ABSTRACT
INTRODUCTION AND OBJECTIVE: Male stress urinary incontinence (SUI) and climacturia are often comorbid with erectile dysfunction (ED) post prostatectomy. While the inflatable penile prosthesis (IPP) is the gold standard surgical option for ED, there are many surgical options for male SUI as well as climacturia including bulking agents, Virtue male sling, AdVance>= male sling, mini Jupette with IPP, and artificial urinary sphincter (AUS). We present our technique and outcomes for mini male sling (MMS) with IPP insertion for mild SUI and climacturia using a hydrophilic monofilament polyester mesh. METHOD(S): After obtaining IRB approval, a retrospective review of all IPPs performed by a single high volume surgeon was performed. Those men who underwent IPP insertion with concomitant MMS were analyzed. The technique of MMS placement involves measurement of an approximately 5x3cm Parietex>= mesh (Covidien, MN) and overlying this ventrally over the bulbar urethra. The Parietex>= mesh includes a hydrophilic absorbable collagen film to minimize tissue reaction and risk of erosion. The lateral edges of the mesh are sutured to the 3- and 9 o'clock positions on the left and right corporal bodies, respectively, using a nonabsorbable, braided suture in an interrupted fashion. Mesh is sutured just proximal to the corporotomy sites. Tightness of mesh was measured using the proximal end of a Debakey forceps, with ease of passage when IPP deflated and inability to pass forceps when IPP inflated indicative of proper sizing. RESULT(S): A total of 63 men underwent IPP with MMS between January 2018 and October 2022. All patients had ED after radical prostatectomy. Average patient age was 67 years old, and average IPP size was 21cm with 1cm rear tip extender (RTE). A total of 59 men had SUI, with average pad per day (PPD) of 1.5. Twenty-five men with SUI had comorbid climacturia, and 4 men had preoperative climacturia without SUI. Average PPD post IPP with MMS was 0.1. Of the 29 men with preoperative climacturia, only one did not have resolution of his symptoms post MMS. There was only one reported complication of acute urinary retention requiring temporary foley catheter placement. Two patients required subsequent AUS insertion for persistent SUI. There were no reported cases of infection or mesh erosion. CONCLUSION(S): The hydrophilic Parietex>= mesh is a safe, easy to use, nonreactive, and effective material for mini male sling insertion at the time of IPP placement for men with ED and mild/moderate SUI or climacturia.
ABSTRACT
OBJECTIVE: To describe the histopathological features of penile tissue of patients who recovered from symptomatic COVID-19 infection and subsequently developed severe erectile dysfunction (ED). MATERIALS AND METHODS: After providing informed consent, penile tissue was collected from patients undergoing surgery for inflatable penile prosthesis due to severe ED under an IRB approved protocol. Two specimens were obtained from men with a history of COVID-19 infection and two specimens were obtained from men with no history of infection (all men tested negative immediately before surgery). Tissue from COVID-19 (+) and COVID-19 (-) specimens were imaged with transmission electron microscopy (TEM). The tissue was analyzed for viral RNA using polymerase chain reaction (PCR) and viral spike protein. Formalin-fixed paraffinembedded tissues were stained with hematoxylin and eosin (H&E) and subjected to immunohistochemical analysis for endothelial Nitric Oxide Synthase (eNOS) expression (marker of endothelial function). Endothelial progenitor cells (EPC) function was assessed ex vivo by determination of endothelial colony forming units from blood samples collected from the COVID-19 (+) and COVID (-) men with severe ED. RESULTS: TEM revealed extracellular viral particles ∼100 nm in diameter, with prominent peplomers (spikes), and electron-dense dots of the nucleocapsid inside the particles near penile vascular endothelial cells of the COVID-19 (+) patients. Notably, viral particles were not detected in tissue obtained from COVID-19 (-) men. COVID-19 RNA was detected in both the penis biopsy samples from men with a history of COVID, but not in the samples from COVID-19 (-) men. There were no significant differences in H&E staining between COVID-19 (+) and COVID-19 (-) men and viral spike protein was not detected. Immunohistochemistry showed decreased eNOS expression in the corpus cavernosum of COVID-19 (+) men compared to COVID-19 (-) men, consistent with endothelial dysfunction. COVID-19 spike protein-positive cells could not be detected by immunofluorescence despite positive COVID-19 PCR. EPC levels from the COVID-19 (+) men were 0 cell/well and 1.167 cell/well respectively compared to mean EPCs from 34 COVID-19 (-) men with severe ED (4.04 cells/well), suggesting impaired endothelial function. CONCLUSIONS: Our study is the first to demonstrate the presence of COVID-19 virus in the penis long after the initial infection in humans. Our study also suggests that widespread endothelial cell dysfunction from COVID-19 infection can contribute to resultant erectile dysfunction. Future studies will evaluate novel molecular mechanisms of how COVID-19 infection leads to ED. IMPACT STATEMENT: COVID-19 can linger in the penis long after initial infection and can contribute to erectile dysfunction.
ABSTRACT
Introduction: The COVID-19 pandemic has changed the lives of many in the past year. As of writing this article, the virus has claimed over half a million American lives and has infected millions more. It has affected many people regardless of age, gender, race, religion, or medical history. We have noticed a unique sequence of events in urology patients with a prior history of inflatable penis prothesis implantation who have gotten critically ill from the SARS-CoV-2 virus. Objective: We report our experience with patients with an inflatable penile prothesis who suffered respiratory failure due to the SARS-CoV-2 virus and findings that would help limit the risk of implant infection and/or erosion if prolonged urethral catherization is needed. Methods: We have encountered 3 patients with a very similar history in the past year. They were all men aged 57-72 years old who had a functioning inflatable penile prothesis (IPP) for many years (3-13) and were intubated for a prolonged period of time (2-4 weeks) after suffering respiratory distress from the SARS-CoV-2 virus. During this time, they all had a prolonged urethral Foley catherization for urinary drainage while in the ICU. They were all subsequently found to have urethral erosion of a penile implant cylinder which was not present prior to hospitalization. Their charts were reviewed. Results: Two patients underwent explantation of their IPP during their hospital stay and one presented to our outpatient office 2 months after discharge with the complaint of urethral cylinder erosion and underwent subsequent explantation. Conclusions: Urethral catheterization is commonly used in the intensive care unit and spinal cord injury patients due to their convenience and efficacy. The friction and inflammation created by prolonged transurethral catheterization can be disastrous for IPPs by increasing the likelihood of infection and/or device erosion. In fact, Steidle and Mulcahy found that five out of their nine patients (55%) with IPPs who had an indwelling or intermittent transurethral catheterization were eventually found to have erosion of their IPP. In addition, indwelling transurethral catheters also confer a higher risk of urinary tract infection. Han et al. found that suprapubic tube placement conferred a statistically significantly lower risk of urinary tract infection when compared to indwelling transurethral catheterization for over five days at an odds ratio of 0.142 (95% CI 0.073-0.0276). Another alternative to bladder drainage in the intubated IPP patient is clean intermittent catherization (CIC), however this poses a unique challenge in the intubated COVID positive patient as it repeatedly exposes healthcare staff the virus-carrying patient. When compared to indwelling transurethral catherization, suprapubic tube placement has been shown to confer a lower risk of urinary tract infection and IPP infection/erosion. This can primarily be explained by its ability to drain the bladder without creating inflammation and friction in the urethra. Therefore, we propose that any team caring for a patient with an IPP and a planned, prolonged indwelling transurethral catheterization consult urology services to have a suprapubic tube temporarily placed. This will ensure that the risk of urinary tract infection and/or IPP erosion is kept as low as possible. Disclosure: Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific, Neotract
ABSTRACT
Introduction: Inflatable penile prosthesis (IPP), an implantable device for treatment of ED, historically have always been done in a hospital setting or outpatient setting. These surgeries are now done more frequently around the world as an in-office procedures. With the increase risk of COVID infections and the improvement of IPP technique we began performing this procedure in the office under local and total intravenous anesthesia. Objective: To present the nuances of office based 3 piece penile prosthesis and the outcome data for the feasibility of in-office implants while minimizing complications. Methods: A retrospective chart review was performed on the 10 IPP patients who had surgery in the office based setting in our clinic. The age ranges varied from 34-58 years of age. All pateints who opted for IPP in the office were screened for any and history of pelvic surgery, renal failure, cardiac stents or heart failure. Preoperatively, Antibiotics used were Vancomycin, Amikacin and oral Fluconazole and oral Neurontin for analgesia. All patients had a preoperative COVID nasal swab or had the vaccine prior to surgery. Intraoperatively Vancomycin, Amikacin and Fluconazole were used for irrigation and implant prep. Smaller table sets with stacking sterile field was used with headlights and loupes. IV sedation was used with the assistance of an anesthesiologist who used Propofol for sedation. A propofol bolus was given prior to entering the space of retzius. The patients also received a penile and pudendal block with a mixture of 1% Lidocaine, 0.5% Marcaine and 1mg Solumedrol for post-op pain management. Postoperatively, Neurontin and Tylenol were given PO and Toradol was given IV. Results: Of the 10 patients selected, 0 patients had infections we had even with a drain being in place 2 patients suffered a hematoma. 1 patient suffered urinary retention, resolving after 24 hours. Patients were cleared for device use between 5 to 8 weeks. 1 patient's implant was recalled;however, the patient did not have a desire for re-operation and has the device and works around the valve. The average procedure time was 53.5 minutes. Incision size range was 1.7 cm to 2.5 cm in length.Drains were placed in all patients for 24 to 48 hours with out puts of 90-160cc. Patients were discharged after 90 minutes in recovery phase. Conclusions: Office based penile prosthesis is safe and feasible in the post COVID world. Nuances such was headlights, loupes and adequate block-aid and sterile field efficiency with preloading and stacking are a necessity. With careful patient selection, in-office implantable penile prosthesis implant can be a safe feasible alternative for patients that have severe ED, have gone through alternative therapies, but either cannot afford and or insurance does not cover this procedure. Disclosure: Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast