Inflatable Prosthesis Research Articles

Contemporary management of ischemic priapism: A 12-year population-based analysis from a large US database.

Priapism is a urological condition characterized by a persistent erection. The management varies based on its subclassifications. Despite established clinical guidelines for ischemic priapism, there is a lack of large-scale research focused on patient characteristics and management strategies. To analyze the contemporary management of ischemic priapism in the US, exploring patient demographics and clinical characteristics, as well as predictors of erectile dysfunction (ED) and penile prosthesis implantation (PPI). We performed a retrospective analysis of the PearlDiver Mariner database, reviewing records from 2010-2021. Adult males diagnosed with ischemic priapism were included. Data analysis covered demographic, clinical variables, and management strategies. Predictors of de novo ED and PPI were evaluated using multivariable logistic regression analysis. Of 36,120 patients, most (93%) received only medical management, and a minority underwent surgical interventions (penile shunt surgery [PSS], PPI or both). Medical management was typically effective, as 67.08% of the patients in this group experienced only one episode of priapism. However, de novo ED occurred in 16.57% of these patients. The majority of patients undergoing PPI had an inflatable prosthesis (81%). Older age (odds ratio, OR 1.02), the presence of metabolic diseases (OR 1.39), neurogenic disorders (OR 1.72), solid pelvic malignancies (OR 1.09), and multiple episodes of priapism were identified as significant predictors of de novo ED (all p<0.05). Similarly, age (OR 1.03), the presence of metabolic diseases (OR 1.23), solid pelvic malignancies (OR 1.99), and multiple episodes of priapism were associated with higher likelihood of PPI (all p<0.05). Most cases of ischemic priapism are managed with the medical therapy. Less than 3% of patients with ischemic priapism receive PPI, and when this occurs an inflatable prosthesis is favored. Age, specific comorbidities, and multiple episodes of priapism appear to be significant predictors of ED and PPI.

Complication and Explantation Rates of Penile Prostheses in Transmasculine Patients: A Meta-analysis

ObjectiveTo synthesize current literature on penile prosthesis implantation post-gender affirming phalloplasty to correlate implant types and complication rates. MethodsA meta-analysis of penile prosthesis in transmasculine patients was initiated in December 2022. Inclusion criteria encompassed randomized clinical trials, cohort studies, and cross-sectional studies reporting on penile prosthesis complications post-gender-affirming phalloplasty. Exclusion criteria were review articles, meta-analyses, studies that exclusively reported on cisgender patients or surgeries other than penile prosthesis implantation. An initial search of five databases yielded a total of 1593 articles. Upon screening, 15 full-text articles were eligible for inclusion. 9 studies were included in the analysis. ResultsThe overall complication rate for the inflatable prosthesis group was 38% (95% CI: 21, 59) and for the malleable prosthesis group was 37% (95% CI: 18, 62). The most probable complications in the inflatable group were infection (14.5%), dysfunction (12.9%), dislocation (5.7%), and leakage (5.4%). The most probable complications in the malleable group were dislocation (14.9%), infection (11.2%), dysfunction (9.1%), and extrusion (7.6%). There was no significant difference in the probability of any complications between the malleable and inflatable prosthesis groups.The best estimate of explantation rates for any reason for the inflatable group was 19% (95% CI: 9, 38) and for the malleable group 13% (95% CI: 4, 33). There was no significant difference in the probability of any reason for explantation between the malleable and inflatable prosthesis groups.

(387) Clinical Experience with Malleable Penile Implantation for Salvaging Inflatable Implant Infection

Abstract Introduction Antibiotic irrigation for treating prostheses is commonly believed to be a proper administration for those whose penile implant contracts with infection. However, there is no standard procedure for the irrigation period. Objective As a result, we encounter patients whose sinusoids were ruined from irrigation attempts for over three months. We sought to report an experience of salvaging penile implantation. Methods From 2010 to 2022, eight patients requested salvage penile implantation for treating unsuccessful inflatable implantation elsewhere. They report repeated antibiotic rescuing and wound debridement from 50 to 121 days of hospitalization. The diameter of the glans penis is measured and recorded in mm. Pelvic X-rays were made while the penis was downward and upward. One 44-year-old patient received no further salvaging penile implant because the corporeal sinusoid had too hardly fused to allow the contrast medium injection. The remaining seven received malleable types of penile implants ambulatory under acupuncture-assisted local anesthesia with which a cavernosal block must be performed in addition to a proximal dorsal nerve block, crural block, and peri penile infiltration. In addition, the novel method of glans enhancement was performed unexceptionally. The approach was longitudinal pubic (n=3) and circumferential (n=2). The pain level was assessed on the acupoint needle location or penis property. It was recorded on blood loss amount and operation times. A 32 to 35 ligation was performed at the retro-coronal venous plexus, which is readily identified by glans milking manipulation. A 5cm coroporotomy was made along the 11 or 1 o'clock position of the corpora cavernosa. To minimize the sinusoidal compression, corporal dilatation was made along the dorsal and medial directions distally and dorsolateral proximally. Neither electrocautery nor a suction apparatus was used because of minimal blood loss from manual compression. The water-tight suture was made to the tunic wound, closed continuously with 6-0 nylon with intermittent enhanced suture per centimeter. The overlying fascia layers and skin were finally closed with 6-zero chromic layer by layer. All patients received postoperative pelvic X-rays evidencing the appropriate housing of the cylinder. Sexual satisfaction was followed up yearly by the INTERNET. Results The operation time was 2.5 to 4.5 hours, and the blood loss was negligible. The pain level was more substantial at the arm acupoint at 71.4% (5/7). It was 11 to 61 months from the first and salvaging prosthesis implantation. The diameter of the glans increased from 26.0±2.3 mm to 35.3±2.2 mm. Four patients report couple satisfaction, whereas the remaining one feels male self-esteemed and female acceptable. All patients reported partial sinusoidal erection and no soft glans syndrome eventually. Conclusions A malleable penile prosthesis is beneficial for salvaging inflatable prosthesis infection. An anatomy-based corporeal dilation seems a proper way to minimize sinusoidal compression, although a larger sample size and longer follow-up are mandatory. The glans enhancement was unexceptionally attainable. Disclosure No.

Use of Soft Penile Prosthesis in Grafting Surgery for Peyronie's Disease and Mild Erectile Dysfunction: Still an Option?

Plaque incision and grafting (PEG) is a primary surgical therapy for severe penile curvature in Peyronie's disease (PD); However, it can increase the risk of erectile dysfunction (ED), particularly in patients with pre-operative mild ED. Soft penile prosthesis (SPP) implantation is a viable treatment option in such cases. This study aims to compare the outcomes of PEG-only approach to PEG plus SPP implantation. Between 2010 and 2019, 32 patients with PD and mild ED (5-item version of the International Index of Erectile Function scores: 17-21) underwent PEG surgery. Two groups were defined based on the surgery type: PEG-only and PEG plus SPP. The long-term outcomes included correction of penile bending, erection quality, intercourse ability, penile length and sensitivity. The overall satisfaction and impact of surgery on sexual activity and quality of life were also assessed. Of the 32 patients, 13 (40.6%) underwent PEG-only surgery, whereas 19 (59.4%) underwent PEG plus SPP. No significant differences were noted between the groups regarding pre-operative characteristics (all p > 0.1) or intra- and post-operative complication rates (all p > 0.2). The median patch area was larger in the PEG-only group (28 cm2 vs. 16.2 cm2; p = 0.001), whereas patients in the PEG plus SPP group were more likely to receive a single patch implant (100% vs. 53.8%; p < 0.001). The penile length increased in 18 patients (61.6%), with significant differences between the two groups (30% vs. 81.2%; p = 0.03). Overall, 14 patients (53.8%) reported greater satisfaction with their sexual life post-operatively, with comparable rates between the groups (p = 0.2). No significant differences were found in the post-operative 5-item version of the International Index of Erectile Function scores or severe post-operative ED (all p > 0.5). SPP placement during corporoplasty in patients with mild ED is safe and feasible, and it may be a suitable option for patients uncertain about inflatable prosthesis placement. The use of SPP resulted in longer penile lengths and necessitated smaller grafts. However, further data are required to understand the long-term clinical implications of this approach.

Pneumonectomy for Unilateral Proximal Interruption of Pulmonary Artery: A Case Series from the Literature.

Unilateral proximal interruption of the pulmonary artery (UPIPA) is a rare congenital disease, and its optimal management remains undefined in the existing literature. The occasional necessity for pneumonectomy is still supported by limited evidence. A systematic review of the literature was conducted using the PubMed search engine, focusing on UPIPA cases that received pneumonectomy. Thirty-one pertinent articles were selected and included in the analysis. A case reported from our institution was included in the analysis. We found 25 adults and seven children affected by UPIPA who received an indication for pneumonectomy, plus an additional case that was reported by our institution. Among adult patients, the predominant indication was hemoptysis (57%), followed by suspected or confirmed lung cancer (23%). Approximately 46% of surgical procedures were classified as urgent or emergent. Postoperative complications were observed in 36% of cases, with no recorded mortality. In pediatric cases, pneumonectomy was primarily a life-saving intervention, performed urgently or emergently in 75% of instances. A possible late complication in pediatric patients involves a mediastinal shift leading to respiratory distress, which may be mitigated using an inflatable prosthesis. Pneumonectomy achieves complete resolution of UPIPA symptoms. In the adult population, its primary indication is hemoptysis, with procedures conducted in both elective and urgent/emergent settings. Despite a mortality rate of zero, a notable proportion of patients may experience postoperative complications. In pediatric cases, the clinical presentation varies more extensively, and pneumonectomy is typically reserved for life-threatening situations, emphasizing the need for careful patient selection.

Primary management of the inframammary fold in breast reconstruction using the thoracoabdominal advancement flap: Surgical technique

Our experience in breast reconstruction confirms the significant importance of reconstructing the inframammary fold in achieving overall aesthetic satisfaction. We describe our technique for primary fixation of the inframammary fold in breast reconstruction using a thoracoabdominal advancement flap. This technique is suitable for patients with a vertical skin laxity of at least 5cm in the future inframammary fold. Prior to the procedure, it requires preparation through physiotherapy, the use of adhesive external breast prosthesis, and skin expansion using an inflatable prosthesis in extreme cases. The surgical approach follows the existing mastectomy scar. After subfascial dissection of the thoracoabdominal advancement flap, the surgeon proceeds to create two separate rows of sutures. The first row mimics the deep attachment of the inframammary fold, fixing the superficial fascia of the flap to the rib periosteum. The second row mimics the superficial attachment of the inframammary fold, fixing the dermis of the flap to the rib periosteum. The main advantage of this technique is its applicability to all breast reconstruction programs.

(344) The Surgical Outcome of Buried Penis Surgery

Abstract Introduction Buried penis is a condition where the penis retracts and becomes hidden beneath the skin. It has a significant impact on quality of life of the patient and can present with a variety of symptom including lower urinary tract symptoms and erectile dysfunction. Whilst there are several causes, obesity is the most common in adults. Objective The aim of this study is to assess the variety of different operations performed with patient and surgeon satisfaction rates. Methods This is a retrospective study on patients with a buried penis operated on between 2010 and 2020. Data retrieved included presenting complaints, previous surgery, co-morbidities, surgical details and patient and surgeon satisfaction rates with cosmesis. Results A total of 141 patients were recruited with buried penis (median age 54, range 20-80). The presenting complaints were inability to void standing n = 30, erectile dysfunction n = 18, small penis n = 94. Aetiological factors included diabetes n=47, vascular disease n=62, penile cancer surgery n= 3 and BXO n= 13. The BMI was recorded in 44 patients (range 23-52) with 7 being morbidly obese (BMI &amp;gt;40). 47 patients had only a weight was recoded with a median of 114kg (range 68-169kgs). A total of 96 (68%) patients had had previous surgery prior to referral and in particular circumcision in 49 patients. The operations performed on the 141 patients were circumcision n=40, scrotoplasty n=35, V-Y plasty n=11, skin grafting n=34, suprapubic fat pad excision n=77, abdominoplasty n=25, malleable penile prosthesis n=7, inflatable prostheses n=7 and division of suspensory ligament n=24. The post-operative length of stay was median 3 days (range 0-52 days) but for abdominoplasty and grafting this was a median of 5 days (range 1-52 days). There were 27 complications (19%); infections (n=15), dehiscence (n=5), haematomas (n=2) The mean follow up was 506 days (range 0-4313 days) with a surgical satisfaction rate of 87% and patient satisfaction of 79%. Of note the highest dissatisfaction occurred in patients having circumcision or suprapubic fat pad removal. Conclusions Buried penis is a complex condition with patients likely requiring a combination of surgical techniques. Circumcision alone usually does not treat the problem and may make things worse. A prolonged hospital stay with significant wound complications may occur but the majority of patients are happy with the final outcome. Disclosure No

(036) Outcomes of Penile Prosthesis Implantation after Transgender Phalloplasty: A Single Center Study

Abstract Introduction Many transmen chose to pursue penile prosthesis (PP) implantation as a stage of genital gender affirming surgery. The prosthesis facilitates penetrative intercourse, as the neophallus lacks rigid erectile tissue. While PP placement is a well-established and relatively low-risk surgical treatment option for erectile dysfunction is the cis-male population, published series of post-phalloplasty prosthesis placement have demonstrated a higher rate of complications and subsequent explant. Objective To demonstrate that an integrated surgical team that participates in all stages of phalloplasty creation can improve penile prosthesis outcomes in transmen. Methods We performed a retrospective review of all transmen who underwent PP implantation at our institution from January 2015 through October 2021, yielding a cohort of 44 men. Men who underwent phalloplasty for another reason (trauma, infection, priapism) were excluded. Both malleable (MPP) and inflatable (IPP) prostheses were included in the cohort. Home phalloplasty refers to phalloplasty performed at our institution, and outside phalloplasty at another institution. The surgical technique emphasizes exclusion of urinary flora from the operative field and avoiding excess anchor material to minimize niduses for infection. We analyzed preoperative, operative, and post-operative characteristics, stratified by whether the phalloplasty was performed at our institution. We also performed logistic regression for predictors of explant in the cohort. Results Cohort characteristics and outcomes are represented in Table 1. 44 PPs were implanted 28 at our institution, 16 at an outside institution. Average age was 32 and 33 in the cohorts, respectively. IPPs were more commonly implanted than MPP. Notably, operative time was significantly lower if the phalloplasty had been constructed at our institution (p=0.014). 16 men total required explant, 7/28 (25%) in the home phalloplasty group and 9/16 (56.3%) in the outside phalloplasty group. Predictors of explantation are shown in Table 2. Significant predictors included age (p=0.013), smoking (p=0.030), operative time (p=0.007), whether the phalloplasty was performed at our institution (p=0.043), and the number of pre-PP revision surgeries (p=0.047). On multivariate logistic regression including all variables significant on univariate analysis, only age (p=0.032) and operative time (p=0.010) remained significant predictors. Conclusions We present a large post-phalloplasty penile prosthesis cohort, demonstrating exceedingly low infection rate and improved explant rate in a cohort of men who all underwent both phalloplasty and prosthesis placement with the same surgical team. Our analysis suggests that phalloplasty characteristics, patient characteristics, and operative time can influence penile prosthesis outcomes. Disclosure No

State-of-art review of current malleable penile prosthesis devices in the commercial market.

The malleable penile implant is often considered an inferior device to the three-piece inflatable penile prosthesis implant. Nonetheless, the malleable prosthesis has its unique advantages such as lower cost, easier to perform and fewer mechanical complications than inflatable prostheses. Furthermore, its role can be extended to patients with issues relating to poor manual hand dexterity, those undergoing a salvage for infection prosthesis and as an emergency surgical measure in patients presenting with acute ischaemic priapism. Over the past few decades, there have been numerous design and technological advancements to improve overall clinical efficacy, mechanical durability, axial rigidity and device concealability of malleable penile prostheses. The following article provides a narrative review of the six major contemporary malleable penile prosthesis devices in the commercial market, namely, the Coloplast Genesis prosthesis, the Boston Scientific Tactra prosthesis, the Zephyr ZSI 100 and 100 (female-to-male) FTM devices, the Rigi10 prosthesis, the TUBE malleable prosthesis and the Shah prosthesis and evaluates the published outcomes. Appropriate patient selection and strict counselling regarding what to expect with malleable prostheses coupled with adherence to safe surgical principles are paramount to ensure excellent clinical success and patient satisfaction rates.

Malleable versus inflatable penile prosthesis: systematic review

Erectile dysfunction (ED) is a prevalent condition affecting quality of life. Penile prostheses are effective for non-responsive cases, with malleable and inflatable types commonly used. Yet, a thorough comparison between them is absent. This systematic review aims to evaluate and compare malleable and inflatable penile prostheses in terms of efficacy, complications, patient satisfaction, and quality of life outcomes. A systematic search was conducted on PubMed, Embase, and Cochrane Library databases for relevant studies published between 2010 and 2022. Studies meeting predefined inclusion and exclusion criteria were selected, and their methodological quality was assessed. Data on surgical success rates, postoperative complications, patient satisfaction, sexual function, and quality of life were extracted and synthesized. A total of 40 studies were included in the review. Analysis of surgical success rates revealed comparable outcomes between malleable and inflatable penile prostheses. Postoperative complications varied, with malleable prostheses associated with lower rates of infection and mechanical failure compared to inflatable prostheses. Patient satisfaction was high for both types of prostheses, although some studies reported higher satisfaction rates with inflatable devices. Sexual function improvements were observed in both groups, but malleable prostheses had a shorter operative time and fewer device-related adverse events. Quality of life outcomes showed positive changes in psychosocial aspects for patients with both types of prostheses. This systematic review provides a comprehensive evaluation of malleable and inflatable penile prostheses for the treatment of ED. Although both prosthesis types effectively address ED, malleable ones show potential benefits: reduced infection/mechanical issues, quicker surgery, and fewer device-related problems. Yet, patient satisfaction leans toward inflatables, highlighting personal preferences in choices. Future research should probe lasting results and patient input to aid optimal prosthesis selection.

HF01-17 PENILE STRETCHING PRACTICES THROUGH TIME AND CULTURE

You have accessJournal of UrologyCME1 May 2022HF01-17 PENILE STRETCHING PRACTICES THROUGH TIME AND CULTURE John Sigalos, Sriram Eleswarapu, and Jesse Mills John SigalosJohn Sigalos More articles by this author , Sriram EleswarapuSriram Eleswarapu More articles by this author , and Jesse MillsJesse Mills More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002541.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The medical literature suggests there is benefit to penile stretching and traction therapy in Peyronie’s disease, after prostatectomy to prevent shortening, erectile dysfunction prior to placement of an inflatable prosthesis, and for men concerned about penile length. We seek to present the historical practices regarding penile stretching and traction therapies. METHODS: Literature review via PubMed, Google scholar, and archive.org for books, journal articles, texts, and historical discussion detailing the practice of penile stretching and traction practices throughout history. RESULTS: Margaret Mead in her studies of Polynesian males described a woven device of plant fiber that was used to help men to stretch their penises. Working in a similar fashion to a Chinese finger trap, the penis is inserted into one end of the device while a weighted object is hung from the other end. The Cholomec tribe from Peru and some African tribes have used the direct hanging of weights on to their penises in attempts to increase penile length. This method of traction does not increase girth. Direct use of weights hanging from the penis has been shown to decrease girth and cause tissue damage. Certain Holy Men from the Sadhu tribes in India have practiced penile stretching via hanging stones from their penises using grass or lianas. Egyptian pharaohs as well may have used weights to increase penile length. The most prominently featured technique of penile stretching is the Arabic jelqing method. Jelqing is still practiced by some to this day, and it involves a regimented milking or massaging of the semi-erect penis from base to tip repeatedly. The man then stops jelqing prior to ejaculation so that the process can be restarted. Jelqing has not been rigorously studied in the medical literature, however one British physician reported on use of jelqing for penile length gain in the 1970s. Richards' study reported on 30 men, who followed a regular program of jelqing three months. According to Richards, 87 percent of the participants experienced increases in penile length with an average 1 inch increase in the length of their penises and a 1 inch increase in girth. A similar milking and exercise method has been used by Sudanese practioners to achieve increased penile size. CONCLUSIONS: There is a long-standing use of penile stretching and traction practices across many cultures and historical time points. Only recently has the medical literature begun to elucidate best practices and objective benefits that men have been seeking for many years. Source of Funding: John Sigalos has received funding from H H LEE Research Program via LB Research and Education Foundation in support of this work © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e217 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Sigalos More articles by this author Sriram Eleswarapu More articles by this author Jesse Mills More articles by this author Expand All Advertisement PDF DownloadLoading ...

V07-09 ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY AND URETHRAL PULL THROUGH OF MEMBRANOUS URETHRA TO BLADDER

You have accessJournal of UrologyCME1 May 2022V07-09 ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY AND URETHRAL PULL THROUGH OF MEMBRANOUS URETHRA TO BLADDER Safiya-Hana Belbina, Scott Spivey-Provencio, Pegah Taheri, E. Charles Osterberg, and Aaron A. Laviana Safiya-Hana BelbinaSafiya-Hana Belbina More articles by this author , Scott Spivey-ProvencioScott Spivey-Provencio More articles by this author , Pegah TaheriPegah Taheri More articles by this author , E. Charles OsterbergE. Charles Osterberg More articles by this author , and Aaron A. LavianaAaron A. Laviana More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While robotic assisted laparoscopic prostatectomy has been a durable treatment option for men with localized prostate cancer over the past two decades, salvage prostatectomies are performed less frequently. In this video, we report a unique case of a salvage prostatectomy and membraneous urethra pull-through in an individual who was treated with both high-intensity focused ultrasound and external beam radiation therapy complicated by prostate cancer recurrence and a severe bulbar urethral stricture that failed direct visual internal urethrotomy. METHODS: The case presents a 71-year-old male with a urological history of prostate cancer in 2010 treated with HIFU. Following biochemical recurrence in 2013 he subsequently underwent salvage EBRT. This was complicated by a severe bulbar urethral stricture necessitating two DVIUs In addition, the patient underwent transurethral resection of the prostate for obstructed voiding symptoms and placement of an inflatable penile prosthesis. From a cancer standpoint, his PSA slowly rose after EBRT from 1.3 in 2019 to 2.7 in 2021. Repeat prostate biopsy showed 1/14 cores positive for Gleason Score 4+4=8 prostate cancer. The patient proceed with a robotic-assisted laparoscopic prostatectomy with a urethral pull through and bilateral pelvic lymph node dissection. The video begins with dissection of the prostatic apex to entirely free up and remove the prostate. Once the prostate is separated from the urethra, the dissection continues until the old bulbar urethral scar is completely removed. After we ensure the remnant urethra is free of scar and patent, the urethra is seen being passed through from below into the pelvic cavity and the anastomosis is performed. We then proceeded with a bilateral pelvic lymphadenectomy using the synchroseal device which obviates the need for any clips. The patient’s inflatable prosthesis reservoir makes the right side more challenging, however, it is feasible with careful dissection. RESULTS: The patient was discharged on post-operative day 1 with all drains removed and his post-operative course remained uncomplicated. On post-operative day 19, he had a normal voiding cystourethrogram. CONCLUSIONS: This case discusses the surgical technique used in a salvage robotic-assisted prostatectomy with membranous urethral pull-through in a patient with previous history of HIFU, salvage EBRT, bulbar urethral stricture, and inflatable penile prosthesis. In this video, we show this is a feasible option in select men and may spare them the burden from undergoing a radical cystoprostatectomy. Source of Funding: n/a © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e661 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Safiya-Hana Belbina More articles by this author Scott Spivey-Provencio More articles by this author Pegah Taheri More articles by this author E. Charles Osterberg More articles by this author Aaron A. Laviana More articles by this author Expand All Advertisement PDF downloadLoading ...

Penile Prosthesis in Transgender Men after Phalloplasty.

A penile prosthesis can be successfully implanted after phalloplasty in transgender men to permit sexual intercourse. A prosthesis can be categorized as malleable or inflatable. The most common penile prosthesis implanted after masculinizing genital surgery is the inflatable prosthesis but this can be a challenging operation with high complication rates. Penile prosthesis in transgender patients differs from cis-patients in many respects but one critical difference is the absence of the tough, protective tunica of the corporal body to contain the prosthesis. This causes greater mobility of the prosthesis under the skin and increases the risk of migration and erosion of the device through the skin. In addition, to overcome the absence of a corpora cavernosa, the proximal portion of the prosthesis must be anchored to bone. Complications include injury to the urethra, vascular injury, skin breakdown, infection, device migration, device failure, extrusion, and erosion. There is no robust data on the use of penile prosthesis in transgender men with only multiple reports of small numbers of patients. While successful implantation can improve patients' quality of life, surgeons should counsel patients about the relatively high risk of the need for revision surgery.

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.

Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications

BackgroundPenile prostheses may be used as a component of genital gender affirmation surgery for the purpose of achieving penile rigidity after phalloplasty, and transgender individuals experience higher complication rates than cisgender individuals. AimTo observe complications with transmasculine penile prosthesis surgery over time and across surgical conditions. MethodsRetrospective chart review of all transmasculine patients with phalloplasty undergoing penile prosthesis placement between 4/14/2017 and 2/11/2020 (80 patients). OutcomesIndependent variables include implant type, previous genital surgeries, and simultaneous genital surgeries. Dependent variables include prosthesis infection and mechanical complication (device malfunction, dislodgement, erosion). ResultsThere was an overall complication requiring surgery rate of 36% and infection rate of 20% (15/67 for inflatable prostheses and 1/13 for semirigid), with 14% (11/80) experiencing infection requiring removal. Differences in infection rates appeared insignificant across categories of previous surgery or with simultaneous surgery, but we did notice a markedly lower rate for semirigid prostheses compared to inflatable. There was a significant relationship between infection and case number, with the probability of infection decreasing over time. Device loss at 9 months was 21% overall. Preoperative conditions of the neophallus such as prior stricture correction and perioperative factors such as simultaneous clean and clean-contaminated procedures seemed to pose no additional increase in complication rates. Clinical ImplicationsType and number of prior and simultaneous non-prosthetic surgeries should not be considered as a risk factor for penile prosthesis after phalloplasty for transmasculine patients, even those that are clean-contaminated Strengths & LimitationsOur cohort size is large compared to currently available studies, although not large enough to generate sufficient power for group comparisons. We have reported every genital surgical step between phalloplasty and penile prosthesis placement and recorded complications with subsequent devices after failure. Patient-reported outcomes were not collected. ConclusionWe demonstrate that preoperative conditions of the neophallus, such as prior stricture correction, and perioperative factors, such as simultaneous clean and clean-contaminated procedures, seem to pose no additional increase in complication rates. Our data suggest that surgical experience may further decrease complications over time.B. L. Briles, R. Y. Middleton, K. E. Celtik, et al. Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications. J Sex Med 2022;19:641–649.

PD31-12 PENILE PROSTHESIS PLACEMENT USING AN OPTIMIZED METHOD BY A DEDICATED TRANSGENDER SURGERY UNIT: A SLOW DECREASE IN HIGH COMPLICATION RATES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) II (PD31)1 Sep 2021PD31-12 PENILE PROSTHESIS PLACEMENT USING AN OPTIMIZED METHOD BY A DEDICATED TRANSGENDER SURGERY UNIT: A SLOW DECREASE IN HIGH COMPLICATION RATES Ravyn Middleton, Brenna Briles, Kenan Celtik, Curtis Crane, Michael Safir, and Richard Santucci Ravyn MiddletonRavyn Middleton More articles by this author , Brenna BrilesBrenna Briles More articles by this author , Kenan CeltikKenan Celtik More articles by this author , Curtis CraneCurtis Crane More articles by this author , Michael SafirMichael Safir More articles by this author , and Richard SantucciRichard Santucci More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002032.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Female to male transgender individuals may seek penile prostheses as part of genital gender affirmation surgery for the purpose of achieving penile rigidity, as this is not achieved with phalloplasty alone. This study aims to observe the types and rates of complications of penile prostheses after phalloplasty, over time and across surgical conditions, and to seek improvements in the complication rate by diligent adherence to proven principles. METHODS: Data was gathered via retrospective chart review of 81 patients at our high-volume center. The natural history of each prosthesis was followed through time. RESULTS: There was an overall complication rate of 36% and infection rate of 20%, with 15% experiencing infection requiring removal. Differences in infection rates were not significant across categories of previous surgery or with simultaneous surgery, but we did notice a markedly lower rate for semirigid prostheses compared to inflatable [infection rate 22% (15/67) for inflatable prostheses and 7% (1/14) for semirigid (p=0.19)]. Infection rates decrease with time and surgical experience: the rate of prosthesis infection improved over time, and the slope of the cumulative curves are much lower for infections (r=0.013) than expected for the number of cases performed over time (r=0.082) (p=0.979). The first 40 patients had an overall infection rate of 28% (11/40), a slope of 0.071 for cases vs time, and 0.013 for infections vs time (p=0.975). The most recent set of 41 patients had a lower overall infection rate of 12% (5/41), a slope of 0.079 for cases, and 0.006 for infections (p=0.969). CONCLUSIONS: Improvements were achieved by strict adherence to proven techniques: no touch techniques (Level 3 evidence), appropriate pre-operative intravenous antimicrobial prophylaxis (Level 2), control of blood sugar in diabetics (Level 2), antibiotic soaked implants (Level 2), hair clipping instead of razor shaving (Level 1), and use of chlorhexidine-based surgical scrub (Level 1). Overall, 28% of patients required surgery for complications. This compares favorably to the meta-analysis of penile prosthesis placements in phalloplasty patients, where the overall rate of complications requiring surgery was 45% for inflatable prostheses, and 42% for non-inflatable prostheses. Using careful surgical technique advised by specific knowledge of phalloplasty anatomy, and following proven infection control methods developed in the cisgender population, we hypothesized and then achieved lower rates of complication in this risky procedure. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e543-e543 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ravyn Middleton More articles by this author Brenna Briles More articles by this author Kenan Celtik More articles by this author Curtis Crane More articles by this author Michael Safir More articles by this author Richard Santucci More articles by this author Expand All Advertisement Loading ...

Penile shortening complaints in males with erectile dysfunction: a narrative review on penile lengthening procedures during penile prosthesis surgery.

Patients complaining of short penile length pose a challenge in urology practice. Those men who present seeking penile lengthening surgery usually overestimate 'normal' penile length, and may in often cases relate their penile length with the degree of masculinity and self-esteem. Penile prosthetic devices are the gold standard treatment of erectile dysfunction (ED) after failure of conservative options. Penile shortening is the most prevalent long-term complaint after successful inflatable penile prosthesis (IPP) placement. This has a significant impact on patient’s overall satisfaction and quality of life. Using PubMed, we performed a thorough literature review of the current procedures of preservation or enhancement of penile length as well as reported perioperative protocols in patients undergoing penile prosthesis (PP) insertion. Keywords used were “penile lengthening”, “penile enhancement”, “penile girth”, “inflatable penile prosthesis” and “glans augmentation”. Several surgical techniques can be offered in the setting of penile shortening concurrently with PP insertion, e.g., sub-coronal approach of PP placement, sliding technique, modified sliding technique (MoST), multiple-slide technique (MuST), and tunica mesh expansion procedure (TMEP). Adjuvant techniques can also improve subjective penile length include, ventral phalloplasty, suprapubic lipectomy, suspensory ligament release and use of expanding penile implants. Preoperative protocols including use of a vacuum erectile device, traction therapy also seem to improve postoperative outcomes, minimizing postoperative pain, and encouraging the early device use. Currently, there is no consensus among experts on a particular lengthening procedure or when they can be performed to optimize outcomes. Furthermore, it is imperative to set proper expectations before surgery, with extensive patient and partner counseling. When used in the properly selected patient, penile lengthening procedures show promising results with minimal complication rates.

The Prevalence and Treatment of Erectile Dysfunction in Male Solid Organ Transplant Recipients.

Erectile dysfunction (ED) is a prevalent and under-recognized complaint among male solid organ transplant recipients. Most research on this topic has focused on kidney transplant recipients alone. In this review, we integrate current research on ED across all types of solid organ transplant recipients and assess the success of current methods of ED treatment in transplant populations. To review the current literature addressing the prevalence and treatment of ED in the male solid organ transplant population. A literature search was conducted using PubMed to identify relevant studies. Search terms included "organ transplant" and "erectile dysfunction." Titles and abstracts were reviewed for relevance. References from identified articles were also searched and included, if appropriate. Review of peer-reviewed literature. The prevalence of ED among transplant recipients is higher than that in the general population: 39.8-86.2% in liver transplant recipients, 54-66% in renal transplant recipients, 71-78% in heart transplant recipients, and 79% in simultaneous pancreas-kidney transplant recipients. Phosphodiesterase-5 inhibitors have up to 80% efficacy in treating ED in kidney transplant recipients. Intracavernosal injections have been used with success rates of 60-70% in cardiac and renal transplant recipients. Penile prostheses have also been shown to be safe and effective across transplant types. A low incidence of infection has been reported in several case series, although there is concern for an increased rate of mechanical complications in pelvic organ transplant recipients. Accordingly, placement of a two-piece or malleable prosthesis or ectopic reservoir placement with a three-piece inflatable prosthesis is suggested in this population. ED is highly prevalent among male solid organ transplant recipients and should be routinely screened in this population. Current modalities of ED treatment used in the general population are safe and effective in solid organ transplant recipients, although success rates are often lower than those in the general population. Payne K, Popat S, Lipshultz LI, etal. The Prevalence and Treatment of Erectile Dysfunction in Male Solid Organ Transplant Recipients. Sex Med Rev 2021;9:331-339.

Management of Priapism: A Contemporary Review.

Current management of ischemic priapism revolves around 3 principles: resolving the acute event, preserving erectile function, and reducing the risk of future recurrences. Although more conservative management options, such as aspiration, irrigation, and surgical shunts, are effective in many patients, those who are refractory to these interventions or have prolonged priapism may benefit from placement of a penile prosthesis (PP). To provide a comprehensive overview of priapism management, highlight the current literature on the utility of penile implants for refractory priapism, and provide insight from a high-volume center on surgical decision making and technique. A complete review of the current guidelines and associated literature was performed. Associated algorithms were evaluated, and our experience was overlaid on the data present in the literature. The current management algorithm for priapism was evaluated. Subsequently, the data on acute and delayed PP placement were assessed. Rates of postoperative infection, erectile dysfunction, and patient satisfaction were also examined. Overall, both delayed and early PP implants are associated with higher rates of failure than routine PP implants. In patients with refractory or prolonged priapism, early implantation may be technically easier, with decreased loss of penile length and associated complications. Patients should be evaluated on an individual basis and counseled on the risks and benefits of PPimplantation in early and delayed time frames. Although there is no definitive evidence at this time regarding the ideal device or timing of implantation, there are well-established pros and cons of malleable vs inflatable prostheses and of acute vs delayed implantation. Mishra K, Loeb A, Bukavina L, etal. Management of Priapism: A Contemporary Review. Sex Med Rev 2020;8:131-139.

Musculocutaneous latissimus dorsi flap for phalloplasty in female to male gender affirmation surgery.

Despite a variety of free flaps that have been described for creation of the neophallus in gender affirmation surgery, none present an ideal solution. We evaluated our patients and outcomes after gender affirmation phalloplasty using musculocutaneous latissimus dorsi free flap. Between January 2007 and May 2017, 129 female transsexuals, aged 20-53years (mean 24years) underwent total phalloplasty using latissimus dorsi free flap. Urethral lengthening was performed by combining a vaginal flap, labia minora flaps and a clitoral skin flap. Suitable sized testicular implants are inserted into the new scrotum. Penile prosthesis implantation, additional urethral lengthening and glans reshaping were performed in the following stages. The mean follow-up period was 43months (ranged from 13 to 137months). There were one partial and two total flap necrosis. The average size of the neophallus was 14.6cm in length and 12.4cm in girth. Total length of the reconstructed urethra during the first stage ranged from 13.4 to 21.7cm (mean 15.8cm), reaching the proximal third or the midshaft of the neophallus in 91% of cases. Satisfactory voiding in standing position was confirmed in all patients. Six urethral fistulas and two strictures were observed and repaired by minor revision. Malleable and inflatable prostheses were implanted in 39 and 22 patients, respectively. Musculocutaneous latissimus dorsi flap is a good choice for phalloplasty in gender affirmation surgery. It provides an adequate amount of tissue with sufficient blood supply for safe urethral reconstruction and penile prosthesis implantation.