Modified malleable prosthesis with a fixed mesh: case series for the Ghattas technique / 亚洲男科学杂志(英文版)

Penile prosthetic implantation represents a cornerstone for patients with organic erectile dysfunction (ED) that is refractory, unsatisfactory, or contra-indicated for other approved medical or mechanical options. In this study, we introduce the "Ghattas technique," wherein we constructed a polypropylene mesh sheath that surrounds and is fixed to a 13-mm malleable prosthesis cylinder, which can increase the cylinder diameter for cases that need a larger prosthesis. All patients underwent preoperative evaluation and completed the five-item International Index of Erectile Function questionnaire (IIEF-5). Postoperative outcomes were evaluated by IIEF-5 and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaires at final follow-up. The mean age of the 23 included patients was 57.9 (standard deviation [s.d.]: 11.4) years and the mean duration of ED was 8.5 (s.d.: 7.9) years. Erection improvement was determined by comparing mean preoperative and postoperative IIEF-5 scores (8.3 [s.d.: 3.9] vs 24.6 [s.d.: 0.6], P < 0.001). High treatment satisfaction was determined according to a mean EDITS score of 94.9 (s.d.: 9.9). The proposed Ghattas technique was safe and effective in our patients, and provides opportunity for cases that need a diameter larger than 13 mm. Further studies are needed to confirm these results.

Ten-year experience with penile prosthetic surgery for the treatment of erectile dysfunction: outcomes of a tertiary referral center and predictors of early prosthetic infection / 亚洲男科学杂志(英文版)

We aimed to evaluate ten-year outcomes of penile prosthesis (PP) implantation for the treatment of erectile dysfunction and to assess predictors of early prosthetic infection (EPI). We identified 549 men who underwent 576 PP placements between 2008 and 2018. Univariate and multivariate analyses were used to identify potential predictors of EPI. An EPI predictive nomogram was developed. Thirty-five (6.1%) cases of EPI were recorded with an explant rate of 3.1%. In terms of satisfaction, 82.0% of the patients defined themselves as "satisfied," while partner's satisfaction was 88.3%. Diabetes (P = 0.012), longer operative time (P = 0.032), and reinterventions (P = 0.048) were associated with EPI risk, while postoperative ciprofloxacin was inversely associated with EPI (P = 0.014). Rifampin/gentamicin-coated 3-piece inflatable PP (r/g-c 3IPP) showed a higher EPI risk (P = 0.019). Multivariate analyses showed a two-fold higher risk of EPI in diabetic patients, redo surgeries, or when a r/g-c 3IPP was used (all P < 0.03). We showed that diabetes, longer operative time, and secondary surgeries were the risk factors for EPI. Postoperative ciprofloxacin was associated with a reduced risk of EPI, while r/g-c 3IPP had higher EPI rates without an increased risk of PP explant. After further validation, the proposed nomogram could be a useful tool for the preoperative counseling of PP implantation.

Penile Reconstructive Surgery in Peyronie Disease: Challenges in Restoring Normal Penis Size, Shape, and Function

Penile Prosthesis Infection: Myths and Realities

Penile prosthesis infection is the most significant complication following prosthesis implant surgery leading to postoperative morbidity, increased health care costs, and psychological stress for the patient. We aimed to identify risk factors associated with increased postoperative penile prosthesis infection. A review of the literature was performed via PubMed using search terms including inflatable penile prosthesis, penile implant, and infection. Articles were given a level of evidence score using the 2011 Oxford Centre for Evidence-Based Medicine Guidelines. Multiple factors were associated with increased risk of post-prosthesis placement infection (Level of Evidence Rating) including smoking tobacco (Level 1), CD4 T-cell count 8.5 (Level 2). Factors with no effect on infection rate include: preoperative cleansing with antiseptic (Level 4), history of prior radiation (Level 3), history of urinary diversion (Level 4), obesity (Level 3), concomitant circumcision (Level 3), immunosuppression (Level 4), age >75 (Level 4), type of hand cleansing (Level 1), post-surgical drain placement (Level 3), and surgical approach (Level 4). Factors associated with decreased rates of infection included: surgeon experience (Level 2), “No Touch” technique (Level 3), preoperative parenteral antibiotics (Level 2), antibiotic coated devices (Level 2), and operative field hair removal with clippers (Level 1). Optimization of pre-surgical and intraoperative risk factors is imperative to reduce the rate of postoperative penile prosthesis infection. Additional research is needed to elucidate risk factors and maximize benefit.

Satisfacción en pacientes con disfunción eréctil usuarios de prótesis de pene maleable, en el periodo 2014 - 2017 en el Hospital Carlos Van Buren / Satisfaction in patients with erectile dysfunction users of malleable penile prosthesis, in the period 2014 - 2017 at Carlos Van Buren Hospital

RESUMEN Introducción: La disfunción eréctil es una patología que afecta, en torno al 20 por ciento de la población masculina que ocasiona un importante deterioro en su calidad de vida. La DE moderada, completa aumenta en relación a la edad. La población en Chile está envejeciendo y su vida sexual se puede ver afectada. El implante de una prótesis de pene maleable es la alternativa cuando los tratamientos médicos no cumplen las expectativas del paciente. Objetivo: Evaluar el grado de satisfacción de los pacientes usuarios de prótesis de pene maleable como tratamiento de Disfunción Eréctil. Pacientes y métodos: Estudio retrospectivo analítico mediante recopilación de historias clínicas de pacientes con disfunción eréctil usuarios de prótesis de pene maleable en el HCVB en el lapso de tiempo comprendido entre mayo 2014 y julio 2017. La satisfacción del tratamiento se valoró empleando una entrevista personal, utilizando el cuestionario EDITS. Resultados: Se encuestaron a 32 pacientes usuarios de prótesis de pene maleable. La media de edad para el uso de prótesis fué de 64,5 (48 ­ 81) años. Según la escala de satisfacción EDITS el uso de las prótesis de pene 84,9 por ciento de los pacientes se encuentran satisfechos con el uso de este tratamiento. 87 por ciento de satisfacción en relación al cumplimiento de las expectativas. La maniobrabilidad y la técnica de uso una satisfacción del 90 por ciento. El 81 por ciento desea continuar usando la prótesis. El 90 por ciento de los pacientes se sienten con mayor confianza al mantener sus relaciones sexuales. El 84 por ciento de las parejas se encuentras satisfechas con el tratamiento de su pareja. Conclusión: La experiencia de nuestro servicio muestra resultados elevados de satisfacción en el uso de prótesis de pene maleables tanto para el paciente como para su pareja en el tratamiento de la disfunción eréctil. Estos resultados nos alientan a seguir con el tratamiento con prótesis maleable para pacientes beneficiarios de nuestro sistema público de salud.(AU)

ABSTRACT Introduction: Erectile dysfunction is a pathology affecting about 20 pertcent of the male population that causes a significant deterioration in their quality of life. Moderate, complete ED increases with age. The population in Chile is aging and their sex life may be affected. The implantation of a malleable penile prosthesis is the alternative when the medical treatments do not meet the expectations of the patient. Objective: To evaluate the degree of satisfaction of patients with malleable penile prosthesis as a treatment for Erectile Dysfunction. Patients and Methods: An analytical retrospective study by means of the compilation of clinical records of patients with erectile dysfunction users of malleable penile prostheses in the HCVB in the time span between May 2014 and July 2017. The satisfaction of the treatment was assessed using a personal interview, using the EDITS questionnaire. Results: We surveyed 32 patients with malleable penile prosthesis. The mean age for prosthesis use was 64.5 (48 ­ 81) years. According to the EDITS satisfaction scale the use of penile prostheses 84.9 pertcent of patients are satisfied with the use of this treatment. 87 pertcent satisfaction in relation to the fulfillment of expectations. The maneuverability and the technique of use a satisfaction of 90 pertcent. 81pertcent want to continue using the prosthesis. 90 pertcent of patients feel more confident about having sex. 84 pertcent of couples are satisfied with their partner's treatment. Conclusion: The experience of our service shows high satisfaction results in the use of malleable prostheses for both the patient and his partner in the treatment of erectile dysfunction. These results encourage us to continue with the treatment with malleable prosthesis for patients who are beneficiaries of our public health system.(AU)

A Case Series of Patients Who Underwent Laparoscopic Extraperitoneal Radical Prostatectomy with the Simultaneous Implant of a Penile Prosthesis: Focus on Penile Length Preservation

PURPOSE: There are many grey areas in the field of penile rehabilitation after radical prostatectomy (RP). The preservation of the full dimensions of the penis is an important consideration for improving patients' compliance for the treatment. We present the first case series of patients treated by laparoscopic extraperitoneal RP and simultaneous penile prosthesis implantation (PPI) in order to preserve the full length of the penis and to improve patients' satisfaction. MATERIALS AND METHODS: From June 2013 to June 2014, 10 patients underwent simultaneous PPI (with an AMS InhibiZone prosthesis) and RP. Patients were evaluated by means of urological visits, questionnaires, and objective measurements before surgery, at discharge from the hospital, on postoperative days 21 to 28, each 3 months for the first year, and each 6 months thereafter. The main outcome measures were biochemical recurrence-free rate, penile length, and quality of life. RESULTS: Ten patients (mean age of 61 years; completed the study follow-up period (median, 32.2 months). No difference was found between the time of surgery and the 2-year follow-up evaluation in terms of penile length. The pre-surgery 36-Item Short Form Health Survey (SF-36) median score was 97. Patients were satisfied with their penile implants, and couples' level of sexual satisfaction was rated median 8. The median postoperative SF-36 score was 99 at 3 months follow-up. CONCLUSIONS: Laparoscopic extraperitoneal RP surgery with simultaneous PPI placement seems to be an interesting possibility to propose to motivated patients for preserving the length of the penis and improving their satisfaction.

Role of Penile Prosthesis in Priapism: A Review

Ischemic priapism is a urological emergency that has been associated with long-standing and irreversible adverse effects on erectile function. Studies have demonstrated a linear relationship between the duration of critically ischemic episodes and the subsequent development of corporal fibrosis and irreversible erectile function loss. Placement of a penile prosthesis is a well-established therapeutic option for the management of erectile dysfunction secondary to ischemic priapism, and will be the focus of this review. Review of the current literature demonstrates a growing utilization of penile prostheses in the treatment of erectile dysfunction secondary to ischemic priapism. Unfortunately, there is a paucity of randomized-controlled trials describing the use of prosthesis in ischemic priapism. As a result, there is a lack of consensus regarding the type of prosthesis (malleable vs. inflatable), timing of surgery (acute vs. delayed), and anticipated complications for each approach. Both types of prostheses yielded comparable complication rates, but the inflatable penile prosthesis have higher satisfaction rates. Acute treatment of priapism was associated with increased risk of prosthetic infection, and could potentially cause psychological trauma, whereas delayed implantation was associated with greater corporal fibrosis, loss of penile length, and increased technical difficulty of implantation. The paucity of high-level evidence fuels the ongoing discussion of optimal use and timing of penile prosthesis implantation. Current guidance is based on consensus expert opinion derived from small, retrospective studies. Until more robust data is available, a patient-centered approach and joint decision-making between the patient and his urologist is recommended.

Inflatable penile prosthesis as tissue expander: what is the evidence?

ABSTRACT Objective: Many patients who undergo inflatable penile prosthesis (IPP) replacement are often upsized to larger cylinders, suggesting the IPP may serve as a tissue expander and increase internal penile length. The objective of this study is to evaluate whether cylinder length increases with subsequent IPP insertion. Materials and Methods: We queried American Medical Systems and Coloplast Patient Information Form databases to identify patients who underwent IPP placement and replacement between 2004-2013. Patients were grouped by device type and time to replacement (<2 or ≥2 years). We selected the 2-year mark for subgroup analysis to allow time for tissue expansion to occur and to exclude patients who underwent early explantation (e.g. erosion or infection). Results: Two thousand, seven hundred and forty nine patients (1,532 AMS 700 LGX, 717 AMS 700 CX, and 500 Coloplast Titan) met the inclusion criteria. Mean time between implants was earlier for LGX (29 months) than CX (39 months) and Titan (48 months) patients (p<0.001). Patients who underwent device replacement at <2 years did not experience an increase in mean cylinder length. On the contrary, patients who underwent device replacement at ≥2 years did experience significant increases in mean cylinder length (LGX 1.2 cm, CX 1.1 cm, and Titan 0.9 cm, p<0.001). The mean increases in length at ≥2 years were similar between the 3 devices (p=0.20). Sixty percent of patients demonstrated increases of >0.5 cm and 40% demonstrated increases of ≥1 cm. Conclusions: As demonstrated, the IPP may provide tissue expansion over time. Further evaluation is needed to determine if increased cylinder length correlates to increased functional length and patient satisfaction.

Prevention and treatment of erectile dysfunction after prostatectomy: An update / 中华男科学杂志

Prostate cancer has the highest incidence among malignant tumors of the urinary system in China. Radical prostatectomy (RP) is the most effective treatment for localized prostate cancer with a good long-term prognosis. Erectile dysfunction (ED) is a common complication after RP, which seriously affects the patient's quality of life. With the rising incidence and early diagnosis of prostate cancer, the proportion of young cases of RP is increasing, and so is the importance of the treatment of post-RP ED. The restoration of erectile function after RP is closely related to the timing of penile rehabilitation as well as to pre- and intra-operative measures such as surgical strategies and methods. Common options for the treatment of post-RP ED include oral medication of phosphodiesterase type 5 inhibitors, application of vasoactive substances in the urethra or corpus cavernosum, use of vacuum erection devices, and implantation of penile prosthesis. Stem cell therapy, nerve transplantation, low-intensity extracorporeal shockwave therapy, and erythropoietin have shown great potential in penile rehabilitation after RP. At present, the stress is placed on the remission of symptoms in the treatment of ED. Stem cell therapy may reverse the cause of disease or cure ED by reversing its pathophysiological changes. A series of clinical trials of stem cell therapy are underway and have preliminarily confirmed the safety of stem cell therapy and proved that it can improve erectile function in patients with post-RP ED. This review focuses on the progress in the prevention and treatment of ED after RP.

Treatment of erectile dysfunction in patients with spinal cord injury / 中华男科学杂志

The majority of men with spinal cord injury (SCI) suffer from different types and degrees of erectile dysfunction (ED). The impact of SCL on erectile function depends on the severity and location of the injury. Some patients can restore the residual sexual potential in the period of SCI recovery. Treatments of ED in men with SCI include psychotherapy, medication of oral PDE5 inhibitors, intracavernous injection of vasoactive drugs, transurethral medication, application of the vacuum erectile device and penile ring, penile prostheses, sacral neuromodulation, etc., among which PDE5 inhibitors remain the first option and usually give good clinical results for those with higher SCI. However, intracavernous injection of vasoactive drugs and combined treatment are preferable for those with lower SCI.

Non-infected penile prosthesis cultures during revision surgery; comparison between antibiotic coated and non - coated devices

ABSTRACT Introduction: Aim of this study is to investigate bacterial growth on non-infected devices and compare antibiotic-coated and non-coated implants. Materials and methods: The charts of 71 patients who underwent revision surgeries for penile prosthesis between 1995 and 2013 were reviewed. Of those, 31 devices were antibiotic-coated prostheses, while 40 of the implants were non-coated. Swab cultures were routinely obtained from corporal, pump or reservoir site during the operation. If a bacterial biofilm was determined on the prosthesis, it was also cultured. Results: A total of 5 different organisms were cultured from 18 patients. Of them, 4 devices were antibiotic-coated and the other 14 were non-coated devices. Staphylococcus epidermidis was the most common organism, while Staphylococcus hominis, beta hemolitic streptococcus, Escherichia coli and Proteus mirabilis were also cultured. All patients who had positive cultures were treated with appropriate antibiotics for four weeks postoperatively. Median follow-up time was 41 months, ranging between 8 and 82 months. One prosthesis (non-coated) became clinically infected in the follow-up period with a totally different organism. Culture positivity rates of antibiotic-coated and non-coated devices were 13% and 35% respectively and the result was significant (p=0.00254). Conclusions: Positive bacterial cultures are present on non-infected penile prostheses at revision surgeries in some of the patients. Antibiotic coated prostheses have much less positive cultures than non-coated devices.

Postprostatectomy Erectile Dysfunction: A Review

In the current era of the early diagnosis of prostate cancer (PCa) and the development of minimally invasive surgical techniques, erectile dysfunction (ED) represents an important issue, with up to 68% of patients who undergo radical prostatectomy (RP) complaining of postoperative erectile function (EF) impairment. In this context, it is crucial to comprehensively consider all factors possibly associated with the prevention of post-RP ED throughout the entire clinical management of PCa patients. A careful assessment of both oncological and functional baseline characteristics should be carried out for each patient preoperatively. Baseline EF, together with age and the overall burden of comorbidities, has been strongly associated with the chance of post-RP EF recovery. With this goal in mind, internationally validated psychometric instruments are preferable for ensuring proper baseline EF evaluations, and questionnaires should be administered at the proper time before surgery. Careful preoperative counselling is also required, both to respect the patient's wishes and to avoid false expectations regarding eventual recovery of baseline EF. The advent of robotic surgery has led to improvements in the knowledge of prostate surgical anatomy, as reflected by the formal redefinition of nerve-sparing techniques. Overall, comparative studies have shown significantly better EF outcomes for robotic RP than for open techniques, although data from prospective trials have not always been consistent. Preclinical data and several prospective randomized trials have demonstrated the value of treating patients with oral phosphodiesterase 5 inhibitors (PDE5is) after surgery, with the concomitant potential benefit of early re-oxygenation of the erectile tissue, which appears to be crucial for avoiding the eventual penile structural changes that are associated with postoperative neuropraxia and ultimately result in severe ED. For patients who do not properly respond to PDE5is, proper counselling regarding intracavernous treatment should be considered, along with the further possibility of surgical treatment for ED involving the implantation of a penile prosthesis.

Pararectal Migration of a Malleable Rod: An Unusual Late Complication

A 75-year-old male had failed to respond conservative therapy for erectile dysfunction and had undergone insertion of a malleable penile prosthesis in 1995. Twenty years after the initial implant he presented with right-sided prosthesis localized in the buttock. There was no infection. The prosthesis was extracted through an incision in the right hip. As in the recent case, mechanical failures in malleable penile prosthesis models, can occur. Penile implant migration back to the buttock without a curve deformity is an extremely rare complication. Clinicians should be alert about possible late complications of penile prosthesis.

Urinary Incontinence Could Be Controlled by an Inflatable Penile Prosthesis

PURPOSE: Due to the increasing numbers of radical prostatectomies (RP) performed for prostate cancer, a substantial and increasing number of patients suffer from postoperative urinary incontinence and erectile dysfunction (ED). The objective of our study was to see whether an inflatable penile prosthesis implantation could control urinary incontinence for patients with the dual problems of ED and incontinence. MATERIALS AND METHODS: From March 2010 through May 2015, 25 post-RP patients were referred to our clinic with ED or incontinence. The degree of incontinence was classified according to the International Consultation on Incontinence Questionnaire-Short Form. Inflatable penile prostheses were implanted in all 25 patients. RESULTS: For one month after implantation, partial or full inflation was performed progressively to control urine leakage. Of 18 patients, 13 patients were categorized with mild or moderate stress incontinence. All 13 patients obtained control of incontinence with partial inflation (30% to 60%) and all reported satisfactory outcomes. Five out of the 18 patients were categorized with severe total incontinence. Three of the 5 patients could tolerate incontinence with full inflation on and off. Thirteen patients out of the total of 18 (72.2%) had their incontinence controlled by an inflating penile prosthesis. CONCLUSIONS: An inflatable penile prosthesis is highly recommended as an initial procedure, especially in patients with the dual problems of ED and incontinence.