State of the Reservoir: Current Concepts of Penile Implant Reservoir Placement and Potential Complications.

PURPOSE OF REVIEW: To discuss mechanical and surgical innovations in inflatable penile prosthesis (IPP) surgery and their implications on reservoir placement and patient outcomes. RECENT FINDINGS: The past decade has seen a new emphasis on optimizing outcomes and minimizing complications associated with IPP reservoirs. Innovations in device design have accordingly yielded safer, more durable IPP outcomes over the past four decades. Modifications in surgical approach for reservoir placement abound for both traditional space of Retzius and ectopic reservoir placement techniques. Surgical and medical history, patient anatomy, and patient preference should all be considered when choosing approach for IPP reservoir placement. Prosthetic urologists should be proficient in multiple approaches to provide the best care to their patients.

Trends in penile prosthesis implantation and analysis of predictive factors for removal.

PURPOSE: This study aims to analyze patient demographics, hospital characteristics, and clinical risk factors which predict penile prosthesis removal. We also examine costs of penile prosthesis removal and trends in inflatable versus non-inflatable penile prostheses implantation in the USA from 2003 to 2015. METHODS: Cross-sectional analysis from Premier Perspective Database was completed using data from 2003 to 2015. We compared the relative proportion of inflatable versus non-inflatable penile prostheses implanted. We separated the prosthesis removal group based on indication for removal-Group 1 (infection), Group 2 (mechanical complication), and Group 3 (all explants). All groups were compared to a control group of patients with penile implants who were never subsequently explanted. Multivariate analysis was performed to analyze patient and hospital factors which predicted removal. Cost comparison was performed between the explant groups. RESULTS: There were 5085 penile prostheses implanted with a stable relative proportion of inflatable versus non-inflatable prosthesis over the 13-year study period. There were 3317 explantations. Patient factors associated with prosthesis removal were non-black race, Charlson Comorbidity Index, diabetes, and HIV status. Hospital factors associated with removal included non-teaching status, hospital region, year of removal, and annual surgeon volume. Median hospitalization costs of all explantations were $10,878. Explantations due to infection cost $11,252 versus $8602 for mechanical complications. CONCLUSIONS: This large population-based study demonstrates a stable trend in inflatable versus non-inflatable prosthesis implantation. We also identify patient and hospital factors that predict penile prosthesis removal which has clinical utility for patient risk stratification and counseling.

Penile Prosthesis Surgery: Current Recommendations From the International Consultation on Sexual Medicine.

INTRODUCTION: Penile prosthesis implantation has emerged as a definitive treatment to restore sexual function to the motivated man with erectile dysfunction. Substantial improvements in the design of inflatable devices have been made since they first became available more than four decades ago. AIM: To review the history of the penile prosthesis, the indications, preoperative evaluation, and patient and partner satisfaction. The current approaches to addressing intra- and postoperative complications, provide an understanding of prosthesis infection, and placement of these devices will be reviewed. METHODS: A committee of worldwide experts in this field was assembled during the 2015 International Consultation on Sexual Medicine (ICSM) and performed a systematic review of the peer-reviewed published medical literature pertaining to penile prosthesis. Particular attention was given to higher level trials when available. Recommendations are based upon the Oxford Criteria. MAIN OUTCOME MEASURES: Unfortunately there is limited level 1 and 2 evidence, and where expert opinion was utilized, the decision was unanimous within the committee with a goal of presenting a clinically relevant guideline pertaining to penile prostheses. RESULTS: Penile prosthesis has undergone an evolution over the past 40 years resulting in a more effective and reliable treatment for advanced erectile dysfunction not responding to less invasive methods including oral treatment with PDE5 inhibitors, vacuum erection device, and intracorporal injection therapy. It should be considered an appropriate treatment option for the man who wishes to restore erectile function and who understands the potential risk of mechanical failure and infection, both of which are less common now as a result of improvements made in device design as well as surgical protocols adhered to in the operating room. Patients must be clearly informed of the risks associated with penile prosthesis including mechanical failure, infection, shortening of the penis, change in sensation and configuration of the penis, as well as injury to local structures. Intraoperative complications are unusual but do occur and can usually be addressed intraoperatively to allow placement of the device at the time of initial surgery. Postoperative complications may also be addressed when they occur but may require more advanced reconstructive surgical techniques. Men with Peyronie's disease, corporal fibrosis due to infection, trauma, prior prosthesis explantation, priapism, and men who have undergone construction of a neophallus may require additional advanced maneuvers to obtain optimum results with a penile prosthesis. CONCLUSION: Penile prosthesis remains as an important, viable, and effective treatment for male erectile dysfunction that does not respond to other less invasive approaches or when these approaches are contraindicated or not acceptable to the patient. These devices provide the patient with the ability to engage in penetrative sexual activity without interfering with urination, ejaculation, sensation, or orgasm. Although mechanical failure can occur, the current devices are more reliable as a result of design modifications. Infection remains the most dreaded complication but since the introduction of antibiotic and hydrophilic coatings, infection is less common. Overall, patient and partner satisfaction appear to be reasonably high when a penile prosthesis is used to restore erectile function.

The Evolution and Utility of the Small-Carrion Prosthesis, Its Impact, and Progression to the Modern-Day Malleable Penile Prosthesis.

INTRODUCTION: Erectile dysfunction has plagued humanity for millennia. For years, treatment had been in the hands of mental health professionals. It was not until the 1970s that urologists created a modality that was marketable, reproducible, and consistently successful at treating impotence, the Small-Carrion Penile Prosthesis. AIM: We present the evolution of the malleable/semi-rigid penile prosthesis, concentrating our efforts reviewing and critiquing the pivotal article published by Drs. Michael P. Small, Hernan M. Carrion, and Julian A. Gordon. We then discuss its continued advancement, current-day utilization, and the future of the malleable prosthesis. METHODS: From the early 1900s, surgeons have been toying with the idea of creating a penile implant. These initial attempts utilized rib cartilage, and eventually synthetic materials, including acrylic, silicone, and polyethylene. RESULTS: In 1975, Drs. Carrion and Small presented their initial experience of 31 patients utilizing their silicone implant. In their manuscript titled, "The Small-Carrion Penile Prosthesis: New Implant for the Management of Impotence," they discuss their technique, perioperative management of complications, and results. CONCLUSIONS: The malleable penile prosthesis continued to evolve throughout the years to the current day Genesis and Spectra. Although the current market is dominated by the inflatable penile prosthesis, there are specific situations where the malleable is ideally utilized. The pivotal article by Drs. Carrion and Small helped pave the way for the "New Era" of penile prosthetics and still remains one of the most impactful contributions to the management of erectile dysfunction.

100 Casos de implante de prótesis de pene de 3 componentes con nuevo sistema de bombeo: experiencia de 3 centros especializados / 100 cases of three-piece Inflatable Penile Prosthesis with new scrotal pump: Evaluation of 3 specialised centres

OBJETIVOS: Presentar nuestra experiencia con la prótesis de pene Coloplast Titan™ One-Touch Release. Evaluamos el correcto funcionamiento de la prótesis, facilidad de manejo, grado de satisfacción del paciente y de su pareja en los primeros 100 casos realizados en tres centros implantadores. MÉTODOS: Revisión retrospectiva de los 100 primeros pacientes tratados mediante la colocación de la prótesis de pene Coloplast Titan™ One-Touch Release (Octubre 2009 a Diciembre 2012). La función eréctil y la satisfacción por parte del paciente y su pareja se evaluaron mediante los cuestionarios: The International Index of Erectile Function (IIEF), Intercourse Satisfaction (IS) y EDITS modificado pre y postoperatorio. La facilidad de manejo fue evaluada en función del número de consultas de aprendizaje. RESULTADOS: La edad media de los pacientes (N:100) fue de 54.2 años (20-77). El seguimiento medio (N = 100) fue de 21 meses (6-44). La longitud media de las prótesis implantadas fue de 18.6 cm (14-23.5). Tan sólo un 3% de pacientes presentaron complicaciones que requirieron exploración quirúrgica. El buen funcionamiento de la prótesis fue confirmado en 99 pacientes (99%). Las diferencias en los valores de IIEF-EF y IIEF-IS pre y postoperatorios fueron +16.8 y +6.4 respectivamente (p < 0.05). El cuestionario EDITS modificado mostraba una satisfacción global del 90% de los pacientes y del 84% de las parejas. El número medio de consultas de aprendizaje fue de 1.28 (1-4). CONCLUSIONES: El modelo de prótesis de pene Coloplast Titan™ One-Touch Release es sencilla de implantar y manejar, con una importante mejora de la función eréctil y la satisfacción del paciente y su pareja

OBJECTIVES: The aim is to assess our experience with new Coloplast Titan™ Inflatable Penile Prosthesis (IPP) with One-Touch Release (OTR) pump. Our 3 main focuses of attention will be prosthesis performance and patient and partner satisfaction in our first 100 cases in 3 specialised centres by 2 principal surgeons. METHODS: Retrospective review was used to assess the Coloplast Titan™ OTR implant procedures/cases in our departments (from October 2009 to December 2012). The changes in Erection Function (EF), Intercourse Satisfaction (IS), overall satisfaction of the patient and partner were assessed by use of the following questionnaires: EF and IS domains of the International Index of Erectile Function (IIEF) and modified EDITS. RESULTS: Mean patient age (N = 100) was 54.2 years old (range: 20-77) with a mean length of follow-up of 21 months (range: 6-44). Mean length of prosthesis implanted was 18.6 cm (14-23.5). Only 3% of patients showed complications requiring surgical exploration. Good prosthesis performance was assessed in 99 patients (99%). Differences in the IIEF-EF and IIEF-IS domain before and after surgery were +16.8 and +6.4 respectively. Patient and partner overall satisfaction were 90% and 84% respectively in modified EDITS. The average number of postoperative teaching sessions needed to teach the patient how to operate the device was 1.28 (1-4). CONCLUSIONS: The Coloplast Titan™ OTR IPP was easy to implant, inflate, and deflate with high levels of EF improvement, patient and partner satisfaction. A small number of postoperative teaching sessions were required for the patient to properly operate the device

The evolution of the inflatable penile prosthetic device and surgical innovations with anatomical considerations.

Historically, early surgical treatment for erectile dysfunction involved the placement of rigid devices outside of the corpora cavernosa. This practice resulted in high rates of erosion and infection. Today, most urologists in the United States place an inflatable penile prosthesis (IPP) with an infection-retardant coating inside the corpora cavernosa. In addition to changes in the type of implant used, surgical techniques have evolved greatly in recent years, resulting in reduced operating times, lower infection rates, and improved outcomes. However, anatomical considerations have directed the prosthetic surgeon to improve patient outcomes and satisfaction rates by employing both new surgical techniques and postoperative maneuvers.

Current status of the surgical management of Peyronie's disease.

Surgery is the standard treatment for patients in the chronic phase of Peyronie's disease. Reconstructive surgeries function by either shortening the convex side of the tunica albuginea (Nesbit procedure, Yachia technique and penile plication) or lengthening the concave side by incision of the plaque with subsequent grafting. Tunical shortening procedures are ideal for men with good erectile capacity, penile curvatures less than 60° and predicted postprocedural length loss of less than 20% of erect penis length. Tunical lengthening procedures with grafting are indicated in patients with severe penile length loss, curvatures greater than 60° and prominent hourglass deformities. Saphenous vein and tunica albuginea are the most commonly used autologous graft materials. Cadaveric or bovine pericardium and 4-layer small intestinal submucosa are promising nonautologous tissues. Penile implantation of a prosthesis is the standard procedure in men with erectile dysfunction who do not respond to conservative treatment. If residual penile curvature is less than 30° after implantation, no further treatment is required. However, residual curve of greater than 30° can be straightened with manual modeling. Additional procedures such as penile plication, the Nesbit procedure, or grafting can be performed if modeling fails to correct the residual deformity.

Have phosphodiesterase-5 inhibitors changed the indications for penile implants?

OBJECTIVE To evaluate the indications for penile prosthesis implantation in the treatment of erectile dysfunction (ED) before and after the introduction of sildenafil. PATIENTS AND METHODS Penile prosthesis implantation was indicated in 144 men with ED at our institution between 1992 and 2007; 83 (55.6%) accepted the procedure, 55 (38.2%) refused it and six (4.2%) accepted but eventually had no surgery. Sixty-seven patients were operated primarily, and the remainder were referred cases with complications after or dissatisfaction with primary operations done elsewhere. Thirty-two were operated before the introduction of sildenafil (BS) and 35 after (AS). RESULTS In the BS group the most frequent aetiology was vascular disease, with 11(34%) vs two (6%) in the AS group. The most frequent aetiology in the AS group was previous radical pelvic surgery (radical prostatectomy, sigmoidectomy, etc.) with 17 (49%) vs none in the BS group. There were no significant differences in complication rates in both groups. Satisfaction rates in patients with malleable and inflatable devices were 36 (86%) and 17 (85%), respectively. CONCLUSIONS After the introduction of oral therapy for ED there were some changes in the aetiology of refractory ED; ED after radical prostatectomy is gaining acceptance as the main reason for a penile implant.

Penile prosthesis implantation surgery: a statewide population based analysis of 2354 patients.

AIMS OF THE STUDY: Minimally invasive therapy for erectile dysfunction (ED) has changed the frequency of penile prosthesis surgery. The purpose of this study is to describe the changes in frequency, hospital stay, hospital charges and penile prosthesis type in North Carolina. MATERIALS AND METHODS: The data source was a statewide hospital discharge database which includes data on hospitalized patients for all 151 hospitals in North Carolina. RESULTS: From 1988-1993, 2354 patients underwent implantation of penile prostheses. The total number of penile prostheses implanted has declined over this six year period. Similarly, hospital stay has declined from an average of 4.03-2.96 d with a 46.6% decrease in total hospital days. Despite this change in hospital stay, hospital charges rose significantly from an average of $7252.48 to $12,842.18 driving total charges from $2973,516.80 to $3,826,969.60 (1993) representing a 28.7% increase. CONCLUSIONS: Minimally invasive therapy and changes in reimbursement have had a major impact on the number of patients undergoing penile prosthesis implantation for ED. This downward trend may continue as more treatment options develop from the marked increase in research in this field. However, this may result in an increase of patients seeking treatment overall.