Three-Piece Inflatable Penile Prosthesis Placement Following Pelvic Radiation: Technical Considerations and Contemporary Outcomes.

BACKGROUND: Pelvic radiation is a known risk factor for the development and progression of erectile dysfunction. When medical therapy fails, the 3-piece inflatable penile prosthesis (IPP) can offer patients a definitive treatment option. Because of radiation-induced vascular changes and tissue fibrosis, a careful surgical approach is necessary to avoid intraoperative complications and attain successful outcomes. Despite its widespread use in prostate cancer treatment, there are no contemporary studies examining the effects that pelvic radiation can have on 3-piece IPP placement and device survival. AIM: To present technical considerations and contemporary outcomes of placing a 3-piece IPP for refractory erectile dysfunction in patients with a history of pelvic radiation. METHODS: We retrospectively reviewed 78 patients who underwent placement of a 3-piece IPP (AMS 700; Boston Scientific, Marlborough, MA, USA) after being treated with pelvic radiotherapy from 2003 through 2016. All patients had been treated with external beam and/or brachytherapy for treatment of prostate malignancy. An infrapubic approach was used in all patients, with reservoir placement in the space of Retzius or in the lateral retroperitoneal space. Patient demographics, perioperative data, and postoperative outcomes including prosthetic infection and mechanical failure were examined and statistical analysis was performed. OUTCOMES: Rates of device infection, revision surgery, and reservoir complications. RESULTS: No intraoperative complications were observed. After a mean follow-up of 49.0 months (6.6-116.8), 2 patients developed an infection of their prosthesis that required explantation. These patients underwent successful IPP removal and immediate reimplantation. 11 patients (14.1%) required revision surgery (pump replacement, n = 4; pump relocation, n = 2; cylinder replacement, n = 4; reservoir replacement owing to leak, n = 1). No reservoir-related complications such as herniation or erosion into adjacent structures were observed. CLINICAL IMPLICATIONS: The 3-piece IPP can be placed safely in a broad range of patients treated with pelvic radiotherapy. STRENGTHS AND LIMITATIONS: This study describes contemporary long-term outcomes of the IPP in patients treated with pelvic radiation and includes patients with prior pelvic surgery and artificial urinary sphincter, which are commonly encountered in practice. It is limited by its single-center experience and lacks a comparison group of patients. Objective patient satisfaction data were not available for inclusion. CONCLUSIONS: The 3-piece IPP can be placed successfully in patients with a history of pelvic radiation without a significant increase in infectious complications, reservoir erosion, or mechanical failure compared with the global literature. Loh-Doyle J, Patil MB, Nakhoda Z, et al. Three-Piece Inflatable Penile Prosthesis Placement Following Pelvic Radiation: Technical Considerations and Contemporary Outcomes. J Sex Med 2018;15:1049-1054.

Structured learning for robotic surgery utilizing a proficiency score: a pilot study.

PURPOSE: We evaluated feasibility and benefit of implementing structured learning in a robotics program. Furthermore, we assessed validity of a proficiency assessment tool for stepwise graduation. METHODS: Teaching cases included robotic radical prostatectomy and partial nephrectomy. Procedure steps were categorized: basic, intermediate, and advanced. An assessment tool ["proficiency score" (PS)] was developed to evaluate ability to safely and autonomously complete a step. Graduation required a passing PS (PS ≥ 3) on three consecutive attempts. PS and validated global evaluative assessment of robotic skills (GEARS) were evaluated for completed steps. Linear regression was utilized to determine postgraduate year/PS relationship (construct validity). Spearman's rank correlation coefficient measured correlation between PS and GEARS evaluations (concurrent validity). Intraclass correlation (ICC) evaluated PS agreement between evaluator classes. RESULTS: Twenty-one robotic trainees participated within the pilot program, completing a median of 14 (2-69) cases each. Twenty-three study evaluators scored 14 (1-60) cases. Over 4 months, 229/294 (78 %) cases were designated "teaching" cases. Residents completed 91 % of possible evaluations; faculty completed 78 %. Verbal and quantitative feedback received by trainees increased significantly (p = 0.002, p < 0.001, respectively). Average PS increased with PGY (post-graduate year) for basic and intermediate steps (regression slopes: 0.402 (p < 0.0001), 0.323 (p < 0.0001), respectively) (construct validation). Overall, PS correlated highly with GEARS (ρ = 0.81, p < 0.0001) (concurrent validity). ICC was 0.77 (95 % CI 0.61-0.88) for resident evaluations. CONCLUSION: Structured learning can be implemented in an academic robotic program with high levels of trainee and evaluator participation, encouraging both quantitative and verbal feedback. A proficiency assessment tool developed for step-specific proficiency has construct and concurrent validity.

Assessment of the diagnostic performance of (18)F-FDG-PET/CT for detection and characterization of solid renal malignancies.

To evaluate the sensitivity of the positron emission tomography (PET) portion of fluorine-18 fluorodeoxyglucose- PET-computerized tomography ((18)F-FDG-PET/CT) to detect solid malignant renal masses, and to assess for metabolic differences based on histopathological type. Nineteen subjects with 25 known solid malignant renal masses who underwent (18)F-FDG-PET/CT were retrospectively evaluated. Qualitative analysis of the PET portion only of (18)F-FDG-PET/CT examinations to assess visual detection of renal masses was initially performed in blinded fashion. Subsequently, measurements of standardized uptake value (SUV) and lesion-to-background ratios were performed for all masses and compared between histopathological types. Of 25 solid malignant renal masses, 18 were renal cell carcinoma (RCC), 3 were renal lymphoma, and 4 were metastases. Twenty-two of 25 were detectable, and all were correctly spatially localized. Fifteen of 22 detectable lesions were exophytic in configuration. The three non-detectable masses were non-exophytic RCC's with average diameter of 2.0cm. Fifteen of 18 of RCC were detectable, whereas all renal lymphomas and metastases were detectable. None of the metabolic parameters were statistically significant between RCC and renal lymphoma. However, all metabolic parameters were statistically significantly greater for renal metastases compared to RCC and renal lymphoma, and for clear cell RCC compared to papillary RCC. In conclusion, the PET portion of (18)F-FDG-PET/CT had a sensitivity of 88% for detection of solid malignant renal lesions in patients with known renal malignancy, and reveals differences in metabolic activity based on histopathological type, which may be useful for purposes of individualized medicine. Further studies are required for more in depth assessment of these preliminary observations.