Duraphase penile prosthesis--results of clinical trials in 63 patients

Technological advances in penile implants: past, present, future

Attempts to "cure" erectile dysfunction (ED) are as old as recorded history. The history of penile prosthetic devices dates back over 500 years, when a French military surgeon designed the first known wooden prosthesis to support micturition. There have since been a great many technological advancements in penile prosthetics. Penile implants for the improvement of sexual function date to the twentieth century. Like all human endeavors, penile prosthesis innovations have progressed via trial and error. This review aims to provide an overview of penile prostheses for the treatment of ED since their introduction in 1936. More specifically, we aim to highlight important advances in penile prosthesis development and discuss dead ends that were abandoned. Highlights include two-piece inflatables, three-piece inflatables, and malleable/semirigid, along with modifications and updates to each basic design that improved both insertion and usability. Dead ends include innovative ideas that were lost to history due to a variety of factors. We also look to the future and discuss expected advances, including remotely activated devices and prostheses designed for special populations, including transgender men.

History, Contemporary Outcomes, and Future of Penile Prostheses: A Review of the Literature

INTRODUCTION

Since their introduction, penile prostheses have consistently remained a superior treatment option for men with erectile dysfunction (ED) refractory to conservative measures. Ongoing enhancements to prosthetic design, materials, and surgical techniques have resulted in improved outcomes.

AIM

To review available literature on notable historical advancements and improvements of the penile prosthesis, summarize contemporary outcomes of recent devices, and discuss possible future directions of the penile prosthesis.

METHODS

A PubMed search was performed of all articles published from 1960 to present relating to penile prosthesis. Priority was given to series with 12 months of follow-up or greater, larger series, and studies reporting on outcomes of more recent prosthetic models.

MAIN OUTCOME MEASURES

Main outcomes included historical review of improvements leading to, and contemporary series reporting on rates of mechanical failures, infections, and satisfaction with penile prostheses.

RESULTS

Penile prostheses have undergone numerous enhancements since initial reports of synthetic materials utilized in the 1950s. Among others, recent notable device enhancements include Parylene coating, Bioflex® material, Inhibizone^TM antibacterial impregnation, hydrophilic coating, lockout valves, and easy release pump mechanisms, all of which have improved mechanical reliability, reduced infection rates, and/or improved patient satisfaction with penile prostheses. Contemporary series of 3-piece penile prostheses report mechanical survival of 81-94%, 68-89%, and 57-76% at 5, 10, and 15 years, respectively. Infection rates of current devices are 1-2% in first-time, low-risk populations, and 2-3% for higher risk groups, with patient and partner satisfaction at 92-100% and 91-95%, respectively. Two-piece and malleable devices are associated with slightly higher mechanical reliability and decreased patient satisfaction. Minimal data currently exist on the outcomes of selected patient populations, including Peyronie's disease and corporal fibrosis.

CONCLUSIONS

Penile prostheses are associated with excellent, long-term outcomes and remain the gold-standard treatment for men with refractory ED. Additional research with prospective studies utilizing objective measures and standardized questionnaires is required. Trost L and Hellstrom WJG. History, contemporary outcomes, and future of penile prostheses: A review of the literature. Sex Med Rev 2013;1:150-163.

Interventions for sexual dysfunction following treatments for cancer

BACKGROUND

The proportion of people living with and surviving cancer is growing. This has led to increased awareness of the importance of quality of life including sexual function in people with cancer. Sexual dysfunction (SD) is a potential long-term complication of cancer treatments.

OBJECTIVES

Evaluate effectiveness of interventions for SD following treatments for cancer and their adverse effects.

SEARCH STRATEGY

The Cochrane Pain, Palliative & Supportive Care Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycInfo, AMED, CINAHL, Dissertation Abstracts and NHS Research Register were searched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) were included that assessed the effectiveness of a treatment for SD. The trial population comprised of adults of either sex who at trial entry had developed SD as a consequence of cancer treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed trial quality. Meta-analysis was considered for trials with comparable key characteristics.

MAIN RESULTS

Eleven RCTs with a total of 1743 participants were identified. The quality of the trials was poor. Ten trials explored interventions for SD in men following treatments for non-metastatic prostate cancer. One trial explored effectiveness in women of a lubricating vaginal cream following radiotherapy for cervical cancer. The strongest evidence (from four trials) was on oral phosphodiesterase type 5 (PDE5) inhibitors for erectile dysfunction (ED) following radiotherapy of the prostate or radical prostatectomy. The results using validated measures in all trials significantly favoured those in the PDE5 inhibitor group(s). The combined results of two trials indicated a significantly greater improvement in ED in the PDE5 inhibitor groups (odds ratio (OR) 10.09 95% confidence interval (CI) 6.20 to 16.43). Negative effects were few and usually mild to moderate headaches or flushing. One trial reported more clinically serious events including six events of tachycardia and six of chest pain. Following prostate cancer treatments there was some evidence that PDE5 inhibitors are more effective in combination with acetyl-L-carnitine and propionyl-L-carnitine and that sexual counselling improves self-administration of prostaglandin intra-cavernous injection for SD. There was some evidence following treatment for prostate cancer that transurethral alprostadil and vacuum constriction devices reduce SD, although in both trials negative effects were fairly common. There is some evidence that vaginal lubricating creams reduce SD.

AUTHORS' CONCLUSIONS

PDE5 inhibitors are an effective treatment for SD secondary to treatments for prostate cancer. Other interventions identified need to be tested in further RCTs. The SD interventions in this review are not representative of the range available for men and women. Further evaluations are needed for these interventions for SD following cancer treatments.

[Penile prosthesis for the treatment of erectile dysfunction]

The erectile dysfunction is a pathology that, with different degrees of intensity, affects nearly the 20% of the spanish adult men. The treatment is usually performed in stages, reserving the penile prosthesis for when other previous treatments have failed. The aim of this work is to evaluate, according to the state of present knowledge, the effectiveness and security of the penile prosthesis for the treatment of the erectile dysfunction. With this purpose 52 articles were selected, observing a 5 years prosthesis survival of 78-91% and a 3-8% of surgical complications. Mechanical failures and infection percentages were smaller in the semi-rigid prosthesis that in the inflatable ones, with high levels of postoperative satisfaction in patients as well as in their couples, even greater than in other treatments available at the present time. The penile prosthesis implantation must be reserved for the organic erectile dysfunction when previous treatments have failed, evaluating the risk-benefit relation and informing the patient of the results that are hoped to be obtained and of the possible complications that can arise. In view of the great concern of our society with the erectile function and the availability of effective drugs, an increase in the demand of penile prosthesis implantation is predictable in those patients highly motivated, but refractory to the less invasive treatments.

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.

Safety and efficacy outcome of mentor alpha-1 inflatable penile prosthesis implantation for impotence treatment

PURPOSE

We investigated safety and efficacy outcome pertaining to the Mentor Alpha-1, 3-piece inflatable penile prosthesis for impotence treatment.

MATERIALS AND METHODS

A 2-phase, multi-institutional, large scale retrospective study, with independently analyzed medical record (phase I) and questionnaire (phase II) data from consecutive eligible patients of 7 physician investigators was performed from March to October 1993.

RESULTS

In phase I there were no morbidities of any type in 394 of the 434 patients (90.8%) (mean age 61 years, range 24 to 88) who underwent Alpha-1 implantation (mean followup 22.2 months, range 0.67 to 44.5). The risk of prosthesis malfunction (fluid leak and auto-inflation) was 2.5%. No cylinder aneurysms were reported. A total of 93.1% of Alpha-1 devices was free from explantation (4.4%) or revision surgery (2.5%) for approximately 2 years from the original implant date. Kaplan-Meier actuarial analyses revealed that cumulative survival of the Alpha-1 prostheses at 12, 24 and 36 months was 98 +/- 1%, 93 +/- 2% and 85 +/- 7% until device malfunction, and 91 +/- 2% 83 +/- 4% and 75 +/- 7% until surgical intervention (revision or explantation). In phase II 89% of the men claimed fulfilled expectations with the Alpha-1 prosthesis as impotence treatment. Satisfaction responses 80% or greater were noted with regard to intercourse ability and confidence, and device rigidity and function. Implantation did not result in greater than 80% satisfaction in partner relationships or feelings (as judged by the patient), social or work confidence, or intercourse frequency. Factors adversely affecting satisfaction included partner feelings of dissatisfaction (as judged by the patient), specific physician investigators and need for explantation/revision surgery.

CONCLUSIONS

In 1 of the largest multi-institutional implant outcome studies thus far performed, safety and efficacy data concerning the Alpha-1 contemporary inflatable device were found markedly improved over earlier inflatable prostheses and now compare favorably with historical data from noninflatable rod type devices.

Early experience with the first pre-connected 3-piece inflatable penile prosthesis: the Mentor Alpha-1

The aim of this clinical investigation was to obtain preliminary treatment outcome data concerning the Mentor Alpha-1, the first 3-piece inflatable penile prosthesis with pre-connected tubing between the pump and the penile cylinders. The study was designed to be the first multi-institutional treatment outcome report for any clinically available penile prosthesis with data analysis to be independent of the participating surgeons. A total of 12 board-certified urologists of mixed surgical training backgrounds and practices implanted the Alpha-1 device in 112 consecutive patients. With a mean of 27 +/- 5 months of followup the surgical complication rate included a 4% mechanical malfunction, 2% infection rate and 9% reoperation rate. Patient experience with the implanted device was computed from information on 96 of the 112 patients who returned a questionnaire. Of the patients 82% stated that the device fulfilled expectations as a treatment for impotence and 83% had improved sexual intercourse by 8 weeks after implantation. Patient satisfaction was computed on a scale of 12 equally weighted interrelated variables. Of the patients 77% recorded 9 or more cumulative satisfaction points. Patient and physician questionnaire data were analyzed for their relation to the cumulative prosthesis satisfaction score. A significant difference in cumulative scores was found for physician reported long-term postoperative problems (mean satisfaction score 8.1 for patients with problems versus 10.2 for patients without problems, p = 0.018). The Alpha-1, with its feature of pre-connected tubing, is a reliable 3-piece inflatable penile prosthesis associated with a high level of patient satisfaction.