Sub-external oblique placement of inflatable penile prosthesis reservoirs-initial experience.

Multiple-component inflatable penile prostheses (IPPs) consist of paired intracorporal cylinders, a scrotal pump, and an abdominal fluid reservoir. In recent years, ectopic (e.g., non-space of Retzius) reservoir insertion techniques have become more popular among implanting urologists. The aim of this study was to describe our technique of sub-external oblique (SEO) placement of IPP reservoirs, and to review our initial experience with this technique. We carried out a retrospective review of the first 50 patients who underwent insertion of a Coloplast Titan® IPP via a scrotal incision, employing a newly developed SEO reservoir insertion technique. All procedures were carried out by a single high-volume surgeon (BBG), and retrospective chart review was carried out. Patients were seen and evaluated on the first post-operative day, then at 2 weeks, 6 weeks, as needed, and periodically thereafter. All 50 patients were available for short-term post-operative follow-up (average 6.6 months, range 3-12 months). The SEO technique was only used if there was no prior inguinal canal surgery, and no evidence of an inguinal hernia. The SEO technique was easy to carry out, and there were no instances of bowel, bladder, blood vessel, nerve, or spermatic cord injury. There were also no cases of reservoir herniation, intraperitoneal insertion, or reservoir visibility. One patient had prolonged pain (4 weeks) related to the reservoir; however, this completely resolved after treatment with non-steroidal analgesics. In asthenic patients, the reservoir could be detected with deep, careful palpation. However, no patients have required or requested IPP revision or removal to date. With short-term follow-up, we found that SEO reservoir insertion has been an easily-performed and safe option for ectopic reservoir insertion. The SEO method has avoided the infrequent but severe complications seen with previously described reservoir insertion techniques. Longer duration of follow-up, and trials by other implanting urologists, will be required to confirm or refute these initial promising results.

CT imaging of inflatable penile prosthesis complications: a pictorial essay.

PURPOSE: Inflatable penile prostheses (IPPs) are widely used in the United States, for patients with erectile dysfunction refractory to other treatments. Complications subsequent to IPP insertion include infection, hematoma, fluid leak, component (cylinder/pump/reservoir) complications, and retained previous IPP components. Radiologists are often called upon to identify and characterize these complications utilizing CT prior to intervention. Our paper aims to provide a guide to familiarize radiologists with normal IPP component imaging and review the CT findings of commonly encountered complications. METHODS: In this study, we retrospectively reviewed CT reports with descriptions of IPPs from 108 patients. We collected CT images of normal IPP components as well as reevaluated the CT findings of 33 patients with an IPP complication and correlated with immediately subsequent operative report. RESULTS: The CT appearance of appropriately positioned normal IPP components in asymptomatic patients and each complication were described and compared to previous literature. CONCLUSIONS: CT is a very useful modality to assess an IPP-related complication. It is inexpensive, fast, and immediately available in emergent situations, e.g., infection, hematoma, and component erosion. Additionally, CT is very sensitive and makes it easier to diagnose a system leak. It can identify most cylinder complications and pump malposition and can be extremely helpful to the surgeon in preoperative planning if revision is needed. After this review, the radiologist should be able to identify normal IPP components and their complications.

Inflatable Penile Prosthesis Insertion in Men with Severe Intracorporal Fibrosis.

OBJECTIVES: To retrospectively review a series of men who underwent attempted inflatable penile prosthesis (IPP) insertion into severely scarred corpora, and to analyze the surgical techniques and instruments that contributed to a successful outcome. PATIENTS AND METHODS: All IPP procedures done by a high-volume prosthetic surgeon during a 5-year period were retrospectively reviewed. Fourteen patients with severe intracorporal fibrosis underwent 15 attempted IPP insertion procedures, and are the subject of this review. RESULTS: A standardized surgical approach was employed for all patients. Thirteen of the 15 procedures were successful (i.e., an IPP was inserted, with satisfactory cylinder position). One procedure failed due to corporal obliteration. One patient underwent an initial failed attempt, but was successfully implanted 10 months later. Two of the 14 patients (14%) developed peri-prosthetic infection and were explanted. CONCLUSION: IPP insertion into scarred corpora is difficult and occasionally impossible. We have developed a standardized surgical approach for these cases, using limited corporal excavation, followed by the use of sequential Uramix and then Carrion-Rossello cavernotomes, that we feel has improved our chance of a successful implant. However, due to the rarity of these cases, it is not possible to make definitive statements concerning the optimal surgical technique.

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.

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.

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.

Pseudo-malfunction of the Coloplast Titan Inflatable Penile Prosthesis One-Touch Release Pump.

OBJECTIVE: To define and describe a type of pseudo-malfunction of the Coloplast Titan Inflatable Penile Prosthesis (IPP) One-Touch Release (OTR) pump (Coloplast Corp, Minneapolis, MN). MATERIALS AND METHODS: We retrospectively reviewed a consecutive series of 550 patients with refractory organic erectile dysfunction who were implanted with a Coloplast Titan IPP with the OTR pump during a period of approximately 4 years. RESULTS: All patients were implanted using standard techniques through an infrapubic or penoscrotal approach. Twenty-nine patients (5.3%) complained that their IPP would not inflate and that the pump bulb felt "hard." Examination revealed that their IPP was working normally; however, the inflate/deflate valve disc had become stuck in the deflate position. Very firm pressure had to be applied to the pump bulb to move the valve disc into the inflate position. Once this was accomplished, the device inflated and deflated normally. Another 14 patients (2.5%) reported this phenomenon to us but were able to apply enough pressure on the pump bulb to rectify it. CONCLUSION: The inflate/deflate valve disc in the Coloplast Titan OTR pump can occasionally become stuck in the deflate position (7.8% of patients in our experience). Patients may be unable to inflate the device and return for evaluation. In all cases we have encountered, firm pressure on the pump bulb caused the valve to shift into the inflate position, and the device worked properly thereafter. Patients and implanting urologists should be aware of this issue and of the way in which it can be rectified.

Outcomes of abdominal wall reservoir placement in inflatable penile prosthesis implantation: a safe and efficacious alternative to the space of Retzius.

INTRODUCTION: Inflatable penile prosthesis (IPP) surgery is a successful therapeutic option for men with erectile dysfunction. Traditional placement of the reservoir in the retropubic space of Retzius is associated with the rare occurrence of significant complications including bladder, bowel, and vascular injury. An alternative site, posterior to the abdominal wall musculature, has been identified as a potentially safer location for reservoir placement. AIMS: The aim of this study was to describe our technique of abdominal reservoir placement during infrapubic IPP surgery and present our outcomes data. METHODS: We retrospectively reviewed our experience with abdominal reservoir placement during virgin IPP cases. Reservoirs placed anterior and posterior to transversalis fascia were analyzed separately. MAIN OUTCOME MEASURE: The main outcome measures was assessment of reservoir-related complications including palpable reservoir, reservoir herniation, and injuries to bowel, bladder, or major blood vessels. RESULTS: There were no injuries to bowel or major blood vessels with abdominal reservoir placement posterior or anterior to the transversalis fascia in properly segregated patients. CONCLUSION: Abdominal reservoir placement is a safe and simple surgical method that can be recommended for most men undergoing IPP placement. Men with a history of pelvic surgery can have the reservoir placed between the rectus abdominis musculature and transversalis fascia, while other men can have the reservoir placed between transversalis fascia and peritoneum in order to avoid a palpable reservoir. By applying this protocol, the catastrophic injuries that occur rarely with retropubic reservoir placement can be reliably avoided.

Prostate cryoablation in patients with multiple-component inflatable penile prostheses.

OBJECTIVE: To evaluate and assess any inflatable penile prosthesis (IPP)-related complications in patients with organ-confined prostate cancer treated definitively with third-generation, ultrasound-guided prostate cryoablation. MATERIAL AND METHODS: From November 2003 to October 2010, we identified 100 consecutive patients with clinically organ-confined prostate cancer who were treated with targeted cryoablation as primary or salvage therapy by a single surgeon. Review of these patients revealed 13 who had previously been diagnosed with organic erectile dysfunction and had been implanted with a multiple-component IPP by the same surgeon. To assess IPP complications related to the cryoablation procedure, we retrospectively reviewed events occurring within a 6-month postoperative follow-up period. RESULTS: For the entire series, the patient ages ranged from 42-84 years (mean 68). Of the 13 patients with IPPs, no device-related complication (eg, IPP infection, erosion, or malfunction) was found. No patient required IPP revision or removal. CONCLUSION: Patients with organ-confined prostate cancer who also have a multiple-component IPP may safely undergo ultrasound-guided prostate cryoablation as definitive therapy. Cryoprobe and thermocouple placement must be carried out carefully, using ultrasound guidance. To avoid IPP reservoir injury, suprapubic tube placement should be avoided.

Coloplast titan inflatable penile prosthesis with one-touch release pump: review of 100 cases and comparison with genesis pump.

INTRODUCTION: In 2008 Coloplast Corporation modified their Titan inflatable penile prosthesis (IPP) with a new One-Touch Release (OTR) pump, in an attempt to facilitate device deflation. There is currently little published data concerning this new pump. AIM: The aim of this pilot study was to assess initial patient and physician experience with the Titan OTR pump. METHODS: Retrospective chart review was used to assess the functionality and surgeon experience with 100 consecutive patients implanted with a Titan OTR pump, compared with 100 prior consecutive patients implanted with a Titan Genesis pump. MAIN OUTCOME MEASURES: The ease of implantation of the OTR pump, the number of required postoperative inflate/deflate teaching visits, and OTR pump functionality were assessed and compared with that of the prior Genesis pump. RESULTS: The mean length of follow-up in the Genesis group (N = 100) was 20.8 months, and mean length of follow-up in the OTR group (N = 100) was 8.4 months. There was one device infection in each group. The average number of postoperative teaching sessions needed to teach the patient how to operate the device was 1.87 in the Genesis group, and 1.19 in the OTR group (P < 0.001). The range of teaching visits was 1-5 in the Genesis group, and 1-3 in the OTR group (P < 0.001). No pump malfunctions were seen in either group. Subjectively, the OTR pump was just as easy to implant as the Genesis pump. In addition, the OTR pump was subjectively easier for the surgeon and the patient to deflate, and just as easy to inflate, compared with the Genesis pump. CONCLUSIONS: This pilot study revealed that the OTR pump functioned as specified by the manufacturer. With short-term follow-up, no pump malfunctions were detected. The OTR pump was associated with a statistically significant reduction in the number of postoperative teaching sessions required for the patient to properly operate the device. It was subjectively just as easy to implant and inflate, and easier to deflate, compared with the Genesis pump.

Inflatable penile prostheses for the treatment of erectile dysfunction: an update.

Male erectile dysfunction (ED) is a common medical condition. Three oral medications (sildenafil, vardenafil and tadalafil, all phosphodiesterase type 5 inhibitors) have been developed and approved for the treatment of ED by the US FDA. Extensive worldwide marketing of these medications has raised public awareness of ED, and allowed many previously untreated men to seek and receive effective therapy. A variety of other ED treatments are available and approved by the FDA, including vacuum-constriction devices and intracavernous or intraurethral alprostadil. However, roughly 30-40% of men with ED are not adequately served by these treatments due to their cost, side effects, contraindications, the need to 'time' sexual activity, or lack of satisfactory erectile response. For men who do not respond to less invasive therapy, an inflatable penile prosthesis can provide a satisfying and effective alternative. This article will review and critique the inflatable penile prostheses that are currently available in the USA and the EU for the treatment of ED.