Simultaneous penile prosthesis and male sling/artificial urinary sphincter

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.

Preliminary Outcomes of the Male Urethral "Mini-Sling": A Modified Approach to the Andrianne Mini-Jupette Procedure With Penile Prosthesis Placement for Climacturia and Mild Stress Urinary Incontinence

INTRODUCTION

Previous worked showed that the Andrianne Mini-Jupette (AMJ) procedure with inflatable penile prosthesis (IPP) significantly improves climacturia or stress urinary incontinence (SUI) that may accompany erectile dysfunction (ED) after radical prostatectomy. However, with the AMJ procedure, the graft is incorporated into the medial aspect of the corporotomy, thereby requiring a more complex closure. Moreover, in the original report, multiple graft materials were used.

AIM

To describe our technique for "male urethral mini-sling" (MUMS) with a Virtue sling mesh, which is a modified approach to the AMJ, and to assess early postoperative outcomes.

METHODS

A retrospective chart review was performed for men who underwent IPP and MUMS placement with a modified Virtue mesh by 2 high-volume prosthetic urologic surgeons using the same technique. After proximal urethral exposure, the MUMS is sutured to the latera corpora over the bulbar urethra, proximal to and separate from the planned corporotomy, with care taken to avoid excessive urethral tension. The IPP is then placed in standard fashion. Changes in patient-reported climacturia and pads per day for SUI were assessed before and after surgery.

RESULTS

36 men underwent both IPP and MUMS placement between January 2016-October 2018. Mean patient age was 68 years. Etiology for ED and urinary symptoms was prostatectomy alone in 30 of 36 (83%) and prostatectomy plus radiation in 6 of 36 (17%). Preoperative urinary symptoms included climacturia in 30 of 36 (83%) and SUI in 27 of 36 (75%). Mean (SD) follow-up was 5.9 (3.7) months. Climacturia resolved in 28 of 30 (93%), and SUI improved in 23 of 27 (85%). The mean (SD) number of pads per day for those patients with SUI decreased significantly from 1.4 (1.1) before surgery to 0.4 (0.6) after surgery (P = .02). 1 patient required MUMS explantation for urethral erosion after prolonged postoperative catheterization.

CLINICAL IMPLICATIONS

The MUMS with modified Virtue mesh at the time of IPP placement can be used to treat ED with climacturia or mild SUI after radical prostatectomy.

STRENGTHS & LIMITATIONS

Strengths include the use of a consistent operative technique with a single graft material by 2 experienced prosthetic urologic surgeons. Limitations include the retrospective study design, use of subjective postoperative outcomes, lack of comparison group, and relatively moderate follow-up duration.

CONCLUSIONS

Our early results suggest that the MUMS significantly improves bothersome climacturia and mild SUI in addition to treating ED, with little added morbidity. Although further study, including longer-term follow-up, is needed, this approach may be considered in the appropriately counseled patient. Valenzuela RJ, Ziegelmann MJ, Hillelsohn JH, et al. Preliminary Outcomes of the Male Urethral "Mini-Sling": A Modified Approach to the Andrianne Mini-Jupette Procedure With Penile Prosthesis Placement for Climacturia and Mild Stress Urinary Incontinence. J Sex Med 2019;16:1310-1317.

Management of Climacturia During Inflatable Penile Prosthesis Surgery

Radical prostatectomy, the preferred treatment option for organ-confined prostate cancer, is associated with a wide variety of sexual dysfunctions including erectile and orgasmic dysfunctions. Climacturia is a type of orgasmic dysfunction that has been reported to occur in 20-60% of men after radical prostatectomy. Several treatment strategies for climacturia have been evaluated and recommended including behavioral changes, use of special devices, medications, specialized therapies, and surgeries. Inflatable penile prosthesis implantation might be the treatment of choice when conservative management approaches fail to treat erectile dysfunction. In this review article, the different options and approaches for the management of climacturia during inflatable penile prosthesis surgery will be discussed.

Sexual Recovery Following Prostate Cancer: Recommendations From 2 Established Canadian Sexual Rehabilitation Clinics

INTRODUCTION

Supportive sexual health care is much-needed adjuvant care to oncologic management for men with prostate cancer (PCa).

AIM

To inspire the initiation of biopsychosocial sexual health programming where it does not exist and to inform program enhancement in existing sexual rehabilitation clinics (SRCs).

METHODS

This article reviews the combined 30-year experience of 2 well-established Canadian SRCs for men and their partners after PCa treatments, interwoven with empirical evidence.

MAIN OUTCOME MEASURE

To comprehensively review the biopsychosocial approach to sexual health assessment of men with PCa and their partners to direct the practicalities of running a successful and sustainable SRC.

RESULTS

A full description of the biomedical and psychosocial approaches, inclusive of comprehensive sexual function, the penile rehabilitation controversy, and other medical and relationship issues affecting sexual adjustment, is provided to highlight the relevance of proper assessment and follow-through for sexual adaptation and adjustment. 10 recommendations for a successful SRC are discussed, including the principles behind developing a sustainable business plan, staff acquisition and training, budget, integration of treatment and research priorities, respectful and multidisciplinary approaches to care, and suggestions of visit formats, protocols, and questionnaires. We recommend a phased approach of an SRC into usual care with the option to provide accessible and equitable care to patients not within proximal access of treating institutions.

CONCLUSION

Sexual rehabilitation after treatment for PCa requires a complex treatment process. Providing sustainable sexual rehabilitation programming under the financially strained environment of the Canadian medical system is a challenge; therefore, to provide Canadian patients and their partners with comprehensive cancer care, they deserve a biopsychosocial approach combined with a creative and systematic implementation strategy. Elliott S, Matthew A. Sexual Recovery Following Prostate Cancer: Recommendations From 2 Established Canadian Sexual Rehabilitation Clinics. Sex Med Rev 2018;6:279-294.

Synchronous Ipsilateral High Submuscular Placement of Prosthetic Balloons and Reservoirs

INTRODUCTION

Synchronous ipsilateral high submuscular placement of artificial urinary sphincter (AUS) pressure-regulating balloons (PRBs) and inflatable penile prosthesis (IPP) reservoirs in a single submuscular tunnel is a novel strategy that could be advantageous for patients who have had major pelvic surgery.

AIM

To report our initial experience with synchronous ipsilateral vs bilateral placement of AUS PRBs and IPP reservoirs in men undergoing implant surgery.

METHODS

We retrospectively reviewed all patients undergoing synchronous AUS and IPP placement from 2007 through 2015 by a single surgeon at our tertiary center. Patients were stratified according to ipsilateral vs bilateral placement of the AUS PRB and IPP reservoir.

MAIN OUTCOME MEASURES

Reoperation rates because of infectious or erosive complications and mechanical failure were assessed.

RESULTS

Of the 968 implant surgeries during the study period, 47 men had synchronous device placement, of whom 17 (36%) underwent ipsilateral placement of the PRB and reservoir. During a median follow-up of 19 months (range = 1-84 months), reoperations were necessary in 12 of 47 (26%) and were similar between groups (ipsilateral, 5 of 17, 29%; bilateral, 7 of 30, 23%; P = .73). Most reoperations were due to AUS-related complications (10 of 12, 83%) and nearly all patients with reoperation (10 of 12, 83%) had compromised urethras (ie, prior urethral surgery, radiation, or prior AUS implantation). The most common indication for reintervention was cuff erosion (4 of 47, 9%), with no difference between groups (ipsilateral, 3 of 17, 18%; bilateral, 1 of 30, 3%; P = .13).

CONCLUSION

Synchronous ipsilateral high submuscular placement of urologic prosthetic balloons could safely facilitate prosthetic surgery in patients with a history of major pelvic and inguinal surgery.

Management of end-stage erectile dysfunction and stress urinary incontinence after radical prostatectomy by simultaneous dual implantation using a single trans-scrotal incision: surgical technique and outcomes

Stress urinary incontinence (SUI) and end-stage erectile dysfunction (ED) after radical prostatectomy (RP) can decrease a patient's quality of life (QoL). We describe a surgical technique involving scrotal incision for simultaneous dual implantation of an artificial urinary sphincter (AUS) and an inflatable penile prosthesis (IPP). Patients with moderate to severe SUI (>3 pads per day) and end-stage ED following RP were selected for dual implantation. An upper transverse scrotal incision was made, followed by bulbar urethra dissection and AUS cuff placement. Through the same incision, the corpora cavernosa was exposed, and an IPP positioned. Followed by extraperitoneal reservoirs placement and pumps introduced in the scrotum. Short-term, intra- and post-operative complications; continence status and erectile function; and patient satisfaction and QoL were recorded. A total of 32 patients underwent dual implantation. Early AUS-related complications were: AUS reservoir migration and urethral erosion. One case of distal corporal extrusion occurred. No prosthetic infection was reported. Over 96% of patients were socially the continent (≤1 pad per day) and > 95% had sufficient erections for intercourse. Limitations of the study were the small number of patients, the lack of the control group using a perineal approach for AUS placement and only a 12 months follow-up. IPP and AUS dual implantation using a single scrotal incision technique is a safe and effective option in patients with SUI and ED after RP. Further studies on larger numbers of patients are warranted.