Penile Prosthesis Surgery: A Review of Prosthetic Devices and Associated Complications

INTRODUCTION

Although more invasive than some of the other currently available therapies, penile prosthesis surgery has the advantages of high patient satisfaction rates and avoidance of systemic adverse events in the vast majority of cases.

AIM

This article provides a review of the more widely used implants and some of the more frequently encountered complications of penile prosthesis surgery.

METHODS

A retrospective review peer reviewed publications relevant to the field of penile prosthesis surgery.

MAIN OUTCOME MEASURES

Review of historical milestones and newer penile prostheses, as well as a review of prosthesis surgery complications.

RESULTS

Improved designs and materials have resulted in decreased incidence of mechanical failures or infectious complications while simultaneously simplifying the operation of these devices.

CONCLUSIONS

Penile prosthesis surgery remains an excellent alternative for restoring erectile function to those in whom medical therapies such as phosphodiesterase inhibitors are contraindicated or who have failed more conservative measures.

Factors influencing the outcomes of penile prosthesis surgery at a teaching institution

OBJECTIVES

To evaluate the long-term outcomes of penile prosthesis surgery at a teaching institution.

METHODS

Patients who had penile prosthesis surgery from 1988 to 1999 at a private teaching hospital and the Dallas Veterans Affairs Medical Center were identified and charts abstracted for age at first prosthesis, ethnicity, etiology of impotence, comorbid medical disease, previous treatments, surgeon, type of prosthesis, perioperative complications, social history, and outcome. Patient outcomes were determined either from recent clinical documentation within the prior year or by telephone survey of patients. Frequent implanters were defined as those surgeons who performed more than 10 procedures during the study period. Kaplan-Meier curves were used to evaluate survival for patients and prostheses; statistical significance was assessed by the log-rank test.

RESULTS

A total of 152 patients were identified, 81 patients at the Veterans Affairs Medical Center and 71 patients at the private hospital. A total of 180 procedures were performed by 15 attending surgeons, 4 of whom performed most (n = 132) of these procedures. No statistically significant difference was noted in patient age between the two hospitals. No statistically significant differences were found in survival of the penile prostheses on the basis of a history of smoking, diabetes, hypertension, or coronary artery disease. First prostheses had statistically significant better survival compared with secondary prostheses (5-year rate 71% versus 42%; 10-year rate 60% versus 35%, P = 0.0002). The overall infection rate at final follow-up was 9.9% and 18.8% for primary and secondary prostheses, respectively (P = 0.03). The 5-year survival outcomes with first prostheses for frequent implanters were superior to those of infrequent implanters (70% versus 63%, P = 0.034). Malleable prostheses had fewer complications than three-piece inflatable prostheses (10-year survival rate 87% versus 50%, P = 0.0081).

CONCLUSIONS

Superior penile prosthesis outcomes were achieved with first penile prostheses when implanted by higher volume implanters. Meticulous technique and experience are important in all penile prosthesis surgery; however, outcome analysis emphasizes that the differences in outcomes are most apparent with first prostheses, which represent the best opportunity for the patient to achieve good results.

Multi-institutional outcome study on the efficacy of closed-suction drainage of the scrotum in three-piece inflatable penile prosthesis surgery

Infection is a devastating complication of penile prosthesis surgery that occurs in approximately 2-5% of all primary inflatable penile primary implants in most series. Prevention of hematoma and swelling with closed-suction drains has been shown not to increase infection rate and yield an earlier recovery time. Despite the intuitive advantages of short-term closed-suction drainage in reducing the incidence of postoperative scrotal swelling and associated adverse effects, many urologists are reluctant to drain the scrotum because of a theoretical risk of introducing an infection. In conclusion, this study was undertaken to evaluate the incidence of infection in three-piece penile prosthesis surgery with scrotal closed-suction drainage. A retrospective review of 425 consecutive primary three-piece penile prosthesis implantations was performed at three institutions in New Jersey, Ohio, and Arkansas from 1998 to 2002. Following the prosthesis insertion, 10 French Round Blake (Johnson & Johnson) or, in a few cases, 10 French Jackson Pratt, closed-suction drains were placed in each patient for less than 24 h. All subjects received standard perioperative antibiotic coverage. Average age at implant was 62 y (range 24-92 y). Operative time (incision to skin closure) was less than 60 min in the vast majority of cases. There were a total of 14 (3.3%) infections and three hematomas (0.7%) during an average 18-month follow-up period. In conclusion, this investigation revealed that closed-suction drainage of the scrotum for approximately 12-24 h following three-piece inflatable penile prosthesis surgery does not result in increased infection rate and is associated with a very low incidence of postoperative hematoma formation, swelling, and ecchymosis.

Does surgical approach affect the incidence of inflatable penile prosthesis infection?

OBJECTIVES

To review retrospectively the rate of infection in 380 consecutive organically impotent men implanted with a Mentor Alpha I inflatable penile prosthesis, stratified by surgical approach (scrotal or infrapubic).

METHODS

Data were obtained from review of medical records. One hundred percent of cases were available for a minimum postoperative follow-up of 6 months.

RESULTS

Twenty patients had a prior penile prosthetic operation and were excluded, leaving 360 primary implants for review. Overall, 6 patients (1.7%) developed periprosthetic infection. Four of these 6 patients were diabetic. Four of 139 infrapubic cases (2.9%) and 2 of 221 scrotal cases (0.9%) developed periprosthetic infection. This difference was not statistically significant (P = 0.15). Equal proportions of the infrapubic (39.6%) and scrotal cases (40.3%) were diabetic patients. The infection rate in patients with and without diabetes was 4 of 144 (2.8%) and 2 of 216 (0.9%), respectively. This difference was not statistically significant (P = 0.18).

CONCLUSIONS

This study indicates that there is no statistically significant difference in the infection rate when the scrotal and infrapubic approaches to inflatable penile prosthesis insertion are compared.

Impact of Surgeon Case Volume on Reoperation Rates after Inflatable Penile Prosthesis Surgery

PURPOSE

We investigated the impact of surgeon annual case volume on reoperation rates after inflatable penile prosthesis surgery.

MATERIALS AND METHODS

The New York Statewide Planning and Research Cooperative System database was queried for inflatable penile prosthesis cases from 1995 to 2014. Multivariate proportional hazards regression was performed to estimate the impact of surgeon annual case volume on inflatable penile prosthesis reoperation rates. We stratified our analysis by indication for reoperation to determine if surgeon volume had a similar effect on infectious and noninfectious complications.

RESULTS

A total of 14,969 men underwent inflatable penile prosthesis insertion. Median followup was 95.1 months (range 0.5 to 226.7) from the time of implant. The rates of overall reoperation, reoperation for infection and reoperation for noninfectious complications were 6.4%, 2.5% and 3.9%, respectively. Implants placed by lower volume implanters were more likely to require reoperation for infection but not for noninfectious complications. Multivariable analysis demonstrated that compared with patients treated by surgeons in the highest quartile of annual case volume (more than 31 cases per year), patients treated by surgeons in the lowest (0 to 2 cases per year), second (3 to 7 cases per year) and third (8 to 31 cases per year) annual case volume quartiles were 2.5 (p <0.001), 2.4 (p <0.001) and 2.1 (p=0.01) times more likely to require reoperation for inflatable penile prosthesis infection, respectively.

CONCLUSIONS

Patients treated by higher volume implanters are less likely to require reoperation after inflatable penile prosthesis insertion than those treated by lower volume surgeons. This trend appears to be driven by associations between surgeon volume and the risk of prosthesis infection.

Penile prosthesis in the organ transplant recipient

OBJECTIVES

To determine whether pelvic organ transplant recipients are at a higher risk of developing complications after placement of a penile prosthesis relative to those receiving a penile prosthesis who did not undergo pelvic organ transplantation.

METHODS

Two hundred eleven men underwent placement of a penile prosthesis by a single urologist at our institution between July 1994 and March 2000. Of these, 46 patients had undergone pelvic organ transplantation before placement of the penile prosthesis. The average time from transplantation was 43 months. The average follow-up after prosthesis placement was 23 months. These patients were monitored for various complications, including infection, malfunction, autoinflation, and injury to the prosthesis. They were compared with a cohort of men who had had a prosthesis placed but had not received pelvic organ transplantation.

RESULTS

The overall complication rate was significantly higher in the transplant patients (22%) than in the nontransplant patients (7.9%) receiving prostheses (P <0.01). Infection was seen in 2 transplant patients (4.3%) and in 7 nontransplant patients (4.2%) (P <1). Malfunction occurred in 4 of the transplant patients (8.7%) and 6 of the nontransplant patients (3.6%) (P <0.2). In those patients with a prosthesis malfunction, 9 of 10 involved a three-piece prosthesis. All four malfunctions in the transplant group occurred in three-piece prostheses. The difference in the rate of malfunction was statistically significant (P <0.001) when comparing the three-piece prosthesis in the transplant and nontransplant patients (P <0.001). Surgical injury to the retroperitoneal reservoir occurred in 4 transplant patients (8.7%) (all with three-piece prostheses) and in none of the nontransplant patients (P <0.001).

CONCLUSIONS

The risk of infection after insertion of penile prostheses in patients with pelvic organ transplantation was similar to that in nontransplant patients. The risk of malfunction and injury to the prosthesis (three-piece) was higher in transplant patients. The overall complication rate was significantly higher in patients after transplantation and can be attributed to the reservoir complications related to three-piece prostheses. In patients with a prosthesis that did not have a retroperitoneal reservoir, no significant difference in the overall complication rate was observed. Pelvic organ transplant recipients in whom traditional conservative therapy for erectile dysfunction fails should be considered candidates for penile prosthesis placement. However, three-piece prostheses should be avoided, as these patients are best served with prostheses that do not require a retroperitoneal reservoir.

Long-Term Follow-Up After Penile Prosthesis Implantation-Survival and Quality of Life Outcomes

INTRODUCTION

Hydraulic penile prostheses have shown an overall good mechanical reliability up to 10 years after surgery; however, few data have been published on very long-term follow-up.

AIM

We looked at long-term (≥15 years) complications, including functional and quality of life (QoL) outcomes, after 3-piece inflatable penile prosthesis (IPP) implantation in patients with erectile dysfunction (ED).

METHODS

Data regarding 149 patients submitting to IPP placement before 2001 were analyzed. All patients were implanted with AMS CX and Ultrex Plus 3-piece prostheses.

MAIN OUTCOME MEASURE

Patients were reassessed to evaluate rates of complications and functional outcomes. The validated questionnaire Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) was used to assess patient QoL. Kaplan-Meier analysis estimated the probability of prosthesis survival (defined as working device/not-explanted).

RESULTS

Median follow-up of 51 patients was 206 months (interquartile range [IQR], 145-257). The etiology of ED was vasculogenic (n = 20; 39%), Peyronie's disease (n = 15; 29%), pelvic surgery (n = 4; 7.8%), organic other than vasculogenic (n = 3; 5.9%), or other (n = 9; 18%). Throughout the follow-up, 24 patients (49%) experienced complications: mechanical failure (n = 19; 79%), pain (n = 3; 12%), orgasmic dysfunctions (n = 1; 4.5%), or device infection (n = 1; 4.5%). The estimated IPP survival was 53% (95% CI, 36-67) at 20-year follow-up. Baseline characteristics (age, Charlson comorbidity index, body mass index, and erectile dysfunction etiology) were not significantly associated with the risk of IPP failure over time by Cox regression analysis. At 20-year follow-up, 41% (95% CI, 19-49) of the patients were still using the device. Among them, QoLSPP median domain scores were high: functional 22/25 (IQR, 20-23), relational 17/20 (IQR, 15-18), personal 14/15 (IQR, 12-15), and social 14/15 (IQR, 11-15).

CLINICAL IMPLICATIONS

The longevity of the device and long-term satisfaction rates should be comprehensively discussed during patient consultation for IPP surgery.

STRENGTHS & LIMITATIONS

To our knowledge, this is the first study reporting long-term QoL outcomes using a dedicated questionnaire for penile prostheses. The low response rate for the telephone interviews, the retrospective design of the study, and the relatively small number of patients are the main limitations.

CONCLUSION

Long-term follow-up data after IPP placement showed that almost half of the devices still worked properly 20 years after the original penile implant, as 60% of patients were still using the device with high satisfaction and adequate QoL outcomes. Both patients and physicians should be aware of the expected life and outcomes of IPP implants. Chierigo F, Capogrosso P, Dehò, et al. Long-Term Follow-Up After Penile Prosthesis Implantation-Survival and Quality of Life Outcomes. J Sex Med 2019;16:1827-1833.

Outcome analysis of penile implant surgery after external beam radiation for prostate cancer

PURPOSE

We evaluated the success and possible complication rates of penile implant surgery in patients who underwent external beam radiation therapy for prostate cancer.

MATERIALS AND METHODS

We reviewed the charts of 43 patients who underwent penile implant surgery after radiation therapy for prostate cancer. The type, dose and volume of radiation were assessed. The types of surgical approach and prosthesis as well as complications were recorded. A total of 34 patients was alive and traceable, and 9 were untraceable (7 dead and 2 missing). The 34 traceable patients were interviewed personally or by telephone to evaluate the function of and satisfaction with the penile implant. Followup of the 9 untraceable patients was assessed through a chart review.

RESULTS

A total of 35 patients (81%) received definitive radiation therapy to the prostate and seminal vesicles, and 8 (19%) underwent radical retropubic prostatectomy followed by radiation therapy to the prostatic bed. Mean age at implant surgery was 67 years (range 36 to 83). In the 43 men 46 procedures were done and mean followup was 40 months. None of the patients in this series had infection or erosion. Of the men 24 (71%) use the prosthesis at least once weekly or more for sexual intercourse, 6 (17%) use it twice monthly, 4 (12%) are not sexually active despite a functioning implant, 2 are not sexually active because of a lack of sexual partners, and 2 are not satisfied with the implant and would not recommend this device. Discomfort from the penile implant was reported by 2 patients, although they currently use the implant for intercourse at least twice weekly.

CONCLUSIONS

Penile prosthesis surgery can be safely and effectively performed after radiation therapy with minimal intraoperative and postoperative complications, and an excellent patient satisfaction rate.

Penile prosthesis implantation in the treatment of Peyronie's disease

PURPOSE

This study was undertaken to evaluate the results and complications of penile prosthesis implantation in patients with erectile dysfunction caused by Peyronie's disease.

MATERIALS AND METHODS

Men undergoing surgical intervention for erectile dysfunction caused by Peyronie's disease at the University of North Carolina School of Medicine were reviewed. Patients included 30 men aged 29-64 (mean = 49.6) with a duration of Peyronie's disease from 12-72 months (mean = 31.4 months). All men had palpable Peyronie's plague, significant penile curvature and plaque formation. All patients underwent implantation of AMS 700CX penile prostheses from 1993 to 1997.

RESULTS

Penile straightening was carried out using modeling in 28 (93%) while plaque incision was necessary in 2 men (7%). All patients had a resultant straight penis with functional penile implant. There were no patients who suffered penile prosthesis infection and no mechanical malfunctions were observed during the follow-up.

CONCLUSIONS

Penile prosthesis implantation with modeling is a safe, simple, effective technique for straightening penile curvature in patients undergoing implantation of penile prosthesis for Peyronie's disease. Penile prosthesis implantation is a safe, effective, low morbidity method for restoring potency in men with male erectile dysfunction and Peyronie's disease.

Inflatable Penile Prosthesis Placement, Scratch Technique and Postoperative Vacuum Therapy as a Combined Approach to Definitive Treatment of Peyronie's Disease

PURPOSE

Peyronie's disease is a devastating condition resulting in penile malformation, erectile dysfunction, pain and emotional distress. In this prospective, 2 institution study we evaluated a multimodal surgical and mechanical combined approach to the definitive treatment of Peyronie's disease and concomitant erectile dysfunction.

MATERIALS AND METHODS

A total of 145 select patients underwent endocavernous disruption of Peyronie's disease plaques via the scratch technique, followed by inflatable penile prosthesis insertion. Postoperatively patients were assigned to vacuum device therapy for 3 minutes twice daily to continue penile curvature correction. Followup continued for 1 year after surgery. Anatomical and functional results were assessed.

RESULTS

Patients with plaques in the proximal third, middle third and subcoronal areas of the penis had a mean ± SD postoperative residual curvature of 21.5 ± 4.5, 17.3 ± 4.8 and 14.1 ± 3.1 degrees, respectively. After 24 weeks of vacuum therapy the mean penile curvature deviation decreased to 8.7 ± 2.5, 9.1 ± 2.9 and 7.7 ± 0.9 degrees, respectively. The mean IIEF-5 (International Index of Erectile Function) score was 9.8 ± 2.3 preoperatively, 18.9 ± 3.1 at 6 months (p <0.001) and 24.1 ± 3.6 at 1 year (p <0.001). The mean EDITS (Erectile Dysfunction Inventory of Treatment Satisfaction) score at the end of followup was 64.6 ± 11.8. Operative and postoperative complications were minimal.

CONCLUSIONS

Our novel combination of intraoperative and postoperative therapies in the treatment of patients with Peyronie's disease and an inflatable penile prosthesis was safe and efficacious with excellent functional outcomes. Penile curvature corrections were statistically significant and complications were negligible.

ORIGINAL RESEARCH—SURGERY: Efficacy and Patient Satisfaction Associated with Penile Prosthesis Revision Surgery

INTRODUCTION

Complications that arise after placement of a penile prosthesis may result in the need for revision surgery. Few contemporary penile prosthesis series have focused solely on describing the efficacy and patient satisfaction associated with penile prosthesis revision surgery.

AIM

To determine the overall success of penile prosthesis revision surgery in providing the patient with a functional implant. Device efficacy and patient satisfaction with penile prosthesis revision surgery will be assessed using psychometrically validated instruments.

MAIN OUTCOME MEASURES

The erectile function (EF) and satisfaction domains of the International Index of Erectile Function (IIEF) were used to quantify the overall efficacy and patient satisfaction with revision surgery.

METHODS

Data were derived from a prospective database of consecutive patients undergoing penile prosthesis revision surgery performed by a single surgeon (B.R.K.). Eleven patients filled out the IIEF prior to surgery and 26 completed it following surgery.

RESULTS

Thirty-nine consecutive patients underwent 55 revision procedures related to a prior penile prosthesis. Thirty-four patients (87%) have a functional implant with a median follow-up of 6.5 months (range 1-42 months). Significant improvements in the overall IIEF, EF domain, and satisfaction domain were seen in those patients studied prior to and following revision surgery. The total IIEF, EF domain, and satisfaction domain of the IIEF for the group of 26 responders were 60.7 +/- 19.3, 26.6 +/- 8.7, and 15.7 +/- 5.6, respectively. Patients with fibrotic corporal bodies scored significantly lower on the EF and satisfaction domains than did any other group.

CONCLUSIONS

Penile prosthesis revision surgery is highly successful in providing men with a functional implant. The prostheses function well and patients are satisfied with their devices. Further study of those men with corporal fibrosis is warranted in order to determine the factors needed to improve their overall satisfaction with revision surgery.

Management of prosthesis infections in urologic surgery

Prosthetic devices are a cornerstone of urologic surgical care. The most disastrous complication of these surgical procedures is infection. The prevention, identification, and management of infections are critical to maintaining functional urologic prosthetic devices. Although the incidence is low, rapid identification of infections once they occur and proper management with antibiotics, surgical intervention, irrigation, and salvage procedures can maintain the function of urologic prosthetic devices despite clinical infection.

Contemporary aspects of penile prosthesis implantation

PURPOSE

Erectile dysfunction today has a number of effective treatment options. This review was undertaken to examine the contemporary role of penile prosthesis implantation in the treatment of this disorder.

MATERIALS AND METHODS

A MEDLINE search was performed on the topic of penile prostheses and implants. Current literature was reviewed with regard to types of penile implants, issues related to prosthesis implantation, results, and patient/partner satisfaction.

RESULTS

Mechanical failure rates for early penile prostheses, especially the inflatable type, were unacceptably high. Advances in both prosthesis design and implantation techniques have resulted in increased device survival with 5-year actuarial survival rates free of mechanical failure ranging from 86.2 to 93.6%. Recent reviews of implant recipients show 83 and 85% satisfaction and for partners 70 and 76% satisfaction.

CONCLUSIONS

When systemic therapy for erectile dysfunction fails, men have a variety of other options to choose from. Penile prosthesis implantation is an option that is feasible for nearly every man with this disorder. Current device survival rates and patient and partner satisfaction rates are high.

Cylinder sizing: less is more

In penile prosthesis implantation traditional cylinder-sizing techniques frequently result in penile cylinders that are too long for the corpora cavernosa. This can result in premature cylinder wear leading to cylinder aneurysm or fluid loss. Additionally, in the case of the length expanding Ultrex penile prosthesis, cylinders that are too long can result in an S-shaped cylinder deformity. We describe a cylinder measurement technique that avoids the problem of oversizing.

Penoscrotal versus minimally invasive infrapubic approach for inflatable penile prosthesis placement: a single-center matched-pair analysis

PURPOSE

To compare perioperative results, safety and efficacy profile in patients receiving inflatable penile prosthesis (IPP) via penoscrotal (PS) or minimally invasive infrapubic (MII) approach for erectile dysfunction.

METHODS

A matched-pair analysis was performed including 42 patients undergoing IPP implantation via PS (n = 21) or MII (n = 21) between 2011 and 2016. Clinical and surgical data were prospectively collected. Patients' and partners' outcomes were assessed by the International Index of Erectile Function (IIEF), Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) and Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaires.

RESULTS

Mean (SD) operative time was 128 (40.6) min in group PS and 91 (43.0) min in group MII (p = 0.041). Complications occurred in 3/21 (14%) and 2/21 (10%) patients in groups PS and MII (p = 0.832). Overall, no differences were observed concerning the device utilisation (p = 0.275). However, in group MII 4/21 (19%) patients were able to resume sexual activity prior to 4 postoperative weeks, while in group PS no patient was (p = 0.012). Mean (SD) scores for questionnaires were similar between groups PS and MII: IIEF [20.9 (7.3) vs. 20.7 (4.8); p = 0.132], patient EDITS [76.0 (25.6) vs. 74.7 (20.8); p = 0.256] and partner EDITS [72.5 (29.1) vs. 73.1 (21.4); p = 0.114]. Similarly, QoLSPP showed comparable results among the groups PS and MII: functional domain [3.9 (1.4) vs. 4.0 (1.2); p = 0.390], personal [4.0 (1.2) vs. 4.1 (1.0); p = 0.512], relational [3.7 (1.5) vs. 3.9 (1.2); p = 0.462] and social [4.0 (1.2) vs. 3.9 (1.2); p = 0.766].

CONCLUSIONS

PS and MII demonstrated to be safe and efficient techniques, leading to high level of both patients and partners satisfaction. Additionally, the minimally invasive infrapubic approach showed a shorter operative time and a tendency for a faster return to sexual activity.

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: surgical implants in the era of oral medication

In patients who are not satisfied with the results of oral agents (phosphodiesterase-5 inhibitors) or in whom oral agents or other medical treatment fails to produce an adequate response, penile prosthesis implantation is an excellent treatment modality for restoring erectile function. Patient/partner acceptance, use, and satisfaction rates of penile pros-theses are better than for many other alternatives including pharmacologic injections. In-flatable penile prostheses are most frequently used and have the highest satisfaction rates. Complications of these multipiece prostheses continue to decline, and patient satisfaction rates, tolerability, and longevity continue to increase.

Penile prosthesis implantation and infection for Sexual Medicine Society of North America

Penile prosthetics have developed over the past three decades into an effective treatment for erectile dysfunction with high reliability and patient satisfaction rates. The morbidity of these devices is principally limited to mechanical malfunction and the most feared complication of prostheses infection. Most penile prosthesis infections are caused by gram positive skin contaminations such as Staphylococci. The signs and symptoms of these infections may be difficult to identify in early stages, but late infections may lead to tissue loss and poor prognosis for prosthesis replacement. Treatment of penile prosthesis infections is best carried out with a salvage technique including aggressive lavage and prosthesis replacement. The success of this technique is salvage of prosthesis and return to function in more than 80% of cases. While penile prosthesis infection continues to be a dreaded complication, early diagnosis and aggressive surgical treatment may salvage the majority of these implants.

Experience with the Ultrex and Ultrex Plus inflatable penile prosthesis: new implantation techniques and surgical outcome

The Ultrex and Ultrex Plus penile prosthesis incorporate sequential design modifications that afford important functional advantages that reduce the potential for mechanical failure. This retrospective study reviews our experience with these models emphasizing innovations in surgical technique and postoperative results. Implantation of Ultrex (31%) and Ultrex Plus (69%) penile prosthesis was performed in 90 impotent men with organic erectile dysfunction following comprehensive multi-disciplinary evaluation. During a follow-up interval of 7-50 months, postoperative outcome was assessed. Of this group, 10% underwent simultaneous explant of another malfunctioning inflatable device or conversion from a semi-rigid prosthesis due to patient preference. Of the remainder, 20% selected implant surgery as their primary therapy while 73% were initially treated with various nonsurgical options prior to implantation. In all patients we employed a single peno-scrotal incision and applied the concept of controlled radial dilatation of all compartments. In our last 32 consecutive patients including eight with previous radical pelvic surgery, we utilized the preperitoneal distention balloon (PDB) facilitating safe and non-traumatic creation of the prevesical space for reservoir insertion. Post operative complications occurred in 8% of patients including pump infection and corporal deformity requiring reimplantation with AMS 700 CX cylinders, or self-contained unitarian prosthesis as a salvage procedure. Satisfactory, functional and anatomic outcome was reported in 95% of patients. Interim advances incorporated into the Ultrex and Ultrex Plus prosthesis have markedly reduced mechanical failure during our follow-up interval of up to 50 months. Importantly, controlled, non-traumatic radial dilatation of the prevesical space by the PDB may encourage broader use of the multicomponent inflatable models, particularly in a setting of pelvic fibrosis due to previous pelvic surgery or radiation.

Infection following penile prosthesis placement at an academic training center remains low despite involvement of surgeons-in-training

Purpose

Primary care providers harbor misconceptions regarding penile prosthetic surgery, largely overestimating the rate of infection. Rates of infection following surgery for primary placement and revision are estimated as 1% to 3% and 10% to 18%, respectively. Our objective was to determine the contemporary incidence of infection following inflatable penile prostheses surgery at an academic training center where surgeons-in-training are routinely involved.

Materials and Methods

Review of a prospectively collected single-surgeon database was performed. All cases of inflatable penile prostheses placement from January 2011 through June 2017 were reviewed. Information regarding training level of assistant surgeon(s) was collected, and follow-up data was compiled regarding postoperative infections and need for revision surgery.

Results

Three hundred nine cases meeting inclusion criteria were identified. Mean patient age was 64.2 years, and mean follow-up was 28.7 months. Distribution involved 257 (83.2%) for primary placement, 45 (14.6%) for removal/replacement, and 7 (2.3%) in setting of prior device removal. Diabetes was noted in 31.1% of men. Surgeon-in-training involvement was noted in 100% of cases. Infection was confirmed in a patient who had skin breakdown over an area of corporal reconstruction with polytetrafluoroethylene. The overall postoperative infection rate was 0.3%.

Conclusions

In this series from an academic training center, infection following penile prosthetic surgery is low, similar to other centers of excellence, even with 100% involvement of surgeons-in-training. This data should be used to better inform primary care providers and members of the general public potentially interested in restoration of sexual function.

Gangrene of the distal penis after implantation of malleable penile prosthesis in a diabetic patient

We present a rare clinical case of distal penile gangrene in a patient with type 2 diabetes mellitus after the implantation of malleable penile prosthesis. Necrosis of the glans penis, urethral meatus, dorsal penile shaft, and corpora cavernosa was observed, and a distal penectomy was performed.

An unusual case of penile augmentation: subcutaneous stone implantation

Different techniques for penile augmentation have been published. We report a 45-year-old man who had undergone a subcutaneous penile stone implantation for enlargement, which is the first published report to our knowledge.

Association of the modified frailty index with adverse outcomes after penile prosthesis implantation

OBJECTIVES

To investigate frailty as a predictor of surgical outcome in elderly patients undergoing penile prosthesis implantation.

MATERIAL AND METHODS

A total of 54 elderly patients, above 60 years of age, underwent penile prosthesis implantation between 2012 and 2014. Their data were collected and retrospectively analyzed. A modified frailty index (mFI) was calculated for each patient based on 11 risk factors from the Canadian Study of Health and Aging Frailty Index. The 1-year adverse outcomes were correlated with mFI, patients' and procedure's risk factors.

RESULTS

Mean age was 64.9 ± 5.2 years. No mortality was reported in our patients, however, one-year adverse outcomes were encountered in 43 (79.6%) patients. Among all studied variables, the 1-year adverse outcomes was not significantly association with mFI, but with preoperative glycosylated hemoglobin A1c (HbA1c) (p = 0.031) and associated Peyronie's disease (PD) (p = 0.000). HbA1c, dyslipidemia, hypertension, PD and duration of the procedure were predictive of infection complications (p < 0.05). Only PD and HbA1c sustained an independent significant impact.

CONCLUSIONS

mFI is not a predictive of post-penile prosthesis implantation adverse outcomes in elderly patients with impotence. Degree of diabetic control and association with PD was associated with the 1-year adverse outcomes and infection complications.

Infection control in outpatient unicomponent penile prosthesis surgery

The aim of this work is evaluate the efficacy of infection control measures with unicomponent penile implants in two ambulatory surgery units in Cairo and Jeddah. This was a retrospective study of 117 consecutive cases. A patient selection and infection control protocol was followed to implant 12 hydraulic, 53 mechanical and 52 malleable prostheses under local bupivacaine penile ring anesthesia and intravenous propofol. No infection occurred that required prosthesis removal, none required hospitalization or urinary catheterization, one crural and two septal perforations were managed intraoperatively; one case was reoperated upon for mechanical failure, two for oversizing and one for undersizing the girth. We conclude that implantation of unicomponent penile implants under triple antibiotic coverage in an ambulatory surgery setting, with rigid infection control measures appears to be effective in preventing infection.