Penile Prosthesis Placement Research Articles

Penile and testicular prosthesis following gender-affirming phalloplasty and scrotoplasty: a narrative review and technical insights.

Transgender and gender diverse (TGD) individuals may seek gender-affirming phalloplasty with specific functional goals, including erectile function sufficient for penetrative sexual intercourse. Individuals seeking penile prosthesis placement must accept the potential risks to their phallic anatomy. We review current practices at our center and narrative review of literature discussing techniques for penile prosthesis and testicular prosthesis placement after phalloplasty and scrotoplasty, as well as surgical outcomes, and quality of life outcomes where available. Early discussion of a staged approach to phallic construction with a last step of implant placement is important during initial phalloplasty counseling. Pre-operative counseling at our multi-disciplinary center includes: discussion of surgical history, complications, goals and priorities; physical exam to evaluate phallic size and position, scrotal size, and other anatomic findings that may influence prosthesis selection; urinary evaluation, including uroflowmetry with post-void residual, and a cystoscopy with retrograde urethrogram if indicated based on symptoms or urinary studies, and discussion of surgical risks, benefits and alternatives. Although none of the commercially available penile prosthesis devices in the United States are designed for phalloplasty, modern inflatable and malleable prostheses are adapted for use in the post-phalloplasty setting. Due to the lack of native corpora cavernosa, highly variable phallic anatomy, and the need to adapt implants designed for natal penile anatomy, complication rates of prosthesis placement after phalloplasty remain high, with reported ranges of complications from 20% to 80%. Major complications requiring surgical revision are common relative to implant placement in natal penile anatomy, and include: infection requiring explantation, device extrusion, erosion, migration or malposition, inadequate rigidity, poor aesthetic result, pain, decrease or loss of erogenous and/or tactile sensation, device failure, injury to the urethra, and injury to the neurovascular supply of the penis with resultant partial or complete flap loss. This broad range of complication rates represents the variability with which results are reported and reflect a lack of clear reporting guidelines, significant variability in techniques, and need for more standardization. To optimize outcomes, it is important that surgeons have an in-depth understanding of phalloplasty anatomy and are equipped to manage potential complications in the short- and long-term.

Single Dilation in Primary Inflatable Penile Prosthesis Placement Is Associated With Fewer Corporal Complications Than Sequential Dilation

To assess the difference in outcomes between single dilation (SingD) and sequential dilation (SeqD) in primary penile implantation, hypothesizing that patients who undergo SeqD had higher rates of noninfectious complications. We performed a multicenter, retrospective study of men undergoing primary inflatable penile prosthesis placement. Intraoperative complications and postoperative noninfectious outcomes were assessed between the two groups. Multivariable analysis was performed to identify predictors of complications. A total of 3293 patients met inclusion criteria. After matching, there were 379 patients who underwent SingD and 379 patients who underwent SeqD. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length (20cm with interquartile range [IQR] 18-21cm vs 20cm with IQR 18-20cm respectively, P=.4). On multivariable analysis, SeqD (OR 5.23 with IQR 2.74-10, P<.001) and older age (OR 1.04 with IQR 1.01-1.06, P=.007) were predictive of postoperative noninfectious complications. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length. SeqD and older age were predictive of postoperative noninfectious complications. During inflatable penile prosthesis placement in the uncomplicated patient without fibrosis, SingD is a safe technique to utilize during implantation that will minimize postoperative adverse events, and promote device longevity without loss of cylinder length.

Oxycodone prescription after inflatable penile prosthesis has risks of persistent use: a TriNetX analysis.

We sought to evaluate the impact of Oxycodone prescriptions on short-term patient outcomes and long-term Oxycodone use following inflatable penile prosthesis (IPP) placement. We queried the TriNetX research database for all adult patients undergoing IPP. Cohorts included opioid naïve patients prescribed postoperative Oxycodone against propensity score-matched patients without a prescription. We compared return visits to the emergency department (ED) within 14 and 90 days of surgery, a diagnosis of opioid abuse or dependence disorder 6 months or later after surgery and persistent Oxycodone use 9-15 months after surgery. After matching, there were 2433 patients in each group. There was an increase in 90-day ED visits based on receipt of Oxycodone (6.8% of patients vs 5.0%, risk ratio (RR) 1.4 95% confidence interval (CI) [1.1, 1.7]). Groups had similar 14-day ED visits (3.7% of patients vs 2.9%, RR 1.3, 95% CI [0.95, 1.7]). Patients prescribed Oxycodone (5.1% of patients vs 2.7%, RR 1.9, 95% CI [1.4, 2.6]) were more likely to have persistent Oxycodone use at 9-15 months. There were low instances of diagnosis of opioid dependence or abuse for both groups limiting comparison. Oxycodone prescription after IPP has risks of persistent use and withholding Oxycodone does not appear to increase postoperative healthcare utilization.

Erectile dysfunction and Peyronie's disease diagnosis rates after penile fracture-a retrospective claims database cohort analysis.

Our objective was to analyze the rates of erectile dysfunction and Peyronie's disease following a penile fracture using a large, multi-institutional claims database. Inclusion criteria included men ages 15 or older with a diagnosis of penile fracture and any office visit within 5 years of the penile fracture. Exclusion criteria included prior erectile dysfunction, prescription of erectile aids, or penile prosthesis placement. Our primary outcome was the diagnosis of erectile dysfunction or prescription of phosphodiesterase-5 inhibitors within 5 years. A secondary analysis assessed rates of Peyronie's disease following penile fracture. 1242 men were identified with penile fracture and subsequently matched to men without penile fracture, resulting in equal cohorts of 1227 men. Men with a history of penile fracture were more likely to receive a diagnosis of erectile dysfunction or require phosphodiesterase-5 inhibitors (RR 3.18, 95% CI: 2.30-4.40). Men who did not undergo immediate repair had higher rates of erectile dysfunction or treatment (RR: 1.84, 95% CI: 1.22-2.78). Men over the age of 45 years who had a penile fracture were more likely to develop erectile dysfunction or treatment compared to men under 45 years (RR: 1.65, 95% CI: 1.14-2.39). Rates of Peyronie's disease were higher in men with a history of penile fracture (5.8% vs 0%, p < 0.0001). Rates of Peyronie's disease were lower if immediate repair of the fracture was performed (RR: 0.20, 95% CI: 0.10-0.41). Men over the age of 45 years with penile fracture were more likely to develop Peyronie's Disease within 5 years compared to men under the age of 45 years penile fracture (RR: 3.72, 95% CI: 1.94-7.16). Penile fracture increases the risk of both erectile dysfunction and Peyronie's disease, especially those treated with conservative measures or over the age of 45 years compared to patients under 45 years with a penile fracture.

A pilot study of inflatable penile prosthesis placement in transgender neophallus using Tutoplast® pericardium graft sock technique.

Placement of an inflatable penile prosthesis (IPP) in a transgender patient's neophallus carries unique considerations versus cis-gender IPP placement in mitigating infection, erosion, and overall complication rates. An example of this includes the lack of an anatomical corpus cavernosum and crura for cylinder placement and anchoring. Multiple grafting approaches and materials have been utilized to mitigate possible cylinder instability and improve anchoring. Here we describe our experience and surgical technique in IPP neophallus placement utilizing a single cylinder with distal and proximal cylinder human cadaver pericardium (Tutoplast®, IOP Ophthalmics, Costa Mesa, CA, USA) grafts. Our goals were to determine postoperative satisfaction and device functionality in patients undergoing transgender neophallus IPP placement using our technique. Both patients report satisfaction and no complications at last follow-up (currently up to 14 and 23 months post-operatively, respectively) with satisfactory erectile function and ability to perform penetrative intercourse. In neophallus IPP placement, the anatomical differences compared to cis-gender IPP operations require unique considerations such as cylinder grafting material selection for proximal cylinder fixation and mitigation of device erosion rates. Optimization of grafting material in neophallus IPP placement in an effort to reduce erosion rates has become increasingly important as frequency of this operation increases. Utilizing human cadaver pericardium graft in distal and proximal cylinder coverage shows beneficial preliminary outcomes in our patients.

Molecular mechanisms of penile traction for penile rehabilitation in a bilateral cavernous nerve crush injury rat model.

Prostate cancer is the most common solid-organ malignancy in adult men. Early detection and treatment of prostate cancer with radical prostatectomy (RP) has improved cancer-specific survival but is associated with penile shortening and erectile dysfunction. Penile traction therapy (PTT) has been demonstrated to increase stretched penile length (SPL) prior to penile prosthesis placement and may improve erectile function (EF) in patients with Peyronie's disease. We aimed to evaluate the efficacy of PTT in preserving penile length and EF after bilateral cavernous nerve crush injury (BCNI) in a rat model. Twenty-four male Sprague-Dawley rats aged 11-13 weeks were randomly assigned to three groups (n=8, each): sham operation with no PTT (Sham), BCNI without PTT (Crush), and BCNI with PTT (Traction). PTT was started on postoperative day 3. A traction force of 1 Newton was applied to the penis for 30 minutes each day for 28 days. After 28 days of traction, the cavernous nerve was stimulated while recording the intracavernosal pressure (ICP) and the mean arterial pressure (MAP) simultaneously. Cavernosal tissue was excised, and western blot analysis for endothelial nitric oxide synthase (eNOS) was performed. Significance was determined by using ANOVA with Tukey-Kruger post-hoc testing. At 4 weeks after nerve injury, the Traction group had significantly greater SPL compared to the Sham and Crush groups (30 vs. 28 and 27 mm, respectively). The Sham group had significantly greater EF (ΔICP/MAP) compared to the Crush group at 2.5, 5, and 7.5 V. The EF of the Traction group was between that of the Sham and Crush groups and was not significantly different from the Sham group at any voltages. Further downstream analysis revealed that the Traction group had significantly greater eNOS expression in cavernosal tissue compared to the Crush group, which was confirmed on western blot analysis and immunohistochemistry (IHC) staining. Findings from this animal study suggest that PTT has the potential to mitigate penile retraction after RP. While more studies are needed to determine the effect of PTT on preservation of EF, the increased eNOS expression observed in the Traction group offers a potential protective mechanism of action.

Partner Involvement Reduces Postoperative Care Burden Following Penile Prosthesis Placement

To determine whether preoperative partner involvement at clinic appointments is associated with deviation from a standardized postoperative care pathway for patients undergoing an inflatable penile prosthesis placement. This is a retrospective study of 170 patients undergoing primary inflatable penile prosthesis placement performed by a single surgeon between 2017 and 2020. A standardized postoperative clinical pathway was used, including planned follow-up visits at 2 weeks (for wound check and device deflation) and 6 weeks (for device teaching). Patient characteristics, including demographics, partner involvement, and the number of follow-up visits were obtained from the medical record. Logistic regression modeling was performed to determine whether partner involvement was associated with unanticipated follow-up visits. Partners were involved in preoperative visits for 92 patients (54%). Additional unplanned follow-up visits were observed for 58 patients (34%) between 0 and 6 weeks and for 28 patients (16%) after 6 weeks from surgery. Partner involvement was associated with reduced odds of unanticipated follow-up visits, both between 0 and 6 weeks (odds ratios 0.37, 95% CI 0.18-0.75) and after 6 weeks (odds ratios 0.33, 95% CI 0.13-0.81) in adjusted models. Having a patient's partner involved during the preoperative period is associated with a significant reduction in unanticipated follow-up. We would recommend that urologists routinely encourage patients considering the insertion of a penile prosthesis to involve their partners in perioperative visits. Further research needed is needed to determine how to best support patients during surgical decision-making and through the postoperative period.

(474) Trends and Costs of Ambulatory vs Inpatient Penile Prosthesis Placement

Abstract Introduction Current literature is limited in assessing nationwide trends of penile prosthesis (PP) placement in the United States largely due to a lack of data on outpatient PP placement. Particularly no nationwide comparison of ambulatory surgery center (ASC) versus inpatient hospital (IH) PP placement has been published. Objective Our objective is to determine the trends of PP placement in ASCs vs IHs utilizing representative nationwide data. Additionally, we examined patient demographics that are associated with the setting for PP placement. Methods Inpatient and outpatient encounters for PP placement between 2016 and 2019 were analyzed using data from the Nationwide Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) from the Healthcare Cost and Utilization Project (HCUP). These are the largest publicly available inpatient and ambulatory surgery databases available in the United States. PP operations were identified by CPT and ICD-10-PCS codes. Subsequent analysis was performed using the established weighting provided by the HCUP, which utilizes stratified cluster sampling to create national estimates. Comparisons of demographics were performed using t-tests and chi-square tests with a p-value for significance &amp;lt;0.05. Results Over the study period, there were 67,722 PP placements in the United States. The percentage placed in ASCs was 93.1%. In 2016, 16,290 PP placements occurred, of which 92.3% were placed in ASCs. Comparatively in 2019, there was a 7.3% increase (17,473) in the number of PP placements, with 94.5% placed in ASCs (p&amp;lt;0.01). Over the study period, 33,008 PP placements were performed in the South (93.8% ASCs), 12,481 in the Midwest (94.6% ASCs), 12,192 in the Northeast (92.4% ASCs), and 10,040 in the West (90.1% ASCs, p&amp;lt;0.01). The average age of patients receiving a PP placement was 64.4 in ASCs compared with 62.5 in IHs (p&amp;lt;0.01). The average cost associated with PP placement in ASCs was $25,935, about half the cost of inpatient settings, which averaged $51,594 (p&amp;lt;0.01). Of all PP implants, the primary payer was medicare for 57.1% (38,660; 93.1% ASCs), medicaid for 4.4% (2980; 86.6% ASCs), private for 33.6% (22,778; 94.3% ASCs), and self-pay for 1.1% (768; 90.9% ASCs, p &amp;lt;0.01). Conclusions Our results suggest that the number of PP placements is consistently rising each year, with an increasing majority of PP placements performed in ASCs. The procedure costs roughly half on average when performed in ASCs compared to IHs. Further investigation is needed to compare complication rates and outcomes of PP placements in ASC versus IH. Disclosure No

(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&amp;lt;0.0001) and more often white (23% vs 16%, p=0.03), with higher rates of erectile dysfunction (56% vs 9%, p&amp;lt;0.0001), type 2 diabetes (32% vs 13%, p&amp;lt;0.0001), and hyperlipidemia (47% vs 20%, p&amp;lt;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&amp;lt;0.0001) and initial prosthesis (3.1% vs 2.1%, p&amp;lt;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

(415) Comparison of Satisfaction With Penile Prosthesis Implantation in Patients With Prostate Cancer Radiation Therapy versus Radical Prostatectomy or Radical Cystoprostatectomy

Abstract Introduction Penile Prosthesis Surgery (PPS) is a commonly used treatment for Erectile Dysfunction (ED), either as first-line therapy or in cases refractory to other treatment options. In patients with urologic malignancies, such as prostate or bladder cancer, surgical interventions like radical prostatectomy (RP) and radical cystoprostatectomy (RCP) as well as alternative treatments such as radiation therapy can all induce ED. PPS as a treatment for ED has high satisfaction rates in the general population. There is limited data available on sexual satisfaction in patients with prosthesis implantation for ED following RP/RCP versus ED following radiation therapy for prostate cancer. Objective The primary objective for our study was to determine if there is a significant difference in device and sexual satisfaction rates between patients receiving PPS for ED post-RP/RCP versus post-prostate cancer radiation therapy quantified via a validated questionnaire. Methods A retrospective chart review from our institutional database was conducted to identify 970 patients who underwent PPS at our institution from 2011 to 2021. Only patients that had Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire data at least 6 months from implant operative date available were included. Eligible patients were screened and placed in one of two groups depending on etiology of ED- following RP/RCP or following prostate cancer radiation therapy. To prevent crossover confounding; patients with history of pelvic radiation were excluded from the RP/RCP group and patients with history of RP/RCP were excluded from the radiation group. Data was obtained from 73 patients in the RP/RCP group (RP=66, RCP=7) and 32 patients in the radiation therapy group (Extended Beam Radiation Therapy (EBRT) = 26, Brachytherapy=6). Demographics, surgical information, etiology of ED, and penile doppler results were recorded for both groups. EDITS questionnaire responses were compared between the two groups as a measurement of device and sexual satisfaction. Additional subgroup analysis was conducted between RP and RCP patients. P&amp;lt;0.05 was statistically significant. Results There was a significant difference in mean survey responses for all 11 questions in the EDITS questionnaire between the RP/RCP group and the radiation group. Specifically, the RP/RCP group had a significantly higher mean score in questions surveying overall satisfaction (p=0.01), level to which device has met their expectations (p=0.03), as well as confidence in engaging in sexual activity with their partner (p&amp;lt;0.001). Additional survey questions administered also found RP/RCP patients reported significantly higher rate of satisfaction with size of penis post-operatively versus the radiation group (p=0.01). Subgroup analysis found no difference in satisfaction (p=0.16), device expectations (p=0.37), or confidence in engaging in sexual activity (p=0.82) between the RP and RCP groups. Conclusions These preliminary findings, while requiring large-scale follow up, suggest that there is greater sexual satisfaction and penile prosthesis device satisfaction in patients undergoing IPP placement following RP/RCP versus radiation therapy for prostate cancer. Use of validated questionnaires should continue to be utilized in quantifying device and sexual satisfaction following penile prosthesis placement. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Run Wang, MD, FACS is a consultant for Boston Scientific, Coloplast, and Teleflex.

(244) Penoscrotal Decompression: A New Paradigm for Managing Prolonged Ischemic Priapism

Abstract Introduction Outcomes of men with delayed presentation of ischemic priapism (&amp;gt;24 hours) are poor. Management options include forming a proximal corporal shunt (poor evidence of efficacy) or immediate penile prosthesis placement with the associated increased risk of erosion and infection. Penoscrotal decompression (PSD) is thought to relieve the acute compartment syndrome of prolonged ischemic priapism (PIP) and restores perfusion. Experience is currently limited to 31 reported cases from several centers in North America. Objective To further assess the role and efficacy of PSD for PIP. Methods Retrospective review of men presenting with ischemic priapism. Only men following PSD were included. Ischemic priapism was confirmed by cavernosal blood gas and biopsy at time of decompression. Duration of ischemia, prior management and clinical outcomes were analyzed. Change in International Index of Erectile Function (IIEF) score was compared. Results Thirteen patients with a median age of 45 years (IQR 37-43) presented between July 2019 and June 2022. Median duration of PIP was 48 hours (IQR 38-56). Etiology of PIP was idiopathic in 5, iatrogenic or recreational drug-related in 6 and sickle-cell disease (SCD) in 2 men. All patients failed corporal aspiration, irrigation and intracavernosal phenylephrine and 2 failed distal corporo-glanular shunting (T-shunt and Winter shunt). All men had successful detumescence with 9 (69%) requiring bilateral PSD. Immediate pain relief was achieved in all but one man who had a very prolonged priapism (120 hours) where no fresh corporal bleeding was found despite bilateral PSD. He had chronic pain from SCD and was lost to follow-up following discharge. Another patient with SCD recurred within 24 hours following unilateral PSD and was successfully managed with intracavernosal phenylephrine. Only one man without SCD developed a recurrence of priapism the next day and he proceeded to insertion of a malleable penile prosthesis on day 2. There was no association between unilateral or bilateral PSD and recurrence of priapism. IIEF scores fell by a median of 12 (IQR 2.25-15.5) and 6 men developed severe erectile dysfunction. Four men have had a penile prosthesis inserted without complication (2x inflatable, 2x malleable) but 2 are awaiting surgery (one was cancelled due to anesthetic concerns). Follow-up was a median of 17.6 months (IQR 1.3 – 19.7) but 4 men were lost to follow-up. One man was unhappy with penile length following penile prosthesis. Conclusions In the first study outside of North America, PSD successfully relieved PIP in all patients with good pain relief for most (n=12, 92%). Six men developed severe refractory erectile dysfunction while 3 had recurrent priapism due to SCD (n=2) and cocaine abuse (n=1). This suggests that the lack of fresh corporal bleeding following PSD is a risk factor for failure and an immediate penile prosthesis should be considered. PSD averted the need for penile prosthesis insertion in 54% of men. PSD should be considered as a viable option for PIP. Disclosure No

(335) Unconsummated Marriage: Findings and Outcomes of Ccouples Visiting an Andrology Clinic

Abstract Introduction Failure to have a penetrative peno-vaginal intercourse among the heterosexual married couples is termed as unconsummated marriage (UCM). Unheard in most western countries, UM is often seen in culturally conservative countries like India where majority still don't have sexual encounters prior to marriage. Nonconsummation is most commonly due to erectile dysfunction (ED, vaginismus or forced marriage. The management requires an aggressive early treatment otherwise some even end up in divorce. Objective To report the clinical characteristics and outcomes of males visiting Andrology clinic seeking treatment for UCM Methods This is a retrospective study of 62 male patients seeking treatment for UCM who presented to the andrology clinic from Jan 2018 to May 2022. All were subjected through detailed clinical history including patient demographics, physical examination and necessary investigations. Wherever possible, the female partner was also involved for discussion and if found abnormal during clinical history was referred to the female reproductive medicine specialists. Results Of the 62 male patients, majority (56, 90%) complained erectile dysfunction as the cause for UCM. Other causes being lack of anatomical knowledge of intercourse (2/62), vaginal pain while attempting penetration (4/62), performance anxiety (5/62) and forced marriage (4/62). There was overlap of more than 1 cause in few patients. The mean duration of UCM was 12.6 months (range 2-128 months). Of the 62 patients, 13 had master’s degree and 42 had bachelor’s degree. Among the 56 patients with ED, 22/56 had already received sildenafil or/and tadalafil from primary care physician with no success. Dual therapy (simultaneous on-demand sildenafil and daily tadalafil) helped 23/56 males to consummate their marriage. Six males didn’t come for follow-up after 2 visits and even refused to answer our questions on phone. Two males did not seek any further treatment for ED after oral medications failed and proceeded with assisted reproductive techniques to conceive for social reasons. Of the four females with vaginismus, 3 successfully consummated following vaginal dilator therapy and psychosexual counselling, but the remaining 1 proceeded with intrauterine insemination to conceive. Consummation was achieved in 6 men who received intra-cavernosal injection of reconstituted 20mcg alprostadil. Three men consummated following penile prosthesis placement (2 semirigid and 1 inflatable). Two couples divorced as the wives wanted “natural” erections from their husbands and not “medicated” erections. Three couples were in the process of divorce. Twelve of the 62 men were accompanied by their parents or in-laws in their first or second clinical visit. Conclusions As against the usual assumption, UCM is commonly seen even among the well-educated class. UCM should be considered as an andrological emergency and timely intervention is required to prevent termination of marriage. When oral medications and counselling doesn’t work, do not hesitate to start on intra-cavernosal injections and occasionally may be a penile implant surgery. Due to social and familial concerns, few may decide to seek assisted reproductive techniques to conceive without sexual intercourse and the same may be considered. Disclosure No

(489) Comparison of Penile Prostheses Outcomes in Veterans with Peyronie’s Disease: A Single-Center Analysis

Abstract Introduction Peyronie’s disease (PD) causes erectile dysfunction (ED) in at least 40% of cases. ED refractory to medical and injection therapy can be treated with implantable penile prosthesis, which may also address the penile deformities. However, prosthesis surgery has significant associated morbidity-including erosive disease and infection-and frequently requires explant or revision. Data for Veterans Affairs (VA) patients with PD is limited, especially with respect to penile prosthesis placement. More information is needed for proper counseling and perioperative planning in this high-risk population. Objective The aim of this study is to compare outcomes and revision rates in Veteran patients with and without PD after primary penile prosthesis implantation. Methods A retrospective cohort study of the xxx VA Medical Center Informatics and Computing Infrastructure database was performed. Veterans who underwent penile prosthesis surgery between January 2013 and February 2022 were identified and included in the study. Patient factors including age, race, procedure type, and relevant comorbidities were collected. Patients with and without history of PD were identified and separated into two cohorts and patient factors of these two groups were compared using chi-square and Fisher’s exact tests. Freedom from revision was analyzed using Cox regression and hazard ratios. Results A total of 229 patients underwent penile prosthesis placement with at least 4 months follow-up. 24 patients (10.48%) with history of PD were identified. The mean age at prosthesis placement of PD patients was younger than that of non-PD patients (61.3 vs 65.0 respectively, p=0.0358). Rear tip extender length was longer in the PD cohort than the non-PD cohort (3.02 cm vs 2.32 cm respectively, p=0.0313). Operative time was shorter in patients with PD than in patients without PD (91 minutes vs 111 minutes respectively, p=0.0409). Prosthesis type, hospital stay, and post-operative complication rates were not significantly different between groups. PD was not associated with significantly increased risk of prosthesis revision or removal (p&amp;gt;0.05). No patients in the PD cohort experienced infection or erosion; two explants were performed for component migration and supersonic transporter deformity respectively. Conclusions Veterans with PD undergoing prosthesis placement have similar revision rates and explant rates as compared to veterans without PD. Additionally, penile prosthesis implantation for men with PD is associated with low morbidity and similar complication rates compared to men without PD undergoing prosthesis placement for erectile dysfunction. Disclosure No

(137) Surgical Outcomes at a Single Institution of Infrapubic insertion of Malleable Penile Prosthesis in Transmen after Phalloplasty

Abstract Introduction Penile reconstruction has allowed transmasculine individuals to attain the aesthetic appearance of male genitalia, however a penile prosthesis is needed to achieve the ridigity and bulk for penetration. High complication rates have been reported with penile prosthesis placement after phalloplasty, with the rate of reoperation exceeding 40% following both inflatable penile prosthesis (IPP) and malleable penile prosthesis (MPP). We describe the experience of a single surgeon with the infrapubic approach for MPP placement after phalloplasty. Objective To review the surgical outcomes of the infrapubic approach to the insertion of the MPP after phalloplasty in transgender men. Methods The infrapubic prosthesis insertion after phalloplasty technique involves a horizontal incision anterior to the pubic symphysis, which allows dissection of the neophallus channel and the anchor site on the pubic symphysis. Surgical outcomes using the Spectra (Boston Scientific, Marlborough, MA) and Genesis (Coloplast, Minneapolis, MN) MPP were analyzed between October 2017 and May 2022. Complications were reviewed and categorized into erosions, infections, device malposition and malfunction, and less common events like necrosis. Results The infrapubic MPP technique was performed on 40 patients by a single surgeon; 35 patients had a prior radial forearm free flap (RFFF) phalloplasty, and 5 had a prior anterolateral thigh flap (ALT) phalloplasty. Of the 30 patients who have continued to follow-up, mean follow-up was 34.9 months. Complications were not mutually exclusive, with 7 implant detachments from the anchor site, 3 malpositions, 2 with pain/activity limitation, and 1 infection. Surgical revision was required in 12 patients (40.0%). There were no neophallus erosions, flap loss, seromas, nor urethral injuries. More complications occurred with the Spectra MPP (9/17 or 52.9%) compared to the Genesis MPP (3/13 or 23.1%). Conclusions Infrapubic MPP insertion in transmen after phalloplasty is associated with high prosthetic surgical revision rates. Fewer complications were identified in the Genesis cohort. Longer term studies with patient reported outcome measures are required for further evaluation. Disclosure No

(457) Comparing Longevity and Need for Revision Between 2- and 3-piece Inflatable Penile Prostheses

Abstract Introduction The management of pharmacotherapy-refractory erectile dysfunction includes placement of an inflatable penile prosthesis (IPP). Although invasive, placement of an IPP is considered a safe procedure with high patient satisfaction rates. Broadly, these devices have two different inflation mechanisms: a two-piece (2p) device consisting of a pump and inflation cylinders, and a three-piece (3p) device, which incorporates a low-pressure reservoir. The relative difference in concealability has long been considered a major factor in patient decision-making. However, the difference in durability and subsequent need for revision amongst the two types of devices have not yet been explored. Objective To investigate differences in longevity and need for revision in patients with 2p and 3p IPPs. Methods After receiving institutional review board approval, a retrospective chart review was performed on all patients that underwent IPP revision or exchange for mechanical failure from 2001 to 2021 at our institution. Only patients who underwent revision of the initial device placed were included in the analysis. Men with retired IPP models or who underwent salvage protocol for infected prosthetics were excluded. Baseline characteristics, including history of diabetes or cardiovascular disease, smoking history, prior radical prostatectomy and/or pelvic radiation, and prior incontinence surgery were recorded. Cox proportional hazard models adjusted for age were developed comparing time to revision between 2p and 3p devices. Baseline characteristics were compared with descriptive statistics. Statistical significance was defined as p &amp;lt; 0.05. Results A total of 64 men underwent IPP exchange or revision during the study period, including 38 and 26 men undergoing revision of 2p and 3p devices, respectively. Baseline characteristics are included in Table 1. The median number of days until first revision was 2,695 for 2p IPP compared to 2,101 for 3p IPP (p = 0.27). On unadjusted proportional hazard analysis, there was a significant longevity benefit for 2p IPP compared to all 3p devices [HR: 1.80 95% CI (1.09, 3.00), p = 0.02]. When controlled for patient age, 2p IPPs continued to have a significant longevity benefit compared to 3p devices [HR 1.87 95% CI (1.13, 3.09), p = 0.02]. Conclusions Amongst our institutional cohort, 2p IPPs have significantly longer durability compared to 3p devices. These findings may be used to counsel patients who are deciding between different devices for management of their erectile dysfunction. 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

(042) Inflatable Penile Prosthesis Placement In Transgender Neophallus Using Novel Human Cadaver Pericardium (Tutoplast®) Graft Sock Technique

Abstract Introduction Placement of an inflatable penile prosthesis (IPP) in a transgender patient’s neophallus carries unique considerations versus cis-gender IPP in mitigating infection, erosion, and overall complication rates. Traditionally, the IPP implants used in cis-males are also employed in transmasculine patients. However, there are unique challenges in the transmasculine population, with one of the most significant being the lack of anatomical corpus cavernosum and crura for cylinder placement and anchoring. To account for this, multiple grafting approaches and materials have been utilized in IPP neophallus placement with the goal of facilitating cylinder anchoring and stability. Here we detail our experiences using a novel grafting approach with Tutoplast® pericardium graft in a “sock” and “cap” technique in IPP placement in a transgender neophallus. Objective Our objective is to evaluate postoperative satisfaction and device functionality in patients undergoing transgender neophallic IPP placement using our technique. Methods We describe our experience and surgical technique in IPP neophallus placement utilizing a single cylinder with novel distal and proximal cylinder human cadaver pericardium (Tutoplast®) graft. Results We performed neophallus IPP placement with this novel grafting technique, with operative images and graft details shown below. Patients had no complaints post-operatively, with cylinder and pump found to be in good position at first post-operative visit 6 weeks following surgery. There was no difficulty with urinating through the neophallus. All patients report continued satisfaction with device as well as ability to perform penetrative intercourse with device activated. All patients reported satisfaction and no complications at last follow-up (range: 3.5 months to 13 months), with all patients possessing continued satisfactory erectile function. One patient noted occasional mild pain in neophallus that self-resolves and does not cause any concern. Conclusions In neophallus IPP placement, the anatomical differences compared to cis-gender IPP operations require unique considerations such as cylinder grafting material selection for proximal cylinder fixation and mitigation of device erosion rates. Utilizing human cadaver pericardium (Tutoplast®) graft in distal and proximal cylinder coverage shows positive preliminary outcomes in our patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Run Wang, MD, FACS is a consultant for Boston Scientific and Teleflex.

(487) Long-term Outcomes Following Partial Plaque Excision and Grafting (PEG) for Peyronie’s Disease and Subanalysis of Patients Who Undergo PEG Despite Pre-operative Counseling Against PEG

Abstract Introduction Peyronie’s Disease (PD) is a debilitating condition characterized by progressive scarring of the tunica albuginea. The resulting deformities are often emotionally devastating to patients, and include erectile dysfunction, painful erections, penile curvature, indentation, hourglass, and hinge deformities. According to previously published surgical algorithm for PD in 1997, partial plaque excision and grafting (PEG) is recommended for patients with &amp;gt;60 degree curvature +/− hinge and strong pre-operative erections while placement of an inflatable penile prosthesis (IPP) is recommended when rigidity is sub-optimal.* Nevertheless, many patients counseled to undergo an IPP refuse and insist on proceeding with PEG due to personal preference. We hypothesize that men counseled to undergo IPP but choose to undergo PEG will report lower satisfaction rates and reduced ability to engage in sexual intercourse post-operatively. Objective Our objective was to evaluate and compare long-term patient-reported outcomes in men who underwent PEG at a single institution between 2007 and 2021. Methods A retrospective chart review was conducted from 2007 to 2021 on PEG surgeries performed at a single, tertiary-care institution in patients ≥18 years old who had &amp;gt;3 months of follow up. Results 251 patients underwent PEG with a mean follow up was 35.5 months. 54 patients (22%) were initially advised to undergo IPP but elected for PEG. Of these 54 patients, 17 (32%) had pre-operative 9-10 subjective erectile rigidity, relative to 110 of 197 (56%) patients who were initially counseled to undergo PEG (p=0.002). On duplex penile ultrasound, patients counseled to undergo IPP had a mean objective erectile rigidity of 7.8, compared to a mean objective rigidity of 8.6 in patients initially counseled to undergo PEG (p 15 units for pre-operative duplex ultrasound evaluation were less likely to be able to engage in post-operative intercourse following PEG surgery (48.6%) relative to those who needed &amp;lt;15 units (71.1%) (p=0.02). Conclusions Patients who were initially counseled to undergo IPP due to sub-optimal erectile rigidity but elected for PEG procedure had worse post-operative ability to engage in penetrative intercourse. Significantly more of these patients also eventually underwent IPP. Pre-operative trimix dosing &amp;lt;15U is a predictor of post-operative erectile function as it may be reflective of better pre-operative erectile quality. Subjective and objective measures of erectile function appear to be critical predictors of post-operative erectile function in patients who had underwent PEG, confirming the previously published 1997 algorithm on the surgical management of PD.* *J Urol 1997; 158: 2149-52. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific (Consultant)

(368) Stuttering Priapism: A Rare Manifestation of Underlying Malignancy

Abstract Introduction First described by Peacock in 1938, malignant priapism (MP) is defined as persistent erection in the absence of sexual stimulation or other triggering factors. The proposed mechanism is due to neoplastic invasion of cavernous sinuses and venous system resulting in poor outflow and painful penile engorgement. Though rare, MP due to penile tumors has been described in cases of hematologic malignancies, primary penile neoplasms, local invasion from urologic primary tumors including prostate and bladder cancer, and penile metastasis from other primary sources. Objective Here we describe a case of metastatic epithelioid sarcoma that presented with recurrent priapism. Methods An otherwise healthy 43 year old male presented with two weeks of intermittent priapism. Initially thought to be traumatic in nature, the patient was managed conservatively with penile irrigation and phenylephrine. Though the patient achieved some improvement in his pain, full detumescence was never achieved. Approximately one month later the patient elected for placement of an inflatable penile prosthesis (IPP) due to persistent incomplete detumescence. At the time of surgery, extensive corporal induration was noted bilaterally. Upon entry into the corpora, copious purulent material was expressed from the tissues and the decision was made to abort the case. Prior to closure, several representative biopsies were collected. Results Blood gas performed at initial presentation was consistent with low flow priapism. Doppler studies showed intact arterial blood flow to the penis bilaterally and pelvic MRI was negative for penile injury though asymmetric enhancement of the corpora was noted incidentally. Surgical pathology revealed an unclassified malignancy and increased proliferation concerning for metastasis. A PET scan was performed which was consistent with widely metastatic disease with mets to the liver, lung, bone, muscles, adrenal glands, brain, and penis. Percutaneous biopsy of an abdominal mass confirmed the diagnosis of epithelioid sarcoma. Despite palliative chemotherapy and radiation the patient succumbed to his cancer just two months after diagnosis. Conclusions Epithelioid sarcoma is a rare soft tissue neoplasm primarily affecting young adult males and representing less than 1% of soft tissue sarcomas. Even rarer is the incidence of metastatic penile tumors, with fewer than 500 cases reported in the literature since 1850. A literature review by Lin YH et al based on reports from 2006 to 2011 suggested that the true incidence of penile metastasis may be higher given that 12% of penile metastasis may be asymptomatic and discovered only at autopsy. To our knowledge, this is the first case of widely metastatic epithelioid sarcoma presenting with priapism secondary to penile metastasis. Disclosure No

(403) Artificial Urinary Sphincter Implantation for Severe Post-Prostatectomy Incontinence in Setting of Salvage Radiotherapy and Prior Inflatable Penile Prosthesis

Abstract Introduction Artificial urinary sphincter (AUS) implantation is one of the most common treatment options for individuals with severe stress urinary incontinence (SUI), which is a common complication after radical prostatectomy (RP). The modern AUS consists of a urethral cuff, pump, and reservoir, which serves as a replacement for the native incompetent sphincter. There are various surgical approaches for AUS insertion, including transperineal, transscrotal, and abdominal approaches. Objective This video covers the surgical technique for the implantation of an AUS for management of SUI. Notably, this patient underwent RP followed by salvage radiotherapy (XRT) for biochemical recurrence of prostate cancer and had prior inflatable penile prosthesis (IPP) placement. Methods A standard step-by-step surgical technique for placement of an AUS through a perineal incision and additional counter incision to allow for high submuscular placement of the pressure-regulating balloon is demonstrated in this unique case of a patient with prior IPP placement and salvage XRT. Results We highlight a meticulous dissection around the urethra in a case that had a challenging urethral dissection secondary to prior radiotherapy and a prior IPP in the proximal corpora. The AUS pump was successfully placed in the subdartos pouch of the scrotum on the contralateral side to avoid the patient’s prior IPP pump. At the conclusion, a flexible cystourethroscopy showed adequate AUS cuff coaptation and cycling. Conclusions This video covers the step-by-step technique for insertion of an AUS with a transperineal approach in the unique context of a patient with prior IPP placement and XRT. Preoperative counseling, evaluation, and careful intraoperative dissection of key parts of the procedure are critical for successful placement of the AUS, especially in patients who are at high-risk for complications, such as in this case. Disclosure No