Delayed placement of an inflatable penile prosthesis is associated with a high complication rate in men with a history of ischemic priapism

Contemporary management of ischemic priapism: A 12-year population-based analysis from a large US database

BACKGROUND

Priapism is a urological condition characterized by a persistent erection. The management varies based on its subclassifications. Despite established clinical guidelines for ischemic priapism, there is a lack of large-scale research focused on patient characteristics and management strategies.

OBJECTIVES

To analyze the contemporary management of ischemic priapism in the US, exploring patient demographics and clinical characteristics, as well as predictors of erectile dysfunction (ED) and penile prosthesis implantation (PPI).

MATERIALS AND METHODS

We performed a retrospective analysis of the PearlDiver Mariner database, reviewing records from 2010-2021. Adult males diagnosed with ischemic priapism were included. Data analysis covered demographic, clinical variables, and management strategies. Predictors of de novo ED and PPI were evaluated using multivariable logistic regression analysis.

RESULTS

Of 36,120 patients, most (93%) received only medical management, and a minority underwent surgical interventions (penile shunt surgery [PSS], PPI or both). Medical management was typically effective, as 67.08% of the patients in this group experienced only one episode of priapism. However, de novo ED occurred in 16.57% of these patients. The majority of patients undergoing PPI had an inflatable prosthesis (81%). Older age (odds ratio, OR 1.02), the presence of metabolic diseases (OR 1.39), neurogenic disorders (OR 1.72), solid pelvic malignancies (OR 1.09), and multiple episodes of priapism were identified as significant predictors of de novo ED (all p < 0.05). Similarly, age (OR 1.03), the presence of metabolic diseases (OR 1.23), solid pelvic malignancies (OR 1.99), and multiple episodes of priapism were associated with higher likelihood of PPI (all p < 0.05).

CONCLUSION

Most cases of ischemic priapism are managed with the medical therapy. Less than 3% of patients with ischemic priapism receive PPI, and when this occurs an inflatable prosthesis is favored. Age, specific comorbidities, and multiple episodes of priapism appear to be significant predictors of ED and PPI.

Penile prosthesis for erectile dysfunction: recommendations from the 5th International Consultation on Sexual Medicine

INTRODUCTION

Penile prosthesis (PP) is one of the main approved therapies for erectile dysfunction (ED). Greater than 50 years of clinical use has led to considerable innovation in PP surgery and patient care.

OBJECTIVES

To summarize the current literature and provide updated clinical evidence to inform healthcare providers on best practices with PP.

METHODS

A consensus panel was held with leading sexual medicine experts during the 5th International Consultation on Sexual Medicine (ICSM). Relevant peer-reviewed literature was reviewed with focus on research from but not limited to the last 10 years. The quality of each individual study was judged with Oxford levels of evidence (LOE) criteria, but overall LOE were not used as systematic review was not performed. The expert panel generated consensus statements based on the quality of evidence and criteria of GRADE (Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

PP provides excellent outcomes for the treatment of ED. The panel developed 35 recommendations building upon previous recommendations. Nine recommendations (4, 5, 11,13,17, 25, 26, 31, and 32) are retained without change from 2015. Twelve recommendations (1, 2, 3, 7, 9,14,16,19,21, 28, 33, and 34) change syntax to make statements more active or change details. Fourteen recommendations (6, 8, 10, 12, 15, 18, 20, 22, 23, 24, 27, 29, 30, and 35) are novel in this update.

CONCLUSION

Since the 4th ICSM, new evidence has emerged to guide PP use in modern sexual medicine. While multi-institutional studies are needed to improve outcomes, key challenges remain: reducing infections, enhancing devices, and improving awareness and accessibility. We recommend following 5th ICSM guidelines while emphasizing the importance of clinical judgment and shared decision-making for optimal PP outcomes.

New findings regarding predictors of Poor Corporal Integrity in Penile Implant Recipients: A Multicenter International Invesigation

OBJECTIVES

To evaluate the pre- and intraoperative variables that impact the integrity of the corporal bodies over time after inflatable penile prosthesis (IPP) placement, as predictors of intraoperative corporal perforation and delayed cylinder complications have not been well characterized.

PATIENTS AND METHODS

We retrospectively reviewed a 16-centre multi-institutional database of IPP surgeries performed by experienced implanters from 2016 to 2021. Poor corporal integrity (PCI) was defined as intraoperative (iPCI) corporal complications or postoperative (pPCI) corporal complications. Multivariable analysis was performed to identify independent predictors of PCI, iPCI, and pPCI. Primary outcomes included intra- and postoperative corporal complications.

RESULTS

We identified 5153 patients for analysis from 5406 IPP cases, finding 152 (2.95%) cases of PCI. On multivariable analysis, predictors of PCI included revision IPP surgery (odds ratio [OR] 8.16, 95% confidence interval [CI] 5.15-12.92; P < 0.001), sequential dilatation (OR 2.12, 95% CI 1.32-3.39; P = 0.002), coronary artery disease (CAD)/peripheral vascular disease (PVD) (OR 1.81, 95% CI 1.18-2.77; P = 0.006), older age (OR 1.02, 95% CI 1.01-1.04; P = 0.013), and corporal scarring (OR 1.58, 95% CI 1.0-2.5; P = 0.049). Predictors of iPCI included revision IPP surgery (OR 7.34, 95% CI 4.18-12.88; P < 0.001), corporal scarring (OR 2.77, 95% CI 1.64-4.69; P < 0.001), radiation therapy (OR 2.25, 95% CI 1.0-5.04; P = 0.049), and older age (OR 1.03, 95% CI 1.0-1.05; P = 0.025). Revision IPP surgery (OR 7.92, 95% CI 3.69-17.01; P < 0.001), sequential dilatation (OR 3.4, 95% CI 1.61-7.19; P = 0.001), CAD/PVD (OR 2.98, 95% CI 1.56-5.72; P = 0.001), and history of priapism (OR 3.59, 95% CI 1.08-11.99; P = 0.038) were predictive of pPCI.

CONCLUSION

Coronary artery disease/PVD, being of older age, having corporal scarring, undergoing IPP revision surgery and sequential dilatation were predictive risk factors for complications associated with PCI. Identifying patients who are at risk of having PCI may improve patient-specific counselling, consideration of referral to more experienced implanters, and surgical planning to potentially promote longer-term device viability.

Surgical Management of Ischemic Priapism: what are the New Options?

Ischemic priapism is a true urologic emergency. Prompt intervention is required to alleviate the compartment syndrome and restore perfusion to the corporal bodies; failure to do so results in irreversible damage, fibrosis, and profound erectile dysfunction. This paper's objective is to review current literature surrounding the management options for ischemic priapism, focusing on newer surgical techniques. A PubMed database search was performed in June 2024, encompassing the terms "priapism," and "surgical management." Articles were reviewed by two authors independently and included if they were deemed to pertain specifically to management of ischemic priapism. In the acute setting (certainly for priapism lasting <24 hours), management is often successful using bedside maneuvers such as aspiration, irrigation, and injection of sympathomimetic agents. For more prolonged priapism, more aggressive intervention is often warranted. Newer tunneling techniques-including penoscrotal decompression and the corporal snake maneuver-have shown promising preliminary results, not just in terms of priapism resolution but also perhaps sexual function recovery.

Early Inflatable penile prosthesis implantation offers superior outcomes compared to delayed insertion following ischemic priapism: a narrative review

Ischemic priapism is a urological emergency which may lead to irreversible erectile dysfunction. One of the accepted treatments is penile prosthesis implantation. Given the scarcity of studies directly comparing timing of penile prosthesis insertion after ischemic priapism, consensus remains elusive. We aim to compare different studies in the literature concerning advantages and disadvantages of early versus delayed inflatable penile prosthesis following ischemic priapism. We analyzed 8 articles that investigated immediate and delayed inflatable penile prosthesis placement after ischemic priapism. Early inflatable penile prosthesis placement is associated with better outcomes, including pain relief, priapism resolution, penile shortening prevention, and quicker sexual activity resumption. However, it still carries a high risk of complications like edema, infection, and distal perforations. Delayed inflatable penile prosthesis insertion poses surgical challenges due to the potential for extensive corporal fibrosis. Comparative analyses have shown elevated complication rates in patients with ischemic priapism who undergo delayed inflatable penile prosthesis insertion, as opposed to those with early insertion. In studies reporting complications rates, the total complication rate in the early group was 3.37%, significantly lower than the delayed group (37.23%). Most studies support the superiority of early inflatable penile prosthesis placement following ischemic priapism over delayed placement. Further research is, however, needed to establish a global consensus on timing of prosthesis insertion.

Early vs delayed insertion of penile prosthesis in patients with refractory priapism: a systematic review and meta-analysis

INTRODUCTION

Refractory priapism, characterized by persistent and prolonged painful erections despite initial treatment maneuvers, can significantly impair erectile function secondary to ischemia-induced corporal tissue fibrosis. These patients will likely require subsequent penile prosthesis (PP) surgery to regain sexual activity, yet consensus regarding the optimal timing of implantation remains lacking.

OBJECTIVES

To evaluate and compare the clinical outcomes associated with early vs delayed PP implantation in individuals with priapism-induced erectile dysfunction (ED).

METHODS

We included studies that focused on refractory priapism leading to ED and its management with PP implantation. We assessed cohort study bias with a risk-of-bias tool and case series bias with the modified Newcastle-Ottawa Scale. Pooled odds ratios (ORs) were calculated by a fixed-effect model.

RESULTS

We included 9 studies, comprising 4 cohort studies and 5 case series, involving a total of 278 patients. Total complications were higher in the delayed group (OR, 4.16; 95% CI, 2.77-6.26). Fibrosis was significantly more pronounced in the delayed group (OR, 118.18; 95% CI, 20.06-696.32). The odds of erosion, infections, and penile injury did not show statistically significant differences between the groups (OR, 2.52 [95% CI, 0.67-9.49], 0.89 [0.38-2.10], 1.83 [0.79-4.26], respectively). Patients' satisfaction resulted in a pooled OR of 0.15 (95% CI, 0.04-0.49) in favor of the early PP insertion group.

CONCLUSION

The results from this study favor an early approach to ED (within 30 days) following ischemic priapism. However, it is important to consider patients' preferences, values, and psychological factors to make an informed decision.

Trends and outcomes of hospitalized patients with priapism in Germany: results from the GRAND study

We aimed to provide evidence on the trends and in-hospital outcomes of patients with low- and high-flow priapism through the largest study in the field. We used the GeRmAn Nationwide inpatient Data (GRAND), provided by the Research Data Center of the Federal Bureau of Statistics (2008-2021), and performed multiple patient-level analyses. We included 6,588 men with low-flow and 729 with high-flow priapism. Among patients with low-flow priapism, 156 (2.4%) suffered from sickle cell disease, and 1,477 (22.4%) patients required shunt surgery. Of them, only 37 (2.5%) received a concomitant penile prosthesis implantation (30 inflatable and 7 semi-rigid prosthesis). In Germany, the total number of patients with low-flow priapism requiring hospital stay has steadily increased, while the number of patients with high-flow priapism requiring hospital stay has decreased in the last years. Among patients with high-flow priapism, 136 (18.7%) required selective artery embolization. In men with low-flow priapism, sickle cell disease was associated with high rates of exchange transfusion (OR: 21, 95% CI: 14-31, p < 0.001). The length of hospital stay (p = 0.06) and the intensive care unit admissions (p = 0.9) did not differ between patients with low-flow priapism due to sickle cell disease versus other causes of low-flow priapism. Accordingly, in men with high-flow priapism, embolization was not associated with worse outcomes in terms of length of hospital stay (p > 0.9), transfusion (p = 0.8), and intensive care unit admission (p = 0.5). Low-flow priapism is an absolute emergency that requires shunt surgery in more than one-fifth of all patients requiring hospital stay. On the contrary, high-flow priapism is still managed, in most cases, conservatively.

Penile implants in low flow priapism

Priapism is a persistent or prolonged erection, in the absence of sexual stimulation, that fails to subside. Prolonged ischaemic or low flow priapism is defined as a full or partial erection persisting for more than 4 h and unrelated to sexual interest or stimulation, characterised by little or no cavernous blood flow. Low flow priapism leads to progressive corporal fibrosis, which could, in turn, lead to long-lasting erectile dysfunction if left untreated. Penile prosthesis implantation is recognised as a management option in refractory and delayed low flow priapism for restoring erectile function with high patient satisfaction rates. However, the ensuing corporal fibrotic scarring poses a surgical challenge to clinicians, given the higher complication rates in this patient subset. Postoperative patient satisfaction has been closely linked to preoperative expectations and perceived loss of penile length. Therefore, thorough patient counselling concerning the risk and benefits of penile implants should be a priority for all clinicians. Moreover, there is a lack of consensus on the ideal prosthesis choice and procedural timing in refractory low flow priapism. In this review, we will examine the existing literature on penile implants in patients with priapism and discuss the options for managing complications associated with penile prosthesis surgery.