Penile prosthesis in the organ transplant recipient

Is it safe to implant a penile prosthesis in a solid organ transplant recipient? A systematic review

Solid organ transplant recipients exhibit an elevated incidence of erectile dysfunction, attributed to comorbidities and specific factors associated with organ failure. While treatment mirrors the general population's, response rates are lower, and there is a heightened concern about implanting a penile prosthesis in immunocompromised patients due to the potential occurrence of severe complications. The aim of this study was to assess the safety of penile prostheses in this population. Among fourteen included studies, ten were case reports or series of cases, and four were non randomized case-control studies with non-transplanted patients as controls. Complications affected 34 patients (11.15%), with mechanical device failures in 18 cases (5.9%) and infections in 13 cases (4.26%). Most infections required hospitalization, antibiotic treatment, and prosthesis removal, with two cases of life-threatening Fournier's gangrene. Case-control studies revealed no differences in overall reoperation rates between transplant recipients and controls. However, pelvic organ transplant recipients undergoing three-piece prosthesis implantation showed higher complications rates related to reservoir issues. Despite limited evidence, case-control studies demonstrated a generally low/moderate risk of bias within each specific domain, although overall bias was moderate/severe. As a result, clinicians may mitigate concerns regarding penile prosthesis implantation in solid organ transplant recipients.

Current treatment options for erectile dysfunction in kidney transplant recipients

INTRODUCTION

Erectile dysfunction (ED) and kidney dysfunction share common risk factors linked to conditions involving endothelial impairment, such as coronary artery disease, dyslipidemia, diabetes mellitus, hypertension, smoking, and obesity. Men with chronic kidney disease experience a high incidence and prevalence of ED. While a functional renal graft can alleviate the issue for some patients, a significant portion of recipients still experience ED (20%-50%).

OBJECTIVES

This narrative review describes the variety of current treatments modalities on ED in kidney transplant recipients (KTRs) and their clinical outcomes.

METHODS

MEDLINE, Web of Science, PubMed, and Google Scholar were used to find eligible articles pertaining to the treatment options of ED in KTRs. A total of 64 articles were evaluated.

RESULTS

In KTRs, ED stems from a multifaceted etiology: anxiety, drug side effects, interference with penile vascularity, or the response of cavernosal muscle to neurotransmitters, along with changes in the endocrine milieu. A diverse range of treatments to restore erectile function has proven to be safe and effective for KTRs. Options include drug therapy, surgical interventions, intracavernosal injection therapies, vacuum erection devices, and extracorporeal shockwave therapy.

CONCLUSION

The initial treatment approach may involve the use of a phosphodiesterase type 5 inhibitors at a low dosage, especially if testosterone-circulating levels align with the diagnosis of hypogonadism. The consideration of a combination therapy involving testosterone and phosphodiesterase type 5 inhibitors should be contemplated due to the associated beneficial effects. Extracorporeal shockwave therapy has shown positive short-term clinical and physiological effects on erectile function in patients who did not respond to first-line treatments, resulting in spontaneous erections sufficient for sexual penetration in 50% of cases. Penile implants should be considered as third-line options based on specific patient needs and compliance with clinical conditions.

A propensity score-matched analysis of intra- and postoperative penile prosthetic complications in the solid organ transplant population

INTRODUCTION

Solid organ transplant (SOT) has an anticipated higher risk of penile prosthesis (PP) complications related to immunosuppression and surgical approach post-SOT. It is still not determined if PP surgery in the SOT population incurs these same higher risks.

OBJECTIVES

To observe differences in intra- and postoperative PP complications between SOT and non-SOT cases from the TriNetX US Collaborative Network, a large real-world database of deidentified patient data from 56 health care organizations within the United States.

METHODS

We used the TriNetX database to perform a propensity score-matched cohort study comparing 10-year outcomes between patients with and without a SOT (kidney, heart, lung, liver, pancreas, and intestine) who underwent a PP procedure. Cohorts were matched on age, race/ethnicity, history of pelvic and abdominal surgery, overweight and obesity status, type 2 diabetes mellitus, atherosclerosis, substance use disorders, socioeconomic difficulties, anticoagulant/antiplatelet medications, and spinal cord injury. Outcomes included intra- and perioperative complications as well as prosthetic complications (mechanical malfunction, fibrosis, displacement, hemorrhage, pain, stenosis, removal with or without replacement, and complex [all postoperative complications]).

RESULTS

There were 233 patients in each group after matching (SOT and non-SOT). The mean ± SD age at the prosthesis procedure was 59.7 ± 9.89 years, and 44% of patients were White (P > .05). There was no significant difference for incidence of intra- and perioperative complications (2.62% vs 2.19%, P = .76). The SOT group did not have a higher 10-year incidence of complex complications (30.58% vs 27.51%, P = .11) or mechanical malfunction (10.35% vs 11.62%, P = .25) when compared with the non-SOT group. No difference was found for other prosthetic-related complications (P > .05).

CONCLUSION

In our analysis, patients with a SOT were not more likely to experience long-term complications related to PP. Surgeons performing PP surgery in the SOT population may consider this procedure a potentially safe and viable option for restoring erectile function.

Management of urologic prosthetic reservoirs at the time of inguinal or pelvic surgery

INTRODUCTION

The artificial urinary sphincter and 3-piece inflatable penile prosthesis each require a fluid storage component and thus have components in the inguinal and pelvic regions. Because of this, patients with urologic prosthetics sometimes present challenges during future nonprosthetic operations. Presently, there is no established guideline for device management with ensuing inguinal or pelvic surgery.

AIMS

This article outlines concerns during pelvic and inguinal surgery for patients with an artificial urinary sphincter and/or inflatable penile prosthesis and proposes an algorithm for preoperative surgical planning and decision making.

METHODS

We conducted a narrative review of the literature on operative management of these prosthetic devices. Publications were identified by searching electronic databases. Only peer-reviewed publications available in English were considered for this review.

RESULTS

We review the important considerations as well as available options for operative management of these prosthetic devices during subsequent nonprosthetic surgery and highlight the advantages and disadvantages of each. Finally, we suggest a framework for helping surgeons determine which management strategy is most appropriate for their individual patients.

CONCLUSION

The best management strategy will differ depending on patient values, the planned surgery, and patient-specific factors. Surgeons should understand and counsel patients on all available options and encourage informed, shared decision making to determine the best individualized approach.

Evaluation of Satisfaction and Outcomes of Patients Who Underwent Two-Piece Inflatable Penile Prosthesis Implantation

Introduction

The aim of this study was to evaluate patient and partner satisfaction, device reliability, and complications in patients who underwent two-piece inflatable penile prosthesis (IPP) implantation.

Patients and methods

The data of 22 patients who underwent two-piece inflatable penile prosthesis implantation in our department between 2015 and 2018 were retrospectively analyzed, and a detailed review of all clinical reports was performed. Phone or face-to-face interviews were undertaken to assess the satisfaction rates of the patients and their partners using the modified Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire.

Results

The mean patient age and partner age were 57.95 ± 6.16 and 58.12 ± 6.66 years, respectively. The mean erectile dysfunction (ED) period was 5.33 ± 2.16 years, and the etiologies of erectile dysfunction were radical pelvic surgery (41%), diabetes mellitus (37%), and vascular disorders (22%). The mean operative time and postoperative hospital stay were 102 ± 29 minutes and 1.8 ± 0.66 days, respectively. Over a mean follow-up period of 29.04 ± 14.48 months, two (9%) cases underwent revision surgery due to mechanical device failure in one and infection in the other. The overall patient and partner satisfaction rates were 73% and 59%, respectively.

Conclusions

The two-piece inflatable penile prosthesis is an effective, reliable, and user-friendly prosthesis with acceptable complication and revision rates and provides a high level of patient and partner satisfaction in selected and fully informed patients.

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.

Penile implant infection factors: a contemporary narrative review of literature

Objective

We aim to review and summarize published literature that features implanted penile devices and details infection of these devices as a complication. In particular, we will detail the factors that influence infection of penile implants.

Background

Types of penile prostheses (PP) include inflatable implants and semirigid implants; these are utilized for treatment of erectile dysfunction. Likely the most feared complication of penile implants is infection. There are a handful of factors that are implicated in device infection.

Methods

Searches were performed using MEDLINE and PubMed databases using keywords and phrases ‘penile implant AND infection’; ‘penile prosthesis AND infection’; ‘penile implant infection’. We have presented results from our literature search. We divided these into ‘Surgical Elements’ and ‘Patient Selection and Factors.’ Each topic is discussed in its own section.

Conclusions

Strides have been made since the initial penile prosthesis (IPP) surgeries to improve infection rates including diabetes control, antibiotic coating of devices, and antibiotic implementation. Going forward, more studies, especially randomized control trials, need to focus on defining levels of diabetic control (sugar control and A1C control), determining the role of metabolic syndrome in infection promotion and determining laboratory values which could be predictive of infection. We present a discussion of important factors to consider in the realm of PP infections. In addition, we include studies which discuss topics for future directions in decreasing the number of infections seen with PP.

Immune Deficiency Does Not Increase Inflatable Penile Prosthesis Reoperation Rates

INTRODUCTION

Immunocompromised patients are postulated to have higher rates of post-operative infection. We sought to determine if inflatable penile prosthesis (IPP) reoperation rates (due to infection, erosion, device malfunction or patient dissatisfaction) are higher among immunocompromised men.

METHODS

We analyzed men who underwent initial IPP insertion from 2000 to 2016 in the New York Statewide Planning and Research Cooperative System database. Immunocompromised patients were propensity-score matched in a 1:3 fashion with immunocompetent patients. We estimated and compared reoperation rates (including removal, reoperation due to infection, revision, or replacement of an IPP after an index procedure) at 30 days, 90 days, 1 year and 3 years of follow up between immunocompromised men and controls by performing a Kaplan Meier analysis and Log-rank tests. Cox proportional hazards models were built to examine the overall association between immune deficient status and the risk of reoperation.

MAIN OUTCOME MEASURE

Reoperation rate and time to reoperation after index IPP placement.

RESULTS

A total of 245 immunocompromised patients who received an initial IPP between 2000 and 2016 were identified. After propensity score matching, we analyzed 235 immunocompromised men and 705 controls. There was no difference in overall reoperation rates between immunocompromised men and controls within any time period assessed (30 days, 90 days, 1 year, or 3 years). In our Cox proportional hazards model, the hazards of overall reoperation, removal, or revision/replacement (HR 1.11 [95% CI 0.74-1.67], HR 1.58 [95% CI 0.90-2.79)], and HR 0.83 [95% CI 0.47-1.45], respectively) were not significant different between immunocompromised men and controls. Reoperation due to infection was also not significantly different between immunocompromised and immunocompetent men (HR 2.06 [95% CI 0.97-4.40]).

STRENGTHS & LIMITATIONS

This study is strengthened by its size as the largest cohort of immunocompromised men treated with IPP to date in the literature, but is limited by the retrospective nature of the database which may introduce selection bias and by the low event rate for IPP reoperation.

CONCLUSIONS

Reoperation rates, including those due to infection, are not significantly different between immunocompromised men and immunocompetent controls. Therefore, immune status in appropriately selected candidates does not appear to place patients at substantially higher risk of explant or revision. Gaffney CD, Fainberg J, Aboukhshaba A, et al. Immune Deficiency Does Not Increase Inflatable Penile Prosthesis Reoperation Rates. J Sex Med 2021;18:1427-1433.

Current Status for Semirigid Penile Prosthetic Devices

PURPOSE OF REVIEW

The goal of this paper was to evaluate the current use of semirigid penile prosthesis (SRPP), surgical techniques for insertion of SRPP, and how to prevent and approach surgical complications.

RECENT FINDINGS

SRPP is a valid option for those who are refractory to medical therapy for erectile dysfunction (ED) and even more appropriate for specific subsets of patient populations. It is important for urologists to know which patient population SRPP is preferred for. Several studies have shown good patient outcomes and patient satisfaction with those who underwent SRPP.

Updates in penile prosthesis infections

Inflatable penile prostheses are an important tool in the treatment of medically refractory erectile dysfunction. One of the major complications associated with these prostheses is infections, which ultimately require device explanation and placement of a new device. Over the past several decades, significant work has been done to reduce infection rates and optimize treatment strategies to reduce patient morbidity. This article reviews the current state of knowledge surrounding penile prosthesis infections, with attention to the evidence for methods to prevent infection and best practices for device reimplantation.

Penile implant infection prevention part 1: what is fact and what is fiction? Wilson's Workshop #9

Inflatable penile prosthesis (IPP) infections are undeniably devastating for patient and surgeon alike. While less common in this modern era, the landscape of prosthesis infection is shifting. Continued examination of risk factors for infection and re-evaluation of common practices remain critical should we aim to advance the field. Quality research on this topic is limited by several factors, among which small sample size and lack of coordinated effort pose the most precarious of challenges. Nonetheless, careful analysis of available data in conjuncture with judicious utilization of established research from other prosthetic fields can help us better grasp the issue at hand. In this review, we aim to do exactly that-to examine available evidence in an effort to discern fact from fiction. In this first part of the three part series, we aim to summarize our understanding of the pathogenesis behind prosthesis infections, explore known preoperative risk factors, and discuss intraoperative considerations for infection prevention. In the second part of this series, we will examine the game changing effect of infection retardant implant coatings. Part three of the series details postoperative prevention strategies, reviews salvage techniques, and discusses additional key considerations.

A Systematic Review of Penile Prosthesis Surgery in Organ Transplant Recipients

INTRODUCTION

There is an increased prevalence of erectile dysfunction in patients with solid organ transplant (SOT) compared with the general population. Many of these patients may become refractory to medical treatment of erectile dysfunction and penile prosthesis (PP) is often recommended. Concerns regarding the safety of PP in patients with SOT are due to their immunosuppressed state.

OBJECTIVE

We aim to review all current literature on the outcomes of patients with SOT who have received PP.

METHODS

A PubMed search was performed to identify articles pertaining to the outcomes of PP in patients with SOT.

RESULTS

We identified and included 14 studies that report on outcomes of PP placement in 143 patients with SOT and 191 non-SOT controls from interval period from 1979 to 2019. Studies included retrospective cohort studies, case series, and case reports. Compared with non-SOT controls who had PP, aggregate analysis demonstrated that patients with SOT who had PP did not develop significantly increased overall complications. However, they were significantly more likely to experience future surgical complications.

CONCLUSION

Our aggregate analysis demonstrated that patients with SOT are not at a significantly increased risk of overall complications when receiving a PP. Nevertheless, there is an increased risk of experiencing PP injury during subsequent surgeries, which may be mitigated by the earlier involvement of a urologist. Given the lack of recent data, large studies are prerequisite to further evaluate the safety and overall outcome of PP surgery in patients with SOT. Dick B, Greenberg JW, Polchert M, et al. A Systematic Review of Penile Prosthesis Surgery in Organ Transplant Recipients. Sex Med Rev 2021;9:636-640.

Three-piece inflatable penile prosthesis: Ectopic reservoir placement

INTRODUCTION

The complications associated to the placement of the reservoir are infrequent but potentially serious. Therefore, technical alternatives have been developed for the performance of the procedure in different locations (ectopic). The aim of this review is to revise the evidence available on the different options for the ectopic placement of the reservoir.

MATERIAL AND METHOD

Narrative review based on a bibliographical search limited to PubMed- indexed relevant manuscripts, in Spanish or English, for the period 2000-2019, using «penile prosthesis», «ectopic reservoir», radical prostatectomy», «radical cystectomy», «pelvic radiotherapy», and «renal transplantation» as key words. Non original articles and reviews were not considered eligible. A total of 11 manuscripts were included.

RESULTS

Pelvic alterations after surgery and/or radiotherapy increase the difficulty in the placement of the prosthesis reservoir. In order to minimize the risk of complications, different modifications have been performed on the devices, and technical innovations have been developed for the submuscular placement of the reservoir. The available evidence regarding the functionality and complications of these techniques is limited to single institution, low volume, and retrospective series with short follow-up periods. The functionality seems to be adequate using the adapted devices. The complications are infrequent and mild in severity.

CONCLUSIONS

Although the available evidence is still limited, the ectopic placement of the reservoir may be considered a safe, effective, and reproducible technique. In addition, it may result particularly useful in cases of altered pelvic anatomy.

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.

Clinical Recommendations From the European Society for Sexual Medicine Exploring Partner Expectations, Satisfaction in Male and Phalloplasty Cohorts, the Impact of Penile Length, Girth and Implant Type, Reservoir Placement, and the Influence of Comorbidities and Social Circumstances

INTRODUCTION

To date, several aspects of inflatable penile prosthesis (IPP) surgical procedure have been poorly studied.

AIM

The aim of this study was to review the evidence associated with IPP implantation and provide clinical recommendations on behalf of the European Society for Sexual Medicine (ESSM). Overall, 130 peer-reviewed studies and systematic reviews, which were published from 2007-2018 in the English language, were included.

METHODS

MEDLINE and EMBASE were searched for randomized clinical trials, meta-analyses, and open-label prospective and retrospective studies.

MAIN OUTCOME MEASURE

The panel provided statements exploring patients and partner expectations, satisfaction in male and phalloplasty cohorts, the impact of penile length, girth and implant type, reservoir placement, the influence of comorbidities, and social circumstances. Levels of evidence were provided according to the Oxford 2011 criteria and graded as for the Oxford Centre for Evidence-Based Medicine recommendations.

RESULTS

In the preoperative setting, it is fundamental to identify and interact with difficult patients with the intention of enhancing the surgeon's ability to establish the surgeon-patient relationship, reduce physical and legal risk, as well as enhancing patient satisfaction. To address this need, the mnemonic Compulsive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial, and Psychiatric ("CURSED") has been suggested to identify patients who are at high risk of dissatisfaction. The current recommendations suggest improving glycemic control in patients with diabetes. Available evidence suggests evaluating transplant recipients with the criteria of Barry, consisting of stable graft function for >6 months, avoidance of intra-abdominal reservoir placement, and low-dose immunosuppression. HIV status does not represent a contraindication for surgery. Smoking, peripheral vascular disease, and hypertension may be associated with an increased risk of revision surgery. Patients with spinal cord injury may receive IPP. Patients aged ≥70 years, as well as obese patients, can be offered IPP. The IPP implantation can be performed in patients with stable Peyronie's disease. Ectopic high submuscular reservoir placement can be considered as an alternative method.

CLINICAL IMPLICATIONS

There is a relevant lack of high-level data and definite conclusions in certain areas remain difficult to draw.

STRENGTH & LIMITATIONS

All studies have been evaluated by a panel of experts providing recommendations for clinical practice. Because of lack of sufficient prospective data, some of the included studies are retrospective and this could be stated as a limitation.

CONCLUSION

This ESSM position statement provides recommendations on optimization of patient outcome by patient selection, and individualized peri- and intra-operative management. ESSM encourages centers to collaborate and to create prospective, multicenter registries in order to address this topic of increasing importance. Osmonov D, Christopher AN, Blecher GA, et al. Clinical Recommendations from the European Society for Sexual Medicine Exploring Partner Expectations, Satisfaction in Male and Phalloplasty Cohorts, the Impact of Penile Length, Girth and Implant Type, Reservoir Placement, and the Influence of Comorbidities and Social Circumstances. J Sex Med 2020;17:210-237.

The Prevalence and Treatment of Erectile Dysfunction in Male Solid Organ Transplant Recipients

INTRODUCTION

Erectile dysfunction (ED) is a prevalent and under-recognized complaint among male solid organ transplant recipients. Most research on this topic has focused on kidney transplant recipients alone. In this review, we integrate current research on ED across all types of solid organ transplant recipients and assess the success of current methods of ED treatment in transplant populations.

AIM

To review the current literature addressing the prevalence and treatment of ED in the male solid organ transplant population.

METHODS

A literature search was conducted using PubMed to identify relevant studies. Search terms included "organ transplant" and "erectile dysfunction." Titles and abstracts were reviewed for relevance. References from identified articles were also searched and included, if appropriate.

MAIN OUTCOME MEASURES

Review of peer-reviewed literature.

RESULTS

The prevalence of ED among transplant recipients is higher than that in the general population: 39.8-86.2% in liver transplant recipients, 54-66% in renal transplant recipients, 71-78% in heart transplant recipients, and 79% in simultaneous pancreas-kidney transplant recipients. Phosphodiesterase-5 inhibitors have up to 80% efficacy in treating ED in kidney transplant recipients. Intracavernosal injections have been used with success rates of 60-70% in cardiac and renal transplant recipients. Penile prostheses have also been shown to be safe and effective across transplant types. A low incidence of infection has been reported in several case series, although there is concern for an increased rate of mechanical complications in pelvic organ transplant recipients. Accordingly, placement of a two-piece or malleable prosthesis or ectopic reservoir placement with a three-piece inflatable prosthesis is suggested in this population.

CONCLUSION

ED is highly prevalent among male solid organ transplant recipients and should be routinely screened in this population. Current modalities of ED treatment used in the general population are safe and effective in solid organ transplant recipients, although success rates are often lower than those in the general population. Payne K, Popat S, Lipshultz LI, et al. The Prevalence and Treatment of Erectile Dysfunction in Male Solid Organ Transplant Recipients. Sex Med Rev 2021;9:331-339.

Two-piece inflatable and semi-rigid penile implants: an effective alternative?

Penile prostheses (PPs) are an excellent treatment to be considered for patients suffering from erectile dysfunction (ED), refractory to oral medications, or unwilling to consider intracavernosal injections or other therapeutic strategies. Nowadays the market is dominated by three-piece inflatable penile prosthesis (IPP), which are considered the best option available. However, in some specific cases three-piece IPP may be superseded by semi-rigid penile prosthesis (SRPP) and two-piece IPP. Despite the advantages of these implants, the literature is quite scarce, not robust and rarely takes into consideration the partner's satisfaction. This clearly affects the strength of our conviction. Most of the studies confirm that SRPPs and two-piece IPPs can be considered a valid alternative in patients with hand dexterity issues, refractory ischaemic priapism, neophallus and in cases of complex anatomies. In addition, the ease of placement and the high confidence level of surgeons make them a powerful tool in the armamentarium of urologists.

Penile Prosthesis Infection: Myths and Realities

Penile prosthesis infection is the most significant complication following prosthesis implant surgery leading to postoperative morbidity, increased health care costs, and psychological stress for the patient. We aimed to identify risk factors associated with increased postoperative penile prosthesis infection. A review of the literature was performed via PubMed using search terms including inflatable penile prosthesis, penile implant, and infection. Articles were given a level of evidence score using the 2011 Oxford Centre for Evidence-Based Medicine Guidelines. Multiple factors were associated with increased risk of post-prosthesis placement infection (Level of Evidence Rating) including smoking tobacco (Level 1), CD4 T-cell count <300 (Level 4), Staphylococcus aureus nasal carriage (Level 2), revision surgery (Level 2), prior spinal cord injury (Level 3), and hemoglobin A1c level >8.5 (Level 2). Factors with no effect on infection rate include: preoperative cleansing with antiseptic (Level 4), history of prior radiation (Level 3), history of urinary diversion (Level 4), obesity (Level 3), concomitant circumcision (Level 3), immunosuppression (Level 4), age >75 (Level 4), type of hand cleansing (Level 1), post-surgical drain placement (Level 3), and surgical approach (Level 4). Factors associated with decreased rates of infection included: surgeon experience (Level 2), "No Touch" technique (Level 3), preoperative parenteral antibiotics (Level 2), antibiotic coated devices (Level 2), and operative field hair removal with clippers (Level 1). Optimization of pre-surgical and intraoperative risk factors is imperative to reduce the rate of postoperative penile prosthesis infection. Additional research is needed to elucidate risk factors and maximize benefit.

Non-Infectious Reservoir-Related Complications During and After Penile Prosthesis Placement

INTRODUCTION

Inflatable penile prosthesis (IPP) surgery offers a high satisfaction rate and low rate of complications when performed by experienced surgeons. However, reservoir placement, either in the space of Retzius (SOR), or alternative/ectopic locations, may lead to an array of serious complications that may require revision surgery.

AIM

To review the prevalence and management options for non-infectious intraoperative and postoperative complications related to prosthetic reservoirs.

METHODS

A Medline PubMed search was used to identify articles related to IPP reservoir-related complications including bladder and bowel injury, vascular injury, autoinflation, herniation, palpability, leakage, and tubing torsion.

MAIN OUTCOME MEASURE

Rates and types of reservoir-related complications during and after IPP surgery.

RESULTS

Non-infectious reservoir-related complications in the intraoperative setting include injury to pelvic structures such as bladder, bowel, and blood vessels. In the postoperative setting, patients may experience autoinflation and reservoir herniation that might require revision surgery. Patients undergoing alternative reservoir placement (ARP) may complain of reservoir palpability and premature mechanical failure secondary to reservoir leakage or tubing torsion.

CONCLUSION

Although most surgeons continue to use the SOR as the main location for reservoir placement, ARP has gained popularity owing to its low risk of bother, minimal loss of functionality, and safety advantages in patients with history of pelvic surgery. Both reservoir placement in the SOR and ARP carry a low rate of complications while maintaining a high satisfaction rate. Clavell-Hernández J, Shah A, Wang R. Non-Infectious Reservoir-Related Complications During and After Penile Prosthesis Placement. Sex Med Rev 2019;7:521-529.

Infection Prevention Considerations for Complex Penile Prosthesis Recipients

PURPOSE OF REVIEW

The purpose of this review is to critically analyze and summarize recent studies in the area of penile prosthesis surgery outcomes with a focus on infection prevention in high-risk patients.

RECENT FINDINGS

Reduction of surgical time in complex prosthesis surgery may reduce infection risk. Concomitant implant surgery is not associated with increased infection risk. Certain immunocompromised patients may be more likely to have penile implant infections, but these may not include patients with well-controlled HIV, well-controlled diabetes, or transplant recipients. Substance abuse is correlated with increased risk of infection after penile implant surgery. Careful patient selection and preoperative optimization can reduce infection risk in spinal cord injury patients. In the last 5 years, there have been several important studies investigating the risk of penile prosthesis infection in complex patients, clarifying which patient categories are at increased risk and how that risk can be mitigated.

Penile Prosthesis in Solid Organ Transplant Recipients-A Matched Cohort Study

OBJECTIVE

To determine whether patients with solid organ transplant (SOT) are at higher risk of developing complications after inflatable penile prosthesis (IPP) implantation.

METHODS

We retrospectively reviewed outcomes data for all patients with SOT who underwent IPP placement at our institution. A cohort of age-matched IPP recipients without SOT were used as controls.

RESULTS

We identified 26 patients who underwent SOT and IPP between 1999 and 2015, and 26 controls. Transplants included heart (3), liver (2), kidney only (17), and kidney and pancreas (4). Mean follow-up time after IPP placement was 29.5 months (SOT group) and 13.5 months (controls). Age at IPP did not significantly differ between groups (53.7 + 8.1 vs 56.4 + 9.0, P = .26), nor did body mass index (30.3 + 5.5 vs 30.2 + 4.7, P = .92), history of prostatectomy (7.7% vs 15.4%, P = .39), rectal surgery (3.9% vs 3.9%, P = 1.00), hyperlipidemia (69.2% vs 69.2%, P = 1.00), hypertension (92.3% vs 76.9%, P = .25), or heart disease (57.7% vs 30.8%, P = .093). Peripheral vascular disease was more common in transplant patients (26.9% vs 3.9%, P = .021), as were stroke (19.2% vs 0.0%, P = .05) and diabetes (84.6% vs 53.6%, P = .016). No significant differences in IPP reoperation rates existed between patients with vs without SOT (11.5% vs 11.5%, P = 1.00), nor did they differ by organ transplanted (P = 1.00). No differences in IPP reoperation rate existed between 2-piece vs 3-piece IPP models (P = .47).

CONCLUSION

Outcomes of IPP implantation in patients with SOT are similar to those of nontransplant patients. Patients with SOT should be considered suitable candidates for penile prosthesis.

Ambicor 2-Piece Inflatable Penile Prosthesis: Who and How?

BACKGROUND

Currently the Ambicor is the only 2-piece inflatable penile prosthesis (IPP) available in the United States. By eliminating the separate reservoir, this provides certain advantages for patient and surgeon. Nevertheless, it composes a small percentage of all IPPs implanted in the United States.

AIM

To detail the surgical technique for implantation, describe the ideal patient candidates best suited for the Ambicor, and discuss the most common and some rare complications with a review of the available published literature in combination with our clinical experience.

METHODS

A PubMed literature search was performed to obtain all peer-reviewed articles published in English specifically on the Ambicor 2-piece IPP. We also reviewed our clinical experience with the Ambicor during the past 2 decades.

RESULTS

The published data remain limited, because few articles on the Ambicor have been published in the past 10 years. Overall complication rates were 2.1% to 9.5%. Patient satisfaction rates were 75% to 96.4%, with similar partner satisfaction rates. Relative contraindications for implantation include patients with significant penile deformities, long narrow phalluses, or short phalluses.

STRENGTHS AND LIMITATIONS

Despite the limited available published data with short follow-up periods, this review provides a comprehensive discussion on the technical aspects and relevant perioperative counseling recommended for Ambicor implantation.

CONCLUSION

The prosthetic urologist should offer the Ambicor 2-piece IPP to patients with erectile dysfunction whose non-surgical treatment has failed. Certain implanters might want to avoid the blind retropubic reservoir placement that occurs with 3-piece IPPs and might not be comfortable with an ectopic approach and therefore prefer using a 2-piece device. We believe the ideal Ambicor candidate is a patient with a current or future pelvic organ transplant, decreased manual dexterity, in need of complete phallic reconstruction, or with known extensive prior abdominopelvic surgery. Abdelsayed GA, Levine LA. Ambicor 2-Piece Inflatable Penile Prosthesis: Who and How? J Sex Med 2018;15:410-415.

Ambicor Two-Piece Inflatable Penile Prosthesis: Background and Contemporary Outcomes

INTRODUCTION

The two-piece inflatable penile prosthesis (IPP; Ambicor) might be a preferred option for men with erectile dysfunction (ED) who have significant retroperitoneal scarring, limited manual dexterity, or other issues. There are reported differences in outcomes and patient and partner satisfaction between three-piece and two-piece IPPs.

AIM

To report contemporary outcomes, patient and partner satisfaction, and mechanical durability data of the two-piece compared with the three-piece IPP.

METHODS

A PubMed search was performed related to two-piece penile prostheses. Emphasis was placed on perioperative outcomes and patient and/or partner satisfaction scores. Non-English-language articles were excluded.

MAIN OUTCOME MEASURES

Use of the Ambicor two-piece penile prosthesis was assessed by outlining the contemporary literature. The etiology of ED in this population, mechanical attributes, penile morphologic changes, satisfaction, and its use in special populations were reviewed.

RESULTS

The most common etiology of ED for placement of the device remains a vasculogenic cause (range = 11-62%). Overall complication rates were 2.1% to 11.2% for the general population. Mechanical failure was seen in 0.7% to 6.1%. Infection rates were 0.7% to 4.8%. Spontaneous deflation was seen in approximately 25%. Higher complication rates were found in transgender patients after neophallus creation and the two-piece IPP could offer better durability compared with the three-piece IPP. Longer operative times, greater use of advanced dilation techniques, and greater length loss also have been reported. Overall satisfaction rates are higher than 85%.

CONCLUSION

The predominant etiology of ED for two-piece penile prosthesis placement is vasculogenic. There is a trend toward IPP insertion in patients after radical prostatectomy or who have spinal cord injury. The two-piece device has similar complication rates and high patient satisfaction scores compared with three-piece IPPs. Further larger prospective studies are needed to validate our findings, resolve discrepancies in published outcomes, and contribute to the sparse data on this subject. Ko OS, Bennett NE. Ambicor Two-Piece Inflatable Penile Prosthesis: Background and Contemporary Outcomes. Sex Med Rev 2018;6:319-327.

[Sexuality, fertility and pregnancy after kidney transplantation]

AIMS

To describe sexuality and fertility alterations secondary to chronic kidney disease and their outcomes after renal transplantation.

MATERIAL AND METHODS

An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords: erectile dysfunction; impotence; sexuality; pregnancy; fertility; renal transplantation. Publications obtained were selected based on methodology, language, date of publication (last 10 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 706 articles. After reading titles and abstracts, 76 were included in the text, based on their relevance.

RESULTS

The observed prevalence of erectile dysfunction is high in men with chronic kidney disease. The causes of erectile dysfunction are numbers and its origin is often multifactorial. Most of the time, kidney transplantation improves sexuality and the management of erectile dysfunction in transplanted men is similar to the general population. Improvement in sexuality in men and women after kidney transplantation may conduct to pregnancy. The outcomes of pregnancy after transplantation are quite good in absence of risk factors such as time to pregnancy less than 1 year after transplantation, uncontrolled high blood pressure, and decreased renal function of the graft. Adaptation of immunosuppression may be required to avoid any teratogenicity for the fetus.

CONCLUSION

Kidney transplantation improves sexuality and fertility in men and women with chronic kidney disease.

Minimising the risk of device infection in penile prosthetic surgery: a UK perspective

We have reviewed articles published on penile prosthetic infection in Medline and EMBASE databases from 2000 to 2012 with the intention of signposting ‘best evidence’ for the UK prosthetic implanter. Using the Oxford Centre for Evidence-based Medicine Levels of Evidence (LE), no paper exceeded an LE of 2b and the majority were LE 4 (case series) and LE 5 (expert opinion). This is not surprising from a UK perspective since HES data for 2009 to 2010 reported 263 penile prosthetic surgeries performed in 35 hospitals, with only five hospitals performing 15 or more. Our literature review suggests that the use of antibiotic-coated IPPs and measures aimed at reducing inoculating bacteria into the surgical wound with alcohol skin preparation, a no-touch technique and peri-operative antibiotic use are most important in minimising the risk of device infection. The use of post-operative antibiotics is contentious (LE 5). It remains unproven whether diabetics have a higher rate of prosthetic infection compared to nondiabetics. In cases of re-implantation for mechanical failure, it remains debatable whether a washout technique should be used and indeed uncertainty remains regarding the pathological role of biofilm in the causation of device infection in this scenario. A washout technique during salvage penile prosthetic surgery for device infection is advocated. Further research on biofilm may offer the best chance of reducing the incidence of device infections overall.

Genitourinary Prosthetics: A Primer for the Non-urologic Surgeon

Genitourinary prosthetics are used for correction of functional deficits and to improve the quality of lives of affected patients. General surgeons must evaluate patients scheduled for nonurologic surgery with urologic devices that can impact their perioperative management. Lack of recognition of these prosthetics preoperatively can lead to unnecessary morbidity for the patient and have legal implications for the surgeon. Close consultation with a urologist may avoid common complications associated with these devices and allows for surgical assistance when operative misadventures do occur. This article reviews 3 common urologic prosthetics: testicular prosthesis, artificial urinary sphincter, and penile prosthesis.

Urological Consequences following Renal Transplantation: A Review of the Literature

Renal transplant (RT) represents the treatment of choice for end-stage renal disease (ESRD) but harbours a wide range of possible complications and therapeutic challenges of urological competence. Dialysis years and clinical medical background of these patients are risk factors for sexual dysfunction and lower urinary tract symptoms (LUTS). On the contrary, RT itself may have a number of possible surgical complications such as ureteral stenosis and urinary leakage, while immunosuppressive treatment is a known risk factor for de-novo malignancies.

The present review describes the main urologic problems of RT patients and their up-to-date treatment options according to the most recently available literature evidences.

Penile prosthesis surgery in the management of erectile dysfunction

Introduction

We reviewed retrospectively the use of penile prostheses, including the indications and complications of penile prosthesis surgery.

Methods

We identified publications and the reported advances in penile prosthesis surgery between 1987 and 2012 in Pub-Med, and published information from American Medical Systems, Inc. (Minnetonka, MN, USA) and Coloplast Corporation (Humlebaek, Denmark), using the keywords ‘penile prosthesis’, ‘erectile dysfunction’, ‘mechanical reliability’, ‘complications’ and ‘infection’.

Results

We describe the novel indications for the use of penile prostheses, the significant advances in implant designs with improved mechanical reliability, the changing landscape of device infection, and the current management of complications. Sixty-eight publications with a grade A, B and C level of evidence are cited.

Conclusion

The clinical indications to implant a penile prosthesis have expanded beyond organic erectile dysfunction. With the many different devices currently available, the choice of which device to implant can be tailored based on an individual’s unique medical conditions, manual dexterity and expectations, and surgeon preference. There must be a conscious effort to prevent device infection, in the light of the development of increasingly virulent organisms. Penile prosthesis surgery is an integral part of the treatment of erectile dysfunction when non-surgical options fail or are contraindicated.

Penile Prosthesis Implantation in Kidney-Transplanted Patients

Most kidney transplantations are performed on middle-aged men for whom problems of sexual potency are still of great importance. Although a functional renal graft improves the problem in some patients and others resolve with oral or intracavernous therapy, about 20% of patients do not have a good response. In non-responders, tricomponent penile prosthesis implantation is possible. In the last 10 years we have implanted with no complications 7 tricomponent AMS 700 prostheses in patients not otherwise responding. Our good results confirm that patients with kidney transplantation should be considered good candidates to the penile prosthesis if the erectile dysfunction persists after different therapies.

[Erectile dysfunction and renal chronic insufficiency: etiology and management]

Erectile dysfunction (ED) has a higher incidence in patients treated for chronic renal insufficiency or in patients who underwent kidney transplanation as it concerns more than 50% of them. Its severity is directly linked with the seriousness of the renal disease. ED is responsible of a deterioration of the quality of life. ED's physiopathology is complex and multifactorial, involving a combination of classical risk factors (endothelial dysfunction), specific factors (e.g., chronic hyperuremia and co-morbidities) and psychological factors. Management of ED must take into account both sides of the disease in order to propose appropriate treatment; i.e, psychological concerns and organic matters. Although literature remains poor in this area, phosphodiesterase-5 inhibitors are increasingly used for these patients as they are safe and efficient most of the time. Pharmacokinetics of phosphodiesterase-5 inhibitors can be disturbed by the simultaneous use of immunosuppressor. As a second line, intra-cavernous injections remain a gold-standard treatment. In case of failure, penile prosthesis can even be considered in case of renal chronic insufficiency and in transplanted patients.

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.

Treating Erectile Dysfunction in Renal Transplant Recipients

Erectile dysfunction is common in male kidney transplant recipients. Interference with the physiology of erections can be attributed to recipient co-morbidities, the renal transplant operation, medication adverse effects, relationship problems and changes in mental health. A treatment-oriented evaluation of erectile dysfunction allows the development of treatment plans that are patient-specific. Hypo-gonadal men whose hormone parameters do not improve after renal transplantation may respond to testosterone replacement therapy. Use of recommended doses of the phosphodiesterase-5 inhibitor sildenafil does not significantly modify trough concentrations of the calcineurin inhibitors ciclosporin and tacrolimus or result in impaired renal allograft function. Tacrolimus has been shown to increase the peak concentration and prolong the elimination half-life of sildenafil in kidney transplant recipients. Daily administration of sildenafil has resulted in decreased blood pressure in kidney transplant recipients with treated hypertension and tacrolimus immunosuppression. Intracavernosal injections of alprostadil, with or without papaverine and phentolamine, are effective treatments for erectile dysfunction after renal transplantation and have not resulted in alterations of ciclosporin concentrations or in deterioration of renal function. Penile prostheses can be successfully implanted after pelvic organ transplantation without significant risk of infection.

The utility of lockout valve reservoirs in preventing autoinflation in penile prostheses

INTRODUCTION

Autoinflation is a troublesome complication following penile prosthesis placement that may be potentiated by prevesical scarring following radical prostatectomy. We evaluated the frequency of autoinflation and other complications following penile prosthesis placement in radical prostatectomy patients and controls as a surrogate to establishing the utility of lockout reservoirs in preventing autoinflation.

METHODS

139 prostheses (including 14 with lockout reservoirs) were placed in 132 men (including 35 post-prostatectomy patients) over a 5(1/2) year period at our institution. Outcomes assessed include postoperative complications and the need for revision or replacement of the prosthesis. Multivariable regression analysis was used to determine the association of patient, device-specific, and perioperative characteristics with these outcomes.

RESULTS

There was no difference in the postoperative complication and re-operation rates between post-prostatectomy patients and controls (both p > 0.77). The incidence of autoinflation in post-prostatectomy patients and controls was 3% and 5%, respectively (p > 0.99). Patients with prior prostheses were 3 times as likely to develop a postoperative complication or require prosthesis revision (p = 0.02).

CONCLUSION

Penile prostheses are well tolerated in post-prostatectomy patients with comparable outcomes to those men with organic erectile dysfunction. The frequency of autoinflation does not appear to be increased in post-prostatectomy patients. Initial results with the lockout valve reservoir in preventing autoinflation are encouraging though additional study is warranted to justify their routine use.