Contemporary aspects of penile prosthesis implantation

Erectile dysfunction: a need for greater awareness

Research has led to effective treatment regimes for erectile dysfunction (ED). Convincing evidence links vascular risk factors (hypertension, diabetes mellitus, hyperlipidaemia and smoking) with ED. This association is not surprising since the corpus cavernosum is a modified vascular tissue. This review presents a brief account of the aetiology, diagnosis and treatment of ED. There is a need to raise awareness of this condition and to make appropriate treatment available to patients.

Salvage Procedure in Case of Urethrocavernous Fistula after Revision Surgery for Malfunctioning Three-Piece Penile Prosthesis

Urethrocavernous fistula is a rare complication of penile prosthesis. Literature lacks any materials regarding this complication's treatment. We report our experience with a 66-year-old man who developed urethrocavernous fistula after penile prosthesis implant. Our technique involves the careful closure of urethral and corpus cavernosum defects with application of TachoSil^® above the sutures. After the salvage procedure, no recurrence of fistula occurred and patient was able to have sexual intercourse. We believe that our technique may be successfully used in case of urethrocavernous fistula after penile prosthesis implant.

A questionnaire for the evaluation of quality of life after penile prosthesis implant: quality of life and sexuality with penile prosthesis (QoLSPP): to what extent does the implant affect the patient's life?

INTRODUCTION

Penile prosthesis implantation is considered to be a satisfactory treatment for erectile dysfunction. Previous studies have assessed mainly prosthesis function and perioperative complications and have measured satisfaction only with regard to sexual performance. Very little, if anything, has been reported on the most relevant question: To what extent does the implant affect the patient's life?

AIM

To develop and validate the pathology-specific Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire, which evaluates patients' quality of life after penile prosthesis implantation.

METHODS

Sixty-nine patients aged 32-82 years who received a three-component hydraulic prosthesis between 1997 and 2009 participated in the study; 47 participated in the retest of the instrument. The QoLSPP questionnaire was developed to examine general and sexual quality of life in four domains: functional, personal, relational, and social. All psychometric properties of the QoLSPP were validated. Internal validity was assessed by means of exploratory factor analysis. Cronbach's alpha was used to evaluate the internal consistency of the items within each factor. Paired-sample t-tests were used to investigate metric stability. Independent-samples t-tests and nonparametric tests were used to evaluate the sensitivity.

MAIN OUTCOME MEASURES

The main outcome measure for the questionnaire was quality of life as biological and psychosocial-relational well-being. Main outcome measures for validation were internal validity, metric stability, and sensitivity of the QoLSPP.

RESULTS

The QoLSPP met the psychometric requirements of internal validity and reliability. Metric stability and sensitivity were tested and confirmed. Respondents reported high satisfaction levels in all quality of life domains. All domains were significantly and positively correlated; the functional domain was most predictive of overall quality of life. More than half of respondents perceived their partners to be very satisfied.

CONCLUSIONS

Prosthesis implantation was correlated with high quality of life in recipients and high perceived quality of couple relationships; partner satisfaction affected patients' quality of life, self-image, relation to the outside world, and satisfaction with implant function.

Prospective analysis of the surgical outcomes and patients' satisfaction rate after the AMS Spectra penile prosthesis implantation

OBJECTIVE

To evaluate the outcomes, the patients', and their partners' satisfaction concerning the AMS Spectra penile prosthesis implantation.

METHODS

Twenty-two unresponsive or dissatisfied patients with phosphodiesterase 5 inhibitor oral therapy or prostaglandin intracavernous injection underwent a Spectra penile prosthesis implantation. No major intraoperative or postoperative complications were observed. The preoperative erectile dysfunction (ED) was rated by the International Index of Erectile Function (IIEF) questionnaire. The patients and their partners were submitted to the IIEF and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaires through telephonic interviews at the third, sixth, and 12th months after the penile surgery.

RESULTS

This study demonstrates that 86.4% of the patients and 52.6% of their partners are satisfied by the AMS Spectra penile prosthesis. The preoperative average IIEF score was equal to 28.5 (range 13-39). The postoperative IIEF rates were 47.7 (43-53), 51.8 (48-58), and 53.9 (50-58) at the third, sixth, and 12th months, respectively. The patient average EDITS score amounted to 39.5 (31-48), 43.4 (36-50), and 45.2 (38-50) at the third, sixth, and 12th months, respectively. The increase between the preoperative and postoperative IIEF parameters resulted to be statistically significant (P <.05) as well as the increase in EDITS at the third, sixth, and 12th months postoperatively.

CONCLUSION

The AMS Spectra is a reliable device to treat ED as shown by the high grade of the patients' satisfaction. Moreover, the AMS Spectra is highly convenient in terms of cost savings in comparison to an inflatable device. In selected patients, this prosthesis should be considered as an effective solution to treat severe ED.

Vacuum erection devices revisited: its emerging role in the treatment of erectile dysfunction and early penile rehabilitation following prostate cancer therapy

INTRODUCTION

Vacuum erection devices (VEDs) are becoming first-line therapies for the treatment of erectile dysfunction and preservation (rehabilitation) of erectile function following treatment for prostate cancer. Currently, there is limited efficacy of the use of phosphodiesterase type 5 inhibitors in elderly patients, or patients with moderate to severe diabetes, hypertension, and coronary artery disease.

AIM

The article aims to study the role of VED in patients following prostate cancer therapy.

RESULTS

Alternative therapies such as VED have emerged as one of the primary options for patients refractory to oral therapy. VED has also been successfully used in combination treatment with oral therapy and penile injections. More recently, there has been interest in the use of VED in early intervention protocols to encourage corporeal rehabilitation and prevention of postradical prostatectomy veno-occlusive dysfunction. This is evident by the preservation of penile length and girth that is seen with early use of the VED following radical prostatectomy. There are ongoing studies to help preserve penile length and girth with early use of VED following prostate brachytherapy and external beam radiation for prostate cancer. Recently, there has also been interest in the use of VED to help maintain penile length following surgical correction of Peyronie's disease and to increase penile size prior to implantation of the penile prosthesis.

CONCLUSION

VEDs can be one of the options for penile rehabilitation after prostate cancer therapy.

Patient expectations prior to coloplast titan penile prosthesis implant predicts postoperative satisfaction

INTRODUCTION

Managing and understanding expectations of patients prior to inflatable penile prosthesis (IPP) surgery is a critical. Clinicians vary in the way they explain the operation, and patients have varied expectations prior to surgery.

AIMS

The goal is to understand the role that preoperative counseling and patients' realistic understanding of IPP surgery play in determining postoperative satisfaction.

METHODS

21 Patients underwent IPP surgery, and received a preoperative expectations survey, then, 4 months later, gave a single score of 1-100 (1 is very dissatisfied, 100 is extremely satisfied).

MAIN OUTCOME MEASURES

The results were correlated with an R(2) value and visualized on a scatter plot. This significance is tested using a two-tailed test.

RESULTS

Lower preoperative expectations scores correlated almost linearly with higher satisfaction scores after surgery. The R (Pearson) value was -0.489, with an R(2) of 0.239. This was significant using a two-tailed test, with a P value of 0.0245.

CONCLUSION

Giving patients an accurate description of the procedure and setting realistic expectations leads to higher postoperative satisfaction.

Penile implantation in Europe: successes and complications with 253 implants in Italy and Germany

INTRODUCTION

Results for prosthesis implantation from everyday clinical practice within Europe are few. This report provides data on the most commonly used penile prostheses (the American Medical Systems [AMS] series).

AIM

The study aimed to assess, retrospectively, complications and patient satisfaction with AMS penile implants in 253 consecutive patients with erectile dysfunction from three European centers.

METHODS

Pre, intra- and postoperative data were obtained from chart review, with a mean follow-up of 60 months; 200 patients were available for evaluation. Patient satisfaction data were collected using the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire.

MAIN OUTCOME MEASURE

Complications and patient satisfaction were assessed. Patient satisfaction was evaluated using a standardized assessment tool (the modified EDITS questionnaire).

RESULTS

Major postoperative complications occurred in 40 (20%) patients, including 9 (22.5%) prosthesis infections, 18 (45%) mechanical failures, and 13 (32.5%) erosions. Patient satisfaction with the AMS 700CX, AMS Ambicor, and AMS 600-650 was 97%, 81%, and 75%, respectively; dissatisfaction was 0%, 5%, and 6%, respectively. Partner satisfaction with the AMS 700CX, AMS Ambicor, and AMS 600-650 was 91%, 91%, and 75%, respectively; dissatisfaction was 0%, 5%, and 6%, respectively. Erections were more natural (harder) than before with the AMS 700CX, AMS Ambicor, and AMS 600-650 in 91%, 85%, and 88%, respectively; hardness was the same as before in 9%, 15%, and 13%, respectively; no erections were less hard than before.

CONCLUSIONS

Postoperative complications differed from those reported in the literature, while patient satisfaction rates were roughly similar. The reporting of specific data for different implant types, plus the use of standardized assessment tools for patient satisfaction is significant as in the future, it will allow comparison of data between centers performing penile prosthesis implants using these devices.

Long-term survival of inflatable penile prostheses: single surgical group experience with 2,384 first-time implants spanning two decades

INTRODUCTION

Long-term revision-free survival, greater than 10 years has never been reported for inflatable penile prostheses. We conducted a historical prospective study to estimate 10 and 15 years survival of first time (virgin) implantations in 2,384 patients with four different models.

AIM

Evaluation of 10- and 15-year mechanical and overall revision-free survival of inflatable penile prostheses.

MAIN OUTCOME MEASURES

Kaplan-Meier product limit method, and comparison using the log rank test, were used to estimate the 10- and 15-year revision-free survival.

METHODS

Data were obtained from medical records and patient interviews, entered into a computerized database, and analyzed by a third party. Information included implant type, date, revision history with date, and reason. Fourteen different inflatables were examined. Mentor Alpha 1, Mentor Alpha NB, AMS 700 CX, and AMS 700 Ultrex had usage for an extended period of time. Because of failure times being confounded as a result of prior implants, only virgin implants were examined.

RESULTS

For the entire series, estimated 10-year revision-free survival for all reasons was 68.5% and the 15-year revision-free survival was 59.7%. Freedom from mechanical breakage at 10 years was 79.4%; 15 years was 71.2%. Recent mechanically enhanced models did even better. In 1992, Mentor Alpha added pump reinforcement to forestall mechanical breakage. This improved 10-year survival from 65.3% to 88.6% (P = 0.0001). In January 2001, AMS CX added a parylene coating to the cylinders that increased 3-year mechanical survival from 88.4 to 97.9% (P = 0.0002).

CONCLUSIONS

This is the first report on long-term reliability of inflatable penile prostheses. We estimated 60% of these virgin implants would survive 15 or more years without revision or extraction. Newer enhanced models are currently available, and our tracking predicts even better long-term survival for these devices.

Erectile Dysfunction Following Radical Retropubic Prostatectomy

Radical prostatectomy has been the time-honoured and standard treatment option for prostate cancer. Erectile dysfunction (ED) is one of the common quality-of-life issues following radical prostatectomy. The recovery of potency following radical prostatectomy varies from 16% to 86%. Although major modifications in surgical technique appear to be promising, the reported ED rates are still high. The time period required for the recovery of erectile function after surgery varies from 6 to 24 months. During this period of neuropraxia lack of natural erections produces cavernosal hypoxia. This cavernosal hypoxia has been implicated as one of the most important factors in the pathophysiology of ED. Cavernosal hypoxia predisposes to cavernosal fibrosis, ultimately producing venous leak and long-term ED. Interruption of this cascade of events has been the major challenge for physicians. Physicians have several options available for the treatment of ED. However, oral treatment options have quickly become established as first-line treatment options. Sildenafil has been most extensively studied in the radical prostatectomy population. In patients who do not respond to oral therapy alone, standard treatment options (intracavernosal injections, vacuum constriction devices and intraurethral alprostadil) are useful. Use of penile prostheses is one of the oldest treatment options available for the treatment of ED but is used only as a last resort. Initial attempts to promote the earlier recovery of erectile function appear to be promising. However, further confirmatory studies are essential. The roles of gene transfer and growth factors are still in experimental stages. In this review we discuss the epidemiology, pathophysiology and treatment options available for ED following radical prostatectomy.

Current role of penile implants for erectile dysfunction

PURPOSE OF REVIEW

The purpose of this review is to appraise new developments and publications in the field of penile prosthetic surgery. Urologists dealing with erectile dysfunction need to recognize the value of penile prosthetic surgery as a very efficacious treatment for this common condition. This type of surgery is needed in a considerable proportion of patients with erectile dysfunction so this review is timely and relevant.

RECENT FINDINGS

The main themes in the literature covered include risk factors for infection of penile prostheses, its prevention with the use of hydrophilic and antibiotic-coated prostheses, particularly in re-operations, and its management with the new rescue procedures. Surgical tips for prosthetic surgery are also reviewed as well as clinical outcomes and factors influencing them.

SUMMARY

Of all the invasive treatments currently available, placement of a penile prosthesis is one of the most successful, giving high levels of satisfaction. With the aid of new technical advances, the risk of infection--the most feared complication--can be minimized so prosthetic surgery may play a major role in the treatment of erectile dysfunction.

Radiological assessment of penile prosthesis: the role of magnetic resonance imaging

Penile implants offer a dependable way of restoring erections in virtually all motivated patients. The satisfaction rate among both patients and partners using these devices is high. Advances in technology have reduced the infection rate and increased the mechanical reliability of these products. However, too often, urologists do not present this option with the same authority as other treatments. The reason is fear of complications and lack of expertise in managing them. Although they are not very frequent, complications may be catastrophic. The most significant postoperative complication associated with the implant surgery is infection of the device, which is quite frequent, but some other important complications are distal and proximal perforation of the albuginea, SST deformity, "S-shaped" deformity of the penis, erosion of a component, and mechanical malfunction of the device. The best way to manage complications is to prevent them, but we do not have many diagnostic tools available. Diagnosis is based on clinical history and physical examination, but imaging techniques are also needed to explore the prosthesis "in situ" to plan the surgical approach if it is needed. In this article we review the different imaging techniques used for the diagnosis of complications of prosthetic surgery of the penis, including conventional radiology, use of sonography, the role of CT scan and the magnetic resonance imaging (MRI) of the penile prosthesis. We conclude that MRI is the most valuable method for the diagnosis of penile prosthesis complications. It is not an ionizing radiation imaging method and has the unique feature among imaging techniques of demonstrating penile anatomy in three orthogonal planes. It is superior to any other imaging method in the definition of soft tissue contrast.