Penile prosthesis in the management of erectile dysfunction following cancer therapy

Downstream Revenue Realized by Facilities Placing Inflatable Penile Prosthesis in Medicare Beneficiaries to Treat Erectile Dysfunction

OBJECTIVES

To quantify the incremental downstream revenue generated from subsequent treatment of men who received an inflatable penile prosthesis (IPP) to treat erectile dysfunction (ED), compared to men without ED.

METHODS

The 100% Medicare Standard Analytic Files were used to conduct a retrospective claims analysis of the 5-year revenue generated by patients receiving IPP to treat their ED, compared to a propensity-matched cohort of men without ED. Men aged 65 years or older with ED who underwent IPP implantation (Current Procedural Terminology® 54405) in a hospital outpatient setting between January 1, 2016 and December 31, 2021, and who had continuous Medicare Parts A and B enrollment for 12 months pre-index IPP and five years post-index IPP discharge date were included in the study. Men without ED but with comparable characteristics were identified and used as a comparator group. Revenue received by hospitals from Medicare was defined as the sum of payments for patient services, other payor-paid amounts, patient deductibles, copayments, and coinsurance. Revenue was inflated to 2022 US dollars. The mean values and their corresponding standard deviations (SD) are reported.

RESULTS

After matching, there were 2,905 men with ED who received an IPP and 7,462 men without ED. The IPP cohort showed a significantly higher 5-year cumulative revenue (mean=$34,571 [SD=$50,234]) compared to the men without ED (mean=$3,189 [SD=$11,527]). When stratified by diagnosis type, the differences in revenue were $10,258 for circulatory disease, $2,646 for diabetes, $2,013 for urology, and $1,043 for prostate cancer. Significantly more IPP patients had at least one health encounter for these conditions over the 5-year follow-up period than their matched controls (55.0% versus 7.8% for circulatory, 46.7% versus 16.8% for urology, 19.3% versus 3.6% for diabetes, and 19.0% versus 3.0% for prostate cancer).

CONCLUSIONS

Men with ED who received IPP generated substantially higher revenue for the healthcare system over a 5-year period, nearly ten times as much, compared to men without ED, excluding the initial cost of the IPP procedure. The presence of ED, coupled with IPP usage, is associated with significantly increased healthcare revenue across a range of medical conditions compared to men without ED. These findings emphasize the financial implications for advanced ED programs to improve access to necessary care for these patients. Healthcare facilities may leverage these insights to effectively allocate resources to deliver critical healthcare to men with ED.

Complication rates in concurrent inflatable penile prosthesis and incontinence surgery: Comparing the penoscrotal versus perineal incision approach

The main objective of this study was to assess the IPP complication rates of patients undergoing placement via perineal incision versus more traditional penoscrotal approach in synchronous dual implantation. We identified 38 patients who underwent dual implantations of an IPP and AUS or urethral sling from 2011 to 2021 at a single tertiary center, 24 via perineal and 14 via penoscrotal incision. All IPP implants were done by a single surgeon. IPP postoperative complications were captured using the Clavien-Dindo classification at three separate time points, < 30 days, 30 days - 6 months, and > 6 months. The perineal group had two complications, IPP explantation due to rectourethral fistula (Grade III, > 6 months), and IPP explantation due to chronic genital pain (Grade III, > 6 months). The penoscrotal group had three complications, post-operative urinary retention requiring catheterization (Grade I, < 30 days), incision site infection (Grade I, < 30 days), and IPP explantation due to infection (Grade III, 30 days to < 6 months). There was no statistically significant difference in rate of patients with IPP complications between the two groups (p = 0.546) or in rate of IPP device malfunction (p = 0.264). These preliminary findings suggest that the single perineal incision is a viable surgical approach in synchronous dual implantation.

Erectile Dysfunction in Pelvic Cancer Survivors and Current Management Options

Pelvic malignancies, including prostate, rectal, and bladder cancers, are among the most frequent malignancies found in the male population. These issues are most effectively and commonly treated with radiotherapy and/or surgery. However, these treatments can cause collateral damage, resulting in significant impacts on quality of life, with erectile dysfunction being one of the most frequent postoperative complications. Currently, there are several treatment options for erectile dysfunction, including oral phosphodiesterase type 5 inhibitors, vacuum erection devices, intracorporeal injections, and penile prosthesis. The latter has shown to be an effective and safe technique, with results comparable to those obtained by patients without pelvic surgery or radiotherapy. The results of early penile rehabilitation programs are promising and they have been incorporated into a greater proportion of treatment plans more recently, with varying degrees of success. In this narrative review, we summarize the literature on erectile dysfunction after pelvic cancer treatments and its management.

Experiences of Support for Sexual Dysfunction in Men With Prostate Cancer: Findings From a U.K.-Wide Mixed Methods Study

BACKGROUND

Men with prostate cancer (PCa) often experience sexual dysfunction following diagnosis and treatment, yet little is known about the support they receive to deal with this.

AIM

To explore men's experiences of support for sexual dysfunction following PCa diagnosis.

METHODS

This study included a U.K.-wide survey of men 18-42 months post-diagnosis of PCa, identified through cancer registries. The survey measured sexual function and the extent to which men perceived sexual dysfunction to be a problem (Expanded Prostate Cancer Index Composite-26), access to and experience of medications, devices, and specialist services for sexual dysfunction, and included a free-text question for further comments. Analysis focussed on men who reported poor sexual function, which they considered a moderate or big problem. Descriptive statistics explored the characteristics of men offered intervention and those that found this helpful. Free-text responses were analyzed using thematic analysis.

OUTCOME

The main outcome of this study was to assess access to and experience of medications, devices, and specialist services for sexual dysfunction.

RESULTS

39.0% of all survey respondents (13,978/35,823) reported poor sexual function, which they considered a moderate or big problem. 51.7% of these men were not offered any intervention to aid sexual functioning. 71.9% of those offered an intervention reported trying it, of whom 48.7% found the intervention helpful. Men treated with surgery or brachytherapy were most likely to be offered an intervention. Medication was the most commonly offered intervention and 39.3% of those who tried medication found this helpful. Although offered less often, approximately half of the men who tried devices or attended specialist services found the intervention helpful. Free-text responses indicated that barriers to accessing support included inadequate information and support from healthcare professionals, embarrassment, negative views about treatment options, concerns about side effects and safety, and inconsistencies between secondary and primary care. Barriers to continuing use included limited effectiveness of treatments, inadequate ongoing support, and funding constraints. Drivers of sexual recovery included patient proactivity and persistence with trying different treatment options and ongoing support from health professionals.

CLINICAL IMPLICATIONS

There is an urgent need to ensure that all men are offered, and have equal access to, sexual care support, with referral to specialist services when required.

STRENGTHS & LIMITATIONS

This study presents data from a large, U.K.-wide, population-based study of men with PCa and includes quantitative and qualitative findings. The possibility of non-response bias should, however, be considered.

CONCLUSION

There are significant shortcomings in the support offered to U.K. men with sexual dysfunction following diagnosis and treatment for PCa which need to be addressed. Watson E, Wilding S, Matheson L, et al. Experiences of Support for Sexual Dysfunction in Men With Prostate Cancer: Findings From a U.K.-Wide Mixed Methods Study. J Sex Med 2021;18:515-525.

Risk profiling in patients undergoing penile prosthesis implantation

Penile prosthesis implantation is the gold standard of surgical therapy for patients with medication-refractory erectile dysfunction. However, this umbrella definition includes significant heterogeneity and associated risk profiles that should be candidly discussed and addressed perioperatively. Factors associated with operative success and patient satisfaction are often surgery specific; however, risk profiling via patient selection, preoperative optimization, proper device selection, and intraoperative consideration are highly correlated. Some examples of common risk profiles include comorbidity(ies) such as cardiovascular disease, diabetes mellitus, prior abdominal surgery, Peyronie's disease, and psychological risk factors. Similarly, integration of surgeon- and patient-amenable characteristics is key to decreasing risk of infection, complication, and need for revision. Finally, patient risk profiling provides a unique context for proper device selection and evidence-based intraoperative considerations.

Three-piece inflatable penile prosthesis: Ectopic reservoir placement

INTRODUCTION

The complications associated to the placement of the reservoir are infrequent but potentially serious. Therefore, technical alternatives have been developed for the performance of the procedure in different locations (ectopic). The aim of this review is to revise the evidence available on the different options for the ectopic placement of the reservoir.

MATERIAL AND METHOD

Narrative review based on a bibliographical search limited to PubMed- indexed relevant manuscripts, in Spanish or English, for the period 2000-2019, using «penile prosthesis», «ectopic reservoir», radical prostatectomy», «radical cystectomy», «pelvic radiotherapy», and «renal transplantation» as key words. Non original articles and reviews were not considered eligible. A total of 11 manuscripts were included.

RESULTS

Pelvic alterations after surgery and/or radiotherapy increase the difficulty in the placement of the prosthesis reservoir. In order to minimize the risk of complications, different modifications have been performed on the devices, and technical innovations have been developed for the submuscular placement of the reservoir. The available evidence regarding the functionality and complications of these techniques is limited to single institution, low volume, and retrospective series with short follow-up periods. The functionality seems to be adequate using the adapted devices. The complications are infrequent and mild in severity.

CONCLUSIONS

Although the available evidence is still limited, the ectopic placement of the reservoir may be considered a safe, effective, and reproducible technique. In addition, it may result particularly useful in cases of altered pelvic anatomy.

Management of Climacturia During Inflatable Penile Prosthesis Surgery

Radical prostatectomy, the preferred treatment option for organ-confined prostate cancer, is associated with a wide variety of sexual dysfunctions including erectile and orgasmic dysfunctions. Climacturia is a type of orgasmic dysfunction that has been reported to occur in 20-60% of men after radical prostatectomy. Several treatment strategies for climacturia have been evaluated and recommended including behavioral changes, use of special devices, medications, specialized therapies, and surgeries. Inflatable penile prosthesis implantation might be the treatment of choice when conservative management approaches fail to treat erectile dysfunction. In this review article, the different options and approaches for the management of climacturia during inflatable penile prosthesis surgery will be discussed.

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.