Penile Prosthesis Surgery Research Articles

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.

MRI of Penile Prostheses: The Challenge of Diagnosing Postsurgical Complications.

Penile implants are surgically inserted devices used for the treatment of erectile disfunction. Improvements in surgical techniques and in the manufacturing of these implants have reduced the risk of intra- and postoperative complications and increased the popularity and use of this therapeutic option. Routine imaging is not recommended before penile prosthesis surgery. Malleable penile prostheses use noninflatable shafts inserted into each corpus cavernosum, which appear hypointense on T1- and T2-weighted MR images. Inflatable penile prostheses (IPPs) may consist of two or three parts and are composed of two cylinders inserted into the corpora cavernosa that are filled with a saline solution to produce rigidity. These appear homogeneously T2 hyperintense and the silicone-based covering of the cylinders appears T2 hypointense, thereby clearly delineating the cylinders. In the case of three-piece IPPs, a reservoir containing the fluid may be placed in the pelvis. The most frequent complications are related to infection and mechanical failure, the latter being more common in IPPs because more components are involved. Less common complications include malpositioning. Detection and management of postoperative complications are challenging, and MRI plays a crucial role as it permits evaluation of the positioning and configuration of the prosthesis components, as well as assists in functional evaluation of IPPs when images are obtained of both the flaccid and inflated states. ©RSNA, 2021.

Midline submuscular penile prosthesis reservoir placement for patients with bilateral inaccessible inguinal rings: technique and outcomes.

One of the most challenging aspects of inflatable penile prosthesis (IPP) surgery is reservoir placement. The traditional space of Retzius (SOR) is not suitable for all patients. For example, radical cystectomy or prostatectomy may alter the anatomical SOR. Hence, traditional placement of the reservoir in this space increases the risk of bowel or vascular injury. Also, patients with bilateral inguinal hernias repaired with mesh, or those with previous reservoirs that have been retained, are not eligible for a Retzius reservoir. Our study reports on the use of midline sub-rectus muscle placement of a penile prosthesis reservoir in these patients as an alternative to high submuscular placement commonly used. A retrospective chart review of male patients who underwent IPP surgery between June 2017 and 2021 was conducted. Patients were divided into two groups based on the location of the reservoir: SOR versus Midline Submuscular Reservoir (MSMR). Complication rates were compared, including herniated reservoirs, infections, bowel injuries, and vascular injuries. Our cohort included 461 patients who underwent IPP surgery between June 2017 and 2021 in one tertiary center. SOR was used in 89% of patients and MSMR in 11% of patients (n = 413 and 48, respectively). Median follow-up for all patients was 28 months. The mean age was 67 ± 8 years. There was no statistically significant difference between the two groups regarding age or comorbidities (BMI, diabetes mellitus, hypertension, hyperlipidemia, and coronary artery disease). The complication rate was low in both the SOR and MSMR groups, with device malfunction being the most common (2% versus 4%, respectively; p = 0.32). The infection rate was 0.5% in the SOR group with no infections in the MSMR group (NS). There was only one case of herniation requiring surgical revision in the SOR group and no cases of bowel or vascular injury. Placement of a penile prosthesis reservoir within a midline rectus submuscular space is a safe and effective technique when the SOR is compromised by previous surgery or bilateral inguinal canals are not accessible.

Hypertension and low cholesterol as risk factors for infection after primary inflatable penile prosthesis surgery

Background: Inflatable penile prosthesis (IPP) is an effective surgical intervention in the treatment of erectile dysfunction. However, infection is a devastating complication of IPP placement. We sought to evaluate the association between medical comorbidities, medications, and serum metabolic lab values, and infection following primary IPP placement in our ethnically diverse population. Methods: A retrospective chart review was performed on all men who had primary IPP placement between 2017–2019 at our institution. Variables collected included patient demographics, medical history, medication usage, and pre- and postoperative lab values, within six months of surgery, including hemoglobin A1c, total cholesterol, and low density lipoprotein. Rates of postoperative infection through 60 days were noted. Patients were grouped either into the infected or non-infected cohort based on postoperative infection status. A Student’s unpaired t-test was used to compare numerical variables and a Pearson chi-square test or Fisher’s exact test was used to compare categorical variables between the cohorts. Results: A total of 293 men underwent primary IPP placement, of whom 14 (4.8%) were in the infected cohort and 279 (95.2%) in the non-infected cohort. The infected cohort was more likely to have a history of hypertension (92.9% vs 74.2%, p = 0.026) and statins medication usage (78.6% vs 52.0%, p = 0.039) when compared to the non-infected cohort, respectively. The infected cohort had a significantly lower postoperative cholesterol value (136.3 mg/dL vs 170.0 mg/dL, p = 0.024) and postoperative low density lipoprotein (LDL) value (65.2 mg/dL vs 92.1 mg/dL, p = 0.020) when compared to the non-infected cohort, respectively. Conclusions: Hypertension and usage of statin medications were more common in men who developed infection following IPP placement. As hypertension can disrupt microvasculature over time, it may contribute to poor healing post-IPP placement. Future research is warranted to determine statins’ anti-inflammatory effect on wound healing and ability to fight infection.

Re: The Rising Incidence of Penile Prosthesis Surgery as the First Line Surgical Treatment for Peyronie’s Disease

Re: The Rising Incidence of Penile Prosthesis Surgery as the First Line Surgical Treatment for Peyronie’s Disease

Stem cell therapy and diabetic erectile dysfunction: A critical review.

Erectile dysfunction (ED) has been identified as one of the most frequent chronic complications of diabetes mellitus (DM). The prevalence of ED is estimated to be about 67.4% in all DM cases worldwide. The pathophysiological process leading to ED involves endothelial, neurological, hormonal, and psychological factors. In DM, endothelial and neurological factors play a crucial role. Damages in the blood vessels and erectile tissue due to insulin resistance are the hallmark of ED in DM. The current treatments for ED include phosphodiesterase-5 inhibitors and penile prosthesis surgery. However, these treatments are limited in terms of just relieving the symptoms, but not resolving the cause of the problem. The use of stem cells for treating ED is currently being studied mostly in experimental animals. The stem cells used are derived from adipose tissue, bone, or human urine. Most of the studies observed an improvement in erectile quality in the experimental animals as well as an improvement in erectile tissue. However, research on stem cell therapy for ED in humans remains to be limited. Nevertheless, significant findings from studies using animal models indicate a potential use of stem cells in the treatment of ED.

Factors Impacting Postoperative Opioid Use Among Patients Undergoing Implantation of Inflatable Penile Prosthesis

BackgroundWhile there is an increasing burden of chronic postoperative opioid use and opioid abuse in the United States, opioid use following inflatable penile prosthesis (IPP) surgery has not been well described. AimDescribe postoperative opioid use following IPP surgery. MethodsSeventy-four consecutive patients undergoing IPP implantation by a single surgeon were enrolled. Self-reported diaries tracked the type and amount of medication taken for 2 weeks following IPP surgery. High opioid consumers were defined as those consuming more than the median amount (10 mg) of opioids during the first 2 weeks postoperatively. Multivariate analyses were performed using stepwise backward elimination. OutcomesQuantification of opioid use postoperatively and factors related to high opioid use. ResultsFifty-six patients were included after 7 were excluded for preoperative opioid use and 11 were excluded for inability to contact. Median age was 67.5. Devices used were Boston Scientific (41, 73%) and Coloplast (15, 27%). All patients received local anesthetic. Most surgeries (44, 79%) were performed as outpatient. Preoperative analgesia with acetaminophen, celecoxib, and pregabalin was administered in 44 (78%), 44 (78%), and 28 (50%) of cases respectively; 32 (57%) of patients received 2 medications, 21 (36%) received three medications. In hospital median morphine equivalents was 7.5 (interquartile range [IQR] 0–7.5). Oxycodone prescribed at discharge was 50 mg (29, 52%), 75 mg (4; 7%), and 100 mg (23; 41%). Median milligrams of oxycodone used was 10 mg (IQR 0–23.5) at 7 days and 10 (IQR 0–37.5) at 14 days postdischarge. On univariate analysis, factors associated with an increased likelihood of high opioid use were morphine equivalents utilized in hospital (odds ratio [OR] 1.13, P < .05) and milligrams oxycodone prescribed at discharge (OR 1.05, P < .001) while patient demographics, procedure characteristics, and analgesic types were not found to be predictive of high opioid use. On multivariate analysis, milligrams oxycodone prescribed at discharge (OR 1.04, P < .005) were associated with an increased likelihood of high opioid use after discharge. Clinical ImplicationsIncreased understanding of opioid use after IPP surgery may improve prescribing patterns after discharge. Strengths & LimitationsThis study quantified post discharge opioid use over the first 14 postoperative days. It is limited by single surgeon, small sample size, and retrospective design. ConclusionProvider opioid prescribing patterns were associated with high opioid consumption postoperatively and a substantial amount of opioids prescribed at discharge remain unused by patients, suggesting that we can reduce or replace the amount of opioids that are prescribed.Ehlers ME, Mohan CS, Akerman JP, et al. Factors Impacting Postoperative Opioid Use Among Patients Undergoing Implantation of Inflatable Penile Prosthesis. J Sex Med 2021;18:1915–1920.

The Dilemma of Penile Prosthesis Implantation in Sex Offenders

BackgroundPenile prosthesis surgeons face an ethical dilemma when confronted with a sex offender who seeks surgical management of erectile dysfunction. AimTo provide practice guidelines to screen and manage patients with a history of sexual violence prior to surgery. MethodsThree urologists with expertise in penile prosthesis surgery and 1 medical bioethicist were asked to contribute their opinions and provide recommendations to address this controversial topic. OutcomesExpert opinion supported by analysis of available literature and institutional experience. ResultsThe authors review current United States legislation, published literature on sex offender registration, and institutional data on the prevalence of sex offenders among men seeking penile prosthesis placement. Within a context established by medical bioethical principles, the authors propose a practice guideline for screening sex offenders prior to penile implantation surgery and referral for trained psychological evaluation prior to surgical management. Strengths & LimitationsStrengths: multidisciplinary approach in data acquisition including bioethical and legal review. Limitations: Lack of available evidence regarding recidivism risk in sex offenders who undergo penile prosthesis placement. ConclusionSex offenders exist among the population of patients seeking surgical placement of a penile prosthesis. A standardized practice guideline for management of this population should be employed with the intention to reduce future harm.Zhang JH, DeWitt-Foy M, Jankowski J, et al. The Dilemma of Penile Prosthesis Implantation in Sex Offenders. J Sex Med 2021;18:1826–1829.

Penile implant infection factors: a contemporary narrative review of literature.

ObjectiveWe aim to review and summarize published literature that features implanted penile devices and details infection of these devices as a complication. In particular, we will detail the factors that influence infection of penile implants.BackgroundTypes of penile prostheses (PP) include inflatable implants and semirigid implants; these are utilized for treatment of erectile dysfunction. Likely the most feared complication of penile implants is infection. There are a handful of factors that are implicated in device infection.MethodsSearches were performed using MEDLINE and PubMed databases using keywords and phrases ‘penile implant AND infection’; ‘penile prosthesis AND infection’; ‘penile implant infection’. We have presented results from our literature search. We divided these into ‘Surgical Elements’ and ‘Patient Selection and Factors.’ Each topic is discussed in its own section.ConclusionsStrides have been made since the initial penile prosthesis (IPP) surgeries to improve infection rates including diabetes control, antibiotic coating of devices, and antibiotic implementation. Going forward, more studies, especially randomized control trials, need to focus on defining levels of diabetic control (sugar control and A1C control), determining the role of metabolic syndrome in infection promotion and determining laboratory values which could be predictive of infection. We present a discussion of important factors to consider in the realm of PP infections. In addition, we include studies which discuss topics for future directions in decreasing the number of infections seen with PP.

Penile implant surgery-managing complications.

Penile prosthesis surgery represents the end-stage treatment for erectile dysfunction. It is conventionally used only in cases of erectile dysfunction refractory to pharmacological treatments or vacuum constriction devices. Contemporary literature suggests that penile prothesis surgery is associated with a high satisfaction rate and a low complication profile. However, it must be appreciated that the complications of surgery can have devastating consequences on a patient’s quality of life and satisfaction and include infection, prosthesis malfunction, penile corporal perforation and penile length loss. Several factors – such as appropriate patient selection, methodical preoperative assessment and patient optimization, specific intraoperative protocols and postoperative recommendations – can reduce the risk of surgical complications. This narrative review discusses the diagnosis and management of both intraoperative and postoperative complications of penile prosthesis surgery.

MP57-05 DOES ASYMMETRY EQUAL CURVATURE? THE CLINICAL SIGNIFICANCE OF ASYMMETRIC CORPORAL MEASUREMENTS AT TIME OF INFLATABLE PENILE PROSTHESIS SURGERY

You have accessJournal of UrologySexual Function/Dysfunction: Surgical Therapy (MP57)1 Sep 2021MP57-05 DOES ASYMMETRY EQUAL CURVATURE? THE CLINICAL SIGNIFICANCE OF ASYMMETRIC CORPORAL MEASUREMENTS AT TIME OF INFLATABLE PENILE PROSTHESIS SURGERY Raevti Bole, Mohamed Ahmed, Ajay Gopalakrishna, Matthew Ziegelmann, Tobias Kohler, and Sevann Helo Raevti BoleRaevti Bole More articles by this author , Mohamed AhmedMohamed Ahmed More articles by this author , Ajay GopalakrishnaAjay Gopalakrishna More articles by this author , Matthew ZiegelmannMatthew Ziegelmann More articles by this author , Tobias KohlerTobias Kohler More articles by this author , and Sevann HeloSevann Helo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002087.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patient satisfaction after inflatable penile prosthesis (IPP) placement has been linked to multiple factors including preexisting curvature. The clinical significance of asymmetric corporal measurements (ACM) unrelated to proximal perforation, crossover or urethral injury is unclear. We sought to assess the clinical significance of intraoperative ACM in patients undergoing IPP surgery. METHODS: A single institution retrospective review of patients undergoing primary IPP placement between 7/2019-9/2020 was performed. Baseline patient characteristics, intraoperative details, and postoperative course were recorded. Regression analysis was conducted to determine factors associated with ACM. RESULTS: A total of 130 patients underwent primary placement of penile prosthesis during this time. Median age was 67 years (IQR 13). Comorbidities included diabetes mellitus in 22.3%, CAD in 22.3%, history of prostatectomy or cystectomy in 33.8%, history of pelvic radiation in 7.7%, and Peyronie’s disease in 21.5%. The median corporal measurement was 21 (IQR 2) bilaterally and median cylinder size 20 cm (IQR 4) bilaterally with 1cm rear tip extenders. Of the 18.5% (24/130) of patients with ACM, asymmetry was as follows: 20.8% (5/24) had a less than 1 cm, 70.8% (17/24) had 1 cm but less than 2 cm, and 8.3% (2/24) had 2 cm or greater. Of these patients 87.5% (21/24) underwent placement of an asymmetric device, only 5% (1/21) of which had residual curvature less than 30 degrees. Despite ACMs, 12.5% (3/24) of patients had a symmetric device placed, one of which had residual curvature. Only 2 patients underwent additional straightening procedures including plication and incision/grafting. Univariate regression did not reveal an association between ACM and residual curvature, adjunctive measures for correction, or postoperative pain or device issues (p >0.05 for all). CONCLUSIONS: Almost 1 in 5 patients undergoing primary placement of penile prosthesis for ED had ACM. However this did not correspond to residual curvature following placement of prosthesis cylinders or requirement for adjunctive straightening techniques. These findings may provide intraoperative reassurance to urologists when noting asymmetric measurements during corporal dilation in penile prosthesis placement. Source of Funding: No © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e979-e980 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Raevti Bole More articles by this author Mohamed Ahmed More articles by this author Ajay Gopalakrishna More articles by this author Matthew Ziegelmann More articles by this author Tobias Kohler More articles by this author Sevann Helo More articles by this author Expand All Advertisement Loading ...

Incidence of Venous Thromboembolism and Safety of Perioperative Subcutaneous Heparin During Inflatable Penile Prosthesis Surgery

ObjectiveTo identify the incidence of venous thromboembolism (VTE) risk factors, postoperative VTE, and to assess the morbidity of perioperative pharmacologic VTE prophylaxis in men undergoing inflatable penile prosthesis (IPP) surgery. MethodsWe retrospectively reviewed 215 patients undergoing IPP surgery between July 2017 and June 2019. Univariate and multivariate statistical analyzes were performed to assess pre-operative Caprini risk score and compare post-operative day 0 scrotal drain output, scrotal hematoma formation, and VTE in men who received subcutaneous heparin (SqH) vs those who did not receive SqH. ResultsOf 215 IPP patients, 84% were classified as high or highest risk for VTE utilizing the Caprini risk score. A total of 119 (55%) received perioperative SqH with or without additional anti-thrombotics. Post-operative day 0 scrotal drain output was higher in those who received SqH compared to those who did not receive SqH, 99.9 mL vs 75.6 mL, respectively (P = .001). Minor scrotal hematomas occurred in similar rates in patients who received perioperative SqH vs those who did not, 3.8% vs 6.3%, respectively (P = .38). Similar results were found on subgroup analysis when eliminating patients who received SqH concurrently with other anti-thrombotics. The overall rate of postoperative VTE was 0.9%. No post-operative infections occurred. ConclusionPatients undergoing IPP surgery are at elevated risk for VTE. To our knowledge, this is the first study showing SqH use in the perioperative IPP surgery setting is safe when used in conjunction with a scrotal drain. Preoperative VTE risk stratification may be performed and can be used to guide clinical decision making regarding pharmacologic prophylaxis.

Correlation of fasting blood sugar at the time of penile prosthesis surgery with the level of glycated hemoglobin and the outcome of surgery

BackgroundThe role of glycemic control in predicting implant infection and other surgical complications is debatable. This study aimed to assess the potential correlation between fasting blood sugar (FBS) levels prior to penile prosthesis surgery (PPS) and the surgical outcomes.MethodsA retrospective study from data collected prospectively in 2015 in a single center. Patients who underwent penile implant procedures were included. Exclusion criteria were if surgery done by low-volume implanter, patients who required revision surgery or not diagnosed with diabetes mellitus. Management was standardized to all patients.ResultsAll complications whether minor or major were documented up to three years. One year after the surgery a Likert scale questionnaire was completed by the patients. In total, 218 patients completed the study at last follow-up. Complications rate was 6.25%. The rate of infection requiring explantation was 3.8%. 0.9% of patients had a superficial infection managed successfully with conservative management. 0.9% had erosion and 0.9% had mechanical failure. There was no statistically significant difference in FBS or glycated hemoglobin (HbA1c) levels in patients with postoperative complications compared to patients with satisfactory postoperative course. FBS level on the day of surgery was within 20 mg/dL (1.11 mmol/L) of the expected range based on HbA1c measurement in 62 patients (28.44%), while in 146 patients (66.98%) the FBS was not within 20 mg/dl (1.11 mmol/L) of the expected range based on preoperative HbA1c level.ConclusionFBS levels on the day of surgery are not correlated with HbA1c levels and PPS outcomes.

The Association Between Hemoglobin A1c Levels and Inflatable Penile Prosthesis Infection: Analysis of US Insurance Claims Data

BackgroundThe association between elevated hemoglobin A1c (HbA1c) levels and the risk of postoperative infection after penile prosthesis surgery remains controversial. AimTo examine the association between HbA1c levels and penile implant infections in men undergoing inflatable penile prosthesis (IPP) surgery for erectile dysfunction using a large insurance claims database. MethodsThis was a retrospective review using Optum's de-identified Clinformatics Data Mart Database. Male subjects 18 years and older with available laboratory data undergoing IPP insertion between 2003 and 2018 were included. Administrative diagnosis and procedural codes were used to assess subsequent penile implant revision surgery status for either infectious or noninfectious causes. Associated conditions were controlled for such as smoking status, hyperlipidemia, hypertension, obesity status, and Peyronie's disease. OutcomesThe main outcomes were risk of revision for infection and time to revision. ResultsA total of 2,363 individuals underwent initial IPP insertion and had available HbA1c data with a mean HbA1c of 6.9%. The overall IPP infection revision rate was 3.9% and the highest rate of 12.1% was seen in the highest HbA1c group (>10%). After adjusting for demographic and health factors, a higher HbA1c level was associated with a higher risk of revision for infection, with every 1 point increase in HbA1c conferring an increased risk of infection requiring revision by 29% (95% CI 17–42%). When infections did occur, they happened sooner in men with HbA1c > 10.0% with an average of 1.3 months vs 3.5 months in the HbA1c < 6.0% group. Clinical ImplicationsThese findings provide insight into the potential relationship between HbA1c levels and postoperative risk of infection after penile prosthesis surgery and may aid in clinical decision-making. Strengths and LimitationsStrengths include the large sample size, length of data coverage, and real-world analysis of surgeries done across the United States. Limitations include the reliance on insurance claims data, the retrospective study design, and lack of additional relevant clinical variables that may impact infection rates. ConclusionsWhile the overall risk of penile prosthesis infection remains modest, the current report notes an increased risk of infection for diabetic men with poor glycemic control.Chen T, Li S, Eisenberg ML. The Association Between Hemoglobin A1c Levels and Inflatable Penile Prosthesis Infection: Analysis of US Insurance Claims Data. J Sex Med 2021;18:1104–1109.

A narrative review of the management of benign prostatic hyperplasia in patients undergoing penile prosthesis surgery.

Penile prosthesis surgery is an effective and durable treatment modality for patients who have failed conservative management for erectile dysfunction (ED). Thorough patient counseling and appropriate preoperative workup lay the foundation for a successful outcome. While the risk of infection of penile prosthesis is rare, it is a dreaded complication with dire consequences. The goal of the prosthetic surgeon is to minimize the risk of preventable complications. Given the common prevalence of benign prostatic hyperplasia (BPH) in this patient population, it is essential that providers are familiar with the implications and nuances of managing both conditions in order to maximize the chances of a favorable result. Due to the relatively infrequent nature of complications associated with the management of BPH in the setting of a penile prosthesis, literature regarding this topic is scarce. In this narrative review we present our own case series illustrating some of the most common scenarios that a prosthetic surgeon may encounter. We have included our suggestions for management in these difficult situations based on our clinical experience. In the following review we have highlighted the importance of identifying and treating BPH in penile implant candidates to reduce postoperative morbidity and to offer critical insights into managing BPH-related complications this population.

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 Rising Incidence of Penile Prosthesis Surgery as the First Line Surgical Treatment for Peyronie's Disease.

Peyronie's disease is a potentially debilitating connective tissue disorder of the penis that at times requires surgical intervention. There is a dearth of multi-center or community-level data regarding management trends. The aim of this study was to perform the first population-based assessment of surgical practice patterns in the treatment of Peyronie's disease among New York State urologists. We used the New York Statewide Planning and Research Cooperative System (SPARCS) database to identify all patients who underwent surgical treatment for Peyronie's disease between 2003 and 2016. We used descriptive statistics and multinomial regression modeling to assess predictors of treatment choice. Among 1,733 patients who underwent surgical treatment for Peyronie's disease, 30% underwent insertion of a penile prosthesis alone and 40% underwent insertion of a penile prosthesis with concurrent auxiliary procedures. Penile prosthesis (alone or in combination) was the first line surgical treatment in 21% of patients without documented erectile dysfunction. Relative rates of performing tunical plication and penile grafting decreased over time (both p <0.05), while insertion of a penile prosthesis/insertion of penile prosthesis with concurrent auxiliary procedures rates correspondingly increased (p=0.012). Insertion of penile prosthesis is by far the most commonly performed primary procedure for Peyronie's disease in New York State, with 1 in 5 patients without erectile dysfunction receiving an implant. While this trend cannot be explained by an administrative data set alone, it does warrant further exploration, as the declining utilization of alternate surgical treatments could compromise surgeon comfort in performing penile grafting and/or tunical plication in the future and may exacerbate disparities in treatment over time.

Development and content validation of a competency-based assessment tool for penile prosthesis surgery.

The aim of this study was to identify potential hazards for the inflatable penile prosthesis (IPP) surgical procedure and from this develop and content validate an IPP intraoperative competency-based assessment tool. A multi-institutional longitudinal prospective observational study was conducted over a 6-month period. Healthcare Failure Mode and Effects Analysis (HFMEA) methodology was used to prospectively risk assess the IPP procedure using a collaborative multidisciplinary team (MDT) approach. International content validation of the developed tool was then undertaken via face-to-face meetings and WebEx seminars. A total of 22 h of observation led to the construction of a detailed process map consisting of 11 stages and 49 sub-stages. HFMEA identified 50 failure modes and 45 failure mode effects, nine failure modes were excluded after analysis leaving 41 key failure modes included in the checklist. The high-risk steps identified were related to corporal dilatation, incorrect sizing of the prosthesis cylinders and incorrect localisationof the superficial inguinal ring for blind reservoir placement. The final content validated IPP assessment tool (PPAT) consisted of 13 processes and 27 sub-processes. We concluded that HFMEA methodology successfully allowed for the identification of key steps within the IPP procedure from which the PPAT was developed. Formal international content validation confirmed that all key procedural steps were included in the PPAT and that completion of all steps would indicate trainee competency in the procedure. Further validation is required before the tool can be used to assess learning curves for the IPP procedure.

156 Does Knowing Pre-operative Penile Length Influence Patient Satisfaction Post Penile Prosthesis Surgery

Patients may undergo penile prosthesis surgery (PPS) as a treatment option for erectile dysfunction (ED). Those who undergo PPS commonly complain of penile shortening after implantation. Furthermore, previous research has shown a decrease in penile length following inflatable penile prosthesis surgery compared to intracavernosal injection at 12 months.

165 Pre-operative Imaging for Revision Penile Prosthesis Surgery: When Exam Alone is not Enough

Revision Implantable Penile Prosthesis (IPP) surgeries can be much more difficult than virgin IPP surgery. Preoperative imaging may be a useful tool for diagnosis and pre-surgical planning. Some patients, however, can be taken for revision surgery based on physical exam findings alone.