Preoperative counseling for penile implant surgery: standardized approach in a high-volume center of excellence

Shared-decision making is crucial in today's society. Although penile prosthesis surgery has had significant improvements regarding technique and materials over the last few decades - with the highest satisfaction rate in erectile dysfunction treatment at present time -, dissatisfaction can occur because of bad preoperative counseling with the creation of unrealistic expectations. This paper includes a small narrative review regarding the most important preoperative variables to be discussed in the preoperative setting. Literature search was conducted in December 2023 using PubMed. Additionally, our own standardized flowchart for preoperative counseling was added. The most important aspects of preoperative counseling include a description of the pathophysiology of erectile dysfunction as well as alternative treatments. Information should be given about which implant categories exist. Additionally, some information about the procedure itself as well as the financial aspect should be communicated. The most frequent and most important complications should be illustrated. Last but not least, the patient's expectations should be evaluated. Our added standardized flowchart with figure acts as a practical guideline for professionals as well as for patients. Our standardized approach for preoperative counseling emphasizes reasonable postoperative expectations aiming for a well-informed patient with high postoperative satisfaction. Our general strategy is to underpromise and overdeliver.

Penile prosthesis in the medically complex patient: a narrative review

Background and Objective

Penile prosthesis surgery is considered a safe and effective treatment for patients with erectile dysfunction. Implantation in the medically complex patient can be a challenge. The benefits of treatment must outweigh the possible risks or complications. A description of possible problems and how to cope with them is given in this narrative review.

Methods

Literature search was performed in January 2023 using different search prompts in PubMed. These articles, excluding non-English and non-full text articles, were listed by the two authors and afterwards, the most relevant ones were included.

Key Content and Findings

This article is divided into five important topics. We evaluated different comorbidities such as spinal cord injury, diabetes mellitus and cardiovascular disease, in which preoperative work-up and counseling is of significant importance. A detailed description of these comorbidities and how to handle these can be found in each section. In addition to the preoperative aspect in organ transplant patients, problems during surgery can arise, e.g., with the reservoir placement. Similarly, in patients with previous pelvic surgery, an ectopic reservoir placement can prevent possible complications.

Conclusions

Preoperative diagnostics are crucial and prosthetic surgery should be done by an experienced high-volume surgeon with a diverse range of surgical techniques at his disposal.

Majority of erectile dysfunction patients would have preferred earlier implantation of their penile prosthesis: validation of the recently changed EAU guidelines

Until 2019, the European Association of Urology guidelines recommended the implantation of a penile prosthesis as a third-line therapy, which has since then changed to "if other treatments fail or depending on the patient's preference". Primary endpoint was to assess whether patients with a penile prosthesis and their partner would have preferred earlier implantation. Secondary endpoints were the reason why patient and partner wanted earlier implantation, how much earlier they wanted it, satisfaction of patient and partner and if patient and partner would have recommended the intervention. We selected patients with a virgin inflatable penile prosthesis operated between April 2013 and December 2019. We included 155 patients and 65 partners. Telephonic interview was conducted in a structured manner. Further data were collected retrospectively. The preference for earlier implantation was reported in 59.4% of patients and 46.2% of partners. Of them, respectively 53.2% and 46.6% would have wanted the prosthesis more than 5 years earlier. Satisfaction was seen in 83.2% of patients and 73.8% of partners. Respectively 82.6% and 78.4% of patients and partners would recommend the procedure. Our results indicate that a more patient-oriented approach with good counseling is desirable and that the "three-level" concept must be abandoned.

Roux-en-Y Gastric Bypass as Conversion Procedure of Failed Gastric Banding: Short-Term Outcomes of 1295 Patients in One Single Center

PURPOSE

Laparoscopic adjustable gastric band (LAGB) has high technical and weight loss failure rates. We evaluate here the 1-year morbidity, mortality, and weight loss of laparoscopic Roux-en-Y-gastric bypass (LRYGB) as a feasible conversion strategy.

METHODS

Patients with a failed primary LAGB who underwent LRYGB from July 2004 to December 2019 were selected from an electronic database at our center. Patients had a conversion to LRYGB at the same time (one-stage approach) or with a minimum of 3 months in between (two-stage approach). Primary outcomes included 30-day morbidity and mortality. Secondary outcomes were body mass index (BMI), percent excess weight loss (%EWL), and percent excess BMI lost (%EBMIL) at 1 year postoperatively.

RESULTS

A total of 1295 patients underwent a conversion from LAGB to LRYGB at our center: 1167 patients (90.1%) in one stage and 128 patients (9.9%) in two stages. There was no mortality. An early (30-day) postoperative complication occurred in 93 patients (7.2%), with no significant difference found between groups. Hemorrhage was the most common complication in 39 patients (3.0%), and the reoperation was required in 19 patients (1.4%). At 1 year postoperatively, the mean BMI was 28.0 kg/m2, the mean %EWL 72.8%, and the mean %EBMIL 87.0%. No statistically significant difference was found between the groups.

CONCLUSION

Conversion to LRYGB can be considered as a safe and effective option with low complication rate and good weight loss outcomes at 1 year. One-stage conversion provides the same early outcome as two-step surgery with a competent surgeon.

Simultaneous implant of inflatable penile prosthesis and artificial urinary sphincter: a single high-volume center experience

Erectile dysfunction and stress urinary incontinence are both an important sequel after local therapy for prostate cancer, such as radical prostatectomy and radiotherapy. The implant of an inflatable penile prosthesis or an artificial urinary sphincter is an option if other treatments fail in both cases. There is a lack of literature regarding a simultaneous dual implantation. The aim of this study is to describe per- and postoperative morbidity and functional results. We included 25 patients operated between January 2018 and August 2022. Data were collected retrospectively. Standardized questionnaires for evaluating satisfaction were administered. There was a median operative time of 45 min (IQR 41.25-58). No intra-operative complications were seen. Four patients needed revision surgery, all of them regarding the sphincter prosthesis. One of these patients had additional revision surgery due to leakage of the penile implant reservoir. There were no infectious complications. There was a median follow-up time of 29 months (IQR 9.5-43). There was a satisfaction rate of 88% with patients and 92% with partners. Postoperative pads per day were reduced to zero or one in 96% of patients. We conclude that the dual implantation of an inflatable penile prosthesis and an artificial urinary sphincter was a safe and effective treatment in our series for patients with conservative treatment-refractory stress urinary incontinence and erectile dysfunction.

Pelvic lymph node dissection in prostate cancer staging: evaluation of morbidity and oncological outcomes

BACKGROUND

To evaluate the morbidity of different surgical approaches for pelvic lymph node dissection (PLND), to evaluate the influence of morbidity on radiotherapy (RT) planning and to evaluate a possible therapeutic effect of a more extensive yield of PLND.

METHODS

From 2000-2016, 228 patients received staging PLND before primary RT in a single tertiary care center. Nine patients were excluded for the evaluation of morbidity. Fifty patients were operated in an open approach, 96 laparoscopic and 73 robot-assisted (RA). Clavien-Dindo classification was used for evaluating complications. Predictors of biochemical recurrence (BCR), clinical relapse (CR), cancer-specific survival (CSS) and overall survival (OS) were evaluated by regression analyses to determine a possible therapeutic effect.

RESULTS

Minimal invasive surgery (laparoscopic or RA) caused five times less major complications (22% vs. 4.3%, p = .001) and a median 3 days shorter hospital stay (5 days versus 2 days, p < .001). Major complications resulted in a delayed (23 days, p < .001) RT start but no oncological effect was seen. Independent oncological predictors were the number of positive nodes (BCR, CR, CSS, OS), a lower age (CR), a higher level of initial prostate-specific antigen (PSA) (BCR) and post-RT PSA (BCR).

CONCLUSION

Minimal invasive surgery can diminish major complications which delay RT start. Nodal staging proved to be of importance for prognosis but no therapeutic effect was seen of performing PLND as such.

Prospective Randomized Controlled Trial Exploring the Effect of TachoSil on Lymphocele Formation After Extended Pelvic Lymph Node Dissection in Prostate Cancer

OBJECTIVE

To explore whether TachoSil, a hemostatic patch, can reduce the incidence of lymphocele formation. Development of a lymphocele is a frequent complication after pelvic lymph node dissection (PLND) for nodal staging in prostate cancer.

MATERIALS AND METHODS

From 2013 to 2017, 100 patients with prostate cancer who were set to undergo a staging PLND before external beam radiotherapy (n = 50) or PLND concomitant with radical prostatectomy (RP) (n = 50) were prospectively randomized 1:1 between bilateral TachoSil placement or nonplacement. Primary end points were radiographic lymphocele development, lymphocele volume (1 week and 1 month postoperatively), and the duration and volume of postoperative catheter drainage.

RESULTS

Patient, tumor, and surgical characteristics of the TachoSil and the control groups did not differ significantly. In total, 65 patients (65%) experienced a radiographic lymphocele up to 3 months after surgery: 29 (58%) in the TachoSil group and 36 (72%) in the control group (P = .34). Significantly less radiographic lymphoceles were observed 1 week postoperatively for patients who underwent sole PLND and 1 month postoperatively for patients who underwent PLND with RP in the TachoSil group compared with the control group (16% vs 48%, P = .024, and 24% vs 52%, P = .047, respectively). The other postoperative characteristics presented no significant differences between the 2 groups, neither for patients undergoing sole PLND nor for patients undergoing PLND with RP.

CONCLUSION

Patients undergoing bilateral TachoSil placement after PLND seem less likely to develop a radiographic lymphocele early postoperatively. Nevertheless, the clinical relevance of the use of TachoSil remains highly debatable.