Complication rates in concurrent inflatable penile prosthesis and incontinence surgery: Comparing the penoscrotal versus perineal incision approach

The main objective of this study was to assess the IPP complication rates of patients undergoing placement via perineal incision versus more traditional penoscrotal approach in synchronous dual implantation. We identified 38 patients who underwent dual implantations of an IPP and AUS or urethral sling from 2011 to 2021 at a single tertiary center, 24 via perineal and 14 via penoscrotal incision. All IPP implants were done by a single surgeon. IPP postoperative complications were captured using the Clavien-Dindo classification at three separate time points, < 30 days, 30 days - 6 months, and > 6 months. The perineal group had two complications, IPP explantation due to rectourethral fistula (Grade III, > 6 months), and IPP explantation due to chronic genital pain (Grade III, > 6 months). The penoscrotal group had three complications, post-operative urinary retention requiring catheterization (Grade I, < 30 days), incision site infection (Grade I, < 30 days), and IPP explantation due to infection (Grade III, 30 days to < 6 months). There was no statistically significant difference in rate of patients with IPP complications between the two groups (p = 0.546) or in rate of IPP device malfunction (p = 0.264). These preliminary findings suggest that the single perineal incision is a viable surgical approach in synchronous dual implantation.

A pilot study of inflatable penile prosthesis placement in transgender neophallus using Tutoplast® pericardium graft sock technique

Placement of an inflatable penile prosthesis (IPP) in a transgender patient's neophallus carries unique considerations versus cis-gender IPP placement in mitigating infection, erosion, and overall complication rates. An example of this includes the lack of an anatomical corpus cavernosum and crura for cylinder placement and anchoring. Multiple grafting approaches and materials have been utilized to mitigate possible cylinder instability and improve anchoring. Here we describe our experience and surgical technique in IPP neophallus placement utilizing a single cylinder with distal and proximal cylinder human cadaver pericardium (Tutoplast®, IOP Ophthalmics, Costa Mesa, CA, USA) grafts. Our goals were to determine postoperative satisfaction and device functionality in patients undergoing transgender neophallus IPP placement using our technique. Both patients report satisfaction and no complications at last follow-up (currently up to 14 and 23 months post-operatively, respectively) with satisfactory erectile function and ability to perform penetrative intercourse. In neophallus IPP placement, the anatomical differences compared to cis-gender IPP operations require unique considerations such as cylinder grafting material selection for proximal cylinder fixation and mitigation of device erosion rates. Optimization of grafting material in neophallus IPP placement in an effort to reduce erosion rates has become increasingly important as frequency of this operation increases. Utilizing human cadaver pericardium graft in distal and proximal cylinder coverage shows beneficial preliminary outcomes in our patients.

Comparison of satisfaction with penile prosthesis implantation in patients with prostate cancer radiation therapy versus radical prostatectomy

Background

Penile prosthesis surgery (PPS) is a commonly used treatment for erectile dysfunction (ED), either as first-line therapy or in cases refractory to other treatment options. In patients with a urologic malignancy such as prostate cancer, surgical interventions like radical prostatectomy (RP) as well as non-surgical treatments such as radiation therapy can all induce ED. PPS as a treatment for ED has high satisfaction rates in the general population. Our aim was to compare sexual satisfaction in patients with prosthesis implantation for ED following RP versus ED following radiation therapy for prostate cancer.

Methods

A retrospective chart review from our institutional database was conducted to identify patients who underwent PPS at our institution from 2011 to 2021. Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire data at least 6 months from implant operative date available was required for inclusion. Eligible patients were placed in one of two groups depending on etiology of ED-following RP or prostate cancer radiation therapy. To prevent crossover confounding; patients with history of pelvic radiation were excluded from the RP group and patients with history of RP were excluded from the radiation group. Data were obtained from 51 patients in the RP group and 32 patients in the radiation therapy group. Mean EDITS scores and additional survey questions were compared between the radiation and RP groups.

Results

There was a significant difference in mean survey responses for 8 of the 11 questions in the EDITS questionnaire between the RP group and the radiation group. Additional survey questions administered also found RP patients reported significantly higher rate of satisfaction with size of penis post-operatively versus the radiation group.

Conclusions

These preliminary findings, while requiring large-scale follow-up, suggest that there is greater sexual satisfaction and penile prosthesis device satisfaction in patients undergoing IPP placement following RP versus radiation therapy for prostate cancer. Use of validated questionnaires should continue to be utilized in quantifying device and sexual satisfaction following PPS.

Is There A Benefit of Restaging Transurethral Resection of Bladder Tumor Prior to Radical Cystectomy With or Without Neoadjuvant Chemotherapy?

BACKGROUND: One of the best predictors of positive outcomes in bladder cancer (BC) is pT0 following radical cystectomy (RC). Discordance between clinical and pathologic staging affects decision-making in patients with clinical absence of disease (cT0). OBJECTIVES: We sought to determine whether a restaging transurethral resection of bladder tumor (re-TURBT) improves clinical staging accuracy relative to pathologic stage RC in patients treated with neoadjuvant chemotherapy (NAC) versus those who did not receive NAC. METHODS: We queried our prospectively maintained IRB approved institutional database to identify 129 patients who underwent RC from 2013 to 2019 with a re-TURBT prior to RC. 53 patients were treated with NAC between their initial and re-TURBT and 76 patients were not treated with NAC. RESULTS: The overall upstaging rate from re-TURBT to RC was 34.9% . There was no significant difference in the upstaging rate between the NAC and no-NAC groups - 31.0% vs. 37.0%, respectively. In patients who were cT0 on re-TURBT, the NAC group did not show a significantly greater rate of pathologic clinical CR (pT0) than the no NAC group - 38.5% vs. 37.5%, respectively. Re-TURBT with staging <  rT2 as a predictor for absence of MIBC on pathologic staging (<ypT2) did not show a significant difference between the NAC and no NAC group, with a negative predictive value (NPV) of 69.0% and 66.7%, respectively. CONCLUSIONS: Re-TURBT after NAC does not show statistically significant improvement in staging accuracy relative to pathologic stage at RC compared to re-TURBT in patients not treated with NAC.

Complication Rates in Patients Using Intracavernosal Injection Therapy for Erectile Dysfunction With or Without Concurrent Anticoagulant Use-A Single-Center, Retrospective Pilot Study

Background

Intracavernosal injection therapy (ICI) is an effective intervention used to treat erectile dysfunction (ED). It has been proposed that caution should be exercised when prescribing ICI to patients currently taking anticoagulants (AC) due to the theoretical increased risk of bleeding, however, there is limited literature describing complication rates of actively anticoagulated patients utilizing ICI.

Aim

We sought to determine whether there was a difference in bleeding and other complications in a cohort of patients using ICI therapy with or without concurrent AC use.

Methods

We reviewed our institutional electronic health record and identified 168 patients who were seen in our clinic from January to August 2020 who had either currently or previously utilized ICI therapy for ED treatment. These patients were surveyed regarding their ICI therapy as well as given the erectile dysfunction inventory for treatment satisfaction questionnaire. Data from 85 patients was obtained; 43 concurrently using AC during ICI therapy and 42 with no AC use. Fisher's exact test for categorical variables and a 2-tailed t-test were used with P < .05 considered to be significant.

Outcome

Documented bleeding events (eg, bruising, hematoma), complications, and mean erectile dysfunction inventory for treatment satisfaction scores were compared between the 2 groups.

Results

There were more absolute bleeding complications in the AC group vs the no AC group, with 3 of 43 AC patients (7%, 95% confidence interval: 2.4–18.6) and 0/42 no AC patients (0%, 95% confidence interval: 0–8.4) experiencing some type of bleeding complication on ICI. However, there was no statistically significant difference found in overall or stratified documented bleeding events and complications between the 2 groups.

Clinical Implications

Patients with concurrent AC usage on ICI therapy reported a higher rate of absolute bleeding complications than our non-AC group.

Strengths and Limitations

The strength of this study is addressing question of safety of ICI therapy in patients with concurrent AC usage. Limitations include single-center retrospective study design and underpowered sample size limiting confidence with which conclusions from data should guide future patient counseling regarding ICI risks.

Conclusion

Findings from a single-center cohort of patients suggest that ICI therapy may be a safe and effective treatment modality for ED in patients with concurrent anticoagulant usage, however, given the higher rate of absolute bleeding events in our AC cohort, future assessment in a higher-powered study is warranted in determining a more accurate estimation of risk or propensity for bleeding complications in patients on AC using ICI therapy.

Blum KA, Mehr JP, Green T, et al. Complication Rates in Patients Using Intracavernosal Injection Therapy for Erectile Dysfunction With or Without Concurrent Anticoagulant Use—A Single-Center, Retrospective Pilot Study. Sex Med 2022;10:100535.