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Urology Nov 2023To assess the difference in outcomes between single dilation (SingD) and sequential dilation (SeqD) in primary penile implantation, hypothesizing that patients who...
OBJECTIVE
To assess the difference in outcomes between single dilation (SingD) and sequential dilation (SeqD) in primary penile implantation, hypothesizing that patients who undergo SeqD had higher rates of noninfectious complications.
METHODS
We performed a multicenter, retrospective study of men undergoing primary inflatable penile prosthesis placement. Intraoperative complications and postoperative noninfectious outcomes were assessed between the two groups. Multivariable analysis was performed to identify predictors of complications.
RESULTS
A total of 3293 patients met inclusion criteria. After matching, there were 379 patients who underwent SingD and 379 patients who underwent SeqD. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length (20 cm with interquartile range [IQR] 18-21 cm vs 20 cm with IQR 18-20 cm respectively, P = .4). On multivariable analysis, SeqD (OR 5.23 with IQR 2.74-10, P < .001) and older age (OR 1.04 with IQR 1.01-1.06, P = .007) were predictive of postoperative noninfectious complications. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length. SeqD and older age were predictive of postoperative noninfectious complications.
CONCLUSION
During inflatable penile prosthesis placement in the uncomplicated patient without fibrosis, SingD is a safe technique to utilize during implantation that will minimize postoperative adverse events, and promote device longevity without loss of cylinder length.
Topics: Male; Humans; Penile Prosthesis; Retrospective Studies; Dilatation; Penile Implantation; Postoperative Complications; Intraoperative Complications; Erectile Dysfunction
PubMed: 37574145
DOI: 10.1016/j.urology.2023.06.037 -
International Journal of Impotence... Sep 2023Penile prosthesis infection remains a rare but devastating complication of implantation. Historically, management of device infection was always extirpation. While... (Review)
Review
Penile prosthesis infection remains a rare but devastating complication of implantation. Historically, management of device infection was always extirpation. While certainly effective, device removal leaves an unhappy patient with a shortened penis. In this last part of a three-part series on the topic of penile prosthesis infection, we seek to highlight new and emerging ideas of infection management which have allowed surgeons the option of preserving the implanted status in select patients.
Topics: Male; Humans; Penile Implantation; Penile Prosthesis; Penile Diseases; Penis
PubMed: 33750937
DOI: 10.1038/s41443-020-00382-8 -
Sexual Medicine Reviews Jun 2024Refractory priapism, characterized by persistent and prolonged painful erections despite initial treatment maneuvers, can significantly impair erectile function... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Refractory priapism, characterized by persistent and prolonged painful erections despite initial treatment maneuvers, can significantly impair erectile function secondary to ischemia-induced corporal tissue fibrosis. These patients will likely require subsequent penile prosthesis (PP) surgery to regain sexual activity, yet consensus regarding the optimal timing of implantation remains lacking.
OBJECTIVES
To evaluate and compare the clinical outcomes associated with early vs delayed PP implantation in individuals with priapism-induced erectile dysfunction (ED).
METHODS
We included studies that focused on refractory priapism leading to ED and its management with PP implantation. We assessed cohort study bias with a risk-of-bias tool and case series bias with the modified Newcastle-Ottawa Scale. Pooled odds ratios (ORs) were calculated by a fixed-effect model.
RESULTS
We included 9 studies, comprising 4 cohort studies and 5 case series, involving a total of 278 patients. Total complications were higher in the delayed group (OR, 4.16; 95% CI, 2.77-6.26). Fibrosis was significantly more pronounced in the delayed group (OR, 118.18; 95% CI, 20.06-696.32). The odds of erosion, infections, and penile injury did not show statistically significant differences between the groups (OR, 2.52 [95% CI, 0.67-9.49], 0.89 [0.38-2.10], 1.83 [0.79-4.26], respectively). Patients' satisfaction resulted in a pooled OR of 0.15 (95% CI, 0.04-0.49) in favor of the early PP insertion group.
CONCLUSION
The results from this study favor an early approach to ED (within 30 days) following ischemic priapism. However, it is important to consider patients' preferences, values, and psychological factors to make an informed decision.
Topics: Humans; Male; Priapism; Penile Implantation; Penile Prosthesis; Erectile Dysfunction; Time Factors; Time-to-Treatment
PubMed: 38465856
DOI: 10.1093/sxmrev/qeae007 -
International Journal of Impotence... May 2024The purpose of this investigation was to examine the timing of penile prosthesis infection management by different responsible organisms. A retrospective cohort study...
The purpose of this investigation was to examine the timing of penile prosthesis infection management by different responsible organisms. A retrospective cohort study was performed of patients who underwent penile prosthesis salvage or explant procedures due to a suspected infection between 2001 and 2018. The cohort consisted of 216 patients from 33 different facilities and six countries. The most common primary organisms responsible for device infections included, Gram-positives (31.5%), no growth cultures (30.6%), Gram-negatives (22.2%), fungal (11.6%), and anaerobic organisms (4.2%). Overall, median time to infection was 1.8 (interquartile range [IQR]: 1.0-3.0) months for all patients. Median time to infection management was similar between responsible organisms: 1.0 (IQR: 1.0-2.3) months for Gram-negatives and 2 months for Gram-positives (IQR: 1.0-1.4), fungal (IQR: 1.0-5.0), anaerobes (IQR: 1.0-2.5), and no growth cultures (IQR: 1.0-3.0, p = 0.56). Median time to infection management was significantly shorter among patients who received aminoglycoside/vancomycin prophylaxis (1.5 months, IQR: 1.0-2.5, p < 0.01) compared to other antibiotic groups. Median time to infection management was significantly longer for patients managed with a three-piece inflatable implant salvage procedure (2.8 months, IQR: 1.0-5.0, p = 0.02) compared to other salvage procedures. Conventional wisdom surrounding early versus late penile prosthesis infections should largely be abandoned. More than half of penile prosthesis infections are surgically managed within 2 months of initial device placement.
PubMed: 36564583
DOI: 10.1038/s41443-022-00659-0 -
International Journal of Impotence... Nov 2023A penile prosthesis/implant is an excellent option for men with erectile dysfunction refractory to medical treatment or with contraindications to medical management. In... (Review)
Review
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.
Topics: Male; Humans; Penile Prosthesis; Penile Implantation; Erectile Dysfunction; Penis; Patient Satisfaction
PubMed: 37741958
DOI: 10.1038/s41443-023-00765-7 -
Therapeutic Advances in Urology 2024Penile shortening, frequently resulting from end-stage Peyronie's disease (PD), has a negative impact on patients' sexual activity and overall quality of life,... (Review)
Review
Risk and benefits of penile length preservation techniques during penile prosthesis implantation: a systematic review by the young academic urologists sexual and reproductive health working group.
BACKGROUND
Penile shortening, frequently resulting from end-stage Peyronie's disease (PD), has a negative impact on patients' sexual activity and overall quality of life, especially when accompanied by Erectile dysfunction (ED). Various surgical techniques have been described to manage concomitant ED and penile shortening through penile prosthesis (PP) implantation.
OBJECTIVES
To evaluate the benefits and risks of different penile length preservation techniques during PP implantation.
DESIGN
A systematic review of the available literature on the use of penile length preservation maneuvers in conjunction with PP implantation was conducted.
DATA SOURCES AND METHODS
For this systematic review, three databases (Medline, Embase and Cochrane) and clinical trial.gov were queried for relevant publications from 1 January 1990 to 1 September 2022. The review process followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.
RESULTS
The qualitative analysis included 15 relevant articles involving 1186 adult patients who underwent penile length preservation techniques during PP implantation. Penile lengthening of 1-7 cm was reported. Overall, postoperative complications were described in up to 21.7% of cases. Only five studies reported functional outcomes, showing a significant improvement in postoperative period based on the administered questionnaire (e.g. IIEF - International Index of Erectile Function, EDITS - Erectile Dysfunction Inventory of Treatment Satisfaction).
CONCLUSION
Penile length preservation procedures appear to offer a viable option for managing acquired penile shortening, particularly in cases of PD. However, they are associated with a significant risk of complications. Proper patient selection, thorough discussion of risks and benefits, and referral to high-volume centers are mandatory to achieve optimal outcomes and minimizing complications.
TRIAL REGISTRATION
PROSPERO database registration CRD42022360758.
PubMed: 38205393
DOI: 10.1177/17562872231215177 -
Archivos Espanoles de Urologia Apr 2024Plaque incision and grafting (PEG) is a primary surgical therapy for severe penile curvature in Peyronie's disease (PD); However, it can increase the risk of erectile... (Comparative Study)
Comparative Study
BACKGROUND
Plaque incision and grafting (PEG) is a primary surgical therapy for severe penile curvature in Peyronie's disease (PD); However, it can increase the risk of erectile dysfunction (ED), particularly in patients with pre-operative mild ED. Soft penile prosthesis (SPP) implantation is a viable treatment option in such cases. This study aims to compare the outcomes of PEG-only approach to PEG plus SPP implantation.
METHODS
Between 2010 and 2019, 32 patients with PD and mild ED (5-item version of the International Index of Erectile Function scores: 17-21) underwent PEG surgery. Two groups were defined based on the surgery type: PEG-only and PEG plus SPP. The long-term outcomes included correction of penile bending, erection quality, intercourse ability, penile length and sensitivity. The overall satisfaction and impact of surgery on sexual activity and quality of life were also assessed.
RESULTS
Of the 32 patients, 13 (40.6%) underwent PEG-only surgery, whereas 19 (59.4%) underwent PEG plus SPP. No significant differences were noted between the groups regarding pre-operative characteristics (all > 0.1) or intra- and post-operative complication rates (all > 0.2). The median patch area was larger in the PEG-only group (28 cm vs. 16.2 cm; = 0.001), whereas patients in the PEG plus SPP group were more likely to receive a single patch implant (100% vs. 53.8%; < 0.001). The penile length increased in 18 patients (61.6%), with significant differences between the two groups (30% vs. 81.2%; = 0.03). Overall, 14 patients (53.8%) reported greater satisfaction with their sexual life post-operatively, with comparable rates between the groups ( = 0.2). No significant differences were found in the post-operative 5-item version of the International Index of Erectile Function scores or severe post-operative ED (all > 0.5).
CONCLUSIONS
SPP placement during corporoplasty in patients with mild ED is safe and feasible, and it may be a suitable option for patients uncertain about inflatable prosthesis placement. The use of SPP resulted in longer penile lengths and necessitated smaller grafts. However, further data are required to understand the long-term clinical implications of this approach.
Topics: Humans; Male; Penile Induration; Erectile Dysfunction; Penile Prosthesis; Middle Aged; Penile Implantation; Prosthesis Design; Severity of Illness Index; Retrospective Studies; Adult; Urologic Surgical Procedures, Male; Treatment Outcome
PubMed: 38715168
DOI: 10.56434/j.arch.esp.urol.20247703.36 -
Translational Andrology and Urology Apr 2024Implantation of a penile prosthesis is a reliable option for men with erectile dysfunction (ED) refractory to less invasive therapies. While the frequency of penile... (Review)
Review
BACKGROUND AND OBJECTIVE
Implantation of a penile prosthesis is a reliable option for men with erectile dysfunction (ED) refractory to less invasive therapies. While the frequency of penile prosthesis infections have decreased, they remain a devastating complication. Herein we discuss why immediate salvage surgery is an essential technique for the management of implant infections. We will also describe the relevant advancements to this technique.
METHODS
We conducted a narrative review via computer based search of PubMed for all relevant articles on penile prosthesis infection management, including guidelines, case series, reviews, and expert opinions. Search terms used included: "inflatable penile prosthesis", "IPP", "penile prosthesis", "salvage", "treatment", "delayed", "immediate". Only English peer-reviewed publications were included.
KEY CONTENT AND FINDINGS
Historically, patients who presented with penile prosthesis infections were exclusively managed with complete removal of the prosthesis without replacement. Although this strategy is safe, it hastens immediate ED and corporal fibrosis, resulting in loss of penile length and increased difficulty with subsequent prosthesis replacement. Previous case series have reported successful treatment of localized penile prosthesis infections with nonsurgical treatment, but the role of conservative treatment remains limited. The current standard of immediate salvage entails removal of the infected prosthesis and washout followed by immediate replacement with a new penile prosthesis. This technique has been demonstrated to be safe and effective, thus allowing patients to resume intercourse and maintain penile length.
CONCLUSIONS
Immediate salvage surgery is safe and effective, and has emerged as the preferred strategy for the management of most patients with a penile prosthesis infection.
PubMed: 38721291
DOI: 10.21037/tau-23-277 -
Urology Jan 2024Musculocutaneous latissimus dorsi (MLD) phalloplasty is a gender-affirming surgical option for transmen which permits penile prosthesis, glansplasty, and urethral...
BACKGROUND
Musculocutaneous latissimus dorsi (MLD) phalloplasty is a gender-affirming surgical option for transmen which permits penile prosthesis, glansplasty, and urethral extension at later stages. This surgery allows for a neophallus of adequate length and girth, and minimal donor site morbidity, but is technically complex.
OBJECTIVE
This video demonstrates a step-by-step technique and tips to optimize outcomes and simplify the operation for the MLD phalloplasty.
MATERIALS AND METHODS
A 33-year-old transmale who previously underwent metoidioplasty presented for an MLD phalloplasty. With the patient in a supine position, the superficial femoral artery and saphenous vein are isolated at the recipient site. The patient is repositioned into a lateral flank position, the flap harvested and tubularized, and inferior aspects of the wound closed prior to harvesting the thoracodorsal artery (TDA) and thoracodorsal vein (TDV) to minimize cold ischemia time. The TDA and TDV are dissected to their root at the subscapular artery and vein. The artery is removed with a patch of the subscapular artery. The patient is initially in a supine position and then returned to a supine position to minimize ischemia time of the flap. The neophallus is attached to the previously created recipient site, and an end-to-side anastomosis is created between the superficial femoral artery and TDA and an end-to-end anastomosis between the saphenous vein and the TDV. If the patient has a thick latissimus dorsi muscle or subcutaneous fat, a split-thickness skin graft can be used to close the ventral phallus to minimize tension on the tubularized neophallus and provide a plate for a future urethral lengthening procedure. Positioning and close post-op monitoring of the neophallus are critical.
RESULTS
A neophallus of adequate length and girth is created with the option for future urethral extension and penile prosthesis placement.
CONCLUSION
Our video demonstrates the technique for a gender-affirming MLD phalloplasty in a transman and tips to optimize outcomes and simplify the operation.
Topics: Male; Humans; Adult; Phalloplasty; Superficial Back Muscles; Surgical Flaps; Sex Reassignment Surgery; Urethra
PubMed: 38167598
DOI: 10.1016/j.urology.2023.10.010 -
The French Journal of Urology Jun 2024With 50 years' experience, inflatable penile implants are the preferred option for erectile dysfunction refractory to pharmacological and mechanical treatment. Technical... (Review)
Review
INTRODUCTION
With 50 years' experience, inflatable penile implants are the preferred option for erectile dysfunction refractory to pharmacological and mechanical treatment. Technical and surgical improvements have optimized patient success and satisfaction. However, multi-factorial dissatisfaction persists.
OBJECTIVE
The aim of this study is to provide an overview of available technological improvements and innovations, as well as the perioperative management and complications of inflatable penile implant surgery.
METHOD
A literature review was carried out over the last twenty years to answer 4 questions: what are the different inflatable penile implants available in 2023, for which indications, results and complications.
RESULTS
Four companies propose inflatable penile implants in France. The main improvements have been in the various components of the prosthesis with better cylinder extension, more ergonomic reservoirs, and more manageable pumps, leading to a better durability. Indications have been extended to patients suffering from Peyronie's disease and in emergency cases of priapism. In response to demand from the transgender population, specific phalloplasty implants have been developed. New options are being developed for difficult cases of retracted penis. Results show a high satisfaction rate. Currently the main challenge is the management of infection with the development of rescue protocols using antibiotics to preserve implants - or replace them in a single operation.
CONCLUSION
After 50years' experience, improvements in penile implants led to effective, satisfactory and safe treatment and can be proposed in new indications. Further development is sill necessary to offer solutions in difficult cases.
Topics: Humans; Penile Prosthesis; Male; France; Erectile Dysfunction; Prosthesis Design; Penile Implantation; History, 20th Century; History, 21st Century; Patient Satisfaction
PubMed: 38599322
DOI: 10.1016/j.fjurol.2024.102635