Partial Component Exchange of a Non-Infected Inflatable Penile Prosthesis is Associated With a Higher Complication Rate.

OBJECTIVE: To describe the infectious and non-infectious complications in men undergoing Inflatable penile prosthesis (IPP) revision with partial and complete component exchange for mechanical malfunction. METHODS: We performed a multicenter retrospective cohort study of patients who underwent IPP revision. Men undergoing procedures for implant infection were excluded. Patients were divided into those who had complete exchange of the entire device or partial exchange of only one or 2 components. Infectious and non-infectious complications were compared between groups. RESULTS: Three hundred sixty-eight men had complete exchange of the entire device and 85 had partial component exchange. Men undergoing partial exchange had a significantly higher infection rate (7.1% vs 2.2%, P = .031). The partial exchange group also was more likely to receive antifungals (51.8 vs 16.6%, P < .001), have a modified salvage washout (77.4 vs 60.2%, P = .004), and less likely to receive vancomycin and gentamicin (63.5 vs 83.7%, P < .001). Time to revision was significantly shorter in the partial exchange group (44.9 vs 168.2 months, P < .001). Mean follow-up was slightly longer in the complete exchange group (18.3 vs 13.0 months). In multivariable analysis, partial exchange surgery, vancomycin and gentamicin prophylaxis, modified salvage washout, and antifungal prophylaxis were no longer associated with postoperative infections. The partial exchange group had greater rates of non-infectious complications (21.2% vs 9.5%, P = .005) such as pump malfunction and tubing breakage. CONCLUSION: Patients undergoing partial component revision had more infectious and non-infectious complications. These findings suggest that partial component exchange increases complications in men undergoing IPP revision.

A Consistent Lack of Consistency in Defining the Acute and Chronic Phases of Peyronie's Disease: A Review of the Contemporary Literature.

INTRODUCTION: Treatment recommendations for Peyronie's Disease (PD) differ based on whether a patient is in the acute/active versus chronic/stable phase of the disease, yet there are no agreed upon criteria for defining these clinical entities. OBJECTIVES: To review the criteria used to define acute and chronic phase PD in modern PD intervention studies METHODS: We performed a search engine review to identify indexed publications for PD intervention studies and review articles / meta-analyses from the year 2011-2020. Outcomes results were catalogued and summarized across articles. As a result of the substantial heterogeneity of outcome measures and follow-up intervals, meta-analytic techniques were not applied to the data analysis. RESULTS: We identified a total of 104 studies that met inclusion criteria and had available information for review (n = 79 primary intervention studies; n = 25 review articles/meta-analyses/guidelines). Among the queried studies, we were unable to identify a consensus with respect to the criteria used to define acute and chronic phases of PD. 33% of primary intervention studies did not specifically define their criteria for acute and chronic phase PD, despite referencing these populations as part of the inclusion criteria in many instances. Studies used heterogenous criteria including total symptom duration, duration of "stable" symptoms, and presence/absence of pain. CONCLUSION: Due to varying definitions across the literature, we were unable to create a standardized definition of acute and chronic phase Peyronie's in terms of time. Our findings emphasize the need for greater consensus in defining the treatment cohorts with future studies that assess treatment for men with PD. Piraino J, Chaudhray H, Ames K, et al. A Consistent Lack of Consistency in Defining the Acute and Chronic Phases of Peyronie's Disease: A Review of the Contemporary Literature. Sex Med Rev 2022;10:698-713.

Does knowing pre-operative penile length influence patient satisfaction post penile prosthesis implantation?

Patients who undergo penile prosthesis implantation as treatment for erectile dysfunction commonly complain of penile shortening after implantation. We conducted a study to determine whether knowledge of pre-operative stretched penile length measurement influences patient satisfaction. This prospective study consisted of 149 patients undergoing inflatable penile prosthesis (IPP) implantation from August 2017 to December 2019. Study group participants underwent pre-operative stretched penile length measurement in clinic while the control group did not. Six months post-operatively, patients completed a modified 14-item Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire to assess overall satisfaction and penile length satisfaction. A total of 102 patients were eligible for final analysis (49 in study group, 53 in control). Mean scores for overall treatment satisfaction were 3.57 and 3.53 (scale from 0 to 4) in the study versus control group, respectively (p = 0.483). Mean scores for satisfaction with penile length were 4.08 and 4.11 (scale from 1 to 5) in the study vs. control group (p = 0.645). The study suggests that knowledge of pre-operative stretched penile length does not influence post-operative satisfaction after penile prosthesis implantation. Therefore, performing pre-operative measurements in clinic solely for informing the patient may be unnecessary. Current interventions aimed at conserving penile length may be effective at maintaining satisfaction with penile length.Trial Registration- This trial is registered and approved by the IRB committee at our institution, ID: HSC-MS-19-0320.

A Consistent Lack of Consistency in Defining the Acute and Chronic Phases of Peyronie's Disease: A Review of the Contemporary Literature.

INTRODUCTION: Treatment recommendations for Peyronie's Disease (PD) differ based on whether a patient is in the acute/active versus chronic/stable phase of the disease, yet there are no agreed upon criteria for defining these clinical entities. OBJECTIVES: To review the criteria used to define acute and chronic phase PD in modern PD intervention studies. METHODS: We performed a search engine review to identify indexed publications for PD intervention studies and review articles / meta-analyses from the year 2011-2020. Outcomes results were catalogued and summarized across articles. As a result of the substantial heterogeneity of outcome measures and follow-up intervals, meta-analytic techniques were not applied to the data analysis. RESULTS: We identified a total of 104 studies that met inclusion criteria and had available information for review (n = 79 primary intervention studies; n = 25 review articles/meta-analyses/guidelines). Among the queried studies, we were unable to identify a consensus with respect to the criteria used to define acute and chronic phases of PD. 33% of primary intervention studies did not specifically define their criteria for acute and chronic phase PD, despite referencing these populations as part of the inclusion criteria in many instances. Studies used heterogenous criteria including total symptom duration, duration of "stable" symptoms, and presence/absence of pain. CONCLUSION: Due to varying definitions across the literature, we were unable to create a standardized definition of acute and chronic phase Peyronie's in terms of time. Our findings emphasize the need for greater consensus in defining the treatment cohorts with future studies that assess treatment for men with PD.

REMOVED: The Augmenta Implant: A Cadaver Model of a Novel Anatomic Subdermal Implant for Cosmetic Penile Enhancement.

This article has been removed: please see Elsevier Policy on Article Withdrawal https://www.elsevier.com/about/our-business/policies/article-withdrawal. This article has been removed due to legal reasons.

Proximal Extracapsular Tunneling: A Simple Technique for the Management of Impending Cylinder Erosion and Complications Related to Corporal Dilation.

INTRODUCTION: Impending cylinder erosion and floppy glans secondary to an undersized penile prosthesis are rare complications that can cause cosmetic deformity and patient discomfort. AIM: To demonstrate a technique for the management of impending cylinder erosion and floppy glans secondary to cylinder under-sizing. METHODS: We retrospectively reviewed 6 patients who required the proximal extracapsular tunneling technique during penile prosthesis revision surgery. MAIN OUTCOME MEASURE: Main outcome was successful placement of a penile prosthesis with proper cylinder placement. RESULTS: Mean patient age for these 6 patients was 71.2 years (64-86 y). After a mean follow-up of 6.6 months, all 6 patients who underwent this procedure had a functional penile prosthesis without evidence of recurrence. CONCLUSION: The proximal extracapsular tunneling technique is a simple approach performed through a single incision that can be used for proper cylinder replacement during penile prosthesis revision surgeries. It may be utilized for the management of impending cylinder erosion and other cases with coporal dilation-related complications in which the surgical pseudo-capsule has already formed around the implant. This technique can be safely performed without the need of a distal counter-incision on the penis. Clavell-Hernández J. Proximal Extracapsular Tunneling: A Simple Technique for the Management of Impending Cylinder Erosion and Complications Related to Corporal Dilation. Sex Med 2021;9:100379.

Immediate preoperative blood glucose and hemoglobin a1c levels are not predictive of postoperative infections in diabetic men undergoing penile prosthesis placement.

Defining the risks associated with diabetes mellitus in patients undergoing penile prosthesis implantation remains controversial. Our study aims to assess whether preoperative hemoglobin a1c and preoperative blood glucose levels are associated with an increased risk for postoperative infection in diabetic men. We performed a retrospective review of 932 diabetic patients undergoing primary penile prosthesis implantation from 18 high-volume penile prosthesis implantation surgeons throughout the United States, Germany, Belgium, and South Korea. Preoperative hemoglobin a1c and blood glucose levels within 6 h of surgery were collected and assessed in univariate and multivariate models for correlation with postoperative infection, revision, and explantation rates. The primary outcome is postoperative infection and the secondary outcomes are postoperative revision and explantation. In all, 875 patients were included in the final analysis. There were no associations between preoperative blood glucose levels or hemoglobin a1c levels and postoperative infection rates; p = 0.220 and p = 0.598, respectively. On multivariate analysis, a history of diabetes-related complications was a significant predictor of higher revision rates (p = 0.034), but was nonsignificant for infection or explantation rates. We conclude preoperative blood glucose levels and hemoglobin a1c levels are not associated with an increased risk for postoperative infection, revision, or explantation in diabetic men undergoing penile prosthesis implantation.

Initial Results of First In Vivo Imaging of Bladder Lesions Using a High-Resolution Confocal Microendoscope.

Purpose: Conventional cystoscopy plays an important role in detection of bladder cancer; however, it is difficult to differentiate benign and neoplastic lesions based on cystoscopic appearance alone. Advanced microscopic modalities, such as confocal laser endomicroscopy and optical coherence tomography, have been shown to provide critical histopathologic information to help identify neoplastic bladder lesions in real time, but their availability and clinical adoption are limited due to a high cost. In this study, we present the first use of a novel and low-cost ($ <5000) confocal high-resolution microendoscope (confocal HRME) for in vivo imaging of bladder lesions. Materials and Methods: In a cohort of 15 patients undergoing white light cystoscopy as part of their standard of care, high-resolution images of proflavine-stained bladder lesions were acquired in vivo using the confocal HRME. Based on these images, we evaluated the ability of the confocal HRME to visualize uroepithelium with subcellular resolution and high contrast. Furthermore, we analyzed the cellular architecture and staining patterns of benign and neoplastic bladder lesions in confocal HRME images and compared results to that of standard cystoscopy and histopathology. Results:In vivo imaging in the pilot study demonstrates that the confocal HRME resolved subcellular structures of bladder uroepithelium with high contrast. In a wide range of clinical conditions from normal bladder wall to benign and neoplastic lesions, confocal HRME images revealed important diagnostic features that correlated to histopathology. Conclusions: The confocal HRME provides an affordable, portable, and easy-to-use tool to allow real-time and high-contrast subcellular characterization of bladder lesions, well suited for bladder cancer detection in community and resource-constrained settings. The ClinicalTrials.gov Identifier: NCT02340650.

Impact of Antimicrobial Dipping Solutions on Postoperative Infection Rates in Patients With Diabetes Undergoing Primary Insertion of a Coloplast Titan Inflatable Penile Prosthesis.

BACKGROUND: Modern-day penile prostheses use infection retardant coating to decrease rates of postoperative infection, subsequently reducing explantation and revision rates as well. The Coloplast Titan models are dipped into antimicrobial solutions right before implantation, and the components used for dipping can be tailored toward the patient. AIM: To compare infection, explantation, and revision rates among different dipping solutions used before implantation for patients with diabetes receiving a Coloplast Titan implant. METHODS: We systematically reviewed 932 patients with diabetes receiving a primary penile implant across 18 different centers from the period April 2003 to August 2018. Of those patients, 473 received a Coloplast device, whereas 459 received an AMS device. Data regarding the type of antimicrobial solution used before implantation were recorded for 468 patients receiving a Coloplast Titan, including whether or not they suffered a postoperative infection and if they underwent explantation and/or revision. Outcome rates were compared using Fisher's exact and Pearson's chi-square tests, and logistic regression modeling was performed to account for covariates. OUTCOMES: The main outcome measures of this study were postoperative infection, explantation, and revision rates. RESULTS: Of the total 932 patients reviewed, 33 suffered a postoperative infection. Of 468 patients receiving Coloplast implants, there was a 3.4% infection rate. The most commonly used antibiotic combination before dipping was vancomycin + gentamicin (59.0%). There was a significantly lower rate of postoperative infection, explantation, and revision when vancomycin + gentamicin was used than those associated with the use of all other dipping solutions ([1.4% vs 6.4%; P = .004], [1.1% vs 8.3%; P < .001], and [2.5% vs 12.5; P < .001], respectively). After adjusting for age, body mass index, preoperative blood glucose level, and hemoglobin A1c, the use of other dips was an independent predictor of postoperative infection (odds ratio: 0.191; P = .049). The inclusion of rifampin in the dipping solution trended toward being a significant risk factor for infection (P = .057). Including antifungals in the dipping solution did not affect infection (P = .414), explantation (P = .421), or revision (P = .328) rates. CLINICAL IMPLICATIONS: Vancomycin + gentamicin was the most efficacious combination of antibiotics used for dipping in terms of preventing postoperative infection and subsequent explantation and revision. STRENGTHS AND LIMITATIONS: Data were sampled across multiple institutions providing a large sample that may be more representative of the population of interest. A key limitation of the study was its retrospective nature, which prevented us from controlling certain variables. CONCLUSION: The use of rifampin did not provide the same type of protection, possibly representing a shift in resistance patterns of common bacteria responsible for device infection. Towe M, Huynh LM, Osman MM, et al. Impact of Antimicrobial Dipping Solutions on Postoperative Infection Rates in Patients With Diabetes Undergoing Primary Insertion of a Coloplast Titan Inflatable Penile Prosthesis. J Sex Med 2020;17:2077-2083.

A Multicenter Investigation Examining American Urological Association Recommended Antibiotic Prophylaxis vs Nonstandard Prophylaxis in Preventing Device Infections in Penile Prosthesis Surgery in Diabetic Patients.

PURPOSE: American Urological Association (AUA) antibiotic prophylaxis recommendations may be insufficient for covering organisms commonly found in penile prosthesis infections. In this study we assess the difference between AUA recommended antibiotic prophylaxis and nonstandard prophylaxis in preventing device infections in penile prosthesis surgery performed in diabetic patients. MATERIALS AND METHODS: A multicenter, retrospective cohort study of diabetic patients undergoing primary penile prosthesis surgery was performed between April 2003 and August 2018. Eighteen institutions from the United States, Europe and Korea contributed. The association between antibiotic prophylaxis type and postoperative penile prosthesis infections, device explantations and revision surgeries was assessed. RESULTS: Standard AUA antibiotic prophylaxis was followed in 48.6% (391) of cases while nonstandard prophylaxis was used in 51.4% (413). Common nonstandard antibiotic prophylaxis included vancomycin-gentamycin-fluoroquinolone, clindamycin-fluoroquinolone, and vancomycin-fluoroquinolone among other combinations. Patients who received AUA prophylaxis had significantly more postoperative device infections (5.6% vs 1.9%, p <0.01) and explantations (8.3% vs 2.0%, p <0.001) compared to those who received nonstandard prophylaxis. Patients who received AUA prophylaxis had significantly higher odds of a postoperative device infection (OR 2.8, 95% CI 1.1-7.3) and explantation (OR 3.6, 95% CI 1.4-9.1) compared to those who received nonstandard prophylaxis. CONCLUSIONS: Diabetic men with erectile dysfunction who received standard AUA prophylaxis for penile prosthesis surgery had significantly greater odds of experiencing a postoperative device infection and device explantation compared to patients who received nonstandard prophylaxis. Our study provides a strong rationale for a prospective investigation to establish the most appropriate prophylaxis strategy in penile prosthesis surgery.

Orgasm-associated urinary incontinence (climacturia) following radical prostatectomy: a review of pathophysiology and current treatment options.

Orgasm-associated urinary incontinence, or climacturia, is a common side effect after radical prostatectomy (RP) that is gaining more attention due to the distress it causes to patients. A range of treatment options have been reported in the literature and are outlined in this review. The goal of our study is to review the pathophysiology and current management options for climacturia following RP. A PubMed search was used to review the current literature relating to the pathophysiology and the treatment of postprostatectomy climacturia. We reviewed the currently available treatment options and their success rates for climacturia. Several techniques were found to subjectively help improve the amount and bother of patients' climacturia. These include pelvic floor muscle training (PFMT), penile variable tension loop, soft silicone occlusion loop, artificial urethral sphincter, male urethral sling, and the Mini-Jupette graft. Success rates ranged from 48% to 100% depending on the modality used. For patients with erectile dysfunction and climacturia, the Mini-Jupette graft could be a valuable option. Given the lack of validated measurement tools and management options, climacturia has become a challenge for urologists. Albeit a condition that has not garnered much attention, there are several management options from conservative to invasive treatments that have shown a hopeful promise for the treatment of climacturia. These options should be discussed with patients to determine the best treatment for each individual. More clinical trials are needed to assess the efficacy and impact of the different treatment options before a definitive recommendation regarding management can be made.

Novel protective penile collar following inflatable penile prosthesis placement: The "Wang Collar".

Penile rehabilitation after inflatable penile prosthesis (IPP) implantation for the treatment of erectile dysfunction includes leaving the device partially inflated so as to preserve the penile length and to maintain hemostasis. With a partially inflated device, the penis becomes more sensitive and more susceptible to unintended insults during the immediate postoperative management. The "Wang Collar," a device intended to protect the penis in the early postoperative period, is hereby described. Three hundred and forty-eight patients had the "Wang Collar" included as part of their post-IPP management from August 2014 to February 2019. The protective collar, devised from a polystyrene cup with the bottom removed, is secured with a tape over the previously dressed and partially inflated penis. In order to evaluate the effectiveness of this device, we conducted surveys on the perioperative staff at three different institutions. The "Wang Collar" has been found to be beneficial in the early postoperative care of patients. Based on the answers to our questionnaire, the perioperative personnel found this device to be highly protective, especially when transporting the patient after IPP surgery, easy to work with, and almost never bothersome or irritative to the patient. We present a novel penile device after IPP placement, which we have found to improve patient satisfaction in the postoperative period. In addition, it eases the care of the patient by the perioperative staff. It is now our routine to use this device after IPP surgery. Further research is necessary to evaluate whether this device can decrease postoperative wound complications.

Epidemiology regarding penile prosthetic surgery.

With the onset of a metabolic syndrome epidemic and the increasing life expectancy, erectile dysfunction (ED) has become a more common condition. As incidence and prevalence increase, the medical field is focused on providing more appropriate therapies. It is common knowledge that ED is a chronic condition that is also associated with a myriad of other disorders. Conditions such as aging, diabetes mellitus, hypertension, obesity, prostatic hypertrophy, and prostate cancer, among others, have a direct implication on the onset and progression of ED. Characterization and recognition of risk factors may help clinicians recognize and properly treat patients suffering from ED. One of the most reliable treatments for ED is penile prosthetic surgery. Since the introduction of the penile prosthesis (PP) in the early seventies, this surgical procedure has improved the lives of thousands of men, with reliable and satisfactory results. The aim of this review article is to characterize the epidemiology of men undergoing penile prosthetic surgery, with a discussion about the most common conditions involved in the development of ED, and that ultimately drive patients into electing to undergo PP placement.

Perplexity of penile rehabilitation following radical prostatectomy.

Radical prostatectomy has significantly improved prostate cancer survival rates but continues to have a negative impact on the patient's erectile function (EF). In attempts to improve erectile dysfunction (ED), clinicians have incorporated different treatment modalities to restore EF. Penile rehabilitation consists of understanding the mechanisms that affect post-prostatectomy EF and utilizing pharmacologic agents, devices, and interventions to promote the male sexual function. This article aims to summarize the available scientific research involving penile rehabilitation. Even though the current literature lacks to prove its irrefutable effectiveness, penile rehabilitation has a positive impact at the molecular and cellular levels, and it is widely adopted in clinic practices.

Non-Infectious Reservoir-Related Complications During and After Penile Prosthesis Placement.

INTRODUCTION: Inflatable penile prosthesis (IPP) surgery offers a high satisfaction rate and low rate of complications when performed by experienced surgeons. However, reservoir placement, either in the space of Retzius (SOR), or alternative/ectopic locations, may lead to an array of serious complications that may require revision surgery. AIM: To review the prevalence and management options for non-infectious intraoperative and postoperative complications related to prosthetic reservoirs. METHODS: A Medline PubMed search was used to identify articles related to IPP reservoir-related complications including bladder and bowel injury, vascular injury, autoinflation, herniation, palpability, leakage, and tubing torsion. MAIN OUTCOME MEASURE: Rates and types of reservoir-related complications during and after IPP surgery. RESULTS: Non-infectious reservoir-related complications in the intraoperative setting include injury to pelvic structures such as bladder, bowel, and blood vessels. In the postoperative setting, patients may experience autoinflation and reservoir herniation that might require revision surgery. Patients undergoing alternative reservoir placement (ARP) may complain of reservoir palpability and premature mechanical failure secondary to reservoir leakage or tubing torsion. CONCLUSION: Although most surgeons continue to use the SOR as the main location for reservoir placement, ARP has gained popularity owing to its low risk of bother, minimal loss of functionality, and safety advantages in patients with history of pelvic surgery. Both reservoir placement in the SOR and ARP carry a low rate of complications while maintaining a high satisfaction rate. Clavell-Hernández J, Shah A, Wang R. Non-Infectious Reservoir-Related Complications During and After Penile Prosthesis Placement. Sex Med Rev 2019;7:521-529.

New Developments in Surgical Treatment for Penile Size Preservation in Peyronie's Disease.

INTRODUCTION: Peyronie's disease (PD) is associated with penile length loss due to atrophy that occurs as a result of fibrous inelastic scarring. Studies have shown diminished penile length and girth, as well as the inability to participate in sexual activity, can lead to decreased quality of life, emotional challenges, and sexual dissatisfaction in a large percentage of men. AIM: To provide a summary of the new developments in the surgical techniques available for the PD patient, with a focus on procedures that provide penile size restoration. METHODS: A MEDLINE PubMed search was used to identify articles related to surgical treatments for PD, including plication procedures, penile prosthesis placement, and techniques for size restoration. MAIN OUTCOME MEASURE: Types of surgical treatments for PD and their outcomes regarding penile length and patient satisfaction. RESULTS: The Nesbit procedure, among other plication procedures, and penile prosthesis placement with modeling or plication are likely to decrease penile length. Although plaque incision with grafting offers restoration of penile length, it carries a risk of postoperative erectile dysfunction (ED). For men with concomitant ED and severe curvature not amenable to prosthesis with modeling or plication, options include grafting, circumferential tunical incisions, subcoronal prosthesis placement, and the sliding technique with its modifications, allowing for management of both PD and ED while restoring penile length. Adjunct procedures, such as ventral phalloplasty and suspensory ligament release, have also been shown to restore length in PD patients. Novel therapies continue to evolve with the goal of preserving length while treating curvature. CONCLUSION: There are numerous surgical options for correcting penile curvature in PD patients, with or without concomitant ED treatment. When determining the optimal procedure, it is important to consider possible preservation of penile length and to discuss possible complications to increase patient satisfaction and improve quality of life. Barrett-Harlow B, Clavell-Hernandez J, Wang R. New Developments in Surgical Treatment for Penile Size Preservation in Peyronie's Disease. Sex Med Rev 2019;7:156-166.

Penile Prosthesis Reservoir Removal: Surgical Description and Patient Outcomes.

BACKGROUND: Removal of the penile prosthesis reservoir can be technically challenging because of its difficult locations either deep in the pelvis or high in the abdominal wall. AIM: To describe a detailed surgical technique for reservoir removal through a penoscrotal approach. METHODS: We describe our preferred method for removal of prosthetic reservoir and present a retrospective review of patient outcomes after reservoir removal. MAIN OUTCOME MEASURE: Primary outcomes included immediate or late complications. Secondary outcomes included operative time. RESULTS: 34 patients underwent reservoir removal with the use of our described technique. 23 patients (67.6%) had reservoirs removed because of device malfunction and 11 (32.4%) because of infection. A total of 18 reservoirs (52.9%) were found in the space of Retzius (SOR), whereas the other 16 (47.1%) were in an alternative/ectopic space. 2 cases (5.9%) required a counterincision to remove the reservoir. Mean overall operative time was 96.2 minutes (range 35-175). There were no complications in this series. There was no statistical difference in operative time between reservoirs removed because of malfunction when compared with infection (P = .283). However, there was a difference in operative time between reservoirs removed from the SOR when compared with those removed from an ectopic space, with mean operating room times of 104.5 and 75.4 minutes, respectively (P = .001). CLINICAL IMPLICATIONS: Reservoir removal through a penoscrotal incision is feasible and safe. STRENGTH & LIMITATIONS: This is the first report, to our knowledge, describing surgical techniques and outcomes for reservoir removal. Limitations include its retrospective nature and lack of validated questionnaires to assess patient satisfaction. CONCLUSION: Although removal of a reservoir deep in the SOR or placed in alternate/ectopic locations can be challenging, the use of a lighted retractor, meticulous dissection, and a few technical maneuvers described allow for safe removal of the reservoir completely intact while avoiding complications. Our technique for a secondary incision in particularly difficult cases is also described. Clavell-Hernández J, Aly SG, Wang R, et al. Penile Prosthesis Reservoir Removal: Surgical Description and Patient Outcomes. J Sex Med 2019;16:146-152.

Penile Size Restoration With Nondegloving Approach for Peyronie's Disease: Initial Experience.

INTRODUCTION: The sliding technique (ST), commonly done with a subcoronal circumcising incision with penile degloving, has been used to restore penile size in patients with severe Peyronie's disease (PD) and erectile dysfunction, but with a potential risk of ischemic injury to the glans penis. AIM: To provide detailed surgical techniques regarding the nondegloving ventral incision and report our initial experience with this approach to perform the ST and penile prosthesis placement in patients with severe PD. METHODS: This was a retrospective review of patient outcomes after penile prosthesis placement with penoplasty for severe PD and erectile dysfunction from January 2015 to December 2017. MAIN OUTCOME MEASURES: Primary outcomes included straightening rates, penile measurement, along with immediate and late complications. Secondary outcomes include operative time and overall patient satisfaction. RESULTS: 12 Patients had significant penile atrophy and/or curvature >60 degrees and underwent inflatable penile prosthesis placement with grafting procedure. Significant penile atrophy was determined by a combination of the patient's subjective report and the surgeon's objective assessment through stretched penile length. 7 (58.3%) of those patients underwent ST, of which the last 5 had the procedure performed through a nondegloving ventral incision. Mean degree of curvature prior to ST was 66 degrees (45-90 degrees). Mean penile length gain was 2.6 cm (2.0-3.0 cm). At a mean follow-up of 15.5 months (3-31 months), only 1 patient had minimal residual curvature of 15 degrees. There were no vascular complications. CLINICAL IMPLICATIONS: This nondegloving technique theoretically maintains blood flow continuity to the glans penis by preserving the continuity of the skin, dartos fascia, and neurovascular bundle. STRENGTHS & LIMITATIONS: Strengths of this study include the novel nature of this approach, no incidence of vascular complications, and adaptability to other grafting procedures during penile prosthesis placement. Limitations include the use of 5-item International Index of Erectile Function scores to assess preoperative erectile function on PD, small population, longer incision, and a possible steep learning curve. CONCLUSION: While ischemic complications of ST and penile prosthesis implantation are rare, there are reports of ischemic injury in patients undergoing a subcoronal circumcising incision with penile degloving. The non-degloving technique with ventral incision provides for an alternative method for ST and penile prosthesis placement to maintain dartos and skin continuity to the glans penis while still allowing for adequate surgical exposure. Clavell-Hernández J, Wang R. Penile Size Restoration With Nondegloving Approach for Peyronie's Disease: Initial Experience. J Sex Med 2018;15:1506-1513.