Use of amnion chorion and umbilical cord grafts in conjunction with penile implant procedures.

Biologics have increased in popularity lately as a novel and exciting new therapy for men with a spectrum of sexual dysfunction ailments-ranging from erectile dysfunction, Peyronie's disease, and ejaculatory disorders. In this series, sequential patients were analyzed who received biologic materials at the time of their penile implant surgery, with various metrics assessed. The information gathered includes recovery time, need for postoperative analgesics, and satisfaction with the final outcome. In this study, early metrics appear to point to improved outcomes in select criteria. Further study will need to address whether treatment with biologics has broader appeal, but in the penile implant patient, the surgery seems to be augmented with the placement of biologic material into the surgical wound.

Live Donor Renal Transplant With Simultaneous Bilateral Nephrectomy for Autosomal Dominant Polycystic Kidney Disease Is Feasible and Satisfactory at Long-term Follow-up.

BACKGROUND: Timing of bilateral nephrectomy (BN) is controversial in patients with refractory symptoms of autosomal dominant polycystic kidney disease (APKD) in need of a renal transplant. METHODS: Adults who underwent live donor renal transplant (LRT) + simultaneous BN (SBN) from August 2003 to 2013 at a single transplant center (n = 66) were retrospectively compared to a matched group of APKD patients who underwent LRT alone (n = 52). All patients received general health and polycystic kidney symptom surveys. RESULTS: Simultaneous BN increased operative duration, estimated blood loss, transfusions, intravenous fluid, and hospital length of stay. Most common indications for BN were pain, loss of abdominal domain, and early satiety. There were more intraoperative complications for LRT + SBN (6 vs 0, P = 0.03; 2 vascular, 2 splenic, and 1 liver injury; 1 reexploration to adjust graft positioning). There were no differences in Clavien-Dindo grade I or II (39% vs 25%, P = 0.12) or grade III or IV (7.5% vs 5.7%, P = 1.0) complications during the hospital course. There were no surgery-related mortalities. There were no differences in readmission rates (68% vs 48%, P = 0.19) or readmissions requiring procedures (25% vs. 20%, P = 0.51) over 12 months. One hundred percent of LRT + SBN allografts functioned at longer than 1 year for those available for follow-up. Survey response rate was 40% for LRT-alone and 56% for LRT + SBN. One hundred percent of LRT + SBN survey responders were satisfied with their choice of having BN done simultaneously. CONCLUSIONS: Excellent outcomes for graft survival, satisfaction, and morbidity suggest that the combined operative approach be preferred for patients with symptomatic APKD to avoid multiple procedures, dialysis, and costs of staged operations.

Review: Alternative Placement of Penile Prosthesis Reservoir and AUS Pressure Regulating Balloon.

INTRODUCTION: Ectopic placement of prosthetic balloons and reservoirs in urological surgery has gained popularity, and early experience suggests that such placement is safe and efficacious. We review the artificial urinary sphincter (AUS) pressure regulating balloon (PRB) and inflatable penile prosthesis (IPP) reservoir placement and the factors relating to ectopic vs. traditional paravesical placement of these devices. METHODS: Articles from peer-reviewed journals, abstracts, and surgeons' series of outcomes form the basis for this review. Relevant mechanical function of devices and pertinent anatomy is reviewed. MAIN OUTCOME MEASURES: To review the current data regarding ectopic and conventional reservoir placement for the AUS and IPP. RESULTS: Traditional and ectopic placements of the AUS PRB and IPP reservoir have been shown to be safe and effective. There are well-documented risks associated with both traditional and ectopic approaches, and these risks must be weighed in the context of a specific clinical scenario and surgeon comfort. CONCLUSION: Traditional and ectopic placement of prosthetic balloons and reservoirs should be guided by patient characteristics and surgeon experience. Our early experience is in agreement with that of others in that ectopic placement of these devices appears to be a viable alternative in the appropriately selected patient and may be a technically easy procedure to learn for the experienced prosthetic surgeon. Reznicek DG, Bryson R, and Kramer AC. REVIEW: Alternative placement of penile prosthesis reservoir and AUS pressure regulating balloon. Sex Med Rev 2015;3:48-55.

Subarachnoid versus General Anesthesia in Penile Prosthetic Implantation: Outcomes Analyses.

The leading patient complaint during the perioperative period for penile prosthesis implantation is postoperative pain, while emesis and urticaria also affect the procedure's perceived success. In analyzing surgical outcomes, assessment of the anesthetic for postoperative pain and side effects should be included. This paper retrospectively reviews 90 consecutive, primary inflatable penile prosthetic operations performed by a single surgeon at one private medical center. Fifty-seven patients were included in final analysis. Patients who had more than one procedure that day or who used chronic pain medication were excluded. The type and amount of each drug used for each respective side effect (within the first 24 hours after procedure) were compared to determine relative benefit. Twenty patients received general anesthesia (denoted herein as "GA") and 37 received spinal (or also known as subarachnoid) anesthesia (denoted herein as "SA"). Patients receiving GA had significantly greater (P < 0.0001) occurrence and amount of intravenous pain treatment than those receiving SA. Patients with SA required less intravenous pain medication and less treatment for nausea/emesis.

A survey of patients with inflatable penile prostheses: assessment of timing and frequency of intercourse and analysis of implant durability.

INTRODUCTION: This study was conducted to determine how long after inflatable penile prosthesis (IPP) surgery patients attempt sexual intercourse and the frequency of subsequent relations. We also examined survival-related factors for the AMS 700 CX, Mentor Alpha 1, and Mentor Alpha Narrow Base. AIMS: The aim was to survey men who received IPPs and collect information about their return to sexual function and frequency of use, and to assess the resilience of their devices. METHODS: Phase I involved retrospective chart review of 1,298 virgin IPP surgeries performed by one surgical team from January 1992 to December 1998. Phase II included 330 subjects selected by stratified, systematic, random sampling from phase I patients. Data were collected by computer-assisted telephone interview, using a 27-question survey. All patients had been instructed to wait 4 weeks before using the implant and were taught how to inflate/deflate their prostheses at the 4-week postsurgical visits. MAIN OUTCOME MEASURES: The survey examines the length of time after surgery for men to resume sexual function. In the same study, information was garnered about mechanical durability of the device. RESULTS: Among phase I subjects, the 5-year survival rate was 83% (N = 1,069) for IPP revision for any reason. Of the 330 phase II subjects, 248 (75%) were successfully contacted; 199 (80%) responded to the full survey and 49 (20%) responded to selected parts of the survey. Sexual intercourse was resumed postoperatively at 1-4 weeks for 41% (78/190), at 5-6 weeks for 31% (59/190), at 7-8 weeks for 16% (30/190), and at >8 weeks for 12% (23/190) of the patients. More than 60% of patients reported using their IPP at least once weekly. CONCLUSION: The three-piece IPP has excellent 5-year survival rates. Most patients return to sexual activity relatively quickly, with high frequency of usage of their prostheses.

An outcomes analysis of over 200 revision surgeries for penile prosthesis implantation: a multicenter study.

INTRODUCTION: Inflatable penile prosthesis (IPP) implantation is a well-established treatment for medically refractory erectile dysfunction, with long-term reliability. Overall survival is 96% at 5 years and 60% at 15 years for primary (virgin) implantation. AIM: The aim of this study was to explore factors associated with success and complications of IPP revision surgery in a multicenter study. MAIN OUTCOME MEASURES: Reasons for revision including mechanical issues, patient dissatisfaction, corporal deformity, and supersonic transport (SST) deformity were recorded. METHODS: At four institutions, 214 clinically uninfected IPP revisions were performed between November 2000 and November 2007. Data were incomplete for 28 cases (14%). Failure-free survival was estimated using Kaplan-Meier's Meier product limit method. RESULTS: The majority of revisions were secondary to mechanical failure (N = 109; 65%) and combined erosion or infection (N = 17 + 15 = 32; 19%). Sixteen percent (N = 26) were carried out on functional uninfected prostheses secondary to patient dissatisfaction (N = 9), SST deformity (N = 10), scrotal hematoma (N = 2), or upsize revision because of corporal fibrosis (N = 5). Average age at revision was 66 years. Mean follow-up time was 55.7 months. In this study, 12 individuals required a secondary revision procedure or suffered a complication. Despite prior reports of high infection rates with revision surgery, only 5.7% of clinically uninfected and noneroded prostheses were complicated by infection or impending extrusion/erosion, following a revision washout protocol. Overall, 93% of cases were successfully revised, providing functioning IPPs. CONCLUSIONS: For this study population, component exchange followed by revision washout showed a low incidence of infection and subsequent mechanical failure.

Penile fracture seems more likely during sex under stressful situations.

INTRODUCTION: The unusual event of penile fracture occurs when there is a disruption of the tunica albuginea surrounding engorged erectile tissue during aggressive sexual behavior. There is often an audible crack and rapid detumescence with subcutaneous hemorrhage that follows. AIMS: Medical literature has described the etiology and treatment of penile fracture. We report the remarkably unusual social situations of a series of patients who sustained this unique injury. METHODS: We conducted a retrospective chart review of 16 patients whose injury was severe enough to require surgical repair at the University of Maryland between 2007 and 2011. Particular attention was paid to the intake interview in the emergency department and the postoperative chart notes by the attending urologist to ascertain out-of-the-ordinary social situations in which the injury was sustained. MAIN OUTCOME MEASURES: The occurrence of penile fracture is sufficiently rare that the author was able to interact personally with most of the patients. The patients were remarkably forthcoming with the personal social dynamics of the sexual encounter. RESULTS: Half of these penile fracture patients sustained the injury during an extramarital affair. Only three patients sustained the injury in a bedroom; the remainder was in out-of-the-ordinary locations for sexual intercourse, e.g., cars, elevator, the workplace, and public restrooms. CONCLUSIONS: Penile fracture patients appear to be a unique population of men who are having sexual intercourse under stressful situations. Extramarital affairs and out-of-the-ordinary locations appear common in patients sustaining this relatively rare injury.

Patient expectations prior to coloplast titan penile prosthesis implant predicts postoperative satisfaction.

INTRODUCTION: Managing and understanding expectations of patients prior to inflatable penile prosthesis (IPP) surgery is a critical. Clinicians vary in the way they explain the operation, and patients have varied expectations prior to surgery. AIMS: The goal is to understand the role that preoperative counseling and patients' realistic understanding of IPP surgery play in determining postoperative satisfaction. METHODS: 21 Patients underwent IPP surgery, and received a preoperative expectations survey, then, 4 months later, gave a single score of 1-100 (1 is very dissatisfied, 100 is extremely satisfied). MAIN OUTCOME MEASURES: The results were correlated with an R(2) value and visualized on a scatter plot. This significance is tested using a two-tailed test. RESULTS: Lower preoperative expectations scores correlated almost linearly with higher satisfaction scores after surgery. The R (Pearson) value was -0.489, with an R(2) of 0.239. This was significant using a two-tailed test, with a P value of 0.0245. CONCLUSION: Giving patients an accurate description of the procedure and setting realistic expectations leads to higher postoperative satisfaction.

Living-donor renal transplantation of grafts with incidental renal masses after ex-vivo partial nephrectomy.

OBJECTIVES: To assess transplantation of high-risk kidneys with incidental renal masses (found occasionally during the routine evaluation of a living kidney donor) into recipients with limited life-expectancy on haemodialysis, as this offers a potential solution to the current organ deficit. PATIENTS AND METHODS: We detected five small (<2.3 cm), incidental, enhancing renal masses during donor evaluation. All patients had a standard metastatic evaluation. After laparoscopic donor nephrectomy a back-table partial nephrectomy was performed and frozen-section analysis was used to confirm both the diagnosis and negative surgical margins before transplantation. RESULTS: Renal cell carcinoma was found in three of the five masses (one each cystic, clear cell and papillary; Fuhrman grades II, II and III, respectively) and the other two patients had angiomyolipoma. There were no long-term complications in the transplanted kidneys. One patient developed delayed acute humoral rejection after transplantation and was treated appropriately. Both donor and recipient were followed with periodic imaging. At a median (range) last follow-up of 15 (1-41) months, four patients were alive and one had died from complications after a fall. The cancer-specific survival was 100%. There was no evidence of local recurrence in any patient at the last follow-up. CONCLUSION: Live donor kidneys with incidental small renal masses might be acceptable for transplantation in high-risk recipients after careful back-table partial nephrectomy.

Sperm retrieval from terminally ill or recently deceased patients: a review.

OBJECTIVE: Requests for sperm extraction in terminally ill or recently deceased patients have been increasing with the gained acceptance and success of assisted reproductive techniques such as in vitro fertilization and intracytoplasmic sperm injection. This review aims to outline the many challenges associated with these requests. MATERIALS AND METHODS: The medical literature surrounding ethical and legal issues of posthumous sperm extraction was examined. RESULTS: Several issues within the field of sperm extraction in the terminally ill patient and the postmortem patient still arouse a significant amount of debate and controversy. One controversial factor surrounds the issue of consent for the tissue extraction and determining when family consent is valid. Other discussions have involved ethical issues, logistics (including cost), and legal issues. CONCLUSIONS: A medical center protocol governing sperm extraction from terminally ill or recently deceased patients would be beneficial, and would likely alleviate stress among the patients' families and healthcare providers. To overcome some of the difficulties surrounding the issue of consent, it might also be valuable for men about to get married or enter into a similar relationship to document their wishes for sperm retrieval should a tragic situation arise. This could be done in the same way that they would prepare a living will.

Penile prosthesis implantation compares favorably in malpractice outcomes to other common urological procedures: findings from a malpractice insurance database.

INTRODUCTION: Some urologists choose not to offer penile prostheses because of concern over malpractice liability. AIM: The aim of this study was to assess whether urologists performing penile prosthesis surgery are placed at a greater malpractice risk. MAIN OUTCOME MEASURES: Percentage of malpractice suits from prosthesis surgery and other urological procedures that result in payment, average resulting payout from these cases, and category of legal issue that ultimately resulted in payout. METHODS: A database from the Physician Insurers Association of America, an association of malpractice insurance companies covering physicians in North America, was analyzed to quantitatively compare penile implant surgery to other urological procedures in medicolegal terms. RESULTS: Compared to other common urological procedures, penile implant is comparable and on the lower end of the spectrum in terms of both the percentage of malpractice suits that result in payment and the amount ultimately paid in indemnity from those cases. Additionally, issues of informed consent play the largest role in indemnities for all urological procedures, whereas surgical technique is the most important issue for prosthesis surgery. CONCLUSIONS: Urologists who are adequately trained in prosthetic surgery should not avoid penile implant procedures for fear of malpractice suits. A focus on communication and informed consent can greatly reduce malpractice risk for urological procedures.

Report of two cases of bladder perforation caused by reservoir of inflatable penile prosthesis.

INTRODUCTION: Rupture of penile prosthesis reservoir into the bladder is an unusual and unexpected occurrence after prosthesis component replacement for malfunction. Scant literature exists describing a pathophysiology, diagnosis, and repair with device salvage. AIM: Our goal is to describe an uncommon event in prosthetic surgery, and discuss the pathophysiology and ways to treat and perhaps avoid this occurrence. METHODS: Two patients presented with gross hematuria in the recovery room following repair of a cylinder to pump tubing break of their inflatable penile prostheses (IPPs). In each operation, the existing reservoir had been left in situ and refilled once placed in circuit with new cylinders and pump. RESULTS: The reservoirs had immediately ruptured into the bladder upon refilling, and were identified intravesically on cystoscopy and computed tomography scan. A one-step approach can be done to salvage the device, remove the eroded reservoir with bladder repair, and new reservoir placed directly into appropriate space. Interpretation. During IPP revision, even when a reservoir is not manipulated simple tubing repair performed, gross hematuria in the recovery room likely signals bladder perforation. We include recommendations for reservoir management with implant revision, as well as surgical management and prevention of this complication. CONCLUSIONS: Bladder perforation can be caused by penile implant revision even when the old reservoir is not manipulated. If this complication occurs, it can be surgically managed immediately. This can also potentially be avoided.