrane Libraries databases in November 2017 to identify all studies investigating 3-piece IPP with a specified surgical access. OUTCOMES: The following key words were used in combination: "infrapubic," "transcrotal," "penoscrotal," "peno-scrotal," and "penile prosthesis." Additional references were obtained from the reference lists of full-text manuscripts. We used a narrative synthesis for the analyses of the studies. RESULTS: 22 Studies reporting data on 3-piece IPP implantation with a specified surgical approach were found in the literature. While IPPs are most commonly positioned through a PS incision, the IP approach is a faster procedure. No cases of glans hypoesthesia after IPP placement with an IP approach were reported, and the overall peri-prosthetic infection rate was 3.3% or less. Patient satisfaction rates were higher than 80% in both groups. CONCLUSIONS: Both the IP and PS approaches are viable and effective strategies for a 3-piece IPP placement, and result in high satisfaction rates. To date there is no evidence that an incision strategy may reduce infection rates. Penile sensory loss following an IP approach remains a virtual risk. It is recommended that the surgeon executing the implant have knowledge of both accesses and be capable of tailoring the incision strategy for complex cases. The chosen method should be based on the patient's specific anatomy, surgical history, and surgeon experience. Palmisano F, Boeri L, Cristini C, et al. Comparison of Infrapubic vs Penoscrotal Approaches for 3-Piece Inflatable Penile Prosthesis Placement: Do We Have a Winner? Sex Med Rev 2018;6:631-639.

Penoscrotal versus minimally invasive infrapubic approach for inflatable penile prosthesis placement: a single-center matched-pair analysis.

PURPOSE: To compare perioperative results, safety and efficacy profile in patients receiving inflatable penile prosthesis (IPP) via penoscrotal (PS) or minimally invasive infrapubic (MII) approach for erectile dysfunction. METHODS: A matched-pair analysis was performed including 42 patients undergoing IPP implantation via PS (n = 21) or MII (n = 21) between 2011 and 2016. Clinical and surgical data were prospectively collected. Patients' and partners' outcomes were assessed by the International Index of Erectile Function (IIEF), Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) and Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaires. RESULTS: Mean (SD) operative time was 128 (40.6) min in group PS and 91 (43.0) min in group MII (p = 0.041). Complications occurred in 3/21 (14%) and 2/21 (10%) patients in groups PS and MII (p = 0.832). Overall, no differences were observed concerning the device utilisation (p = 0.275). However, in group MII 4/21 (19%) patients were able to resume sexual activity prior to 4 postoperative weeks, while in group PS no patient was (p = 0.012). Mean (SD) scores for questionnaires were similar between groups PS and MII: IIEF [20.9 (7.3) vs. 20.7 (4.8); p = 0.132], patient EDITS [76.0 (25.6) vs. 74.7 (20.8); p = 0.256] and partner EDITS [72.5 (29.1) vs. 73.1 (21.4); p = 0.114]. Similarly, QoLSPP showed comparable results among the groups PS and MII: functional domain [3.9 (1.4) vs. 4.0 (1.2); p = 0.390], personal [4.0 (1.2) vs. 4.1 (1.0); p = 0.512], relational [3.7 (1.5) vs. 3.9 (1.2); p = 0.462] and social [4.0 (1.2) vs. 3.9 (1.2); p = 0.766]. CONCLUSIONS: PS and MII demonstrated to be safe and efficient techniques, leading to high level of both patients and partners satisfaction. Additionally, the minimally invasive infrapubic approach showed a shorter operative time and a tendency for a faster return to sexual activity.

The infrapubic surgical approach for inflatable penile prosthesis placement.

In this invited article, we briefly review the history of the penile prosthesis and the various surgical approaches that have been described. With intra-operative photos and illustrations, we discuss Dr. Perito's infrapubic surgical approach. We also highlight the patient selection, post-operative care and complications.

V-Neck Technique: A Novel Improvement to the Infra-Pubic Placement of an Inflatable Penile Implant.

BACKGROUND: Infra-pubic placement of an inflatable penile prosthesis (IPP) has a well-known configuration deformity from contralateral tubing that crosses the corporal bodies, resulting in tubing visibility and irritation under the penile skin. AIM: To present a novel step to eliminate this tubing crossover deformity. METHODS: The V-neck technique was applied to five patients, two of whom underwent suprapubic fat pad excision with simultaneous infra-pubic IPP placement and three patients who underwent only infra-pubic IPP placement. The technique added an additional 1 minute of procedure time. The reservoir was placed on one (ipsilateral) side into the space of Retzius. OUTCOMES: Primary outcome measurements were esthetic appeal at follow-up, immediate postoperative complications, and difficulty of implementation of the technique. RESULTS: The technique included the following steps. (i) The standard infra-pubic approach, as popularized by Perito (J Sex Med 2008;5:27-30), was used to place the reservoir and cylinders. The ipsilateral and contralateral cylinders and the reservoir were clamped and unconnected. (ii) Finger dissection was used to create a sub-phallic window and a U-shaped aortic clamp was used to pass the contralateral tubing. (iii) After passing the green tubing through the window, all connections were performed in the usual fashion. Tubing crossover was eliminated, as was passage of the right and left cylinder tubes down their respective gutters. Postoperative follow-up at 2 weeks showed no visible tubing. CLINICAL IMPLICATIONS: This simple maneuver could help prevent the discomfort of tubing crossover deformity commonly seen after infra-pubic placement of an IPP. STRENGTHS AND LIMITATIONS: This unique maneuver can be applied to all infra-pubically placed IPPs. Limitations include the small patient population and short follow-up. Whether this maneuver will make revision surgery more difficult is unclear. CONCLUSION: This technique is a novel step to infra-pubic IPP placement that adds minimal operative time and could eliminate visible tubing. Shah BB, Baumgarten AS, Morgan K, et al. V-Neck Technique: A Novel Improvement to the Infra-Pubic Placement of an Inflatable Penile Implant. J Sex Med 2017;14:870-875.