Dipping Titan implants in Irrisept solution (0.05% chlorhexidine gluconate) and exposure to various aerobic, anaerobic, and fungal species.

BACKGROUND: The organisms causing penile implant infections are changing from predominantly indolent gram-positive infections to more aggressive gram-negative and fungal infections because of antibiotic selection pressures based on novel next-generation sequencing DNA data. AIM: To evaluate the effectiveness of Irrisept solution (0.05% chlorhexidine gluconate) in decreasing isolate colony counts from a Titan implant by using a novel kill time washout methodology to mirror real-world usage. METHODS: Sterilized Titan discs were dipped in Irrisept or saline. An inoculum of 109 organisms of a single bacterial or fungal species was placed on the discs. Bacterial and fungal strains were tested: Bacteroides fragilis, Candida albicans, Enterococcus faecalis, Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, and Staphylococcus epidermidis. The discs were then irrigated 3 times with Irrisept or saline. Microorganisms were sonicated off the discs and placed on appropriate agar and conditions for each species. The plates were incubated for 48 to 72 hours at the temperature and under the conditions appropriate for each species. Colonies on the plates were hand counted. OUTCOMES: Irrisept effectively decreased microbial colony counts in all the species tested. RESULTS: Irrisept was shown to effectively decrease microbial colony counts from 3 to 6 log10 in all species tested. A 3-log10 reduction is considered the target level of performance that would indicate that a compound or product has effective killing activity against an organism of interest. The saline control with bulb syringe irrigation did not demonstrate reduction of microbial colony counts in any of the species tested. CLINICAL IMPLICATIONS: Irrisept is effective against all of the organisms causing modern-day infections with penile implant surgery and may decrease clinical infection rates to lower levels. STRENGTHS AND LIMITATIONS: The strength of this study is that we used quantitative microbial reduction counting and the largest array of bacterial and fungal species causing modern-day penile implant infections. The limitation is that this is an in vitro study and the clinical implications of our findings are not yet known. CONCLUSION: Quantitative microbial reduction counting shows that Irrisept is effective against the most commonly known modern-day organisms causing penile implant infections.

Effect of 0.05% chlorhexidine gluconate in water on the hydrophilic inflatable penile prosthesis: biocompatibility, adherence, and dip time.

BACKGROUND: Rates of infection after inflatable penile prosthesis range from 1% to 3%; however, a new surgical irrigation solution is Food and Drug Administration cleared as antimicrobial wound lavage and appears to be safe for patients and noncaustic during hydrophilic inflatable penile prosthesis (hIPP) dipping and irrigation. AIM: To evaluate if 0.05% chlorhexidine (CHG) lavage is caustic to the hIPP coating and if dip adherence is dependent on time. METHODS: Preconnected hIPP devices were tested at a Coloplast research and development laboratory. The devices were soaked in the 0.05% CHG lavage solution or normal saline for 1, 15, 30, and 60 minutes. Subsequently, all parts were dried for 15 minutes in a 35 °C oven. A Congo red dye test was performed following a Coloplast-validated and Food and Drug Administration-cleared test method to ensure product reliability. Implants were then visually inspected for deleterious effects as well as dip coverage. In addition, we evaluated 0.05% CHG lavage solution vs previously published hIPP dipping solutions. OUTCOMES: 0.05% CHG lavage does not appear to damage the hIPP coating, and adherence of this solution is not dependent on dip time. RESULTS: All components of the preconnected hydrophilic IPPs were tested for coating adherence and defects. All tested IPPs achieved a "satisfactory" coating, meaning a uniform coat without flaking or clumping. Furthermore, there were no noticeable caustic effects or differences in coating adherence between the normal saline-soaked control and 0.05% CHG-coated arms with increasing dip time. A review of the literature for 0.05% CHG lavage solutions vs previously published hIPP dipping solutions revealed that it may have some advantages over previously reported antibiotic solutions. CLINICAL IMPLICATIONS: This study serves as a foundation to introduce 0.05% CHG lavage to the urologic literature as a potentially new "magic bullet" irrigation. STRENGTHS AND LIMITATIONS: Major strengths of the study are that it is the first study of its kind to address the question of what dip duration should be used and whether it is scientifically reproducible. A limitation is the in vitro model, thus needing validation in a clinical setting. CONCLUSION: 0.05% CHG does not appear to negatively affect the hIPP coating or differ in adherence with increasing dip time; however, long-term device performance has not been verified.

Comparing the Italian and North American prospective registries on penile prosthesis surgery: are there relevant differences in treatment indications and patients' management?

Previous studies have shown discrepancies among countries in terms of treatment indications and patients' management due to different health care policies. Penile prosthesis implantation (PPI) is a highly effective treatment for erectile dysfunction (ED), which may have different accessibility according to the type of health system. We compared clinical characteristics of patients included in two national registries on PPI to investigate the influence of different health care systems on treatment indication and accessibility. The multicenter Italian Nationwide Systematic Inventarization of Surgical Treatment for ED (INSIST-ED) Registry and the multicenter Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration (PROPPER), respectively for Italy and North America were considered. Clinical characteristics of patients included in both registries were compared using Wilcoxon Rank Sum test and the Pearson's Chi square test. Patients submitted to PPI in Italy are significantly younger (age: 61.2 vs. 63.8 years; p ≤ 0.001) compared with North America. The majority of patients are treated for post-radical prostatectomy ED in both registries (Italy: 31%; North America: 27%), although diabetes and cardiovascular diseases are more frequent reasons for PPI in the PROPPER registry (p ≤ 0.001), reflecting differences in disease prevalence among countries. In North America a non-hydraulic implant is considered only in 1% of cases as compared with 3% in Italy (p ≤ 0.001). In terms of postoperative management, a compressive surgical dressing (98% vs. 24%; p ≤ 0.001) is a more common strategy in North America. Finally, in Italy most surgeries are performed in a public hospital (82%), while the private setting (70.8%) is more common in North America (p ≤ 0.001). These findings suggest differences in health care systems between Italy and North America. A system like the American one would guarantee easier access to PPI in countries where the National Health System is mainly based on reimbursement to public hospital settings and where patients choosing private settings have to pay by themselves.

Distal Biologic Cap for Impending Distal Erosion.

INTRODUCTION: Management for distal impending erosion can be difficult and has been previously managed with counter incisions which can lead to unsightly scars and increased infection risk. AIM: To demonstrate a novel technique in management of impending erosion. METHODS: We retrospectively reviewed patients who underwent placement of a distal biologic cap for impending erosion. MAIN OUTCOME MEASURE: The main outcome was thesuccessful placement of inflatable penile prosthesis through a single incision. RESULTS: All patients who underwent this procedure are functional and have had no evidence of recurrence. CLINICAL IMPLICATIONS: A simple approach to manage impending distal erosion. STRENGTH & LIMITATIONS: Limitations include small sample size and short duration of follow-up. CONCLUSION: The distal biologic cap is a simple alternative technique to treat distal impending erosion of an inflatable penile prosthesis and can be performed safely without the need for additional incisions on the penis and with a minimal increase in operative times. Karpman E, DiGiorgio L, Carrion RE. Distal Biologic Cap for Impending Distal Erosion. J Sex Med 2020;17:551-555.

GreenLight Laser Enucleation of the Prostate (GreenLEP): Initial Experience with a Simplified Technique.

OBJECTIVE: To present outcomes of a simplified GreenLight laser enucleation of the prostate (GreenLEP) technique and to inform urologists considering incorporation of enucleation into their practice. METHODS: We reviewed all consecutive GreenLEPs by a single surgeon from 2015 to 2018. Baseline patient characteristics, pre-enucleation prostate volume, enucleated adenoma weight, blood loss, lasering time, and energy utilized were recorded. Primary outcomes were urinary flow rate (uroflow) and postvoid residual. Secondary outcomes included International Prostate Symptom Score (IPSS) and prostate-specific antigen change. Primary and secondary outcomes were measured up to 3 years and compared using Student's t test. Adverse event and complication rates were recorded. RESULTS: One hundred and eight patients underwent GreenLEP with mean follow up of 10.2 months. Statistically significant improvements were noted at 3 months in Qmax (237%, P <.01) and Qavg (227%, P <.01), with changes remaining durable through 2 years. Statistically significant improvements were noted at 3 months in International Prostate Symptom Score (-64%, P <.01), postvoid residual (-83%, P <.01), and prostate-specific antigen change (-77%, P <.01). Adverse event and complication rates were comparable to other published enucleation studies. Sexual activity was reported in 36% of patients, all of whom reported retrograde ejaculation. Patients experienced dysuria (6%), stress urinary incontinence (6%), urge urinary incontinence (16%), urethral stricture (6%), bladder perforation (n = 2), prostatic capsular perforation (n = 1), and ureteral injury (n = 1). CONCLUSION: Simplified GreenLEP shows effective and durable results with an acceptable adverse event and complication profile. This technique is optimal for novice enucleators familiar with photoselective vaporization.

A Simplified Technique for GreenLight Laser Enucleation of the Prostate.

OBJECTIVE: To present a simplified technique for GreenLight laser enucleation of the prostate (GreenLEP), designed to reduce the learning curve commonly associated with endoscopic prostate enucleation. MATERIALS AND METHODS: GreenLEP is a novel endoscopic treatment for BPH which allows for durable resection of large glands with minimal energy use, minimal bleeding and has been shown to be non-inferior to holmium laser enucleation of the prostate (HoLEP). Furthermore, GreenLEP has been shown to be superior to GreenLight PVP For glands >80 g with respect to operative time, unplanned hospital readmission and decrease in post treatment PSA and prostate size. Unfortunately, a steep learning curve has remained a roadblock for adaptation by many urologists. Our technique for lobe-by-lobe GreenLEP is described and shown. RESULTS: GreenLEP allows for removal of the entire transition zone in patients with large glands traditionally best treated with staged TURP or simple prostatectomy. A lobe-by-lobe approach allows the urologist to learn the procedure in a stepwise fashion as they become increasingly comfortable with the technique. During the learning process, some lobes may be addressed by enucleation while others by vaporization. CONCLUSION: This simplified technique allows novice enucleators with GreenLight experience to feel more comfortable with GreenLEP, simplifying the learning curve.

Penile Prosthesis Implantation in Patients With Peyronie's Disease: Results of the PROPPER Study Demonstrates a Decrease in Patient-Reported Depression.

BACKGROUND: Although there is a strong correlation between erectile dysfunction and Peyronie's disease (PD), there are limited data on the efficacy and satisfaction of inflatable penile prosthesis (IPP) placement in this population. AIM: To assess the efficacy and overall satisfaction of IPP placement in men with erectile dysfunction and concomitant PD using the Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration (PROPPER). METHODS: Data from the PROPPER study were examined to determine patient baseline characteristics and primary and secondary etiologies before IPP treatment and included type and size of implant received, presence of corporal fibrosis, and operative time. Men completed 5 validated questionnaires at baseline and annually out to 5 years. OUTCOMES: IPP placement was performed in 250 patients with PD with comparable surgical times and outcomes as in patients without PD. RESULTS: 1,180 men underwent IPP insertion at 11 sites; of these, 250 (21.2%) were diagnosed with PD. This is an ongoing study; 1- and 2-year data are available for 177 (70.8%) and 130 (52.0%) patients, respectively. Intraoperatively, 51.2% patients with PD had corporal fibrosis, with an average operative time of 52.8 minutes. At baseline, 19.3% of men (36 of 187) with PD reported being depressed, with a decrease to 10.5% (6 of 57; P = .02) and 10.9% (5 of 46; P = .07) at 1- and 2-year follow-ups, respectively. More than 80% of patients with PD were satisfied or very satisfied at 1- and 2-year follow-ups. In addition, more than 88% of patients with PD were using their device at the 1- and 2-year follow-up visits. CLINICAL IMPLICATIONS: Patients with concomitant PD and erectile dysfunction can safely and effectively have an IPP placed with similar outcomes as patients without PD. STRENGTHS AND LIMITATIONS: The 1st limitation was that all participating prosthetic urologists were high-volume implanters and these results might not be representative of those of general urologists. A 2nd limitation was that none of the patients were randomized. A 3rd limitation was that although most study points were mandatory, some of the data collection, including depression data, was optional, with not all sites participating. A 4th limitation was that depression data were self-reported. CONCLUSION: IPP can be inserted in patients with PD with acceptable patient satisfaction and usage and depressive symptoms appear to lessen in patients with PD after IPP placement. Khera M, Bella A, Karpman E, et al. Penile Prosthesis Implantation in Patients With Peyronie's Disease: Results of the PROPPER Study Demonstrates a Decrease in Patient-Reported Depression. J Sex Med 2018;15:786-788.

Inflatable penile prosthesis implant length with baseline characteristic correlations: preliminary analysis of the PROPPER study.

BACKGROUND: "Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration" (PROPPER) is a large, multi-institutional, prospective clinical study to collect, analyze, and report real-world outcomes for men implanted with penile prosthetic devices. We prospectively correlated co-morbid conditions and demographic data with implanted penile prosthesis size to enable clinicians to better predict implanted penis size following penile implantation. We present many new data points for the first time in the literature and postulate that radical prostatectomy (RP) is negatively correlated with penile corporal length. METHODS: Patient demographics, medical history, baseline characteristics and surgical details were compiled prospectively. Pearson correlation coefficient was generated for the correlation between demographic, etiology of ED, duration of ED, co-morbid conditions, pre-operative penile length (flaccid and stretched) and length of implanted penile prosthesis. Multivariate analysis was performed to define predictors of implanted prosthesis length. RESULTS: From June 2011 to June 2017, 1,135 men underwent primary implantation of penile prosthesis at a total of 11 study sites. Malleable (Spectra), 2-piece Ambicor, and 3-piece AMS 700 CX/LGX were included in the analysis. The most common patient comorbidities were CV disease (26.1%), DM (11.1%), and PD (12.4%). Primary etiology of ED: RP (27.4%), DM (20.3%), CVD (18.0%), PD (10.3%), and Priapism (1.4%), others (22.6%). Mean duration of ED is 6.2¡À4.1 years. Implant length was weakly negatively correlated with White/Caucasian (r=-0.18; P<0.01), history of RP (r=-0.13; P<0.01), PD as comorbidity (r=-0.16; P<0.01), venous leak (r=-0.08; P<0.01), and presence of stress incontinence (r=-0.13; P<0.01). Analyses showed weak positive correlations with Black/AA (r=0.32; P<0.01), CV disease as primary ED etiology (r=0.08; P<0.01) and pre-operative stretched penile length (r=0.18; P<0.01). There is a moderate correlation with pre-operative flaccid penile length (r=0.30; P<0.01). CONCLUSIONS: Implanted penile prosthesis length is negatively correlated with some ethnic groups, prostatectomy, and incontinence. Positive correlates include CV disease, preoperative stretched penile length, and flaccid penile length.

Management of Distal & Proximal Penile Prosthesis Crossover.

The Surgical Techniques Section is sponsored in part by Coloplast.

The Who, How and What of Real-World Penile Implantation in 2015: The PROPPER Registry Baseline Data.

PURPOSE: To date, the published data on patients treated with penile implantation generally consist of small series of single surgeon, retrospective experiences rather than prospective or large, multicenter evaluations. This study establishes a baseline of data collection from the PROPPER (Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration). The PROPPER is the first large, prospective, multicenter, multinational, monitored, and internal review board approved study of real-world outcomes for patients with penile implants. MATERIALS AND METHODS: Data from the PROPPER study were examined to determine patient baseline characteristics and primary and secondary etiologies before treatment of erectile dysfunction. Data include type and size of implant received, surgical steps/techniques used during implantation, and duration of hospital stay. RESULTS: Through April 2, 2015 a total of 1,019 patients were enrolled in the study at 11 sites, with radical prostatectomy being the predominant etiology in 285 (28%). Of those 285 patients treated with radical prostatectomy 280 (98.2%) received an AMS 700™. Of these patients 65.0% (182 of 280) had placement of the reservoir in the traditional retropubic space vs 31.8% (89 of 280) in a submuscular location. Of those patients not treated with radical prostatectomy receiving an AMS 700, fewer underwent reservoir placement in the submuscular location (17.7%, 124 of 702, vs 80.9%, 568 of 702; p <0.001). Of those patients receiving an AMS 700, those treated with radical prostatectomy and those with diabetes had more outpatient admissions (less than 24 hours, 56.8% and 52.1%, respectively) compared to those with cardiovascular disease and Peyronie's disease (42.0% and 35.6%, respectively, p <0.001). CONCLUSIONS: This first-of-its-kind, large, prospective, multicenter study reveals most penile implant cases in North America receive an inflatable penile prosthesis and that radical prostatectomy is the most common primary etiology of penile implant surgery. Moreover, patients treated with radical prostatectomy were more likely to have the reservoir placed in a submuscular location, have a longer operating room time and be admitted to the hospital overnight compared with other patient groups.

Adjuvant Maneuvers for Residual Curvature Correction During Penile Prosthesis Implantation in Men with Peyronie's Disease.

INTRODUCTION: The surgical treatment of comorbid erectile dysfunction and Peyronie's disease has long included the implantation of an inflatable penile prosthesis as well as a number of adjuvant maneuvers to address residual curvature after prosthesis placement. AIM: To review the various surgical options for addressing curvature after prosthesis placement, with specific attention paid to an original article by Wilson et al. reporting on modeling over a penile prosthesis for the management of Peyronie's disease. METHODS: A literature review was performed analyzing articles reporting the management of penile curvature in patients undergoing implantation of an inflatable penile prosthesis. MAIN OUTCOME MEASURES: Reported improvement in Peyronie's deformity as well as the complication rate associated with the various surgical techniques described. RESULTS: Modeling is a well-established treatment modality among patients with Peyronie's disease undergoing penile prosthesis implantation. A variety of other adjuvant maneuvers to address residual curvature when modeling alone is insufficient has been presented in the literature. CONCLUSIONS: Over 20 years of experience with modeling over a penile prosthesis have proven the efficacy and safety of this treatment option, providing the surgeon a simple initial step for the management of residual curvature after penile implantation which allows for the use of additional adjuvant maneuvers in those with significant deformities.

Reservoir alternate surgical implantation technique: preliminary outcomes of initial PROPPER study of low profile or spherical reservoir implantation in submuscular location or traditional prevesical space.

PURPOSE: Alternative reservoir site placement has become an accepted technique for patients who require an inflatable penile prosthesis. To our knowledge there has been no prospective evaluation of this technique, which is currently off label. We performed a prospective, multicenter, multinational, internal review board approved study to evaluate the effectiveness and safety of alternative reservoir site placement. MATERIALS AND METHODS: PROPPER initiated in June 2011, is a database containing patient outcomes of inflatable penile prosthesis implantation. Patients with AMS® penile prostheses continue to be enrolled at 13 North American sites. We examined PROPPER study data to determine surgical implantation use patterns for the AMS 700™ series. We evaluated reservoir implantation site and complications by implantation site. RESULTS: A total of 759 patients had been implanted with an AMS 700 series implant by the time of evaluation. Mean patient followup was 17.8 months (range 0 to 36). There was no reported case of revision surgery for a palpable reservoir and no report of vascular or hollow viscous injury associated with alternative reservoir site placement. Two cases of reservoir herniation in the alternative reservoir site placement group and 2 in the space of Retzius group were treated with reservoir reimplantation. Patients with 1-year assessment available were satisfied or very satisfied with the device and reported a frequency of use of more than once per month. CONCLUSIONS: Alternative reservoir placement in the submuscular location is an option in patients who undergo inflatable penile prosthesis surgery. Implant surgeons should consider alternative reservoir site placement a safe, effective alternative to reservoir placement in the space of Retzius.

Vasectomy reversal outcomes among patients with vasal obstructive intervals greater than 10 years.

OBJECTIVE: To analyze the vasectomy reversal (VR) outcomes specifically among patients with vasal obstructive intervals (VOIs) of >10 years. The VOI has been shown to be a significant predictor of outcome after VR. Although no strict cutoff exists, couples have frequently been discouraged from considering a VR strictly according to the interval from vasectomy. MATERIALS AND METHODS: From 2006 to 2011, all consecutive VRs performed by 2 fellowship-trained microsurgeons were analyzed. The patients were stratified into 4 categories according to the duration of the VOI: <10, 10-15, >15-20, and >20 years. The postoperative semen parameters, patency rates, and pregnancy outcomes were compared among the 4 groups. RESULTS: Of 535 consecutive VRs, 177 patients (33%) had a VOI of >10 years. The couple characteristics, type of VR required, postoperative semen quality, and patency and pregnancy rates among the 4 groups were analyzed. The men with longer VOIs were older (P <.001) and had older female partners (P = .006). Although the VOI influenced the type of reversal performed, favorable semen concentrations (average >20 million/mL in all groups) and patency (average >90%) and pregnancy rates (range 24%-39%) were achieved in men with a VOI >10 years. CONCLUSION: Although the interval since vasectomy has a significant effect on the type of VR required, provided a surgeon is proficient in both microsurgical vasovasostomy and vasoepididymostomy, favorable semen parameters and patency and pregnancy rates can be achieved in men with a VOI >10 years. Couples should not be discouraged from considering VR simply according to the VOI.

A guide for inflatable penile prosthesis reservoir placement: pertinent anatomical measurements of the retropubic space.

INTRODUCTION: The primary concern for many prosthetic urologic surgeons in placing the three-piece inflatable penile prosthesis (IPP) is the concept of "blind reservoir placement." Extensive reports permeate the literature regarding bladder, bowel, vascular, and various hernial complications occurring while attempting to place the reservoir into the retropubic space. However, despite these widely documented complications, there is a paucity of published literature on surgically pertinent anatomical measurements of the retropubic space relating to reservoir placement. The focus of this project was to evaluate the special relationships and anatomical measurements of the retropubic space to better aid the surgeon in the safe placement of the reservoir. AIM: Analyses of the spatial measurements of reservoir placement into the retropubic space with a focus on utilizing a penoscrotal approach were conducted. In addition, we reviewed and evaluated the published literature for important contributions surrounding the various surgical techniques during placement of a penile prosthesis reservoir. METHODS: Cadaveric pelvic specimens were dissected to determine the distance and angulation (in degrees) from the inguinal ring to several critical anatomic structures in the pelvis. This format was utilized to simulate the basic features of reservoir placement into the classic retropubic space. We also reviewed and evaluated the published literature for important contributions describing the various surgical techniques in the placement of penile prosthesis reservoirs into the retropubic space. MAIN OUTCOME MEASURES: Anatomic measurements were obtained from the inguinal ring to the bladder, external iliac vein, and superior origin of the dorsal suspensory ligament at the anterior apex of the pendulous penis. The angle was measured from the inguinal ring to these structures and recorded. We also reviewed the published literature for various penoscrotal IPP surgical techniques involving placement of the reservoir into the retropubic space to further supplement the pertinent spatial relationships data acquired in this study. RESULTS: Of the 28 cadavers, 3 were excluded because of signs of major pelvic surgery, and an additional 6 sides were excluded because of unilateral fibrosis/surgery or difficulty in exposure. Distance to the decompressed bladder was 5-8 cm (average 6.45 cm) at a 15-30 (22.8) degrees medial measurement from the inguinal ring. The filled bladder was 2-4 cm (average 2.61 cm) from the inguinal ring. The external iliac vein distance from the inguinal ring was 2.5-4 cm (average 3.23 cm) at a 20-60 (36.4) degrees lateral measurement from the inguinal ring. Heretofore, the published literature does not appear to have detailed measurements that are provided in this study. CONCLUSIONS: These anatomical measurements of the retropubic space demonstrate the importance of decompressing the bladder and avoiding deep dissection lateral to the inguinal ring, as the external iliac vein is much closer than currently espoused. We feel that these data are significant to the surgeon proceeding with reservoir placement during IPP surgery.

Current opinions on alternative reservoir placement for inflatable penile prosthesis among members of the Sexual Medicine Society of North America.

INTRODUCTION: The Sexual Medicine Society of North America (SMSNA) includes as its members the most experienced prosthetic surgeons in North America who implant inflatable penile prostheses (IPPs). Obliteration of the space of Retzius (SOR) resulting from robotic-assisted laparoscopic prostatectomy (RALP) is a growing concern that has prompted many surgeons to look for alternative locations for reservoir placement during IPP implantation. AIM: The aim of this article is to educate the community of prosthetic urologists about potential complications and alternative locations for IPP reservoir placement. METHODS: A panel of high-volume experienced prosthetic surgeons discussed their views on alternative IPP reservoir implantation during a symposium focused on this topic. After reviewing reservoir complications, physician members of the SMSNA in attendance were surveyed using an audience response system (ARS) to facilitate sharing of knowledge, opinions, and recommendations related to reservoir implantation. MAIN OUTCOME MEASURES: Six ARS questions were used to identify the percentages of SMSNA member physicians with concerns about traditional IPP reservoir placement and utilizing alternative reservoir placement (ARP), and the impact of changing practice patterns on patient safety. RESULTS: A majority (81%) of experienced implant surgeons surveyed think that RALP sometimes or frequently makes traditional IPP reservoir placement more difficult. Placement of the reservoir in an alternative location is sometimes or frequently advantageous for patient safety. A vast majority (97%) of the 95 respondents indicated that ARP techniques should be included in physician training courses. CONCLUSIONS: Physicians have concerns about reservoir placement in the SOR in RALP patients, which may explain why ARP is popular among SMSNA members. Device manufacturers should support physician training that provides for ARP. Clinical outcomes in RALP patients are needed to better understand the risks and benefits, and define the ideal location of reservoir placement in this population.

Capsular contraction with s-shaped deformity of nonlength-expanding inflatable penile prosthesis cylinders: management and prevention strategies.

INTRODUCTION: Capsular contraction (CC) occurring with inflatable penile prosthesis (IPP) reservoirs has been reported by urologists as a cause of autoinflation. The concept of CC occurring around IPP cylinders has not been studied. AIMS: Herein we report a case of CC occurring with nonlength-expanding IPP cylinders, resulting in an S-shaped deformity. MAIN OUTCOME MEASURES: We sought to report a novel cause of S-shaped deformity in patients after IPP surgery. METHODS: We reviewed a recent clinical case and conducted a literature review on capsular scar formation in prosthetic surgery. We also conducted a literature review of the inflammatory cascade related with prosthetic surgery. RESULTS: Capsular contracture of nonlength-expanding cylinders resulting in S-shaped deformity has not been previously reported. The role of certain inflammatory markers seems to play a common role of capsular contracture in the penis and other prosthetic implantation sites. CONCLUSIONS: Capsular contractures around the cylinders of an IPP can cause deformity, even in patients who have appropriately sized, nonlength-expanding cylinders. A better understanding is needed regarding the mechanical properties of the tunica albuginea and the inflammatory cascade associated with penile implant surgery. This case represents an argument for early and aggressive postoperative inflation of the IPP. Future studies should evaluate the role of inflammation modulators as adjuvant therapy after IPP surgery. Karpman E and Henry G. Capsular contraction with S-shaped deformity of nonlength-expanding inflatable penile prosthesis cylinders: Management and prevention strategies. Sex Med 2013;1:95-98.

Streamlined approach for infrapubic placement of an inflatable penile prosthesis.

The streamlined approach for infrapubic placement of an inflatable penile prosthesis is a variation of the traditional infrapubic approach. A better understanding of operative techniques and recent clinical outcome studies have led to an evolution of the original infrapubic approach. Small incisions and efficient operative maneuvers can shorten operative times and expedite postoperative recovery.