Optimizing Outcomes in Penile Implant Surgery.

Since their initial release in the 1970s, modern penile prostheses have been subjected to continuous improvement with respect to both device engineering and surgical technique. Proper implantation begins with appropriate patient selection and counseling; these are essential elements to optimize results and set expectations postoperatively. An evidence-based protocol for the prevention of infections is essential. A pain management protocol should be initiated even before surgery. Strict adherence to recommended intraoperative techniques minimizes the risk complications; when complications occur, a step-by-step process for management improves odds of resolution. Safe techniques to increase the perceived or actual penile length postimplant can markedly improve patient satisfaction. Postoperatively, the surgeon and the patient should follow strict evidence-based instructions to optimize the overall outcomes of penile prosthesis surgery.

Sustained Glycemic Control Observed in Diabetic Men Who Improve Hemoglobin A1c Values to Allow for Elective Penile Prosthesis Placement.

OBJECTIVES: We hypothesize that men with diabetes mellitus whose inflatable penile prosthesis (IPP) implantation is delayed for unacceptably high hemoglobin A1c (HbA1c) will have durable improvements in their glycemic control after achieving acceptable HbA1c levels for surgery. METHODS: Per institutional protocol, an A1c <9% must be documented prior to IPP placement. After IRB approval, a single surgeon IPP database was retrospectively queried for data specific to diabetes mellitus management. Men without HbA1c values at ≥1-year follow-up were excluded. Univariate and multivariate statistical analyses were performed to assess associations with sustained HbA1c control. RESULTS: From January 2011 to March 2019, 138 diabetics undergoing IPP were identified. Thirty-seven were excluding for insufficient follow-up. Nineteen of the 101 analyzed men (18.8%) were delayed a median 4 months (range 2-17) for elevated HbA1c values (median 10.1, range 9.1-12.3). Following improvements, median preoperative HbA1c remained higher (8.2% vs 7.0%) in delayed men (P < .001). Among delayed recipients, 11 (58%) improved without medication changes while insulin was newly initiated (5) or dosage was increased (5) in 42%. At 32 months follow-up, a HbA1c <9% was similarly maintained in delayed and nondelayed men (74% vs 87%, P = .17). Delayed men more commonly required insulin therapy at follow-up (89.5% vs 54.9%, P = .008), but had a similar median change in BMI (+0.1 vs +0.1, P = .65). Device infection occurred in 1 nondelayed patient (0.7%). CONCLUSION: Men who improve HbA1c for IPP surgery are likely to demonstrate persistent improvement. IPP implantation appears to be safe in diabetic men with HbA1c <9%.

Visión global de las guías clínicas en cirugía de la disfunción eréctil: EUA-AUA / Clinical guidelines on erectile dysfunction surgery: EAU-AUA perspectives

INTRODUCCIÓN: El implante de una prótesis de pene se considera un tratamiento de tercera línea y está indicada en pacientes que no responden adecuadamente a farmacoterapia o cuando el paciente desea una solución definitiva del problema. Actualmente los dispositivos más empleados son prótesis de 3 componentes, que actualmente suponen más del 90% de los implantes utilizados. MATERIAL Y MÉTODO: El presente estudio realiza una revisión de la evidencia y las recomendaciones de las guías de práctica clínica en pacientes con disfunción eréctil es los que se plantea un tratamiento quirúrgico. RESULTADOS: Las recomendaciones de las guías de práctica clínica sobre cirugía en pacientes con disfunción eréctil se resumen en los siguientes puntos: los varones con disfunción eréctil deben ser informados sobre la opción de tratamiento con implante de prótesis de pene, comentándose los beneficios, los riesgos y las consecuencias; los varones con disfunción eréctil en los que se ha decidido implantar una prótesis de pene deben recibir consejo sobre las expectativas posquirúrgicas; no debe realizarse implante de prótesis peneana en pacientes con enfermedad sistémica, cutánea o infección del tracto urinario; en varones jóvenes con disfunción eréctil y obstrucción arterial peneana o pélvica focal que no presenten enfermedad vascular generalizada o disfunción venooclusiva puede considerarse la reconstrucción arterial peneana; en varones con disfunción eréctil, no se recomienda cirugía venosa del pene. CONCLUSIONES: El empleo de prótesis de pene ofrece altas tasas de satisfacción tanto al paciente como a su pareja. Sin embargo, es necesario informar adecuadamente de las posibles complicaciones y las consecuencias

INTRODUCTION: The implantation of a penile prosthesis is considered a third-line treatment and is indicated in patients who do not respond adequately to pharmacotherapy or require definitive treatment. Currently, the most used devices are 3-component penile prostheses, which presently account for more than 90% of the implants used. MATERIAL AND METHODS: We reviewed the evidence and the recommendations of the clinical practice guidelines regarding surgery in patients with erectile dysfunction. RESULTS: The recommendations of the clinical practice guidelines on surgery in patients with erectile dysfunction are summarized as follows: men with erectile dysfunction should be informed about the option of penile prosthesis implant treatment, commenting on the benefits, risks and consequences; men with erectile dysfunction who have agreed to receive penile prosthesis should be advised on post-surgical expectations; penile prosthesis implants should not be performed in patients with systemic, cutaneous or urinary tract infection; in young men with erectile dysfunction and focal penile or pelvic arterial obstruction who do not have generalized vascular disease or veno-occlusive dysfunction, penile arterial reconstruction can be considered; in men with erectile dysfunction, penile venous surgery is not recommended. CONCLUSIONS: The use of penile prostheses offers high satisfaction rates to both the patient and his partner. However, it is crucial to adequately inform and warn patients about possible complications and consequences

Clinical guidelines on erectile dysfunction surgery: EAU-AUA perspectives. / Visión global de las guías clínicas en cirugía de la disfunción eréctil: EUA-AUA.

INTRODUCTION: The implantation of a penile prosthesis is considered a third-line treatment and is indicated in patients who do not respond adequately to pharmacotherapy or require definitive treatment. Currently, the most used devices are 3-component penile prostheses, which presently account for more than 90% of the implants used. MATERIAL AND METHODS: We reviewed the evidence and the recommendations of the clinical practice guidelines regarding surgery in patients with erectile dysfunction. RESULTS: The recommendations of the clinical practice guidelines on surgery in patients with erectile dysfunction are summarized as follows: men with erectile dysfunction should be informed about the option of penile prosthesis implant treatment, commenting on the benefits, risks and consequences; men with erectile dysfunction who have agreed to receive penile prosthesis should be advised on post-surgical expectations; penile prosthesis implants should not be performed in patients with systemic, cutaneous or urinary tract infection; in young men with erectile dysfunction and focal penile or pelvic arterial obstruction who do not have generalized vascular disease or veno-occlusive dysfunction, penile arterial reconstruction can be considered; in men with erectile dysfunction, penile venous surgery is not recommended. CONCLUSIONS: The use of penile prostheses offers high satisfaction rates to both the patient and his partner. However, it is crucial to adequately inform and warn patients about possible complications and consequences.

A guide for inflatable penile prosthesis reservoir placement: pertinent anatomical measurements of the retropubic space.

INTRODUCTION: The primary concern for many prosthetic urologic surgeons in placing the three-piece inflatable penile prosthesis (IPP) is the concept of "blind reservoir placement." Extensive reports permeate the literature regarding bladder, bowel, vascular, and various hernial complications occurring while attempting to place the reservoir into the retropubic space. However, despite these widely documented complications, there is a paucity of published literature on surgically pertinent anatomical measurements of the retropubic space relating to reservoir placement. The focus of this project was to evaluate the special relationships and anatomical measurements of the retropubic space to better aid the surgeon in the safe placement of the reservoir. AIM: Analyses of the spatial measurements of reservoir placement into the retropubic space with a focus on utilizing a penoscrotal approach were conducted. In addition, we reviewed and evaluated the published literature for important contributions surrounding the various surgical techniques during placement of a penile prosthesis reservoir. METHODS: Cadaveric pelvic specimens were dissected to determine the distance and angulation (in degrees) from the inguinal ring to several critical anatomic structures in the pelvis. This format was utilized to simulate the basic features of reservoir placement into the classic retropubic space. We also reviewed and evaluated the published literature for important contributions describing the various surgical techniques in the placement of penile prosthesis reservoirs into the retropubic space. MAIN OUTCOME MEASURES: Anatomic measurements were obtained from the inguinal ring to the bladder, external iliac vein, and superior origin of the dorsal suspensory ligament at the anterior apex of the pendulous penis. The angle was measured from the inguinal ring to these structures and recorded. We also reviewed the published literature for various penoscrotal IPP surgical techniques involving placement of the reservoir into the retropubic space to further supplement the pertinent spatial relationships data acquired in this study. RESULTS: Of the 28 cadavers, 3 were excluded because of signs of major pelvic surgery, and an additional 6 sides were excluded because of unilateral fibrosis/surgery or difficulty in exposure. Distance to the decompressed bladder was 5-8 cm (average 6.45 cm) at a 15-30 (22.8) degrees medial measurement from the inguinal ring. The filled bladder was 2-4 cm (average 2.61 cm) from the inguinal ring. The external iliac vein distance from the inguinal ring was 2.5-4 cm (average 3.23 cm) at a 20-60 (36.4) degrees lateral measurement from the inguinal ring. Heretofore, the published literature does not appear to have detailed measurements that are provided in this study. CONCLUSIONS: These anatomical measurements of the retropubic space demonstrate the importance of decompressing the bladder and avoiding deep dissection lateral to the inguinal ring, as the external iliac vein is much closer than currently espoused. We feel that these data are significant to the surgeon proceeding with reservoir placement during IPP surgery.

EAU guidelines on penile curvature.

CONTEXT: Penile curvature can be congenital or acquired. Acquired curvature is secondary due to La Peyronie (Peyronie's) disease. OBJECTIVE: To provide clinical guidelines on the diagnosis and treatment of penile curvature. EVIDENCE ACQUISITION: A systematic literature search on the epidemiology, diagnosis, and treatment of penile curvature was performed. Articles with the highest evidence available were selected and formed the basis for assigning levels of evidence and grades of recommendations. EVIDENCE SYNTHESIS: The pathogenesis of congenital penile curvature is unknown. Peyronie's disease is a poorly understood connective tissue disorder most commonly attributed to repetitive microvascular injury or trauma during intercourse. Diagnosis is based on medical and sexual histories, which are sufficient to establish the diagnosis. Physical examination includes assessment of palpable nodules and penile length. Curvature is best documented by a self-photograph or pharmacologically induced erection. The only treatment option for congenital penile curvature is surgery based on plication techniques. Conservative treatment for Peyronie's disease is associated with poor outcomes. Pharmacotherapy includes oral potassium para-aminobenzoate, intralesional treatment with verapamil, clostridial collagenase or interferon, topical verapamil gel, and iontophoresis with verapamil and dexamethasone. They can be efficacious in some patients, but none of these options carry a grade A recommendation. Steroids, vitamin E, and tamoxifen cannot be recommended. Extracorporeal shock wave treatment and penile traction devices may only be used to treat penile pain and reduce penile deformity, respectively. Surgery is indicated when Peyronie's disease is stable for at least 3 mo. Tunical shortening procedures, especially plication techniques, are the first treatment options. Tunical lengthening procedures are preferred in more severe curvatures or in complex deformities. Penile prosthesis implantation is recommended in patients with erectile dysfunction not responding to pharmacotherapy. CONCLUSIONS: These European Association of Urology (EAU) guidelines summarise the present information on penile curvature. The extended version of the guidelines is available on the EAU Web site (www.uroweb.org/guidelines/).

Anti-infection dip suggestions for the Coloplast Titan Inflatable Penile Prosthesis in the era of the infection retardant coated implant.

INTRODUCTION: Infection is the worst complication seen with inflatable penile prosthesis (IPP). Both the American Medical Systems (AMS) and Coloplast IPP have infection retardant coatings. AMS is coated at the factory with rifampicin and minocycline (InhibiZone). The Coloplast IPP has a hydrophilic coating covalently bonded to its components that will absorb any aqueous solution before implantation and provides increased surface lubricity to decrease bacterial adherence. AIM: We tested several antibiotic dips comparing zones of inhibition (ZOI) against five commonly infecting bacteria with coated Coloplast implants. Results were compared with those ZOI created with strips of an AMS IPP precoated with InhibiZone. METHODS: Pieces of sterile Coloplast Titan IPP were dipped in (i) trimethoprim/polymixin B ophthalmic solution; (ii) trimethoprim/sulfamethoxazole infusion solution; (iii) bacitracin; (iv) rifampicin/minocycline; and (v) rifampin/trimehtoprim/sulfamethoxazole. ZOI for the Titan strips and for AMS InhibiZone coated strips were tested against Staphylococcus epidermidis, Staphylococcus lugdunensis, Staphylococcus aureus, Pseudomonas, and Enterococcus. MAIN OUTCOME MEASURE: ZOIs of the Coloplast Titan for each of the medicated solutions were compared with ZOI created by undipped strips of a sterile InhibiZone coated IPP placed on plates of the identical bacteria. RESULTS: All dips except bacitracin showed ZOI≥InhibiZone (P≥0.005) for most organisms. Because of broad-spectrum effectiveness, ease of handling, and cost, infusion vial of trimehtoprim/sulfamethoxazole seemed optimal at this time. If trimehtoprim/sulfamethoxazole is unavailable; the ZOI with Polytrim ophthalmic solution zones were almost as good. CONCLUSIONS: The Coloplast strips when dipped in several solutions showed equal or significantly larger ZOI against commonly infecting organisms than the InhibiZone coated strips. At the present time using off the shelf trimethoprim sulfamethoxazole infusion solution seems optimum. The flexibility of choosing the drug eluting from the Coloplast device seems promising in the changing bacterial environment.

Trauma, gender reassignment, and penile augmentation.

INTRODUCTION: Penile trauma is common with standard management options. Gender reassignment techniques are rapidly changing and penile augmentation remains a controversial topic. Consequently, there is need for a state-of-the-art information in this area. AIM: This study aims to develop an evidence-based state-of-the-art consensus report on the management of penile trauma, gender, reassignment and penile augmentation. METHODS: The study provides state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical management of penile trauma, gender reassignment and penile augmentation, representing the opinion of leading experts developed in a consensus process over a 2-year period. MAIN OUTCOME MEASURES: Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. CONCLUSIONS: Penile fracture should be managed surgically. Information should be readily available to patients to help them decide the surgical technique desired for gender reassignment and to justify any form of penile augmentation.

Centers of excellence concept and penile prostheses: an outcome analysis.

PURPOSE: Outcome analysis has shown that the center of excellence concept, in which all of a specific type of surgery is done by 1 surgeon rather than by multiple surgeons in a group, provides superior outcomes for total joint replacement, radical cancer and heart valve surgery. We compared penile prosthesis implantation outcomes between the center of excellence and multiple surgeon approaches in a large, single specialty urological surgical practice. MATERIALS AND METHODS: Between February 2001 and August 2004 a total of 57 penile prostheses were implanted by 10 surgeons at a large urology practice (multiple surgeon group). Between July 2004 and April 2005 a total of 57 penile prostheses were placed by a single surgeon (center of excellence group). Chart review of the 2 patient groups was performed. RESULTS: The patient groups showed no statistical differences in age, race, cause of impotence or percent with diabetes. The median cylinder length of prostheses placed by the center of excellence surgeon was 2 cm greater than the length of the cylinders placed by the multiple surgeon team (p <0.0001). Excluding cases requiring additional procedures the median placement time was considerably shorter for the center of excellence surgeon than for the multiple surgeon team (34 vs 94 minutes, p <0.0001). There were 8 iatrogenic failures (infection, erosion and poor positioning) requiring surgical removal in the multiple surgeon group but none in the COE group (p <0.05). Although followup for the multiple surgeon team was longer, Kaplan-Meier revision-free survival curves showed significantly longer survival for the center of excellence group (log rank test p = 0.0283). CONCLUSIONS: The center of excellence concept in penile prosthesis surgery appears to deliver superior surgical outcomes in terms of shorter operative time, longer cylinders and fewer iatrogenic complications.

Prospective long-term results and quality-of-life assessment after Dura-II penile prosthesis placement.

OBJECTIVES: To evaluate prospectively the long-term device reliability and patient satisfaction after Dura-II malleable penile prosthesis implantation. METHODS: Between 1992 and 1996, 94 patients underwent Dura-II implantation for erectile dysfunction. Patients were prospectively examined and completed standardized questionnaires regarding sexual activity, prosthesis function, intercourse satisfaction, and overall quality of life. An independent statistician analyzed these data. RESULTS: The mean patient age was 63 years, and the mean patient follow-up was 5.7 years. Eighty-five patients were available for long-term evaluation. Fourteen patients died during the follow-up period. One patient was lost to follow-up, and eight prostheses (9%) were explanted; however, no mechanical defects were found in the explanted prostheses. Seventy-six percent and 87% of patients reported satisfactory rigidity and ease of concealing the device, respectively. Seventy-six percent of patients remained sexually active during the evaluation period, and 87% of patients reported that the prosthesis improved their overall quality of life. Eighty-five percent would undergo the implant surgery again, and 88% percent of patients would recommend the Dura-II prosthesis to a friend. CONCLUSIONS: The Dura-II malleable penile prosthesis provides good rigidity, ability to conceal the device, and mechanical reliability, as demonstrated by the results of this long-term study. Most patients stated they would have the prosthesis placed again and would recommend it to a friend.