Current management of penile implant infections, device reliability, and optimizing cosmetic outcome.

Penile implants hold a major position in the treatment algorithm for patients with erectile dysfunction who find medications and vacuum erection devices ineffective or unsatisfactory. As with any surgical procedure, adverse events may occur. The infection rate associated with implant placement has been lowered to the range of 1 % or less due to multifactorial improvements including no-touch techniques, the use of antibiotic-coated devices, and improved quality measures in the operating room. Urologists have been proactive in employing techniques and procedures which minimize loss of erectile length, hence enhancing patient satisfaction. Flat reservoirs have been developed and techniques of placing these to avoid problems in the space of Retzius have reduced complication rates as well. Device reliability has improved to the point that penile implants are among the most durable mechanical surgical products that contribute to patient and partner satisfaction, which is by far the greatest among all the treatments of erectile dysfunction.

Penile prosthesis salvage: a historical look at the Mulcahy technique and a review of the latest literature.

Historically, management of inflatable penile prosthesis infection was explantation of the device with delayed reimplantation at a later date. In 1991, this paradigm was challenged when early attempts at washout and immediate salvage proved successful. The clinical experiences and data generated over the past 30 years have allowed implanters to refine their salvage procedures to improve patient outcomes. In this article, we review the original Mulcahy technique for salvage and discuss updates to this protocol based on recent data.

Technological advances in penile implants: past, present, future.

Attempts to "cure" erectile dysfunction (ED) are as old as recorded history. The history of penile prosthetic devices dates back over 500 years, when a French military surgeon designed the first known wooden prosthesis to support micturition. There have since been a great many technological advancements in penile prosthetics. Penile implants for the improvement of sexual function date to the twentieth century. Like all human endeavors, penile prosthesis innovations have progressed via trial and error. This review aims to provide an overview of penile prostheses for the treatment of ED since their introduction in 1936. More specifically, we aim to highlight important advances in penile prosthesis development and discuss dead ends that were abandoned. Highlights include two-piece inflatables, three-piece inflatables, and malleable/semirigid, along with modifications and updates to each basic design that improved both insertion and usability. Dead ends include innovative ideas that were lost to history due to a variety of factors. We also look to the future and discuss expected advances, including remotely activated devices and prostheses designed for special populations, including transgender men.

Twenty years later: is the scrotal one-incision AUS of value?

The artificial urinary sphincter, known as AMS 800, has been the gold standard for treating moderate to severe stress urinary incontinence in males for 40 years. Yet, the number of sphincters done globally is quite small and the majority of urologists doing them are infrequent implanters. Estimates for 2019 showed half of implanters did only one implant that year and worldwide only around 13,000 implantations were performed. The traditional two-incision technique of perineal exposure for cuff placement and abdominal incision for pump and pressure regulating balloon persists as the most common technique to surgically place an artificial urinary sphincter. Present estimates are that upwards of 80% are done via the perineal approach and that approach is the highly favored incision of large volume centers. The scrotal one-incision approach was invented by Wilson 20 years ago and was aimed at making the implantation of a sphincter quicker, easier and safer for the occasional implanter. These physicians perform 1-2 devices per year, comprise 60% of implanters who perform the surgery yearly, and implant 22% of all implanted devices. Our article targets these infrequent inserters discussing the history of the two techniques and what the authors have learned about the advantages and hazards of the one scrotal incision procedure over the last two decades.

The last survivor of unitary and two-piece inflatables-the Ambicor. Does it still have a role in today's implant marketplace?

The history of the development of today's very dependable three-piece inflatable penile prostheses is fascinating. In its infancy, the three piece was plagued with frequent revisions and a relatively complex insertion and consequently unitary and two-piece prostheses flourished with the implanting urologists. While the surgery was less difficult because these devices did not require the dreaded reservoir insertion, they often proved unsatisfactory to patients in flaccidity, erection and longevity. By the turn of this century all of the unitary and two-piece inflatables had been withdrawn from the market except the Ambicor two-piece inflatable penile prosthesis. This paper covers the history of the various unitary and 2-piece inflatable models before examining a critical question: is the Ambicor 2-piece still a needed implant today?

Long-term infection outcomes after original antibiotic impregnated inflatable penile prosthesis implants: up to 7.7 years of followup.

PURPOSE: Although some studies suggest that most infections associated with inflatable penile prosthesis implantation develop within year 1 after surgery, device related infections have been reported 5 years after implantation or later and the infection risk with time is not well characterized. We previously reported a statistically significantly lower infection rate for original inflatable penile prostheses impregnated with antibiotic treatment with minocycline and rifampin vs nonimpregnated inflatable penile prostheses at 1-year followup. Long-term data are now available on infection revision after initial implantation of antibiotic impregnated vs nonimpregnated prostheses. MATERIALS AND METHODS: We retrospectively reviewed patient information forms voluntarily filed with the manufacturer after the initial implantation of more than 39,000 inflatable penile prostheses to compare the revision rate due to infection for antibiotic impregnated vs nonimpregnated implants between May 1, 2001 and December 31, 2008. Life table analysis was used to evaluate device survival from revision surgery. RESULTS: On life table survival analysis initial revision events due to infection were significantly less common in the impregnated vs the nonimpregnated group (log rank p <0.0001). At up to 7.7 years of followup 1.1% of 35,737 vs 2.5% of 3,268 men with impregnated vs nonimpregnated implants underwent initial revision due to infection. CONCLUSIONS: To our knowledge this long-term outcome analysis provides the first substantial clinical evidence of a decrease in costly infection related revision using an antibiotic impregnated inflatable penile prosthesis.

New enhancements of the scrotal one-incision technique for placement of artificial urinary sphincter allow proximal cuff placement.

INTRODUCTION: Urinary incontinence impairs sexual functioning and sexual satisfaction. Traditional artificial urinary sphincter (AUS) implantation requires perineal incision for cuff placement and a second inguinal incision for reservoir and pump placement. We believed AUS could be placed easier and quicker through one scrotal incision. Aim. In an effort to effect more proximal placement of the cuff while keeping the advantages of the one scrotal incision technique, we report enhancements to the original surgical technique. METHODS: Thirty patients have been operated upon using the enhanced technique. A modification of the SKW retractor system (AMS) facilitates deep bulbar exposure. Twenty patients were first time implantations and 10 were revisions with five of the revisions having had the original AUS placed by traditional two-incision technique. Two of the first time AUS patients received an inflatable penile prosthesis through the same incision. MAIN OUTCOME MEASURES: We evaluated site of cuff placement, sizes of cuffs used, postoperative continence status. RESULTS: All of the virgin AUS required dissection of the bulbocavernosus muscle prior to cuff placement. In scrotally placed revisions, replacement cuffs were situated considerably proximal (4.5-7.5 cm) to the original cuff site. The perineal placed revisions were accomplished through a scrotal incision with replacement of two cuffs in the same site and the three other patients immediately distal. No intraoperative complications were seen. One patient developed scrotal hematoma requiring drainage. Only 15 patients are available for follow-up and all are socially continent (one pad or less). CONCLUSIONS: Transscrotal approach is used safely and efficiently for penile implants and AUS implantation. The new enhancements to the one-scrotal incision technique allow more proximal cuff placement as evidenced by the bulbocavernosus muscle dissection and use of larger cuffs. Continence rate is similar to rates achieved with perineal placement of cuff found in the literature.

Penile prosthesis infection: progress in prevention and treatment.

Almost four decades ago, modern penile implants were introduced as a treatment of erectile dysfunction. Infection associated with placement of an implant is a feared complication, and fortunately, has become less common due to a number of measures, including antibiotic-coated devices and chlorhexidine-alcohol skin preparation. When an infection around an implant occurs, the device should be removed. An option, termed a salvage (or rescue) procedure, is cleansing the wound with a series of antiseptic solutions and replacing a new prosthesis during the same procedure, with success in the range of 85%. The alternative is to return at a later date to replace the implant. However, the latter approach is associated with a difficult insertion, a shorter erection, and a less satisfied patient. Most patients elected the salvage approach because they were highly motivated to continue sexual activity to have the implant placed initially.

Penile implant infection prevention part II: device coatings have changed the game.

The single most important factor in the reduction of penile implant infections has been the infection retardant coatings. Virtually every inflatable penile prosthesis (IPP) sold for the last 15 years in America has been coated and the device infection rate has dropped over 50% to less than 1% in experienced implanter practices. The vast majority of penile implants are contaminated with bacteria at time of surgery and the bacteria live within the implant spaces in a quiescent fashion protected by a biofilm secreted by the organisms that makes them impermeable to antibiotics or the body's defense mechanisms. Only very rarely do the bacteria cause a clinical infection. Medicine has no clue why this atypically happens. There are new recommendations for systemic prophylactic antibiotics-a testimonial to the changing face of the bacteria causing device infection. New washout solutions are being utilized and new salvage guidelines are being studied.

Penile implant infections: prevention and treatment.

Penile implants remain a mainstay in treating erectile dysfunction (ED). Despite competing therapies, the number of devices implanted has increased each year. Implant infection continues to be a problem, but recent advances in antibiotic-coated devices and copious use of antiseptic irrigation have reduced the incidence. When confronted with an implant infection, a salvage procedure has gained acceptance that involves immediate replacement of the infected implant after antiseptic washing of the implant cavities. This procedure minimizes shortening of the implant erection and facilitates placement of cylinders in corporal bodies. Among patients and health care providers, satisfaction with penile implant remains the highest for all ED treatments.

Simulation Training in Penile Implant Surgery: Assessment of Surgical Confidence and Knowledge With Cadaveric Laboratory Training.

INTRODUCTION: Constraints on surgical resident training (work-hour mandates, shorter training programs, etc.) and availability of expert surgical educators may limit the acquisition of prosthetic surgical skills. As a result, training courses are being conducted to augment the prosthetic surgery learning experience. AIM: To evaluate the impact of a hands-on cadaver-based teaching program on resident procedural knowledge and procedural confidence with placement of a penile prosthesis. MAIN OUTCOME MEASURE: Changes in procedural knowledge and self-confidence following a focused training program on penile prosthetics. METHODS: As part of the 2017 Society of Urologic Prosthetic Surgeons and the Sexual Medicine Society of North America Annual Meeting, 31 urology residents participated in a simulation lab in prosthetic urology. The lab included didactic lectures and a hands-on cadaveric laboratory. Participants completed surveys before and after the course. Wilcoxon Signed Rank tests for matched pairs were used to compare respondents' pre- and postcourse knowledge (% questions answered correctly) and confidence ratings. Prior implant experience was assessed. RESULTS: 31 residents participated in this study. The majority of the participants were 4th- (41.9%) and 5th-year residents (38.7%). Participants showed a significant improvement in procedural knowledge test scores (68.8±13.4 vs 74.2 ± 13.0, P < .05) and self-reported increased median surgical confidence levels (4 vs 3, P value < .001) after completion of the cadaveric course. Subgroup analysis demonstrated that residents with prosthetic surgery experience of <10 cases benefited the most. In addition, improvement in surgical confidence levels observed was greater than the improvement in surgical knowledge. The overall cost of the simulation training course was approximately $1,483 per resident. CONCLUSION: Simulation training in prosthetic surgery seems to improve surgical confidence and knowledge. Further research is needed to better understand the benefits and limitations of simulation training. Lentz AC, Rodríguez D, Davis LG. Simulation training in penile implant surgery: Assessment of surgical confidence and knowledge with cadaveric laboratory training. Sex Med 2018;6:332-338.

Current use of penile implants in erectile dysfunction.

Penile implants became popular with the introduction of effective models more than 30 years ago. Today they play a secondary but definitive role in the treatment of erectile dysfunction at times when more conservative therapies have failed. Improvements in reducing the incidence of infection, treating infection with antiseptic washes, enhancing device longevity, and instituting new techniques to manage complicated implantation procedures have made them more acceptable to patients. Although penile implants are the least often chosen and most invasive treatment for erectile dysfunction, they have the highest satisfaction rate--in the range of 80% to 90%--among both patients and partners.