ORIGINAL RESEARCH—SURGERY: Upsizing of Inflatable Penile Implant Cylinders in Patients with Corporal Fibrosis

Long-term experience with AMS-700 CXR inflatable penile prosthesis in high-risk patients with corporal fibrosis

Despite the widespread use of narrow diameter inflatable penile prosthesis (IPP) cylinders in patients with corporal fibrosis, outcomes data is sparse. We evaluated patients who underwent IPP placement with AMS™ 700 Controlled Expansion Restricted (CXR) cylinders from 2007-2021. Patient characteristics, device details, and surgical outcomes were assessed. A non-validated questionnaire was also distributed to patients to assess satisfaction. Among 982 IPPs placed over the study period at our institution, 49 (5.0%) used CXR cylinders. Indications for narrow cylinders: prior explant for infection (67.3%), ischemic priapism (16.3%), and idiopathic fibrosis (16.3%). Median corporal length was 19 cm (IQR 17-21 cm). Discordant intraoperative corporal measurements (24.5%) and RTE lengths (26.5%) were common. Post-operative complications occurred in 8 patients (16.3%) and included 3 infections (6.1%), 2 cylinder herniations (4.1%), 2 mechanical failures (4.1%), and one case of glans necrosis (2.0%). Five of these (10.2%) required explantation, while 4 (8.2%) were managed with revision. Over the follow-up period, 73.5% of patients reported satisfaction with rigidity. Primary drivers of dissatisfaction were perceived loss of penile length and girth. The AMS™ 700 CXR is a useful tool for challenging corporal fibrosis cases and shows acceptable surgical outcomes with moderate patient acceptability.

Penoscrotal inflatable penile prosthesis recipients often fully recover from pain at two weeks following placement

The symptoms and duration of pain following inflatable penile prosthesis (IPP) surgery remains poorly understood. We characterize postoperative pain following penoscrotal 3-piece inflatable penile prosthesis placement in patients managed with a standardized pain management protocol. This is a single-center prospective analysis of 96 virginal penoscrotal 3-piece IPP recipients (9/2019 to 9/2021) excluding patients with chronic pain, IPPs performed with alternative approaches or concomitantly with other surgeries and those with infections. Standardized pain questionnaire was performed by phone on post-operative day (POD) 2, 7, 14, and 30. The primary outcome was self-reported pain scores, measured by pain score 0-10 (0 = no pain, 10 = unbearable, "worst pain you have ever felt") at various locations (incision, penile, scrotal, abdominal) over the first 30 days postoperatively. A majority of pain reported was outside the scrotal area with 67.6% of complaints in the shaft, glans, abdomen and incision. From POD2 to POD30, there was a significant decrease in severe pain from 46.2 to 11.1% (p = 0.05) with an increase in mild pain from 23.1 to 62.4% (p = 0.05). Roughly half of the participants (47.9%, n = 46) reported no pain by POD14. Penoscrotal IPP recipients often fully recover from pain at the two-week period following surgery and those with lingering discomfort predominantly complain of penile shaft and glans pain.

Surgical tips in difficult penile prosthetic surgery: a narrative review

Penile prosthesis implantation continues to represent a reliable solution to address erectile dysfunction when oral medications fail, are not tolerated or are contraindicated, and most typically is associated with excellent satisfaction rates and durable results. Despite the dramatic improvements in the prostheses' design, in the surgical instruments and techniques over the years, certain categories of patients still pose a significant surgical challenge. The aim of the current review is to provide a quick and useful practical guidance based on our expertise in the identification and management of the difficult penile prosthesis implantation cases. A narrative review design was here preferred to fulfil our purpose. The search strategy included a range of terms, e.g. penile prosthesis, corporal fibrosis, infection, ischaemic priapism, Peyronie's disease, radical prostatectomy, pelvic surgery. Extensive corporal fibrosis after explantation of an infected device or after prolonged ischaemic priapism may represent the most difficult situations to deal with in penile prosthesis implantation surgery. Penile prosthesis implantation in patients with Peyronie's disease and in those who previously underwent radical prostatectomy also presents with an increased risk of complications. Experienced surgeons need to be able to recognise promptly and manage urethral perforation, cylinder crossover, tunical perforation and erosion, as these complications are more common when dealing with difficult penile prosthesis implantation cases. Applying penile lengthening techniques and principles can be useful in selected cases to ensure better postoperative satisfaction rates, especially in those patients who have experienced a more significant degree of loss of length preoperatively. High-volume-implanting surgeons should always be involved in complex cases to minimise the risk of complications. A thorough preoperative counselling can set realistic patients' expectations in this context, further contributing to postoperative satisfaction.

Lightweight macroporous mesh can be used for corporal reconstruction during penile prosthesis surgery

BACKGROUND

Options to reinforce or reconstruct the corpora cavernosa during penile prosthesis surgery are limited. Synthetic grafts may confer a higher infection risk. Lightweight macroporous mesh is a promising alternative due to better integration and tissue ingrowth.

AIM

The study sought to report the first experience of using lightweight mesh to reinforce or reconstruct the corpora.

METHODS

The medical records of all patients undergoing insertion or revision of penile prosthesis between May 2016 and May 2021 were reviewed retrospectively. Patient characteristics, management, and outcomes were extracted in which mesh was used for corporal reconstruction. Poliglecaprone-25/polypropylene mesh (UltraPro) was used in all cases. The surgical technique and alternatives were summarized.

OUTCOMES

The outcomes were infection rate, postoperative complications by Clavien-Dindo classification, and patient-reported outcomes.

RESULTS

Mesh was required during penile prosthesis surgery in 21 men (median age 56 [range, 18-74] years). Reasons for reconstruction were severe corporal fibrosis (n = 6), impending erosion (n = 6), crossover/perforation (n = 6), congenital corporal agenesis (n = 2), and excision of Peyronie's plaque. All but 2 patients (with corporal agenesis) presented for revision penile prosthesis surgery with a median number of previous revision attempts of 2 (range, 1-5). Two (10%) patients required explant after a mean follow-up of 23 ± 8.7 months. One man developed infection of the device 2 years after surgery, translating to an infection rate of 5% despite a high prevalence of diabetes (25%) in this cohort. Another required explantation due to debilitating chronic pain after 3 months. Further revision surgery for stiction syndrome was required in a third patient. Finally, another man was not satisfied with the position of the pump within the scrotum or the axial rigidity of the device, despite a second opinion suggesting no issues with the device. All men were sexually active following surgery.

CLINICAL IMPLICATIONS

A lightweight mesh can be considered to reinforce or reconstruct the corpora cavernosa in complex cases in which there are no alternative techniques available.

STRENGTHS AND LIMITATIONS

This is the first study using a lightweight macroporous mesh for revision penile prosthesis surgery. This was a well-characterized cohort of patients. A larger cohort with 5-year follow-up would be preferable.

CONCLUSION

These early results suggest that a lightweight macroporous mesh may be an acceptable synthetic graft for corporal reconstruction. Poliglecaprone-25/polypropylene mesh may be ideal because it is partially absorbable, easy to handle, and not bulky.

Delayed placement of an inflatable penile prosthesis is associated with a high complication rate in men with a history of ischemic priapism

BACKGROUND

Corporal fibrosis is known to result from prolonged priapism; however, the impact of the timing of penile prosthesis placement after priapism on complication rates is poorly understood.

AIM

We sought to evaluate the impact of timing of inflatable penile prosthesis (IPP) placement on complications in men with a history of ischemic priapism.

METHODS

We performed a multicenter, retrospective cohort study of patients with a history of priapism undergoing IPP placement by 10 experienced implantation surgeons. We defined early placement as ≤6 months from priapism to IPP. We identified a 1:1 propensity-matched group of men without a history of priapism and compared complication rates between men who had early placement, late placement, and no history of priapism.

OUTCOMES

Our primary outcome was postoperative noninfectious complications, and secondary outcomes included intraoperative complications and postoperative infection.

RESULTS

A total of 124 men were included in the study with a mean age of 50.3 ± 12.7 years. A total of 62 had a history of priapism and 62 were matched control subjects. The median duration of priapism was 37 (range, 3-168) hours and the median time from ischemic priapism to IPP placement was 15 months (range, 3 days to 23 years). Fifteen (24%) men underwent early (≤6 months) IPP placement at a median time of 2 months (range, 3 days to 6 months) following the ischemic priapism event. The remaining 47 (76%) underwent placement >6 months following priapism at a median time of 31.5 months (range, 7 months to 23 years). The complication rate in the delayed placement group was 40.5% compared with 0% in the early placement group and control group. Cylinder-related complications such as migration or leak accounted for 8 (57%) of 14 of the postoperative noninfectious complications. Full-sized cylinders were used in all patients who had a cylinder related complication.

CLINICAL IMPLICATIONS

Priapism patients should be referred to prosthetic experts early to decrease complication rates in those needing an IPP.

STRENGTHS AND LIMITATIONS

This is a multicenter study from experienced prosthetic urologists but is limited by the retrospective nature and small number of patients in the early placement group.

CONCLUSION

IPP complication rates are high in men with a history of ischemic priapism, especially when implantation is delayed beyond 6 months.

Early versus delayed penile prosthesis insertion for refractory ischemic priapism

Objectives

Penile prosthesis insertion is a well-established therapeutic option in refractory ischemic priapism but there is a lack of standardization regarding the timing of surgery, the type of prosthesis (malleable or inflatable), as well as the possible complications. In this study, we retrospectively compared early versus delayed penile prosthesis insertion in patients with refractory ischemic priapism.

Methods

42 male patients who presented with refractory ischemic priapism during the period between January 2019 and January 2022 were included in this study. All patients had malleable penile prosthesis insertion by four highly experienced consultants. Patients were divided into two groups based on the time of the prosthesis insertion. 23 patients had immediate insertion of the prosthesis within the first week of the onset of priapism while the remaining 19 patients had delayed prosthesis insertion three months or later after the onset of priapism. The outcome as well as the intra- and the postoperative complications were recorded.

Results

Postoperative complications such as prosthesis erosion and infection were higher among the early insertion group while the delayed insertion group had higher incidence of intraoperative complications such as corporal perforation and urethral injury. The insertion of the prosthesis was much more difficult among the delayed insertion group due to fibrosis which made dilatation of the corpora very difficult. The length and the width of the penile implant were significantly higher among the early insertion group as compared to the delayed insertion group.

Conclusions

Early penile prosthesis insertion for refractory ischemic priapism is a safe and effective treatment option as delayed prosthesis insertion is more difficult and challenging due to corporal fibrosis and is associated with higher complication.

The International Penile Prosthesis Implant Consensus Forum: clinical recommendations and surgical principles on the inflatable 3-piece penile prosthesis implant

Despite significant scientific advances in the modern three-piece inflatable penile prosthesis implant surgery, it is not without surgical risks and can carry additional cosmetic and psychosocial consequences in poorly selected and consented individuals. To address this problem, an international group of key opinion leaders and high-volume prosthetic surgeons reviewed the current guidelines and clinical evidence, discussed their experiences, and formed a consensus regarding inflatable penile prosthesis surgery. The findings of this consensus panel were presented at the 17th biennial Asia Pacific Society of Sexual Medicine scientific meeting. The experts concluded that proper patient selection, informed consent and strict adherence to safe surgical principles are important to optimize clinical outcomes. Furthermore, most intraoperative complications, if recognized, can be addressed intraoperatively to enable placement of the device at the time of initial surgery. Men with significant corporal fibrosis due to Peyronie's disease, prior prosthesis explantation and priapism, and men who have undergone construction of a neophallus, as well as men who receive concurrent continence surgery, are complex cases requiring additional care and advanced techniques to obtain optimal surgical outcomes. Variability in patient care - in terms of postoperative antibiotic use, pain management, scrotal care, and cycling of the penile prosthesis implant - must be reduced to enable optimization and assessment of outcomes across patient groups.

Small Diameter Penile Implants: A Survey on Current Utilization and Review of Literature

Background

Inflatable penile prostheses (IPPs) with smaller diameter cylinders have been in use for over 30 years, yet the literature is sparse on their utilization patterns amongst prosthetic surgeons.

Aim

To understand current usage of small diameter penile implants (SDPI) among prosthetic surgeons.

Methods

IRB approval was obtained to conduct a survey of prosthetic surgeons. A 23-question online survey was distributed via email to physician members of the Sexual Medicine Society of North America (SMSNA) and Society of Urologic Prosthesis Surgeons (SUPS). The survey included questions regarding surgeon experience and volume, frequency of SDPI utilization, indications for SDPI, surgical strategy in the setting of SDPI (approach, use of concordant modeling/grafting), reservoir and pump management, and perceived infection risk and patient satisfaction.

Main Outcome Measure

SDPI were utilized by the vast majority of respondents in certain clinical situations such as corporal fibrosis or anatomically small corpora, and surgeons have had a favorable experience with these as a final destination implant or as a place-holder until reimplantation with a normal diameter device.

Results

Fifty individuals responded to the survey, 48 of whom routinely utilized SDPI. The most common indication for SDPI placement was corporal fibrosis from prior infection, followed by anatomically small corpora and priapism. The most common maximal dilation diameter was 10 mm (47%), an additional 23% of respondents utilized SDPI with 11 mm dilation. 75.4% of respondents sometimes or always intended to upsize to standard diameter cylinders in the future. 68.8% of surgeons routinely counseled patients on the possibility of reduced grith and rigidity with SDPI. Patient satisfaction was perceived to be comparable to standard diameter cylinders in 56.3% of respondents, while the remaining 43.6% believed it to be lower than traditional cylinders. Utilization of SDPI can be an important tool for prosthetic surgeons faced with difficult cases due to corporal fibrosis or small corpora. This survey provides new insight into patterns of SDPI utilization by surgeons. A limitation of the study is that patient satisfaction is indirectly addressed through surgeons’ perception and experience, further research will be necessary to include patient questionnaires regarding device satisfaction.

Conclusion

SDPI are necessary in certain scenarios that preclude the use of normal diameter cylinders. These implants may offer satisfactory erections, but can also be upsized to standard diameter cylinders in the future.

Campbell SP, Kim CJ, Allkanjari A et al. Small Diameter Penile Implants: A Survey on Current Utilization and Review of Literature. Sex Med 2022;10:100458.

Modern treatment strategies for penile prosthetics in Peyronie's disease: a contemporary clinical review

Peyronie's disease is a common condition resulting in penile deformity, psychological bother, and sexual dysfunction. Erectile dysfunction is one common comorbid condition seen in men with Peyronie's disease, and its presence significantly impacts treatment considerations. In a man with Peyronie's disease and significant erectile dysfunction who desires the most reliable treatment, penile prosthesis placement should be strongly considered. In some instances, such as those patients with relatively mild curvature, prosthesis placement alone may result in adequate straightening. However, many patients will require additional straightening maneuvers such as manual modeling, penile plication, and tunica albuginea incision with or without grafting. For patients with severe penile shortening, penile length restoration techniques may also be considered. Herein, we provide a comprehensive clinical review of penile prosthesis placement in men with Peyronie's disease. Specifically, we discuss preoperative indications, intraoperative considerations, adjunctive straightening maneuvers, and postoperative outcomes.

Penile prosthesis implant in the special populations: diabetics, neurogenic conditions, fibrotic cases, concurrent urinary continence surgery, and salvage implants

Penile prosthesis implant (PPI) remains an effective and safe treatment option for men with erectile dysfunction (ED). However, PPI surgery can be associated with a higher risk of complications in certain populations. This article provides a critical review of relevant publications pertaining to PPI in men with diabetes, significant corporal fibrosis, spinal cord injury, concurrent continence surgery, and complex salvage cases. The discussion of each category of special populations includes a brief review of the surgical challenges and a practical action-based set of recommendations. While specific patient populations posed considerable challenges in PPI surgery, strict pre- and postoperative management coupled with safe surgical practice is a prerequisite to achieving excellent clinical outcomes and high patient satisfaction rate.

Multicenter surgical outcomes of penile prosthesis placement in patients with corporal fibrosis and review of the literature

Penile prosthesis (PP) insertion in the setting of corporal fibrosis can be challenging and a variety of techniques have been described to accomplish this, however the necessity of these maneuvers is debatable. Our objective was to investigate techniques and outcomes of PP placement in patients with corporal fibrosis at tertiary referral centers. Multicenter outcomes of 42 patients (mean age 53.4 ± 1.9 years) with corporal fibrosis who underwent placement of PP over a 10-year period were reviewed. The most common etiology of corporal fibrosis was prior PP explant due to either infection (40.5%) and/or erosion (16.7%). Fourteen patients (33.3%) had a history of priapism, 5 (11.9%) of which had one or more distal surgical penile shunts. Techniques used for PP placement included: sequential dilation (8-12 mm) with standard dilators in 15 (35.7%), dilation with cavernotomes in 25 (59.5%) and limited sharp corporal excision and dilation with cavernotomes in 1 (2.4%). Narrow cylinders were employed in ten patients (23.8%). Major complications occurred in one patient (2.4%) who underwent explant for infection and distal erosion. Most patients with corporal fibrosis can undergo successful placement of a PP using standard dilators or cavernotomes. Sharp corporal excision and other measures are rarely required.

Home modeling after penile prosthesis implantation in the management of residual curvature in Peyronie's disease

The aim of this study was to study the clinical effectiveness of a structured home modeling (HM) protocol in Peyronie's disease (PD) patients who have residual curvature up to 45° after inflatable penile prosthesis (PP) placement. A total of 92 patients with PD and coexistent refractory erectile dysfunction received inflatable PP. If residual curvature after manual modeling (MM) was more than 45°, incision-grafting was performed. If curvature was <45° after MM, patients were instructed to perform HM daily for 6 months, after 4 weeks from PP implantation. The mean preoperative penile curvature was 39.4 ± 5.7° (30-60). Sixteen (17.4%) patients required incision-grafting and the remaining 76(82.6%) patients followed HM protocol. The mean postoperative residual curvature after MM was 29.7 ± 3.2° (5-50). Sixty-five (85.5%) patients who underwent HM had 10° or less residual curvature after 3 months and 72 (94.7%) patients had 10° or less residual curvature after 6 months. Seventy (92.1%) patients responded as satisfied or very satisfied on the questionnaire with the outcome after 6 months. HM of the penis over Inflatable PP may straighten the penis without the need for an additional surgical maneuver in vast majority of the PD patients having residual curvature of <45°.

Surgical implant options in patients with penile fibrosis due to infection or previous explants

Penile fibrosis due to previous penile infection and/or prosthesis explants entails situations of high surgical complexity. In these cases, reimplantation should follow an alternative scheme, aimed at minimizing perioperative and postoperative complications, as well as achieving maximum efficiency of the procedure and greater postoperative satisfaction of the patient and his partner. This article reviews the main surgical alternatives for these cases.

Cylinder insertion into scarred corporal bodies: prosthetic urology's most difficult challenge: some suggestions for making the surgery easier

Corporal fibrosis is a process that involves excessive deposition of scar tissue in response to infection, trauma, or ischemia. It does not occur merely as a result of previous IPP surgery. Excessive development of corporal fibrosis is certain after extraneous and disastrous events such as priapism or the removal of a device for infection. The usual surgical planes and spaces are obliterated by proliferation of scar both in the tissues overlying the corpora and the space within the corpora previously occupied by erectile tissue. To maximize success, specialized instruments, downsized cylinders, and lots of experience are necessities. Prosthetic urology produces, for the most part, happy patients. Fibrosis guys, to a man are not happy. Let the expert have the unhappy patient!

Current practice in the management of ischemic priapism: an anonymous survey of ISSM members

Penile shunting is the standard of care in management of ischemic priapism refractory (IPR) to non-surgical interventions. Due to high rates of impotence, corporal fibrosis, and loss of penile length, recent literature suggests these patients benefit from immediate penile prosthesis (PP) placement. An IRB-exempt anonymous electronic survey of the 2168 members of the International Society for Sexual Medicine (ISSM) was conducted. The survey included demographic information, confidence, and experience-related management of IPR. The aim was to evaluate current practice patterns in management of IPR and to investigate the role of immediate PP implantation in the management of prolonged (>36 h) IPR. The survey response rate was 11.6% (n = 251). Most respondents were urologists (173), from the USA (49.1%), and had completed a fellowship in male sexual medicine, men's health, reconstruction, or andrology (71.1%). The majority (91.3%) see at least one case of prolonged priapism (>36 h) that requires surgical management yearly. When looking at volume in training and after, our respondents had a significantly higher experience with penile prostheses (over 70%, > = 10) as compared with shunts (less than 40%, > = 10). Overall, 70.9% of respondents felt more comfortable with a malleable PP than a shunt. However, penile shunts are still preferred as the first line of surgical management by ~80% of respondents as compared with 12.7% who instead prefer a PP. We also found that under 40% of respondents currently use penile MRI or corporal biopsies in their management of prolonged assessment. This is the first study to assess current clinical practices in management of IPR globally. As in any anonymous self-reported survey-based research, recall and sampling bias are an inherent limitation. Penile shunting for IPR continues to be the preferred treatment despite emerging data. Respondents performed PP surgery routinely and feel more confident placing PP than performing penile shunting procedures.

Additional procedures performed at time of penile prosthesis implantation: a review of current literature

Penile prosthesis implantation for treatment of medical refractory erectile dysfunction remains the gold standard. However, some men have additional pathology present such as Peyronie's Disease, penile shortening, penoscrotal webbing, buried penis or other penoscrotal anatomical abnormalities that may be addressed at the time of prosthesis implantation. Although several techniques are described, there remains a lack of data regarding the outcomes. We sought to identify the results of available literature regarding the additional procedures performed at the time of penile prosthesis implantation that provide defined surgical outcomes rather than merely describe surgical techniques. Surgical outcomes to procedures provide more realistic clinical outcome for readers than simply the description of novel techniques or expert opinions. We performed a review of the MEDLINE database to identify additional procedures performed in conjunction with penile prosthesis placement. Many procedures are described in review articles, however, with limited data regarding their outcomes. The included articles must describe additional procedures performed in conjunction with penile prosthesis placement. Perioperative office techniques and management were included if it changed the surgical technique. All abstracts obtained through search criteria were reviewed. Only articles written in English, on human subjects with documented surgical results and relevant articles were included in this study. After a thorough literature search, a total of 24 articles were identified. Penile lengthening procedures at the time of penile prosthesis comprise most of the literature on this subject. Lengthening procedures are as simple as Peyronie's plaque excision and grafting to complex sliding and lengthening procedures requiring complete neurovascular bundle and partial urethral mobilization. Additionally, aggressive cylinder sizing and prolonged postoperative cycling at home are also described. Glanulopexy may be necessary when malpositioning of the glans is present. Other options such as scrotoplasty are also available options for those patients with scrotal webs. Notably there is a paucity of published literature regarding girth enhancement, buried penis repair, hernia repair, and vasectomy at time of penile prosthesis placement. There are numerous procedures that can be performed in the same operative setting as penile prosthesis. Although the procedures do have a common goal to provide optimal postoperative natural appearance, length, straightness, girth and function, the techniques employed must be tailored to each patient as there is not a one-procedure fits all in this patient population.

The Impact of Immediate Salvage Surgery on Corporeal Length Preservation in Patients Presenting with Penile Implant Infections

PURPOSE

Removal of an infected penile implant often results in corporeal fibrosis, irreversible penile shortening and dissatisfaction with future implant surgery. Salvage surgery may avoid these problems but to our knowledge no study to date has evaluated these specific end points. We evaluated patients who presented to our center with an infected implant to determine the impact of salvage surgery on penile length.

MATERIALS AND METHODS

We evaluated consecutive patients undergoing removal of an infected penile prosthesis with immediate salvage or delayed reimplantation using a comprehensive, prospective database. Total corporeal length prior to and following immediate salvage or delayed reimplantation were compared. The impact of patient age, comorbidities, bacterial species, initial penile length and time to reimplantation on subsequent total corporeal length was evaluated.

RESULTS

The cohort consisted of 40 patients. Overall 81% of salvaged cases were successful, resulting in a mean 0.6 cm (95% CI 0.20 to 1.1) reduction in total corporeal length. Delayed reimplantation resulted in a mean 3.7 cm (95% CI 2.9-4.5) total corporeal length loss. In patients who underwent delayed reimplantation the total corporeal length reduction was directly proportionate to the initial penis size of the patient. No statistically significant impact on penile length was attributable to patient age, diabetes, bacterial species or time to reimplantation.

CONCLUSIONS

When possible, salvage surgery should be offered to patients with an infected penile implant. Our data confirmed that successful salvage surgery preserves penile length. When a device is explanted and replaced at a later date, patients can expect to lose 15% to 30% of penile length irrespective of age, diabetes, type of infecting organism and time to reimplantation.

Role of Penile Prosthesis in Priapism: A Review

Ischemic priapism is a urological emergency that has been associated with long-standing and irreversible adverse effects on erectile function. Studies have demonstrated a linear relationship between the duration of critically ischemic episodes and the subsequent development of corporal fibrosis and irreversible erectile function loss. Placement of a penile prosthesis is a well-established therapeutic option for the management of erectile dysfunction secondary to ischemic priapism, and will be the focus of this review. Review of the current literature demonstrates a growing utilization of penile prostheses in the treatment of erectile dysfunction secondary to ischemic priapism. Unfortunately, there is a paucity of randomized-controlled trials describing the use of prosthesis in ischemic priapism. As a result, there is a lack of consensus regarding the type of prosthesis (malleable vs. inflatable), timing of surgery (acute vs. delayed), and anticipated complications for each approach. Both types of prostheses yielded comparable complication rates, but the inflatable penile prosthesis have higher satisfaction rates. Acute treatment of priapism was associated with increased risk of prosthetic infection, and could potentially cause psychological trauma, whereas delayed implantation was associated with greater corporal fibrosis, loss of penile length, and increased technical difficulty of implantation. The paucity of high-level evidence fuels the ongoing discussion of optimal use and timing of penile prosthesis implantation. Current guidance is based on consensus expert opinion derived from small, retrospective studies. Until more robust data is available, a patient-centered approach and joint decision-making between the patient and his urologist is recommended.

Inflatable penile prosthesis implant length with baseline characteristic correlations: preliminary analysis of the PROPPER study

Background

“Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration” (PROPPER) is a large, multi-institutional, prospective clinical study to collect, analyze, and report real-world outcomes for men implanted with penile prosthetic devices. We prospectively correlated co-morbid conditions and demographic data with implanted penile prosthesis size to enable clinicians to better predict implanted penis size following penile implantation. We present many new data points for the first time in the literature and postulate that radical prostatectomy (RP) is negatively correlated with penile corporal length.

Methods

Patient demographics, medical history, baseline characteristics and surgical details were compiled prospectively. Pearson correlation coefficient was generated for the correlation between demographic, etiology of ED, duration of ED, co-morbid conditions, pre-operative penile length (flaccid and stretched) and length of implanted penile prosthesis. Multivariate analysis was performed to define predictors of implanted prosthesis length.

Results

From June 2011 to June 2017, 1,135 men underwent primary implantation of penile prosthesis at a total of 11 study sites. Malleable (Spectra), 2-piece Ambicor, and 3-piece AMS 700 CX/LGX were included in the analysis. The most common patient comorbidities were CV disease (26.1%), DM (11.1%), and PD (12.4%). Primary etiology of ED: RP (27.4%), DM (20.3%), CVD (18.0%), PD (10.3%), and Priapism (1.4%), others (22.6%). Mean duration of ED is 6.2¡À4.1 years. Implant length was weakly negatively correlated with White/Caucasian (r=−0.18; P<0.01), history of RP (r=−0.13; P<0.01), PD as comorbidity (r=−0.16; P<0.01), venous leak (r=−0.08; P<0.01), and presence of stress incontinence (r=−0.13; P<0.01). Analyses showed weak positive correlations with Black/AA (r=0.32; P<0.01), CV disease as primary ED etiology (r=0.08; P<0.01) and pre-operative stretched penile length (r=0.18; P<0.01). There is a moderate correlation with pre-operative flaccid penile length (r=0.30; P<0.01).

Conclusions

Implanted penile prosthesis length is negatively correlated with some ethnic groups, prostatectomy, and incontinence. Positive correlates include CV disease, preoperative stretched penile length, and flaccid penile length.

The management of the acute ischemic priapism: A state of the art review

OBJECTIVE

To review the current literature on early penile prosthesis implantation in patients with refractory ischemic priapism (IP).

ACQUISITION OF EVIDENCE

A systematic search for the terms "penile prosthesis", "priapism", "impotence", "fibrosis", "downsized prosthesis cylinders", and "patient satisfaction" has been carried out in PubMed, EMBASE, Cochrane, SCOPUS and Science Citation Index databases.

SYNTHESIS OF EVIDENCE

Cavernosal tissue damage in IP is time related. Conservative measures and aspiration with or without intracorporeal instillation of α-adrenergic agonists are usually successful in the early stages. Shunt surgery in patients remains debatable, as the lack of response to aspiration and instillation of α-adrenergic agonists indicates that irreversible changes in the cavernosal smooth muscle are likely to have already occurred. Immediate penile prosthesis implantation in patients with refractory IP settles the priapic episode, maintains the long term rigidity necessary to engage in penetrative sexual intercourse and prevents the otherwise inevitable penile shortening. Although complication rates after penile prosthesis implantation in acute priapism are higher than in virgin cases, they are still lower than after implantation in patients with severe corporal fibrosis due to chronic priapism. Regardless of the complication rates, penile prosthesis implantation in refractory IP should be preferred as it allows the preservation of penile length, which is one of the main factors influencing postoperative patient's satisfaction following surgery.

Inflatable penile prosthesis as tissue expander: what is the evidence?

OBJECTIVE

Many patients who undergo inflatable penile prosthesis (IPP) replacement are often upsized to larger cylinders, suggesting the IPP may serve as a tissue expander and increase internal penile length. The objective of this study is to evaluate whether cylinder length increases with subsequent IPP insertion.

MATERIALS AND METHODS

We queried American Medical Systems and Coloplast Patient Information Form databases to identify patients who underwent IPP placement and replacement between 2004-2013. Patients were grouped by device type and time to replacement (<2 or ≥2 years). We selected the 2-year mark for subgroup analysis to allow time for tissue expansion to occur and to exclude patients who underwent early explantation (e.g. erosion or infection).

RESULTS

Two thousand, seven hundred and forty nine patients (1,532 AMS 700 LGX, 717 AMS 700 CX, and 500 Coloplast Titan) met the inclusion criteria. Mean time between implants was earlier for LGX (29 months) than CX (39 months) and Titan (48 months) patients (p<0.001). Patients who underwent device replacement at <2 years did not experience an increase in mean cylinder length. On the contrary, patients who underwent device replacement at ≥2 years did experience significant increases in mean cylinder length (LGX 1.2 cm, CX 1.1 cm, and Titan 0.9 cm, p<0.001). The mean increases in length at ≥2 years were similar between the 3 devices (p=0.20). Sixty percent of patients demonstrated increases of >0.5 cm and 40% demonstrated increases of ≥1 cm.

CONCLUSIONS

As demonstrated, the IPP may provide tissue expansion over time. Further evaluation is needed to determine if increased cylinder length correlates to increased functional length and patient satisfaction.

The use of penile prostheses in the management of priapism

Priapism is a relatively uncommon condition that can result in erectile dysfunction (ED) and corporal fibrosis. Cases of prolonged priapism are particularly prone to ED, which arises when priapism is treatment refractory or had a delayed presentation. Due to the emergent nature of priapism, it behooves urologists to be familiar with all potential treatment modalities to minimize adverse outcomes. In this review paper, we aim to summarize the literature regarding the use of penile prosthesis (PP) implantation in the setting of ischemic priapism (IP). In some patients who present later or have prolonged initial treatment, early insertion of PP may be indicated.

Three-piece Penile Prosthesis Implantation in Refractory Ischemic Priapism-Tips and Tricks

INTRODUCTION AND OBJECTIVES

Implantation of a penile prosthesis in a patient with significant corporal fibrosis can pose a significant challenge to the surgeon, necessitating the knowledge of specific techniques used to dilate and close aggressively scarred corpora. The objective of our instructional video is to discuss 2 techniques used to approach corporal fibrosis: proper and safe use of cavernotomes for dilation and use of narrower prostheses.

METHODS

In this video, we present a 53-year-old man with a history of priapism 3 years ago that lasted 4 days in the setting of trazodone use. He was managed with corporal irrigation and subsequently developed severe erectile dysfunction. Notably, the patient had a history of sickle cell anemia, and on physical examination was noted to have densely fibrotic corpora. After extensive counseling regarding options, he chose a penile implant. The surgical was planned using the "no touch technique." After the corporotomies were made, we began dilating the corpora. Hegar dilators and Dilamezinsert were attempted at first but met significant resistance. We switched to cutting cavernotomes and were able to dilate up to 11-Fr distally and up to 13-Fr proximally. The proper use of cavernotomes is highlighted in our video, with care being taken to aim the cutting edge of the cavernotome laterally away from the urethra. We also used the narrowest inflatable prosthesis available to us (Coloplast Titan narrow-base) and describe the narrower devices available in inflatable and malleable forms as an option for less-than-ideally dilated corpora. The pump and reservoir placement was completed uneventfully.

RESULTS

The patient was admitted overnight for observation and check of a complete blood count given his history of sickle cell anemia. He was able to be discharged after 23 hours of observation. The patient presented to the clinic 4 weeks later for pump activation. He was able to achieve good rigidity and had a penile length adequate for penetration after maximal activation.

CONCLUSION

This video discusses the approach to penile prosthesis placement in patients with significant corporal fibrosis. It highlights the proper use of cutting cavernotomes and the availability of narrow-diameter prostheses, both malleable and inflatable.

Management of refractory ischemic priapism: current perspectives

OBJECTIVES

The aim of the present manuscript is to review the current literature on priapism, focusing on the state-of-the-art knowledge of both the diagnosis and the treatment of the refractory ischemic priapism (IP).

METHODS

Pubmed and EMBASE search engines were used to search for words "priapism", "refractory priapism", "penile prosthesis", "diagnosis priapism", "priapism treatment", "penile fibrosis", "priapism therapy". All the studies were carefully examined by the authors and then included in the review.

RESULTS

First-line treatment involves ejaculation, physical exercise and cold shower followed by corporal blood aspiration and injection of α-adrenoceptor agonists. Subsequently, a distal or proximal shunt may be considered. If none of the treatment is effective or the priapism episode lasts >48 hours penile prosthesis implantation could be the only option to solve the priapism and treat the ongoing erectile dysfunction.

CONCLUSION

The management of IP is to achieve detumescence of persistent penile erection and to preserve erectile function after resolution of the priapic episode. On the other hand, penile fibrosis and following shortening should be prevented. Early penile prosthesis implantation in patients with refractory IP is able to solve both the priapic episode and prevent the otherwise certain penile shortening. Penile prosthesis implantation is the actual gold standard of care in cases of refractory IP.

Inflatable Penile Prosthesis Insertion in Men with Severe Intracorporal Fibrosis

OBJECTIVES

To retrospectively review a series of men who underwent attempted inflatable penile prosthesis (IPP) insertion into severely scarred corpora, and to analyze the surgical techniques and instruments that contributed to a successful outcome.

PATIENTS AND METHODS

All IPP procedures done by a high-volume prosthetic surgeon during a 5-year period were retrospectively reviewed. Fourteen patients with severe intracorporal fibrosis underwent 15 attempted IPP insertion procedures, and are the subject of this review.

RESULTS

A standardized surgical approach was employed for all patients. Thirteen of the 15 procedures were successful (i.e., an IPP was inserted, with satisfactory cylinder position). One procedure failed due to corporal obliteration. One patient underwent an initial failed attempt, but was successfully implanted 10 months later. Two of the 14 patients (14%) developed peri-prosthetic infection and were explanted.

CONCLUSION

IPP insertion into scarred corpora is difficult and occasionally impossible. We have developed a standardized surgical approach for these cases, using limited corporal excavation, followed by the use of sequential Uramix and then Carrion-Rossello cavernotomes, that we feel has improved our chance of a successful implant. However, due to the rarity of these cases, it is not possible to make definitive statements concerning the optimal surgical technique.

Patient satisfaction and penile morphology changes with postoperative penile rehabilitation 2 years after Coloplast Titan prosthesis

A common complaint after inflatable penile prosthesis surgery is reduced penile length. We previously reported how using the Coloplast Titan inflatable penile prosthesis with aggressive new length measurement technique (NLMT) coupled with postoperative IPP rehabilitation of the implant for 1-year helped to improve patient satisfaction and erectile penile measurements. This is a 2 years follow-up of a prospective, three-center, study of 40 patients who underwent Titan prosthesis placement, with new length measurement technique for erectile dysfunction. Patient instructions were to inflate daily for 6 months and then inflate maximally for 1–2 h daily for 6–24 months. Fifteen penile measurements were taken before and immediately after surgery and at follow-up visits. Measurement changes were improved at 24 months as compared to immediately postoperative and at 12 months. 67.8% of subjects were satisfied with their length at 2 years, and 77% had perceived penile length that was longer (30.8%) or the same (46.2%) as prior to the surgery. 64.3% and 17.9% of subjects had increased and unchanged satisfaction, respectively, with penile length as compared to prior to penile implant surgery. All but one subject (96.5%) was satisfied with the overall function of his implant. This study suggests using the Coloplast Titan with aggressive cylinder sizing, and a postoperative penile rehabilitation inflation protocol can optimize patient satisfaction and erectile penile measurements at 2 years postimplant.

Implantation of AMS 700 LGX penile prosthesis preserves penile length without the need for penile lengthening procedures

Implantation of an inflatable penile prosthesis (IPP) is a well-established definitive solution for erectile dysfunction when conservative treatments fail. Penile implants may shorten the penis. The AMS 700 LGX IPP is in common use but reports on its mechanical reliability, medium-term postsurgical patient satisfaction, and mean penile length preservation are lacking. We investigate the mean penile length, mechanical reliability, and patient satisfaction at 6 and 12 months after implantation of the AMS 700 LGX. This prospective study consecutively enrolled men undergoing first-time IPP implant surgery from February 2009 to April 2012. Stretched flaccid penile length, penile length at 50% and 100% of stiffness (P50 and P100) and International Index of Erectile Function (IIEF) and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) scores, were measured at 6 and 12 months postsurgery. Of 45 patients who underwent AMS 700 LGX implantation (median age 61 years) and completed 6 months’ follow-up, 36 (80%) completed the study. A significant difference in stretched flaccid penile length was seen between 6 and 12 months (P = 0.033). P100 was also significantly increased at 6 and 12 months, with a mean 10% increase (1.3 ± 0.4 cm) from baseline to 12 months. Differences in mean IIEF scores at 6 and 12 months were significant for the desired domain (P = 0.0001) and for overall satisfaction (P = 0.002); however, mean EDITS scores at 6 and 12 months were not significantly improved. AMS 700 LGX is a powerful tool for preserving penile length in men undergoing penile prosthesis implantation.

Strategies for maintaining penile size following penile implant

INTRODUCTION

Loss of penile size is a common complaint that can negatively affect patient satisfaction rates following successful penile prosthetic implant surgery.

OBJECTIVE

The aim of this review is to describe the various strategies that have been used to maintain penile length or girth after the insertion of a penile prosthetic implant.

METHODS

An extensive systematic literature review was performed, based on a search of the PUBMED database for articles published between 2002 to 2012. The following key words were used: penile prosthesis, implant, penile length, size, penis, enhancement, enlargement, phalloplasty, girth, lengthening, and augmentation. Only English-language articles that were related to penile prosthetic surgery and penile size were sought.

DISCUSSION

Based on the results of our search, strategies were classified into 3 groups based on the timepoint in relation to the primary penile prosthetic insertion surgery, which included pre-insertion, intraoperative and post-insertion.

CONCLUSIONS

Strategies to preserve and potentially increase penile size are of great importance to all implanters. Besides traction therapies and surgeries to enhance perceived penile size, refinements in the surgical approach are simple ways to optimize penile length. A direct comparison of treatment outcomes evaluating the various approaches is not currently possible, owing to divergent study techniques. The implanting surgeon can best serve his patient by adopting a combination of different strategies that are individualized and specific to the patient's needs.

A practical overview of considerations for penile prosthesis placement

Penile prostheses have remained the gold-standard therapy for medically refractory erectile dysfunction (ED) since their popularization. Advances in device design and surgical techniques have yielded improved rates of infection, satisfaction, and mechanical survival of devices. Operative techniques in penile prosthesis surgery include the use of adjunctive procedures (such as ventral phalloplasty and release of the suspensory ligament), management of penile fibrosis, and manoeuvres to correct Peyronie's-disease-related curvature. Complications include urethral and corporal perforation, crossover, infection, impending erosion, and/or supersonic transporter deformity. Long-term data regarding mechanical, overall, and infection-free survival demonstrate excellent results, and, given the consistently high satisfaction rates and limited alternatives for medically refractory ED, penile prostheses are likely to remain a relevant and important treatment strategy for the foreseeable future.

Strategies for penile prosthesis placement in Peyronie's disease and corporal fibrosis

Peyronie's disease (PD) is a wound healing disorder of the tunica albuginea of the penis. PD is generally categorized into two phases: the early acute inflammatory and late chronic fibrotic. Surgical reconstruction is only recommended during the latter established phase. There are a variety of options when erections are functional. However, when erectile dysfunction is present, the gold standard treatment is the placement of an inflatable penile prosthesis with or without additional straightening procedures. General recommendations include that after implanting and inflating the cylinders, if a clinically significant curvature is present, manual modeling is performed. If a residual curve >30° remains after modeling, then various techniques, including plaque releasing incision, is the next step. Grafting can be considered if tunical defects are >2.0 cm. Causes of corporal fibrosis include complications from an infected implant such as explantation, priapism, penile trauma, and prolonged use of an intracavernosal injection agent. Implant placement in the setting of corporal fibrosis can be technically challenging. Available strategies include incision or excision of the scar, corporotomies with or without grafting, the use of cavernotomes, or other specialized dilators, implant downsizing, and transcorporeal resection.

Early insertion of a malleable penile prosthesis in ischaemic priapism allows later upsizing of the cylinders

OBJECTIVE

Early insertion of a penile prosthesis in prolonged ischaemic priapism is easier to perform than late prosthesis placement, and preserves the penile length. The aim of this study was to assess whether a delayed exchange to an inflatable implant allows upsizing of the cylinders in patients who have undergone early insertion for refractory ischaemic priapism.

MATERIALS AND METHODS

Over a 30 month period, 10 patients with ischaemic priapism underwent an early insertion of a malleable penile prosthesis. The mean age was 41.3 years and the mean duration of priapism was 188 h. Following a median period of 130.5 days, all of these patients underwent exchange of the malleable to an inflatable prosthesis.

RESULTS

At the time of penile implant exchange, a median upsize in the length of the cylinders of 1 cm in either one or both corporal bodies (range 0-3 cm) was recorded. Five patients had deliberate downsizing at the initial operation owing to a previous shunt. The mean score on the five-item International Index of Erectile Function (IIEF-5) before insertion of the malleable prosthesis was 24 (range 20-25). Three months after the initial insertion of a malleable penile implant the satisfaction rate according to the IIEF-5 score was 80%. Three months after the exchange, the patient satisfaction rate increased to 90%.

CONCLUSION

Insertion of a malleable penile prosthesis is an acceptable option for patients with refractory ischaemic priapism. Although some patients deliberately have a shorter implant inserted initially owing to a previous distal shunt procedure, following a period of resolution the cylinders can be upsized at a later operation.

Prospective evaluation of postoperative penile rehabilitation: penile length/girth maintenance 1 year following Coloplast Titan inflatable penile prosthesis

INTRODUCTION

The most prevalent long-term complaint after successful inflatable penile prosthesis (IPP) surgery is reduction of penile length. The purpose of this study was to evaluate penile measurements in patients whose implantation experience included the aggressive new length measurement technique (NLMT) coupled with postoperative IPP rehabilitation (daily inflation) of the implant for 1 year. Moreover, we aimed to document objective data concerning dimensional changes of the phallus over time. Postoperative IPP rehabilitation has been discussed and presented at meetings, but no multi-institutional prospective data have been published.

AIM

Our goal was to assess results using the Coloplast Titan IPP, with NLMT, and postoperative rehabilitation.

METHODS

After IRB approval, we conducted a prospective, three-center study of 40 patients who underwent IPP placement, with NLMT for end organ failure erectile dysfunction with the Coloplast Titan IPP. The patient was instructed to inflate daily for 6 months and then inflate maximally for 1-2 hours daily for 6-12 months. Fifteen penile measurements were taken before and immediately after surgery and at follow-up visits.

MAIN OUTCOME MEASURE

Penile length measurements after implantation compared with 12 months postimplantation.

RESULTS

Penile measurement changes were statistically significantly improved at 12 months as compared with immediately postoperative and at 6 months. A total of 64.5% of subjects were satisfied with their length at 1 year, and 74.2% had perceived penile length that was longer (29%) or the same (45.2%) as prior to the surgery; 61.3% and 16.1% of subjects had increased and unchanged satisfaction, respectively, with penile length as compared with prior to IPP surgery. All but two subjects (93.4%) were satisfied with the overall function and dimensions of their IPP.

CONCLUSION

This study suggests using the Coloplast Titan IPP with aggressive cylinder sizing, and a postoperative penile rehabilitation inflation protocol may help optimize patient satisfaction and erectile penile measurements.

Capsular contraction with s-shaped deformity of nonlength-expanding inflatable penile prosthesis cylinders: management and prevention strategies

Introduction

Capsular contraction (CC) occurring with inflatable penile prosthesis (IPP) reservoirs has been reported by urologists as a cause of autoinflation. The concept of CC occurring around IPP cylinders has not been studied.

Aims

Herein we report a case of CC occurring with nonlength-expanding IPP cylinders, resulting in an S-shaped deformity.

Main Outcome Measures

We sought to report a novel cause of S-shaped deformity in patients after IPP surgery.

Methods

We reviewed a recent clinical case and conducted a literature review on capsular scar formation in prosthetic surgery. We also conducted a literature review of the inflammatory cascade related with prosthetic surgery.

Results

Capsular contracture of nonlength-expanding cylinders resulting in S-shaped deformity has not been previously reported. The role of certain inflammatory markers seems to play a common role of capsular contracture in the penis and other prosthetic implantation sites.

Conclusions

Capsular contractures around the cylinders of an IPP can cause deformity, even in patients who have appropriately sized, nonlength-expanding cylinders. A better understanding is needed regarding the mechanical properties of the tunica albuginea and the inflammatory cascade associated with penile implant surgery. This case represents an argument for early and aggressive postoperative inflation of the IPP. Future studies should evaluate the role of inflammation modulators as adjuvant therapy after IPP surgery. Karpman E and Henry G. Capsular contraction with S-shaped deformity of nonlength-expanding inflatable penile prosthesis cylinders: Management and prevention strategies. Sex Med 2013;1:95–98.

Distal penile shaft reconstruction and reinforcement: the "double-windsocks" technique

INTRODUCTION

The management of penile prosthesis protrusion and the implantation of a prosthesis in fibrotic penile corporal bodies represents a challenging task even for experienced surgeons.

AIM

To demonstrate the long-term efficacy and safety of a new technique for distal shaft reconstruction and reinforcement in cases of penile prosthesis protrusion or cases of penile prosthesis implantation in corporal fibrosis.

METHODS

Between August 2007 and August 2012, 69 patients underwent surgery for penile prosthesis protrusion (45 patients) or severe distal corporal fibrosis (24 patients). The mean age at the time of surgery was 56 years (range 38-69). All patients underwent distal shaft reconstruction using our technique, involving the creation of two neocorpora ("double windsocks").

MAIN OUTCOME MEASURES

Functional outcome and patient satisfaction were evaluated with item numbers 1 and 7 of the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire. Furthermore, clinical data concerning the early postoperative outcome were analyzed retrospectively.

RESULTS

Mean follow-up time was 22.5 months (range 6-48). Based on answers to EDITS questionnaire item 1, 42 patients (60.9%) were very satisfied and 19 patients (27.5%) were somewhat satisfied with the outcome of the procedure. Furthermore, answers to the self-confidence domain question (EDITS item 7) revealed that 63 patients (91.3%) felt that the treatment had a positive effect with respect to their ability to engage in sexual activity. No patient exhibited device extrusion, postoperative infection, or skin dehiscence, and glans sensation as well as orgasmic ability were also preserved in all cases. Neuropraxia was reported in five cases (3.4%) immediately after the operation. The recovery of orgasmic ability was delayed in 17 (24.6%) patients. All patients were able to perform sexual intercourse postoperatively.

CONCLUSION

The "double-windsocks" technique is an effective option for difficult cases of distal penile shaft reconstruction and reinforcement.

Treatments for fibrosis of the corpora cavernosa

Introduction

Corporal fibrosis usually occurs after explantation of an infected penile prosthesis, severe penile trauma, refractory low-flow priapism, Peyronie’s disease, or the chronic intracavernous injection of vasoactive drugs.

Methods

We analysed current treatmentss for penile fibrosis. We searched PubMed using the keywords ’penile corporal fibrosis’, ’treatment’ and ’penile fibrosis’, resulting in 63 matches, of which 19 articles met the inclusion criteria.

Results and conclusions

This review covers conservative medical therapy for corporal fibrosis and surgical therapeutic methods. The roles of phosphodiesterase- 5 inhibitors and pentoxifylline are analysed. Surgical therapy includes implantation of a penile prosthesis and corporal reconstruction, and these are reviewed. Corporal fibrosis is a major problem for patients, and is associated with severe erectile dysfunction. Conservative treatment options can be applicable in the early phase, but simultaneous corporal reconstruction procedures with concomitant implantation of a penile prosthesis should be attempted in severe cases of corporal fibrosis.

Penile prosthesis surgery in the management of erectile dysfunction

Introduction

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

Methods

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

Results

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

Conclusion

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

Ventral phalloplasty

PURPOSE

To present the surgical technique of ventral phalloplasty as an adjunct procedure to the classic prosthetic surgery.

MATERIALS AND METHODS

In this video we demonstrate how to perform a ventral phalloplasty in a patient that has undergone a penile prosthesis implantation. Our technique consists of: delineation of the penile scrotal web, excision of this redundant skin, and re-approximation of the wound to mimic the natural median raphe.

RESULTS

The ventral phalloplasty improves the perception of phallic length, as well as patients' satisfaction after prosthetic surgery.

CONCLUSION

Penile length perception is the main concern of patients that have undergone penile prosthesis implantation. In this video we demonstrate that the ventral phalloplasty can improve perception of phallic length, and can be an important adjunct to the classic prosthetic surgery.

Evaluation of Satisfaction and Axial Rigidity with Titan XL Cylinders

The inflatable penile prosthesis (IPP) has high patient satisfaction rates and good mechanical reliability rates in multiple studies. The number one patient compliant at six months is penile length. Recently, new technique for aggressive sizing of the cylinders has been published on in the literature. One IPP company has produced a new product that has longer length cylinders (XL) than those available. However, traditionally long cylinders were felt to lack axial rigidity. Therefore, a prospective, multicenter, central IRB-approved, monitored study was performed on the new product to address these concerns. At 2 centers, a total of 17 patients underwent surgical implantation of these new XL cylinders. These patients were questioned for patient satisfaction and tested for axial rigidity using a Fastsize Erectile Quality Monitor. The results showed excellent patient satisfaction rates and great axial rigidity with the Fastsize Erectile Quality Monitor. The XL cylinders appear to give the IPP surgeon the ability to use longer cylinders with good patient satisfaction and great axial rigidity.

Penile enhancement procedures with simultaneous penile prosthesis placement

Here we present an overview of various techniques performed concomitantly during penile prosthesis surgery to enhance penile length and girth. We report on the technique of ventral phalloplasty and its outcomes along with augmentation corporoplasty, suprapubic lipectomy, suspensory ligament release, and girth enhancement procedures. For the serious implanter, outcomes can be improved by combining the use of techniques for each scar incision. These adjuvant procedures are a key addition in the armamentarium for the serious implant surgeon.