Inflatable penile prosthesis (IPP): diagnosis of complications

MR imaging of penile pathology and prostheses

Penile MRI is a vital yet underutilized diagnostic tool that provides detailed information crucial for managing various penile pathologies. Due to its infrequent use, many radiology trainees lack confidence in interpreting these exams. This article reviews the anatomy, key technical considerations, and interpretive pearls for penile trauma, Peyronie's disease, priapism, penile neoplasms, prosthesis evaluation, and a few miscellaneous conditions. Through illustrative case examples, this review aims to enhance the understanding and proficiency of radiologists in performing and interpreting penile MRI in these clinical scenarios.

Complication rates in concurrent inflatable penile prosthesis and incontinence surgery: Comparing the penoscrotal versus perineal incision approach

The main objective of this study was to assess the IPP complication rates of patients undergoing placement via perineal incision versus more traditional penoscrotal approach in synchronous dual implantation. We identified 38 patients who underwent dual implantations of an IPP and AUS or urethral sling from 2011 to 2021 at a single tertiary center, 24 via perineal and 14 via penoscrotal incision. All IPP implants were done by a single surgeon. IPP postoperative complications were captured using the Clavien-Dindo classification at three separate time points, < 30 days, 30 days - 6 months, and > 6 months. The perineal group had two complications, IPP explantation due to rectourethral fistula (Grade III, > 6 months), and IPP explantation due to chronic genital pain (Grade III, > 6 months). The penoscrotal group had three complications, post-operative urinary retention requiring catheterization (Grade I, < 30 days), incision site infection (Grade I, < 30 days), and IPP explantation due to infection (Grade III, 30 days to < 6 months). There was no statistically significant difference in rate of patients with IPP complications between the two groups (p = 0.546) or in rate of IPP device malfunction (p = 0.264). These preliminary findings suggest that the single perineal incision is a viable surgical approach in synchronous dual implantation.

Maximizing outcomes in penile prosthetic surgery: exploring strategies to prevent and manage infectious and non-infectious complications

Inflatable Penile Prostheses (IPP) implantation is a surgical treatment for patients desiring definitive treatment for erectile dysfunction. While this procedure has proven to be effective, it also carries its own set of unique risks that need to be carefully considered. The article reviews the current understanding of complications associated with penile prosthetic surgery and provides strategies to mitigate these adverse events. This article covers various aspects of IPP implantation, including the risks of infection, bleeding, injury to nearby structures, glans ischemia, and device malfunction. It also discusses the importance of careful preoperative screening to identify risk factors and the implementation of infection reduction strategies such as antimicrobial prophylaxis, skin prep, and operative techniques. In addition, it emphasizes the need for postoperative vigilance and prompt management of any complications that may arise. Overall, the article provides a comprehensive overview of the risks and strategies for mitigating complications associated with IPP implantation. Our recommendations are given based on the current consensus in the field and highlight the importance of careful planning, attention to detail, and effective communication between healthcare providers and patients. Despite the potential risks, this review underscores the fact that complications following penile prosthesis implantation are relatively rare.

Mechanical indications for inflatable penile prosthesis revision: analysis and implications for revision surgery

BACKGROUND

Despite technical advancements, inflatable penile prostheses (IPPs) are inherently at risk of mechanical failure given their nature as hydraulic devices.

AIM

To characterize IPP component failure location at the time of device revision and stratify by manufacturer: American Medical Systems (Boston Scientific [BSCI]) and Coloplast (CP).

METHODS

A retrospective review of penile prosthesis cases from July 2007 to May 2022 was conducted, identifying men who underwent revision surgery. Cases were excluded if documentation did not denote the cause of failure or the manufacturer. Mechanical indications for surgery were categorized by location (eg, tubing, cylinder, or reservoir leak; pump malfunction). Nonmechanical revisions were excluded (component herniation, erosion, or crossover). Categorical variables were assessed with Fisher exact or chi-square analysis; Student t-test and Mann-Whitney U test were used for continuous variables.

OUTCOMES

Primary outcomes included specific location of IPP mechanical failure among BSCI and CP devices and time to mechanical failure.

RESULTS

We identified 276 revision procedures, 68 of which met inclusion criteria (46 BSCI and 22 CP). Revised CP devices were longer than BSCI devices (median cylinder length, 20 vs 18 cm; P < .001). Log-rank analysis revealed a similar time to mechanical failure between brands (P = .096). CP devices failed most often due to tubing fracture (19/22, 83%). BSCI devices had no predominant site of failure. Between manufacturers, tubing failure was more common in CP devices (19/22 vs 15/46 for BSCI, P < .001), while cylinder failure was more common among BSCI devices (10/46 vs 0/22 for CP, P = .026).

CLINICAL IMPLICATIONS

The distribution of mechanical failure is significantly different between BSCI and CP devices; this has implications regarding the approach to revision surgery.

STRENGTHS AND LIMITATIONS

This is the first study to directly compare when and where mechanical failure occurs in IPPs and to compare the 2 main manufacturers head-to-head. This study would be strengthened by being repeated in a multi-institutional fashion to provide more robust and objective evaluation.

CONCLUSION

CP devices commonly failed at the tubing and rarely elsewhere, while BSCI devices showed no predominant failure site; these findings may inform decision making regarding revision surgery.

Outcomes of Inflatable Penile Prosthesis following Radical Cystectomy - A matched Cohort Analysis

OBJECTIVE

To evaluate outcomes of inflatable-penile-prosthesis (IPP) implantation after radical-cystectomy compared with other etiologies of erectile dysfunction.

MATERIALS AND METHODS

All inflatable penile prostheses within the past 20 years in a large regional health system were reviewed, and erectile dysfunction etiology was determined as radical-cystectomy, radical-prostatectomy, or organic/other ED. Cohorts were generated by 1:3 propensity score match using age, body mass index, and diabetes status. Baseline demographics and relevant comorbidities were evaluated. Clavien-Dindo complications, grade, and reoperation were assessed. Multivariable logarithmic regression was used to identify the predictors of 90-day complications following IPP implantation. Log-rank analysis was used to assess the time-to-reoperation after IPP implantation in patients with a history of cystectomy compared with non-cystectomy etiologies.

RESULTS

Of 2600 patients, 231 subjects were included in the study. Comparing patients undergoing IPP for cystectomy vs. pooled non-cystectomy indications, those who underwent radical-cystectomy had a higher overall complication rate(24% vs. 9%, p=0.02). Clavien-Dindo complication grades did not differ across groups. Reoperation was significantly more common following cystectomy (cystectomy: 21% vs. non-cystectomy: 7%, p=0.01), however time to reoperation did not differ significantly by indication (cystectomy: 8 years vs non-cystectomy: 10 years, p=0.09). Among cystectomy patients, 85% of reoperations were due to mechanical failure.

CONCLUSION

Compared to other erectile dysfunction etiologies, patients undergoing IPP with a history of cystectomy have an increased risk of complications within 90-days of implantation and need for surgical device revision, but no greater risk for high-grade complications. Overall IPP remains a valid treatment option after cystectomy.

Isolated nerve palsy following insertion of a three-piece inflatable penile prosthesis

Case report of a 57-year-old male who underwent insertion of an inflatable penile prosthesis due to erectile dysfunction, secondary to poorly controlled Type 2 diabetes and Peyronie’s disease. The surgical procedure was uneventful and there were no immediate post-operative complications. During a routine follow-up, the patient described problems with the deflation of the implant and severe lower back and leg pain. Diagnostic MRI scans revealed reservoir migration, impingement of the obturator nerve and oedema in the adductor muscle group. The reservoir was initially repositioned, and later on removed due to ongoing symptoms.

MRI of Penile Prostheses: The Challenge of Diagnosing Postsurgical Complications

Penile implants are surgically inserted devices used for the treatment of erectile disfunction. Improvements in surgical techniques and in the manufacturing of these implants have reduced the risk of intra- and postoperative complications and increased the popularity and use of this therapeutic option. Routine imaging is not recommended before penile prosthesis surgery. Malleable penile prostheses use noninflatable shafts inserted into each corpus cavernosum, which appear hypointense on T1- and T2-weighted MR images. Inflatable penile prostheses (IPPs) may consist of two or three parts and are composed of two cylinders inserted into the corpora cavernosa that are filled with a saline solution to produce rigidity. These appear homogeneously T2 hyperintense and the silicone-based covering of the cylinders appears T2 hypointense, thereby clearly delineating the cylinders. In the case of three-piece IPPs, a reservoir containing the fluid may be placed in the pelvis. The most frequent complications are related to infection and mechanical failure, the latter being more common in IPPs because more components are involved. Less common complications include malpositioning. Detection and management of postoperative complications are challenging, and MRI plays a crucial role as it permits evaluation of the positioning and configuration of the prosthesis components, as well as assists in functional evaluation of IPPs when images are obtained of both the flaccid and inflated states. ^©RSNA, 2021.

Imaging review of penile pathologies encountered in the emergency department

While penile pathology is uncommon, prompt diagnosis and treatment of emergent and urgent penile pathology are necessary to prevent complications. This paper will review the imaging findings of the most common critical penile pathologies, including traumatic, vascular, infectious, foreign body-related, and urethral pathology, in addition to penile prosthesis complications. Each entity will be discussed in the context of presentation and treatment and complications of each pathology will be discussed.

Revision Surgery for Inflatable Penile Prosthesis (IPP): A Single-Center Experience and Pictorial Representation

OBJECTIVE

To elucidate factors influencing Inflatable Penile Prosthesis (IPP) revision and describe outcomes associated with revision surgery.

METHODS

A single surgeon, retrospective review of all patients who underwent IPP revision between 2008-2016, was performed. Patient age, BMI, operative duration, blood loss, hospital duration, time from most recent penile implant to revision surgery, etiology of revision, and whether the patient had a prior failed revision surgery were all collected and analyzed.

RESULTS

A total of 57 patients, who had undergone IPP revision between the years 2008-2016, with at least 3 years of follow-up, were included in the investigation. Mean patient age and BMI were 68 and 29.2 kg/m², respectively. The mean time between the most recent implant operation to revision was 8.4 years. Four patients (7%) reported IPP revision failure within a 3-year follow-up period.

CONCLUSION

IPP revision demonstrates a relatively high success rate, in the short term, and should be offered to patients as a safe and effective option.

Infected penile prosthesis: literature review highlighting the status quo of prevention and management

INTRODUCTION

Erectile dysfunction affects over 50% of men 70 years and above, and penile prosthesis (PP) is its third-line treatment. Complications of PPs include infection, however, no formal guidelines exist for its management.

METHODS

We performed a literature search and reviewed 53 recent published literatures of experiences with management of PP infections, prevention, and treatment.

RESULTS

Acute infection can present early with pain and discharge and detection of early signs is of utmost importance. MRI studies are more sensitive than CT studies to diagnose and plan surgical intervention. Introduction of antibiotic impregnated devices attributed to the reduction of infection rates with superiority proven for certain types; the no-touch technique had further reduced this rate. The Mulcahy salvage remains the most widely used surgical approach for treatment despite modifications and novel techniques described; conservative management of PP infections is recently reported with promising results.

CONCLUSIONS

Despite absence of strict guidelines for the management of infected PPs, we reviewed and discussed numerous panel opinions and suggestions throughout literature. More research into the pathology, prevention, conservative management and advances in surgical treatment of this condition are called for to produce guidelines that unite the efforts to tackle these infections.

Risk profiling in patients undergoing penile prosthesis implantation

Penile prosthesis implantation is the gold standard of surgical therapy for patients with medication-refractory erectile dysfunction. However, this umbrella definition includes significant heterogeneity and associated risk profiles that should be candidly discussed and addressed perioperatively. Factors associated with operative success and patient satisfaction are often surgery specific; however, risk profiling via patient selection, preoperative optimization, proper device selection, and intraoperative consideration are highly correlated. Some examples of common risk profiles include comorbidity(ies) such as cardiovascular disease, diabetes mellitus, prior abdominal surgery, Peyronie's disease, and psychological risk factors. Similarly, integration of surgeon- and patient-amenable characteristics is key to decreasing risk of infection, complication, and need for revision. Finally, patient risk profiling provides a unique context for proper device selection and evidence-based intraoperative considerations.

MRI of common penile pathologies and penile prostheses

MRI can delineate finer details of penile anatomy and pathology due to inherent higher soft-tissue contrast and spatial resolution. It can characterize inflammation and identify abscesses, localize penile fractures, guide surgical planning in penile fibrosis and Peyronie's disease, and depict components of the penile prosthesis and its complications. MRI is a great investigative tool for penile neoplasms, including locally infiltrative neoplasms where clinical examination is limited, and local staging is crucial for surgical planning.

Imaging of the adult male urethra, penile prostheses and artificial urinary sphincters

To discuss the imaging appearances of various pathologies affecting adult male urethra and to review the role of imaging in the assessment of artificial urinary sphincters and penile prostheses. Diagnosis of common male urethral diseases heavily depends on two conventional fluoroscopic techniques namely retrograde urethrography and voiding cystourethrography. These are useful in evaluating common urethral diseases like traumatic injury, infections, and strictures. Cross-sectional imaging can be useful in evaluating periurethral pathologies. Artificial urinary sphincters, slings, and periurethral bulking agents are used in the management of urinary incontinence and imaging can be utilized to detect complications in these devices. Cross-sectional imaging especially MRI plays a significant role in evaluating the different types of penile prostheses and their malfunctioning.

MRI of the Penis: Indications, Anatomy, and Pathology

The purpose of this review is to discuss the role of magnetic resonance imaging (MRI) in the evaluation of penile pathology. Normal penile anatomy as well as the appearance of neoplastic and non-neoplastic entities on MRI will be reviewed. While ultrasound remains the first line imaging modality in evaluating most penile pathology, MR imaging has specific advantages owing to improved soft tissue resolution, ability to evaluate less accessible or complex anatomy (such as at the base of the penis), and the ability to detect subtle enhancement. Therefore, MRI is useful for when ultrasound and/or clinical findings are equivocal or incongruent. In addition, MR imaging is essential for preoperative surgical planning and is the imaging modality of choice in evaluating penile prostheses. The added value of MRI in these settings makes it an integral component to the management of many pathological entities affecting the penis.

CT imaging of inflatable penile prosthesis complications: a pictorial essay

PURPOSE

Inflatable penile prostheses (IPPs) are widely used in the United States, for patients with erectile dysfunction refractory to other treatments. Complications subsequent to IPP insertion include infection, hematoma, fluid leak, component (cylinder/pump/reservoir) complications, and retained previous IPP components. Radiologists are often called upon to identify and characterize these complications utilizing CT prior to intervention. Our paper aims to provide a guide to familiarize radiologists with normal IPP component imaging and review the CT findings of commonly encountered complications.

METHODS

In this study, we retrospectively reviewed CT reports with descriptions of IPPs from 108 patients. We collected CT images of normal IPP components as well as reevaluated the CT findings of 33 patients with an IPP complication and correlated with immediately subsequent operative report.

RESULTS

The CT appearance of appropriately positioned normal IPP components in asymptomatic patients and each complication were described and compared to previous literature.

CONCLUSIONS

CT is a very useful modality to assess an IPP-related complication. It is inexpensive, fast, and immediately available in emergent situations, e.g., infection, hematoma, and component erosion. Additionally, CT is very sensitive and makes it easier to diagnose a system leak. It can identify most cylinder complications and pump malposition and can be extremely helpful to the surgeon in preoperative planning if revision is needed. After this review, the radiologist should be able to identify normal IPP components and their complications.

Usefulness of magnetic resonance imaging in the postsurgical assessment of patients with inflatable penile prostheses

OBJECTIVE

To describe the types of penile prostheses and their components, to review the appropriate magnetic resonance imaging (MRI) acquisition protocol, and to describe the normal imaging findings and possible complications in patients with inflatable penile implants.

CONCLUSION

Three-piece inflatable penile prostheses are the last link in the treatment chain for erectile dysfunction. They can develop complications, which are classified as non-infectious related to the surgical technique, infectious, or due to mechanical failure of the device. MRI is the most appropriate imaging technique for the postsurgical evaluation of penile prostheses. Images are acquired in three planes using sequences with high spatial resolution, first with the prosthesis at rest and then with the prosthesis activated.