Modern utilization of penile prosthesis surgery: a national claim registry analysis

Penile prosthesis for erectile dysfunction in France: A six-year nationwide database analysis

INTRODUCTION

Urological consultations for erectile dysfunction (ED) are increasing worldwide. Penile prosthesis (PP) implantations are performed when other treatments are unsuccessful. However, there is no data regarding PP implantations in France beyond the year 2016.

OBJECTIVES

This study aimed to describe the changes in the number and type of PP implants used for the treatment of ED in France from 2016 to 2021 and the hospitalization rates following implantation using French national data from the Program for the Medicalization of Information Systems (PMSI).

MATERIALS AND METHODS

We analyzed data on PP implantations in all France hospitals. PPs were coded into three types according to the Common Classification of Medical Procedures (CCAM). The number of patients admitted to hospital with complications twelve months after implantation was also recorded.

RESULTS

During the study period, 3675 men received 3868 PPs in France. A gradual increase in the total number of implanted PPs was observed, with an overall increase of 33.8%. In 2020, there was a sharp decline in the number of implanted PPs, primarily owing to the COVID-19 pandemic. The most commonly used implant was PPs with an extracavernous compartment, comprising 85% of all PPs. Twelve months after implantation, only 1-2% of the patients were rehospitalized.

CONCLUSION

PP implantation surgeries are highly reproducible and have a low incidence of complications, in terms of rehospitalization after one year of placement (1.8%). Moreover, there was an increase in the demand for penile prosthesis implantations in France between 2016 and 2021.

LEVEL OF EVIDENCE

4: Descriptive epidemiological study.

Management of male erectile dysfunction: From the past to the future

Erectile dysfunction is a common disease of the male reproductive system, which seriously affects the life quality of patients and their partners. At present, erectile dysfunction is considered as a social-psychological-physiological disease with complex etiology and various treatment methods. Oral PDE5I is the first-line treatment for erectile dysfunction with the advantages of high safety, good effect and non-invasiveness. But intracavernosal injection, hormonal replacement therapy, vacuum erection device, penile prosthesis implantation can also be alternative treatments for patients have organic erectile dysfunction or tolerance to PDE5I. With the rapid development of technologies, some new methods, such as low-intensity extracorporeal shock wave and stem cell injection therapy can even repair the organic damage of the corpora cavernosa. These are important directions for the treatment of male erectile dysfunction in the future. In this mini-review, we will introduce these therapies in detail.

Bibliometric and visualization analysis of literature relating to diabetic erectile dysfunction

Introduction

Diabetic erectile dysfunction (DMED) refers to erectile dysfunction secondary to diabetes. Erectile dysfunction is characterized by a persistent inability to achieve and maintain an erection sufficient to permit satisfactory sexual activity.

Methods

Based on the Web of Science core collection database, we firstly analyzed the quantity and quality of publications in the field of DMED, secondly profiled the publishing groups in terms of country, institution, author's publication and cooperation network, and finally sorted out and summarized the hot topics of research.

Results

From 2001 to 2022, a total of 1,403 articles relating to this topic were published in 359 journals. They represent the global research status, potential hotspots, and future research directions. The number of DMED-related publications and citations has steadily increased over the few past decades. Academic institutions from Europe and the United States have played a leading role in DMED research. The country, institution, journal, and author with the most publications were the United States (294), INHA University (39), the Journal of Sexual Medicine (156), and Ryu, Ji-Kan (29), respectively. The most common keywords were erectile dysfunction (796), men (256), diabetes (254), diabetes mellitus (239), prevalence (180), corpus cavernosum (171), dysfunction (155), mellitus (154), nitric-oxide synthase (153), and expression (140). The main keyword-based research topics and hotspots in the DMED field were oral sildenafil, smooth muscle relaxation, nitric oxide synthase, gene therapy, metabolic syndrome, cavernous nerve injury, stem cell, and penile prosthesis.

Discussion

The terms oral sildenafil, smooth muscle relaxation, nitric oxide synthase, gene therapy, metabolic syndrome, cavernous nerve injury, stem cell, and penile prosthesis will be at the forefront of DMED-related research.

Under-recognized factors affecting penile implant satisfaction in patients

INTRODUCTION

Surgical management via penile prosthesis is an option for patients who have failed medical management. There is a paucity of literature surrounding factors contributing to patient satisfaction after implant surgery. The objective of this study was to characterize patients' and surgeons' attitudes toward factors affecting satisfaction with this procedure.

METHODS

Two patient cohorts were identified and contacted via email: a medical management of erectile dysfunction (ED) cohort and a penile implant patient cohort. A third cohort, Canadian urologists who perform penile implant surgeries, was also contacted. The surveys consisted of 5-7 questions, including a rating question regarding the importance of various penile implant factors.

RESULTS

Forty-six ED patients, 45 post-implant patients, and 12 urologists completed the survey. The mean overall satisfaction on a 10-point scale was 6.49 (standard deviation [SD] 2.92). Most (67%) urologists selected patient satisfaction as one of their least favorite aspects of penile implant surgery. Compared to postimplant patients, ED patients reported greater importance in the areas of appearance (p=0.035), soft glans (p=0.040), and concealment of implant (p=0.007). Urologists ranked natural feel (p=0.019) and generating a discrete erection (p=0.022) as less important than patients.

CONCLUSIONS

This is the first study that examines which specific variables of penile implant surgery are associated with satisfaction while comparing surgeons' understanding of what patients desire from this surgery. This study identifies several factors deemed important by patients but under-recognized by urologists. This knowledge can aid urologists in optimizing preoperative counselling and improving patient satisfaction.

Incidence of Venous Thromboembolism and Safety of Perioperative Subcutaneous Heparin During Inflatable Penile Prosthesis Surgery

OBJECTIVE

To identify the incidence of venous thromboembolism (VTE) risk factors, postoperative VTE, and to assess the morbidity of perioperative pharmacologic VTE prophylaxis in men undergoing inflatable penile prosthesis (IPP) surgery.

METHODS

We retrospectively reviewed 215 patients undergoing IPP surgery between July 2017 and June 2019. Univariate and multivariate statistical analyzes were performed to assess pre-operative Caprini risk score and compare post-operative day 0 scrotal drain output, scrotal hematoma formation, and VTE in men who received subcutaneous heparin (SqH) vs those who did not receive SqH.

RESULTS

Of 215 IPP patients, 84% were classified as high or highest risk for VTE utilizing the Caprini risk score. A total of 119 (55%) received perioperative SqH with or without additional anti-thrombotics. Post-operative day 0 scrotal drain output was higher in those who received SqH compared to those who did not receive SqH, 99.9 mL vs 75.6 mL, respectively (P = .001). Minor scrotal hematomas occurred in similar rates in patients who received perioperative SqH vs those who did not, 3.8% vs 6.3%, respectively (P = .38). Similar results were found on subgroup analysis when eliminating patients who received SqH concurrently with other anti-thrombotics. The overall rate of postoperative VTE was 0.9%. No post-operative infections occurred.

CONCLUSION

Patients undergoing IPP surgery are at elevated risk for VTE. To our knowledge, this is the first study showing SqH use in the perioperative IPP surgery setting is safe when used in conjunction with a scrotal drain. Preoperative VTE risk stratification may be performed and can be used to guide clinical decision making regarding pharmacologic prophylaxis.

Practical Considerations in Inflatable Penile Implant Surgery

BACKGROUND

Penile prosthesis implantation remains an effective solution for men with medical-refractory erectile dysfunction (ED) following radical pelvic surgery. Despite the distortion of pelvic anatomy, a penile implant can be performed with excellent clinical outcomes provided strict patient selection, proper preoperative workup and safe surgical principles are adhered to.

AIM

To provide practical recommendations on inflatable penile prosthesis (IPP) implantation in patients with medical-refractory ED, with an emphasis on patient selection and counselling, preoperative workup as well as surgical considerations to minimize intraoperative complications.

METHODS

A Medline search on relevant English-only articles on penile prostheses and pelvic surgery was undertaken and the following terms were included in the search for articles of interest: "bladder cancer", "prostate cancer", "rectal cancer", "pelvic surgery" and "inflatable penile implant".

OUTCOMES

Clinical key recommendations on patient selection, preoperative workup and surgical principles.

RESULTS

Patients should be made aware of the mechanics of IPP and the informed consent process should outline the benefits and disadvantages of IPP surgery, alternative treatment options, cost, potential prosthetic complications and patient's expectations on clinical outcomes. Specialised diagnostic test for workup for ED is often not necessary although preoperative workup should include screening for active infection and optimising pre-existing medical comorbidities. Precautionary measures should be carried out to minimise infective complication. Corporal dilation and reservoir placement can be challenging in this group, and surgeons may require knowledge of advanced reconstructive surgical techniques when dealing with specific cases such as coexisting Peyronie's disease and continence issue.

CLINICAL TRANSLATION

Strict patient selection and counselling process coupled with safe surgical principles are important to achieve excellent linical outcomes and patient satisfaction rates.

STRENGTHS AND LIMITATIONS

This masterclass paper provides an overview of the practical considerations for men who are undergoing IPP surgery following radical pelvic surgery. Limitations include the lack of highquality data and detailed surgical description on each surgical troubleshooting steps for various prosthetic-related complications.

CONCLUSION

The IPP implantation can be performed efficiently and safely in patients following radical pelvic surgery. Chung E, Mulhall J. Practical Considerations in Inflatable Penile Implant Surgery. J Sex Med 2021;18:1320-1327.

Challenging Ethical Scenarios in the Surgical Treatment of Erectile Dysfunction: A Survey of High-Volume Penile Prosthesis Surgeons

OBJECTIVE

To investigate how surgeons approach ethically challenging scenarios that arise in penile prosthesis surgery and identify patient-related factors that impact their approach.

METHODS

A survey was distributed to the Society for Urologic Prosthetic Surgeons membership consisting of 6 ethically challenging scenarios: an HIV+ patient, a patient with cognitive disability, a registered sex offender, a nonverbal patient, a litigious patient, and an uncontrolled diabetic patient whose insurance will lapse soon. Additional clinical information was provided to assess how the likelihood to offer surgery might change. The primary outcome was the likelihood of offering surgery in each scenario.

RESULTS

The response rate was 15.6% (n = 29). When compared to the baseline patient, respondents had a lower likelihood of offering surgery in all scenarios except the HIV+ patient, with the lowest likelihood of offering surgery to a sex offender (P < .01). Within each scenario, factors associated with an increased odds of offering surgery included knowledge that a patient with Down Syndrome is high functioning (odds ratio [OR] 5.0, confidence interval [CI]: 1.4-17.8), that a prior sex offender is currently married (OR 16.5, CI:3.5-99.8), that a litigious patient sued a surgeon for a retained sponge (OR 6.3, CI:1.7-24.3), and that a nonverbal patient had expressed prior interest in penile prosthesis surgery (OR 4.5, CI: 1.3-16.2).

CONCLUSION

Ethical principles, including respect for autonomy, nonmaleficence, beneficence, and justice, are appropriately applied by urological prosthetic surgeons when ethical challenges arise. While the likelihood of offering penile prosthesis surgery is decreased with most ethical dilemmas, specific clinical factors often augment decision-making.

Novel Emerging Therapies for Erectile Dysfunction

Currently, several treatments exist for the improvement of erectile dysfunction (ED). These include medical therapies such as phosphodiesterase type 5 inhibitors (PDE5-Is), invasive methods such as intracavernosal injection therapy of vaso-active substances, vacuum erection devices, and penile prosthesis implants. However, the percentage of patients that are unresponsive to available treatments and who drop out from treatments remains high. Current evidence reveals that the pathogenesis of ED is related to multiple factors including underlying comorbidities, previous surgery, and psychological factors. Diverse approaches using novel molecular pathways or new technologies have been tested as potential therapeutic options for difficultto-treat ED populations. Melanocortin receptor agonist, a centrally acting agent, showed promising results by initiating erection without sexual stimulation in non-responders to PDE5-Is. Recent clinical and pre-clinical studies using human tissues suggested that new peripherally acting agents including the Max-K channel activator, guanylate cyclase activator, and nitric oxide donor could be potential therapies either as a monotherapy or in combination with PDE5-Is in ED patients. According to several clinical trials, regeneration therapy using stem cells showed favorable data in men with diabetic or post-prostatectomy ED. Low-intensity shock wave therapy also demonstrated promising results in patients with vasculogenic ED. There are growing evidences which suggest the efficacy of these emerging therapies, though most of the therapies still need to be validated by well-designed clinical trials. It is expected that, should their long-term safety and efficacy be proven, the emerging treatments can meet the needs of patients hitherto unresponsive to or unsatisfied by current therapies for ED.

An assessment of current penile prosthesis reimbursement guidelines for insurance plans nationwide

A lack of uniformity exists for insurance payer coverage for all categories of penile prostheses (PP). We sought to determine common insurance coverage criteria and barriers to implantation across common insurance plans from healthcare referral regions (HRR) nationwide. Coverage criteria and stipulations were reviewed regarding erectile dysfunction (ED) etiology, ED duration, contributing comorbid conditions, medications, drug use, diagnostic tests, use of procedures and prior interventions. Seventy of 100 plans included coverage criteria. 36.1% provided coverage only in cases of gender dysphoria. 27.7% required documentation of trial, contraindication or intolerance to pharmacologic therapy, with varying descriptors of what this entailed. 13.8% required at least consideration of prior pharmacologic therapy. 4.2% required trial or contraindication to classic second-line therapies. 25.0% stated that ED must be organic. Psychogenic ED was covered by 12.5% of plans. Eleven plans required at least 6 or 12 months of symptoms. Laboratory evaluation to rule out hypogonadism or hyperprolactinemia was required by five plans. Insurance coverage criteria for PP placement were highly variable by state and plan. Coverage is provided for PP implantation in most cases for ED of organic etiology following failure of pharmacologic therapy when contributing comorbidities are optimally managed.

[Penile prostheses: Description of a series of implants with and without dilatation of the corpora cavernosa]

INTRODUCTION

Penile prosthesis (PP) implantation is the treatment of choice for refractory erectile dysfunction (ED). They show a high satisfaction rate (75%-100%) and a complication rate that varies between 2.1% and 28.8%. The standard surgical technique includes dilatation of the corpora cavernosa (CC) prior to the insertion of the cylinders. This step takes time and is critical for the occurrence of complications. The aim of this study is to describe the results of a series of PP implanted using the techniques with and without dilatation of the CC.

MATERIALS AND METHODS

One-hundred and 20 patients with refractory ED in whom a PP was implanted by 2 surgeons in different centers. Comorbidities, operative characteristics, satisfaction and postoperative complications were evaluated.

RESULTS

The average age was 61±9.6 years. The most prevalent comorbidities were: history of radical prostatectomy, high-blood pressure and diabetes mellitus. Forty-two malleable and 78 hydraulic prostheses were implanted. Eleven patients had a previous PP. The median operative time was 70minutes (35-140). The satisfaction reported was 95.8%. Ten patients presented complications. In the group in which the surgery was performed without dilatation of the CC (n=80), the operative time was shorter (62.5minutes [35-105] versus 90minutes [60-140] respectively, p<0.0001). There was no difference in complications (p=0.73) or levels of satisfaction (p=0.196) when comparing the technique with and without dilatation of the CC.

CONCLUSION

In our series, a shorter operative time was observed with the technique without dilatation of the CC, but there were no differences in complications. A prospective and randomized study is required to make a stronger recommendation regarding to dilatation of the CC.

Commercial Insurance Coverage for Inflatable Penile Prosthesis at a Tertiary Care Center

Introduction

Inflatable penile prosthesis has become an important treatment modality for men with erectile dysfunction that is refractory to medication. Despite high levels of patient satisfaction following inflatable penile prosthesis placement and inflatable penile prosthesis coverage by Medicare, coverage by commercial insurance providers is unknown. The purpose of this study was to determine the coverage of inflatable penile prosthesis by commercial insurance providers.

Methods

Following institutional review board approval all men with erectile dysfunction interested in obtaining inflatable penile prosthesis at our tertiary care center between January 2016 and December 2017 were evaluated. We reviewed billing records for CPT code 54405 during the study period to evaluate the insurance provider for all men who received an inflatable penile prosthesis. We also reviewed a manually maintained record of excluded or denied inflatable penile prosthesis claims for men who desired inflatable penile prosthesis but could not obtain it. Through medical record review we recorded the etiology of erectile dysfunction and the specific type of insurance policy for each man.

Results

Medicare is the most common insurer for inflatable penile prosthesis, insuring 87 of 220 (39.5%) men seeking inflatable penile prosthesis between 2016 and 2017. Among the remaining 127 men seeking inflatable penile prosthesis with commercial insurance coverage 61 (48.0%) were unable to obtain the device due to exclusions in their coverage or denials. Among commercially insured men seeking inflatable penile prosthesis 77 (62.6%) and 37 (30.0%) had health maintenance organization and preferred provider organization plans, respectively. The most prevalent indications for inflatable penile prosthesis among the entire study population were radical prostatectomy (30.9%), organic erectile dysfunction (30.5%) and diabetes mellitus (20.9%).

Conclusions

The largest insurer for inflatable penile prosthesis in the Miami region is Medicare. While some patients seeking inflatable penile prostheses can receive insurance coverage, a large percentage (48.0%) are not able to receive coverage despite having a medical necessity for the treatment of erectile dysfunction.

Trends in Penile Prosthetics: Influence of Patient Demographics, Surgeon Volume, and Hospital Volume on Type of Penile Prosthesis Inserted in New York State

INTRODUCTION

Penile prostheses (PPs) are a discrete, well-tolerated treatment option for men with medical refractory erectile dysfunction. Despite the increasing prevalence of erectile dysfunction, multiple series evaluating inpatient data have found a decrease in the frequency of PP surgery during the past decade.

AIMS

To investigate trends in PP surgery and factors affecting the choice of different PPs in New York State.

METHODS

This study used the New York State Department of Health Statewide Planning and Research Cooperative (SPARCS) data cohort that includes longitudinal information on hospital discharges, ambulatory surgery, emergency department visits, and outpatient services. Patients older than 18 years who underwent inflatable or non-inflatable PP insertion from 2000 to 2014 were included in the study.

OUTCOMES

Influence of patient demographics, surgeon volume, and hospital volume on type of PP inserted.

RESULTS

Since 2000, 14,114 patients received PP surgery in New York State; 12,352 PPs (88%) were inflatable and 1,762 (12%) were non-inflatable, with facility-level variation from 0% to 100%. There was an increasing trend in the number of annual procedures performed, with rates of non-inflatable PP insertion decreasing annually (P < .01). More procedures were performed in the ambulatory setting over time (P < .01). Important predictors of device choice were insurance type, year of insertion, hospital and surgeon volume, and the presence of comorbidities.

CLINICAL IMPLICATIONS

Major influences in choice of PP inserted include racial and socioeconomic factors and surgeon and hospital surgical volume.

STRENGTHS AND LIMITATIONS

Use of the SPARCS database, which captures inpatient and outpatient services, allows for more accurate insight into trends in contrast to inpatient sampling alone. However, SPARCS is limited to patients within New York State and the results might not be generalizable to men in other states. Also, patient preference was not accounted for in these analyses, which can play a role in PP selection.

CONCLUSIONS

During the past 14 years, there has been an increasing trend in inflatable PP surgery for the management of erectile dysfunction. Most procedures are performed in the ambulatory setting and not previously captured by prior studies using inpatient data. Kashanian JA, Golan R, Sun T, et al. Trends in Penile Prosthetics: Influence of Patient Demographics, Surgeon Volume, and Hospital Volume on Type of Penile Prosthesis Inserted in New York State. J Sex Med 2018;15:245-250.

30-day adverse event rates following penile prosthesis surgery: an American College of Surgeons National Surgical Quality Improvement Program based evaluation

Background

Commonly utilized as a third-line therapy for erectile dysfunction (ED) management, the penile prostheses have become a staple treatment for ED refractory to pharmacological interventions. There is however a paucity of data in the literature pertaining to short-term adverse outcomes following penile prosthesis surgery. We thus sought to leverage the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to evaluate such outcomes within 30 days of surgery in these patients. We hypothesized that such data will lead to a more informed patient-physician consultation.

Methods

Relying on the ACS-NSQIP database [2005–2013], patients undergoing penile prosthesis placement were identified utilizing the Current Procedural Terminology (CPT) codes: 54400, 54401, 54405, 54406, 54407, 54408, 54410, 54411, 54416 and 54417. Outcomes assessed included system-wise categorized complications, length-of-stay (LOS), and re-intervention, readmission and 30-day mortality rates. Descriptive statistics were used to analyze available data. Multivariate analysis could not be performed due to small sample size.

Results

Overall, 98 cases of patients who underwent surgery for penile prosthesis placements between the years 2005 and 2013 were reported by the ACS-NSQIP affiliated hospitals. The median age was 65 years (interquartile range, 58–70 years). The overall 30-day complication rate was 11.3% (n=11); 5 of the 11 complications were infectious in etiology, and three were a postoperative blood transfusion event. The median LOS was 1 day. One (1.0%) patient needed to return to the operating room, two patients (2.6%) were readmitted and there was one (1.0%) death within 30 days of the original surgery.

Conclusions

Surgery for penile prosthesis appears to be a safe operation despite the routinely advanced age of the patients requiring it. Complications in the immediate postoperative setting are usually infectious. This data can be used in the clinical setting for a more informed patient-physician discussion and patient expectation management.

Pain Management in Penile Prosthetic Surgery: A Review of the Literature

INTRODUCTION

The literature on perioperative pain control and management in inflatable penile prosthesis placement is not firmly established. Because inflatable penile prosthesis placement is an elective procedure, pain can be one of the many issues that influence patient decision making. Pain control also presents a unique challenge to providers in an era of widespread opiate abuse.

AIM

To review published data on pain management before, during, and after penile prosthetic surgery.

METHODS

Peer-reviewed literature and conference abstracts were analyzed for all relevant publications related to this issue.

RESULTS

The past several decades have seen a shift from general to local anesthesia for penile prosthetic surgery. This has been well characterized and is seen as successful with different local anesthetic options and techniques. To date, only one study has provided follow-up for longer than 1 week regarding postoperative pain management for prosthetic surgery.

CONCLUSION

Perioperative pain management for the patient receiving a penile prosthetic is well characterized; postoperative pain management is not. Although periprocedural local anesthesia has been well described for penile prosthesis surgery, a standardized postoperative pain management plan does not exist. This review highlights the need for further characterization of postoperative pain and the subsequent development of an algorithmic approach for management. Reinstatler L, Shee K, Gross MS. Pain Management in Penile Prosthetic Surgery: A Review of the Literature. Sex Med Rev 2018;6:162-169.

Penile Lengthening, Girth, and Size Preservation at the Time of Penile Prosthesis Insertion

INTRODUCTION

Penile prosthetic devices are the gold standard treatment of medication-refractory erectile dysfunction. Inflatable penile prosthetic (IPP) devices have been available and used for more than four decades. Oftentimes, medical conditions causing erectile dysfunction also cause penile shortening, causing decreased patient quality of life.

AIM

To identify and review all available penile lengthening procedures that can be performed at time of IPP insertion.

METHODS

An extensive, systematic literature review was performed using PubMed searching for key terms penile lengthening, inflatable penile prosthesis, penile girth, corporoplasty, glans augmentation, and penile enhancement; all articles with subjective and/or objective penile length outcomes were reviewed.

MAIN OUTCOME MEASURES

A review of various techniques for penile length and girth preservation and enhancement during penile prosthesis insertion.

RESULTS

Several advanced and novel techniques were found for penile length preservation and enhancement at time of IPP insertion, including the sub-coronal IPP insertion technique, and adjuvant maneuvers during insertion, such as the sliding technique, modified sliding technique, multiple slice technique, and circumferential incision and grafting. Other adjuvant techniques that can enhance perception of increased length include ventral phalloplasty, suprapubic lipectomy, and suspensory ligament release. Further enhancement can be obtained using augmentation corporoplasty and glans augmentation with hyaluronic acid and other fillers. The different techniques vary in complexity and could require specialized training and experience. Maximum length gain appears to be limited by the length of the neurovascular bundles.

CONCLUSION

Overall, surgical penile lengthening procedures at time of IPP insertion appear safe and effective for treatment of patients with penile shortening and severe erectile dysfunction. These therapies can significantly improve patient self-esteem and quality of life in properly selected patients. Tran H, Goldfarb R, Ackerman A, Valenxuela RJ. Penile Lengthening, Girth and Size Preservation at the Time of Penile Prosthesis Insertion. Sex Med Rev 2017;5:403-412.

Utilization of penile prosthesis and male incontinence prosthetics in Saudi Arabia

Background:

Erectile dysfunction is a prevalent disease affecting over 50% of men between the ages of 40 and 70 years. Penile prosthesis represents the end of the line treatment when other less invasive therapies fail or are contraindicated. Male stress urinary incontinence can significantly diminish quality of life and lead to embarrassment and social withdrawal. Surgical therapies, such as male urethral slings and artificial urinary sphincters (AUS), are considered effective and safe treatments for male stress incontinence. No data exist on the utilization of penile prosthesis or male incontinence surgical treatment in Saudi Arabia. Generally, urological prosthetic surgery is performed either in private hospitals or in government hospitals. Our aim was to assess the trend of penile prosthesis and male incontinence device utilization in Saudi Arabia.

Materials and Methods:

We utilized sales’ data of penile prosthetics, male slings, and AUS from the only two companies selling these devices in Saudi Arabia (AMS^® and Coloplast^®), from January 2013 to December 2016.

Results:

There were 2599 penile prosthesis implantation procedures done in the study period, with 67% of them performed in private institutions. There was a progressively increased use of penile prosthetics which nearly doubled from 2013 to 2016. The main type of prosthesis utilized was the semirigid type 70% versus 11% of the 2-piece inflatable and 17% of the 3-piece inflatable device. Only 10 slings and 31 AUS were inserted during the same study period.

Conclusions:

There is an increased utilization of penile prosthetics in Saudi Arabia. The private sector performs the majority of penile prosthesis procedures, and most of them are of the semirigid type. The governmental sector is more likely to perform inflatable penile prosthesis and male incontinence device procedures. Male incontinence prosthetics’ use is very limited in Saudi Arabia.

A Novel Thermal-activated Shape Memory Penile Prosthesis: Comparative Mechanical Testing

OBJECTIVE

To compare a novel nickel-titanium (Ni-Ti) shape memory alloy (SMA) penile prosthesis of our own design with commercially available prostheses using a format similar to mechanical testing done at major penile prosthesis manufacturers. We evaluated the mechanical parameters of commercially available penile prostheses and used this information to guide the development of the Ni-Ti-based physiological penile prosthesis that expands and becomes erect with a small amount of heat applied.

METHODS

A penile prosthesis consisting of an exoskeleton of temperature-tuned Nitinol was designed and prototyped. Mechanical testing was performed in a model of penile buckling, penile lateral deviation, and original penile shape recovery commonly used by penile prosthesis manufacturers for testing.

RESULTS

Our SMA penile prosthesis demonstrated useful mechanical characteristics, including rigidity to buckling when activated similar to an inflatable penile prosthesis (2.62 kgf SMA vs 1.42 kgf inflatable penile prosthesis vs 6.45 kgf for a malleable prosthesis). The Ni-Ti also became more pliable when deactivated within acceptable mechanical ranges of existing devices. It could be repeatedly cycled and generate a restorative force to become erect.

CONCLUSION

An SMA-based penile prosthesis represents a promising new technology in the treatment of erectile dysfunction. We demonstrated that an Ni-Ti-based prosthesis can produce the mechanical forces necessary for producing a simulated erection without the need for a pump or reservoir, comparable with existing prostheses.

[Evolution of the number and type of penile prostheses implanted in France for erectile dysfunction: Analysis of French national coding database (2006-2013)]

OBJECTIVES

Patients who are not responding to injectable and/or vacuum oral pharmacological treatments can receive a penile prosthesis. Three types of penile prostheses are used in France: rigid, semi-rigid and inflatable prostheses 3-piece or 2-piece. We have assessed the National surgical insertion practices between 2006 and 2013 (number of prostheses insertions, types, procedure locations, number of surgeons and distribution [public or private sectors]).

MATERIALS AND METHODS

Data analysis from the French Technical Agency of Information on Hospitals (ATIH) (2006-2013) using the common classification of medical acts (CCAM) and after code extractions related to this surgery (JHLA002, JHLA003, JHLA004).

RESULTS

Between 2006 and 2013, the number of penile implants in France doubled (307 to 633), inflatable penile prostheses with an extracavernous component remained the most frequently used (87 %) (228 to 552) (+142 %). The use of semi-rigid prostheses declined by 26.7 %. The distribution between the private and public sector was close to 1 in 2013. More than half of French penile prostheses were implanted in three regions (Île-de-France, Languedoc-Roussillon, Rhône-Alpes). Nearly 62 % of surgeons implanted only one or two three-compartment prostheses in 2013.

CONCLUSION

The number of penile prostheses in France doubled between 2006 and 2013. Three regions were particularly active as far as this surgery is concerned (Île-de-France, Languedoc-Roussillon, Rhône-Alpes). They were boosted by 5 surgeons with more than 20 prostheses surgeries a year.

LEVEL OF EVIDENCE

4.

Time course and predictors of use of erectile dysfunction treatment in a Veterans Affairs medical center

The objective of this study was to define the pattern and time course of use of ED treatments in a Veterans Affairs (VA) medical center and to identify clinical or demographic variables that are associated with the use of second- or third-line ED treatments. We identified 702 men treated for ED at the Greater Los Angeles Veterans Affairs between 2007 and 2013. We extracted demographics, Charlson co-morbidity score, pertinent surgical/medication history as well as use of ED treatments from medical records. On multivariate analysis, age over 65 (OR 1.83, 95% CI: 1.31-2.56) and Charlson co-morbidity score of 1 (OR 1.77, 95% CI: 1.13-2.77) and 2+ (OR 2.07, 95% CI: 1.28-3.36) were significantly associated with use of medicated urethral suppositories for erection (MUSE)/intracorporal injections (ICI) compared with PDE5i/erection devices. Across all men who used second- or third-line treatments, median time until receiving MUSE was 0.6 years and median time until receiving ICI/implant was 2 years. We conclude that men who will ultimately use more invasive ED treatments, such as men with more co-morbidities, tend to have a prolonged treatment course. This information may be incorporated into a shared decision-making model for more efficient treatment of ED.

Penile Prosthesis Surgery: Current Recommendations From the International Consultation on Sexual Medicine

INTRODUCTION

Penile prosthesis implantation has emerged as a definitive treatment to restore sexual function to the motivated man with erectile dysfunction. Substantial improvements in the design of inflatable devices have been made since they first became available more than four decades ago.

AIM

To review the history of the penile prosthesis, the indications, preoperative evaluation, and patient and partner satisfaction. The current approaches to addressing intra- and postoperative complications, provide an understanding of prosthesis infection, and placement of these devices will be reviewed.

METHODS

A committee of worldwide experts in this field was assembled during the 2015 International Consultation on Sexual Medicine (ICSM) and performed a systematic review of the peer-reviewed published medical literature pertaining to penile prosthesis. Particular attention was given to higher level trials when available. Recommendations are based upon the Oxford Criteria.

MAIN OUTCOME MEASURES

Unfortunately there is limited level 1 and 2 evidence, and where expert opinion was utilized, the decision was unanimous within the committee with a goal of presenting a clinically relevant guideline pertaining to penile prostheses.

RESULTS

Penile prosthesis has undergone an evolution over the past 40 years resulting in a more effective and reliable treatment for advanced erectile dysfunction not responding to less invasive methods including oral treatment with PDE5 inhibitors, vacuum erection device, and intracorporal injection therapy. It should be considered an appropriate treatment option for the man who wishes to restore erectile function and who understands the potential risk of mechanical failure and infection, both of which are less common now as a result of improvements made in device design as well as surgical protocols adhered to in the operating room. Patients must be clearly informed of the risks associated with penile prosthesis including mechanical failure, infection, shortening of the penis, change in sensation and configuration of the penis, as well as injury to local structures. Intraoperative complications are unusual but do occur and can usually be addressed intraoperatively to allow placement of the device at the time of initial surgery. Postoperative complications may also be addressed when they occur but may require more advanced reconstructive surgical techniques. Men with Peyronie's disease, corporal fibrosis due to infection, trauma, prior prosthesis explantation, priapism, and men who have undergone construction of a neophallus may require additional advanced maneuvers to obtain optimum results with a penile prosthesis.

CONCLUSION

Penile prosthesis remains as an important, viable, and effective treatment for male erectile dysfunction that does not respond to other less invasive approaches or when these approaches are contraindicated or not acceptable to the patient. These devices provide the patient with the ability to engage in penetrative sexual activity without interfering with urination, ejaculation, sensation, or orgasm. Although mechanical failure can occur, the current devices are more reliable as a result of design modifications. Infection remains the most dreaded complication but since the introduction of antibiotic and hydrophilic coatings, infection is less common. Overall, patient and partner satisfaction appear to be reasonably high when a penile prosthesis is used to restore erectile function.