Penile implants: a look into the future

A systematic review comparing different approaches for inflatable penile prosthesis revision: partial-component exchange, complete-component exchange, or reservoir "drain and retain"

INTRODUCTION

In cases of a noninfected malfunctioning inflatable penile prosthesis (IPP) device, surgeons often opt to exchange all of the device rather than the defective component for fear of an increased infection rate and future mechanical dysfunction.

OBJECTIVES

To assess whether partial-component exchange of an IPP device has comparable outcomes to complete explant and replacement of an IPP device with or without a retained reservoir.

METHODS

A systematic review was conducted following the PRISMA 2020 and AMSTAR guidelines. Searches were performed on MEDLINE (Ovid), PubMed, and the Cochrane Library from inception to June 2023, identifying studies reporting outcomes and complications of revision surgery for noninfected malfunctioning IPP devices. Three groups were compared: those undergoing single- or 2-component exchange, those with complete explantation and replacement, and those with replacement of all components while retaining the primary reservoir.

RESULTS

Analysis included 11 articles comprising 12 202 patients with complete device replacement, 234 with partial device exchange, and 151 with retained reservoirs following revision. Mean ages ranged from 62 to 68 years, with median follow-up times between 3 and 84 months. Partial-component exchange showed a higher infection rate (6.3%) as compared with complete replacement (2.7%) and reservoir retention (3.9%). Similarly, partial exchange had a higher complication rate (23.9%) when compared with complete replacement (11.3%) and reservoir retention (19.6%). Mechanical failure rates for partial exchange were similar across the 3 groups (10%, 2.8%, and 5.8%, respectively).

CONCLUSION

Partial-component exchange during IPP revision is associated with higher infection and perioperative complication rates but comparable rates of mechanical failure as compared with complete-component replacement, with or without retaining the original reservoir.

Does time of intraoperative exposure to the aerobiome increase microbial growth on inflatable penile prostheses?

Inflatable penile prosthesis (IPP) implantation is a surgical approach for the management of erectile dysfunction (ED). A feared complication is IPP infection, and increased operative time is a risk factor for infection. Exposure of an IPP implant to ambient air in the operating room (OR aerobiome) is thought to contribute to risk of infection from increased operative time, but this is not well-supported. The objective of this study was to evaluate if exposure to the OR aerobiome increased microbial colonization of IPPs. This was an ex vivo study using an uncoated IPP, observing standard surgical sterility and OR conditions. A sterile swab was collected every 30 min for 3 h from each IPP component. Positive controls consisted of swabs exposed to unprepped scrotal skin during in-office vasectomies. All swabs underwent quantitative polymerase chain reaction (qPCR) and next generation sequencing (NGS). Bioinformatic processing was carried out and taxonomic assignment was performed. No microbial growth was detected on any component of the IPPs at any time point, while positive control swabs all detected various skin flora, including bacterial and fungal growth. These findings suggest that exposure to the OR aerobiome does not increase the risk of IPP microbial colonization, at least within a 3-hour period. Further in vivo studies are needed.

Addressing the need for preclinical study of penile prosthesis infection: a new animal model and narrative review

Background and Objective

Erectile dysfunction (ED) is a common condition in men, and many patients refractory to conservative treatment may undergo penile prostheses (PPs) placement. The primary concern following PP implantation is device infection. Although antibiotic and hydrophilic coatings have reduced the incidence of inflatable PP (IPP) infections, there remains room for improvement. Optimization of PP outcomes requires a practical in vivo model to better understand mechanisms of infection and to test new infection control strategies. We aimed to describe a new rabbit model which contains a functional IPP and review previously reported animal PP models.

Methods

An IPP was placed into rabbit flanks and cycled for functionality testing. Rabbits were evaluated for signs of pain and distress over 14 days. Separately, narrative review methodology was utilized to search the PubMed and Scopus databases for all publications through March 21, 2023, which studied PP within an in vivo setting. Three independent reviewers ultimately selected 12 papers from 1992-2021 for inclusion.

Key Content and Findings

Several animal studies highlighted the initial functionality or feasibility of devices for ED before their introduction in the clinical setting. There are several subsequent studies aimed at optimizing the type of antibiotic use or coating material using segments of PP material in an in vivo setting. However, the literature lacks a contemporary animal model containing a functional IPP. Our novel rabbit model offers a safe, practical way to implant a functioning IPP and investigate new perioperative infection prevention and treatment strategies before trials in the clinical setting.

Conclusions

Animal models have played a key role in testing medical devices, including PPs, prior to their clinical introduction. Our review uncovered no modern animal studies involving placement of a functional PP. A new animal model can facilitate study of evolving microorganism profiles, novel methods to enhance antibiotic delivery, and proposed treatment options.

A narrative review on malleable and inflatable penile implants: choosing the right implant for the right patient

A penile prosthesis/implant is an excellent option for men with erectile dysfunction refractory to medical treatment or with contraindications to medical management. In this narrative review, we discuss the different types of penile prostheses and the considerations for patient and device selection to maximize satisfaction. There are three main prosthesis types to choose from: three-piece inflatable devices, two-piece inflatable devices, and malleable/semirigid devices. The three-piece devices are the gold standard in advanced economy countries but require reservoir placement and manual dexterity, which can be limiting to some patients. The two-piece inflatable devices are a good option for patients who have standard-sized penises, lack significant penile pathology, have limited dexterity issues, or should avoid reservoir placement due to potential complications. The malleable devices are popular in countries where insurance coverage is limited but are increasingly used in advanced economy countries for length conservation in specific patient populations. Finally, not every patient needs an implant, and assessing partner sexual function is an important consideration for patient-partner satisfaction. Surgeons need to be familiar with the strengths and limitations of each device and the patient characteristics that will yield the best outcome from penile prosthesis surgery.

Does Medicaid Cover Penile Prosthesis Surgery? A State-by-State Analysis

BACKGROUND

Malleable [MPP] and inflatable [IPP] penile prosthesis surgery for the management of erectile dysfunction is a reliable treatment option with high success rates and excellent patient satisfaction; however, Medicaid coverage transparency is poor leaving a knowledge gap in this population.

AIM

The present study seeks to assess Medicaid coverage for MPP and IPP by state as evidenced by inclusion in publicly available physician fee schedules.

METHODS

State Medicaid websites were utilized to access public physician fee schedules. Individual search queries were performed for CPT codes 54400 and 54405 which represent insertion of MPP and IPP, respectively. Data were recorded for each device, including the coverage status, physician fees, and the presence of clear documentation of a prior authorization requirement.

OUTCOMES

Medicaid physician fee schedules were accessible for 49 out of 50 US states, and 28 states reported coverage for at least one type of penile prosthesis.

RESULTS

Two states reported coverage for MPP only, one state reported coverage for IPP only, and 24 states reported coverage for both devices. One state reported that it did not cover either device, but listed coverage for a self-contained IPP (CPT 54401) only. Mean physician reimbursement was $477.15 (290.82-$1175.50) for MPP placement and $691.76 (421.68-$1794.27) for IPP. Eleven states documented prior authorization requirements within their fee schedules, while the remaining 17 states did not. Criteria for approval for prior authorization were not clearly stated in any fee schedule.

CLINICAL IMPLICATIONS

Efforts to clearly document approval criteria and educate Men's Health providers on available coverage could result in a significant improvement in sexual satisfaction in the Medicaid population.

STRENGTHS AND LIMITATIONS

Graphical representation of states offering Medicaid penile prosthetic coverage and physician reimbursement ranges are provided with comparison to Medicare rates. Limitations include heterogeneity in fee schedules, lack of prior authorization requirement details, inability to correlate to successful claims data, and the evolving nature of Medicaid coverage for the given procedures.

CONCLUSIONS

Medicaid coverage exists for penile prosthetic surgery in 28 states, although often with significant, non-transparent prior authorization criteria. Barnard JT, Grimaud L, Yafi FA. Does Medicaid Cover Penile Prosthesis Surgery? A State-by-State Analysis. J Sex Med 2021;18:1455-1460.

Cadaveric Penile Prosthesis Workshop training improves surgical confidence levels of urologists: South Asian Society for Sexual Medicine course survey

OBJECTIVES

To analyze the impact of South Asia's first cadaveric hands-on workshop on urologists' training in inflatable penile prosthesis surgery.

METHODS

A total of 72 urologists/andrologists participated in the 2019 South Asian Society for Sexual Medicine Pre-congress Penile Prosthesis hands-on workshop. The workshop included 4 h of lectures and 2 h of hands-on cadaveric laboratory experience using three-piece inflatable penile prosthesis. The Shapiro-Wilk test was used on self-rated procedural confidence levels, which proved the normality. A non-parametric McNemar test was used to examine the change in the number of correct answers.

RESULTS

Of those who attended the cadaver laboratory, just 45 who answered the survey both before and after the workshop were included for analysis. Significant objective improvements were noted in procedural knowledge test scores (44.30 ± 0.027 vs 72.44 ± 0.024, P < 0.05) and median surgical confidence levels (4 vs 3 and 2, P < 0.001) of the urologists after the completion of the workshop.

CONCLUSIONS

Cadaveric hands-on workshop training improves urologists' procedural knowledge and surgical confidence levels in carrying out three-piece inflatable penile prosthesis surgery. The feasibility of such workshops should be considered in increasing the surgical expertise of general urologists in prosthetic urology.

A prospective study analyzing both inflation and deflation preference for commonly available inflatable penile prostheses

Despite popularity, satisfaction rates of inflatable penile prosthesis (IPP) use can be improved by evaluating the ability to operate devices in the preoperative setting. The purpose of this study was to prospectively analyze the preference of three commonly available IPPs. In total, 125 IPP-naïve men 60 years of age or older were prospectively recruited from an outpatient Urology clinic from June 2019 to January 2020. A questionnaire standardized to all encounters was utilized to collect demographics, selected medical information, and key pinch strength. Participants were then asked to rank three models in terms of preference (from 1 to 3, 1 representing most preferred) for each inflation and deflation in a double-blinded manner. Statistical analysis was performed using ANOVA, a Chi-square test and multivariable logistical regression analysis. The results demonstrated preference for Coloplast Titan (44%) for inflation, and preference for AMS 700 (40%) for deflation. Men who preferred the Coloplast Titan inflation had a lower chance of preferring the AMS 700 MS deflation (OR = 0.29; p = 0.010) and Coloplast Titan Touch deflation (OR = 0.27; p = 0.012). Preference for Coloplast Titan was weakly associated with participant history of coronary artery disease (OR = 5.96, p = 0.006) and osteoarthritis (OR = 3.04, p = 0.044). Neither key pinch strength nor age was associated with preference for a particular model. IPP-naïve men over 60 years favor Coloplast Titan for inflation and AMS 700 for deflation, and men who preferred the Coloplast Titan for inflation were less likely to choose the AMS 700 MS or Coloplast Titan Touch for deflation. Further studies should aim to confirm these findings.

Does Lowering Hemoglobin A1c Reduce Penile Prosthesis Infection: A Systematic Review

INTRODUCTION

Hemoglobin A1c (HbA1c), a glycated form of hemoglobin, develops when glucose is elevated in the blood. It is used as a marker of how well a diabetic patient has been controlling their blood sugar over the previous 3-4 months. Some use HbA1c as a predictor of infection risk during prosthetic surgery, and many surgeons require patients to lower it preoperatively.

OBJECTIVE

This study was designed to comprehensively review the literature relating HbA1c and penile prosthesis (PP).

METHODS

A PubMed search of English-language articles identified studies that investigate the relationship between HbA1c levels and PP infection. Studies were only included if they reported the mean HbA1c of all PP patients and compared patients who did/did not develop a prosthetic infection. References from relevant articles are included.

RESULTS

A total of 6 studies, 1992-2020, were identified. 2 studies occurred before the advent of antibiotic-enhanced devices in the early 2000s and have limited applicability to the modern era. Of the 4 studies published after, 2 reported a significant difference in mean HbA1c when comparing patients who developed a prosthetic infection and those who did not (9.1% vs 7.5%, P = .000 and 9.5% vs 7.8%, P < .001). The other 2 studies reported no significant difference in mean HbA1c when comparing patients who developed a prosthetic infection and those who did not (7.0% vs 7.6%, P > .05; and 7.6% vs 7.5%, P = .598).

CONCLUSION

Current data regarding HbA1c as a predictor of PP infection are inconclusive, with no consensus. HbA1c is increasingly used as a predictor of postsurgical prosthetic infection, with some urologists requiring patients with elevated HbA1c to acutely lower it before elective surgery. While there are a number of established health benefits of controlling elevated blood sugar, larger randomized controlled trials need to validate whether acutely lowering perioperative HbA1c decreases risk of prosthetic infection. Dick BP, Yousif A, Raheem O, et al. Does Lowering Hemoglobin A1c Reduce Penile Prosthesis Infection: A Systematic Review. Sex Med Rev 2021;9:628-635.

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.

Fundamentals of prosthetic urology

The field of prosthetic urology demonstrates the striking impact that simple devices can have on quality of life. Penile prosthesis and artificial urinary sphincter implantation are the cornerstone procedures on which this specialty focuses. Modern research largely concentrates on decreasing the rates of complication and infection, as the current devices offer superior rates of satisfaction when revision is not necessary. These techniques are also able to salvage sexual function and continence in more difficult patient populations including female-to-male transgender individuals, those with ischemic priapism, and those with erectile dysfunction and incontinence secondary to prostatectomy. This review summarizes modern techniques, outcomes, and complications in the field of prosthetic urology.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Neurogenic bladder is an independent risk factor for complications associated with inflatable penile prosthesis implantation

Men with neurogenic bladder (NGB) often have concomitant erectile dysfunction and may be considered for inflatable penile prosthesis (IPP) placement. However, it is unclear if NGB is a risk factor for complications associated with IPP placement. The aim of this study is to compare surgical outcomes after IPP placement in a contemporary cohort of patients with NGB to that of a non-neurogenic control group. To accomplish this, consecutive records of patients who underwent IPP implantation between 2007 and 2018 were retrospectively reviewed. Patients with a known neurologic lesion and documented NGB by clinical or urodynamic criteria were compared with a non-neurogenic control group of men with erectile dysfunction. We found that patients in the NGB cohort were younger (median age 48 vs. 62 years, p < 0.001) and less likely to void spontaneously prior to surgery (3% vs. 97%, p < 0.001). The most common cause for NGB was spinal cord injury (46%). There was a 24.3% overall rate of complication (infection, erosion, or mechanical failure) in the NGB cohort compared with a 7.5% rate in the non-neurogenic control group (p = 0.001). On multivariate logistic regression modeling, NGB (OR 3.47; 95% CI 1.13-10.71; p = 0.03) was independently associated with risk of IPP complication. First time penile prosthesis was associated with lower risk of IPP complication (OR 0.25 95% CI 0.09-0.71; p = 0.01). In conclusion, patients with NGB are at increased risk for complications after IPP placement. Patients should be counseled accordingly, and all efforts should be made to stabilize bladder function prior to surgery.

Infrapubic approach for placement of inflatable penile prosthesis: contemporary review of technique and implications

Inflatable penile prosthesis (IPP) is an effective treatment for erectile dysfunction refractory to nonsurgical management. The infrapubic approach for IPP placement is less frequently employed than the penoscrotal approach, with only about 25% of IPPs placed via this method. Underutilization of the infrapubic method may be due to fear of injuring the penile dorsal neurovascular bundle, perceived difficulties of scrotal pump placement through a distant location, or insufficient distal corporal exposure. However, this approach appears to result in favorable operative times, faster time to device activation, equivalent postoperative satisfaction and quality of life, and similar complication rates. We provide a contemporary review of literature published before May 2019 regarding the infrapubic approach for IPP placement, technical considerations, and postoperative expectations.

Retained Reservoirs of Inflatable Penile Prosthesis: A Systematic Review of the Literature and a Guide to Perioperative Management

INTRODUCTION

Retained reservoirs can be a complex problem for clinicians who manage patients with inflatable penile prostheses (IPPs). Although the general safety of retained reservoirs is well documented, data on the long-term outcomes of these foreign bodies is scarce. In recent years, complications associated with retained reservoirs and the subsequent management of these cases have become more recognized.

AIM

To review, analyze, and summarize the concept of retained reservoirs and their associated complications with retained reservoirs and to provide a guide for management of complicated retained reservoir patients.

METHODS

We performed a systematic review of the PubMed database on retained reservoir-related complications and perioperative management.

MAIN OUTCOME MEASURES

We reviewed all publications that detailed complications associated specifically with retained penile prosthesis reservoirs and analyzed perioperative strategies used by providers. Any publication outlining IPP reservoir-related complication(s) stemming from a reservoir that was part of a functioning IPP was excluded.

RESULTS

Although the risk is low, serious complications can and do arise from retained reservoirs. To properly manage these patients, clinicians must have knowledge of the prosthetic history and maintain a low threshold for obtaining cross-sectional imaging. By using methodical perioperative planning, the need for reintervention in patients with complications can be reduced, and improved surgical outcomes can be achieved.

CONCLUSIONS

The management of retained reservoirs and their complications can be a clinical challenge for prosthetics providers. As such, more data regarding long-term outcomes and management strategies of retained reservoirs are required to better serve this subset of patients with prostheses. Reddy AG, Tsambarlis PN, Akula KP, et al. Retained Reservoirs of Inflatable Penile Prosthesis: A Systematic Review of Literature. Sex Med Rev 2020;8:355-363.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Ambulatory urodynamic monitoring: state of the art and future directions

Urodynamic studies are a key component of the clinical evaluation of lower urinary tract dysfunction and include filling cystometry, pressure-flow studies, uroflowmetry, urethral function tests and electromyography. However, pitfalls of traditional urodynamics include physical and emotional discomfort, artificial test conditions with catheters and rapid retrograde filling of the bladder, which result in variable diagnostic accuracy. Ambulatory urodynamic monitoring (AUM) uses physiological anterograde filling and, therefore, offers a longer and more physiologically relevant evaluation. However, AUM methods rely on traditional catheters and pressure transducers and do not measure volume continuously, which is required to provide context for pressure changes. Novel telemetric AUM (TAUM) methods that use wireless, catheter-free, battery-powered devices to monitor bladder pressure and volume while patients carry out their daily activities are currently being investigated. TAUM devices under current development are innovating in the areas of remote monitoring, rechargeable energy sources, device deployment and retrieval and materials engineering to provide increased diagnostic accuracy and improved comfort for patients with incontinence or voiding dysfunction. These devices hold promise for improving the diagnosis and management of patients with lower urinary tract disorders.

CT imaging of inflatable penile prosthesis complications: a pictorial essay

PURPOSE

Inflatable penile prostheses (IPPs) are widely used in the United States, for patients with erectile dysfunction refractory to other treatments. Complications subsequent to IPP insertion include infection, hematoma, fluid leak, component (cylinder/pump/reservoir) complications, and retained previous IPP components. Radiologists are often called upon to identify and characterize these complications utilizing CT prior to intervention. Our paper aims to provide a guide to familiarize radiologists with normal IPP component imaging and review the CT findings of commonly encountered complications.

METHODS

In this study, we retrospectively reviewed CT reports with descriptions of IPPs from 108 patients. We collected CT images of normal IPP components as well as reevaluated the CT findings of 33 patients with an IPP complication and correlated with immediately subsequent operative report.

RESULTS

The CT appearance of appropriately positioned normal IPP components in asymptomatic patients and each complication were described and compared to previous literature.

CONCLUSIONS

CT is a very useful modality to assess an IPP-related complication. It is inexpensive, fast, and immediately available in emergent situations, e.g., infection, hematoma, and component erosion. Additionally, CT is very sensitive and makes it easier to diagnose a system leak. It can identify most cylinder complications and pump malposition and can be extremely helpful to the surgeon in preoperative planning if revision is needed. After this review, the radiologist should be able to identify normal IPP components and their complications.

Biomechanical Studies of the Inflatable Penile Prosthesis: A Review

INTRODUCTION

The penile prosthesis remains the primary surgical treatment for refractory erectile dysfunction. Over the decades, inflatable penile prostheses' mechanical reliability, patient satisfaction, safety, and functional erectile restoration have greatly improved. During this time, many studies of biomechanical properties of the prosthesis have been conducted to better understand their biomimicry to the erect human phallus.

AIM

To review all current literature on the biomechanical properties of the penile prosthesis, including prosthesis biomechanical function, and variability in model-related performance.

METHODS

A Medline PubMed search was used to identify all articles of interest related to subjects involving the penile prosthesis and its related biomechanical properties. The following were included in the search for articles of interest: "biomechanics," "mechanics," "mechanical properties," "axial rigidity," "penile implant," and "penile prosthesis." Articles were further screened for content and English language.

MAIN OUTCOME MEASURE

Here we perform a literature review of the bio-mechenical function, performance, and patient satisfaction of penile implants.

RESULTS

Axial rigidity helps determine the ability of an erect penis to complete vaginal intromission and pelvic thrusting without buckling. Recent cadaveric data show that at maximum inflation, Coloplast and American Medical Systems (AMS) implants had comparable performance. Variability was seen at various lower fill pressures, where more severe buckling was observed. Coloplast Titan showed a tendency toward better resistance to longitudinal and horizontal forces. The AMS CX device showed similar performance to the Titan, and the AMS LGX device was shown to be most sensitive to fill pressure variation. Additionally, rear tip extenders (RTEs) appear to negatively affect axial loading, especially in settings of larger implants.

CONCLUSION

Current research suggests that circumferentially expanding devices, such as AMS CX and Coloplast Titan, show better resistance to longitudinal (penetration) and horizontal (gravity) forces and, unlike the AMS LGX device, are less sensitive to device fill pressure. Additionally, RTEs have been shown to negatively impact axial loading, especially in larger cylinder inflatable penile prostheses >20 cm in length. Madiraju SK, Wallen JJ, Rydelek SP, et al. Biomechanical Studies of the Inflatable Penile Prosthesis: A Review. Sex Med Rev 2019;7:369-375.