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. AIM: To present a novel surgical concept of suprapubic fat pad excision with a concomitant placement of inflatable penile prosthesis. METHODS: A transverse incision begins slightly medial to the anterior superior iliac spine, with the superior edge crossing transversely to the contralateral anterior superior iliac spine. The inferior border is incised in a curvilinear fashion, with the medial apex being approximately 1 cm above the base of the penis. Dissection is carried down to the lower abdominal anterior fascia, which leads to excision of the suprapubic fat pad. Using this same exposure, the inflatable penile prosthesis (IPP) is placed via an infrapubic approach. The wound is reapproximated in multiple layers, and 2 drains are placed, 1 subcutaneous in the area of the fat pad excision and the other in the scrotum around the pump. MAIN OUTCOME MEASURES: Primary outcomes included penile implant functionality, ability to engage in sexual activity, and cosmetic satisfaction. RESULTS: A total of 8 patients have undergone suprapubic fat pad excision with simultaneous placement of IPP at our institution. Average body mass index of our patient cohort was 36.6. 1 patient developed prosthetic infection after inadvertent removal of his drains in the immediate postoperative period. At last follow-up, all other patients have excellent cosmetic and functional outcomes. CLINICAL IMPLICATIONS: This technique can lead to higher patient satisfaction with their penile implant, enhanced sexual performance, and improved quality of life for patients with concurrent erectile dysfunction and significant suprapubic fat pad. STRENGTHS & LIMITATIONS: This unique technique has never been previously described. It allows placement of IPP in the setting of fat pad excision without any additional incisions. Limitations include the small patient population and relatively short follow-up. CONCLUSIONS: Suprapubic fat pad excision is a safe and reproducible technique that can be performed simultaneously with the placement of an IPP in appropriately selected patients. Patients must be counseled appropriately on the expectations of surgeries and the theoretical increased risk of postoperative complications, such as infection. Baumgarten AS, Beilan JA, Shah BB, et al. Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis J Sex Med 2019;16:333-337.

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.

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.

INTRODUCTION: Penile prosthesis infections remain challenging despite advancements in surgical technique, device improvements, and adoption of antibiotic prophylaxis guidelines. AIM: To 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. METHODS: This 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 MEASURES: Intraoperative culture data from infected IPPs. RESULTS: Two 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. CONCLUSION: This 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.

Delayed postoperative hematoma formation after inflatable penile prosthesis implantation.

INTRODUCTION: Infrequent but serious postoperative complications following inflatable penile prosthesis (IPP) insertion include infection, malfunction, and bleeding. Although prior publications report methods to reduce immediate postoperative bleeding, there is little in the literature concerning the etiology, diagnosis, imaging, and management of delayed bleeding after IPP insertion. AIM: The aim of the study was to review cases of delayed postoperative bleeding following IPP insertion in a large single-surgeon series. METHODS: We carried out a retrospective chart review of 600 patients implanted with a Coloplast Titan IPP with One-Touch Release pump by a single surgeon, and analyzed cases of delayed postoperative bleeding. MAIN OUTCOME MEASURE: The main outcome measure was an analysis of the incidence, causes, diagnostic methods, treatment, and final outcome of these cases. RESULTS: Three out of 600 consecutive patients (0.5%) developed a delayed (defined as >5 days postoperative) hematoma following IPP insertion. All patients presented postoperatively with a swollen surgical site, and all were evaluated with a pelvic computed tomography scan to completely define the extent of the hematoma. Two patients developed a delayed hematoma because of excessive physical activity; the remaining patient bled because of premature administration of enoxaparin sodium (Lovenox) by his cardiologist. All three patients were successfully treated with hospital admission, intravenous antibiotics, wound exploration, hematoma evacuation, and antibiotic washout. All three IPPs were successfully salvaged; none developed peri-prosthetic infection. CONCLUSIONS: The incidence of delayed postoperative hematoma following IPP surgery was 0.5% in our series of 600 cases. All cases were successfully managed with intravenous antibiotics, hematoma evacuation, and antibiotic washout. Because of the low incidence of this complication, definitive statements concerning prevention and management cannot be made. However, we now recommend avoiding postoperative anticoagulants for at least 5 days if possible, and avoiding vigorous physical activity for at least 3 weeks.

Subcutaneous Placement of Inflatable Penile Prosthesis Reservoirs.

OBJECTIVE: To review our experience with subcutaneous inflatable penile prosthesis reservoir insertion in a large, single-surgeon series. MATERIALS AND METHODS: We carried out a retrospective review of 1000 consecutive Coloplast Titan inflatable penile implant procedures carried out by a single high-volume surgeon. Eight patients underwent subcutaneous reservoir placement (SRP) and are the subject of this review. RESULTS: Eight of our last 1000 patients underwent SRP. SRP was only employed in patients with a thick subcutaneous abdominal fat layer, which would be capable of concealing the reservoir. Seven patients recovered uneventfully, and none reported a palpable or visible reservoir. One patient, who had 5 prior penile implant procedures, developed peri-prosthetic infection, and required complete device removal. Reservoir removal in this obese patient was facilitated by the device's subcutaneous location. CONCLUSION: SRP is a viable option for carefully selected obese patients. We suggest that this approach only be utilized in those with high body mass index and a thick subcutaneous abdominal fat layer. In thinner patients, the reservoir will be visible and/or palpable; we do not recommend subcutaneous placement under those circumstances.

Floppy Glans Syndrome: Pathogenesis and Treatment.

INTRODUCTION: Floppy glans syndrome (FGS) is a potential complication of penile prosthesis placement in patients with erectile dysfunction. FGS affects a very small proportion of these patients, and it can manifest in a ventral, dorsal, or lateral droop of a hypermobile glans, which can cause affected patients to complain of painful, unsatisfying, or otherwise difficult attempts at sexual intercourse. Incorrect cylinder sizing can even result in extreme conditions such as flail penis or S-shaped deformity. AIM: The aim of this review is to outline the types, causes, and management options for FGS. METHODS: This review was conducted after a thorough literature search in addition to experience managing FGS at the authors' institution. MAIN OUTCOME MEASURES: Clarification of the nomenclature for FGS, supersonic transporter deformity, flail penis, and crossover to define, diagnose, and treat these conditions. RESULTS: In many cases of FGS, poor intraoperative prosthetic cylinder positioning and sizing can lead to insufficient compression of the deep dorsal and circumflex veins between the Buck fascia and the corpora cavernosa, even when cylinders are maximally inflated. When the adjacent tissue does not adequately restrict blood flow through these vessels, then glanular tumescence becomes increasingly difficult to achieve, particularly in patients with severe erectile dysfunction who have poor glanular blood flow at baseline. FGS also can be a result of poor underlying glanular structural support. Thus, droop is possible even when cylinders have an appropriate size and position. Treatment options range from medical management to surgical correction. Distal penoplasty and glanulopexy have been described as effective methods of correcting the FGS deformity and avoiding the more invasive option of prosthetic cylinder replacement. These options are especially valuable in patients who undergo adequate cylinder sizing intraoperatively. CONCLUSION: FGS is not monolithic, and careful diagnosis is essential to determining the appropriate treatment course.

Advances in Surgical Reconstructive Techniques in the Management of Penile, Urethral, and Scrotal Cancer.

This article reviews the most up-to-date surgical treatment options for the reconstructive management of patients with penile, urethral, and scrotal cancer. Each organ system is examined individually. Techniques and discussion for penile cancer reconstruction include Mohs surgery, glans resurfacing, partial and total glansectomy, and phalloplasty. Included in the penile cancer reconstruction section is the use of penile prosthesis in phalloplasty patients after penectomy, tissue engineering in phallic regeneration, and penile transplantation. Reconstruction following treatment of primary urethral carcinoma and current techniques for scrotal cancer reconstruction using split-thickness skin grafts and flaps are described.

Primary Ureteral Lymphoma Presenting with Acute Flank Pain.

Non-Hodgkin's lymphoma (NHL) represents 4% of newly diagnosed cancer in 2013 with a 59-82% 5-year survival depending on the tumor location. Primary presentation of lymphoma consists of lymphadenopathy or swelling of the lymph nodes and non-specific systemic symptoms such as fevers, night sweats, and weight loss. Less commonly, NHL arises from non-lymphoid tissue. We report a unique case of NHL arising from the ureteral wall which was visualized via non-contrast CT and direct vision through ureteroscopy.