Inflatable Penile Prosthesis Insertion Research Articles

Early Inflatable penile prosthesis implantation offers superior outcomes compared to delayed insertion following ischemic priapism: a narrative review.

Ischemic priapism is a urological emergency which may lead to irreversible erectile dysfunction. One of the accepted treatments is penile prosthesis implantation. Given the scarcity of studies directly comparing timing of penile prosthesis insertion after ischemic priapism, consensus remains elusive. We aim to compare different studies in the literature concerning advantages and disadvantages of early versus delayed inflatable penile prosthesis following ischemic priapism. We analyzed 8 articles that investigated immediate and delayed inflatable penile prosthesis placement after ischemic priapism. Early inflatable penile prosthesis placement is associated with better outcomes, including pain relief, priapism resolution, penile shortening prevention, and quicker sexual activity resumption. However, it still carries a high risk of complications like edema, infection, and distal perforations. Delayed inflatable penile prosthesis insertion poses surgical challenges due to the potential for extensive corporal fibrosis. Comparative analyses have shown elevated complication rates in patients with ischemic priapism who undergo delayed inflatable penile prosthesis insertion, as opposed to those with early insertion. In studies reporting complications rates, the total complication rate in the early group was 3.37%, significantly lower than the delayed group (37.23%). Most studies support the superiority of early inflatable penile prosthesis placement following ischemic priapism over delayed placement. Further research is, however, needed to establish a global consensus on timing of prosthesis insertion.

(099) A Preliminary Investigation on the Incidence of Complications and Patient Contentment Following the Surgical Implantation of Inflatable Penile Prosthesis After Salvage Radical Prostatectomy

Abstract Introduction Erectile dysfunction (ED) is a common complication post salvage radical prostatectomy (RP). Yet, there is scant data in the literature on complication rates and patient satisfaction in those that undergo inflatable penile prosthesis (IPP) insertion post salvage radical prostatectomy (RP) following targeted radiotherapy for treatment of localized prostate cancer. It is understood that these patients have a higher rate of complications as they have experienced both radiation and prostatectomy adverse events which could alter their overall satisfaction after prosthetic surgeries. Objective Our aim is to conduct a preliminary analysis of IPP complication rates and satisfaction rates in patients that had 3-piece IPP implantation following salvage radical prostatectomy. Methods A retrospective chart review from our institutional database was done from 2018 to 2021. The inclusion criteria were patients that had an inserted 3-piece IPP and a history of salvage RP following radiation therapy. Only patients that participated Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire at least 6 months from implant date were included. Data on satisfaction, IPP infection rates, mechanical failure rates, and overall complications was also collected. Complications include hematoma, erosion, reservoir hernia. Results A total of 22 patients were included in the study. The median age (IQR) is 65 (64–67) years and the median time (IQR) from RP to IPP insertion is 23 (11–49) months. All patients were approached in a penoscrotal manner with submuscular placement of reservoir (Table 1). The satisfaction rate was high at 91.8% on follow up. Overall complications rate was observed in 2 patients. One patient had a mechanical pump failure at 37.9 months while another patient had signs and symptoms of scrotal wall infection at 15 months. Both devices were easily replaced with no post op complication and remained functional on further follow up. Conclusions In patients that underwent salvage prostatectomy IPP insertion, they reported high satisfaction rates and low complication rates despite the exposure to both prostate cancer treatments adverse events. Further research is needed to confirm the results obtained and to investigate the underlying causes for the observed outcomes. The scientific process is iterative, and the answers obtained from one study often lead to more questions and the need for additional investigations. Disclosure No.

(025) Laparoscopic Assisted Reservoir Removal of an Infected Inflatable Penile Prosthesis in a Patient with Ipsilateral Inguinal Hernia Mesh Implant

Abstract Introduction Infection is a devastating complication of penile prosthesis implantation ranging from 0.33 to 11.4%. 1 Although a salvage procedure is an option in case of infection, the rule of thumb is to remove all device components. 2 Special considerations and pre-operative planning are essential for better outcome in the management of such condition. We are presenting a video case presentation demonstrating the use of laparoscopic assisted approach to aid in the extraction of the reservoir of an infected penile prosthesis from a patient who had ipsilateral inguinal hernia mesh implant Objective To demonstrate the feasibility and efficacy laparoscopic assisted approach in the removal of difficult to extract inflatable penile prosthesis (IPP) reservoir. Methods A 72-year-old gentleman with past medical history of Diabetes and hypertension presented to our clinic 3 weeks after an IPP insertion that was done in another center. He was complaining of right inguinal bulge and scrotal pain. The bulge developed suddenly without any preceding event. Examination confirmed a prosthesis reservoir herniation in to the right groin. Plan CT abdomen& pelvis confirmed the diagnosis. In three days, the herniated reservoir was managed by inguinal exploration, repositioning of the same reservoir in the right Retzius space and posterior inguinal canal wall repair using a mesh. The patient was discharged on post-operative day 1 in a stable condition, but unfortunately, he developed persistent scrotal pain that progressed into an overt scrotal infection over the early follow up period. During the examination, a scrotal collection was observed, swap was taken from the draining pus and results showed moderate growth of pseudomonas aeruginosa. On the other hand, the inguinal scar showed good healing with no tenderness, indicating the presence of an intact and non-infected inguinal mesh. Therefore, the decision was made to remove all components of the prosthesis without removing the mesh. Considering the anticipated challenges associated with removing the reservoir of the IPP through a scrotal approach, a decision was made to incorporate an additional laparoscopic-assisted abdominal approach for reservoir removal. Results Removal of the IPP cylinders and pump was performed through a scrotal incision, then a laparoscopic assisted abdominal approach was used successfully to remove the reservoir. After the IPP explant procedure, patient had an uneventful smooth recovery at the two and four weeks follow up visits, he was advised to use Vacuum erection device (VED) to alleviate possible penile fibrosis/shortening. A penile prosthesis reimplantation procedure was planned in a 6 months period Conclusions Laparoscopic assisted approach for penile prosthesis reservoir extraction is a feasible and safe technique that can be used in anticipated cases of difficult reservoir extraction. Pre-operative assessment, planning and counselling are crucial in obtaining a favorable outcome in such complex cases. Disclosure No.

(195) Penile Implants: Restoring Erectile Function Regardless of Age. A Mini–Case Series

Abstract Introduction Given the overall aging of the population, erectile dysfunction has become an increasingly relevant issue among the elderly. When elective surgery is offered, the patient's age is often taken into consideration as a potential limiting factor. Moreover, the importance of addressing the quality of life and sexual satisfaction of older men tends to be overlooked in the management of erectile dysfunction. Objective The aim of this study is to investigate the safety of implanting penile prostheses (PP) in patients aged 90 years and older, as well as the potential complications associated with this age group. Methods The database of patients was screened between the years 2003 and 2023, to identify patients at least 90 years and older who underwent the implantation of penile prosthesis by a single surgeon at two large volume centers. We collected demographic information for the patients, including their past medical and surgical history, medication list, anesthesia perioperative assessment and recommendations, details of the surgical procedure, intraoperative and postoperative recovery period, as well as clinic follow-up. Results Between 2003 and 2023, a total of 2000 men underwent PP surgery at the two centers. Out of the total number of patients, only two were 90 years or older at the time of implantation. One patient was a first timer, while the other had two previous PP surgeries over the span of 15 years for mechanical failure reasons. Both surgeries were performed using different device types, without any intraoperative or postoperative complications. At their three and six months follow up visits, both patients demonstrated the ability to cycle the implant smoothly, reported satisfactory penetrative intercourse with their partners, and improved sexual intimacy through Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire. They were followed for a total of 1 year with no long-term negative effects. Conclusions Despite reporting only two cases in this specific cohort, it demonstrates that implantation of PP is a safe and effective treatment for elderly men with ED. Maintaining satisfactory sexual activity in this age group is vital and achievable through inflatable penile prosthesis (IPP) insertion. There are several complex factors that must be considered prior to operating on an older patient due to medical comorbidities and age. However, with proper patient selection, pre-operative counseling and optimization, this operation can be effectively performed in patients who are at least 90 years old. Simply, age is not a limitation to undergo penile implant. Disclosure No.

(017) Comparing Complication Rates and Continence Control in Concurrent Dual Implantation of Inflatable Penile Prosthesis/Artificial Urinary Sphincter vs. Inflatable Penile Prosthesis/Male Sling: An Updated Comparative Pilot Study

Abstract Introduction Artificial urinary sphincter (AUS) and bulbourethral male sling are used frequently in the management of post prostatectomy urinary incontinence (UI) in men. Some surgeons used to combine an inflatable Penile Prosthesis (IPP) procedure at the same setting to treat concurrent erectile dysfunction (ED). Recent clinical trials have aimed to determine the comparative effectiveness between the male sling and the artificial urinary sphincter (AUS) in men with urodynamic stress urinary incontinence (SUI) after prostate surgery, focusing on non-inferiority. Objective We aim to compare continence control and complications rates in patients who underwent bulbourethral slings or AUS during IPP surgery via perineal approach. Methods A retrospective chart review was done in a large tertiary center. Post prostatectomy patients who underwent perineal dual implantation IPP and AUS or bulbourethral sling for ED and UI purposes, between 2014 and 2022 were included. Clinical data, patients’ demographics were retrieved. Post-operative outcomes with regards to IPP complication rates, revision rates for IPP/ AUS / Male sling, and continence control at 6 weeks, 6 months and 1 year were collected and included in the analysis. Continence control rates were assessed by the number of pads used per day on subsequent follow up visits for both groups. Results A total of 32 patients met the inclusion criteria. 16 Patients underwent synchronous IPP and AUS insertion, whereas another 16 patients underwent IPP with bulbourethral sling procedure. Patient demographics, median follow up & complication rates are summarized below in Table 1. In both groups the procedure was done through a perineal approach. There was no significant difference in baseline data among groups. Complication rates between AUS devices and bulbourethral slings showed no statistically significant differences (12.5% vs 6.25% p= 0.22 respectively). Infection rates and need for revision also did not show any statistically significant differences. With regards to post-operative continence rates, both groups had comparable outcome with no significant differences (P = 0.81). Upon the 6 months follow up visit, the AUS group, 56% were pad free, 19% used 1 pad per day, 19% used 2 pads per day, and 6% used 3 pads or more per day, while in the sling group, 50% were pad free, 25% used 1 pad per day, 19% used 2 pads per day, and 6% used 3 pads or more per day. Patients were followed for a total of 1 year after the surgery. Conclusions The combined insertion of IPP with either AUS or sling procedures has comparable outcomes with regards to continence rate and device- related complications. Each incontinence surgery should be chosen according to surgeon experience and specific patient indications. Further prospective studies on a larger sample of patients with longer follow up period are needed to solidify these findings and will guide patient's decision and preference for incontinence surgeries along with IPP once indicated. Disclosure No.

(170) Missed Urinary Leak During an Inflatable Penile Prosthesis Insertion Presenting as a Post-Operative Hydrocoele

Abstract Introduction This is a case of a revision of a three-piece penile prosthesis in a 53-year-old gentleman who had received an infrapubic implantable penile prosthesis (IPP) in Turkey over 12 months ago. He complained of an unsupported floppy shaft when the prosthesis was inflated, as well as a right hemi scrotal bulging which was exacerbated by activity but showed no signs of infection. A hydrocele had occurred 2 months following the IPP insertion and was confirmed on imaging. The MRI showed the pump within the hydrocele. He had previously had a laparoscopy gastric banding and a bilateral inguinal hernia repair with mesh. Objective Video to demonstrate the surgical case Methods This is a video demonstrating the steps of this operation. The procedure started with a transverse penoscrotal incision and dissection through the dartos muscle. The initial corporotomy allowed removal of the first cylinder of the prosthesis. Upon removing the right cylinder, the hydrocele was opened to reveal the presence of turbid fluid, 150ml of fluid was aspirated and sent for microbiology investigations. The next stage involved removal of the left cylinder and 7.5cm of rear-tip extenders (RTE) were subsequently removed intact, with further RTE from the right removed separately using a nasal speculum. Therefore, a 20cm IPP was removed with 7.5cm RTE on each side. An antibiotic salvage wash (Rifampicin/Gentamicin) was performed several times. At this point a 26cm + 1cm (13mm) malleable prosthesis was inserted as a spacer. The previous infrapubic wound was opened to remove the reservoir, 75ml of fluid was aspirated from around the reservoir prior to removal. Attempts are made to identify a possible fistula with flexible cystoscopy, but normal urethra, bladder neck and bladder are seen. Giving no evidence of any fistula into the abdominal cavity or urethral injury to explain fluid in the corporal cavities or around the components of the prosthesis. Methylene blue and distention were also used to attempt to identify a bladder leak, however this was also unremarkable. A suprapubic catheter was inserted to ensure the decompression of the urinary system to allow any small/undetected leaks to heal. This was done under direct vision using a cystoscope prior to being secured. Results The patient had a replacement of the inflatable penile prosthesis to a malleable prosthesis, a suprapubic catheter inserted and a drainage of his hydrocele. The patient recovered well from surgery and on examination the prosthesis tips were seated nicely in the glans. The fluid microbiology culture did not grow any organism. A subsequent cystogram showed no signs of any bladder leak. The patient was happy with the outcome and underwent a trial without catheter. He has a planned review and will be considered for an exchange to an inflatable device at this time. Conclusions This is an unusual presentation of a hydrocele, in the absence of any infective symptoms which is suggestive of a contained urine leak and even a missed bladder injury from the first prosthesis surgery. However, no fistula was found during the surgery or the post-operative cystogram. Disclosure No.

(284) A Preliminary Investigation on the Incidence of Complications and Patient Contentment Following the Surgical Implantation of Inflatable Penile Prosthesis After Salvage Radical Prostatectomy

Abstract Introduction Erectile dysfunction (ED) is a common complication post salvage radical prostatectomy (RP). Yet, there is scant data in the literature on complication rates and patient satisfaction in those that undergo inflatable penile prosthesis (IPP) insertion post salvage radical prostatectomy (RP) following targeted radiotherapy for treatment of localized prostate cancer. It is understood that these patients have a higher rate of complications as they have experienced both radiation and prostatectomy adverse events which could alter their overall satisfaction after prosthetic surgeries. Objective Our aim is to conduct a preliminary analysis of IPP complication rates and satisfaction rate in patients that had 3-piece IPP implantation following salvage radical prostatectomy. Methods A retrospective chart review from our institutional database was done from 2018 to 2021. The inclusion criteria were patients that had an inserted 3-piece IPP and a history of salvage RP following radiation therapy. Only patients that participated Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire at least 6 months from implant date were included. Data on satisfaction, IPP infection rates, mechanical failure rates, and overall complications was also collected. Complications include hematoma, erosion, reservoir hernia. Results A total of 22 patients were included in the study. The median age (IQR) is 65 (64-67) years and the median time (IQR) from RP to IPP insertion is 23 (11-49) months. All patients were approached in a penoscrotal manner with submuscular placement of reservoir (Table 1). The satisfaction rate was high at 91.8% on follow up. Overall complications rate was observed in 2 patients. One patient had a mechanical pump failure at 37.9 months while another patient had signs and symptoms of scrotal wall infection at 15 months. Both devices were easily replaced with no post op complication and remained functional on further follow up. Conclusions In patients that underwent salvage prostatectomy IPP insertion, they reported high satisfaction rates and low complication rates despite the exposure to both prostate cancer treatments adverse events. Further research is needed to confirm the results obtained and to investigate the underlying causes for the observed outcomes. The scientific process is iterative, and the answers obtained from one study often lead to more questions and the need for additional investigations. Disclosure No.

(116) Breaking the Silence: Should I Be Concerned About Penile Fracture when Injecting Collagenase Clostridium Histolyticum?

Abstract Introduction Collagenase clostridium histolyticum (CCH) was first approved by the FDA in December 2013 for the nonsurgical management of Peyronie’s disease (PD) in men who are otherwise healthy. Penile fracture (PF) is a rare but concerning adverse event with known association with CCH administration. Objective To determine the risk of PF in men with PD who are receiving CCH and correlations between the risk of PF and comorbidities previously excluded in studies investigating the safety of CCH, namely the IMPRESS trial. Methods The TriNetX database was used to measure the rate of hospital visits for penile fracture using the ICD-10 code S39.840A. Results were limited to patients who were diagnosed with PD (ICD-10 N48.9) and were seen between July 2013 to July 2023. Patients were excluded if they had a history of surgical intervention for PD, including plaque excision and grafting, penile plication, and insertion of inflatable penile prosthesis. An odds ratio (OR) was calculated to compare the rates of PF between patients who had and had not received CCH. For those who received CCH, OR’s were calculated to determine if the presence of certain comorbidities increased the risk of PF. Results Within the examined time period, 44,542 patients with PD experienced 280 PF’s. The rate of PF in those who had and had not received CCH were 1.25% (N = 37) and 0.59% (N = 243) respectively, OR 2.122 (95% CI: 1.499-3.001, p<0.0001). Tobacco use, diabetes mellitus, peripheral vascular disease, hypertension, hyperlipidemia, erectile dysfunction, and hypogonadism were not associated with an increased risk of PF in men receiving CCH (p>0.05) (Table 1). Conclusions While the rate of PF following CCH use for PD was low at 1.25%, this was significantly higher than in those who did not receive CCH. Despite this, men who were previously excluded from studies examining the safety of CCH use for PD due to comorbidity burden were without an increased rate of PF, suggesting that these men may be able to receive CCH without additional risk of PF. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Antares Pharma, Clarus Therapeutics, Coloplast.

(224) The Use of an Acellular Dermal Matrix for Peyronie’s Plaque Excision and Grafting

Abstract Introduction The optimal surgical approach for severe Peyronie’s disease (PD) and the ideal grafting material are debatable. Acellular dermal matrices (ADM), among other graft materials that have been reported in the literature, are ideal candidates for graft choice due to the ability to retain structural integrity during the healing process and low immunoreactivity levels. Their use remains novel and only a few small studies have described outcomes of ADM grafting for PD. Objective The current study reports on the largest cohort of patients in the literature undergoing PEG with ADM (FlexHD Pliable). Methods After IRB approval, we reviewed the medical records of all patients undergoing PEG with Flex HD Pliable at our institution between the period of 2014 to 2023. A total of 52 patients with PD underwent PEG with FlexHD Pliable graft, with or without simultaneous inflatable penile prosthesis (IPP) insertion. Preoperative urological assessment of plaque was undertaken using penile color duplex ultrasound (PNUS) and degree of angulation and calcifications were recorded. All patients underwent surgery by a single surgeon. Results Patient’s age was 59.1+/-8.4 (43 to 81) years old. Dorsal curvature was recorded in 46.2% of patients, 23% had lateral, 13.5% had ventral and 17.3 % of patients had a combined curvature. Average penile curvature was 61+/-16 degrees (range 30-90 degrees). Hourglass deformity was recorded in 29.4% of cases; plaque calcification was confirmed on PNUS. The mean time between onset of curvature and surgical treatment was 25±37.9 months (range: 1-204 months). 19.2% patients failed intralesional treatment with Xiaflex prior to surgery and 4% had prior surgical treatment. In 75% of cases, simultaneous IPP placement was performed and in 25% of cases we performed PEG with FlexHD Pliable grafting only. Mean operative time for PEG was 114±22 minutes and simultaneous IPP placement prolonged the average operative time to 147±38 minutes. The average defect size was 21±8.3 cm2 (range: 4-48 cm2). A complete curvature correction was achieved in 90.4% and 9.6% had an average residual curvature of 11.25 °±4.8° (range: 5 ° -15 °). Eight patients (15.4%) reported postsurgical complications. Among them, two patients (3.8%) with altered penile sensation. One patient reported absence of sensation at the tip in the right mid glans; a decreased sensation at the ventral part of the penile shaft was recorded in the second case. There was one case of reactive hydrocele following IPP placement (2%) and five patients (9.6%) developed hematomas: 2 subcapsular graft hematomas required needle aspiration under PNUS guidance, a left spermatic cord hematoma and two penile hematomas that resolved spontaneously. Recurrent curvature onset was recorded in 4 patients (7.7%), but only 2 (3.8%) required re-operation. None of the patients suffered from infection-related complications. Conclusions Our results demonstrate the largest experience with ADM grafting for PD in the literature. PEG with FlexHD Pliable is a safe alternative to other commercially available grafting materials with a low complication rate. In the absence of a gold standard treatment for PD grafting materials, FlexHD Pliable is a practical and valuable option for this surgery. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Irrimax.

(316) Age Is Not a Number When It Comes to Penile Prosthesis Implantation. A Mini–Case Series

Abstract Introduction Given the overall aging of the population, erectile dysfunction has become an increasingly relevant issue among the elderly. When elective surgery is offered, the patient's age is often taken into consideration as a potential limiting factor. Moreover, the importance of addressing the quality of life and sexual satisfaction of older men tends to be overlooked in the management of erectile dysfunction. Objective The aim of this study is to investigate the safety of implanting penile prostheses (PP) in patients aged 90 years and older, as well as the potential complications associated with this age group. Methods The database of patients was screened between the years 2003 and 2023, to identify patients at least 90 years and older who underwent the implantation of penile prosthesis by a single surgeon at two large volume centers. We collected demographic information for the patients, including their past medical and surgical history, medication list, anesthesia peri-operative assessment and recommendations, details of the surgical procedure, intra-operative and postoperative recovery period, as well as clinic follow-up. Results Between 2003 and 2023, a total of 2000 men underwent PP surgery at the two centers. Out of the total number of patients, only two were 90 years or older at the time of implantation. One patient was a first timer, while the other had two previous PP surgeries over the span of 15 years for mechanical failure reasons. Both surgeries were performed using different device types, without any intra-operative or postoperative complications. At their three and six months follow up visits, both patients demonstrated the ability to cycle the implant smoothly, reported satisfactory penetrative intercourse with their partners, and improved sexual intimacy through Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire. They were followed for a total of 1 year with no long-term negative effects. Conclusions Despite reporting only two cases in this specific cohort, it demonstrates that implantation of PP is a safe and effective treatment for elderly men with ED. Maintaining satisfactory sexual activity in this age group is vital and achievable through inflatable penile prosthesis (IPP) insertion. There are several complex factors that must be considered prior to operating on an older patient due to medical co-morbidities and age. However, with proper patient selection, pre-operative counseling and optimization, this operation can be effectively performed in patients who are at least 90 years old. Simply, age is not a limitation to undergo penile implant. Disclosure No.

(220) Does Complication and Continence Rates Differ When Combining Inflatable Penile Prosthesis with Post Prostatectomy Incontinence Procedures Inserted Via Perineal Approach? An Updated Pilot Study

Abstract Introduction Artificial urinary sphincter (AUS) and bulbourethral male sling are used frequently in the management of post prostatectomy urinary incontinence (UI) in men. Some surgeons used to combine an inflatable Penile Prosthesis (IPP) procedure at the same setting to treat concurrent erectile dysfunction (ED). Recent clinical trials have aimed to determine the comparative effectiveness between the male sling and the artificial urinary sphincter (AUS) in men with urodynamic stress urinary incontinence (SUI) after prostate surgery, focusing on non-inferiority. Objective We aim to compare continence control and complications rates in patients who underwent bulbourethral slings or AUS during IPP surgery via perineal approach. Methods A retrospective chart review was done in a large tertiary center. Post prostatectomy patients who underwent perineal dual implantation IPP and AUS or bulbourethral sling for ED and UI purposes, between 2014 and 2022 were included. Clinical data, patients’ demographics were retrieved. Post-operative outcomes with regards to IPP complication rates, revision rates for IPP/ AUS / Male sling, and continence control at 6 weeks, 6 months and 1 year were collected and included in the analysis. Continence control rates were assessed by the number of pads used per day on subsequent follow up visits for both groups. Results A total of 32 patients met the inclusion criteria. 16 Patients underwent synchronous IPP and AUS insertion, whereas another 16 patients underwent IPP with bulbourethral sling procedure. Patient demographics, median follow up & complication rates are summarized below in Table 1. In both groups the procedure was done through a perineal approach. There was no significant difference in baseline data among groups. Complication rates between AUS devices and bulbourethral slings showed no statistically significant differences (12.5% vs 6.25% p= 0.22 respectively). Infection rates and need for revision also did not show any statistically significant differences. With regards to post-operative continence rates, both groups had comparable outcome with no significant differences (P = 0.81). Upon the 6 months follow up visit, the AUS group, 56% were pad free, 19% used 1 pad per day, 19% used 2 pads per day, and 6% used 3 pads or more per day, while in the sling group, 50% were pad free, 25% used 1 pad per day, 19% used 2 pads per day, and 6% used 3 pads or more per day. Patients were followed for a total of 1 year after the surgery. Conclusions The combined insertion of IPP with either AUS or sling procedures has comparable outcomes with regards to continence rate and device- related complications. Each incontinence surgery should be chosen according to surgeon experience and specific patient indications. Further prospective studies on a larger sample of patients with longer follow up period are needed to solidify these findings and will guide patient's decision and preference for incontinence surgeries along with IPP once indicated. Disclosure No.

(405) Penile Prosthesis Implantation and Peyronie's Disease: How to Approach the Residual Curvature – A Detailed Demonstration of Moulding Technique and Grafting Procedure

Abstract Introduction Insertion of a penile prosthesis is the treatment of choice in men with Peyronie’s disease and concomitant erectile dysfunction. The aim of surgery is to straighten the penis and allow adequate rigidity for sexual intercourse. A conundrum arises when there is residual curvature during device testing. Objective This video highlights strategies that will aid the implanter when faced with these intraoperative challenges. Methods This video illustrates three different scenarios and suggests strategies that can be used when there is a residual penile curvature following inflatable penile prosthesis insertion: 1) Manual moulding – In this scenario, a persistent left lateral curvature is successfully straightened by moulding the plaque following device insertion. The cylinders are fully inflated and the tubes to the pump are double clamped. One hand is positioned distal to the apex of the curvature while the other is proximal. The penis is manipulated in the opposite direction to the curvature. 2) Residual curvature after manual moulding – The plaque can be incised at the point of maximal curvature and grafted If there is a significant persistent curvature (>30 degrees) following moulding. A fibrin sealant patch was used in this patient and it offers a quick and effective choice for grafting the tunical defect. 3) Upfront plaque incision and grafting - Some patients are not suitable for moulding following penile prosthesis insertion. Examples include ventral penile curvature and ossified plaques. In this patient with a ventral curvature, the plaque was incised and the tunical defect grafted with bovine pericardial graft prior to corporal dilatation. Results All three patients had an uneventful post-operative outcome. They were encouraged to cycle the device from 3 weeks and allowed to commence sexual intercourse after 6 weeks post-surgery. Conclusions Manual moulding is a safe and effective first line option for residual penile curvature following inflatable penile prosthesis insertion. Plaque incision and grafting can be considered if moulding fails or where manual moulding is contraindicated. There are several choices for graft material including fibrin sealant patch or bovine pericardium. Disclosure No

(401) Insertion of A 2-Piece Inflatable Penile Prosthesis with Combined General and Regional Anesthesia

Abstract Introduction Inflatable penile prosthesis placement is widely used for treatment of medically refractory erectile dysfunction. In patients with prior pelvic or abdominal surgery, use of a 2-piece inflatable penile prosthesis avoids the need for placement of a reservoir in the pelvis, which can be a complicated procedure due to possible retropubic scarring. A pudendal nerve block can be employed as a regional anesthesia strategy for penile surgery to reduce use of intraoperative and postoperative opiates. Objective This video covers the placement of a 2-piece inflatable penile prosthesis under general and regional anesthesia in a patient with a complex surgical history. Methods The video demonstrates a step-by-step technique for the pudendal nerve block and placement of the 2-piece prosthesis. Results A 63-year-old male with history of multiple abdominal and pelvic surgeries was treated severe, refractory ED with insertion of a 2-piece inflatable penile prosthesis under general and regional anesthesia. He did not require any intraoperative opiates. He had a normal and uneventful postoperative recovery with a reduced postoperative opiate requirement. The prosthesis cycled properly four weeks after surgery. Conclusions In select patients undergoing insertion of a penile prosthesis, the use of a pudendal nerve block in combination with general anesthesia can reduce the perioperative opiate requirement. Disclosure No

(247) Complication Rates After Penile Prostheses In Men with History of Priapism – A Retrospective Claims Database Cohort Analysis

Abstract Introduction Penile prostheses can be placed in men with a history of priapism who develop erectile dysfunction, or as initial management of acute ischemic priapism. However, little is known about long-term complications associated with prostheses in these men. Objective To assess the risk of penile prosthesis complications in men with a history of priapism. Methods We searched the TriNetX insurance claims database to create a cohort of men ages ≥16 years old with 1) a diagnosis of priapism (ICD-10: N48.4), 2) a diagnosis of erectile dysfunction (ICD-10: N52), and 3) had undergone prosthesis placement (insertion of penile prosthesis inflatable and self-contained [CPT: 54401], insertion of semi-rigid penile prosthesis [CPT 54400], or insertion of multiple component inflatable penile prosthesis [CPT: 54405]). Three complications were assessed: penile prosthesis infection (ICD-10: T83.61), penile prosthesis mechanical breakdown (ICD-10: T83.410A), and penile prosthesis displacement or migration (ICD-10: T83.420). Rates of and duration to IPP removal (CPT: 54415-17, 54406, 54410-11) were also assessed. To compare rates of complications, the priapism cohort was compared to a cohort of men with a diagnosis of erectile dysfunction and prosthesis placement but without a history of priapism or corpora cavernosal irrigation, matched by age, race, diabetes status, and obesity (E66). When assessing risk of prosthesis complications, we utilized 1:1 greedy nearest-neighbor propensity score matching to control for confounding variables. Results A total of 665 men were identified with a diagnosis of priapism and erectile dysfunction who subsequently received a penile prosthesis. A control group of 31,345 patients with erectile dysfunction and a penile prosthesis but without priapism or history of irrigation was identified, and ultimately 660 men in the case and control cohorts were matched by age, race, diabetes status, and obesity. Men of with a history of priapism were more likely to experience penile prosthesis infection (5.0% vs 2.7%; Risk Ratio (RR): 1.83, 95% Confidence Interval (CI) 1.04-3.22) and mechanical breakdown of the prosthesis (7.3% vs 3.8%, RR: 1.92, 95%CI 1.20-3.08). There was no difference in the rate of penile prosthesis displacement or migration (3.5% vs 2.4%, RR: 0.76, 95%CI 0.77-2.70). Overall rates of penile prosthesis explantation were higher in men with a history of priapism 14.6% vs 8.4% (RR: 1.73, 95%CI 1.27-2.36). Rates of early explantation (within 6 months of placement) were similar between the two groups, 3.3% vs 2.9% (RR: 1.16, 95%CI 0.63-2.11). Rate of explantation of semi-rigid prostheses were significantly higher in men with a history of priapism, 27% vs 9.6% (RR: 2.54, 95%CI 1.62-3.93). Of the 17 men undergoing explantation of semi-rigid prosthesis with history of priapism, only 4 men (23%) went on to have a 3-piece penile prosthesis placed. Conclusions In this US claims-based database comparison between prosthetic complications in men with and without a history of priapism, men with priapism were more likely to experience infection, mechanical breakdown and explantation. There was no difference in rate of device displacement or migration, or in timing of device explantation. This real-world data provides context for counseling men with priapism who undergo prosthesis placement. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Urogen Pharma, Janssen Global Services, Regeneron Pharmaceuticals

(111) Clinical Practice Patterns for Surgical Shunts and Penile Prosthesis Placement in Men with Priapism – A Retrospective Claims Database Analysis

Abstract Introduction New AUA/SMSNA guidelines for management of acute ischemic priapism have been released, but actual practice patterns can be difficult to assess as overall incidence is low and men often seek care at multiple institutions. Objective To assess the rates of surgical shunting and prosthetic placement for acute ischemic priapism using a large multi-institutional claims database. Methods A US claims database network (TriNetX Diamond Network) was queried from 2010 to 2020. We constructed a cohort of men ages ≥16 years old with 1) a diagnosis of priapism (ICD-10: N48.4) and 2) who had undergone an irrigation of the corpora cavernosa for priapism (CPT: 54220). We assessed the number of men who then had a surgical penile shunt (corpora cavernosa-glans penis fistulation [CPT: 54435], corpora cavernosa-corpus spongiosum shunt [CPT: 54430], or corpora cavernosa-saphenous vein shunt [CPT: 54420]) or penile prosthesis placement (insertion of penile prosthesis inflatable and self-contained [CPT: 54401], insertion of semi-rigid penile prosthesis [CPT 54400], or insertion of multiple component inflatable penile prosthesis [CPT: 54405]). Time to surgical procedure and order of procedures were collected, as well as background information including age, race, diabetes status (ICD-10: E11), hyperlipidemia status (ICD-10: E78), sickle cell status (ICD-10: D57.0-1), and if men were classified to have drug-induced priapism (ICD-10: N48.33). Results 6,392 men were identified with the diagnosis of priapism and the procedure of corpora cavernosa irrigation. Of these men, 693 (11%) proceeded to surgical shunt (94 had corpora cavernosa-glans penis fistulation, 321 men had corpora cavernosa-corpus spongiosum shunt, and 78 men had corpora cavernosa-saphenous vein shunt). 144 men (2%) underwent initial penile prosthesis placement (Figure 1). Of the men undergoing initial penile prosthesis 94 (65%) occurred within the first year of the initial corpora cavernosal irrigation with the majority (81 of 94, 86%) being 3-piece inflatable penile prostheses and the majority in a “delayed” manner between 3 to 12 months after initial priapism irrigation (Table 1). Men who underwent initial penile prosthesis placement were older (55.1±13.0 vs 43.0±13.7 years, p<0.0001) and more often white (23% vs 16%, p=0.03), with higher rates of erectile dysfunction (56% vs 9%, p<0.0001), type 2 diabetes (32% vs 13%, p<0.0001), and hyperlipidemia (47% vs 20%, p<0.0001) when compared to men who underwent initial penile shunt procedure (Table 2). Finally, when assessing choice of initial shunts versus initial penile prosthesis pre- and post-2015, overall rates of initial shunt (10.0% vs 8.5%, p<0.0001) and initial prosthesis (3.1% vs 2.1%, p<0.0001) were significantly lower after 2015 when compared with rates prior to 2015. Conclusions In this US claims-based analysis of men presenting with ischemic priapism and treated with initial irrigation, we found that a small percentage (11%) continued to surgical shunting. Only 2% were managed with an initial prosthesis, most often a 3-piece device in a delayed manner. Men receiving initial prostheses were more likely to have more comorbidities, and overall surgical management of priapism has decreased overtime. In the setting of the new AUA/SMSNA guidelines, this data provides real-world practice patterns. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Urogen Pharma, Janssen Global Services, Regeneron Pharmaceuticals

(104) A Multicenter Evaluation of Penile Curvature Correction in Men with Peyronie’s Disease Undergoing Inflatable Penile Prosthesis Placement

Abstract Introduction Inflatable penile prosthesis (IPP) insertion is recommended for the treatment of patients with Peyronie’s Disease (PD) and significant erectile dysfunction (ED). Adjunctive procedures such as modeling, plication, or incision/excision and grafting can be used when there is residual curvature after IPP placement. Objective To evaluate the management of curvature correction in patients with PD undergoing IPP among high-volume prosthetic urologists. Methods We performed a retrospective study of 205 patients diagnosed with PD undergoing IPP by 7 high volume penile prosthetic surgeons. Demographic, intraoperative, and postoperative data were collected and analyzed. Descriptive statistics were performed using mean and standard deviation for continuous variables, while incidence and percentages were used for categorical variables. We calculated the mean change in penile curvature after IPP insertion for each of the adjunctive correction techniques. Intra- and post-operative complications were collected. Results 205 patients met inclusion criteria with a mean age of 60.7 years (SD=9.2) and a median follow-up of 6 months (0.5-58.5 months). The mean preoperative curvature was 43.4° (SD=18.9°) with dorsal curvature being the most common. Overall, 73 (35.60%) patients had IPP only with no adjunctive curvature correction procedure, 24 (11.70%) underwent plication, 10 (4.90%) underwent grafting, and 98 (47.80%) underwent modeling. Preoperatively, the mean starting curvature was 35.7° for the IPP-only group, 48.1° for the plication group, 60.6° for the grafting group, and 46.0° for the modeling group, p<0.001. Patients undergoing grafting had significantly fewer comorbidities compared to the other groups: only 1 (10%) had diabetes and none were smokers or had cardiovascular disease, p<0.001. After penile curvature correction, the mean curvature change was 25.5° for the IPP-only group, 40.0° for the plication group, 55.0° for the grafting group, and 35.0° for the modeling group, p <0.001 (Figure 1). Intraoperatively, proximal perforation occurred in 2 (0.96%) patients, managed by a rear tip extender sling. Post-operatively, there were 33 (16.10%) non-infectious and 4 (1.90%) infectious complications. There was no significant difference in complications between groups. Conclusions Although incision/excision and grafting seem to provide the greatest penile curvature correction for PD patients undergoing IPP placement, this adjunctive correction procedure is less commonly performed among high volume prosthetic urologists. Our results suggest grafting is reserved for patients with greater preoperative curvature and fewer preoperative comorbidities. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Antares Pharma: SpeakBoston Scientific, Clarus Therapeutics, Coloplast, Cynosure, Promescent, Sprout, Viome, Hims & Hers Health, Inc.

(419) In Vivo Next Generation Sequencing Identifies More Isolates vs. Standard Culture During Revision Inflatable Penile Prosthesis Insertion: A Single Center Experience

Abstract Introduction The presence of biofilm at the inflatable penile prosthesis (IPP) component sites, which resists eradication, likely increases postoperative infection rates in revision surgery. The microbiome of (IPP) revision surgery has been shown to be increasingly complex and the weak microbe Staph epidermidis is no longer prevailing and was previously considered the major causative agent for overt infections. Furthermore, next generation sequencing (MicrogenDx, Lubbock, TX, USA) has been used recently to demonstrate that in certain scenarios such as mechanical malfunction, erosion, and infection, specific microbes dominate. Due to the disastrous complications with postoperative IPP infection, it is paramount to provide additional evidence for increased utilization of next generation sequencing over traditional cultures during IPP revision surgery. This will serve to guide postoperative treatment if necessary. Objective We investigated a cohort of IPP revision patients receiving intraoperative low concentration chlorhexidine (CHG) lavage to see whether next generation sequencing or traditional cultures of the pump space reveals more isolates. Methods A total of 31 patients with indwelling IPPs underwent revision surgery for both infectious and noninfectious reasons between May 2021 and March 2022 by a single, high volume implant surgeon who solely uses 0.05% CHG dip and irrigation. Once the pump capsule was entered, swabs were taken from the pump space and sent for traditional culture and next generation sequencing. All cultures were obtained prior to irrigation with 0.05% chlorhexidine (CHG) solution (Irrimax corporation, Lawrenceville, GA, USA). All patients received perioperative clindamycin, gentamicin, and fluconazole. Results 1 patient was excluded due to missing next generation sequencing results. Of the 30 remaining patients, 4 presented with infectious and 26 with noninfectious etiologies. 93% (28/30) patients had negative traditional cultures prior to irrigation with 0.05% CHG; however, 21% (6/28) of these patients had isolates on next generation sequencing. Only 7% (2/30) had positive preop irrigation cultures and isolates on next generation sequencing. Both of these patients presented with infection. 1 of these patients had a concordant next generation sequencing result. However, the other patient had multiple isolates. The traditional culture showed only pseudomonas a. On NGS, it was the third most abundant on NGS at only 4% compared to the most and second most abundant being E. coli at 83% and Klebsiella p. at 12%. Conclusions These results suggests that a greater number of isolates are obtained using next generation sequencing compared to traditional cultures during IPP revision surgery. Consequently, this may lead to better prevention and/or better guide treatment of postoperative IPP infection in the setting of IPP replacement. Although, further studies are needed prior to universally adopting this modality. Disclosure Yes, this is sponsored by industry/sponsor: MicrogenDx. Clarification Industry funding only - investigator initiated and executed study. Any of the authors act as a consultant, employee or shareholder of an industry for: MicrogenDx.

(452) Glans Necrosis is Not a Risk for Simple Inflatable Penile Prosthesis Insertion Performed via Subcoronal Incision

Abstract Introduction Some studies have questioned subcoronal incision via IPP as a risk factor for glans ischemia or necrosis. We analyzed the largest ever reported series of IPP via subcoronal incision. Objective To report complications related with subcoronal incision for IPP placement Methods We studied 898 men who had subcoronal IPP placement from 5/2015-3/2022 by single surgeon. 817 were first-time patients under local anesthesia, with 81 revisions under spinal anesthesia including 707 circumcised and 181 uncircumcised subjects. Most (76%) uncircumcised men underwent coincident circumcision; the remainder refused. Implants were Coloplast Titan (489) and AMS 700 (329) in 329 (36.6%) diabetics and 38 (4%) Peyronie’s. We report postoperative occurrence of device infections and glans/penile skin problems. Results Mean follow up was 47.3 months (3-81 months). Modeling (64%) and corporal relaxing incisions (36%) straightened the Peyronie’s patients. Transient distal penile skin edema which resolved within 2 to 4 months was noted in 673 cases (74.9%). Edema developed in 68.3% previously circumcised patients, 100% of concomitant circumcised patients and 96.2% of patients who had refused circumcision. One previously circumcised patient experienced prolonged edema of 7 months. Five previously circumcised patients (0.5%) developed partial distal penile skin necrosis on the proximal side of the subcoronal incision (Figure-1) with all but one healing without grafting. The other patient sustained necrotic wound dehiscence which led to device infection and removal. There were zero cases of glans ischemia or necrosis. Only 2 patients became infected (0.2%). Conclusions Subcoronal incision for simple IPP placement or revision is not an independent risk factor for glans ischemia or necrosis. Most postoperative patients do experience transient distal penile skin edema without glans involvement which heals without sequelae regardless of circumcision status. Very rarely (0.5%) penile skin loss may occur. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, International Medical Devices, Rigicon, Uramix.

Long-term assessment of the safety and effectivity of the mini-jupette sling: 5-year follow-up of the original series.

In 2017, a prospective multicenter, multinational, investigational pilot study was conducted examining outcomes using a novel surgical technique, the Mini-Jupette sling, for the management of erectile dysfunction (ED) patients with climacturia and/or minimal stress urinary incontinence (SUI) after prostate procedures. Climacturia has been reported in up to 64% of patients following radical prostatectomy (RP). We sought to report the 5-year outcomes from this original cohort to assess long-term safety and effectivity of the mini-jupette sling in the treatment of ED and concomitant mild SUI and/or climacturia. This is a single-arm, multicenter, retrospective, observational study. We identified patients who were enrolled in the previous multicenter study with post-RP ED and climacturia and/or mild SUI- 2 PADS PER DAY (PPD) and underwent inflatable penile prosthesis (IPP) insertion with simultaneous placement of a mini-jupette sling. Data were collected including current PPD, subjective improvement in climacturia/SUI, complications, need for revision of IPP or additional urinary incontinence surgery, and date of most recent follow-up. SPSS was used for statistical analysis. Of the original 38 patients, 5 have since died and 10 were lost to follow-up with 23/38 (61%) patients available for evaluation of long-term outcomes. The average follow-up time was 59 months (SD =8.8) with a mean age of 69 years (SD =6.8). Most patients (n=21, 91%) had subjective improvement of SUI and climacturia. One patient with persistent bothersome incontinence underwent artificial urinary sphincter (AUS) placement in 2018 with no complications, while the other is still considering a repeat procedure due to minor but persistent SUI. The mean PPD decreased from 1.4 preoperatively to 0.4 at a mean of 5 years of follow-up. Most patients reported satisfaction in their urinary symptoms with 91% and 73% reporting improvement in SUI and climacturia respectively, compared to 86% and 93% respectively in the original series. One (4.3%) patient had an IPP revision for pump malfunction. There were no device infections reported. The mini-jupette sling appears to be a safe and effective procedure with durable improvements in SUI and climacturia at 5 years of follow-up.

PD42-09 INTRACAVERNOSAL INJECTION HISTORY IS ASSOCIATED WITH INCREASED INTRA- AND POSTOPERATIVE INFLATABLE PENILE PROSTHESIS COMPLICATIONS: A MULTI-INSTITUTIONAL ANALYSIS

PD42-09 INTRACAVERNOSAL INJECTION HISTORY IS ASSOCIATED WITH INCREASED INTRA- AND POSTOPERATIVE INFLATABLE PENILE PROSTHESIS COMPLICATIONS: A MULTI-INSTITUTIONAL ANALYSIS