Evolution of penile prosthetic devices

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.

Salvage procedures for infected penile implants: A comprehensive review and analysis of functional outcomes

BACKGROUND

The salvage procedure for infected penile implants (IPs) has been a subject of interest since its inception in the late 1980s, yet its widespread adoption remains limited. The aim of this study was to realize a systematic literature review to provide a comprehensive analysis of salvage techniques for IPs and assess their efficacy, specifically focusing on functional success.

METHODS

A systematic literature review was conducted using PubMed, employing Mesh terms related to penile prosthesis, penile implant, infection, and salvage procedures. Articles in French or English were considered for the final analysis, with exclusion of literature reviews.

RESULTS

Fifteen articles detailing various salvage techniques for IPs were identified. Mulcahy's initial technique was described in 1996, and consisted of complete removal of infected components, extensive lavage, and subsequent replacement with a similar implant. Success rates ranged from 80% to 100%, with emerging trends favoring the use of malleable implants during salvage. Unfortunately, functional data remained limited. When salvage penile prosthesis placement involved a malleable prosthesis, between 20% and 33% of patients underwent conversion to hydraulic prosthesis.

CONCLUSION

The salvage procedure for infected penile implants is a reliable method, with success rates surpassing 80%. The need for comparative studies assessing the type of implant used during salvage is required to tailor conservative management strategies for optimal patient outcomes. Finally, few data have been published regarding subsequent conversions from malleable penile implants to hydraulic penile implants after salvage.

Recent technological development of penile prosthesis: a literature review

Background and Objective

In contemporary Urology, the gold standard for treatment of erectile dysfunction refractory to medical therapy has been implantation with a penile prosthesis. The past 40 years has witnessed evolutions in technology and surgical techniques, which have led to increased patient satisfaction rates and decreased complication and infection rates. This review is an update to a prior review article that evaluates these advancements in the context of patient satisfaction and different rates of complications following surgeries. In addition, the review compares malleable and inflatable prostheses with regard to infection rate, mechanical failure rate, and erosion rate.

Methods

A literature search was conducted using Medline and Google Scholar to examine papers from 1973 to the present day. Keywords, such as, "penile prosthesis surgery", "malleable penile prosthesis", "inflatable penile prosthesis", "two-piece Inflatable Penile Prosthesis (IPP)", and "three-piece IPP" were utilized during the search. A total of 76 papers were included, and all were in English.

Key Content and Findings

Studies on the latest models of each of the three prostheses (malleable, two-piece IPP, three-piece IPP) revealed patient satisfaction ratings at or above 75%. Both types of IPPs were associated with greater satisfaction and lower erosion rates while malleable prostheses were associated with lower mechanical failure rates. Although no significant differences in infection rates were noted between the prosthesis types, a history of diabetes, obesity, and smoking were predictive of infection events.

Conclusions

The three-piece IPP, if indicated for a suitable patient, is generally accepted as the best type of prosthesis given its biological mimicry to an erect human penis.

Implants with Sensing Capabilities

Because of the aging human population and increased numbers of surgical procedures being performed, there is a growing number of biomedical devices being implanted each year. Although the benefits of implants are significant, there are risks to having foreign materials in the body that may lead to complications that may remain undetectable until a time at which the damage done becomes irreversible. To address this challenge, advances in implantable sensors may enable early detection of even minor changes in the implants or the surrounding tissues and provide early cues for intervention. Therefore, integrating sensors with implants will enable real-time monitoring and lead to improvements in implant function. Sensor integration has been mostly applied to cardiovascular, neural, and orthopedic implants, and advances in combined implant-sensor devices have been significant, yet there are needs still to be addressed. Sensor-integrating implants are still in their infancy; however, some have already made it to the clinic. With an interdisciplinary approach, these sensor-integrating devices will become more efficient, providing clear paths to clinical translation in the future.

Relationships between erectile dysfunction, prostate cancer treatment type and inflatable penile prosthesis implantation

PURPOSE

The prevalence of erectile dysfunction (ED) and the utilization of inflatable penile prosthesis (IPP) among prostate cancer patients are understudied. The aim of the study was to examine the relationships between ED, prostate cancer treatment type and IPP implantation in a national cohort.

MATERIALS AND METHODS

We identified a retrospective cohort of Surveillance, Epidemiology, and End Results (SEER)-Medicare patients diagnosed with locoregional prostate cancer between 2006 and 2011 and treated with surgery or radiation. Chi-square tests were used to detect significant differences in ED rates as well as use of IPP among the subset with ED. Multivariable logistic regression was used to examine factors associated with the use of IPP.

RESULTS

Among 31,233 patients in our cohort, 10,334 (33.1%) received prostatectomy and 20,899 (66.9%) received radiation. ED within 5 years was significantly more common in the prostatectomy group relative to those the radiation group (65.3% vs. 33.8%, p<0.001). In the subset of 13,812 patients with ED, the radiation group had greater median time to ED diagnosis compared to the prostatectomy group (346 vs. 133 days, p<0.001). IPP implantation was more frequent for prostatectomy patients than for radiation patients (3.6% vs. 1.4%, p<0.001). Cancer treatment type, race, and marital status were significantly associated with IPP utilization.

CONCLUSIONS

ED is highly prevalent among prostate cancer patients, and IPP implantation is be underutilized. ED rates, time to ED diagnosis and utilization of IPP differed significantly by prostate cancer treatment type.

Safety and Efficacy of Inflatable Penile Prostheses for the Treatment of Erectile Dysfunction: Evidence to Date

Erectile dysfunction (ED) is a common problem, and prevalence rates are expected to rise as life expectancy increases worldwide. In more severe cases of ED, penile prosthesis implantation has been an excellent option for patients. Over the past few decades, significant design improvements have been made to the penile prosthesis and modifications to surgical technique to improve clinical outcomes. The purpose of this review is to summarize the safety and efficacy of FDA-approved penile implants in the US market. Design modifications have greatly improved the safety and reliability of the implant. Development of improved surgical techniques has decreased intraoperative injuries and reservoir-related complications. With its high overall satisfaction rates and low risk of complications, the inflatable penile prosthesis remains an excellent option for patients with erectile dysfunction.

The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis

BACKGROUND

The 3-piece inflatable penile prosthesis includes an easy-to-use pump and fluid filled reservoir which is placed in either the space of Retzius (SOR) or in an alternative ectopic location. Reservoir placement in the SOR is a blind procedure despite the SOR being surrounded by many critical structures. To date only a handful of cadaveric studies have described the relevant anatomy.

AIM

To use magnetic resonance imaging (MRI) as an in-vivo model to study relevant retropubic anatomy critical for SOR reservoir placement.

METHODS

The study population included men with elevated prostate specific antigen or biopsy proven prostate cancer who (i) underwent pelvic MRI, (ii) without prior pelvic or inguinal surgery, and (iii) without pelvic radiation therapy. All MRIs were completed with a 3-Tesla scanner and endorectal coil. Both T1 and T2 weighted images were captured in both axial and sagittal planes. All images were reviewed by 2 independent reviewers under the supervision of a dedicated body MRI radiologist. Bladder volume was calculated using an ellipsoid formula.

OUTCOMES

Relevant measurements included (i) the distance between the external inguinal ring (EIR) at the level of the pubic tubercle to the external iliac vein (EIV), (ii) the distance from the EIR at the pubic tubercle to the bladder (accounting for bladder volume) and (iii) the distance from the midline pubic symphysis to the bladder (accounting for bladder volume). Pearson correlation was used to determine correlated measurements.

RESULTS

A total of 24 patients were included. Median participant age was 63 years (interquartile range, 59-66). The mean EIR-EIV distance was 3.0 ± 0.4 cm, the mean EIR-bladder distance was 1.8 ± 1.0 cm and the mean distance from the superior pubic symphysis to bladder was 0.9 ± 0.3 cm. There was a weak correlation between bladder volume and distance between the EIR and bladder (r = -0.30, P = .16).

CLINICAL IMPLICATIONS

The use of MRI as an in-vivo model is a high-fidelity tool to study real time unaltered anatomy and allows for surgical preparation, diagnosis of anatomic variants and acts as a valuable teaching tool.

STRENGTHS & LIMITATIONS

This is the first in-vivo model to report relevant retropubic anatomy in penile implant surgery. Our study is limited by sample size and inclusion of participants with no history of prior pelvic intervention.

CONCLUSION

We demonstrate the utility of MRI as an in-vivo model, as opposed to cadaveric models, for the understanding of relevant retropubic anatomy for implant surgeons. Punjani N, Monteiro L, Sullivan J F et al. The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis. J Sex Med 2021;18:1830-1834.

Current Status for Semirigid Penile Prosthetic Devices

PURPOSE OF REVIEW

The goal of this paper was to evaluate the current use of semirigid penile prosthesis (SRPP), surgical techniques for insertion of SRPP, and how to prevent and approach surgical complications.

RECENT FINDINGS

SRPP is a valid option for those who are refractory to medical therapy for erectile dysfunction (ED) and even more appropriate for specific subsets of patient populations. It is important for urologists to know which patient population SRPP is preferred for. Several studies have shown good patient outcomes and patient satisfaction with those who underwent SRPP.

Infected penile prosthesis: literature review highlighting the status quo of prevention and management

INTRODUCTION

Erectile dysfunction affects over 50% of men 70 years and above, and penile prosthesis (PP) is its third-line treatment. Complications of PPs include infection, however, no formal guidelines exist for its management.

METHODS

We performed a literature search and reviewed 53 recent published literatures of experiences with management of PP infections, prevention, and treatment.

RESULTS

Acute infection can present early with pain and discharge and detection of early signs is of utmost importance. MRI studies are more sensitive than CT studies to diagnose and plan surgical intervention. Introduction of antibiotic impregnated devices attributed to the reduction of infection rates with superiority proven for certain types; the no-touch technique had further reduced this rate. The Mulcahy salvage remains the most widely used surgical approach for treatment despite modifications and novel techniques described; conservative management of PP infections is recently reported with promising results.

CONCLUSIONS

Despite absence of strict guidelines for the management of infected PPs, we reviewed and discussed numerous panel opinions and suggestions throughout literature. More research into the pathology, prevention, conservative management and advances in surgical treatment of this condition are called for to produce guidelines that unite the efforts to tackle these infections.

Epidemiology regarding penile prosthetic surgery

With the onset of a metabolic syndrome epidemic and the increasing life expectancy, erectile dysfunction (ED) has become a more common condition. As incidence and prevalence increase, the medical field is focused on providing more appropriate therapies. It is common knowledge that ED is a chronic condition that is also associated with a myriad of other disorders. Conditions such as aging, diabetes mellitus, hypertension, obesity, prostatic hypertrophy, and prostate cancer, among others, have a direct implication on the onset and progression of ED. Characterization and recognition of risk factors may help clinicians recognize and properly treat patients suffering from ED. One of the most reliable treatments for ED is penile prosthetic surgery. Since the introduction of the penile prosthesis (PP) in the early seventies, this surgical procedure has improved the lives of thousands of men, with reliable and satisfactory results. The aim of this review article is to characterize the epidemiology of men undergoing penile prosthetic surgery, with a discussion about the most common conditions involved in the development of ED, and that ultimately drive patients into electing to undergo PP placement.

A Comparison Between AMS 700 and Coloplast Titan: A Systematic Literature Review

There are only two three-piece inflatable penile prostheses (IPP) available to patients in the American market: the AMS (American Medical Systems) 700^TM series (Boston Scientific, Massachusetts) and the Coloplast Titan® series (Coloplast, Minnesota), and data comparing the two are scant. The aim of our study was to summarize the current scientific evidence comparing the two.

A systematic literature review was conducted on PubMed. A 10-year filter was placed to include only studies published after Coloplast launched the Titan Touch® release pump. Eligibility criteria included articles discussing specifically the AMS 700^TM and Coloplast Titan® models. Further searches for studies on patient/partner satisfaction were conducted. Abstracts were reviewed to include studies focusing specifically on the models we are studying and studies on patient satisfaction using the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire.

The Coloplast device demonstrated slightly greater resistance to the stimulated forces of penetration and gravity. Coloplast implants coated with vancomycin/gentamicin had the highest infection rate followed by the AMS penile prosthesis and the rifampin/gentamicin coating had the lowest infection rate. Prosthesis durability and survival were similar between both brands. Overall satisfaction was high but comparisons are inconsistent.

The literature is inconclusive about which device is superior. We suggest randomized, multicenter, prospective studies to help further elucidate the highlights of each product.

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.

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

Objective

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

Methods

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

Results

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

Conclusion

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

[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.

Two-piece inflatable and semi-rigid penile implants: an effective alternative?

Penile prostheses (PPs) are an excellent treatment to be considered for patients suffering from erectile dysfunction (ED), refractory to oral medications, or unwilling to consider intracavernosal injections or other therapeutic strategies. Nowadays the market is dominated by three-piece inflatable penile prosthesis (IPP), which are considered the best option available. However, in some specific cases three-piece IPP may be superseded by semi-rigid penile prosthesis (SRPP) and two-piece IPP. Despite the advantages of these implants, the literature is quite scarce, not robust and rarely takes into consideration the partner's satisfaction. This clearly affects the strength of our conviction. Most of the studies confirm that SRPPs and two-piece IPPs can be considered a valid alternative in patients with hand dexterity issues, refractory ischaemic priapism, neophallus and in cases of complex anatomies. In addition, the ease of placement and the high confidence level of surgeons make them a powerful tool in the armamentarium of urologists.

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.

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.

A Surgeon's Guide to the Various Antibiotic Dips Available During Penile Prosthesis Implantation

PURPOSE OF REVIEW

Inflatable penile prosthesis (IPP) is a treatment for erectile dysfunction. IPPs have undergone improvements; however, post-surgical infections still occur. Furthermore, the type of pathogens infecting the implants has changed recently from Gram-positive to Gram-negative bacteria and fungi due to advances in antibiotic dips targeting the skin flora. To protect against infection, the AMS 700 is pre-coated with InhibiZone (mixture of Rifampin/Minocycline) and the Coloplast Titan, with several antibiotic dip options of differing efficacies. This review discusses strategies to decrease the infection rates in implant surgery, focusing on antibiotic dips.

RECENT FINDINGS

Current research endorses the use of rifampin/gentamicin as the most studied combination; however, some studies have utilized different dips for additional coverage including the InhibiZone on the AMS 700. With the increasing prevalence of diabetes and Gram-negative organisms, there is a need to develop strategies for increased coverage against infections. Controlled studies with different antibiotic combinations are needed to identify the ideal cocktail to decrease infection.

The Serendipitous Story of Sildenafil: An Unexpected Oral Therapy for Erectile Dysfunction

INTRODUCTION

The serendipitous discovery of sildenafil (Viagra [sildenafil citrate]) as a treatment for erectile dysfunction (ED) is one of the most fascinating drug development stories of our time. When sildenafil was approved by the U.S. Food and Drug Administration in 1998, it revolutionized the treatment protocol for men with ED, once considered a psychological issue or an inevitable part of aging.

AIM

To review the discovery of sildenafil and its role in changing the field of sexual medicine in the context of the epidemiology and history of treatment for ED.

METHODS

For this narrative review, a literature search was conducted to identify essential articles and was supplemented by author observations from a historical perspective.

MAIN OUTCOME MEASURE

A broad overview of ED and its past, current, and future treatments.

RESULTS

ED is a prevalent condition for which medical treatment had been limited to genitally localized interventions, including surgery, vacuum pumps, injectable therapies, and intraurethral suppositories. The discovery of sildenafil provided a safe, oral pharmacotherapy for the treatment of ED, sparking greater understanding of the science behind ED and its role in men's overall health.

CONCLUSION

The approval of sildenafil initiated a global conversation about ED that had profound implications for patients, methods of clinical practice, and academic sexual medicine. These changes will catalyze continued advances in ED treatment. Goldstein I, Burnett AL, Rosen RC, et al. The serendipitous story of sildenafil: an unexpected oral therapy for erectile dysfunction. Sex Med Rev 2019;7:115-128.

Infection Retardant Coatings Impact on Bacterial Presence in Penile Prosthesis Surgery: A Multicenter Study

OBJECTIVE

To investigate patients for positive culture rates with or without infection retardant coatings (IRC) penile prostheses (PPs) and to examine changes in culture positive isolates found in patients presenting overt clinical infection.

METHODS

Cultures were obtained from PPs immediately upon surgical exposure of the pump. 236 patients were broken down into 2 groups, with each further divided into 2 groups. The noninfected group included 208 patients: 133 with uncoated PPs and 75 with IRC implants. The infected group included 28 patients: 16 with uncoated PP and 12 with IRC inflatable penile prostheses (IPP). Additionally, sensitivity to the combination of tetracycline and rifampin were evaluated on all cultures.

RESULTS

In the noninfected group, culture positive isolates were found in 85 patients with uncoated PP's and in 32 patients with IRC implants [P value = 0.0003]. Cultures positive for Staphylococcus genus were found in 75 uncoated PP patients, while 20 patients with IRC implants had an isolate of this genus. In the infected group, culture positive isolates were found in 7 patients with uncoated PP and 6 patients with IRC IPPs [P value = 1.000]. Positive cultures for Staphylococcus genus were found in 6 patients with uncoated PP, while 3 patients with IRC IPP had an isolate of this genus. All bacterial isolates were sensitive to the combination of tetracycline and rifampin.

CONCLUSION

Positive bacterial cultures have been shown to be present on clinically uninfected IPPs at time of revision surgery. Culture isolates grown from patients with IRC IPPs reveal a nontraditional bacterial profile: fewer cultured isolates of Staphylococcus genus.

Medical pre-operative considerations for patients undergoing penile implantation

Penile prosthesis surgery has become the standard treatment for patients with erectile dysfunction refractory to medical management. Refinements in the both the surgical technique and device manufacturing have made this a safe and reliable treatment with excellent patient satisfaction. In this review, we will overview the basic medical and pre-operative considerations for patients undergoing penile prosthesis implantation. We intend to provide a simple and practical checklist for the implanter to reference when considering implantation of a penile prosthesis.

Penile implants: a look into the future

Inflatable penile prosthesis (IPP) has been around since the 1970’s as a durable and one-time cure for erectile dysfunction (ED). For the past 40 years, many changes have been made to make the device better and currently IPP boasts a high percentage of long-term patient satisfaction. The next paradigm shift in IPP treatment for ED is upon us. Funding for ED related medications and devices has been a hot topic in health policy over the last 10 years. This suggests that the device must improve and patient advocacy and education must increase for IPP to remain as a viable solution for ED. In this paper, we conduct a literature search for innovations in IPP and argue that IPP must constantly improve to compete with oral, injectable, shockwave, and potentially gene therapies.

Salvage penile prosthetic surgery utilizing temporary malleable implants

The inflatable penile prosthesis (IPP) is an effective erectile dysfunction (ED) treatment modality when oral and injectable therapies fail to achieve satisfactory results. Unfortunately, infection of the prosthetic remains a dreaded complication occurring in a small fraction of patients despite advances in device design and surgical techniques. With a prosthetic infection or erosion, classic management has included removal of all hardware with thorough irrigation of the infected spaces. To prevent corporal fibrosis and scarring that can make a subsequent implant challenging, an immediate salvage procedure with a three-piece prosthesis has been advocated when possible. However, there has been recent interest in using malleable devices during salvage procedures to serve as a temporary implant and further improve outcomes. Based on a literature review of immediate salvage procedures for infected penile prostheses, management with typical Mulcahy washout and IPP reimplant may be quite successful in appropriately selected patients. Based on one case series and a second multicenter trial of malleable salvage procedures, utilizing a malleable as a temporary implant is similarly, if not more, successful at eradicating prosthetic infection. The malleable implant not only serves as a temporary space-filling corporal implant to prevent fibrosis, but may also prove an adequate destination therapy for some given the lower than expected rate of delayed conversion to inflatable prosthesis. Future studies are needed to better characterize the role of malleable devices for penile prosthetic salvage and query patient satisfaction with the malleable device and repeated surgeries.

A history of penile implants

Erectile dysfunction (ED) has long been described by physicians and patients, with treatments for ED proposed starting in the 8^th century BC. In the last 50 years, however, there have been many advances in medical and surgical management of ED, notably the introduction of the inflatable penile prosthesis (IPP) in 1973 and phosphodiesterase type 5 inhibitors (PDE5Is) in 1998. Here we review the evolution of the IPP from 1973 through the current day. The 3-piece device was first described in 1973 by Dr. F. Brantley Scott, who helped found American Medical Systems (AMS) to market and sell the device. In 1983, Mentor (now Coloplast) started marketing a competing device. AMS and Mentor have made multiple modifications to the device over the years, which have increased rigidity, durability and patient satisfaction, and have decreased surgical variability, post-operative infection and spontaneous inflation. Today, the IPP is a safe and effective option for many men who have failed medical therapies, with high satisfaction from both patients and partners.

Usefulness of magnetic resonance imaging in the postsurgical assessment of patients with inflatable penile prostheses

OBJECTIVE

To describe the types of penile prostheses and their components, to review the appropriate magnetic resonance imaging (MRI) acquisition protocol, and to describe the normal imaging findings and possible complications in patients with inflatable penile implants.

CONCLUSION

Three-piece inflatable penile prostheses are the last link in the treatment chain for erectile dysfunction. They can develop complications, which are classified as non-infectious related to the surgical technique, infectious, or due to mechanical failure of the device. MRI is the most appropriate imaging technique for the postsurgical evaluation of penile prostheses. Images are acquired in three planes using sequences with high spatial resolution, first with the prosthesis at rest and then with the prosthesis activated.

Ischaemic priapism: A clinical review

OBJECTIVE

Ischaemic priapism is a rare condition characterised by little or no cavernosal blood flow, pain and rigidity of the penis. Immediate intervention is required to restore blood flow, prevent necrosis and erectile dysfunction. This review was conducted to determine the best course of treatment and identify areas in current guidelines to which improvements could be made.

MATERIAL AND METHODS

PubMed, Ovid, MEDLINE (1946-December 2016) and the Cochrane Library were searched as sources for literature. Key studies in each of the areas of management were identified and analysed.

RESULTS

A total of 45 articles were reviewed. The first step in treatment should be aspiration of corporeal blood. Further studies are needed to make firm recommendations as to whether irrigation should follow, as currently literature is inconclusive. If this fails to cause detumescence, sympathomimetics should be injected. The sympathomimetic of choice is phenylephrine as it is effective, specific and causes minimal cardiovascular side effects. It should be injected at a concentration of 100-500 μg/mL, with 1 mL being injected every 3-5 minutes for up to an hour (maximum 1mg in an hour). Surgical shunting is the next step, except in the cases of delayed priapism (48-72 hours duration) where immediate penile prosthesis insertion may be considered more appropriate. Distal shunts should be performed first, followed by proximal ones to minimise damage leading to erectile dysfunction. There exists little evidence recommending one shunting procedure over another. The final intervention is insertion of a penile prosthesis. Literature suggests that an inflatable prosthesis inserted immediately will yield the greatest patient satisfaction.

CONCLUSION

A review of the literature has highlighted areas in which further research needs to be done to make conclusive recommendations, including whether irrigation should accompany aspiration and efficacy of shunting procedures. Further studies are required to ensure that patients receive the treatment most likely to cause detumescence and maintain erectile function.

Prostate cancer survivorship: Implementation of survivorship care plans to meet the mandate and enhance urologic practice through collaborative care

Prostate cancer is the most common malignancy among the male survivorship population in the United States, representing 44% of approximately 7 million survivors. In the era of modern medicine and value-based care, successfully treating only the cancer is not sufficient. The cancer survivor represents an individual in need of restoration and protection against future events. A well-designed and well-supported survivorship program not only meets a mandate for accreditation, it logically translates into better patient care. This review summarizes the history of the survivorship movement, outlines some key elements of a survivorship program, and highlights the opportunity to apply these principles to improve cancer-related care, develop relationships with colleagues that may allow increased identification of men at risk, and expand both the experience and outcomes of individual specialists within men's health.

The Evolution and Utility of the Small-Carrion Prosthesis, Its Impact, and Progression to the Modern-Day Malleable Penile Prosthesis

INTRODUCTION

Erectile dysfunction has plagued humanity for millennia. For years, treatment had been in the hands of mental health professionals. It was not until the 1970s that urologists created a modality that was marketable, reproducible, and consistently successful at treating impotence, the Small-Carrion Penile Prosthesis.

AIM

We present the evolution of the malleable/semi-rigid penile prosthesis, concentrating our efforts reviewing and critiquing the pivotal article published by Drs. Michael P. Small, Hernan M. Carrion, and Julian A. Gordon. We then discuss its continued advancement, current-day utilization, and the future of the malleable prosthesis.

METHODS

From the early 1900s, surgeons have been toying with the idea of creating a penile implant. These initial attempts utilized rib cartilage, and eventually synthetic materials, including acrylic, silicone, and polyethylene.

RESULTS

In 1975, Drs. Carrion and Small presented their initial experience of 31 patients utilizing their silicone implant. In their manuscript titled, "The Small-Carrion Penile Prosthesis: New Implant for the Management of Impotence," they discuss their technique, perioperative management of complications, and results.

CONCLUSIONS

The malleable penile prosthesis continued to evolve throughout the years to the current day Genesis and Spectra. Although the current market is dominated by the inflatable penile prosthesis, there are specific situations where the malleable is ideally utilized. The pivotal article by Drs. Carrion and Small helped pave the way for the "New Era" of penile prosthetics and still remains one of the most impactful contributions to the management of erectile dysfunction.

Stretch due to Penile Prosthesis Reservoir Migration

A 43-year old patient presented to the emergency department with stretch, due to impossible deflation of the penile prosthesis, 4 years after successful implant. A CT-scan showed migration of the reservoir to the left rectus abdominis muscle. Refilling of the reservoir was inhibited by muscular compression, causing stretch. Removal and replacement of the reservoir was performed, after which the prosthesis was well-functioning again. Migration of the penile prosthesis reservoir is extremely rare but can cause several complications, such as stretch.

Silicone implants and lymphoma: The role of inflammation

The risk of hematological malignancies is mainly determined by genetic background, age, sex, race and ethnicity, geographic location, exposure to certain chemicals and radiation; along with the more recently proposed immune factors such as chronic inflammation, immunodeficiencies, autoimmunity, and infections. Paradigmatic examples include the development of lymphoma in Sjögren's syndrome and Hashimoto thyroiditis, gastric MALT lymphoma in Helicobacter pylori infection, or lymphomas associated with infections by Epstein-Barr virus, human herpes virus 8 (HHV 8) and leukemia/lymphoma virus 1 (HTLV-1). A growing number of reports indicates an increased risk of lymphoma, particularly of the anaplastic large cell (ALCL) type. The implants, specifically those used in the past, elicit chronic stimulation of the immune system against the prosthetic material. This is particularly the case in genetically susceptible hosts. We suggest that polyclonal activation may result in monoclonality in those at risk hosts, ultimately leading to lymphoma. We suggest that patients with an inflammatory response against silicone implants be monitored carefully.