Erosion of inflatable penile prosthesis reservoir into neobladder.

INTRODUCTION: Erosion of the reservoir into surrounding tissues is a rare complication after inflatable penile prosthesis (IPP) implantation. AIM: To present a new case and a review of the literature including discussion of pathogenesis, risk factors, and management options. METHODS: We present the case of a 75-year-old male who underwent placement of an IPP for postoperative erectile dysfunction with a history of bladder cancer requiring radical cystoprostatectomy and Studer neobladder. Six years after IPP placement, he presented with recurrent febrile urinary tract infection that seemed to be precipitated by cycling of his penile prosthesis. Cystoscopy and cross-sectional computed tomography imaging demonstrated erosion of the inflatable penile prosthesis reservoir into the neobladder. RESULTS: Patient underwent open removal of the IPP reservoir and cystorrhaphy with a plan for future prefascial reimplantation of an IPP reservoir. CONCLUSIONS: In patients with a history of abdomino-pelvic surgery or radiation therapy, the retroperitoneal space may be extremely fibrotic and the transversalis fascia may have thickened. Potential intraoperative complications as well as reservoir erosion may be avoided by using a two-piece device or ectopic reservoir placement. Management options for reservoir erosion include explantation of the entire device as well as reservoir removal with salvage of remaining components.

Outcomes of Inflatable Penile Prosthesis following Radical Cystectomy: A Matched Cohort Analysis.

OBJECTIVE: To evaluate outcomes of inflatable-penile-prosthesis (IPP) implantation after radical-cystectomy compared to other etiologies of erectile dysfunction. MATERIALS AND METHODS: All IPPs within the past 20 years in a large regional health system were reviewed, and erectile dysfunction (ED) etiology was determined as radical-cystectomy, radical-prostatectomy, or organic/other ED. Cohorts were generated by 1:3 propensity score match using age, body mass index, and diabetes status. Baseline demographics and relevant comorbidities were evaluated. Clavien-Dindo complications, grade, and reoperation were assessed. Multivariable logarithmic regression was used to identify the predictors of 90-day complications following IPP implantation. Log-rank analysis was used to assess the time-to-reoperation after IPP implantation in patients with a history of cystectomy compared with noncystectomy etiologies. RESULTS: Of 2600 patients, 231 subjects were included in the study. Comparing patients undergoing IPP for cystectomy vs pooled noncystectomy indications, those who underwent radical-cystectomy had a higher overall complication rate (24% vs 9%, p = 0.02). Clavien-Dindo complication grades did not differ across groups. Reoperation was significantly more common following cystectomy (cystectomy: 21% vs noncystectomy: 7%, p = 0.01), however time to reoperation did not differ significantly by indication (cystectomy: 8 years vs noncystectomy: 10 years,p = 0.09). Among cystectomy patients, 85% of reoperations were due to mechanical failure. CONCLUSION: Compared to other erectile dysfunction etiologies, patients undergoing IPP with a history of cystectomy have an increased risk of complications within 90-days of implantation and need for surgical device revision, but no greater risk for high-grade complications. Overall IPP remains a valid treatment option after cystectomy.

Therapeutic durability of the male transobturator sling: midterm patient reported outcomes.

PURPOSE: The male transobturator AdVance™ sling is a viable option for mild to moderate post-prostatectomy incontinence. As this treatment is relatively new, our study provides an analysis of efficacy through patient reported outcomes and pad use. MATERIALS AND METHODS: A telephone survey and chart review were conducted on all patients receiving a sling before 2010 by either of 2 surgeons at a large academic institution. The survey included the Patient Global Impression of Improvement and Severity instruments, pad use characteristics before and after sling surgery, and items assessing durability of efficacy. Patient determined (subjective) success was very much or much better on the Patient Global Impression of Improvement without subsequent incontinence therapy. Quantitative success was defined as a decrease to 2 or fewer pads per day. We assessed therapeutic durability in a subanalysis of patients interviewed twice, first in a prior study. RESULTS: From initial office followup to 2 years, quantitative success decreased from 87.3% to 62.5% and pad use doubled from a mean±SD of 0.8±1.7 to 1.7±2.5 pads per day. Patient determined success was 53.6% at 2 years. A subgroup of 25 patients interviewed at 7 and 29 months after sling surgery had quantitative success significantly decrease by 20% (p=0.03), subjective success decrease by 4% (p=0.56) and pad use significantly increase (p=0.01) from 1.4±2.2 to 2.3±3.2 pads per day. CONCLUSIONS: Most patients receiving the AdVance sling did see improvement in post-prostatectomy incontinence and a decrease in pad use, but in 20% of patients this benefit decreased with time. Nevertheless, patients remained satisfied and perceived the treatment as successful.

Congenital penile curvature: update and management.

Congenital penile curvature results from disproportionate development of the tunica albuginea of the corporal bodies and is not associated with urethral malformation. Patients usually present after reaching puberty as the curvature becomes more apparent with erections, and severe curvature can make intercourse difficult or impossible, at which point surgical repair is recommended. Excellent outcomes can be expected with surgical intervention. The three most commonly used repair techniques are the original Nesbit procedure, modified Nesbit procedure, and plication. Nesbit and modified Nesbit techniques require that an incision is made in the tunica albuginea while plication techniques utilize plicating sutures without an incision. While Nesbit and modified Nesbit techniques are more complex operations, these generally result in less recurrences and more satisfactory outcomes as opposed to the quicker and simpler plication technique.

Patient perceived effectiveness of a new male sling as treatment for post-prostatectomy incontinence.

PURPOSE: Objective measures show the AdVance() sling provides some benefit in post-prostatectomy incontinence. To our knowledge no validated, patient determined outcomes have been used to assess this procedure. We described the patient perceived effectiveness and postoperative complications. MATERIALS AND METHODS: A retrospective chart review was followed by a telephone survey consisting of the Patient Global Impression of Improvement, Patient Global Impression of Severity, and questions about recommending the surgery, daily pad use and complications. Successful outcomes were Patient Global Impression of Improvement responses of very much better or much better without further incontinence treatment. Objective success is defined as pad-free or a reduction to 2 or less pads daily. RESULTS: A total of 35 patients received the sling a median of 25 months after prostatectomy. Telephone surveys were administered a mean of 35 weeks after the sling procedure and 33 patients were contacted. Of the cases 18 (51.4%) and 21 (60%) were patient determined and objective successes, respectively. Of the patients with subjective treatment failure 3 would recommend the surgery to a friend and 12 were undecided or would not. Furthermore, no patients with subjective treatment failure were pad-free and 10 (58.8%) had pads that were mostly wet on changing. For the entire population a reduction in median daily pad use from 2.5 to 1 was observed as well as a strong association (p <0.01) between Patient Global Impression of Improvement and Patient Global Impression of Severity responses. Three individuals pursued further treatment with bulking agents and 3 had retention that resolved. CONCLUSIONS: The AdVance sling is safe, and demonstrates similar subjective and objective outcomes. The procedure can benefit some individuals with post-prostatectomy incontinence and, therefore, may be another treatment option for this condition.

Implants, mechanical devices, and vascular surgery for erectile dysfunction.

INTRODUCTION: The field of erectile dysfunction (ED) is evolving and there is a need for state-of-the-art information in the area of treatment. Aim. To develop an evidence-based, state-of-the-art consensus report on the treatment of erectile dysfunction by implants, mechanical devices, and vascular surgery. METHODS: To provide state-of-the-art knowledge concerning treatment of erectile dysfunction by implant, mechanical device, and vascular surgery, representing the opinions of 7 experts from 5 countries developed in a consensus process over a 2-year period. MAIN OUTCOME MEASURE: Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. RESULTS: The inflatable penile prosthesis (IPP) is indicated for the treatment of organic erectile dysfunction after failure or rejection of other treatment options. Comparisons between the IPP and other forms of ED therapy generally reveal a higher satisfaction rate in men with ED who chose the prosthesis. Organic ED responds well to vacuum erection device (VED) therapy, especially among men with a suboptimal response to intracavernosal pharmacotherapy. After radical prostatectomy, VED therapy combined with phosphodiesterase type 5 therapy improved sexual satisfaction in patients dissatisfied with VED alone. Penile revascularization surgery seems most successful in young men with absence of venous leakage and isolated stenosis of the internal pudendal artery following perineal or pelvic trauma. Currently, surgery to limit venous leakage is not recommended. CONCLUSIONS: It is important for the future of the field that patients be made aware of all treatment options for erectile dysfunction in order to make an informed decision. The treating physician should be aware of the patient's medical and sexual history in helping to guide the decision. More research is needed in the area of revascularization surgery, in particular, venous outflow surgery.

Perioperative Educational Interventions and Contemporary Sexual Function Outcomes of Radical Prostatectomy.

INTRODUCTION: Men undergoing prostatectomy can have unrealistic preoperative expectations regarding sexual function after surgery and may desire more education on recovery and symptom management. AIM: To present contemporary data on recovery of sexual function after prostatectomy and characterize how it is impacted by perioperative patient educational interventions. METHODS: A comprehensive review of the English-language literature available by PubMed search. MAIN OUTCOME MEASURES: Rates of sexual function recovery after prostatectomy and the impact of educational interventions on these and related outcomes. RESULTS: Available studies describe heterogeneous educational and support interventions that differ by patient selection, content, method of delivery, timing, and duration. Interventions with group-based education or peer support benefitted sexual satisfaction metrics. Many studies included men and their partners in supportive interventions. However, the few randomized controlled trials directly analyzing the effect of partner attendance revealed no additional benefit to outcomes. Interventions within 6 weeks of prostatectomy variably aided measures of sexual recovery. Some studies with greater time between prostate cancer treatment and interventions revealed only temporary improvements in outcomes. Yet durable improvements in sexual satisfaction and sexual function were observed in some men enrolled years after prostate cancer treatment. At times, web-based interventions had lower completion rates, but sexual function outcomes were comparable to traditional in-person interventions within randomized trials. CONCLUSION: Educational interventions imparted variable benefit to sexual function and satisfaction, with group-based designs mostly benefitting satisfaction outcomes. Despite standardized interventions, men reported worse-than-expected outcomes, suggesting an emphasis on counseling regarding changes in erectile function at multiple time points before surgery and during the recovery period may be helpful. Earlier interventions may help with recovery by establishing more accurate patient expectations. Regarding accessibility, future endeavors may be improved with internet-based educational content, as such interventions appeared to provide comparable benefits to in-person sessions. Faris AER, Montague DK, Gill BC. Perioperative Educational Interventions and Contemporary Sexual Function Outcomes of Radical Prostatectomy. Sex Med Rev 2019;7:293-305.

Increasing size with penile implants.

Penile prosthesis implantation is suitable treatment for men with erectile dysfunction when nonsurgical treatment options fail or are otherwise unsatisfactory. Three-piece inflatable penile prostheses closely approach the ideal of producing normal penile flaccidity and erection. Nevertheless, even in men with normal corpora cavernosa, many report their prosthetic erection is shorter than their former natural erection. This is due to the lack of glans tumescence and the use of penile cylinders, which only expand in girth. Using girth- and length-expanding cylinders can decrease the loss of penile length frequently seen with prosthesis implantation. Some penile prosthesis recipients have abnormal corpora following radical prostatectomy or after removal of an infected penile prosthesis, or as the result of Peyronie's disease, obesity, or ischemic priapism. In these men with abnormal corpora, associated penile-lengthening procedures can be combined with penile prosthesis implantation. However, experience is limited with these combined procedures.

Penile Prosthesis in Solid Organ Transplant Recipients-A Matched Cohort Study.

OBJECTIVE: To determine whether patients with solid organ transplant (SOT) are at higher risk of developing complications after inflatable penile prosthesis (IPP) implantation. METHODS: We retrospectively reviewed outcomes data for all patients with SOT who underwent IPP placement at our institution. A cohort of age-matched IPP recipients without SOT were used as controls. RESULTS: We identified 26 patients who underwent SOT and IPP between 1999 and 2015, and 26 controls. Transplants included heart (3), liver (2), kidney only (17), and kidney and pancreas (4). Mean follow-up time after IPP placement was 29.5 months (SOT group) and 13.5 months (controls). Age at IPP did not significantly differ between groups (53.7 + 8.1 vs 56.4 + 9.0, P = .26), nor did body mass index (30.3 + 5.5 vs 30.2 + 4.7, P = .92), history of prostatectomy (7.7% vs 15.4%, P = .39), rectal surgery (3.9% vs 3.9%, P = 1.00), hyperlipidemia (69.2% vs 69.2%, P = 1.00), hypertension (92.3% vs 76.9%, P = .25), or heart disease (57.7% vs 30.8%, P = .093). Peripheral vascular disease was more common in transplant patients (26.9% vs 3.9%, P = .021), as were stroke (19.2% vs 0.0%, P = .05) and diabetes (84.6% vs 53.6%, P = .016). No significant differences in IPP reoperation rates existed between patients with vs without SOT (11.5% vs 11.5%, P = 1.00), nor did they differ by organ transplanted (P = 1.00). No differences in IPP reoperation rate existed between 2-piece vs 3-piece IPP models (P = .47). CONCLUSION: Outcomes of IPP implantation in patients with SOT are similar to those of nontransplant patients. Patients with SOT should be considered suitable candidates for penile prosthesis.

Predicting success after artificial urinary sphincter: which preoperative factors drive patient satisfaction postoperatively?

BACKGROUND: To determine which preoperative factors drive patient-reported quality of life (QoL) after artificial urinary sphincter (AUS) implantation. METHODS: Men receiving AUS after prostate cancer treatment were identified from a prospectively collected dataset. Preoperative factors were recorded during the initial incontinence consultation. Patients underwent urodynamic testing (UDS) preoperatively at surgeon discretion. Patients were surveyed by telephone postoperatively and given the EPIC Urinary Domain (EPIC-UD) and Urinary Distress Inventory (UDI-6) questionnaires. Differences in postoperative maximum pads per day (MxPPD) and questionnaire scores were compared across preoperative factors, with P¡Ü0.05 indicating statistical significance. RESULTS: Telephone survey was completed by 101 of 238 patients (42%). Median age was 69 [63-75] years, BMI was 29 [26-32] kg/m2. MxPPD was 5 [3-9] preoperatively and 2 [1-3] postoperatively (r=0.255, P=0.011). Postoperative median EPIC-UD was 82 [67-89] and UDI-6 was 22 [11-36]. Postoperative MxPPD was lower in patients who reported being able to store urine before AUS {2 [1-2] vs. 2 [1-4], P=0.046}, and lower with urodynamically-proven detrusor overactivity (DO) {1.5 [1-2] with vs. 2 [1-4] without, P=0.050}. Detrusor pressure at maximum flow was negatively associated with QoL as measured by EPIC-UD score (r=-0.346, P=0.013) and UDI-6 score (r=0.413, P=0.003). Although 41 (41%) patients had a history of radiation, postoperative outcomes did not significantly differ with or without a history of radiation. CONCLUSIONS: Few preoperative factors predict QoL after AUS insertion.

Foley or Fix: A Comparative Analysis of Reparative Procedures at the Time of Explantation of Artificial Urinary Sphincter for Cuff Erosion.

OBJECTIVE: To examine artificial urinary sphincter (AUS) cuff erosion intraoperative management methods: Foley catheter placement, abbreviated urethroplasty (AU), or mobilization with primary urethral anastomosis (PA). We reviewed these options to compare postoperative complications and probability of AUS reimplantation. MATERIALS AND METHODS: Medical records of patients treated for AUS cuff erosion from 2005 to 2015 were retrospectively reviewed. We divided patients into 3 groups based on intraoperative management of the urethra: Foley only, AU, or PA. Patient characteristics, operative times, outcomes, complications, and reimplantation factors were recorded and analyzed. RESULTS: Seventy-five patients with a median age of 77 years (72-83) were treated for AUS cuff erosion. Fifty-two underwent Foley placement, 8 AU, and 15 PA. Mean follow-up was 13 months (0-106). Severe erosions were more common in the PA group than Foley or AU (100% vs 37%, 100% vs 38%, P <.001, P <.001, respectively). Severe erosions treated with Foley were more likely to develop strictures than mild erosions (38% vs 5%, P = .009). Tandem cuff patients treated with Foley were more likely to develop diverticuli than single cuff patients (33% vs 4%, P = .016). There was no difference in probability of reimplantation between PA and Foley or AU (63% vs 69%, 63% vs 33%, P = .748, P = .438, respectively). CONCLUSIONS: Foley catheter placement alone may represent suboptimal management for severe or tandem cuff erosions due to increased risk of urethral complications. Urethral defect management should be determined at the time of explantation by individual patient characteristics and surgeon experience.

Genitourinary manifestations of sickle cell disease.

Sickle cell disease is a common genetic disorder characterized by sickling of red blood cells under conditions of reduced oxygen tension. In turn, sickling leads to intravascular hemolysis and vaso-occlusive events with subsequent tissue ischemia-reperfusion injury affecting multiple organs, including the genitourinary system. Our review of the genitourinary manifestations of sickle cell disease focuses on sickle cell nephropathy, priapism, and other genitourinary complications such as papillary necrosis and renal medullary carcinoma.