Primary versus revision implant for inflatable penile prosthesis: A propensity score-matched comparison

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.

Management of the Inflatable Penile Prosthesis Reservoir at time of revision surgery: remove, retain, or recycle?

BACKGROUND

Three common strategies exist for managing the inflatable penile prosthesis reservoir during revision surgery: the original reservoir can be (a) removed, (b) deactivated and left in situ, sometimes referred to as "drain and retain" (DR), or (c) validated and reconnected to new cylinders, which we have termed "reservoir recycling" (RR).

AIM

To compare the efficacy and safety of the RR approach to penile prosthesis revision against DR and the recommended approach of complete device removal and replacement.

METHODS

A retrospective chart review of our single-surgeon inflatable penile prosthesis database between 2007 and 2022 was performed, identifying revision surgeries. Cases were stratified by reservoir management technique. Patients who had undergone at least 1 follow-up visit and had complete documentation regarding reservoir handling were included. Reservoir-related complications necessitating surgical intervention such as infection and device failure were compared between the 3 groups using a chi-square test. Mean follow-up duration, time to revision, and operative time were also assessed.

OUTCOMES

The primary outcome was the incidence of reservoir-related complications requiring surgical intervention and secondary outcomes included time to revision surgery and operative time.

RESULTS

Among 140 patients meeting inclusion criteria, 62 underwent full reservoir replacement (FR), 48 DR, and 30 RR. Compared to FR, DR and RR groups had similar mean time to revision and intraoperative time. Follow-up duration was similarly limited for all 3 groups at a median of approximately 4.5 months. There were no postoperative infections in the RR cohort. However, when compared to the DR and FR groups, this did not reach significance (P = .398). There was no difference in mechanical failure rate between the 3 groups (P = .059). Nonmechanical failure was also similar between all 3 groups (P = .165).

CLINICAL IMPLICATIONS

These results suggest that RR exhibits comparable outcomes to DR and FR, making it a viable option during select penile prosthesis revision surgeries, potentially decreasing morbidity without compromising outcomes.

STRENGTHS AND LIMITATIONS

This is the first study to evaluate outcomes after RR. Limitations include small sample size, limited follow-up, and single-surgeon experience.

CONCLUSION

There was no difference in reservoir-related complications when comparing the 3 methods. These preliminary results suggest that reservoir recycling may provide a safe and effective reservoir-handling alternative in inflatable penile prosthesis revision surgery.

Quality of life and sexuality with penile prosthesis: a systematic review and pooled analysis

INTRODUCTION

Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) is the first validated questionnaire to specifically evaluate the satisfaction of patients undergoing penile prosthesis implantation. Our primary aim was to conduct a systematic review and pooled analysis of articles reporting QoLSPP.

EVIDENCE ACQUISITION

A comprehensive bibliographic search on the MEDLINE, Scopus, Web of Science, and Cochrane Library databases was performed in April 2023. Studies were selected if they assessed male subjects (P) undergoing penile prosthesis implantation (I) with or without comparison with other treatments (C), reporting the patient satisfaction according to QoLSPP (O). Prospective and retrospective original studies were included (S). The risk of bias was assessed using the ROBINS-I tool and the Knoll method. Means and standard deviations (SDs) of QoLSPP scores were included in the pooled analysis. PROSPERO ID: "CRD42023427261."

EVIDENCE SYNTHESIS

A total of 10 studies investigating 1105 patients were included in the systematic review; of these, eight articles describing the outcomes of 693 subjects were eligible for the pooled analysis. Overall serious risk of bias was found in 2/3 of nonrandomized comparative studies (66%), while seven single-arm studies (100%) were classified as having a high risk of bias. Pooled analysis of the QoLSPP-Functional domain revealed an overall effect size (ES) of 4.22 points (95% CI 4.04-4.40; P<0.001). The QoLSPP-Relational pooled score was 4.17 points (95% CI 4.03-4.31; P<0.001). The QoLSPP-Social pooled score corresponded to 4.21 points (95% CI 4.02-4.40; P<0.001). Pooled analysis of the QoLSPP-Personal domain showed an overall ES of 3.97 points (95% CI 3.61-4.32; P<0.001). There was insufficient data to pool QoLSPP total scores.

CONCLUSIONS

Patients undergoing penile prosthesis implantation report positive scores in all QoLSPP domains, demonstrating high satisfaction levels. Future studies are needed to improve the evidence on the topic.

Mid-term outcomes of minimally invasive infrapubic approach for inflatable penile prosthesis implantation: A single-center study and literature review

BACKGROUND

The minimally invasive infrapubic approach (MIIA) for inflatable penile prosthesis (IPP) placement has shown favorable peri-operative safety and efficacy profile, but scarce data exist on long-term follow-up.

OBJECTIVES

We investigated the safety and efficacy of IPP implantation via the MIIA after a minimum 5-year follow-up.

MATERIALS AND METHODS

We identified data of implanted patients prospectively included in our institutional database. Complications and functional outcomes were assessed by using validated tools. Specifically, quality of life and patient satisfaction were evaluated by the Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaire. Kaplan-Meier method was used to analyze IPP survival (defined as a working IPP).

RESULTS

Overall, 67 patients implanted by MIIA with a median (IQR) age of 64 years (61-70) were included. The median (IQR) follow-up duration was 71 months (63-80). Fifteen (22%) patients experienced complications: minor (Clavien ≤2) events included changes in penile sensitivity (n = 1; 1.5%), orgasmic dysfunction (n = 1; 1.5%), pain (n = 5; 7%), urinary tract infection (n = 2; 3%), and chronic discomfort (n = 1; 1.5%); major (Clavien 3) complications were represented by mechanical failure (n = 3; 4.5%), IPP infection (n = 1; 1.5%), and cylinder protrusion (n = 1; 1.5%). The estimated IPP survival was 94% (95% CI, 91.4-96.6), 92.5% (95% CI, 89.7-95.3), and 92.5% (95% CI, 89.7-95.3) at 3, 5, and 7 years after implantation, respectively. In patients using the device at follow-up (n = 61; 91%), median (IQR) scores for QoLSPP domains demonstrated favorable functional outcomes and patient satisfaction: functional 21 (19-23), personal 16 (15-18), relational 14 (12-15), and social 12 (11-14).

DISCUSSION AND CONCLUSION

This study represents the longest follow-up using validated tools to assess the outcomes of IPP implantation via MIIA so far. IPP placement via MIIA confirms to be safe and to offer high satisfaction to both patients and partners at mid-term evaluation.

High flow priapism following the insertion of an inflatable penile prosthesis mimicking autoinflation: a case report

Penile prosthesis implantation is a surgical option for erectile dysfunction when other treatments fail or the patient prefers implantation. Although penile prosthesis is generally considered safe and effective, various complications have been reported in the literature. High-flow priapism, resulting from an arteriovenous fistula between the cavernosal artery and the corpora cavernosa, is a rare complication after penile prosthesis implantation. Managing the condition as autoinflation may lead to unfortunate complications. A 54-year-old male patient underwent a penile prosthesis implantation due to erectile dysfunction lasting for 5 years. Doppler ultrasound revealed arterial insufficiency that was refractory to oral and intracavernosal treatments. A 3-piece inflatable penile prosthesis (Coloplast - Titan) was implanted through a midline penoscrotal incision without any complications. The patient reported uncontrolled tumescence after activating the device, which led us to suspect autoinflation. The final diagnosis was high-flow priapism due to an arteriovenous fistula in the cavernosal artery. The patient was given an antiandrogenic medication and the prosthesis was deflated for 3 months. The fistula closed without any additional intervention. High-flow priapism is a rare but potential complication of penile prosthesis implantation. Careful evaluation and management of patients' symptoms are necessary for diagnosing and treating this condition. This case highlights the importance of considering high-flow priapism as a potential cause of uncontrolled tumescence after penile prosthesis implantation and the possibility of successful non-surgical management.

Mechanical indications for inflatable penile prosthesis revision: analysis and implications for revision surgery

BACKGROUND

Despite technical advancements, inflatable penile prostheses (IPPs) are inherently at risk of mechanical failure given their nature as hydraulic devices.

AIM

To characterize IPP component failure location at the time of device revision and stratify by manufacturer: American Medical Systems (Boston Scientific [BSCI]) and Coloplast (CP).

METHODS

A retrospective review of penile prosthesis cases from July 2007 to May 2022 was conducted, identifying men who underwent revision surgery. Cases were excluded if documentation did not denote the cause of failure or the manufacturer. Mechanical indications for surgery were categorized by location (eg, tubing, cylinder, or reservoir leak; pump malfunction). Nonmechanical revisions were excluded (component herniation, erosion, or crossover). Categorical variables were assessed with Fisher exact or chi-square analysis; Student t-test and Mann-Whitney U test were used for continuous variables.

OUTCOMES

Primary outcomes included specific location of IPP mechanical failure among BSCI and CP devices and time to mechanical failure.

RESULTS

We identified 276 revision procedures, 68 of which met inclusion criteria (46 BSCI and 22 CP). Revised CP devices were longer than BSCI devices (median cylinder length, 20 vs 18 cm; P < .001). Log-rank analysis revealed a similar time to mechanical failure between brands (P = .096). CP devices failed most often due to tubing fracture (19/22, 83%). BSCI devices had no predominant site of failure. Between manufacturers, tubing failure was more common in CP devices (19/22 vs 15/46 for BSCI, P < .001), while cylinder failure was more common among BSCI devices (10/46 vs 0/22 for CP, P = .026).

CLINICAL IMPLICATIONS

The distribution of mechanical failure is significantly different between BSCI and CP devices; this has implications regarding the approach to revision surgery.

STRENGTHS AND LIMITATIONS

This is the first study to directly compare when and where mechanical failure occurs in IPPs and to compare the 2 main manufacturers head-to-head. This study would be strengthened by being repeated in a multi-institutional fashion to provide more robust and objective evaluation.

CONCLUSION

CP devices commonly failed at the tubing and rarely elsewhere, while BSCI devices showed no predominant failure site; these findings may inform decision making regarding revision surgery.

A Systematic Review of Partner Satisfaction After Penile Prosthesis with Special Emphasis on LGBTQ + Populations

PURPOSE OF REVIEW

Despite the current surgical advances and patients' satisfactions after penile prosthesis (PP) implantation, there has been paucity of data on reported partner satisfaction and their quality-of-life (QoL). Our objective was to summarize the current literature on partner satisfaction for both heterosexual and non-heterosexual populations, respectively. We specifically conducted a systematic review according to the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards, and stratified studies into three tiers by methodological rigor.

RECENT FINDINGS

After an initial search of 172 articles, 33 studies met the inclusion criteria for the final review: 30 for heterosexual partner satisfaction, and 3 for LGBTQ patient satisfaction were included due to lack of published literature on partner satisfaction for LGBTQ patients. For heterosexual partner satisfaction, 10 studies were classified as Tier 1, 11 studies were classified as Tier 2, and 9 studies were classified as Tier 3. From an initial search of 13 records, three studies consisting of 272 patients met the inclusion criteria for our LGBTQ review. Across all the tiers, studies noted satisfaction rates between 50 and 90% and improved satisfaction and sexual QoL metrics compared to pre-surgery rates. That said, partner satisfaction rates were also consistently lower than patient satisfaction rates. Although the range of evidence quality varies, the available literature suggests significant improvements in and relatively high rates of partner satisfaction after PP implantation. Given the diversity of study designs and widespread use of non-validated or non-specific questionnaires in the current literature, future research should focus on prospective studies and/or data collection using validated, PP-specific questionnaires.