Revisión sistemática de la implantación de prótesis de pene en cirugía mayor ambulatoria / Systematic review of the implantation of penile prosthesis in major ambulatory surgery

Introducción y objetivo La implantación de prótesis deZ pene (PP) es una alternativa eficaz para la disfunción eréctil. Aunque inicialmente la cirugía de PP se realizaba en régimen hospitalario, existe una tendencia creciente a realizar el implante de PP en un modelo de cirugía mayor ambulatoria (CMA). El objetivo de este estudio es realizar una revisión sistemática de la literatura para identificar la evidencia disponible sobre la implantación de PP en el marco de la CMA en comparación con el procedimiento realizado en régimen hospitalario. Material y métodos Se realizó una búsqueda en las bases de datos electrónicas PubMed, EMBASE, Cochrane Library y MEDES y en los suplementos no indexados de los congresos científicos para identificar artículos relacionados con la implantación quirúrgica de PP en CMA hasta febrero de 2021. Los términos de búsqueda incluyeron prótesis de pene, disfunción eréctil, cirugía ambulatoria, atención ambulatoria y cirugía. Resultados Entre las 171 publicaciones obtenidas (51 en PubMed, 73 en EMBASE, 3 en Cochrane, 2 mediante MEDES y 42 mediante búsqueda manual), se seleccionaron finalmente 5 estudios. No hubo diferencias significativas entre la CMA y el régimen hospitalario en términos del tipo de dispositivo, el abordaje quirúrgico o la ubicación del reservorio. Las tasas de complicaciones observadas en ambos grupos fueron similares. La implantación de PP en régimen de CMA supuso un menor coste que la cirugía en régimen hospitalario y se asoció con tasas aceptables de satisfacción de los pacientes y un adecuado control del dolor. Conclusiones Los estudios demostraron que la implantación de PP en régimen de CMA puede lograr resultados similares en términos de seguridad y satisfacción a la implantación de PP en el régimen hospitalario, pudiendo también reducir los costes y mejorar la eficiencia. Esta investigación podría ayudar a los responsables de la toma de decisiones a extender la cirugía de PP al régimen ambulatorio (AU)

Introduction and objective Penile prosthesis (PP) implantation is an effective option for erectile dysfunction. Although initially PP surgery was carried out in an inpatient setting, there is a growing trend to implant PP in a major ambulatory surgery (MAS). This study aimed to perform a systematic review of the literature to identify available evidence of the implantation of PP under MAS setting and go carry out a comparison between MAS and inpatient procedures. Material and methods PubMed, EMBASE, Cochrane Library and MEDES electronic databases and non-indexed supplements for scientific congresses were searched to identify articles related to the surgical implantation of PP in MAS up to February 2021. Key search terms included penile prosthesis, erectile dysfunction, ambulatory surgery, ambulatory care, and surgery. Results Among 171 publications retrieved (51 PubMed, 73 EMBASE, 3 Cochrane, 2 using MEDES and 42 manual searching), 5 studies were finally selected. There were no significant differences between MAS or inpatient setting in terms of the type of device, surgical approach, or location of reservoir. Complication rates observed in both groups were similar. Implantation of PP in MAS was less expensive than inpatient surgery and was associated with acceptable patient satisfaction rates and adequate pain control. Conclusions Studies demonstrated that outpatient PP surgery can achieve similar outcomes in terms of safety and satisfaction to implantation of PP in the inpatient setting, while it could reduce costs and improve the efficiency. This research could provide support decision makers to extend PP surgery into the ambulatory setting (AU)

Systematic review of the implantation of penile prosthesis in major ambulatory surgery.

INTRODUCTION AND OBJECTIVE: Penile prosthesis (PP) implantation is an effective option for erectile dysfunction. Although initially PP surgery was carried out in an inpatient setting, there is a growing trend to implant PP as a major ambulatory surgery (MAS). This study aimed to perform a systematic review of the literature to identify available evidence of the implantation of PP under MAS setting and go carry out a comparison between MAS and inpatient procedures. MATERIAL AND METHODS: PubMed, EMBASE, Cochrane Library and MEDES electronic databases and non-indexed supplements for scientific congresses were searched to identify articles related to the surgical implantation of PP in MAS up to February 2021. Key search terms included penile prosthesis, erectile dysfunction, ambulatory surgery, ambulatory care, and surgery. RESULTS: Among 171 publications retrieved (51 PubMed, 73 EMBASE, 3 Cochrane, 2 using MEDES and 42 manual searching), 5 studies were finally selected. There were no significant differences between MAS or inpatient setting in terms of the type of device, surgical approach, or location of reservoir. Complication rates observed in both groups were similar. Implantation of PP in MAS was less expensive than inpatient surgery and was associated with acceptable patient satisfaction rates and adequate pain control. CONCLUSIONS: Studies demonstrated that outpatient PP surgery can achieve similar outcomes in terms of safety and satisfaction to implantation of PP in the inpatient setting, while it could reduce costs and improve the efficiency. This research could support decision makers to extend PP surgery into the ambulatory setting.

Análisis de satisfacción y resultados quirúrgicos de un programa de cirugía mayor ambulatoria para el implante de prótesis de pene / Analysis of satisfaction and surgical outcomes of a major ambulatory surgery program for penile implant

INTRODUCCIÓN Y OBJETIVO: El implante de prótesis de pene (PP) es llevado a cabo en muchos centros como régimen de hospitalización. Recientemente en nuestro centro hemos iniciado su realización como cirugía mayor ambulatoria (CMA), reduciendo la estancia hospitalaria. El objetivo de este estudio ha sido evaluar la viabilidad, complicaciones y satisfacción de las PP implantadas en CMA en nuestro centro. MATERIAL Y MÉTODOS: Estudio observacional retrospectivo de los resultados y satisfacción de las PP realizadas en CMA en el Hospital Universitario de Bellvitge durante 2018. RESULTADOS: En 2018 se realizaron 49 PP: 27 (55,1%) hospitalizadas y 22 (44,9%) ambulatorias. De estas 22, 2 (9,1%) fueron segundos implantes. Los pacientes recibieron anestesia general y bloqueo locorregional crural, dorsal del pene y del plano transverso del abdomen (TAP). Las tasas de complicaciones entre hospitalizados y CMA fueron similares, 2 (7%) y 1 (5%) respectivamente, sin reportar ningún caso de infección ni requerir la retirada del implante. Postoperatoriamente se realizó una encuesta telefónica contactando a 19 (86%) pacientes: 16 (84%) consideraron adecuado el tiempo de estancia, 15 (79%) volverían a intervenirse en CMA y 15 (79%) lo recomendarían, siendo el motivo de reticencia la preocupación por la falta de asistencia médica en el domicilio y evitar volver a las 24 h para retirar el drenaje. Todos tuvieron buen control del dolor sin requerir mórficos en el postoperatorio. CONCLUSIONES: En nuestra serie, el implante de PP en CMA ha resultado ser viable y seguro. A pesar de que existen puntos de mejoría, se mantiene una correcta satisfacción del paciente y buen control del dolor, sin implicar un aumento de las complicaciones ni readmisiones

INTRODUCTION AND OBJECTIVE: Penile prosthesis (PP) surgery is performed in many institutions as an inpatient procedure. We have recently initiated a major ambulatory surgery (MAS) program, thus reducing the hospital stay. The objective of this study was to assess the feasibility, complications and satisfaction of the implantation of outpatient surgery PP program in our hospital. MATERIAL AND METHODS: Retrospective observational study evaluating the results and satisfaction of PP implanted as an outpatient procedure in Bellvitge University Hospital during 2018. RESULTS: During 2018 we implanted 49 PP: 27 (55%) inpatient surgeries vs. 22 (45%) outpatient surgeries. Of these 22, 2 (9%) were second implants. All patients underwent both general anesthesia and crural, proximal dorsal nerve and transversus abdominis plane block (TAP). Complication rates between inpatient and outpatient procedures were similar, 2 (7%) and 1 (5%), respectively, without reporting infections or requiring PP removal. Postoperatively, a satisfaction telephone survey was conducted in 19 (86%) patients: 16 (84%) considered the time of hospital stay as appropriate, 15 (79%) would have preferred to be operated again in an outpatient care setting and 15 (79%) would recommend it. The patients' main concerns were related to being at home with no medical assistance at home and about coming back the next day for drainage removal. All patients reported well-controlled pain without requiring opioid intake in any case. CONCLUSIONS: In our series, PP implantation in an ambulatory care setting is feasible and safe. Although there are some aspects that should be improved, the program showed acceptable satisfaction rates and an adequate postoperative pain control, neither raising the administration of opioids, nor increasing complications and re-admission rates

Cirugía de prótesis peneana: indicaciones y técnica infrapúbica / Infrapubic surgical approach for penile prosthesis surgery: Indications and technique

CONTEXTO: El implante de prótesis de pene es actualmente el tratamiento más resolutivo para la disfunción eréctil tras la ineficacia o contraindicación del tratamiento farmacológico. Son muchas las vías de abordaje descritas para su implante, prevaleciendo en la actualidad la vía escrotal, la infrapúbica y la subcoronal. OBJETIVOS: Describir la técnica quirúrgica del abordaje infrapúbico, evaluar sus indicaciones, complicaciones y valorar sus ventajas y desventajas respecto al abordaje escrotal. ADQUISICIÓN Y SÍNTESIS DE LA EVIDENCIA: Se realizó una búsqueda de publicaciones desde el año 1983 hasta la actualidad en bases de datos (Medline PubMed y Cochrane Library) siguiendo los criterios PRISMA. Dieciséis artículos fueron incluidos: 4 prospectivos, 4 retrospectivos, una revisión sistemática, una ensayo aleatorizado, un artículo original, 5 artículos de opinión/descripción de técnica quirúrgica. DISCUSIÓN: Según los artículos revisados, actualmente el abordaje más usado es el escrotal. Aun así, la vía infrapúbica es una técnica más rápida y con tendencia a reducir el tiempo de retorno a la actividad sexual. Las tasas de complicaciones son escasas, teniendo cifras similares al abordaje escrotal, sin haberse recogido casos de hipostesia del glande y con tasas de infección inferiores al 3%. Además, cuenta con cifras de satisfacción elevadas, superando el 80%. CONCLUSIONES: El implante de prótesis de pene requiere de una familiarización con los diferentes abordajes quirúrgicos para adaptar cada técnica a cada caso. La vía infrapúbica, a pesar de no ser la más empleada, es igual de válida que la vía escrotal para el implante de prótesis de pene de 3 componentes, siendo eficaz, segura y con altas tasas de satisfacción para los pacientes y sus parejas

CONTEXT: Penile prosthesis surgery is currently the most effective treatment for erectile dysfunction when medical treatment is ineffective or contraindicated. Among the surgical approaches described in the literature, the scrotal, infrapubic and subcoronal are the most common in the daily clinical practice. OBJECTIVES: The main objectives were to describe the infrapubic surgical technique evaluating its indications and complications, as well as comparing its advantages and disadvantages with the penoscrotal approach. ACQUISITION AND SYNTHESIS OF THE EVIDENCE: A literature review from 1983 until current date was carried out in Medline (PubMed and Cochrane Library databases) following PRISMA standards. Sixteen studies were included: 4 prospective, 4 retrospective, one systematic review, one randomized trial, one original article, 5 expert opinion/surgical technique descriptive paper. DISCUSSION: According to the literature reviewed, although the penoscrotal approach is the most applied, the infrapubic approach showed a shorter operative time and a tendency for an earlier recovery of sexual activity after surgery. Complications are rare, having similar rates to the penoscrotal approach; no cases of glans hypoesthesia have been reported and peri-prosthetic infection rates were less than 3%. Satisfaction rates of infrapubic penile prosthesis were higher than 80%. CONCLUSIONS: Penile prosthesis implantation requires of a profound knowledge of the different surgical approaches in order to best adapt each technique based on each individualized case. The infrapubic approach, even if it is not the most used, is as feasible and reliable as the penoscrotal approach. The infrapubic approach is effective and safe, with high level of both, patients and partners' satisfaction

Analysis of satisfaction and surgical outcomes of a major ambulatory surgery program for penile implant. / Análisis de satisfacción y resultados quirúrgicos de un programa de cirugía mayor ambulatoria para el implante de prótesis de pene.

INTRODUCTION AND OBJECTIVE: Penile prosthesis (PP) surgery is performed in many institutions as an inpatient procedure. We have recently initiated a major ambulatory surgery (MAS) program, thus reducing the hospital stay. The objective of this study was to assess the feasibility, complications and satisfaction of the implantation of outpatient surgery PP program in our hospital. MATERIAL AND METHODS: Retrospective observational study evaluating the results and satisfaction of PP implanted as an outpatient procedure in Bellvitge University Hospital during 2018. RESULTS: During 2018 we implanted 49 PP: 27 (55%) inpatient surgeries vs. 22 (45%) outpatient surgeries. Of these 22, 2 (9%) were second implants. All patients underwent both general anesthesia and crural, proximal dorsal nerve and transversus abdominis plane block (TAP). Complication rates between inpatient and outpatient procedures were similar, 2 (7%) and 1 (5%), respectively, without reporting infections or requiring PP removal. Postoperatively, a satisfaction telephone survey was conducted in 19 (86%) patients: 16 (84%) considered the time of hospital stay as appropriate, 15 (79%) would have preferred to be operated again in an outpatient care setting and 15 (79%) would recommend it. The patients' main concerns were related to being at home with no medical assistance at home and about coming back the next day for drainage removal. All patients reported well-controlled pain without requiring opioid intake in any case. CONCLUSIONS: In our series, PP implantation in an ambulatory care setting is feasible and safe. Although there are some aspects that should be improved, the program showed acceptable satisfaction rates and an adequate postoperative pain control, neither raising the administration of opioids, nor increasing complications and re-admission rates.

Infrapubic surgical approach for penile prosthesis surgery: Indications and technique. / Cirugía de prótesis peneana: indicaciones y técnica infrapúbica.

CONTEXT: Penile prosthesis surgery is currently the most effective treatment for erectile dysfunction when medical treatment is ineffective or contraindicated. Among the surgical approaches described in the literature, the scrotal, infrapubic and subcoronal are the most common in the daily clinical practice. OBJECTIVES: The main objectives were to describe the infrapubic surgical technique evaluating its indications and complications, as well as comparing its advantages and disadvantages with the penoscrotal approach. ACQUISITION AND SYNTHESIS OF THE EVIDENCE: A literature review from 1983 until current date was carried out in Medline (PubMed and Cochrane Library databases) following PRISMA standards. Sixteen studies were included: 4 prospective, 4 retrospective, one systematic review, one randomized trial, one original article, 5 expert opinion/surgical technique descriptive paper. DISCUSSION: According to the literature reviewed, although the penoscrotal approach is the most applied, the infrapubic approach showed a shorter operative time and a tendency for an earlier recovery of sexual activity after surgery. Complications are rare, having similar rates to the penoscrotal approach; no cases of glans hypoesthesia have been reported and peri-prosthetic infection rates were less than 3%. Satisfaction rates of infrapubic penile prosthesis were higher than 80%. CONCLUSIONS: Penile prosthesis implantation requires of a profound knowledge of the different surgical approaches in order to best adapt each technique based on each individualized case. The infrapubic approach, even if it is not the most used, is as feasible and reliable as the penoscrotal approach. The infrapubic approach is effective and safe, with high level of both, patients and partners' satisfaction.

Comparative analysis of penile implants in patients with vasculogenic erectile dysfunction versus postradical prostatectomy erectile dysfunction.

Penile prosthesis is the treatment of choice for erectile dysfunction (ED) refractory to medical treatment; vasculogenic ED and ED postradical prostatectomy (PRP) are the main aetiologies. Few studies have compared surgical outcomes of penile prosthesis placement for vasculogenic versus PRP severe erectile dysfunction. This study includes 117 cases corresponding to virgin implants for ED of either vasculogenic aetiology or PRP (58 for PRP and 59 for vasculogenic cases). We analysed data corresponding to: age, comorbidity, type of prosthesis, presence of fibrosis that hinders dilation, need for modelling, size of implanted cylinders and complications (intra and postoperative). In the results the rate of hypertension, diabetes, dyslipidaemia and ischemic heart disease was higher in vasculogenic ED. All of the prostheses were hydraulic; 24.1% of two components and 75.9% of three in the PRP group; 39% components of two and 61% of three in the vasculogenic group. With regard to the presence of cavernous fibrosis and need for modelling, no significant differences were found. However, significant differences were observed in the size of the implanted cylinders; PRP of 18.30 ± 2.11 cm versus 19.21 ± 1.71 cm in vasculogenic ED (p = 0.01643). There were no significant differences between the groups in infection rates, mechanical failure or extrusion. In conclusion the implantation of penile prosthesis in ED after PRP is associated with a shorter cylinder length compared with vasculogenic origin. Although there was a certain non-significant tendency to the need for modelling manoeuvres in PRP, there were no significant differences in postoperative outcomes including infection or mechanical failure.

El peso de la comorbilidad del paciente se correlaciona con la gravedad de la disfunción eréctil / The Patient's Comorbidity Burden Correlates with the Erectile Dysfunction Severity

Objetivo: Explorar la relación entre la disfunción eréctil (DE), los niveles de testosterona y el Índice de comorbilidad de Charlson (ICC). Material y métodos: Estudio transversal en pacientes derivados a la unidad de andrología de 7 hospitales españoles. La DE se diagnosticó y clasificó mediante el International Index of Erectile Function. Los niveles de testosterona, la prevalencia de cada comorbilidad y el ICC se compararon entre pacientes con distintos grados de DE. Además de la correlación entre la testosterona total y el ICC, la influencia de cada comorbilidad y de la severidad de la DE en el ICC se evaluaron mediante una regresión lineal múltiple. Resultados: El estudio incluyó 430 hombres con una media de 61 años de edad. El ICC medio fue 3,5 y la testosterona total 15,2nmol/l; 389 (91%) de los sujetos tenían algún grado de DE: 97 (23%) leve, 149 (35%) leve a moderada, 86 (20%) moderada y 57 (13%) severa. La severidad de la DE se asoció a un nivel menor de testosterona (p = 0,002) y a un mayor ICC (p < 0,001). Los niveles de testosterona fueron significativamente menores en pacientes con obesidad, diabetes, hipercolesterolemia e hipertrigliceridemia (p < 0,05). Sin embargo, únicamente la diabetes y la hipertensión mostraron una relación significativa con la DE. El modelo multivariado, que incluía variables relacionadas con todas las comorbilidades evaluadas, los niveles de testosterona y la severidad de la DE, predijo el ICC (p < 0,001, R2 = 0,426). La severidad de la DE mostró una contribución significativa al modelo (p = 0,011), pero la testosterona total no (p = 0,204). Conclusiones: El ICC se asocia significativamente con la severidad de la DE, pero muestra una correlación débil con los niveles de testosterona

Objective: To explore the potential relationship between erectile dysfunction (ED), low testosterone levels, and the Charlson Comorbidity Index (CCI). Material and methods: Cross-sectional study on patients referred to the andrology unit in 7 Spanish centers. The ED was diagnosed and graded using the International Index of Erectile Function (IIEF-5) score. Total testosterone, the prevalence of each comorbidity, and the CCI were compared between patients with different grades of ED. Besides, the correlation between total testosterone and the CCI score, the influence of each comorbidity, and the ED severity on the CCI was assessed in a multiple linear regression. Results: The study included 430 men with a mean age of 61 years. The mean CCI was 3.5, and mean total testosterone 15.2 nmol/L; 389 (91%) subjects had some grade of ED: 97 (23%) mild, 149 (35%) mild-to-moderate, 86 (20%) moderate, and 57 (13%) severe. The increase in ED severity was significantly associated with a decrease in total testosterone (P = .002), and an increase in the CCI score (P < .001). Testosterone levels were significantly lower in patients with obesity, diabetes, hypercholesterolemia, and hypertriglyceridemia (P < .05). However, only the prevalence of diabetes and hypertension was significantly associated with the severity of ED. The multivariate analysis including variables related to all assessed comorbidities, total testosterone levels, and the DE severity significantly predicted the CCI score (P < .001, R2 = .426). The severity of ED significantly contributed to this model (P = .011), but total testosterone did not (P = .204). Conclusions: The CCI is significantly associated with the ED severity, but it shows a weak correlation with the testosterone levels

The Patient's Comorbidity Burden Correlates with the Erectile Dysfunction Severity. / El peso de la comorbilidad del paciente se correlaciona con la gravedad de la disfunción eréctil.

OBJECTIVE: To explore the potential relationship between erectile dysfunction (ED), low testosterone levels, and the Charlson Comorbidity Index (CCI). MATERIAL AND METHODS: Cross-sectional study on patients referred to the andrology unit in 7 Spanish centers. The ED was diagnosed and graded using the International Index of Erectile Function (IIEF-5) score. Total testosterone, the prevalence of each comorbidity, and the CCI were compared between patients with different grades of ED. Besides, the correlation between total testosterone and the CCI score, the influence of each comorbidity, and the ED severity on the CCI was assessed in a multiple linear regression. RESULTS: The study included 430 men with a mean age of 61 years. The mean CCI was 3.5, and mean total testosterone 15.2 nmol/L; 389 (91%) subjects had some grade of ED: 97 (23%) mild, 149 (35%) mild-to-moderate, 86 (20%) moderate, and 57 (13%) severe. The increase in ED severity was significantly associated with a decrease in total testosterone (P=.002), and an increase in the CCI score (P<.001). Testosterone levels were significantly lower in patients with obesity, diabetes, hypercholesterolemia, and hypertriglyceridemia (P<.05). However, only the prevalence of diabetes and hypertension was significantly associated with the severity of ED. The multivariate analysis including variables related to all assessed comorbidities, total testosterone levels, and the DE severity significantly predicted the CCI score (P<.001, R2=.426). The severity of ED significantly contributed to this model (P=.011), but total testosterone did not (P=.204). CONCLUSIONS: The CCI is significantly associated with the ED severity, but it shows a weak correlation with the testosterone levels.

Effects of testosterone treatment on bone mineral density in men with testosterone deficiency syndrome.

The decline in testosterone levels found in men with testosterone deficiency syndrome (TDS) is associated with a decrease in bone mineral density (BMD). To study the safety profile and efficacy of testosterone treatment on BMD in patients with TDS. In this 2-year prospective open-label study, patients were administered 50 mg of testosterone gel daily (adjustable after 3 months up to 75-100 mg or down to 25 mg) for 12 months, followed by treatment with 1000 mg of testosterone undecanoate every 2-3 months from months 12-24. Outcome measures were as follows: (i) Changes in clinical chemistry safety parameters and total testosterone, sex hormone binding globulin and calculated free testosterone (cFT) levels; (ii) Changes in Aging Males' Symptoms Scale (AMS) and International Prostate Symptom Score scores; and (iii) Changes in lumbar spine and hip BMD. A total of 50 men aged 50-65 years with TDS (AMS >26 and cFT <0.250 nmol/mL) took part in the study. There was no significant impact of testosterone on safety. Prostate-specific antigen and haematopoietic parameters increased significantly, although the changes were not clinically significant. Total and cFT increased significantly after 3 months (p < 0.001) and there were significant improvements after 3 months in AMS scores (p < 0.001). BMD improved significantly in L2-L4 (2.90 and 4.5%), total femur (0.74 and 3%) and trochanter (1.09 and 3.2%) at 12 and 24 months respectively. Testosterone treatment in men with TDS has a good safety profile, leads to significant improvement in lumbar spine and hip BMD, and improves symptoms, as assessed by the AMS questionnaire.