A Guide for Inflatable Penile Prosthesis Reservoir Placement: Pertinent Anatomical Measurements of the Retropubic Space

Complications and troubleshooting in primary penile prosthetic surgery-a review

Penile implant surgery is the gold standard to treat erectile dysfunction with success rates of over 90%. The first penile implants were developed in the early 1900s. Since then, several types of implants have been developed including malleable implants, two-piece inflatable implants, and three-piece inflatable implants. The three-piece inflatable penile prosthesis, which was introduced in 1973, is the most widely used type of penile implant in the United States. Penile implant surgery has undergone numerous advancements over the years, improving outcomes and patient satisfaction. However, as with any surgical procedure, there are risks and complications associated with penile implant surgery. It is important for surgeons to understand these potential complications and to have strategies in place to manage and prevent them to achieve the best possible outcomes for their patients.

Maximizing outcomes in penile prosthetic surgery: exploring strategies to prevent and manage infectious and non-infectious complications

Inflatable Penile Prostheses (IPP) implantation is a surgical treatment for patients desiring definitive treatment for erectile dysfunction. While this procedure has proven to be effective, it also carries its own set of unique risks that need to be carefully considered. The article reviews the current understanding of complications associated with penile prosthetic surgery and provides strategies to mitigate these adverse events. This article covers various aspects of IPP implantation, including the risks of infection, bleeding, injury to nearby structures, glans ischemia, and device malfunction. It also discusses the importance of careful preoperative screening to identify risk factors and the implementation of infection reduction strategies such as antimicrobial prophylaxis, skin prep, and operative techniques. In addition, it emphasizes the need for postoperative vigilance and prompt management of any complications that may arise. Overall, the article provides a comprehensive overview of the risks and strategies for mitigating complications associated with IPP implantation. Our recommendations are given based on the current consensus in the field and highlight the importance of careful planning, attention to detail, and effective communication between healthcare providers and patients. Despite the potential risks, this review underscores the fact that complications following penile prosthesis implantation are relatively rare.

Anatomic considerations of inflatable penile prosthetics: lessons gleaned from surgical body donor workshops

Surgical implantation of an inflatable penile prosthesis (IPP) remains the gold-standard treatment for severe erectile dysfunction. The ideal surgical technique requires a thorough understanding of the relevant anatomy. This includes anatomic considerations related to, but not limited to, dissection and exposure of penoscrotal fasciae and tissues, corporal configuration, and abdominal structures. Insights obtained from pre-dissected anatomic specimens can obviate urethral injury, nerve damage, corporal perforation, inappropriate sizing, crossover, or implant malposition. We present penile implant-specific anatomic dissections and topographic landmarks identified over the last decade in the course of surgical training programs provided for IPP implantation.

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.

Increasing role of counterincision for high submuscular penile prosthesis reservoir placement

Background

Inflatable penile prosthesis (IPP) reservoir placement into the high submuscular (HSM) space is safe and well tolerated. Recent studies have proposed that reservoirs placed via an abdominal counterincision (CI) may offer more precise and durable positioning as compared with a transinguinal (TI) approach.

Aim

Herein we compare the CI-HSM and TI-HSM techniques with respect to operative time, pain control, and postoperative complications.

Methods

We reviewed our penile prosthesis database at a large single-surgeon tertiary referral center from 2014 to 2021 to compare those who underwent virgin reservoir placement via the CI-HSM technique vs the TI-HSM technique. Statistical analysis was performed with the Mann-Whitney U test for continuous variables and the chi-square test and Fisher exact test for discrete variables.

Outcomes

Operative time, postoperative complications, morphine milligram equivalents prescribed, and postoperative correspondence were compared between patients undergoing the CI-HSM and TI-HSM techniques.

Results

Among 456 virgin IPP implants, the CI-HSM technique was used in 34 cases (7.5%) and the TI-HSM technique in 422 cases (92.5%). Of these 456 cases, 92 (20.2%) were combined with ancillary procedures such as artificial urinary sphincter, urethral sling, or penile plication (6/34, CI; 86/422, TI). Cases employing the CI-HSM technique had a 19.9% greater median operative time: 81.5 minutes (IQR, 69.3-106.5) vs 68 minutes (IQR, 57.8-80.3; P < .01). A similar proportion of patients in the CI-HSM group (2/34, 5.9%) were treated for infection as in the TI-HSM group (17/422, 4.0%; P = .64). Reservoir herniation was seen in 12 patients in the TI-HSM group (2.8%) and in none of the CI-HSM group, but this did not reach significance (P > .99). No differences were identified between patients in the TI-HSM and CI-HSM groups with regard to postoperative morphine milligram equivalents prescribed, narcotic medication refills, or postoperative correspondence.

Clinical Implications

CI-HSM reservoir placement was associated with similar surgical outcomes to TI-HSM without increased infection risk or need for narcotic pain management.

Strengths and Limitations

Although this study is a large contemporary series addressing a clinically important subject, it is limited by its retrospective preliminary nature and nonrandomized unmatched design. Patient pain regimens were assessed via discharge prescriptions, although data regarding narcotic consumption were not available in the medical record.

Conclusions

IPP reservoir placement via the CI-HSM technique is safe and well tolerated. Increased operative time of the CI-HSM technique as compared with the TI-HSM technique is clinically negligible given its potential safety benefits of direct visualization of reservoir placement.

Midline submuscular penile prosthesis reservoir placement for patients with bilateral inaccessible inguinal rings: technique and outcomes

Introduction

One of the most challenging aspects of inflatable penile prosthesis (IPP) surgery is reservoir placement. The traditional space of Retzius (SOR) is not suitable for all patients. For example, radical cystectomy or prostatectomy may alter the anatomical SOR. Hence, traditional placement of the reservoir in this space increases the risk of bowel or vascular injury. Also, patients with bilateral inguinal hernias repaired with mesh, or those with previous reservoirs that have been retained, are not eligible for a Retzius reservoir. Our study reports on the use of midline sub-rectus muscle placement of a penile prosthesis reservoir in these patients as an alternative to high submuscular placement commonly used.

Methods

A retrospective chart review of male patients who underwent IPP surgery between June 2017 and 2021 was conducted. Patients were divided into two groups based on the location of the reservoir: SOR versus Midline Submuscular Reservoir (MSMR). Complication rates were compared, including herniated reservoirs, infections, bowel injuries, and vascular injuries.

Results

Our cohort included 461 patients who underwent IPP surgery between June 2017 and 2021 in one tertiary center. SOR was used in 89% of patients and MSMR in 11% of patients (n = 413 and 48, respectively). Median follow-up for all patients was 28 months. The mean age was 67 ± 8 years. There was no statistically significant difference between the two groups regarding age or comorbidities (BMI, diabetes mellitus, hypertension, hyperlipidemia, and coronary artery disease). The complication rate was low in both the SOR and MSMR groups, with device malfunction being the most common (2% versus 4%, respectively; p = 0.32). The infection rate was 0.5% in the SOR group with no infections in the MSMR group (NS). There was only one case of herniation requiring surgical revision in the SOR group and no cases of bowel or vascular injury.

Conclusion

Placement of a penile prosthesis reservoir within a midline rectus submuscular space is a safe and effective technique when the SOR is compromised by previous surgery or bilateral inguinal canals are not accessible.

Inflatable penile prosthesis reservoir placement-Are we ready for a paradigm change?

In 2002, Steve Wilson pioneered new procedures for alternative placement of reservoirs for inflatable prostheses in patients who have suffered damage to the space of Retzius following pelvic surgery or obliteration of the transversalis fascia by mesh hernia repair. Since then, surgical techniques and tools for ectopic reservoir placement have gradually gained acceptance to minimize palpability, and the risk of visceral and vascular lesions for high risk patients has been all but eliminated. Lockout valves and high submuscular placement techniques are now recommended, and reports of vascular, bowel or bladder injuries are uncommonly rare. While surgeons continue their search for safer and more effective placement methods, new skills and instruments are constantly being introduced to make recommendations to minimize complications and provide safety and functionality. Additional studies and comparisons of techniques are needed to achieve a consensus of best practice for reservoir placement solutions.

Direct Vision, Transfascial (DVT) Approach to Submuscular Reservoir Placement in Patients Undergoing Multicomponent Penile Implant Surgery Following Prior Pelvic Surgery or Radiation Therapy

BACKGROUND

Submuscular reservoir placement has fulfilled a critical need for patients desiring multicomponent penile implants following pelvic surgery and radiation therapy. Passage of the reservoir through the inguinal canal into the submuscular space is often challenging and carries the risk of the reservoir being placed unknowingly outside of the targeted space.

AIM

To evaluate the safety and accuracy of a direct vision, transfascial (DVT) approach to submuscular reservoir placement.

METHODS

We retrospectively reviewed outcomes for consecutive patients undergoing DVT submuscular reservoir placement abstracted from a large IRB-approved database at our institution. Postimplant cross-sectional imaging performed on many of these patients was used to ascertain the final location of the reservoir.

OUTCOMES

Outcome measures included the perioperative and intermediate-term safety and complications of the procedure. Postimplant imaging ascertained the accuracy in providing patients with a submuscular reservoir.

RESULTS

There were 107 DVT submuscular reservoirs placed in 100 consecutive patients. No intraoperative complications occurred, there were no postoperative rectus hematomas, and there were 4 (3.7%) postoperative infections. With a mean follow up of 17.5 +/- 20.5 months there was one reservoir herniation, one patient had autoinflation, and one patient required repositioning of a high riding pump. There were 4 mechanical malfunctions requiring revision at a median of 74 months (range: 69-108 months.) following implant placement. Of the 43 patients who underwent imaging: 34 (79%) reservoirs were accurately positioned, 5 (12%) were in the lateral abdominal wall, 1(2%) was in the retroperitoneum, and 3 (7%) were intraperitoneal. Intraperitoneal reservoirs occurred exclusively in postcystectomy patients.

CLINICAL IMPLICATIONS

The DVT approach is technically safe, although a slightly higher than expected infection risk was noted. It provides accurate reservoir placement for the majority of imaged patients. Postcystectomy patients have a risk of insidious intraperitoneal reservoir placement. Preoperative counseling should mention this and postimplant imaging may be considered for some of these patients. Imaging may also helpful prior to future revision surgery in order to identify and remove insidious intraperitoneal reservoirs.

STRENGTHS AND LIMITATIONS

We investigated 100 patients, almost half underwent cross sectional imaging. Weaknesses include the retrospective nature of this single-institutional study, which may not have similar outcomes at other centers.

CONCLUSION

DVT submuscular reservoir placement is safe following pelvic surgery and radiation therapy. Despite careful and deliberate surgical technique imaging found that approximately 20% of reservoirs are not in their expected location. Intraperitoneal reservoirs are of concern, particularly in postcystectomy patients. Kava BR, Levine A, Hauser N, et al. Direct Vision, Transfascial (DVT) Approach to Submuscular Reservoir Placement in Patients Undergoing Multicomponent Penile Implant Surgery Following Prior Pelvic Surgery or Radiation Therapy. J Sex Med 2021;XX:XXX-XXX.

Distance from Critical Pelvic Structures: Radiographic Comparison of High Submuscular and Space of Retzius IPP Reservoir Placement Techniques

OBJECTIVES

To evaluate the distance from critical pelvic structures (CPS, defined as bladder and iliac vessels) among inflatable penile prosthesis (IPP) reservoirs placed into the space of Retzius (SOR) and high submuscular (HSM) locations using cross-sectional imaging. IPP reservoir placement into the HSM location has been proposed as a strategy to prevent injury due to greater distance from CPS.

METHODS

Our institutional database was retrospectively reviewed to identify men who underwent IPP insertion between 2007 and 2020 and had available cross-sectional abdominopelvic imaging after the time of surgery. Patients were grouped based on reservoir placement technique (SOR vs. HSM). Staff radiologists blinded to placement technique evaluated reservoir position to determine the shortest distance between CPS and the reservoir and if a mass effect was present on CPS. Variables were analyzed using chi-squared, Fisher's exact, and student's T-tests as indicated.

RESULTS

Among 1,010 IPP cases performed during the study interval, 139 (13%) were imaged. Compared with SOR reservoirs (n = 32), HSM reservoirs (n =107) were significantly less likely to induce a mass effect on the bladder (72 vs. 9%, p = <0.01) or iliac vessels (34 vs. 4%, p = <0.01) and were located roughly five times further from the bladder (10 ± 22 vs. 49 ± 36 mm, p = <0.01) and iliac vessels (5 ± 9 vs. 23 ± 26 mm, p = <0.01).

CONCLUSIONS

This study radiographically confirms that IPP reservoirs are located significantly further away from CPS following HSM placement compared to SOR placement.

Penile implant surgery-managing complications

Penile prosthesis surgery represents the end-stage treatment for erectile dysfunction. It is conventionally used only in cases of erectile dysfunction refractory to pharmacological treatments or vacuum constriction devices. Contemporary literature suggests that penile prothesis surgery is associated with a high satisfaction rate and a low complication profile. However, it must be appreciated that the complications of surgery can have devastating consequences on a patient’s quality of life and satisfaction and include infection, prosthesis malfunction, penile corporal perforation and penile length loss. Several factors – such as appropriate patient selection, methodical preoperative assessment and patient optimization, specific intraoperative protocols and postoperative recommendations – can reduce the risk of surgical complications. This narrative review discusses the diagnosis and management of both intraoperative and postoperative complications of penile prosthesis surgery.

The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis

BACKGROUND

The 3-piece inflatable penile prosthesis includes an easy-to-use pump and fluid filled reservoir which is placed in either the space of Retzius (SOR) or in an alternative ectopic location. Reservoir placement in the SOR is a blind procedure despite the SOR being surrounded by many critical structures. To date only a handful of cadaveric studies have described the relevant anatomy.

AIM

To use magnetic resonance imaging (MRI) as an in-vivo model to study relevant retropubic anatomy critical for SOR reservoir placement.

METHODS

The study population included men with elevated prostate specific antigen or biopsy proven prostate cancer who (i) underwent pelvic MRI, (ii) without prior pelvic or inguinal surgery, and (iii) without pelvic radiation therapy. All MRIs were completed with a 3-Tesla scanner and endorectal coil. Both T1 and T2 weighted images were captured in both axial and sagittal planes. All images were reviewed by 2 independent reviewers under the supervision of a dedicated body MRI radiologist. Bladder volume was calculated using an ellipsoid formula.

OUTCOMES

Relevant measurements included (i) the distance between the external inguinal ring (EIR) at the level of the pubic tubercle to the external iliac vein (EIV), (ii) the distance from the EIR at the pubic tubercle to the bladder (accounting for bladder volume) and (iii) the distance from the midline pubic symphysis to the bladder (accounting for bladder volume). Pearson correlation was used to determine correlated measurements.

RESULTS

A total of 24 patients were included. Median participant age was 63 years (interquartile range, 59-66). The mean EIR-EIV distance was 3.0 ± 0.4 cm, the mean EIR-bladder distance was 1.8 ± 1.0 cm and the mean distance from the superior pubic symphysis to bladder was 0.9 ± 0.3 cm. There was a weak correlation between bladder volume and distance between the EIR and bladder (r = -0.30, P = .16).

CLINICAL IMPLICATIONS

The use of MRI as an in-vivo model is a high-fidelity tool to study real time unaltered anatomy and allows for surgical preparation, diagnosis of anatomic variants and acts as a valuable teaching tool.

STRENGTHS & LIMITATIONS

This is the first in-vivo model to report relevant retropubic anatomy in penile implant surgery. Our study is limited by sample size and inclusion of participants with no history of prior pelvic intervention.

CONCLUSION

We demonstrate the utility of MRI as an in-vivo model, as opposed to cadaveric models, for the understanding of relevant retropubic anatomy for implant surgeons. Punjani N, Monteiro L, Sullivan J F et al. The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis. J Sex Med 2021;18:1830-1834.

Incidence of Venous Thromboembolism and Safety of Perioperative Subcutaneous Heparin During Inflatable Penile Prosthesis Surgery

OBJECTIVE

To identify the incidence of venous thromboembolism (VTE) risk factors, postoperative VTE, and to assess the morbidity of perioperative pharmacologic VTE prophylaxis in men undergoing inflatable penile prosthesis (IPP) surgery.

METHODS

We retrospectively reviewed 215 patients undergoing IPP surgery between July 2017 and June 2019. Univariate and multivariate statistical analyzes were performed to assess pre-operative Caprini risk score and compare post-operative day 0 scrotal drain output, scrotal hematoma formation, and VTE in men who received subcutaneous heparin (SqH) vs those who did not receive SqH.

RESULTS

Of 215 IPP patients, 84% were classified as high or highest risk for VTE utilizing the Caprini risk score. A total of 119 (55%) received perioperative SqH with or without additional anti-thrombotics. Post-operative day 0 scrotal drain output was higher in those who received SqH compared to those who did not receive SqH, 99.9 mL vs 75.6 mL, respectively (P = .001). Minor scrotal hematomas occurred in similar rates in patients who received perioperative SqH vs those who did not, 3.8% vs 6.3%, respectively (P = .38). Similar results were found on subgroup analysis when eliminating patients who received SqH concurrently with other anti-thrombotics. The overall rate of postoperative VTE was 0.9%. No post-operative infections occurred.

CONCLUSION

Patients undergoing IPP surgery are at elevated risk for VTE. To our knowledge, this is the first study showing SqH use in the perioperative IPP surgery setting is safe when used in conjunction with a scrotal drain. Preoperative VTE risk stratification may be performed and can be used to guide clinical decision making regarding pharmacologic prophylaxis.

The Tubing, Hitch and Lasso, Intussusception Anchor (THALIA) Technique: A Novel Approach to Fixate the Penile Implant Reservoir

BACKGROUND

Penile implant reservoir herniation or migration after inflatable penile prosthesis (IPP) placement may occur with standard or submuscular placement. Additionally, fixating the tubing in patients with retained reservoirs may be helpful for future prosthetic surgeons.

AIM

We describe a novel technique to fixate IPP reservoirs in the preferred position.

METHODS

We present our preferred technique to fixate IPP reservoirs to prevent migration or herniation.

OUTCOMES

We evaluated our success in preventing reservoir herniation or migration.

RESULTS

35 cases successfully underwent our new technique. 30 cases involved reservoirs that were thought to be at a high risk for migration. 5 cases were performed in non-infected retained reservoir scenarios where a reasonable attempt at removal either failed or was considered high risk. No immediate reservoir or infectious complications occurred. Mean follow-up was 5 months. The technique extended the case time by 5-10 minutes.

CONCLUSION

Our novel technique is feasible, and although further follow-up and power are needed, fixating the pump tubing may reduce reservoir complications. Yang D, Heslop D, Houlihan M, et al. The Tubing, Hitch and Lasso, Intussusception Anchor (THALIA) Technique: A Novel Approach to Fixate the Penile Implant Reservoir. J Sex Med 2021;18:224-229.

Prevalence of post-prostatectomy erectile dysfunction and a review of the recommended therapeutic modalities

Radical prostatectomy (RP) represents one of the most commonly used first-line treatment modalities in men with localized prostate cancer. One of the most feared post-surgical complications is erectile dysfunction (ED), usually caused by direct damage to the cavernous nerves or due to neuropraxia. Penile rehabilitation is an emerging concept that was proposed to stimulate and accelerate recovery of erectile function after RP. The goal is to improve blood flow to the penis, increasing cavernous oxygenation and avoiding fibrosis. The most common used modalities include oral phosphodiesterase type 5 inhibitors (PDE5-I), vacuum erection devices (VEDs), intracorporeal injection (ICI) therapy, medicated urethral system for erections (MUSE), and a combination of these treatments. For those patients with severe ED, ED refractory to medical therapy and/or seeking long term reliable results, the penile prosthesis implant remains an excellent alternative. We conducted a broad review of post-prostatectomy ED prevalence with different techniques and the success rates of the different therapeutic approaches.

A Modified Surgical Technique for Reservoir Placement During Inflatable Penile Prosthesis Implantation

INTRODUCTION

At the moment, there is an ongoing debate regarding the controversial issue of the ideal reservoir placement (RP) surgical technique during implantation of a 3-piece inflatable penile prosthesis, but a definitive winner has not yet emerged.

AIM

In this light, we herein describe our modified technique for RP into the space of Retzius through the external oblique muscle fascia and present its results.

METHODS

In total, 253 inflatable penile prosthesis procedures (110 AMS 700 and 143 Coloplast Titan) via a single transverse penoscrotal incision were retrospectively reviewed. 2 Kocher-Langenbeck retractors were placed over the right side of the penoscrotal incision and were used to retract the incision superior to the pubic bone. Then, the external oblique muscle fascia was incised medially to the spermatic cord which was retracted laterally. Next, a "W", Vicryl 1, stay suture was placed to the incision, and under direct visualization, external oblique muscle fibers were dissected and fascia transversalis was perforated using a Metzenbaum scissor. A Foerster lung grasping clamp was then used to dissect further into the extraperitoneal space and create the reservoir space. The reservoir was placed into the created space and fascia incision was closed using the prepositioned stay suture. The procedure was then completed in a standard fashion.

OUTCOMES

The main outcome measures were intraoperative or postoperative complications of our modified RP technique.

RESULTS

All 253 patients were available for short-term follow-up (average 9.1 months, range 3-22 months). No intraoperative or postoperative complications were reported. Reservoir-related prolonged pain (1 month) was reported by 1 patient, resolving completely after treatment with non-steroidal analgesics.

CONCLUSION

We are, surely, not proposing that our modified RP technique should supplant all other methods; rather, it should be considered another useful option for RP in the implanter's armamentarium. Mykoniatis I, Osmonov D, van Renterghem K. A Modified Surgical Technique for Reservoir Placement During Inatable Penile Prosthesis Implantation. Sex Med 2020;8:378-382.

Novel protective penile collar following inflatable penile prosthesis placement: The "Wang Collar"

Penile rehabilitation after inflatable penile prosthesis (IPP) implantation for the treatment of erectile dysfunction includes leaving the device partially inflated so as to preserve the penile length and to maintain hemostasis. With a partially inflated device, the penis becomes more sensitive and more susceptible to unintended insults during the immediate postoperative management. The “Wang Collar,” a device intended to protect the penis in the early postoperative period, is hereby described. Three hundred and forty-eight patients had the “Wang Collar” included as part of their post-IPP management from August 2014 to February 2019. The protective collar, devised from a polystyrene cup with the bottom removed, is secured with a tape over the previously dressed and partially inflated penis. In order to evaluate the effectiveness of this device, we conducted surveys on the perioperative staff at three different institutions. The “Wang Collar” has been found to be beneficial in the early postoperative care of patients. Based on the answers to our questionnaire, the perioperative personnel found this device to be highly protective, especially when transporting the patient after IPP surgery, easy to work with, and almost never bothersome or irritative to the patient. We present a novel penile device after IPP placement, which we have found to improve patient satisfaction in the postoperative period. In addition, it eases the care of the patient by the perioperative staff. It is now our routine to use this device after IPP surgery. Further research is necessary to evaluate whether this device can decrease postoperative wound complications.

Damage Control Considerations During IPP Surgery

PURPOSE OF REVIEW

This review summarizes the latest reports in inflatable penile prosthesis (IPP) complication management.

RECENT FINDINGS

IPP complications are rare, and reports are limited to retrospective studies. However, recent multi-institutional studies and use of national databases have provided further insight into risk factors for complications. Guidance on complication management is largely limited to techniques recommended by experts within the field. American Urological Association guidelines place IPP implantation as a first line erectile dysfunction treatment. However, the majority of cases are performed by low-volume (≤ 4 cases/year) surgeons. Herein, we summarize the IPP literature and our personal experience to provide guidance on managing IPP complications.

Inflatable penile prosthesis in the radical prostatectomy patient: a review

In the population of patients with prostate cancer, survivorship has come to the forefront of continuity-of-care. In addition to urinary control, erectile function is a significant issue after radical pelvic surgery. Penile prosthesis surgery remains an excellent option for restoring erectile function to those for whom more conservative measures have failed. This review article outlines the anatomical, surgical and post-operative consideration involved in the placement of a penile prosthesis in this special patient population.

Troubleshooting intraoperative complications of penile prosthesis placement

Placement of a penile prosthesis is an excellent option for well-selected patients, offering high patient satisfaction and a low rate of complications. Most urologists who perform the procedure are not high volume implanters and may have limited experience with troubleshooting intraoperative issues. In this review, the authors use current literature to provide recommendations for the management of various intraoperative issues such as difficultly with dilation, incongruent measurement, perforation, urethral injury, crossover, complications of reservoir placement, penile curvature, glans mobility, and hemostasis are all discussed. Preparedness for the management of intraoperative issues can help improve patient outcomes and limit morbidity.

Penile prosthesis in the management of erectile dysfunction following cancer therapy

Erectile dysfunction (ED) is a common problem in older men and occurs with even greater frequency following the treatment of pelvic malignancies. Inflatable penile prosthesis (IPP) implantation is a safe and effective form of definitive ED treatment for those men who fail more conservative measures, and it can be used with similar outcomes in men following cancer therapy. Although many of these men remain dissatisfied with other therapeutic options for ED, IPPs are underutilized in this population. This review will discuss the current practice patterns, outcomes and nuances to surgical technique regarding the use of IPPs in patients with ED following cancer therapy.

The Evolution of the Inflatable Penile Prosthesis Reservoir and Surgical Placement

The traditional inflatable penile prosthesis (IPP) reservoir placement is below the transversalis fascia in the space of Retzius. In 2002, Dr. Steve Wilson described ectopic reservoir placement, thereby providing a safe and effective alternative for implant surgeons. This new approach obviated the need for a second incision and decreased operative times during surgery. In the manuscript, he also described the introduction of a reservoir lock-out valve, which prevents autoinflation of the penile implant. The development of lockout valves and flat reservoirs has contributed to the early success and feasibility of submuscular placement techniques. Thirteen years after Dr. Wilson's pivotal study, this technique should be in the armamentarium of all urologic prosthetic surgeons. Accordingly, in certain subsets of patients, ectopic/ submuscular reservoir site placement should be considered a safe, effective alternative to standard reservoir placement in the space of Retzius.

The Prevention and Management of Noninfectious Complications of Penile Implants

INTRODUCTION

Penile implants have been a mainstay in the treatment of erectile dysfunction for more than four decades. The satisfaction rate with the functioning of these devices has been very high. Problems can develop with the device itself or with the tissues surrounding it. Knowledge of preventing and managing these adverse events is critical to a successful outcome and sustained patient satisfaction.

AIM

A narrative of the prevention and management of noninfectious complications of penile implant placement gained from the author's extensive experience is presented.

METHODS

Each category of penile implant complications is presented as a separate subtitle. The initial categories are intraoperative problems; the subsequent groups involve postoperative adverse events.

MAIN OUTCOME MEASURE

To gather information for this manuscript, I reviewed 40 publications and found 32 relevant and helpful.

RESULTS

Attending to the details necessary for proper placement of prosthetic parts during the initial surgery will minimize the chance of problems developing. Prompt attention to postoperative problems will thwart their progression to a more extensive adverse situation, which will be more difficult to remedy.

CONCLUSIONS

Complications during penile implant placement and in the postoperative period may occur. Knowledge of maneuvers to avoid their occurrence and prompt attention to correcting problems as they arise are paramount to a successful outcome and to maintaining high satisfaction rates. Mulcahy JJ. The prevention and management of noninfectious complications of penile implants. Sex Med Rev 2015;3:203-213.

Current management of erectile dysfunction in prostate cancer survivors

PURPOSE OF REVIEW

Although no standard management of erectile dysfunction in prostate cancer (CaP) survivors exists, many treatment options are available. This review summarizes the current understanding of the cause and management of erectile dysfunction in CaP survivors.

RECENT FINDINGS

Erectile dysfunction after radical therapy for CaP may be more common than previously thought. Genetics and vascular comorbidities may have a significant impact on erectile dysfunction after CaP treatment. Although penile rehabilitation with medical modalities show good efficacy in motivated patients, the return of erectile function is never guaranteed with nonsurgical management. Penile prosthesis placement results in early return to sexual function after CaP treatment with high patient satisfaction rates. Various techniques allow safe placement of a three-piece penile prosthesis in patients with a history of pelvic surgery.

SUMMARY

To optimize recovery of erectile function and prevent loss of penile length, penile rehabilitation should be initiated expeditiously after prostatectomy or radiation. In patients with refractory erectile dysfunction, dexterous and motivated patients remain excellent candidates for first and second-line medical therapies. However, early placement of a penile prosthesis following radical prostatectomy is now a proven and viable option.

Reservoir alternate surgical implantation technique: preliminary outcomes of initial PROPPER study of low profile or spherical reservoir implantation in submuscular location or traditional prevesical space

PURPOSE

Alternative reservoir site placement has become an accepted technique for patients who require an inflatable penile prosthesis. To our knowledge there has been no prospective evaluation of this technique, which is currently off label. We performed a prospective, multicenter, multinational, internal review board approved study to evaluate the effectiveness and safety of alternative reservoir site placement.

MATERIALS AND METHODS

PROPPER initiated in June 2011, is a database containing patient outcomes of inflatable penile prosthesis implantation. Patients with AMS® penile prostheses continue to be enrolled at 13 North American sites. We examined PROPPER study data to determine surgical implantation use patterns for the AMS 700™ series. We evaluated reservoir implantation site and complications by implantation site.

RESULTS

A total of 759 patients had been implanted with an AMS 700 series implant by the time of evaluation. Mean patient followup was 17.8 months (range 0 to 36). There was no reported case of revision surgery for a palpable reservoir and no report of vascular or hollow viscous injury associated with alternative reservoir site placement. Two cases of reservoir herniation in the alternative reservoir site placement group and 2 in the space of Retzius group were treated with reservoir reimplantation. Patients with 1-year assessment available were satisfied or very satisfied with the device and reported a frequency of use of more than once per month.

CONCLUSIONS

Alternative reservoir placement in the submuscular location is an option in patients who undergo inflatable penile prosthesis surgery. Implant surgeons should consider alternative reservoir site placement a safe, effective alternative to reservoir placement in the space of Retzius.