Are Urine Cultures Necessary Prior to Urologic Prosthetic Surgery?

INTRODUCTION: A preoperative negative urine culture is generally advised before implantation of urologic prosthetics to prevent device infection. However, a review of the medical literature indicates sparse evidence to support this practice. AIM: To describe outcomes for patients undergoing prosthetic implantation without preoperative urine cultures. METHODS: The cases of men undergoing artificial urinary sphincter (AUS) and/or inflatable penile prosthesis (IPP) placement at a tertiary care center from 2007 through 2015 were reviewed. Of 713 devices implanted in 681 patients (337 AUSs in 314 patients, 376 IPPs in 367), 259 cases without preoperative urine cultures were analyzed (41%). Patients received standard perioperative antibiotics. MAIN OUTCOME MEASURES: Device infection was diagnosed clinically. Average follow-up was 15 months. RESULTS: Device infection occurred in 4 of 259 patients (1.5%) with no difference noted in infection rate between device groups (AUS = 3 of 174 [2%]; IPP = 1 of 85 [1%]; P = .99); this rate appears to be consistent with the infection rate of numerous other published prosthetic series. Common skin organisms were implicated as the infectious agents in half the infected devices. Only one patient (0.4%) developed an Escherichia coli infection. CONCLUSION: This study suggests that prosthetic urologic surgery can be safely performed without preoperative urine cultures. Kavoussi NL, Viers BR, Pagilara TL, et al. Are Urine Cultures Necessary Prior to Urologic Prosthetic Surgery? Sex Med Rev 2018;6:157-161.

Inflatable penile prosthesis as tissue expander: what is the evidence?

ABSTRACT Objective: Many patients who undergo inflatable penile prosthesis (IPP) replacement are often upsized to larger cylinders, suggesting the IPP may serve as a tissue expander and increase internal penile length. The objective of this study is to evaluate whether cylinder length increases with subsequent IPP insertion. Materials and Methods: We queried American Medical Systems and Coloplast Patient Information Form databases to identify patients who underwent IPP placement and replacement between 2004-2013. Patients were grouped by device type and time to replacement (<2 or ≥2 years). We selected the 2-year mark for subgroup analysis to allow time for tissue expansion to occur and to exclude patients who underwent early explantation (e.g. erosion or infection). Results: Two thousand, seven hundred and forty nine patients (1,532 AMS 700 LGX, 717 AMS 700 CX, and 500 Coloplast Titan) met the inclusion criteria. Mean time between implants was earlier for LGX (29 months) than CX (39 months) and Titan (48 months) patients (p<0.001). Patients who underwent device replacement at <2 years did not experience an increase in mean cylinder length. On the contrary, patients who underwent device replacement at ≥2 years did experience significant increases in mean cylinder length (LGX 1.2 cm, CX 1.1 cm, and Titan 0.9 cm, p<0.001). The mean increases in length at ≥2 years were similar between the 3 devices (p=0.20). Sixty percent of patients demonstrated increases of >0.5 cm and 40% demonstrated increases of ≥1 cm. Conclusions: As demonstrated, the IPP may provide tissue expansion over time. Further evaluation is needed to determine if increased cylinder length correlates to increased functional length and patient satisfaction.

Inflatable penile prosthesis as tissue expander: what is the evidence?

OBJECTIVE: Many patients who undergo inflatable penile prosthesis (IPP) replacement are often upsized to larger cylinders, suggesting the IPP may serve as a tissue expander and increase internal penile length. The objective of this study is to evaluate whether cylinder length increases with subsequent IPP insertion. MATERIALS AND METHODS: We queried American Medical Systems and Coloplast Patient Information Form databases to identify patients who underwent IPP placement and replacement between 2004-2013. Patients were grouped by device type and time to replacement (<2 or ≥2 years). We selected the 2-year mark for subgroup analysis to allow time for tissue expansion to occur and to exclude patients who underwent early explantation (e.g. erosion or infection). RESULTS: Two thousand, seven hundred and forty nine patients (1,532 AMS 700 LGX, 717 AMS 700 CX, and 500 Coloplast Titan) met the inclusion criteria. Mean time between implants was earlier for LGX (29 months) than CX (39 months) and Titan (48 months) patients (p<0.001). Patients who underwent device replacement at <2 years did not experience an increase in mean cylinder length. On the contrary, patients who underwent device replacement at ≥2 years did experience significant increases in mean cylinder length (LGX 1.2 cm, CX 1.1 cm, and Titan 0.9 cm, p<0.001). The mean increases in length at ≥2 years were similar between the 3 devices (p=0.20). Sixty percent of patients demonstrated increases of >0.5 cm and 40% demonstrated increases of ≥1 cm. CONCLUSIONS: As demonstrated, the IPP may provide tissue expansion over time. Further evaluation is needed to determine if increased cylinder length correlates to increased functional length and patient satisfaction.

Preoperative Urine Culture Results Correlate Poorly With Bacteriology of Urologic Prosthetic Device Infections.

INTRODUCTION: Although preoperative negative urine culture results and treatment of urinary tract infections are generally advised before artificial urinary sphincter (AUS) and penile prosthesis (PP) surgery to prevent device infection, limited evidence exists to support this practice. AIM: To evaluate the relation between preoperative urine culture results and the bacteriology of prosthetic device infections. METHODS: Men undergoing AUS and/or PP placement at a tertiary referral center from 2007 through 2015 were analyzed. A total of 713 devices were implanted in 681 patients (337 AUSs in 314 patients and 376 PPs in 367 patients), of whom 259 (36%) did not have preoperative urine culture and were excluded. The remaining 454 patients received standard broad-spectrum perioperative antibiotics. Two patient groups were identified based on preoperative urine cultures: group 1 had negative urine culture results and group 2 had untreated asymptomatic positive urine culture results identified postoperatively. MAIN OUTCOME MEASURES: Device infection was diagnosed clinically and cultures obtained from the explanted device and tissue spaces were compared with preoperative urine culture results. RESULTS: Although multivariate analysis showed that patients undergoing AUS placement had a 4.5-fold greater risk of positive urine culture results (114 of 250, 45%) compared with those undergoing PP placement (36 of 204, 18%; P < .001), infection rates between device types were similar (8 of 250 for AUSs [3%] and 7 of 204 for PPs [3%]; P = .89). At a median follow-up of 15 months, device infection occurred in 15 of 454 devices (3%) implanted and no differences in infection rates were noted between urine culture groups (10 of 337 in group 1 [3.3%] and 5 of 117 in group 2 [4.3%]; P = .28). Remarkably, only 1 of 15 device infections (7%) had the same organism present at preoperative urine culture. CONCLUSIONS: Despite the finding that patients with AUS placement had a 4.5 times higher rate of positive urine culture results than patients with PP placement, preoperative urine culture results appeared to show little correlation with the bacteriology of prosthetic device infections.

Rapid excision of massive localized lymphedema of the male genitalia with vessel sealing device.

INTRODUCTION: To present a series of patients who underwent surgical treatment for massive localized lymphedema (MLL) of the male genitalia and explore the utility of the LigaSure hemostatic vessel sealing device (VSD) for resection of advanced cases. MATERIALS AND METHODS: Although conservative and microsurgical treatments have been reported, MLL of the male genitalia requires open surgical resection with primary reconstruction. We reviewed our prospectively maintained database of all lymphedema excisions performed between January 2007 and December 2014 comparing resection with Bovie electrocautery to resection with the LigaSure VSD. Our analysis focused on any significant differences in rate of resection, estimated blood loss (EBL), and recurrence. RESULTS: Nineteen patients with MLL of the male genitalia underwent excision with either LigaSure (8 patients) or conventional Bovie electrocautery (11 patients). Rate of resection was significantly faster with LigaSure compared to Bovie (33.74 g/min versus 5.32 g/min, p = .035). Additionally, estimated EBL per gram of tissue resected was decreased in the LigaSure group (0.41 mL/g versus 0.17 mL/g, p = .057). Two of the 11 Bovie patients (18%) had recurrence of lymphedema requiring repeat resection, while none of the LigaSure patients developed recurrence. CONCLUSIONS: Resection of genital lymphedema using the LigaSure device offers promising results in managing advanced MLL of the male genitalia with the potential for faster resections, less EBL per tissue resected, and a lower rate of recurrence.

Classification System for Individualized Treatment of Adult Buried Penis Syndrome.

BACKGROUND: The authors present their experience with reconstructive strategies for men with various manifestations of adult buried penis syndrome, and propose a comprehensive anatomical classification system and treatment algorithm based on pathologic changes in the penile skin and involvement of neighboring abdominal and/or scrotal components. METHODS: The authors reviewed all patients who underwent reconstruction of adult buried penis syndrome at their referral center between 2007 and 2015. Patients were stratified by location and severity of involved anatomical components. Procedures performed, demographics, comorbidities, and clinical outcomes were reviewed. RESULTS: Fifty-six patients underwent reconstruction of buried penis at the authors' center from 2007 to 2015. All procedures began with a ventral penile release. If the uncovered penile skin was determined to be viable, a phalloplasty was performed by anchoring penoscrotal skin to the proximal shaft, and the ventral shaft skin defect was closed with scrotal flaps. In more complex patients with circumferential nonviable penile skin, the penile skin was completely excised and replaced with a split-thickness skin graft. Complex patients with severe abdominal lipodystrophy required adjacent tissue transfer. For cases of genital lymphedema, the procedure involved complete excision of the lymphedematous tissue, and primary closure with or without a split-thickness skin graft, also often involving the scrotum. The authors' overall success rate was 88 percent (49 of 56), defined as resolution of symptoms without the need for additional procedures. CONCLUSION: Successful correction of adult buried penis often necessitates an interdisciplinary, multimodal approach. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Intraoperative Decision-making for Precise Penile Straightening During Inflatable Penile Prosthesis Surgery.

OBJECTIVE: To present a novel algorithm for definitive reconstruction of penile curvature in men undergoing inflatable penile prosthesis (IPP) surgery as an alternative to manual penile modeling and grafting procedures. METHODS: Patients with erectile dysfunction and concomitant penile curvature undergoing IPP placement were divided into 2 treatment groups: (1) group 1, penile deformity known preoperatively, and (2) group 2, penile curvature recognized intraoperatively after IPP placement. Group 1 patients underwent penile plication after artificial erection and immediately before IPP insertion via the same penoscrotal incision, whereas group 2 patients were treated with a Yachia (Heineke-Mikulicz) corporoplasty over the intact cylinders. Patients completed postoperative Patient Global Impression of Improvement (PGI-I) questionnaires assessing overall satisfaction. RESULTS: Among 405 men receiving IPP at our institution from 2007 to 2014, 30 patients received synchronous correction of penile curvature (7%). Group 1 included 23 of 30 (77%) patients, and 7 of 30 (23%) were in group 2. Overall mean initial curvature was 36°, and all patients were corrected to < 10°. Average operative times were 18 minutes longer compared with patients who underwent IPP placement alone (82 vs 64 minutes, P <.05). At an average follow-up of 13 months (range 7-32), 19 of 20 (95%) group 1 and 6 of 7 (86%) group 2 patients who completed surveys reported an improved overall condition. No patient reported chronic pain, recurrent deformity, or device malfunction. CONCLUSION: Penile curvature can be safely and reliably corrected at the time of IPP placement, regardless of whether the deformity was identified preoperatively.

Repeat Excision and Primary Anastomotic Urethroplasty for Salvage of Recurrent Bulbar Urethral Stricture.

PURPOSE: We compared the results of initial excision and primary anastomosis urethroplasty to the excision and primary anastomosis outcomes of other challenging reoperative clinical settings, including secondary cases (prior urethroplasty of any technique other than excision and primary anastomosis) and repeat cases (prior excision and primary anastomosis). MATERIALS AND METHODS: We reviewed our database of patients who underwent excision and primary anastomosis urethroplasty for bulbar urethral stricture at our tertiary referral center from 2007 to 2014. Patients without available data and those with a history of lichen sclerosus, radiation, pelvic fracture urethral injuries, distal strictures and/or hypospadias were excluded from analysis. Patient characteristics and outcomes were compared between those undergoing initial, secondary, and repeat excision and primary anastomosis urethroplasty for bulbar urethral stricture. RESULTS: Among 898 urethroplasties performed during the study period we identified 305 men who underwent excision and primary anastomosis urethroplasty of the bulbar urethra, including an initial procedure in 268 of 305 (88%) and reoperation in 37 (12%). Of patients with reoperation 18 of 37 (49%) underwent secondary excision and primary anastomosis following a different type of prior urethroplasty and 19 (51%) underwent repeat excision and primary anastomosis. Repeat excision and primary anastomosis in the bulbar urethra was successful in 18 of 19 patients (95%), which was comparable to the success rate of initial bulbar excision and primary anastomosis (251 of 268 or 94%) as well as secondary bulbar excision and primary anastomosis (17 of 18 or 94%, p = 0.975) with a similar mean stricture length. Mean followup for all patients was 41.5 months (range 6 to 90) and mean followup in each group was greater than 30 months. CONCLUSIONS: Repeat excision and primary anastomosis urethroplasty has excellent results for short bulbar strictures, comparable to those achieved in the initial and secondary setting.

Ventral Slit Scrotal Flap: A New Outpatient Surgical Option for Reconstruction of Adult Buried Penis Syndrome.

INTRODUCTION: We present a novel technique using ventral slit with scrotal skin flaps (VSSF) for the reconstruction of adult buried penis without skin grafting. TECHNICAL CONSIDERATIONS: An initial ventral slit is made in the phimotic ring, and the penis is exposed. To cover the defect in the ventral shaft skin, local flaps are created by making a ventral midline scrotal incision with horizontal relaxing incisions. The scrotal flaps are rotated to resurface the ventral shaft. Clinical data analyzed included preoperative diagnoses, length of stay, blood loss, and operative outcomes. Complications were also recorded. Fifteen consecutive patients with a penis trapped due to lichen sclerosus (LS) or phimosis underwent repair with VSSF. Each was treated in the outpatient setting with no perioperative complications. Mean age was 51 years (range, 26-75 years), and mean body mass index was 42.6 kg/m(2) (range, 29.8-53.9 kg/m(2)). The majority of patients (13 of 15, 87%) had a pathologic diagnosis of LS. Mean estimated blood loss was 57 cc (range, 25-200 cc), mean operative time was 83 minutes (range, 35-145 minutes), and all patients were discharged on the day of surgery. The majority of patients (11 of 15, 73.3%) remain satisfied with their results and have required no further intervention. Recurrences in 3 of 15 (20.0%) were due to LS, panniculus migration, and concealment by edematous groin tissue; 2 of these patients underwent subsequent successful skin grafting. CONCLUSION: VSSF is a versatile, safe, and effective reconstructive option in appropriately selected patients with buried penis, which enables reconstruction of penile shaft skin defects without requiring complex skin grafting.

Does Pressure Regulating Balloon Location Make a Difference in Functional Outcomes of Artificial Urinary Sphincter?

PURPOSE: We compared functional outcomes in patients who received an artificial urinary sphincter in the space of Retzius vs the same device placed at a high submuscular location. MATERIALS AND METHODS: We reviewed a prospectively maintained database of patients who received an artificial urinary sphincter between July 2007 and December 2014. After cuff placement was completed via a perineal incision, a 61 to 70 cm H2O pressure regulating balloon was placed through a separate high scrotal incision in the space of Retzius or in a high submuscular tunnel. Demographics, perioperative comorbidities and functional outcomes were compared between the groups. RESULTS: A total of 294 consecutive patients underwent artificial urinary sphincter placement. Mean followup was 23 months. Space of Retzius and high submuscular placement was performed in 140 (48%) and 154 patients (52%), respectively. Functional outcomes were similar between the groups, including the continence rate (defined as 0 or 1 pad daily) in 81% vs 88% (p = 0.11), the erosion rate in 9% vs 8% (p = 0.66) and the explantation rate in 10% vs 11% (p = 0.62). Artificial urinary sphincter revision for persistent incontinence was required in a similar proportion of the 2 groups (13% vs 8%, p = 0.16) with a comparable mean followup (24 vs 23 months, p = 0.30). Kaplan-Meier analysis revealed no difference between the groups in the rate of explantation (p = 0.70) or revision (p = 0.06). CONCLUSIONS: High submuscular placement of a pressure regulating balloon at artificial urinary sphincter surgery is a safe, effective alternative with functional outcomes equivalent to those of traditional placement in the space of Retzius.

In situ urethroplasty after artificial urinary sphincter cuff erosion.

Artificial urinary sphincter (AUS) cuff erosion is a challenging complication traditionally managed with device removal and Foley catheter drainage. Urethral stricture can result secondary to the healing process, delaying AUS reimplantation. In situ urethroplasty (ISU) technique is a definitive repair at the time of device removal. Early results demonstrate a decreased rate of stricture formation compared to traditional management with little additional operative time and no additional complications. Patients undergoing ISU have less delay prior to AUS reimplantation, leading to possible benefit in health-related quality of life (HRQL) outcomes.

Malleable penile prosthesis is a cost-effective treatment for refractory ischemic priapism.

INTRODUCTION: Refractory ischemic priapism (RIP) can be difficult to treat, consuming significant healthcare-related resources. Acute insertion of a malleable penile prosthesis (MPP) has been reported as an effective therapy that treats the priapism and restores sexual function. AIM: We report our 6-year, urban public hospital experience with acute insertion of MPP in patients with RIP. METHODS: We retrospectively reviewed the records of patients receiving MPPs for RIP from 2007 to 2013. Data analyzed included duration of erection, number of emergency room (ER) visits, hospital admissions, days of hospitalization, and postoperative course. Costs were estimated using standard Medicare reimbursement rates. MAIN OUTCOME MEASURE: Healthcare-related costs of treatment of RIP episodes in men presenting to our institution. RESULTS: During the study period, 14 men underwent MPP placement acutely for refractory priapism. Thirteen presented with RIP, and one had stuttering priapism over a 14-day hospitalization. Etiologies included sickle cell anemia (4/13, 29%), medication-induced (3/14, 21%), and idiopathic (7/14, 50%). Average preoperative duration of RIP was 82 hours with considerable consumption of health-care resources (average US $83,818 estimated cost, 4 ER visits [range 1-27], 2 hospital admissions [range 1-5], 1.5 shunt procedures [range 1-3], 5 irrigation and drainage procedures using phenylephrine injection [range 2-20], and 5 hospital admission days [range 2-14]). All patients were discharged within 24 hours of MPP surgery. CONCLUSIONS: The management of RIP is associated with multiple ER visits, prolonged hospital admissions, and significant resource utilization. MPP insertion is efficacious for the immediate resolution of refractory priapism, with potential cost and resource benefits.

Ventral and dorsal buccal grafting for 1-stage repair of complex anterior urethral strictures.

OBJECTIVE: To describe our 14-year experience with a 1-stage tissue transfer urethroplasty technique. METHODS: Eighteen patients underwent reconstruction with circumferential buccal grafting. All patients had anterior urethral strictures that included segments of total or near-total obliteration not amenable to excisional or augmented anastomotic repair and intact corpus spongiosum that could serve as a graft recipient bed. The mobilized corpus spongiosum was incised dorsally without transection, thereby preserving the continuity of the blood supply within the spongy tissue. Buccal mucosa was quilted to the corporal bodies to reconstruct the dorsal aspect of the urethra. Where there was obliterative or near-obliterative stricture disease, additional buccal mucosa was quilted to the dorsally incised, nontransected corpus spongiosum in continuity with the distally and proximally spatulated urethra. The repair was then completed by approximating dorsal and ventral buccal mucosal graft segments. RESULTS: Follow-up included voiding cystourethrogram at 3 weeks, cystoscopy 4 months after surgery (1 patient refused), and subsequent follow-up. There was 1 early stricture recurrence, which was successfully treated with direct vision internal urethrotomy (success 94%, and 100% after 1 urethrotomy). Every patient was contacted and assessed at the time of manuscript preparation. All patients are currently free of obstructive symptoms attributed to stricture disease with a mean follow-up of 50 months (range, 5-171 months). CONCLUSION: Dorsal and ventral buccal grafting appears to be an excellent option for a 1-stage repair of long obliterative anterior urethral strictures and strictures that include segments of obliterative or near-obliterative disease in selected cases.