Satisfaction rate at 1-year follow-up in patients treated with penile implants: data from the multicentre prospective registry INSIST-ED

Cavernous tissue preservation technique versus conventional technique during penile prosthesis implantation: a prospective comparative study

BACKGROUND

Few prospective studies in literature with long postoperative follow-up compared between cavernous tissue sparing and conventional penile prosthesis implantation techniques.

AIM

To compare between cavernous tissue sparing and conventional penile prosthesis implantation techniques in terms of patient and partner satisfaction and perioperative outcomes.

METHODS

In All, 60 Patients with severe erectile dysfunction were randomized into 2 equal groups; patients undergoing conventional malleable penile prosthesis implantation, and patients undergoing the cavernous tissue-sparing technique. Postoperatively, prosthesis function and patient satisfaction were assessed at 6 weeks after surgery and then 3-6 and 12 months using EDITS and QoLSPP questionnaires. Patients were asked about residual penile tumescence. Perioperative data were recorded.

RESULTS

Modified EDITS questionnaire after 3,6, and 12 months was 76.9 ± 18, 79 ± 17 and 82.3 ± 16 respectively. As QOLSPP questionnaire, 46 (73.8%) subjects were highly satisfied, 25 patients (83.3%) in cavernous tissue sparing and 21 patients (70.00%) in Conventional group. While 14 (26.2%) were less satisfied, 5 patients (16.7%) Cavernous tissue sparing and 9 patients (30.00%) in Conventional group. In the cavernous tissue-sparing group, 26 of 30 patients (86.6%) reported having a significantly higher incidence of residual penile tumescence versus 2 of 30 patients (6.6%) in the conventional surgery group (P < .001). The age of highly satisfied subjects was significantly lower than those less satisfied (p = 0.025), while the BMI of highly satisfied subjects was significantly lower than those less satisfied (p = 0.001).

CONCLUSION

There is a significantly higher incidence of residual penile tumescence in Cavernous tissue sparing group. Many factors affect male satisfaction rates after PPI as age, and BMI.

Risk of unfavorable outcomes after penile prosthesis implantation - results from a national registry (INSIST-ED)

Like all surgeries, penile prosthesis implantation (PPI) has the potential for both postoperative complications and suboptimal patient satisfaction. In order to assess risk factors for poor satisfaction, we reviewed patients who had been prospectively recruited in a national multi-institutional registry of penile prostheses procedures (INSIST-ED) from 2014 to 20121. Patient baseline characteristics and postoperative complications were recorded. The primary endpoint of this study was unfavorable outcomes after inflatable PPI, defined as significant postoperative complications (Clavien-Dindo ≥2) and/or Sexuality with Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) scores below the 10th percentile. A total of 256 patients were included in the study. The median age was 60 years (IQR 56-67). The most common cause of erectile dysfunction (ED) was organic (42.2%), followed by pelvic surgery/radiotherapy (39.8%) and Peyronie's disease (18.0%). Postoperative complications were recorded in 9.6%. High-grade complications (Clavien ≥2) occurred in 4.7%. At 1-year follow-up, the median QoLSPP total score was 71 (IQR 65-76). In all, 14.8% of patients were classified as having experienced unfavorable outcomes because of significant postoperative complications and/or QoLSPP scores below the 10th percentile. Logistic regression analysis demonstrated patient age to be non-linearly associated with the risk of experiencing unfavorable outcomes. A U-shaped correlation showed a lower risk for younger and older patients and a higher risk for middle-aged men. ED etiology and surgical volume were not associated with PPI outcomes. Physicians should, therefore, be aware that middle-aged men may be at higher risk of being unsatisfied following PPI compared to both younger and older patients.

Quality of life and sexuality with penile prosthesis: a systematic review and pooled analysis

INTRODUCTION

Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) is the first validated questionnaire to specifically evaluate the satisfaction of patients undergoing penile prosthesis implantation. Our primary aim was to conduct a systematic review and pooled analysis of articles reporting QoLSPP.

EVIDENCE ACQUISITION

A comprehensive bibliographic search on the MEDLINE, Scopus, Web of Science, and Cochrane Library databases was performed in April 2023. Studies were selected if they assessed male subjects (P) undergoing penile prosthesis implantation (I) with or without comparison with other treatments (C), reporting the patient satisfaction according to QoLSPP (O). Prospective and retrospective original studies were included (S). The risk of bias was assessed using the ROBINS-I tool and the Knoll method. Means and standard deviations (SDs) of QoLSPP scores were included in the pooled analysis. PROSPERO ID: "CRD42023427261."

EVIDENCE SYNTHESIS

A total of 10 studies investigating 1105 patients were included in the systematic review; of these, eight articles describing the outcomes of 693 subjects were eligible for the pooled analysis. Overall serious risk of bias was found in 2/3 of nonrandomized comparative studies (66%), while seven single-arm studies (100%) were classified as having a high risk of bias. Pooled analysis of the QoLSPP-Functional domain revealed an overall effect size (ES) of 4.22 points (95% CI 4.04-4.40; P<0.001). The QoLSPP-Relational pooled score was 4.17 points (95% CI 4.03-4.31; P<0.001). The QoLSPP-Social pooled score corresponded to 4.21 points (95% CI 4.02-4.40; P<0.001). Pooled analysis of the QoLSPP-Personal domain showed an overall ES of 3.97 points (95% CI 3.61-4.32; P<0.001). There was insufficient data to pool QoLSPP total scores.

CONCLUSIONS

Patients undergoing penile prosthesis implantation report positive scores in all QoLSPP domains, demonstrating high satisfaction levels. Future studies are needed to improve the evidence on the topic.

Patient-Reported Outcome Measures in High-Risk Medical Device Registries: A Scoping Review

Little is known about the methods and outcomes of patient-reported outcome measure (PROM) use among high-risk medical device registries. The objective of this scoping review was to assess the utility and predictive ability of PROMs in high-risk medical device registries. We searched Ovid Medline, Embase, APA PsychINFO, Cochrane Library, and Scopus databases for published literature. After searching, 4323 titles and abstracts were screened, and 262 full texts were assessed for their eligibility. Seventy-six papers from across orthopedic (n = 64), cardiac (n = 10), penile (n = 1), and hernia mesh (n = 1) device registries were identified. Studies predominantly used PROMs as an outcome measure when comparing cohorts or surgical approaches (n = 45) or to compare time points (n = 13) including pre- and postintervention. Fifteen papers considered the predictive ability of PROMs. Of these, 8 treated PROMs as an outcome, 5 treated PROMs as a risk factor through regression analysis, and 2 papers treated PROMs as both a risk factor and as an outcome. One paper described PROMs to study implant survival. To advance methods of PROM integration into clinical decision-making for medical devices, an understanding of their use in high-risk device registries is needed. This scoping review found that there is a paucity of studies using PROMs to predict long-term patient and clinical outcomes in high-risk medical device registries. Determination as to why PROMs are rarely used for predictive purposes in long-term data collection is needed if PROM data are to be considered suitable as real-world evidence for high-risk device regulatory purposes, as well as to support clinical decision-making.

Level of Evidence 4

Mid-term outcomes of minimally invasive infrapubic approach for inflatable penile prosthesis implantation: A single-center study and literature review

BACKGROUND

The minimally invasive infrapubic approach (MIIA) for inflatable penile prosthesis (IPP) placement has shown favorable peri-operative safety and efficacy profile, but scarce data exist on long-term follow-up.

OBJECTIVES

We investigated the safety and efficacy of IPP implantation via the MIIA after a minimum 5-year follow-up.

MATERIALS AND METHODS

We identified data of implanted patients prospectively included in our institutional database. Complications and functional outcomes were assessed by using validated tools. Specifically, quality of life and patient satisfaction were evaluated by the Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire. Kaplan-Meier method was used to analyze IPP survival (defined as a working IPP).

RESULTS

Overall, 67 patients implanted by MIIA with a median (IQR) age of 64 years (61-70) were included. The median (IQR) follow-up duration was 71 months (63-80). Fifteen (22%) patients experienced complications: minor (Clavien ≤2) events included changes in penile sensitivity (n = 1; 1.5%), orgasmic dysfunction (n = 1; 1.5%), pain (n = 5; 7%), urinary tract infection (n = 2; 3%), and chronic discomfort (n = 1; 1.5%); major (Clavien 3) complications were represented by mechanical failure (n = 3; 4.5%), IPP infection (n = 1; 1.5%), and cylinder protrusion (n = 1; 1.5%). The estimated IPP survival was 94% (95% CI, 91.4-96.6), 92.5% (95% CI, 89.7-95.3), and 92.5% (95% CI, 89.7-95.3) at 3, 5, and 7 years after implantation, respectively. In patients using the device at follow-up (n = 61; 91%), median (IQR) scores for QoLSPP domains demonstrated favorable functional outcomes and patient satisfaction: functional 21 (19-23), personal 16 (15-18), relational 14 (12-15), and social 12 (11-14).

DISCUSSION AND CONCLUSION

This study represents the longest follow-up using validated tools to assess the outcomes of IPP implantation via MIIA so far. IPP placement via MIIA confirms to be safe and to offer high satisfaction to both patients and partners at mid-term evaluation.

An observational, national and multicentric study to describe the detection, diagnosis and treatment of erectile dysfunction and premature ejaculation from the patient's perspective

INTRODUCTION AND OBJECTIVES

To examine the opinions, attitudes and perceptions of patients regarding the diagnosis and treatment protocols of erectile dysfunction (ED) and premature ejaculation (PE) and their interaction with the urology specialists.

MATERIAL AND METHODS

Observational, national and multicentric study based on a self-designed online questionnaire in which ED and PE patients described their perception of ED and PE at diagnosis and during treatment and monitoring, the patient-physician relationship and the role of the patient's partner in the course of the disease.

RESULTS

306 ED and 70 PE participants were recruited. After the occurrence of the first symptoms, the time elapsed until the patient decided to go to the doctor was 28.6 months for PE and 14.0 months for ED (p<0.001). ED patients saw physicians more frequently (especially those aged between 60 and 69 years: 60.7%, p<0.001) than PE patients (52.1% vs 36.8%, respectively; p<0.001) and discussed this problem with their partner more (34.0% vs 22.8%, p<0.001). These disorders were mainly diagnosed at the urologist's office (ED: 74.8% vs 42.5%; PE: 75.7% vs 34.3%; diagnosis vs detection). One third of all participants reported that the sexual problem was not the main reason for the visit. The time elapsed between the first consultation for related symptoms and therapy was 8.7 months (oral drugs) and 7.6 months (dapoxetine) for ED and PE, respectively. ED patients and their partners felt particularly better once treatment had started (p<0.001). PE patients presented the highest degree of sexual dissatisfaction (78%). 50% of the patients agreed with the statement that initiating a discussion about sexual concerns was regarded as taboo and most of them did not say that their partner had encouraged them to seek medical advice.

CONCLUSION

A concerted effort is called for to expand ED and PE patients' proactivity in taking care of their own and their partner's sexual health. Current therapies would appear to have a benefit in couples' sexual relationships.

Which patient may benefit the most from penile prosthesis implantation?

BACKGROUND

Penile prosthesis implantation has been associated with overall good functional outcomes. Of relevance, some patients reported higher level of satisfaction and quality of life.

AIM

We investigated the profile of the patients who may benefit the most from penile prosthesis implantation.

MATERIALS AND METHODS

Data from a national multi-institutional registry of penile prostheses including patients treated from 2014 to 2017 in Italy (Italian Nationwide Systematic Inventarization of Surgical Treatment for Erectile Dysfunction) were analyzed. All data have been prospectively recorded by 45 surgeons on a dedicated website (www.registro.andrologiaitaliana.it) and revised by a single data manager. Patients' baseline characteristics were recorded. In order to simultaneously evaluate perceived penile prosthesis function and quality of life, all patients were re-assessed at 1-year follow-up using the validated questionnaire Quality of Life and Sexuality with Penile Prosthesis. High quality of life after surgery was defined as a score higher than the 75th percentile in each of the subdomains of the Quality of Life and Sexuality with Penile Prosthesis questionnaire. Logistic regression analysis tested the association between clinical characteristics and high quality of life after penile prosthesis implantation.

RESULTS

Follow-up data were available for 285 patients (median age 60 years; interquartile range: 56-67) who underwent penile prosthesis implantation. Erectile dysfunction etiology was organic in 40% (114), pelvic surgery/radiotherapy in 39% (111), and Peyronie's disease in 21% (60) of the cases. Patients showed good overall Quality of Life and Sexuality with Penile Prosthesis scores at 1-year follow-up for functional (22/25), personal (13/15), relational (17/20), and social (13/15) domains. Overall, 27.0% (77) of patients achieved scores consistent with the high quality of life definition. These patients did not differ in terms of median age (60 vs. 62), type of prosthesis (inflatable penile prostheses: 95% in both of the cases), and post-operative complications (10% vs. 14%) than those with lower quality of life score (all p &gt; 0.1). At logistic regression analysis, erectile dysfunction etiology was the only factor independently associated with high quality of life at 1 year after surgery (p = 0.02). Patients treated for Peyronie's disease (odds ratio: 2.62; p = 0.01; 95% confidence interval: 1.20-5.74) were more likely to report better outcomes after accounting for age, post-operative complications, and surgical volume.

CONCLUSION

Penile prosthesis implantation is associated with an overall good quality of life. The subset of patients affected by erectile dysfunction secondary to Peyronie's disease seemed to benefit the most from penile prosthesis implantation in terms of functional outcomes, relationship with their partners and the outside world, and perceived self-image. The systematic use of validated questionnaires specifically addressed at evaluating quality of life and satisfaction after penile prosthesis implantation should be further implemented in future studies to better define the predictors of optimal satisfaction after penile prosthesis implantation.

Development and Validation of the Satisfaction Survey for Inflatable Penile Implant (SSIPI)

BACKGROUND

No validated English language patient-reported outcome (PRO) currently exists that assesses satisfaction with inflatable penile prosthesis (IPP). Satisfaction data have been largely based primarily on surgeon assessment of patients or using questionnaires that have not been designed for this purpose.

AIM

To develop an English-language validated PRO that assesses patient satisfaction after IPP surgery.

METHODS

Initially, a literature review and discussions with experts defined domains important to IPP satisfaction (pain, appearance, function, overall satisfaction). The initial 35-item Satisfaction Survey for Inflatable Penile Implant (SSIPI) was developed. Cognitive interviews were then performed with IPP patients (n = 12) to gain feedback on the SSIPI domains and items. These data were used to modify SSIPI with the addition of 2 questions for a final item number of 37. Patients from 4 centers, who were between 6 months and 5 years after IPP, were administered the questionnaire through RedCap. Reliability statistics and content analysis were used to winnow questions to yield the final 16-item version of the SSIPI. Internal consistency was assessed via Cronbach's alpha and item-total correlation. Test-retest reliability was assessed via intraclass correlation coefficients using baseline and 2-week data. For convergent validity, the Erectile Dysfunction Inventory of Treatment Satisfaction and the Self-Esteem and Relationship (SEAR) questionnaire were used. For discriminant validity, the International Prostate Symptom Score (IPSS) was used. Confirmatory factor analysis was used to assess the factor structure of the SSIPI.

OUTCOMES

Internal consistency, test-retest reliability, convergent and discriminant validity, and confirmatory factor analysis were assessed.

RESULTS

118 men were surveyed. Mean age was 66.8 ± 9.5 years. The 16-item SSIPI showed high internal consistency with an overall Cronbach's Alpha of 0.97 (domains 0.85-0.89). Item-total correlations for individual items to subscales ranged from 0.60 to 0.91. The overall test-retest reliability was 0.94 (domains 0.87-0.93). Erectile Dysfunction Inventory of Treatment Satisfaction and Self-Esteem and Relationship had correlations of 0.84 overall (domains 0.57-0.79) and 0.47 overall (domains 0.34-0.44), respectively. International Prostate Symptom Score (discriminant validity) had correlations of -0.29 overall (domains -0.17 to -0.31).

CLINICAL IMPLICATIONS

SSIPI is the first English-language validated IPP satisfaction PRO. This will enable clinicians to collect satisfaction data in a standardized way.

STRENGTHS AND LIMITATIONS

As strengths we have used a rigorous psychometric process and have no industry sponsorship. Limitations include small numbers of specific subpopulations.

CONCLUSION

The SSIPI has demonstrated robust psychometric properties. Salter CA, Bach PV, Jenkins L, et al. Development and Validation of the Satisfaction Survey for Inflatable Penile Implant (SSIPI). J Sex Med 2021;18:1641-1651.

Penile Implant Surgery Satisfaction Assessment

BACKGROUND

Several studies reported high satisfaction rates (> 90%) for patients and their partners after penile prosthesis (PP) implantation.

AIM

To describe and critically discuss the current evidence regarding the assessment of patient and partner satisfaction after penile implant surgery.

METHODS

A critical narrative review of the studies investigating the patient and partner satisfaction after PP implantation was designed. Papers in English-language published until January 2021 were included.

OUTCOMES

The main outcome investigated was patient and partner satisfaction after penile implant surgery.

RESULTS

The International Index of Erectile Function , the Erectile Dysfunction Inventory of Treatment Satisfaction , the Treatment Satisfaction Scale , and the Quality of Life and Sexuality with Penile Prosthesis are the best-known validated tools used to assess satisfaction after PP implantation. Except for Quality of Life and Sexuality with Penile Prosthesis , they were not validated in patients undergoing penile implant surgery. The lack of an "ad hoc" tool has led to the widespread of nonvalidated questionnaires. Several tools can be useful in the preimplantation counseling, such as the mnemonic Compulsive/obsessive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial, and Psychiatric , the Minnesota Multiphasic Personality Inventory, the Brief Sexual Symptom Checklist for Men , the Attitude towards Penile Implant , and the Attitude Attributed to the Partner towards Penile Implant .

CLINICAL IMPLICATIONS

Improvement of knowledge regarding the available tools to evaluate the satisfaction after penile implant surgery.

STRENGTHS & LIMITATIONS

Comprehensive and thorough review of all the main validated questionnaires available to assess satisfaction in patients with PP. Lack of a systematic approach and quantitative data analysis.

CONCLUSION

Despite the high satisfaction rate reported in the literature, most of the studies used suboptimal or non-validated questionnaires to assess patients undergoing penile implant surgery. Future research is needed to develop and validate a specific, complete and easy-to-use questionnaire. Manfredi C, Fortier É, Faix A, et al. Penile Implant Surgery Satisfaction Assessment. J Sex Med 2021;18:868-874.

Preoperative Psychological Evaluation for Patients Referred for Penile Prosthesis Implantation

BACKGROUND

Patients may remain dissatisfied after penile prosthesis implantation for the treatment of erectile dysfunction. Studies showing the results of standardized protocols for preoperative psychological evaluation are lacking.

PURPOSE

To estimate the rate of patients considered psychologically unfit for penile prosthesis implantation and to compare their characteristics with those considered fit after the implementation of a standardized psychological profile evaluation protocol for men with erectile dysfunction.

METHODS

Cross-sectional evaluation of men referred for penile prosthesis implantation by their urologists, based on organic causes for the erectile dysfunction, including a semi-structured (sexual and relational anamnesis of the patient and their partner, information about expectations about the results of the penile prosthesis implantation and possible complications) and a structured instrument including validated tools for the evaluation of depression and/or anxiety symptoms. These were the Self Reporting Questionnaire (SRQ-20), the 36-Item Short-Form Health Survey for quality of life, and the Five-Factor Model (FFM) for behavioral tendencies. After at least 3 interviews, the psychology team rated the patients as fit or unfit for surgery. Unfit patients were those with any of a set of warning signals indicating risk for dissatisfaction even after penile implantation.

MAIN OUTCOME MEASURE

The prevalence of patients considered "unfit for surgery."

RESULTS

The quality of life scores were good, but 27.6% of patients (95% confidence interval, CI: 16.7-40.9%) were unfit for surgery. Being unfit was associated with obesity (P = .027), anxiety and/or depression symptoms (P < .001) and high levels of neuroticism (P = .001).

CONCLUSION

The preoperative evaluation protocol combining standardized and validated tools shows that more than one-quarter of patients with a medical indication for penile prosthesis implantation were not in good psychological conditions for the surgery. The development of psychological evaluation protocols can help identify patients in need of adequate care before penile implantation. M de Mello Ferreira dos Reis, EA Corrêa Barros, M Pollone, et al. Preoperative Psychological Evaluation for Patients Referred for Penile Prosthesis Implantation. Sex Med 2021;9:100311.

The Absence of a Validated English-Language Survey to Assess Prosthesis Satisfaction: A Prospective Cohort Using the Sexual Quality of Life After Penile Prosthesis

BACKGROUND

Prior assessments of sexual quality of life (SQoL) after penile prosthesis implantation have been performed without validated implant-specific tools. The Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire was designed and validated in Italian to specifically evaluate SQoL after a penile prosthesis is placed.

AIM

We aim to better characterize prosthesis-specific SQoL after inflatable penile prosthesis placement using the English translation of the QoLSPP questionnaire.

METHODS

A total of 395 consecutive patients received an inflatable penile prosthesis between January 1, 2009 and November 27, 2017, and 270 had functional emails to whom the QoLSPP questionnaire was sent. 90 surveys were completed by 75 first-time implantees and 15 patients who underwent removal/replacement surgery. Responses were considered positive if ≥ 3. Among first-time implantees, subpopulation analysis was carried out by age at survey completion (<55 years, 55-65 years, and ≥66 years), age of penile prosthesis at survey completion (<1 year, 1-5 years, and >5 years), device model (Coloplast Titan, AMS 700 CX, and AMS LGX), history of a psychiatric diagnosis, etiology of erectile dysfunction, total device length > or ≤ 21 cm, diabetes status, and body mass index < /≥ 30. Responses were analyzed in R using t-tests for continuous variables and Chi-squared tests (Fisher's for small counts) for categorical variables.

OUTCOMES

The main outcome measure of this study was sexual quality of life assessed by QoLSPP.

RESULTS

Patients completed the survey on average 3.15 years from their most recent prosthesis placement. 84% of first-time implantees had positive responses. Among them, there were no significant differences in the proportion of positive responses by device type, age, history of a psychiatric diagnosis, total implanted device length, etiology of erectile dysfunction, diabetes, or body mass index statuses (all P > .05). There was no difference in SQoL between first-time implantees and those who underwent removal/replacement surgery (P = 1.0).

CLINICAL IMPLICATIONS

Patients experience a positive impact on their SQoL following implantation of a penile prosthesis.

STRENGTHS & LIMITATIONS

Our study is the first to apply the English language QoLSPP which demonstrates high prosthesis specific SQoL but is limited by size and a lack of a validated English language tool.

CONCLUSIONS

The positive impact on patients' SQoL with penile prosthesis is 84% when assessed by the English QoLSPP questionnaire. While these results mirror those reported from Italy, the English-speaking patient population is plagued with a lack of a validated tool to assess satisfaction, a void the academic and prosthetic community must fill to better understand the impact prostheses have on their patients. Carlos EC, Nosé BD, Barton GJ, et al. The Absence of a Validated English-Language Survey to Assess Prosthesis Satisfaction: A Prospective Cohort Using the Sexual Quality of Life After Penile Prosthesis. J Sex Med 2020;17:2307-2310.

Comparing the Italian and North American prospective registries on penile prosthesis surgery: are there relevant differences in treatment indications and patients' management?

Previous studies have shown discrepancies among countries in terms of treatment indications and patients' management due to different health care policies. Penile prosthesis implantation (PPI) is a highly effective treatment for erectile dysfunction (ED), which may have different accessibility according to the type of health system. We compared clinical characteristics of patients included in two national registries on PPI to investigate the influence of different health care systems on treatment indication and accessibility. The multicenter Italian Nationwide Systematic Inventarization of Surgical Treatment for ED (INSIST-ED) Registry and the multicenter Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration (PROPPER), respectively for Italy and North America were considered. Clinical characteristics of patients included in both registries were compared using Wilcoxon Rank Sum test and the Pearson's Chi square test. Patients submitted to PPI in Italy are significantly younger (age: 61.2 vs. 63.8 years; p ≤ 0.001) compared with North America. The majority of patients are treated for post-radical prostatectomy ED in both registries (Italy: 31%; North America: 27%), although diabetes and cardiovascular diseases are more frequent reasons for PPI in the PROPPER registry (p ≤ 0.001), reflecting differences in disease prevalence among countries. In North America a non-hydraulic implant is considered only in 1% of cases as compared with 3% in Italy (p ≤ 0.001). In terms of postoperative management, a compressive surgical dressing (98% vs. 24%; p ≤ 0.001) is a more common strategy in North America. Finally, in Italy most surgeries are performed in a public hospital (82%), while the private setting (70.8%) is more common in North America (p ≤ 0.001). These findings suggest differences in health care systems between Italy and North America. A system like the American one would guarantee easier access to PPI in countries where the National Health System is mainly based on reimbursement to public hospital settings and where patients choosing private settings have to pay by themselves.

Analysis of satisfaction and surgical outcomes of a major ambulatory surgery program for penile implant

INTRODUCTION AND OBJECTIVE

Penile prosthesis (PP) surgery is performed in many institutions as an inpatient procedure. We have recently initiated a major ambulatory surgery (MAS) program, thus reducing the hospital stay. The objective of this study was to assess the feasibility, complications and satisfaction of the implantation of outpatient surgery PP program in our hospital.

MATERIAL AND METHODS

Retrospective observational study evaluating the results and satisfaction of PP implanted as an outpatient procedure in Bellvitge University Hospital during 2018.

RESULTS

During 2018 we implanted 49 PP: 27 (55%) inpatient surgeries vs. 22 (45%) outpatient surgeries. Of these 22, 2 (9%) were second implants. All patients underwent both general anesthesia and crural, proximal dorsal nerve and transversus abdominis plane block (TAP). Complication rates between inpatient and outpatient procedures were similar, 2 (7%) and 1 (5%), respectively, without reporting infections or requiring PP removal. Postoperatively, a satisfaction telephone survey was conducted in 19 (86%) patients: 16 (84%) considered the time of hospital stay as appropriate, 15 (79%) would have preferred to be operated again in an outpatient care setting and 15 (79%) would recommend it. The patients' main concerns were related to being at home with no medical assistance at home and about coming back the next day for drainage removal. All patients reported well-controlled pain without requiring opioid intake in any case.

CONCLUSIONS

In our series, PP implantation in an ambulatory care setting is feasible and safe. Although there are some aspects that should be improved, the program showed acceptable satisfaction rates and an adequate postoperative pain control, neither raising the administration of opioids, nor increasing complications and re-admission rates.

Infrapubic surgical approach for penile prosthesis surgery: Indications and technique

CONTEXT

Penile prosthesis surgery is currently the most effective treatment for erectile dysfunction when medical treatment is ineffective or contraindicated. Among the surgical approaches described in the literature, the scrotal, infrapubic and subcoronal are the most common in the daily clinical practice.

OBJECTIVES

The main objectives were to describe the infrapubic surgical technique evaluating its indications and complications, as well as comparing its advantages and disadvantages with the penoscrotal approach.

ACQUISITION AND SYNTHESIS OF THE EVIDENCE

A literature review from 1983 until current date was carried out in Medline (PubMed and Cochrane Library databases) following PRISMA standards. Sixteen studies were included: 4 prospective, 4 retrospective, one systematic review, one randomized trial, one original article, 5 expert opinion/surgical technique descriptive paper.

DISCUSSION

According to the literature reviewed, although the penoscrotal approach is the most applied, the infrapubic approach showed a shorter operative time and a tendency for an earlier recovery of sexual activity after surgery. Complications are rare, having similar rates to the penoscrotal approach; no cases of glans hypoesthesia have been reported and peri-prosthetic infection rates were less than 3%. Satisfaction rates of infrapubic penile prosthesis were higher than 80%.

CONCLUSIONS

Penile prosthesis implantation requires of a profound knowledge of the different surgical approaches in order to best adapt each technique based on each individualized case. The infrapubic approach, even if it is not the most used, is as feasible and reliable as the penoscrotal approach. The infrapubic approach is effective and safe, with high level of both, patients and partners' satisfaction.

Analysis of preoperative and postoperative expectations of penile implant candidates

Penile prosthesis implantation is a good option for the treatment of refractory erectile dysfunction. However, the patient's expectations, among other factors, condition his satisfaction after surgery. This review article aims to present the scientific evidence available concerning patient satisfaction with penile prosthesis surgery.

Initial experience of a single center with the use of ZSI 475 penile prosthesis

Objective

To evaluate surgical outcomes after implantation of the Zephyr ZSI 475 inflatable penile prosthesis (IPP) and patients' quality of life.

Methods

From December 2014 to September 2018, 15 patients underwent prosthesis implantation with ZSI 475. A retrospective review of clinical data was performed. Patients' quality of life after implantation was investigated with Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire.

Results

The median age of patients was 57 years and the average follow-up time was 22 months. Twelve patients received a standard implantation due to severe erectile dysfunction (ED); three patients also presented penile curvature and additional corporoplasty with grafting was necessary. Three procedures had to be interrupted due to defects of the insertion tools. In one case a manufacturing defect resulted in a pump leak. In one case, a severe postoperative complication occurred, which requested explanation of the device. During the follow-up, four patients experienced mechanical failure of the prosthesis. Results of QoLSPP questionnaire at 12 months were skewed toward the positive end of the scale in all domains.

Conclusion

In our initial experience, ZSI 475 suffered a high rate of mechanical failures; on the other hand, the company showed great commitment in order to improve the quality and reliability of the device. The lower cost of ZSI 475 may add to the chances of the product to become a cost-effective alternative to treat those patient who need a IPP.

Post malleable Penile Prosthesis Satisfaction in elderly patients: Serial assessments

Post penile implant sexual satisfaction in elderly patients is a multifactorial issue. In the present study, we investigated the possible implication of age on satisfaction after malleable penile implant surgery in elderly patients. We compared post-operative sexual satisfaction in the elderly with that of a younger age group (reference group). Patients were classified into three groups according to their ages (group I <45, group II between 45 and 65, and group III older than 65 years old). Modified Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire was used at 3, 6 and 12 months after implant surgery. EDITS scores showed statistically significant high satisfaction rates in all age groups. EDITS scores were higher in the early post-operative period in younger groups compared to elderly patients. However, the difference between groups was insignificant at 12 months post-operatively (p value = .06). Our results show that elderly patients have a high post-operative satisfaction rate close to that of younger age groups, and they are suitable candidates for penile implant surgery with good and realistic post-operative sexual satisfaction expectations.

Long-Term Follow-Up After Penile Prosthesis Implantation-Survival and Quality of Life Outcomes

INTRODUCTION

Hydraulic penile prostheses have shown an overall good mechanical reliability up to 10 years after surgery; however, few data have been published on very long-term follow-up.

AIM

We looked at long-term (≥15 years) complications, including functional and quality of life (QoL) outcomes, after 3-piece inflatable penile prosthesis (IPP) implantation in patients with erectile dysfunction (ED).

METHODS

Data regarding 149 patients submitting to IPP placement before 2001 were analyzed. All patients were implanted with AMS CX and Ultrex Plus 3-piece prostheses.

MAIN OUTCOME MEASURE

Patients were reassessed to evaluate rates of complications and functional outcomes. The validated questionnaire Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) was used to assess patient QoL. Kaplan-Meier analysis estimated the probability of prosthesis survival (defined as working device/not-explanted).

RESULTS

Median follow-up of 51 patients was 206 months (interquartile range [IQR], 145-257). The etiology of ED was vasculogenic (n = 20; 39%), Peyronie's disease (n = 15; 29%), pelvic surgery (n = 4; 7.8%), organic other than vasculogenic (n = 3; 5.9%), or other (n = 9; 18%). Throughout the follow-up, 24 patients (49%) experienced complications: mechanical failure (n = 19; 79%), pain (n = 3; 12%), orgasmic dysfunctions (n = 1; 4.5%), or device infection (n = 1; 4.5%). The estimated IPP survival was 53% (95% CI, 36-67) at 20-year follow-up. Baseline characteristics (age, Charlson comorbidity index, body mass index, and erectile dysfunction etiology) were not significantly associated with the risk of IPP failure over time by Cox regression analysis. At 20-year follow-up, 41% (95% CI, 19-49) of the patients were still using the device. Among them, QoLSPP median domain scores were high: functional 22/25 (IQR, 20-23), relational 17/20 (IQR, 15-18), personal 14/15 (IQR, 12-15), and social 14/15 (IQR, 11-15).

CLINICAL IMPLICATIONS

The longevity of the device and long-term satisfaction rates should be comprehensively discussed during patient consultation for IPP surgery.

STRENGTHS & LIMITATIONS

To our knowledge, this is the first study reporting long-term QoL outcomes using a dedicated questionnaire for penile prostheses. The low response rate for the telephone interviews, the retrospective design of the study, and the relatively small number of patients are the main limitations.

CONCLUSION

Long-term follow-up data after IPP placement showed that almost half of the devices still worked properly 20 years after the original penile implant, as 60% of patients were still using the device with high satisfaction and adequate QoL outcomes. Both patients and physicians should be aware of the expected life and outcomes of IPP implants. Chierigo F, Capogrosso P, Dehò, et al. Long-Term Follow-Up After Penile Prosthesis Implantation-Survival and Quality of Life Outcomes. J Sex Med 2019;16:1827-1833.

Damage Control Considerations During IPP Surgery

PURPOSE OF REVIEW

This review summarizes the latest reports in inflatable penile prosthesis (IPP) complication management.

RECENT FINDINGS

IPP complications are rare, and reports are limited to retrospective studies. However, recent multi-institutional studies and use of national databases have provided further insight into risk factors for complications. Guidance on complication management is largely limited to techniques recommended by experts within the field. American Urological Association guidelines place IPP implantation as a first line erectile dysfunction treatment. However, the majority of cases are performed by low-volume (≤ 4 cases/year) surgeons. Herein, we summarize the IPP literature and our personal experience to provide guidance on managing IPP complications.

An update on the best approaches to prevent complications in penile prosthesis recipients

Placement of inflatable penile prosthesis is a procedure frequently performed for medication-refractory erectile dysfunction. Device implantation is not without risks, and as the frequency of device implantation increases, so do associated complications. The aim of this work is to review the most frequent operative complications associated with implantation of inflatable penile prostheses, and to review the best approaches to prevent these most common complications. Complications can broadly be categorized as infectious, noninfectious tissue-related, device-related, or related to patient and partner satisfaction. With understanding of these complications and ways to avoid them, as well as with appropriate patient selection and counseling, the inflatable penile prosthesis is an excellent option for the treatment of erectile dysfunction.