A Review of Economic Evaluations of Erectile Dysfunction Therapies.

INTRODUCTION: Erectile dysfunction (ED) is a common and costly urologic condition with increasing prevalence as men age. Cost-effectiveness of ED therapies and whether cost-effectiveness varies for different populations of men remains underexplored. AIM: To review and summarize available published data on the economic evaluation of ED therapies and to identify gaps in the literature that still need to be addressed. METHODS: All relevant peer-reviewed publications and conference abstracts were reviewed and incorporated. RESULTS: There are a number of medical and surgical treatment options available for ED. The economic evaluation of phosphodiesterase-5 inhibitors, particularly sildenafil, has been well described. However, minimal research has been conducted to assess the cost-effectiveness of intracavernosal injections, intraurethral suppositories, penile prosthesis surgery, vacuum erection devices, and other emerging therapies in men with different causes of ED. CONCLUSION: Available economic evaluations of ED therapies are dated, do not reflect present-day physician, pharmaceutical, and device costs, fail to account for patient comorbidities, and may not be generalizable to today's ED patients. Substantial research is needed to evaluate the cost-effectiveness of ED treatments across different patient populations, countries, and reimbursement systems. Rezaee ME, Ward CE, Brandes ER, et al. A Review of Economic Evaluations of Erectile Dysfunction Therapies. Sex Med Rev 2019;8:497-503.

Future considerations in prosthetic urology.

Since their popularization, genitourinary prosthetics have remained a gold-standard therapy for the treatment of erectile dysfunction and stress urinary incontinence and in cases of testicular loss or dysfunction. They have also represented an area of significant innovation, which has contributed to excellent long-term outcomes. Given this history, the objective of the current review was to provide a 5-10-year outlook on anticipated trends and developments in the field of genitourinary prosthetics. To accomplish this objective, a PubMed and patent search was performed of topics relating to penile and testicular prostheses and urinary sphincters. In regard to penile prostheses, findings demonstrated several new concepts including temperature-sensitive alloys, automated pumps, devices designed specifically for neophalluses, and improved malleable designs. With artificial urinary sphincters, new concepts include the ability to add or remove fluid from an existing system, two-piece systems, and new mechanisms to occlude the urethra. For testicular prosthetics, future implementations may not only better replicate the feel of a biological testicle but also add endocrinological functions. Beyond device innovation, the future of prosthetics is also one of expanding geographic boundaries, which necessitates variable cost modeling and regulatory considerations. Surgical trends are also changing, with a greater emphasis on nonnarcotic, postoperative pain control, outpatient surgeries, and adjunctive techniques to lengthen the penis and address concomitant stress incontinence, among others. Concomitant with device and surgical changes, future considerations also include a greater need for education and training, particularly given the rapid expansion of sexual medicine into developing nations.

Analysis of Hospital Readmissions After Prosthetic Urologic Surgery in the United States: Nationally Representative Estimates of Causes, Costs, and Predictive Factors.

BACKGROUND: The surgical treatment of urinary incontinence and erectile dysfunction by prosthetic devices has become part of urologic practice, although sparse data exist at a national level on readmissions and hospital costs. AIM: To assess causes and costs of early (≤30 days) and late (31-90 days) readmissions after implantation of penile prostheses (PPs), artificial urinary sphincters (AUSs), or PP + AUS. METHODS: Using the 2013 and 2014 US Nationwide Readmission Databases, sociodemographic characteristics, hospital costs, and causes of readmission were compared among PP, AUS and AUS + PP surgeries. Multivariable logistic regression models tested possible predictors of hospital readmission (early, late, and 90 days), increased hospital costs, and prolonged length of stay at initial hospitalization and readmission. OUTCOME: Outcomes were rates, causes, hospital costs, and predictive factors of early, late, and any 90-day readmissions. RESULTS: Of 3,620 patients, 2,626 (73%) had PP implantation, 920 (25%) had AUS implantation, and 74 (2%) underwent PP + AUS placement. In patients undergoing PP, AUS, or PP + AUS placement, 30-day (6.3% vs 7.9% vs <15.0%, P = .5) and 90-day (11.6% vs 12.8% vs <15.0%, P = .8) readmission rates were comparable. Early readmissions were more frequently caused by wound complications compared with late readmissions (10.9% vs <4%, P = .03). Multivariable models identified longer length of stay, Charlson Comorbidity Index score higher than 0, complicated diabetes, and discharge not to home as predictors of 90-day readmissions. Notably, hospital volume was not a predictor of early, late, or any 90-day readmissions. However, within the subset of high-volume hospitals, each additional procedure was associated with increased risk of late (odds ratio = 1.06, 95% CI = 1.03-1.09, P < .001) and 90-day (odds ratio = 1.03 95% CI = 1.02-1.05, P < .001) readmissions. AUS and PP + AUS surgeries had higher initial hospitalization costs (P < .001). A high hospital prosthetic volume decreased costs at initial hospitalization. Mechanical complications led to readmission of all patients receiving PP + AUS. CLINICAL IMPLICATIONS: High-volume hospitals showed a weaker association with increased initial hospitalization costs. Charlson Comorbidity Index, diabetes, and length of stay were predictors of 90-day readmission, showing that comorbidity status is important for surgical candidacy. STRENGTHS AND LIMITATIONS: This is the first study focusing on readmissions and costs after PP, AUS, and PP + AUS surgeries using a national database, which allows ascertainment of readmissions to hospitals that did not perform the initial surgery. Limitations are related to the limited geographic coverage of the database and lack of surgery- and surgeon-specific variables. CONCLUSIONS: Analysis of readmissions can provide better care for urologic prosthetic surgeries through better preoperative optimization, counseling, and resource allocation. Pederzoli F, Chappidi MR, Collica S, et al. Analysis of Hospital Readmissions After Prosthetic Urologic Surgery in the United States: Nationally Representative Estimates of Causes, Costs, and Predictive Factors. J Sex Med 2017;14:1059-1065.

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.

Erectile dysfunction in spinal cord injury: a cost-utility analysis.

BACKGROUND: There is a high incidence of erectile dysfunction after spinal cord injury. This can have a profound effect on quality of life. Treatment options for erectile dysfunction include sildenafil, intracavernous injections of papaverine/alprostadil (Caverject), alprostadil/papaverine/phentolamine ("Triple Mix"), transurethral suppository (MUSE), surgically implanted prosthetic device and vacuum erection devices. However, physical impairments and accessibility may preclude patient self-utilization of non-oral treatments. METHODS: The costs and utilities of oral and non-oral erectile dysfunction treatments in a spinal cord injury population were examined in a cost-utility analysis conducted from a government payer perspective. Subjects with spinal cord injury (n=59) reported health preferences using the standard gamble technique. RESULTS: There was a higher health preference for oral therapy. The cost-effectiveness results indicated that sildenafil was the dominant economic strategy when compared with surgically implanted prosthetic devices, MUSE(R) and Caverject. The incremental cost-utility ratios comparing sildenafil with triple mix and vacuum erection devices favoured sildenafil, with ratios less than CAN$20,000 per quality adjusted life year gained. CONCLUSION: Based on this study, we conclude that sildenafil is a cost-effective treatment for erectile dysfunction in the spinal cord injury population.

Cost and time benefits of dual implantation of inflatable penile and artificial urinary sphincter prosthetics by single incision.

OBJECTIVES: To evaluate the efficiency, safety, and cost-effectiveness of synchronous prosthetic treatment of male urinary incontinence and impotence using a single transverse scrotal incision. METHODS: A total of 92 inflatable penile prostheses (IPPs), 21 artificial urinary sphincters (AUSs), and 15 combined IPPs/AUSs were implanted in 128 men at Brooke Army Medical Center and the University of Texas Health Science Center at San Antonio. The operative times and outcomes were compared among three groups (group 1, IPP; group 2, AUS; and group 3, dual IPP/AUS). We performed cost estimates of synchronous versus two-stage implant procedures. RESULTS: Dual implantation in a single-stage procedure significantly reduced (24.7%) the operative time (P <0.05, mean 113 minutes) compared with the total time for the individual procedures (IPP, average of 78 minutes; AUS, average of 72 minutes; total 150 minutes). No prosthetic infections or erosions occurred in this series. Dual implantation was associated with approximately a $7000 cost savings compared with individual procedures. CONCLUSIONS: The results of our study have shown that dual prosthetic implantation through a single incision is safe, efficient, and cost-effective.

The role of penile prosthetic surgery in the modern management of erectile dysfunction.

The management of erectile dysfunction looks set to be revolutionised with the introduction of effective oral therapies. There will remain, however, some men who do not respond to conservative measures. This article reviews the important role of penile prosthetic surgery as a treatment option in these patients.

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.

Management of impotence after treatment of carcinoma of the prostate.

Impotence commonly occurs as a result of treatment of carcinoma of the prostate. We review the etiology, evaluation, and treatment options available for these patients as well as our experience with fifty prostate cancer patients who underwent placement of penile prostheses. Several excellent alternatives are available for patients with impotence resulting from treatment of carcinoma of the prostate.

Outpatient 3-piece inflatable penile prosthesis.

The 3-piece inflatable penile prosthesis was implanted in 74 consecutive organically impotent outpatients during the last 4 years. The classical infrapubic surgical approach required minor alterations to adapt to the outpatient setting. This cost-reducing technique is safe medically and cogent financially.

Cost-benefit analysis of pharmacologic erection program (PEP) versus penile prosthesis.

We compared the current dollar inclusive costs of the two most commonly implanted penile prostheses with our pharmacologic erection program (PEP). The inclusive cost of implantation for the inflatable penile prosthesis (IPP) is $9,000 and for the malleable penile prosthesis (MPP) $3,150. The inclusive cost of PEP at maximal dose and maximal frequency of use over a five-year period is $3,450. Penile prosthesis was found to be more cost-effective for the long-term treatment of younger impotent men, whereas in the elderly group the use of PEP over a limited time span may be equally or more cost-effective.