Androgens and Urethral Health: How Hypogonadism Affects Postoperative Outcomes of Patients Undergoing Artificial Urinary Sphincter or Inflatable Penile Prosthesis Placement.

OBJECTIVE: To determine the role of androgens in penile and urethral health, we sought to understand what impact hypogonadism may have on artificial urinary sphincter (AUS) and inflatable penile prosthesis (IPP) outcomes. We hypothesize that patients with hypogonadism are at increased risk of reinterventions, complications, and infections. METHODS: We queried the TriNetX Global Database in March 2023 for patients receiving an AUS or IPP, looking at lifetime reintervention, complication, and infection rates. We conducted multiple comparisons: (1) eugonadal patients against hypogonadal patients, (2) hypogonadal patients on testosterone replacement therapy (TRT) against hypogonadal patients not on TRT, and (3) hypogonadal patients on TRT against eugonadal patients. RESULTS: Hypogonadal patients undergoing AUS had more complications (33.5% vs 28.3%), higher reintervention rates (27.7% vs 24.3%) and higher infection rates (7.3% vs 6.8%), albeit none reaching significance. Hypogonadal patients undergoing IPP had significantly higher infection rates (6.3% vs 4.4%, RR 1.5 (1.04, 2.04)) and reintervention rates (14.9% vs 11.9%, RR 1.3 (1.04, 1.61)), but not complication rates (21.9% vs 18.9%). When comparing patients with hypogonadism on TRT vs off TRT, there was not a significant difference in reinterventions, or complications, in AUS and IPP patients, but there were significantly more infections in IPP patients (7.0% vs 3.9%, RR 1.9 (1.002, 3.5)). CONCLUSION: Hypogonadal patients have more reinterventions, complications, and infections following urologic implant surgery, to varying levels of significance. TRT may not be completely protective to improve tissue health but with many limitations that should be explored in further research.

Single Dilation in Primary Inflatable Penile Prosthesis Placement Is Associated With Fewer Corporal Complications Than Sequential Dilation.

OBJECTIVE: To assess the difference in outcomes between single dilation (SingD) and sequential dilation (SeqD) in primary penile implantation, hypothesizing that patients who undergo SeqD had higher rates of noninfectious complications. METHODS: We performed a multicenter, retrospective study of men undergoing primary inflatable penile prosthesis placement. Intraoperative complications and postoperative noninfectious outcomes were assessed between the two groups. Multivariable analysis was performed to identify predictors of complications. RESULTS: A total of 3293 patients met inclusion criteria. After matching, there were 379 patients who underwent SingD and 379 patients who underwent SeqD. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length (20 cm with interquartile range [IQR] 18-21 cm vs 20 cm with IQR 18-20 cm respectively, P = .4). On multivariable analysis, SeqD (OR 5.23 with IQR 2.74-10, P < .001) and older age (OR 1.04 with IQR 1.01-1.06, P = .007) were predictive of postoperative noninfectious complications. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length. SeqD and older age were predictive of postoperative noninfectious complications. CONCLUSION: During inflatable penile prosthesis placement in the uncomplicated patient without fibrosis, SingD is a safe technique to utilize during implantation that will minimize postoperative adverse events, and promote device longevity without loss of cylinder length.

Do Sodium-Glucose Co-Transporter 2 Inhibitors Increase the Risk of Urologic Implant Reintervention?

OBJECTIVE: To understand whether patients taking sodium-glucose co-transporter 2 inhibitors (SGLT2i) would be at a similar risk of genitourinary device infection or failure as patients not taking these medications. METHODS: We queried the TriNetX database for all adult male patients undergoing artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) and compared patients taking SGLT2i against those not. Cohorts and outcomes were defined using current procedural terminology and International Classification of Diseases (ICD-10) codes. We used Age, body mass index, diabetes, smoking history and history of prostatectomy to generate propensity score matching. Our primary outcome was need for reintervention after implantation based on current procedural terminology codes. Secondary outcomes included infection rate and overall complication rate based on ICD-10 codes. Analytics were performed via TriNetX which calculated risk ratios. RESULTS: Analyses were run on November 28, 2022. After propensity score matching, there were 319 and 83 patients in each IPP and AUS cohort and comorbidity profiles were similar. Patients with an IPP on an SGLT2i were at a lower risk of overall complication (10.6% vs 16.1%, RR 0.66, P = .049). There was similar rates for AUS and risk of complication and for either implant on risk of infection or reintervention. CONCLUSION: Patients taking SGLT2is may be safely offered urologic implants. Patients taking an SGLT2 had a lower risk of complication for IPP, and there were similar rates of infection and reintervention for both IPP and AUS.

Trends in treatments for erectile dysfunction in Chile between 2010 and 2020 with special focus on penile prostheses.

OBJECTIVES: Evidence regarding demand trends for erectile dysfunction (ED) treatments are scarce in South America. This study aims to evaluate trends in ED treatments in Chile over a 10-year period (2010- 2020) and estimate the potential number of candidates for penile prosthesis. MATERIALS AND METHODS: Sales trends of pharmacological treatments and penile prosthesis were obtained from market studies. The potential number of candidates for penile prosthesis implantation was calculated by crossing epidemiological data with previously reported ED prevalence, proportion of sexually active men, percentage of men seeking medical assistance for ED, and the proportion of patients who are non-responders to ED oral drug therapies Results: In the 10-year studied period, the Chilean male population older than 50 years increased 34.7%, with an average annual variation (AAV) of 3.4%. For the same period, the sales of oral drug therapies for ED increased by 71.3% (AAV 6.2%), the sales of intracavernosal vasoactive agents (ICVA) decreased by 0.4% (AAV -0.2%), and penile prosthesis sales increased by 113% (AAV 6.7%). We estimated that only 0.05% of sexually active men older than 50 years old with ED who sought medical assistance finally had a penile prosthesis implanted to manage their condition. CONCLUSIONS: Demand for ED oral drug therapies significantly increased in Chile during the last decade, while ICVA remained stable. The annual rate of penile prosthesis implantation increased. However, the gap between the potential penile prosthesis candidates and the actual number of devices implanted is suspected to remain extremely high.

Prevention of Penile Prosthesis Infection.

INTRODUCTION: Management protocols for treatment of severe erectile dysfunction have changed little in the last 20 years. Most algorithms consider penile prostheses as the last option of treatment in patients who have failed medical management. Despite multiple advances in current devices, prosthetic infection remains the most feared complication by implanting surgeons and patients. This report tries to make a compilation of the factors that can be impacted to prevent penile implant infections, and to make penile implantation a safer and more reliable way to solve an erection deficit. PURPOSE OF REVIEW: List events related to the surgical act (pre-operative, intra-operative, and post-operative) that are related to the risk of infection to contextualize possible actions/measures used to avoid prosthetic infection. RECENT FINDINGS: The impact of coated implants on reduction of infection rates. The recommendation to use chlorhexidine-based solutions over iodine solution for preoperative skin preps. Appears to be no difference in infection rates according to the approach chosen by the surgeon (infrapubic vs penoscrotal). The change in the microbial colonies that are colonizing implants in recent years are dramatic. Lack of evidence of which solutions to use for salvage or revision washout surgery: Chemical eradication or mechanical lavage cleansing?. Despite the importance of metabolic control in the literature, there is a disparity in exact glycemic values ​prior to the intervention in our literature. Factors such as preparation of the operative site, presence of comorbidities or previous surgeries, surgical time, or additional maneuvers during surgery can negatively impact the final result of penile prosthetic surgery.

Desafios e importância da avaliação pré-operatória na doença de Peyronie / Challenges and importance of the preoperative evaluation in Peyronie's disease

A doença de Peyronie, notória desde 1743, segue sendo um grande desafio na prática médica, com prevalência relevante e grande impacto na vida sexual dos casais. O tratamento cirúrgico é a principal modalidade terapêutica capaz de restabelecer a vida sexual nos pacientes com doença de Peyronie significativa. A escolha do momento de implementação do tratamento cirúrgico, bem como a escolha da técnica a ser empregada, varia de acordo com três pontos centrais: a fase da doença, a deformidade apresentada e a função erétil. Estes pilares para a decisão terapêutica do paciente com doença de Peyronie possuem nuances, não sendo simples a caracterização destes fatores em muitos casos. Uma avaliação pré-operatória criteriosa, fundamental para a melhor escolha terapêutica, exige experiência e um conhecimento aprofundado sobre o tema. O objetivo do presente artigo é promover uma ampla discussão acerca de fatores primordiais da avaliação pré-operatória de pacientes com doença de Peyronie.

A salvage procedure for redo penile prosthesis implantation in phalloplasty (De castro technique) for congenital aphallia.

INTRODUCTION: We present a different salvage procedure for penile prosthesis implantation in a De Castro neophallus. METHODS: A patient with congenital aphallia had been operated at the age of 11. Ten years later he had two non successful attempts of prosthesis implantation. Surgery consisted of adapting the implants into the aortic graft and folding it in the middle over the cylinders to reinforce its strength. RESULTS: Patient had a successful postoperative course and has now 6 months of follow-up. DISCUSSION: In a systematic review of penile prosthetic outcomes and complications in gender-affirming surgery, most of the prostheses were inflatable (83.6%) and single-cylinder (61.0%). At a mean follow-up of 3.0 years: 36.2% of prosthesis complications, 60.0% of patients had their original implant present and 83.9% reported achieving penetration. We decided to use vascular grafts as a scaffold because of former non successful attempts. CONCLUSION: The use of vascular prosthesis as a device to implant the penile prosthesis seems to be a safe and effective alternative in an attempt to offer erectile function to the neophallus in case of congenital aphallia.

Optimal Modeling: an Updated Method for Safely and Effectively Eliminating Curvature During Penile Prosthesis Implantation.

OBJECTIVES: To assess outcomes of a variant of traditional modeling ("optimal modeling," OM) in patients with residual curvature following prosthesis implantation. METHODS: We performed a retrospective review of all patients who underwent penile implant insertion. Patients with >30° of residual curvature after cylinder placement and inflation underwent OM and were compared 1:1 to a demographically-matched cohort who received implantation without ancillary straightening. Optimal modeling was performed by forcibly bending the erect penis in the direction opposite the point of maximal curvature while maintaining glanular pressure to prevent urethral injury. This was performed for 90-second intervals for as many cycles as necessary to achieve <15° curvature. RESULTS: Eighty patients were included in the final analysis; 40 (50.0%) underwent optimal modeling while 40 (50.0%) did not need additional straightening following surgery. The mean premodeling curvature was 47.8° (range 30°-90°) while post-modeling curvature improved to a mean of 10.6° (range 0°-30°, P < .001); 87.5% of patients had <15° of residual curvature. Patients in the OM cohort experienced longer operative times (82.7 vs 75.8 min, P = .15). No patient in either group experienced an intraoperative or postoperative complication at a mean follow-up of 29.9 months. CONCLUSION: Although many prosthetic urologists forego manual modeling in cases of moderate-severe penile curvature, our contemporary series shows it to be both safe and effective. OM may preclude the need for more time-consuming and complex surgical procedures.

Minimizing Penile Prosthesis Implant Infection: What Can We Learn From Orthopedic Surgery?

The implantation of penile protheses for the surgical treatment of erectile dysfunction has risen in popularity over the past several decades. Considerable advances have been made in surgical protocol and device design, specifically targeting infection prevention. Despite these efforts, device infection remains a critical problem, which causes significant physical and emotional burden to the patient. The aim of this review is to broaden the discussion of best practices by not only examining practices in urology, but additionally delving into the field of orthopedic surgery to identify techniques and approaches that may be applied to penile prothesis surgery.

Risk factors associated with penile prosthesis infection: systematic review and meta-analysis.

PURPOSE: The aim of this study was to identify the factors associated with infection in patients who undergo penile prosthesis implantation. METHODS: We performed a systematic review/meta-analysis, including clinical trials, quasi-experiments, retrospective and prospective cohort studies, and case-control studies. Searching was done in CENTRAL, MEDLINE, and EMBASE databases. Participants were patients who had erectile dysfunction, regardless of the etiology, and underwent penile prosthesis implantation. Two researchers reviewed each reference by title and abstract. The statistical analysis was performed using Review Manager 5.3 (RevMan® 5.3). RESULTS: A total of 513 studies were found with the search strategies. After excluding duplicates, 40 studies with a total of 175,592 patients were included in the qualitative and quantitative analysis. Among patient characteristics, we found that diabetes mellitus and immunosuppression appear to have increase odds of infection. Related to the procedure, infection-retardant-coated penile prosthesis and primary (first) surgery appear to lower odds of infection. CONCLUSIONS: Diabetes mellitus and immunosuppression were associated with increased infection rates; infection-retardant coating of the prosthesis and primary surgery were associated with reduced infection rates.