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The Journal of Sexual Medicine Jul 2021During the last century, surgical management of erectile dysfunction has evolved from an experimental concept to a core treatment modality with widespread use among the... (Review)
Review
BACKGROUND
During the last century, surgical management of erectile dysfunction has evolved from an experimental concept to a core treatment modality with widespread use among the men's health community. Over time, innovations in materials, mechanical design elements, device coatings, and surgical technique have provided patients with low-risk, reliable, and reproducible erectile function with high satisfaction rates.
AIM
To provide a foundation for future innovation by improving understanding of historical penile prosthetics and the rationale behind incremental technological improvements for the contemporary Men's Health physician.
METHODS
Literature review was conducted to generate a comprehensive review of historical technological innovations in penile implant surgery. Companies with FDA approved penile prosthetics in use in the United States were contacted for information regarding technological innovations in the past and future devices in development. A separate literature review was performed to identify any significant future device design elements being tested, even in the ex vivo setting, which may have future clinical applications.
OUTCOMES
Technological innovations in penile implant surgery were described.
RESULTS
Current options for the prosthetic surgeon include malleable penile prostheses (MPP), self-contained (2-piece) inflatable penile prostheses, and multicomponent (3-piece) inflatable penile prostheses. Current MPPs consist of a synthetic coated solid core which allow for manipulation of the penis for concealability while maintaining sufficient axial rigidity to achieve penetration when desired. Multi-component (3-Piece) IPPs currently include the Coloplast Titan and Boston Scientific/AMS 700 which consist of a fluid reservoir, intrascrotal pump, and intracavernosal cylinders. The devices have undergone numerous design updates to the cylinders, pump, reservoir, tubing, and external coatings to increase reliability and decrease short- and long-term complications.
CLINICAL IMPLICATIONS
Future innovations in penile prosthetic surgery seek to broaden the indications and applicability to the transgender community and improve both safety and functionality for patient and partner.
STRENGTHS & LIMITATIONS
The review is limited primarily to penile prosthetics approved for current or historical clinical use in the United States and may not be representative of the global prosthetic environment. Additionally, the research and development of future innovations, particularly those provided by device manufacturers, is likely limited by non-disclosure to maintain a competitive advantage.
CONCLUSIONS
Penile prosthetic surgery will undoubtedly remain integral to the treatment of erectile dysfunction, and education regarding the current state of technological innovation will empower the prosthetic surgeon and biomedical engineering community to improve contemporary patient care and drive the development of the next generation of implantable penile prosthetics. Barnard JT, Cakir OO, Ralph D, et al. Technological Advances in Penile Implant Surgery. J Sex Med 2021;18:1158-1166.
Topics: Boston; Erectile Dysfunction; Humans; Male; Patient Satisfaction; Penile Implantation; Penile Prosthesis; Reproducibility of Results
PubMed: 34183291
DOI: 10.1016/j.jsxm.2021.04.011 -
International Journal of Impotence... Nov 2023
Review
Topics: Male; Humans; Penile Implantation; Penile Prosthesis; Erectile Dysfunction; Educational Status; Patient Satisfaction
PubMed: 36966226
DOI: 10.1038/s41443-023-00688-3 -
International Journal of Impotence... Jan 2020Priapism is a urological emergency that is defined as a prolonged penile erection lasting more than 4 h, remaining despite orgasm and in the absence of sexual... (Review)
Review
Priapism is a urological emergency that is defined as a prolonged penile erection lasting more than 4 h, remaining despite orgasm and in the absence of sexual stimulation. Without prompt and complete detumescence, time-dependent changes occur to the smooth muscle of the corpus cavernosa that can result in permanent erectile dysfunction and penile deformity (curvature, shortening and loss of girth). The diagnosis is confirmed with a hypoxic and acidotic blood sample from the corpus cavernosa. The trapped blood inside the corpus cavernosa is aspirated and can be irrigated with 0.9% normal saline. Intracavernosal injection of a sympathomimetic agent is used to cause smooth muscle contraction if the previous measures fail. Failure or recurrence of priapism following these conservative measures is an indication for surgical management. Shunt procedures that create a connection with the corpus cavernosa and a neighbouring structure are often used first line. Multiple shunt procedures have been described and these are summarised in this article. Distal shunt procedures are the most commonly used as they are easier to perform and seem to have at least comparable detumescence and potency rates. Refractory or prolonged (>48 h) ischaemic priapism maybe an indication of immediate placement of a penile prosthesis.
Topics: Erectile Dysfunction; Humans; Ischemia; Male; Penile Prosthesis; Penis; Priapism; Vascular Surgical Procedures
PubMed: 31570823
DOI: 10.1038/s41443-019-0197-9 -
The Urologic Clinics of North America Nov 2019The treatment of gender dysphoria related to genitourinary anatomy can be effectively treated with phalloplasty. A phalloplasty may include some or all of the following:... (Review)
Review
The treatment of gender dysphoria related to genitourinary anatomy can be effectively treated with phalloplasty. A phalloplasty may include some or all of the following: penile shaft, glans, shaft urethra, perineal urethra, scrotoplasty, vaginectomy, testicular implants, and erectile devices. The literature does not currently support a gold standard for how best to stage these procedures. This article reviews current techniques for phalloplasty staging and proposes that a staged urethral reconstruction is a reliable technique that allows for potential complications to be managed individually, while minimizing the severity of complications and their impact on the outcome of the final reconstruction.
Topics: Female; Gender Dysphoria; Genitalia, Female; Humans; Male; Patient Selection; Penile Prosthesis; Postoperative Complications; Sex Reassignment Surgery; Transsexualism; Urethra
PubMed: 31582031
DOI: 10.1016/j.ucl.2019.07.011 -
Minerva Urology and Nephrology Dec 2023Inflatable penile prosthesis are the definitive treatment for erectile dysfunction. The two most used surgical approaches to position the implants are the penoscrotal... (Review)
Review
INTRODUCTION
Inflatable penile prosthesis are the definitive treatment for erectile dysfunction. The two most used surgical approaches to position the implants are the penoscrotal and the infrapubic. Current trends showed that the penoscrotal approach is extensively preferred however, there is not conclusive evidence demonstrating the superiority of one technique over the other. The aim of this review is to summarize the scientific evidence available and to underline strengths and weaknesses of the two techniques.
EVIDENCE ACQUISITION
We conducted a comprehensive search of MEDLINE, Cochrane Library, and National Center for Biotechnology Information PubMed to identify relevant published articles. The included studies had to explicitly examine the use of three-piece inflatable penile prosthesis with a focus on the surgical access method and complications.
EVIDENCE SYNTHESIS
Twenty-six articles were included in the review: seven narrative reviews, five retrospective observational studies, five prospective observational studies, and nine mixed methodology studies. The most frequent approach was the penoscrotal, which was also found more comfortable (RG1) by the operators in one study. The infrapubic approach lasts less and one study demonstrated higher satisfaction by the patients.
CONCLUSIONS
There is no evidence of significant differences in complications among the penoscrotal and infrapubic approaches. While the infrapubic approach is faster and patients were more satisfied, the penoscrotal approach is the most used by far. This is likely related to the more straightforward procedure through this access and the excellent surgical field exposure. For these reasons, it is also preferred in the most complex cases.
Topics: Humans; Male; Observational Studies as Topic; Patient Satisfaction; Penile Implantation; Penile Prosthesis; Penis; Retrospective Studies
PubMed: 38126284
DOI: 10.23736/S2724-6051.23.05475-7 -
International Journal of Impotence... May 2020Radical prostatectomy (RP) represents one of the most commonly used first-line treatment modalities in men with localized prostate cancer (PCa). Despite efforts to... (Review)
Review
Radical prostatectomy (RP) represents one of the most commonly used first-line treatment modalities in men with localized prostate cancer (PCa). Despite efforts to preserve the neurovascular bundles with nerve sparing (NS) surgery, erectile dysfunction (ED) remains common after RP and this may significantly affect patients' quality of life (QoL). The aim of this paper is to evaluate the outcome of simultaneous placement of penile prosthesis and RP. The ideal candidates for simultaneous penile prosthesis implantation are those who report pre-existent refractory ED and patients in whom there is a high risk of extracapsular disease, such as any cT2c or cT3, and undergo non-nerve sparing RP. If the patient chooses to undergo PPI to treat his refractory ED it is clear that this procedure will be associated with higher patients' satisfaction rates, if carried out simultaneously with RP rather than at a later stage. A simultaneous procedure would avoid two admissions, reduce hospitalization time and guarantee a faster recovery of sexual function, preventing the otherwise unavoidable loss of penile length. Since the urologist does not need to preserve the neurovascular bundles, as the penile implant will take care of postoperative rigidity, RP can be performed more radically from an oncological point of view, thus reducing the risk of recurrence and metastasis, especially in patients with high risk of locally advanced disease. In conclusion, simultaneous PPI with RP provides early sexual rehabilitation, improving patients' quality of life, without compromising surgical outcomes. However, larger series will be necessary, to better identify the patients who are more likely to benefit from nerve sparing surgery and postoperative penile rehabilitation from those who would are more likely to develop refractory ED post RP and would therefore benefit from simultaneous implantation of a penile prosthesis.
Topics: Erectile Dysfunction; Humans; Male; Penile Implantation; Penile Prosthesis; Prostatectomy; Prostatic Neoplasms; Quality of Life
PubMed: 31395986
DOI: 10.1038/s41443-019-0176-1 -
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 -
The Journal of Sexual Medicine May 2023While implantation of an inflatable penile prosthesis (IPP) is commonly performed via infrapubic or penoscrotal approaches, the subcoronal (SC) approach for IPP...
BACKGROUND
While implantation of an inflatable penile prosthesis (IPP) is commonly performed via infrapubic or penoscrotal approaches, the subcoronal (SC) approach for IPP implantation may safely and reliably allow for additional reconstructive procedures through a single incision.
AIM
The aim of this study is to report outcomes, including complications, of the SC approach and to determine common characteristics of patients undergoing the SC approach.
METHODS
A retrospective chart review from May 11, 2012, to January 31, 2022, was performed at a single, tertiary care institution to identify patients with IPP implantation via the SC approach.
OUTCOMES
Postoperative information was reviewed and extracted from all clinic notes available following the date of IPP implantation in the electronic medical record, detailing any complications including wound complications, need for revision or removal, device malfunction, and infections.
RESULTS
Sixty-six patients had IPP implantation via the SC approach. Median follow-up duration was 29.4 (interquartile range 14.9-50.1) months. One (1.8%) patient had a simple wound complication. Two (3.6%) experienced postoperative infection of the prosthesis, which resulted in explantation of the device. One of these infected prostheses later experienced partial glans necrosis. Revision for mechanical failure or unsatisfactory cosmetic result was performed in 3 (7.3%) IPPs placed via a SC incision.
CLINICAL IMPLICATIONS
The SC approach for implantation of IPP is safe and feasible with low complication and revision rates. It offers urologists an alternative to the classic infrapubic and penoscrotal approaches, both of which would require a second incision for additional reconstructive procedures required to adequately address deformities associated with severe Peyronie's disease. Therefore, urologists who treat these specialized populations of men may benefit from having the SC approach in their array of techniques for IPP implantation.
STRENGTHS AND LIMITATIONS
The limitations of this study include its retrospective nature, risk of selection bias, lack of comparison groups, and sample size. This study reports on early experience with the SC approach performed by a single high-volume reconstructive surgeon, who treats a specialized population of patients requiring complex repair during implantation of an IPP, particularly those with Peyronie's disease.
CONCLUSION
The SC incision for IPP implantation has low rates of complications and remains our approach of choice for IPP implantation in patients with severe Peyronie's disease, including curvatures >60°, severe indentation with hinge, and grade 3 calcification, which are unlikely to respond adequately to manual modeling alone.
Topics: Male; Humans; Penile Implantation; Penile Induration; Penile Prosthesis; Retrospective Studies; Patient Satisfaction; Erectile Dysfunction
PubMed: 37076135
DOI: 10.1093/jsxmed/qdad049 -
Abdominal Radiology (New York) Sep 2020MRI can delineate finer details of penile anatomy and pathology due to inherent higher soft-tissue contrast and spatial resolution. It can characterize inflammation and... (Review)
Review
MRI can delineate finer details of penile anatomy and pathology due to inherent higher soft-tissue contrast and spatial resolution. It can characterize inflammation and identify abscesses, localize penile fractures, guide surgical planning in penile fibrosis and Peyronie's disease, and depict components of the penile prosthesis and its complications. MRI is a great investigative tool for penile neoplasms, including locally infiltrative neoplasms where clinical examination is limited, and local staging is crucial for surgical planning.
Topics: Abscess; Humans; Magnetic Resonance Imaging; Male; Penile Induration; Penile Prosthesis; Penis
PubMed: 31154485
DOI: 10.1007/s00261-019-02080-6 -
Current Urology Reports Jan 2021The 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... (Review)
Review
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.
Topics: Erectile Dysfunction; Humans; Kidney Failure, Chronic; Kidney Transplantation; Male; Patient Satisfaction; Penile Implantation; Penile Induration; Penile Prosthesis; Penis; Priapism; Plastic Surgery Procedures; Spinal Cord Injuries
PubMed: 33420928
DOI: 10.1007/s11934-020-01028-4