Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice

BACKGROUND

The definitive treatment for erectile dysfunction is the surgical implantation of a penile prosthesis, of which the most common type is the 3-piece inflatable penile prosthesis (IPP) device. IPP surgery in outpatient freestanding ambulatory surgical centers (ASC) is becoming more prevalent as payers and health systems alike look to reduce healthcare costs.

AIM

To evaluate IPP surgical outcomes in an ASC as compared to contemporaneously-performed hospital surgeries.

METHODS

A database of all patients undergoing IPP implantation by practitioners in the largest private community urology group practice in the United States, from January 1, 2013 to August 1, 2019, was prospectively compiled and retrospectively reviewed. Cohorts of patients having IPP implantation performed in the hospital vs ASC setting were compared.

MAIN OUTCOME MEASURE

The primary outcome measure was to compare surgical data (procedural and surgical times, need for hospital transfer from ASC) and outcomes (risk for device infection, erosion, and need for surgical revision) between ASC and hospital-based surgery groups.

RESULTS

A total of 923 patients were included for this analysis, with 674 (73%) having ASC-based surgery and 249 (27%) hospital-based, by a total of 33 surgeons. Median procedural (99.5 vs 120 minutes, P < .001) and surgical (68 vs 75 minutes, P < .001) times were significantly shorter in the ASC. While the risk for device erosion and need for surgical revision were similar between groups, there was no higher risk for prosthetic infection when surgery was performed in the ASC (1.7% vs 4.4% [hospital], P = .02), corroborated by logistic regression analysis (odds ratio 0.39, P = .03). The risk for postoperative transfer of an ASC patient to the hospital was low (0.45%). The primary reason for mandated hospital-based surgery was medical (51.4%), though requirement as a result of insurance directive (39.7%) was substantial.

CLINICAL IMPLICATIONS

IPP implantation in the ASC is safe, has similar outcomes compared to hospital-based surgery with a low risk for need for subsequent hospital transfer.

STRENGTHS & LIMITATIONS

The strengths of this study include the large patient population in this analysis as well as the real-world nature of our practice. Limitations include the retrospective nature of the review as well as the potential for residual confounding.

CONCLUSION

ASC-based IPP implantation is safe, with shorter surgical and procedural times compared to those cases performed in the hospital setting, with similar functional outcomes. These data suggest no added benefit to hospital-based surgery in terms of prosthetic infection risk. Weinberg AC, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice. J Sex Med 2020;17:1025-1032.

Inflatable Penile Prosthesis Implantation in the Ambulatory Setting: A Systematic Review

INTRODUCTION

Erectile dysfunction is a common problem that may be definitively treated with the implantation of an inflatable penile prosthesis (IPP). The preponderance of available data on IPP surgery derives from institutional studies, most notably from academic centers or large single-surgeon series, where the majority of procedures are performed in a hospital setting. Because insurance companies and health systems look to reduce health care costs, IPP surgery in outpatient freestanding ambulatory surgery centers (ASC) is becoming more prevalent.

AIM

To review the utility of surgery in an ASC setting and to explore its role in the modern practice of urology, focusing on IPP implantation.

METHODS

A critical review was performed of the literature on ambulatory surgery, with specific focus on IPP surgery, using the PubMed database. Key search terms and phrases included erectile dysfunction, penile prosthesis, ambulatory surgery, ambulatory surgery center, outpatient surgery.

MAIN OUTCOME MEASURE

The main outcome measure was the use of IPP implantation in an ASC.

RESULTS

In contemporary surgical practice, the implementation of ambulatory surgery in free-standing centers is increasing. The principal benefits include reducing cost and improving efficiency. Studies on the modern use of IPPs support the prospect of implantation in an ambulatory setting, which can achieve similar outcomes to surgeries classically performed in the inpatient hospital setting. Novel approaches to anesthesia, surgical, and nursing care have revolutionized IPP surgery so that it can now be safely and effectively performed in the ambulatory setting.

CONCLUSION

The role of ambulatory IPP implantation has increased, with the majority of cases being performed outside the hospital. Although there will always be a need for hospital-based surgery, such as significant medical comorbidities, more studies demonstrating the safety and feasibility of ambulatory surgery are needed. For those men who would otherwise be candidates for ambulatory surgery but whose insurance mandates hospital-based treatment, such studies proving utility, safety, and reduced cost could inspire policy change and broaden the ambulatory practice of IPP surgery. Segal RL, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis Implantation in the Ambulatory Setting: A Systematic Review. Sex Med Rev 2020;8:338-347.

[Repetition and fear of dying]

In this paper a revision is made of the qualifications of Repetition (R) in Freuds work, i.e. its being at the service of the Pleasure Principle and, beyond it, the binding of free energy due to trauma. Freud intends to explain with this last concept the "fort-da" and the traumatic dreams (obsessively reiterated self-reproaches may be added to them). The main thesis of this work is that R. is not only a defense against the recollection of the ominous past (as in the metaphorical deaths of abandonment and desertion) but also a way of maintaining life and identify fighting against the inescapable omninous future (known but yet experienced), i.e. our own death. Some forms of R. like habits, identificatory behaviors and sometimes even magic, are geared to serve the life instinct. A literary illustration shows this desperate fight.

The murine disposition and pharmacokinetics of the antineoplastic agent, diaziquone (NSC 182986)

We have studied the murine disposition and pharmacokinetics of diaziquone (AZQ), a new aziridinylbenzoquinone antitumor agent that is currently undergoing clinical trials. 14C-AZQ, dissolved in dimethylacetamide/0.01M phosphate buffer, pH 6.5, 5:95 (v/v), was administered iv to mice at a dosage of 6 mg/kg (18 mg/m2). After injection, mice were killed and plasma and organs were obtained and analyzed for total radioactivity and for chloroform-extractable 14C. Both total plasma radioactivity and chloroform-extractable plasma 14C declined very rapidly. By 3 hr, chloroform-extractable 14C was about 0.2% of its initial concentration. Within 30 min after injection, more radioactivity remained in the aqueous phase than was extracted into chloroform. When analyzed by TLC, all chloroform-extractable radioactivity in plasma as well as in brain, heart, liver, and skeletal muscle co-chromatographed with parent AZQ. Tissue distribution of 14C was extensive. 14C concentrations (dpm/g tissue wet weight) were initially greatest in heart and lung, but by 2 min after injection, were greatest in kidney, and by 10 min were second greatest in liver. Substantial amounts of total and chloroform-extractable 14C were found in brains. By 3 hr after injection, total 14C in all tissues exceeded total 14C in plasma. The apparent volume of distribution of AZQ was approximately 1 ml/g and the total body clearance of AZQ was 0.9 ml/min or 130 ml/min/m2. Extraction of tissues with chloroform showed conversion of AZQ into non-chloroform-extractable metabolites. This conversion was reproduced in vitro by mouse liver homogenate at 37 degrees C but not at 0 degree C.