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Translational Andrology and Urology Oct 2023Transgender and gender diverse (TGD) individuals may seek gender-affirming phalloplasty with specific functional goals, including erectile function sufficient for... (Review)
Review
BACKGROUND AND OBJECTIVE
Transgender and gender diverse (TGD) individuals may seek gender-affirming phalloplasty with specific functional goals, including erectile function sufficient for penetrative sexual intercourse. Individuals seeking penile prosthesis placement must accept the potential risks to their phallic anatomy.
METHODS
We review current practices at our center and narrative review of literature discussing techniques for penile prosthesis and testicular prosthesis placement after phalloplasty and scrotoplasty, as well as surgical outcomes, and quality of life outcomes where available.
KEY CONTENT AND FINDINGS
Early discussion of a staged approach to phallic construction with a last step of implant placement is important during initial phalloplasty counseling. Pre-operative counseling at our multi-disciplinary center includes: discussion of surgical history, complications, goals and priorities; physical exam to evaluate phallic size and position, scrotal size, and other anatomic findings that may influence prosthesis selection; urinary evaluation, including uroflowmetry with post-void residual, and a cystoscopy with retrograde urethrogram if indicated based on symptoms or urinary studies, and discussion of surgical risks, benefits and alternatives. Although none of the commercially available penile prosthesis devices in the United States are designed for phalloplasty, modern inflatable and malleable prostheses are adapted for use in the post-phalloplasty setting. Due to the lack of native corpora cavernosa, highly variable phallic anatomy, and the need to adapt implants designed for natal penile anatomy, complication rates of prosthesis placement after phalloplasty remain high, with reported ranges of complications from 20% to 80%.
CONCLUSIONS
Major complications requiring surgical revision are common relative to implant placement in natal penile anatomy, and include: infection requiring explantation, device extrusion, erosion, migration or malposition, inadequate rigidity, poor aesthetic result, pain, decrease or loss of erogenous and/or tactile sensation, device failure, injury to the urethra, and injury to the neurovascular supply of the penis with resultant partial or complete flap loss. This broad range of complication rates represents the variability with which results are reported and reflect a lack of clear reporting guidelines, significant variability in techniques, and need for more standardization. To optimize outcomes, it is important that surgeons have an in-depth understanding of phalloplasty anatomy and are equipped to manage potential complications in the short- and long-term.
PubMed: 37969769
DOI: 10.21037/tau-23-122 -
International Journal of Impotence... Nov 2023For patients with large calcified tunical plaque or severe corporal fibrosis which are likely to have a pronounced and persistent residual curvature which may not be... (Review)
Review
For patients with large calcified tunical plaque or severe corporal fibrosis which are likely to have a pronounced and persistent residual curvature which may not be correct by penile prosthesis implantation alone, other adjunctive manoeuvres such as penile plication and/or plaque incision with grafting may be necessary. The sequence between penile plication and penile prosthesis implantation is largely dependent on several factors such as the severity of penile curvature, the presence of (calcified) tunical plaque(s) and whether aggressive corporal dilation and subsequent penile remodelling with an inflated implant can straighten any residual penis curvature. The advantages of pre-placement of penile plication sutures prior to penile prosthesis implantation are the avoidance of inadvertent damage to the underlying penile prosthesis implant, the ability to adjust the tension on the rows of the plication sutures based on residual curvature with the device fully inflated, and potentially minimising the duration of surgery. In contrast, penile prosthesis implantation followed by penile plication to correct residual curvature, this sequence of surgery may negate the need for penile plications if penile remodelling is effective, or the residual curvature is less than 15 degrees where postoperative manual remodelling may continue to improve the penile cosmesis. When performed by expert surgeons and adhering to safe surgical principles, there is no doubt that patients will be satisfied with the outcomes and highly appreciative of the final penile cosmesis and the ensuing optimal outcomes.
Topics: Male; Humans; Penile Implantation; Penile Induration; Penile Prosthesis; Penis; Sutures
PubMed: 37864087
DOI: 10.1038/s41443-023-00774-6 -
Translational Andrology and Urology Jul 2023
PubMed: 37554531
DOI: 10.21037/tau-23-296 -
Translational Andrology and Urology Dec 2023Penile prosthesis surgery is considered a safe and effective treatment for patients with erectile dysfunction. Implantation in the medically complex patient can be a... (Review)
Review
BACKGROUND AND OBJECTIVE
Penile prosthesis surgery is considered a safe and effective treatment for patients with erectile dysfunction. Implantation in the medically complex patient can be a challenge. The benefits of treatment must outweigh the possible risks or complications. A description of possible problems and how to cope with them is given in this narrative review.
METHODS
Literature search was performed in January 2023 using different search prompts in PubMed. These articles, excluding non-English and non-full text articles, were listed by the two authors and afterwards, the most relevant ones were included.
KEY CONTENT AND FINDINGS
This article is divided into five important topics. We evaluated different comorbidities such as spinal cord injury, diabetes mellitus and cardiovascular disease, in which preoperative work-up and counseling is of significant importance. A detailed description of these comorbidities and how to handle these can be found in each section. In addition to the preoperative aspect in organ transplant patients, problems during surgery can arise, e.g., with the reservoir placement. Similarly, in patients with previous pelvic surgery, an ectopic reservoir placement can prevent possible complications.
CONCLUSIONS
Preoperative diagnostics are crucial and prosthetic surgery should be done by an experienced high-volume surgeon with a diverse range of surgical techniques at his disposal.
PubMed: 38196703
DOI: 10.21037/tau-23-71 -
Translational Andrology and Urology Apr 2024Priapism is a rare condition characterized by persistent erection of the penis that lasts more than 4 hours in the absence of sexual stimulation and is associated with... (Review)
Review
BACKGROUND
Priapism is a rare condition characterized by persistent erection of the penis that lasts more than 4 hours in the absence of sexual stimulation and is associated with significant morbidity and complications, including erectile dysfunction and penile fibrosis. Surgical management of priapism can be extremely challenging. We herein provide a comprehensive review that aims to evaluate the role of penile prosthesis (PP) implantation in the management of priapism.
METHODS
A systematic literature search was performed using the following databases: PubMed, Embase, and Scopus to identify studies that evaluated the effectiveness of PP implantation in treating priapism and the long-term complications, outcomes, and patients' satisfaction rate.
RESULTS
Out of 717 English-language studies published between 2002 and 2022, 17 were chosen for this review. Majority of patients had a malleable PP (MPP) implant, either early or delayed after the priapism episode. Early placement (EP) of PP is widely defined between studies ranging from less than 72 hours, within 1 week, and within 3 weeks. Most common causes of priapism were sickle cell anemia (SCA), medication-induced, and idiopathic. Studies show a higher satisfaction rate ranging between 80% and 100%, with sexual intercourse achievement ranging between 64.2% and 100%. Based on the GRADE system, included studies rated as very low quality of evidence. Commonly reported complications that arise after PP procedures, include device infection, erosion, curvature, and mechanical malfunction, such as auto-inflation.
CONCLUSIONS
PP can be an effective treatment option for priapism, particularly in cases of ischemic priapism lasting more than 36 hours or recurrent priapism that is medically refractory. However, due to the very low quality of evidence, larger, well-designed studies are warranted where long-term outcomes, patients' satisfaction, and complications following priapism-related PP implantation are measured as endpoints.
PubMed: 38721288
DOI: 10.21037/tau-23-224 -
Arab Journal of Urology 2024As available data on implantation-related infections is contradictory, the aim was to identify the predictors of penile prosthesis infection. (Review)
Review
BACKGROUND
As available data on implantation-related infections is contradictory, the aim was to identify the predictors of penile prosthesis infection.
METHODS
We performed an umbrella review and meta-analysis including systematic reviews with extractable data. Literature search was done in two databases: PubMed and Google Scholar. The participants were males with erectile dysfunction regardless of etiology who underwent penile implant surgery. Using a standardized form, three trained researchers reviewed each reference (systematic review) by title and abstract. The meta-analysis was performed using Review Manager 5.4.1 (RevMan® 5.4.1).
RESULTS
A total of 78 systematic reviews were identified with the search strategies. Of these, 35 duplicates were removed. Thirty-seven full-text reviews were then excluded after revision. Six systematic reviews with a total of 271,226 patients (156,553 patients in the study group and 114,673 patients in the control group) were included in the meta-analysis. The analysis identified various predictors of adverse outcomes (infection). Among them were glycated hemoglobin (HbA1c) and different characteristics of penile implants.
CONCLUSIONS
The systematic review and meta-analysis revealed significant risk factors/predictors of penile prosthesis infection: glycated hemoglobin levels; reoperation, and two predictors associated with the type of penile prosthesis. The weighted mean HbA1c levels of patients with and without infections were 8.37% and 7.17% respectively. The OR was as follows: first surgery/revision OR 0.36 (95% CI 0.29-0.45); antibiotic-coated/non-coated prosthesis OR 0.47 (95% CI 0.31-0.72); malleable/inflatable prosthesis OR 3.51 (95% CI 1.41-8.74).
PubMed: 38481412
DOI: 10.1080/2090598X.2023.2242204 -
Translational Andrology and Urology Sep 2023With the general population aging and thus more patients developing bothersome erectile dysfunction, stress urinary incontinence and overactive bladder, there will... (Review)
Review
BACKGROUND AND OBJECTIVE
With the general population aging and thus more patients developing bothersome erectile dysfunction, stress urinary incontinence and overactive bladder, there will likely be a higher demand for three common interactive implants in urology, the penile prosthesis, artificial urinary sphincter (AUS) and sacral neuromodulation (SNM). Further, the prevalence of mild and major neurocognitive disorders (also known as mild cognitive impairment and dementia, respectively) is expected to increase. While the aforementioned urologic implants have excellent short and long term outcomes, there are also known device issues such as malfunction or misuse that may require surgical removal and/or revision. The objective of this narrative review is to describe the association of cognitive impairment and urologic implants.
METHODS
We performed a search on PubMed between the years 1975-2023 for English language articles that reported on any type or severity of cognitive impairment and its association with penile prosthesis, AUS and/or SNM. While peer-reviewed published manuscripts were prioritized, abstracts that fit our search criteria were also included.
KEY CONTENT AND FINDINGS
Data assessing outcomes of patients with cognitive impairment who undergo placement of a urologic implant are limited. There is an association between AUS failure or misuse with cognitive impairment. SNM is efficacious in this population in the short term. In patients who develop dementia, an inflatable penile prosthesis can be deflated via in-office needle puncture and an AUS can be deactivated. The Memory Alteration Test, Quick Screen for Mild Cognitive Impairment and the Saint Louis University Mental Status Examination are relatively quick screening tests with good sensitivity and specificity for mild cognitive impairment.
CONCLUSIONS
While data on the association between urologic implants and cognitive impairment are sparse, there are tools that urologists can use to screen patients for cognitive impairment. With screening, urologists can provide appropriate preoperative counseling (including recommending against implantation) and can provide closer postoperative monitoring. Further study is required to assess which patients should be excluded from device implantation and how to properly assess for cognitive impairment in a manner that is both beneficial for the patient and convenient and efficient for a urologist.
PubMed: 37814692
DOI: 10.21037/tau-23-226 -
Translational Andrology and Urology Jul 2023
PubMed: 37554524
DOI: 10.21037/tau-23-242 -
Therapeutic Advances in Urology 2023The malleable penile implant is often considered an inferior device to the three-piece inflatable penile prosthesis implant. Nonetheless, the malleable prosthesis has... (Review)
Review
The malleable penile implant is often considered an inferior device to the three-piece inflatable penile prosthesis implant. Nonetheless, the malleable prosthesis has its unique advantages such as lower cost, easier to perform and fewer mechanical complications than inflatable prostheses. Furthermore, its role can be extended to patients with issues relating to poor manual hand dexterity, those undergoing a salvage for infection prosthesis and as an emergency surgical measure in patients presenting with acute ischaemic priapism. Over the past few decades, there have been numerous design and technological advancements to improve overall clinical efficacy, mechanical durability, axial rigidity and device concealability of malleable penile prostheses. The following article provides a narrative review of the six major contemporary malleable penile prosthesis devices in the commercial market, namely, the Coloplast Genesis prosthesis, the Boston Scientific Tactra prosthesis, the Zephyr ZSI 100 and 100 (female-to-male) FTM devices, the Rigi10 prosthesis, the TUBE malleable prosthesis and the Shah prosthesis and evaluates the published outcomes. Appropriate patient selection and strict counselling regarding what to expect with malleable prostheses coupled with adherence to safe surgical principles are paramount to ensure excellent clinical success and patient satisfaction rates.
PubMed: 37465318
DOI: 10.1177/17562872231179008