Narrative review of immediate salvage for penile prosthesis infection.

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.

Overcoming barriers to immediate penile implant salvage surgery: a narrative review.

Background and Objective: Since immediate salvage (IS) surgery for infected penile prosthesis (PP) was introduced nearly 30 years ago, an abundance of evidence has emerged in support of its use. IS remains underutilized by the modern urologist despite its distinct advantages. While some medical literature proposes reasons for the underuse of IS, no comprehensive review attempts to address the numerous factors limiting its implementation. Our objective is to analyze the barriers to IS surgery for infected PP with the goal of expanding utilization of this technique through a practical and standardized approach for treating urologists. Methods: A narrative review of available English, peer-reviewed, medical literature relevant to the barriers to IS was completed. Searches were expanded to include literature from surgical specialties in general if hypothesized barriers were incompletely described in available PP publications. Key Content and Findings: The major barriers that are likely contributing to the low rates of IS for PP surgery can be broadly classified into three major categories: institutional/systemic, medical/surgical, and patient preference. Institutional/systemically driven barriers include surgeon comfort with PP surgery, low national availability of urologists, inaccessibility of prosthetics or critical ancillary staff at the time of patient presentation and limited operating room (OR) access. Medical/surgical barriers primarily relate to reinfection fears, perceived contraindications to IS, and overall patient stability at the time of presentation. Patient preference factors inhibiting IS involve loss of trust in the medical team, psychosocial distress, dissatisfaction with the initial device prior to infection and anxiety regarding postoperative recovery. Many of the identified barriers can be overcome with increased surgical training, improved patient and surgeon understanding of PP infection, or precautionary planning. Conclusions: Of the factors that contribute to low utilization of IS, many are misunderstood or unknown. Recognition of these barriers may equip urologists to provide better care to patients with prosthesis infection.

Does climate impact inflatable penile prosthesis infection (IPP) risk? Assessment of temperature and dew point on IPP infections.

BACKGROUND: Variations in climate have been associated with a greater risk of surgical site infections, urinary tract infections, and changes in the skin microbiome; however, limited data exist on the impact of climate on inflatable penile prosthesis (IPP) infections. AIM: We sought to evaluate the impact of climate on the risk of IPP infections in a large international, multicenter cohort. METHODS: We performed a multi-institutional, retrospective study of patients undergoing IPP surgery. We then evaluated whether the month or season, during which surgery was performed, affected device infections. Implant infections were defined as infections requiring device explantation. A univariate logistic regression analysis was undertaken. OUTCOMES: Our primary outcome was implant infection. RESULTS: A total of 5289 patients with a mean age of 62.2 ± 10.8 years received IPP placement. There was a fairly even distribution of implants performed in each season. A total of 103 (1.9%) infections were recorded. There were 32 (31.1%) IPP infections in patients who underwent surgery in the summer, followed by 28 (27.2%) in the winter, 26 (25.2%) in the spring, and 17 (16.5%) in the fall. No statistically significant differences were recorded in terms of season (P = .19) and month (P = .29). The mean daily temperature (P = .43), dew point (P = .43), and humidity (P = .92) at the time of IPP placement was not associated with infection. CLINICAL IMPLICATIONS: These findings provide reassurance to prosthetic urologists that infection reduction strategies do not need to be tailored to local climate. STRENGTHS AND LIMITATIONS: Climate data were not directly recorded for each hospital, but rather based on the monthly averages in the city where the surgery was performed. CONCLUSION: The climate at time of IPP placement and time of year of surgery is not associated with IPP infection risk.

Safety outcomes of the first Rigi10™ malleable penile prostheses implanted worldwide.

Implantation of penile prosthesis is considered when conservative measures fail or are unacceptable to patients' wishing treatment for erectile dysfunction. In the United States (US), inflatable penile prostheses are more often used than malleable penile prostheses (MPP). Outside the US, the reverse is true because third-party reimbursement is not available, and MPP is considerably cheaper. Two American manufacturers make MPP; presently, a new manufacturer, Rigicon (Ronkonkoma NY), has recently begun to sell its MPP worldwide. Patient information forms submitted to the manufacturer between March 1, 2019, and December 8, 2022, were used to conduct an initial safety study for 605 first-time patients implanted with Rigicon10® by 46 physicians in 15 countries with a mean follow-up of 21.6 months. It has the same configuration of trimmable, paired silicone rods containing a twisted stainless-steel wire for bendability. However, it is available in six widths with hydrophilic coating compared to three widths offered by competitors. Revision or explantation was needed in 6 of 605 patients (0.99%) with half of those being removed for dissatisfaction (0.50%). Two (0.33%) suffered device infection and one (0.16%) required removal for erosion. Kaplan-Meier's statistical analysis showed three-year implant survival from revision = 99.2%. It demonstrated a comparable safety record with less than 1.00% of patients requiring reoperation.

Single Dilation in Primary Inflatable Penile Prosthesis Placement Is Associated With Fewer Corporal Complications Than Sequential Dilation.

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.

Management of urologic prosthetic reservoirs at the time of inguinal or pelvic surgery.

INTRODUCTION: The artificial urinary sphincter and 3-piece inflatable penile prosthesis each require a fluid storage component and thus have components in the inguinal and pelvic regions. Because of this, patients with urologic prosthetics sometimes present challenges during future nonprosthetic operations. Presently, there is no established guideline for device management with ensuing inguinal or pelvic surgery. AIMS: This article outlines concerns during pelvic and inguinal surgery for patients with an artificial urinary sphincter and/or inflatable penile prosthesis and proposes an algorithm for preoperative surgical planning and decision making. METHODS: We conducted a narrative review of the literature on operative management of these prosthetic devices. Publications were identified by searching electronic databases. Only peer-reviewed publications available in English were considered for this review. RESULTS: We review the important considerations as well as available options for operative management of these prosthetic devices during subsequent nonprosthetic surgery and highlight the advantages and disadvantages of each. Finally, we suggest a framework for helping surgeons determine which management strategy is most appropriate for their individual patients. CONCLUSION: The best management strategy will differ depending on patient values, the planned surgery, and patient-specific factors. Surgeons should understand and counsel patients on all available options and encourage informed, shared decision making to determine the best individualized approach.

Partial Component Exchange of a Non-Infected Inflatable Penile Prosthesis is Associated With a Higher Complication Rate.

OBJECTIVE: To describe the infectious and non-infectious complications in men undergoing Inflatable penile prosthesis (IPP) revision with partial and complete component exchange for mechanical malfunction. METHODS: We performed a multicenter retrospective cohort study of patients who underwent IPP revision. Men undergoing procedures for implant infection were excluded. Patients were divided into those who had complete exchange of the entire device or partial exchange of only one or 2 components. Infectious and non-infectious complications were compared between groups. RESULTS: Three hundred sixty-eight men had complete exchange of the entire device and 85 had partial component exchange. Men undergoing partial exchange had a significantly higher infection rate (7.1% vs 2.2%, P = .031). The partial exchange group also was more likely to receive antifungals (51.8 vs 16.6%, P < .001), have a modified salvage washout (77.4 vs 60.2%, P = .004), and less likely to receive vancomycin and gentamicin (63.5 vs 83.7%, P < .001). Time to revision was significantly shorter in the partial exchange group (44.9 vs 168.2 months, P < .001). Mean follow-up was slightly longer in the complete exchange group (18.3 vs 13.0 months). In multivariable analysis, partial exchange surgery, vancomycin and gentamicin prophylaxis, modified salvage washout, and antifungal prophylaxis were no longer associated with postoperative infections. The partial exchange group had greater rates of non-infectious complications (21.2% vs 9.5%, P = .005) such as pump malfunction and tubing breakage. CONCLUSION: Patients undergoing partial component revision had more infectious and non-infectious complications. These findings suggest that partial component exchange increases complications in men undergoing IPP revision.

AUA-recommended Antibiotic Prophylaxis for Primary Penile Implantation Results in a Higher, Not Lower, Risk for Postoperative Infection: A Multicenter Analysis.

PURPOSE: Our aim was to determine if the AUA-recommended prophylaxis (vancomycin + gentamicin alone) for primary inflatable penile prosthesis surgery is associated with a higher infection risk than nonstandard regimens. MATERIALS AND METHODS: We performed a multicenter, retrospective study of patients undergoing primary inflatable penile prosthesis surgery. Patients were divided into those receiving vancomycin + gentamicin alone and those receiving any other regimen. A Cox proportional-hazards model was constructed adjusted for major predictors. A subgroup analysis to identify the appropriate dosage of gentamicin was also performed. RESULTS: A total of 4,161 patients underwent primary inflatable penile prosthesis placement (2,411 received vancomycin + gentamicin alone and 1,750 received other regimens). The infection rate was similar between groups, 1% vs 1.2% for standard vs nonstandard prophylaxis. In the multivariable analysis, vancomycin + gentamicin (HR: 2.7, 95% CI: 1.4 to 5.4, P = .004) and diabetes (HR: 1.9, 95% CI: 1.03 to 3.4, P = .04) were significantly associated with a higher risk of infection. Antifungals (HR: 0.08, 95% CI: 0.03 to 0.19, P < .001) were associated with lower risk of infection. There was no statistically significant difference in infection rate between weight-based gentamicin compared to 80 mg gentamicin (HR: 2.9, 95% CI: 0.83 to 10, P = .1). CONCLUSIONS: Vancomycin + gentamicin alone for antibiotic prophylaxis for primary inflatable penile prosthesis surgery is associated with a higher infection risk than nonstandard antibiotic regimens while antifungal use is associated with lower infection risk. A critical review of the recommended antimicrobial prophylactic regimens is needed. Prospective research is needed to further elucidate best practices in inflatable penile prosthesis antimicrobial prophylaxis.

Infection rates following urologic prosthetic revision without replacement of any device components compared to partial or complete device exchange: a single-center retrospective cohort study.

Urologic implant revision carries a higher infection risk than virgin implantation. Historically, exchanging device components at the time of revision was performed to reduce infection risk. We hypothesize that revision without replacement of any parts of the device may not be associated with increased infection risk. A single-center, retrospective cohort study was performed on patients undergoing urologic implant revision from 2000 to 2021. Revisions involving exchange of any/all device components (+CE) were compared to revisions without exchange of any components (-CE). The primary outcome was infection or erosion within 12 weeks of revision. Infection rates were compared using Fischer exact test. Infection-free survival (IFS) was compared with Kaplan-Meier (KM) log-rank test and Cox proportional hazards (CPH) model. 551 revisions were included, including 497 revisions with CE and 54 without CE. Among those with at least 12 weeks follow-up, no difference was seen in infection rates within 12 weeks of revision [-CE 3/39 (7.7%) vs. +CE 10/383 (2.6%)], p = 0.109). In addition, IFS was comparable between groups (log-rank test p = 0.22, HR for -CE 1.65 (0.65-4.21). Revision surgery for IPP or AUS without CE may not present an elevated risk of infection in the properly selected patient.

Indications and Outcomes for Intermittent Catheterization following Bulbar AUS Cuff Placement.

OBJECTIVE: To evaluate the functional and surgical impact of CIC protocols in men with a bulbar AUS in place. Stress urinary incontinence (SUI) and poor bladder emptying are both sequelae of prostate cancer treatment, though there is sparse data to guide concomitant management. The safety of intermittent catheterization (CIC) in men with an artificial urinary sphincter (AUS) at the bulbar urethra remains unclear. METHODS: We performed a retrospective review of all bulbar urethral AUS procedures at our institution. Inclusion criteria were patients with a history of prostate cancer treatment, AUS placement for SUI, and a history of CIC before and/or after AUS placement. All eligible cases were retrospectively reviewed. Surgical and continence outcomes were analyzed. RESULTS: A total of 57 patients were identified with a history of CIC and AUS placement under the care of two surgeons. Eighteen continued to perform CIC or first initiated CIC after AUS placement and 39 discontinued CIC prior to AUS placement. The incidence of erosion was no different amongst patients who continued or discontinued CIC after AUS placement (17.9% vs 22.2%, P = .79). There was no difference in future AUS removal or replacement (56.4% vs 44.4%, P = .41). Both groups experienced improvement in urinary incontinence after placement of an AUS. CONCLUSION: Bulbar AUS placement in the setting of continuous intermittent catheterization can be considered in patients who are not surgical candidates for definitive treatment of their outlet obstruction.

Synchronous Surgical Management of Erectile Dysfunction and Stress Urinary Incontinence: A Systematic Review and Meta-Analysis of Reoperation Rates.

INTRODUCTION: The efficacy, safety, and postoperative outcomes of synchronous surgery for concomitant erectile dysfunction (ED) and stress urinary incontinence (SUI) remain unclear. OBJECTIVES: We performed a systematic review and meta-analysis to evaluate the available synchronous surgical approaches for concomitant ED and SUI and to assess the reoperation rates compared to asynchronous surgery and surgery only for ED or SUI. METHODS: We searched PubMed, Cochrane Library, and Embase databases until June 2022 for relevant studies. Based on data availability, we performed a meta-analysis of odds ratios (ORs) comparing reoperation rates after synchronous surgery in patients with concomitant ED and SUI versus asynchronous surgery, as well as surgery solely for ED or SUI (PROSPERO: CRD42022326941). RESULTS: We included 18 studies in the systematic review (16,517 patients) and 5 in the meta-analysis. Comparing synchronous implantation of penile prosthesis and artificial urinary sphincter (AUS) versus asynchronous surgery, no statistically significant differences were observed in the reoperation rates [OR:0.98, 95% confidence interval (CI): 0.52-1.84, I2:0%). Comparing synchronous implantation of both penile prosthesis and AUS versus implantation of only a penile prosthesis or an AUS, combined surgery was associated with higher reoperation rates (OR:2.02, 95%CI: 1.29-3.16, I2:36% and OR:1.7, 95%CI: 1.25-2.32, I2:0%, respectively). Synchronous surgery led to high satisfaction rates and significant improvement in ED and SUI. Evidence for the combination of penile prosthesis with a male sling or the ProACT device is low, but data suggests it may be safe and effective. The synchronous placement of a Mini-Jupette sling and penile prosthesis represents a promising treatment modality for the correction of ED and mild SUI and/or climacturia. CONCLUSIONS: Synchronous penile prosthesis and AUS implantation appears safe and effective in patients with severe ED and SUI. Further high-quality studies are mandatory to strengthen the current scarce evidence for synchronous surgery in patients with ED and SUI. Pyrgidis N, Barham DW, Hammad M, et al. Synchronous Surgical Management of Erectile Dysfunction and Stress Urinary Incontinence: A Systematic Review and Meta-Analysis of Reoperation Rates. Sex Med Rev 2022;10:782-790.

Current Techniques for the Objective Measures of Erectile Hardness.

INTRODUCTION: One of the most discussed topics in the urology provider's office is that of the male penile erection. Moreover, this is also a frequent basis for consultation by primary care practitioners. As such, it is essential that urologists are familiar with the various means by which the male erection may be evaluated. OBJECTIVES: This article describes several techniques presently available that may serve to objectively quantify the rigidity and hardness of the male erection. These techniques are meant to bolster information gathered from the patient interview and physical examination to better guide patient management. METHODS: An extensive literature review was performed examining publications in PubMed on this subject, including corresponding contextual literature. RESULTS: While validated patient questionnaires have been routinely employed, the urologist has many additional means available to uncover the extent of the patient's pathology. Many of these tools are noninvasive techniques that involve virtually no risk to the patient and take advantage of pre-existing physiologic properties of the phallus and its blood supply to estimate corresponding tissue stiffness. Specifically, Virtual Touch Tissue Quantification which precisely quantifies axial and radial rigidity, can provide continuous data on how these forces change over time, thus providing a promising comprehensive assessment. CONCLUSION: Quantification of the erection allows for the patient and provider to assess response to therapy, aids the surgeon in choice of appropriate procedure, and guides effective patient counseling regarding expectation management. Rohrer GE, Premo H, Lentz AC. Current Techniques for the Objective Measures of Erectile Hardness. Sex Med Rev 2022;10:648-659.

Valsalva leak point pressure (VLPP) greater than 70 cm H2O is an indicator for sling success: a success prediction model for the male transobturator sling.

INTRODUCTION AND OBJECTIVES: Urodynamic studies are often performed in the evaluation of post-prostatectomy urinary incontinence (PPUI). The male transobturator sling (TOS) is a minimally invasive treatment for PPUI. Others have reported their results with a specific Valsalva leak point pressure (VLPP) that predicts a good outcome with the male TOS. Our objective was to determine the relationship of the pre-operative VLPP on the success rate of the male TOS in a high-volume, single center. We hypothesized that a higher pre-operative VLPP better predicts successful outcomes. METHODS: We reviewed patients undergoing a male TOS placement from 2006 to 2012 at our institution. Patients who underwent TOS placement were identified using our patient data portal (DEDUCE). Demographic, urodynamic, and follow-up data were extracted by chart review. Post-operative success was defined by the use of 0 or 1 security pad, a negative stress test on exam, or pad weight of less than 8 g per 24 h. Cox and linear regression models were performed. RESULTS: 290 patients were included. All patients underwent a radical prostatectomy for prostate cancer and presented with PPUI. Mean age at surgery was 66.3 (± 7.4) years and 84% were Caucasian. Median time to follow-up was 5 months (IQR 1-15). A linear regression model shows an inverse prediction curve for sling failure versus VLPP (p = 0.02). The hazard ratio for failure with a VLPP of ≤ 70 cm H2O compared with a VLPP of > 70 cm H2O, adjusted for pelvic radiation and 24-h pad weight was 0.5 (95% CI 0.2-0.98). CONCLUSION: Patient selection is imperative in the success of the male TOS for patients with PPUI. In our cohort of patients with PPUI, those with a pre-procedural VLPP of > 70 cm H2O were 50% less likely to fail after TOS placement versus those with a VLPP ≤ 70 cm H2O. In our practice, we use these data to support the use of VLPP cut off of 70 cm H2O as an indicator for success to help in the evaluation and counseling of patients.

Small Diameter Penile Implants: A Survey on Current Utilization and Review of Literature.

BACKGROUND: Inflatable penile prostheses (IPPs) with smaller diameter cylinders have been in use for over 30 years, yet the literature is sparse on their utilization patterns amongst prosthetic surgeons. AIM: To understand current usage of small diameter penile implants (SDPI) among prosthetic surgeons. METHODS: IRB approval was obtained to conduct a survey of prosthetic surgeons. A 23-question online survey was distributed via email to physician members of the Sexual Medicine Society of North America (SMSNA) and Society of Urologic Prosthesis Surgeons (SUPS). The survey included questions regarding surgeon experience and volume, frequency of SDPI utilization, indications for SDPI, surgical strategy in the setting of SDPI (approach, use of concordant modeling/grafting), reservoir and pump management, and perceived infection risk and patient satisfaction. MAIN OUTCOME MEASURE: SDPI were utilized by the vast majority of respondents in certain clinical situations such as corporal fibrosis or anatomically small corpora, and surgeons have had a favorable experience with these as a final destination implant or as a place-holder until reimplantation with a normal diameter device. RESULTS: Fifty individuals responded to the survey, 48 of whom routinely utilized SDPI. The most common indication for SDPI placement was corporal fibrosis from prior infection, followed by anatomically small corpora and priapism. The most common maximal dilation diameter was 10 mm (47%), an additional 23% of respondents utilized SDPI with 11 mm dilation. 75.4% of respondents sometimes or always intended to upsize to standard diameter cylinders in the future. 68.8% of surgeons routinely counseled patients on the possibility of reduced grith and rigidity with SDPI. Patient satisfaction was perceived to be comparable to standard diameter cylinders in 56.3% of respondents, while the remaining 43.6% believed it to be lower than traditional cylinders. Utilization of SDPI can be an important tool for prosthetic surgeons faced with difficult cases due to corporal fibrosis or small corpora. This survey provides new insight into patterns of SDPI utilization by surgeons. A limitation of the study is that patient satisfaction is indirectly addressed through surgeons' perception and experience, further research will be necessary to include patient questionnaires regarding device satisfaction. CONCLUSION: SDPI are necessary in certain scenarios that preclude the use of normal diameter cylinders. These implants may offer satisfactory erections, but can also be upsized to standard diameter cylinders in the future. Campbell SP, Kim CJ, Allkanjari A et al. Small Diameter Penile Implants: A Survey on Current Utilization and Review of Literature. Sex Med 2022;10:100458.

Update on the Medical and Surgical Management of Urethral Condyloma.

INTRODUCTION: Condyloma acuminata (CA) of the urethra presents a management challenge due to high recurrence rates, difficulty in accessing urethral lesions, risk of stricture formation, and potential for sexual dysfunction. While standard treatment modalities are acceptable for some external genital condyloma, they are not always feasible or appropriate for urethral lesions. OBJECTIVES: We sought to review the literature on epidemiology, presentation, diagnosis and treatment of urothelial CA with a focus on surgical treatment options. METHODS: We performed a comprehensive literature search of PubMed to identify all studies pertaining to urethral CA through November 2020. RESULTS: Urethral CA is a relatively rare, but challenging disease to manage with a considerable amount of treatment side effects and downstream morbidity associated. In our comprehensive review we have found a wide selection of treatment modalities ranging from minimally invasive strategies to surgical reconstructive techniques. Proper follow-up to monitor for disease recurrence at the 3-4 month mark is appropriate and will determine subsequent treatment strategies as needed. Future studies and treatment directions include novel drug delivery models to optimize minimally invasive topical drug efficacy. CONCLUSION: Treatment of urethral CA should be approached in a step-wise fashion. Medical therapy would be an appropriate option for asymptomatic or minimally symptomatic patients with small lesions who desire to avoid any interventions. If patient is symptomatic, has extensive disease burden or has failed medical therapy intervention should be considered with options including PDT, laser ablation or surgical excision with or without urethral reconstruction. Appropriate selection depends on patient characteristics and preferences along with prior treatment history. Kim CJ, Campbell SP, Allkanjari A, et al. Update on the Medical and Surgical Management of Urethral Condyloma. Sex Med Rev 2022;238-252.