Penoscrotal Approach Research Articles

(270) LISWT Before Penile Prosthesis Implantation Might Facilitate Dilation of Fibrotic Corpora

Abstract Introduction Severe corporeal fibrosis presents significant challenges in penile implant insertion. LISWT studies in rats and humans have suggested its ability to rejuvenate cavernous bodies through various mechanisms and growth factors. Objective This prompted our evaluation of LISWT's effectiveness in facilitating prosthesis implantation in patients with penile fibrosis, which are typically considered difficult cases. Methods A 34-year-old male smoker with a history of sickle cell disease, bilateral hip replacements, and splenectomy due to sickle cell crisis sought penile prosthesis implantation. He presented with severe erectile dysfunction and corporeal fibrosis following two ischemic priapism episodes caused by sickle cell disease, which were treated with distal shunts 4 and 1 years prior, respectively (Fig. 1). After obtaining consent, the patient underwent four cycles of LISWT, spaced one month apart. Each cycle consisted of four weekly sessions using the PiezoWave2 device from Richard WOLF with settings of 0.16mj/mm2 energy flux density, 6Hz frequency, and 10mm wave focus penetration depth. In each session, the patient received a total of 6000 shocks, distributed between the perineum, dorsum penis, and the lateral aspect of the penis. Results A month post-LISWT, the patient's Erection Hardness Score (EHS) improved from 0 to 1 following an intracavernous injection of 20 mcg of alprostadil (Fig. 2). Subsequently, he underwent a malleable penile implant procedure through the penoscrotal approach. Cavernosal dilation was successful up to 10mm using a Hegar dilator, with bilateral corporal measurements of 8cm proximally and 9cm distally. A Tactra malleable penile prosthesis (9.5mm girth and 17cm length) from Boston Scientific was implanted without complications (Fig. 3.A.B) Conclusions In cases of severe corporeal fibrosis, pre-treatment with LISWT may aid in the dilation of the corpora during penile prosthesis implantation, potentially reducing complications. Randomized studies are warranted to validate this indication Disclosure No.

Primary implantation of an artificial urinary sphincter using the perineal and penoscrotal approaches: Functional results and assessment of reoperative procedures

IntroductionArtificial urinary sphincter (AUS) is the standard treatment for severe stress urinary incontinence in men. While the perineal access is considered the gold standard, some authors have proposed penoscrotal AUS in order to facilitate the procedure. The main objective of our study was to evaluate the duration of survival without revision surgery (SSRC) according to the surgical approach for primary implantation. Material and methodsData from 1179 patients implanted in France between 1991 and 2020 with an AMS 800 AUS were retrospectively analyzed. A total of 762 men were implanted perineally (VP) and 417 penoscrotally (VPS). ResultsMedian follow-up was 20 vs. 25months respectively. The groups were equivalent overall, apart from the use of anticoagulants (11% VP vs. 6.3% VPS P=0.014). In our population, 54% patients were considered as “dry” in the case of VPS vs. 42% for VP. There was no significant difference in terms of survival time without reoperation, revision, replacement or explantation. In univariate and multivariate analysis, age over 70years was predictive of more reinterventions, whereas the use of a 4.5cm cuff was protective, with hazard ratios of 1.42 (P=0.001) and 0.78 (P=0.04), respectively. ConclusionThe penoscrotal approach does not appear to be associated with more complications, has good functional results and no significant difference in reoperation-free survival. A prospective multicenter non-inferiority study could be of interest to confirm our findings. Level of evidence4.

(047) Practice Patterns for Inflatable Penile Prosthesis Revisions Within a Large Fully Integrated Healthcare System

Abstract Introduction Revision Inflatable Penile Prosthesis (IPP) surgery is considered to be more surgically complex than virgin IPP implantation. Not all implanters perform revision surgery. Moreover, there is a paucity of data on the practice patterns of implanters regarding revision surgery. We aimed to evaluate the practice patterns of revision vs virgin inflatable penile prosthesis implantation within a large fully integrated healthcare system. Objective We aimed to evaluate the practice patterns of revision vs virgin inflatable penile prosthesis implantation within a large fully integrated healthcare system. Methods After Institutional Review Board approval, we reviewed the Kaiser Permanente Southern California (KPSC) database for all IPPs implanted within a 10 year period (2009-2019) at 15 medical centers. Patients undergoing virgin and revision penile prosthetic surgery were identified using CPT codes. Preoperative patient characteristics, intra-operative and postoperative outcomes were obtained via retrospective chart review. Univariate and multi-variate logistic regressions were performed. Results Between 2009 and 2019, 1,093 IPP surgeries were performed at KPSC, 115 of which were revision cases (10.5%). A total of 66 surgeons performed at least 1 IPP surgery (median=5 IPPs/surgeon, Range 1-160). Yet, revision IPPs were performed by only 32 surgeons, of which 4 surgeons were responsible for 61 of the revisions (p<0.05). When compared to virgin cases, revision cases had a longer median operative time (121 mins vs 96 mins, p <0.001), were more likely to be a penoscrotal approach (OR 3.17, p<0.05), have an ectopic reservoir placement (63.5% vs 35.7%, p<0.001), and significantly less likely to have a concurrent procedure done (OR 0.21, p<0.05) all based on multivariable logistic regression analysis. Nevertheless, device infection rates were not significantly different (revision 2.6% vs virgin 4.5%, p=0.43). There was no difference in intra-operative complications between revision and virgin cases (2.6% vs 1.4%, P=0.5). Median follow up was 4.1 years. Conclusions To our knowledge, this is one the largest series of revision IPPs done at multiple centers among more than 30 surgeons with long term follow up. Our data suggests that most IPP revisions are done by a select few implanters. Despite longer operative times, device infection rates were less than virgin cases, though not statistically significant. Within our large fully integrated healthcare system, in the hands of high-volume revision implanters, device infection and intraoperative complications rates remain quite low. These findings could help implanters counsel future patients regarding revision IPP surgery. Disclosure No.

Penoscrotal approach for inflatable penile prosthesis implant: why it should be preferred.

Inflatable penile prosthesis are the definitive treatment for erectile dysfunction. The two most used surgical approaches to position the implants are the penoscrotal and the infrapubic. Current trends showed that the penoscrotal approach is extensively preferred however, there is not conclusive evidence demonstrating the superiority of one technique over the other. The aim of this review is to summarize the scientific evidence available and to underline strengths and weaknesses of the two techniques. We conducted a comprehensive search of MEDLINE, Cochrane Library, and National Center for Biotechnology Information PubMed to identify relevant published articles. The included studies had to explicitly examine the use of three-piece inflatable penile prosthesis with a focus on the surgical access method and complications. Twenty-six articles were included in the review: seven narrative reviews, five retrospective observational studies, five prospective observational studies, and nine mixed methodology studies. The most frequent approach was the penoscrotal, which was also found more comfortable (RG1) by the operators in one study. The infrapubic approach lasts less and one study demonstrated higher satisfaction by the patients. There is no evidence of significant differences in complications among the penoscrotal and infrapubic approaches. While the infrapubic approach is faster and patients were more satisfied, the penoscrotal approach is the most used by far. This is likely related to the more straightforward procedure through this access and the excellent surgical field exposure. For these reasons, it is also preferred in the most complex cases.

(507) Predictors of Postoperative IPP Length: A Multicenter, Multinational Analysis

Abstract Introduction Inflatable penile prosthesis (IPP) placement is associated with high postoperative patient satisfaction. Patients often express concerns about postoperative penile length. There is scant evidence in the literature of clinical and surgical factors that predict IPP length. Objective To evaluate predictors of cylinder length for men undergoing primary IPP placement in a large multicenter cohort. Methods Patients undergoing primary IPP placement for treatment of erectile dysfunction at 16 high-volume implant centers were included. All patients had preoperative demographics, surgical characteristics, and device length retrospectively collected at their respective institutions and combined for analysis. Descriptive statistics were reported for the full group. Univariate analysis was utilized to isolate variables significantly associated with device length and all variables reaching p<0.1 were included in linear regression modeling. Results 3,953 men underwent primary IPP placement. The mean age was 61.8±10.4 years and BMI was 29.8±4.2 kg/m2. The mean total device length was 20.6±2.1cm. 1291 (32.7%) had diabetes mellitus, 641 (16.2%) were smokers, 705 (17.8%) had a prior radical prostatectomy, 195 (4.9%) had prior radiation, 549 (13.9%) had Peyronie’s disease, and 884 (22.4%) had a history of intracavernosal injections. In univariate analysis, BMI (B=0.05, 95%CI 0.04 to 0.07, p<0.001), a history of Peyronie’s disease (20.4 vs 20.6cm, p=0.02), and use of intracavernosal injection (20.7 v 20.9cm, p=0.02) were predictors of shorter total device length. Use of rear tip extenders (20.7 v 20.0cm, p<0.001), penoscrotal approach (21.0 v 20.3, p<0.001), and single corporal dilation (20.8 v 20.4cm, p<0.001) were associated with longer length. In multivariable analysis, a history of Peyronie’s disease (B=-0.29, 95%CI -0.47 to -0.11, p=0.002) and greater BMI (B=0.05, 95%CI 0.03 to 0.07, p<0.001) were predictors of shorter total device length. Independent predictors of longer device length were penoscrotal approach (B=-0.85, 95%CI -1.03 to -0.65, p<0.001), rear tip extender use (B=1.00, 95%CI 0.84 to 1.17, p<0.001), and single corporal dilation (B=-0.5, 95%CI -0.67 to -0.34, p<0.001). Conclusions In this series, Peyronie’s disease and greater BMI are independent predictors of shorter IPP device length, while use of rear tip extenders, single corporal dilation, and penoscrotal approach are independent predictors of longer device length. These results are important in counseling patients regarding expectations of postoperative length. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Intuitive Surgical, Fidelis, Urofill, Boston Scientific, Endo Pharma, Coloplast, Cynosure, Antares Pharma, Clarus Pharmaceuticals, Acerus Pharma

(530) Blood Thinners: Does it Need to be Held for IPP Surgery?

Abstract Introduction Penile prosthesis placement in men on active anti-coagulation (AC) is controversial. The bleeding risk of continued blood thinners must be weighed against the increased thrombotic risk for patients when stopping them. Previously utilized techniques to decrease complication rates from AC include the use of a malleable implant only, leaving the IPP partially inflated for hemostasis, and placement of a drain. Objective We sought to assess outcomes of penile implant placement in men on clopidogrel, warfarin, apixaban, enoxaparin, and rivaroxaban in a multi-institutional study. Methods Data from 3 high volume implant centers were retrospectively obtained. Demographic characteristics, comorbidities, case information including secondary procedures, placement of drain, drain output, and complications were recorded. Data on patients with aspirin any dose alone were not included as all 3 centers do not routinely discontinue ASA at time of penile implant. One center never placed drains and used a penoscrotal approach, one center left a drain at least one day and removed when output was < 50 ml/8 hours and used a penoscrotal approach, and the last center placed a drain for 3 days and utilized an infra-pubic approach. Results 202 patients were continued on AC throughout surgery. 112 patients were on clopidogrel, 35 warfarin, 38 apixaban, 1 enoxaparin, 15 rivaroxaban, and 1 on combination therapy with clopidogrel and enoxaparin. AC requirement included peripheral vascular disease (55%), CHF (11%), cardiac stents (11.6%), DVT/PE/history of thrombosis (7%), atrial fibrillation (11%), cardiac valves (2.2%), stroke (1.3%), and preventive (0.9%). Nine patients on AC (3.98%) experienced complications including 4 significant events (1.9%): 1 major retropubic bleed requiring transfusion, 3 IPP infections and 5 minor events: 3 minor hematomas, 1 minor wound dehiscence and 1 CT negative stroke event. Drain outputs for the 3 day center averaged 113 ml, 81 ml and 30 ml of output per day respectively with a total average output average of 223 ml and experienced no hematomas nor infections. Drain output for the center with removal when < 50 ml/8 hours averaged 121 ml with the majority or patients having the drain for only one day. Drain output was significantly higher than historical non AC controls (121 vs. 72 ml p=.001) but there was no difference in hematoma rate. Three hematomas and 1 infection occurred in this group. AC type, revision surgery, scrotoplasty, or reservoir technique did not affect outcomes nor drainage (P>.05). Complication rate (IPP infection and hematoma rate) where not different when compared to large cohorts from respective institutions. Conclusions Our data shows a 1.9% rate of major complications in patients undergoing IPP placement on anticoagulation in high volume implant centers. Although this approach appears feasible and similar in complication rates in men not on AC, careful consideration of the risk benefit ratio should be undertaken. Our data indicate closed suction draining for 3 days may be warranted. Additionally, the retropubic bleed case argues for only submuscular reservoirs placed under direct vision which minimizes occult bleeding risk. In the majority of cases, elective IPP surgery should be delayed until it is safe to discontinue anticoagulation therapy. Disclosure No

(410) Multiple Slit Incisions with Tachosil® Grafting for Treatment of Peyronie’s Disease and ED

Abstract Introduction Plaque incision or partial excision with collagen fleece grafting and IPP implantation is a well-established treatment for severe penile curvatures associated with ED. Nevertheless, multiple plaque incisions combined with Tachosil® grafting may have added advantages. Objective We demonstrate step-by-step the treatment of a case of severe ED with an over 60 degree dorsal curvature mainly on the left side and an hour glass indentation on the right side of the penile shaft. We highlight the advantages of multiple plaque incisions and Tachosil® grafting combined with IPP implantation for these specific cases. Methods After IPP implantation via the penoscrotal approach, the neurovascular bundle was mobilized. For the left sided curvature we underwent multiple deep transverse slits starting from and around the point of maximum curvature using a low energy cutting current (20 to 30 Watts). Our transverse incisions were complimented with the modeling technique. For the right sided waist formation we underwent longitudinal slits. The area of incisions was covered by a Tachosil® graft. Results The multiple horizontal incisions led to a vertical release thus straightening of the curved penile shaft. Longitudinal slits led to a horizontal release, therefore expanding and obliterating of the waist formation. Conclusions The multiple slit technique together with Tachosil® grafting may have added advantages compared to the conventional plaque incision/excision utilizing the same graft. The smaller defects created by the multiple tunical incisions may avoid potential cylinder protrusion, facilitate better sealing of the collagen fleece, lower the incidence of hematoma and/or infections and allow complimentary modeling of the penis. Moreover, complex deformities may also be treated simultaneously with success. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast.

(100) Extended Reality-Assisted Surgery (XRAS): A Novel Surgical Training Tool During Cadaver Lab

Abstract Introduction XRAS (extended reality-assisted surgery) is a revolutionary modality that assists the surgeon in real-time by overlaying 3-dimensional computer-generated images into the users’ field of view. Objective To insert a Titan 3-piece inflatable penile implant (IPP) on cadaver A and a male virtue sling on cadaver B while utilizing XRAS as a training tool. Methods Two cadavers were used for this lab. While 2 surgeons were present and operating on the physical bodies, 2 additional physicians were remote and communicating via HoloLens 2 Developer Editions. By utilizing the Apoqlar©Hamburg, Germany application, the 2 remote surgeons could communicate, observe, and advise the live surgery. Cadaver A was in the supine position for a penoscrotal approach while B was in the lithotomy position for placement of the male virtue sling. A questionnaire was issued to attendees after the procedures to evaluate the role of the HoloLens in the operating room. Results While performing the respective surgeries on the two cadavers, XRAS was successfully implemented in real-time. Superimposed virtual surgical devices were placed and manipulated in 3D space during surgery to allow for augmented surgical technique during penile implant and male virtue sling insertion. The questionnaire yielded findings that, of the 4 attendees who participated in the surgery, all were in favor of integrating XRAS into the operating room. Attendees reported minimal overheating and discomfort, and sufficient battery life for a 90-minute interval. Conclusions XRAS represents the next paradigm shift in surgery and surgical training. It provides an augmented surgical view all while ergonomically positioned on the head of the surgeon. Implementation of XRAS in surgery can improve efficiency, education, accuracy, and surgical outcomes. Further studies and evolution of the software are needed to elucidate the value of such technology for real-time surgery. Disclosure Yes, this is sponsored by industry/sponsor: Coloplast Clarification Industry funding only - investigator initiated and executed study Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast

MP62-16 FACTORS ASSOCIATED WITH VIRGIN INFLATABLE PENILE PROSTHESIS INFECTION: 10 YEARS OF DATA IN A LARGE HEALTH CARE SYSTEM

You have accessJournal of UrologyCME1 Apr 2023MP62-16 FACTORS ASSOCIATED WITH VIRGIN INFLATABLE PENILE PROSTHESIS INFECTION: 10 YEARS OF DATA IN A LARGE HEALTH CARE SYSTEM Nancy Ye, Joanie Chung, Polina Reyblat, Irene Chen, Eugene Rhee, and George Abdelsayed Nancy YeNancy Ye More articles by this author , Joanie ChungJoanie Chung More articles by this author , Polina ReyblatPolina Reyblat More articles by this author , Irene ChenIrene Chen More articles by this author , Eugene RheeEugene Rhee More articles by this author , and George AbdelsayedGeorge Abdelsayed More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) is the recommended treatment for erectile dysfunction refractory to medical management. Device infection is a dreaded complication leading to significant patient morbidity and increased healthcare costs. This study aims to determine factors associated with device infection in a large fully integrated healthcare system. METHODS: IPPs implanted between 2009 and 2019 at Kaiser Permanente Southern California were retrospectively reviewed. Perioperative and intra-operative variables were assessed to identify factors associated with device infection. Particular attention was paid to patient demographics, co-morbid conditions, surgeon volume, intra-operative antibiotics, operative time, and concurrent procedures. Univariate and multivariable logistic regression analyses were performed. RESULTS: 978 virgin IPPs were implanted in the study period by 66 different implanters. Overall device infection rate was 4.5% (44/978). We identified four surgeons, who performed >100 IPP surgeries within the study period, as high-volume implanters (HVI). They collectively implanted 441 IPPs (45%). Patients who had IPPs placed by HVI were significantly less likely to develop a device infection compared to other surgeons (OR 0.49, p<0.05). On multivariable logistic regression analysis, hemoglobin A1c, body mass index, operative time, anti-coagulation, prior pelvic surgery, radiation, or spinal cord injury were not associated with device infection. Yet, patients who received prophylactic intravenous (IV) antibiotics per American Urological Association (AUA) Best Practice Statement were less likely to have a device infection than patients who received other antibiotics (OR 0.35, p<0.05). Additionally, IPP placement via penoscrotal approach was associated with greater likelihood of device infection compared to infrapubic approach (OR 4.67, p<0.05). Mean follow-up was 4.9 years. CONCLUSIONS: Device infection was associated with non-high-volume implanters as well as prophylactic IV antibiotics outside of AUA recommendations. Operative time, long considered to be associated with device infections, was not associated with device infection on either univariate or multivariable logistic regression analysis in this large cohort with long term follow up. Greater understanding of patient and surgeon factors associated with device infection may help decrease patient morbidity and better prepare implanters. Source of Funding: n/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e868 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nancy Ye More articles by this author Joanie Chung More articles by this author Polina Reyblat More articles by this author Irene Chen More articles by this author Eugene Rhee More articles by this author George Abdelsayed More articles by this author Expand All Advertisement PDF downloadLoading ...

PD42-04 BLOOD THINNERS: DO THEY NEED TO BE HELD FOR IPP SURGERY?

You have accessJournal of UrologyCME1 Apr 2023PD42-04 BLOOD THINNERS: DO THEY NEED TO BE HELD FOR IPP SURGERY? Niki Parikh, Reza Roshandel, Ryan Griggs, Gerard Henry, Paul Perito, Coral Gables, Saint Helena, and Tobias Kohler Niki ParikhNiki Parikh More articles by this author , Reza RoshandelReza Roshandel More articles by this author , Ryan GriggsRyan Griggs More articles by this author , Gerard HenryGerard Henry More articles by this author , Paul PeritoPaul Perito More articles by this author , Coral GablesCoral Gables More articles by this author , Saint HelenaSaint Helena More articles by this author , and Tobias KohlerTobias Kohler More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003352.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) placement on active anticoagulation (AC) is controversial. Techniques utilized to decrease complications include use of malleable implant, partial inflation of IPP for hemostasis, and placement of drain; however risk and benefits must be weighed. We sought to assess outcomes of IPP in men on AC in a multi-institutional study. METHODS: Data from 3 high-volume implant centers was retrospectively analyzed. Demographics, comorbidities, secondary procedures, drain placement/output, and complications were recorded. Aspirin was excluded as it is not routinely held. Center 1 utilizes a penoscrotal approach without drain placement, center 2 a penoscrotal approach with drain placement (removal when output <50 mL/8 hours), and center 3 an infra-pubic approach with drain for 3 days. RESULTS: 202 patients were continued on AC throughout surgery. 112 patients were on clopidogrel, 35 warfarin, 38 apixaban, 1 enoxaparin, 15 rivaroxaban, and 1 on combination therapy with clopidogrel and enoxaparin. AC requirement included peripheral vascular disease (55%), CHF (11%), cardiac stents (11.6%), DVT/PE/history of thrombosis (7%), atrial fibrillation (11%), cardiac valves (2.2%), stroke (1.3%), and preventive (0.9%). Nine patients on AC (3.98%) experienced complications including 4 significant events (1.9%): 1 major retropubic bleed requiring transfusion, 3 IPP infections and 5 minor events: 3 minor hematomas, 1 minor wound dehiscence and 1 CT negative stroke event. Drain outputs for center 3 averaged 113 ml, 81 ml, and 30 ml of output per day respectively with a total average output average of 223 ml and experienced no hematomas nor infections. Drain output for center 2 averaged 121 ml with the majority or patients having the drain for only one day. Drain output was significantly higher than historical non-AC controls (121 vs. 72 ml p=.001) but there was no difference in hematoma rate. Three hematomas and 1 infection occurred in this group. AC type, revision surgery, scrotoplasty, or reservoir technique did not affect outcomes nor drainage (p>.05). Complication rate (IPP infection and hematoma rate) where not different when compared to large cohorts from respective institutions. CONCLUSIONS: In high-volume implant centers, major complication rate of 1.9% occurred in IPP patients on AC. Although IPP is feasible in this patient population, drain for 3 days and submuscular reservoir placement may be indicated. In most, elective IPP surgery should be delayed until it is safe to discontinue anticoagulation. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1112 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Niki Parikh More articles by this author Reza Roshandel More articles by this author Ryan Griggs More articles by this author Gerard Henry More articles by this author Paul Perito More articles by this author Coral Gables More articles by this author Saint Helena More articles by this author Tobias Kohler More articles by this author Expand All Advertisement PDF downloadLoading ...

V11-12 MULTIPLE SLIT INCISIONS WITH TACHOSIL® GRAFTING FOR TREATMENT OF PEYRONIE'S DISEASE AND ED

You have accessJournal of UrologyCME1 Apr 2023V11-12 MULTIPLE SLIT INCISIONS WITH TACHOSIL® GRAFTING FOR TREATMENT OF PEYRONIE'S DISEASE AND ED Ahmed Ragheb and Daniar Osmonov Ahmed RaghebAhmed Ragheb More articles by this author and Daniar OsmonovDaniar Osmonov More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003337.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Plaque incision or partial excision with collagen fleece grafting and inflatable penile prosthesis (IPP) implantation is a well-established treatment for severe penile curvatures associated with ED. Nevertheless, multiple plaque incisions combined with Tachosil® grafting may have added advantages. We demonstrate step-by-step the treatment of a case of severe ED with an over 60 degree dorsal curvature mainly on the left side and an hour glass indentation on the right side of the penile shaft. We highlight the advantages of multiple plaque incisions and Tachosil® grafting combined with IPP implantation for these specific cases. METHODS: After IPP implantation via the penoscrotal approach, the neurovascular bundle was mobilized. For the left sided curvature we underwent multiple deep transverse slits starting from and around the point of maximum curvature using a low energy cutting current (20 to 30 Watts). Our transverse incisions were complimented with the modeling technique. For the right sided waist formation we underwent longitudinal slits. The area of incisions was covered by a Tachosil® graft. RESULTS: The multiple horizontal incisions led to a vertical release thus straightening of the curved penile shaft. Longitudinal slits led to a horizontal release, therefore expanding and obliterating the waist formation. CONCLUSIONS: The multiple slit technique together with Tachosil® grafting may have added advantages compared to the conventional plaque incision/excision utilizing the same graft. The smaller defects created by the multiple tunical incisions may avoid potential cylinder protrusion, facilitate better sealing of the collagen fleece, lower the incidence of hematoma and/or infections and allow complimentary modeling of the penis. Moreover, complex deformities may also be treated simultaneously with success. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1002 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Ragheb More articles by this author Daniar Osmonov More articles by this author Expand All Advertisement PDF downloadLoading ...

Shaeer's infrapubic technique for penile prosthesis implantation through a single midline corporotomy: A single-center pilot study.

With the infrapubic approach (IPA) for penile prosthesis implantation, lateral corporotomies carry the risk of injury to the laterally coursing dorsal nerves. We sought to describe for the first time Shaeer's IPA, a modification of the IPA whereby malleable penile prosthesis cylinders are implanted through a single midline corporotomy in the bed of the deep dorsal vein, anatomically off the course of the dorsal nerves of the penis. We compared semirigid penile prosthesis implantation via the single midline corporotomy IPA (IPA-S, n = 11) to the classic IPA with laterally placed dual corporotomies (IPA-D, n = 11) and to the penoscrotal approach (PSA; n = 13). Shaeer's IPA is performed through an infrapubic incision. A 3- to 5-cm length of the deep dorsal vein is stripped. A single 3- to 5-cm midline corporotomy is cut along the bed of the vein. Dilation, sizing, and implantation are performed through the single corporotomy on either side of the midline septum. Patients are discharged the same day and are allowed to bend the implant after 2weeks and to commence intercourse after 3 weeks. Operative time, postoperative satisfaction, International Index of Erectile Function 5 (IIEF-5), and possible complications were recorded. There were no statistically significant differences in age, postimplantation IIEF-5, or satisfaction between the 3 groups. Average operative time for the IPA-S group was 21.8% shorter than that for the IPA-D group, and 34.5% shorter than for the PSA group. Those differences were statistically significant. No complications were recorded in the IPA-S group. Infection occurred in 1 PSA case, and partial hypoesthesia in 1 IPA-D case. The midline corporotomy confers an anatomical advantage that may help avoid nerve injury, thereby increasing the safety of the IPA. The main limitation of this study is the limited sample number, considering that this is a pilot study. The Shaeer's Midline-Corporotomy IPA is a minimally invasive technique for implantation of a semirigid penile prosthesis, with an anatomical advantage that may decrease the possibility of dorsal nerve injury.

A comparison of the perineal and penoscrotal approaches in artificial urinary sphincter implantation for the control of male stress urinary incontinence.

The two most common surgical approaches to treat stress urinary incontinence in men are the traditional perineal and the new penoscrotal approach for artificial urinary sphincter (AUS) implantation. Each method carries its own advantages and disadvantages. The few reports that compare the approaches have disparate outcomes. Compare the outcome of first time AUS implantation by the perineal versus the penoscrotal approach. Retrospective study. Tertiary referral center. We included all male patients who underwent primary perineal or penoscrotal AUS placement between June 2004 and October 2018 at our tertiary care hospital. Patients were followed at least one year postoperatively. Rates of dry, infection, erosion, malfunction, atrophy, revision. 44 males who underwent 68 procedures. Twenty-five (56.8%) patients underwent a perineal and 19 (43.2%) underwent a penoscrotal approach. The patients had 68 procedures: 36 (52.9%) perineal and 32 (47.1%) penoscrotal approaches. The median (25th-75th percentiles) age at the time of surgery was 61.0 (51.0-68.0) years (n=68 procedures). The median (25th-75th percentiles) operative time was significantly shorter for the penoscrotal approach, 87 (69-140), vs. 93 (72-210) minutes for the perineal approach (P=.016). The 44 patients were followed up for a mean (SD) of 52.5 (20.3) months for the 68 procedures. Postoperative complications occurred in 16 (36.36%) patients; 11 (44%) perineal approach patients and 5 (26.3%) penoscrotal. There were no significant differences in complications of infection, erosion, malfunction, or urethral atrophy between the two groups. Only removal/revision was significantly more common with the perineal approach (10 patients perineal and two patients penoscrotal, P=.042). At the last follow-up, dryness was comparable among groups. The outcomes of AUS placement are comparable between perineal and penoscrotal approaches in terms of complications and one year dryness. The penoscrotal approach however has shorter operative time and less need for revision and removal. Small sample size, single-center. None.

Complicated artificial urinary sphincter insertion using the transcorporal cuff: keys to the tunical flap technique.

Urethral sphincter insufficiency following radical prostatectomy (RP) is a common cause of non-neurogenic stress urinary incontinence (SUI). Artificial urinary sphincter (AUS) insertion remains the standard of care for fit patients with SUI refractory to non-operative interventions. The proximal urethra is a common location for uncomplicated AUS placement. However, previous failed AUS, urethroplasty, or pelvic radiotherapy (RT) may compromise urethral tissue requiring technique modifications that optimise outcomes. In these situations, transcorporal cuff (TC) placement has been well described to facilitate continence restoration in men where there is no other feasible option other than urinary diversion or permanent incontinence. In the traditional TC approach, the procedure may be complicated by haematoma due to difficulty in completely closing the corporal defects behind the urethra. This narrated video demonstrates the tunical flap (TF) modification for transcorporal AUS implantation via a perineal and penoscrotal approach in patients with prior failed AUS placements secondary to urethral erosion. The TF technique for transcorporal AUS insertion provides circumferential reinforcement with tunica albuginea from the corpora cavernosa. Here, we show how this technique provides additional urethral support for compromised urethral tissue to help prevent cuff erosion. The TF preserves the corporal volume and does not limit candidacy for future penile prosthesis implantation. In our early results, there have been no postoperative haematoma formation with this technique.

The outcomes of penile prosthesis in neurologic patients: a multicentric retrospective series.

Neurological disease is a known entity for causing erectile dysfunction (ED). Pharmacological therapies are not always effective these patients - penile prosthesis implant (PPI) is an established surgical treatment option. For a variety of reasons, neurological patients may experience differing outcomes of PPI compared to those whose ED arises from other causes. We investigated outcomes of PPI in neurological patients using the Italian multi-institutional national registry of penile prostheses [Italian Nationwide Systematic Inventarization of Surgical Treatment for ED (INSIST-ED)]. Patients undergoing PPI were investigated via the INSIST-ED registry, from 2014 to 2021. Data were prospectively recorded by 45 surgeons on a dedicated website (www.registro.andrologiaitaliana.it) and reviewed by a data manager. We subselected patients with neurological disease undergoing PPI for ED, and these patients were reviewed at 3, 6, and 12 months, and annually thereafter. Postoperative complications and functional outcomes were evaluated through validated questionnaires [International Index of Erectile Function-5 (IIEF-5), Sexual Encounter Profile 2-3, and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS)]. A nonvalidated questionnaire was administered to assess patient satisfaction. A total of 33 patients were included with a median age of 49 [interquartile range (IQR) 41-55]. Median follow-up was 83 months (IQR 67-99.5). A penoscrotal approach for PPI was performed in most cases (90.9%), while infrapubic was used in three cases (9.1%). Inflatable and malleable devices were implanted in 30 (90.9%) and 3 cases (9.1%), respectively. Intraoperative complications occurred in one case (3%). Early postoperative complications (<90 days) were observed in three cases (9.1%): two wound dehiscence (Clavien-Dindo G1 and G3a respectively) and one device infection requiring prosthesis explant (Clavien-Dindo G3a). Mechanical failures of inflatable devices were not observed during the follow-up period. Median IIEF-5 before surgery was 8 (IQR 7-9). At the latest follow-up, IIEF-5 was 22 (IQR 19-23.5), and median EDITS was 79 (IQR 64-88). A total of 28 patients (84.8%) self-reported to be fully satisfied with the PPI. Although PPI in the neurological population has been historically considered to be at increased risk, in our study, PPI complications and infections rates in this cohort did not differ from general population.

Artificial Urinary Sphincter in a High-Risk Urethra: Transcorporal Gullwing Modification Description of the Technique.

In this report, we describe a modification of transcorporal artificial urinary sphincter place ment known as Gullwing modification. Using a penoscrotal approach, bilateral corpora cavernosa flaps are harvested and sutured in the midline covering the lateral and ventral surfaces of the urethra. Transcorporal cuff placement provides dorsal reinforcement, thus having extra tissue buttressing all the circumference in cases of a fragile urethra due to previous urethral cuff erosion, urethroplasty, or pelvic radiotherapy. After previous urethral cuff erosion, radiotherapy, and urethral reconstruction, our patient complained of severe stress urinary incontinence. Due to the high risk of urethral complications, we proceed to a transcorporal artificial sphincter placement with urethral reinforcement through a bilateral cavernosal flap. The surgery was successfully completed, and after 6 weeks, sphincter was activated with satisfac tory results. Two years after surgery, his continence status is stable without complications. Urethral complications associated with artificial urinary sphincter surgery remain a challenge for the reconstructive surgeon. Reinforcement of the ventral aspect of the urethra through corpora cavernosal flaps may reduce the likelihood of urethral erosion in high-risk cases.

Complication rates in concurrent inflatable penile prosthesis and incontinence surgery: Comparing the penoscrotal versus perineal incision approach.

The main objective of this study was to assess the IPP complication rates of patients undergoing placement via perineal incision versus more traditional penoscrotal approach in synchronous dual implantation. We identified 38 patients who underwent dual implantations of an IPP and AUS or urethral sling from 2011 to 2021 at a single tertiary center, 24 via perineal and 14 via penoscrotal incision. All IPP implants were done by a single surgeon. IPP postoperative complications were captured using the Clavien-Dindo classification at three separate time points, < 30 days, 30 days - 6 months, and > 6 months. The perineal group had two complications, IPP explantation due to rectourethral fistula (Grade III, > 6 months), and IPP explantation due to chronic genital pain (Grade III, > 6 months). The penoscrotal group had three complications, post-operative urinary retention requiring catheterization (Grade I, < 30 days), incision site infection (Grade I, < 30 days), and IPP explantation due to infection (Grade III, 30 days to < 6 months). There was no statistically significant difference in rate of patients with IPP complications between the two groups (p = 0.546) or in rate of IPP device malfunction (p = 0.264). These preliminary findings suggest that the single perineal incision is a viable surgical approach in synchronous dual implantation.

Penile Fracture with Urethral Rupture

Penile fracture with an associated urethral injury is a rare urological emergency resulting from trauma to the erect penis during vigorous sexual intercourse. The patient often presents with swelling of the penis, discoloration of the penile skin, localized pain, and hematuria with a typical history of sudden detumescence during intercourse. Subcoronal penile degloving incision has been conventionally described and is frequently used by many clinicians for the management of penile fracture-urethral injury. Here, we describe a case of complex penile fracture managed through the vertical penoscrotal incision. The penoscrotal approach confers excellent exposure to both the ruptured corpus cavernosum and urethra. This approach ensures successful outcomes in such an emergency procedure without having disadvantages of the degloving incision.

PD28-09 SINGLE PERINEAL INCISION IN SIMULTANEOUSLY PLACED PENILE IMPLANT AND ARTIFICIAL SPHINCTER: A COMPARISON OF COMPLICATIONS AND DEVICE LONGEVITY

You have accessJournal of UrologyCME1 May 2022PD28-09 SINGLE PERINEAL INCISION IN SIMULTANEOUSLY PLACED PENILE IMPLANT AND ARTIFICIAL SPHINCTER: A COMPARISON OF COMPLICATIONS AND DEVICE LONGEVITY Kirema Macharia, Kyle Blum, Travis Green, Justin Mehr, Leyla Akhverdiyeva, Alex Leonard, and Run Wang Kirema MachariaKirema Macharia More articles by this author , Kyle BlumKyle Blum More articles by this author , Travis GreenTravis Green More articles by this author , Justin MehrJustin Mehr More articles by this author , Leyla AkhverdiyevaLeyla Akhverdiyeva More articles by this author , Alex LeonardAlex Leonard More articles by this author , and Run WangRun Wang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002576.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) is commonly implanted via a penoscrotal or infrapubic incision. It is known that artificial urinary sphincters (AUS) are more effective when placed through a perineal approach. The most common approach for the synchronous implantation of an IPP and AUS has been through dual incisions (penoscrotal/infrapubic and perineal) or a single penoscrotal approach. We have developed a technique to simultaneously implant an IPP and AUS through a single perineal incision. Presently, no data is available that compares the complications and device longevity of a single perineal approach versus a penoscrotal approach for dual implants. METHODS: We retrospectively identified 45 patients who underwent an AUS/IPP synchronous dual implantation at a large single-institution tertiary referral center between 2011 to 2019. These patients were surveyed regarding their AUS/IPP devices using a series of questions. Out of these patients, a total of 23 patients had responses available for analysis; 13 with penoscrotal incision and 10 via perineal incision. Device malfunction, infection, and Clavien-Dindo classification (CD) for complications were analyzed. Fisher’s exact test for categorical variables was used and p <0.05 was considered to be significant. Follow up ranged from 1.6 to 124.9 months. RESULTS: A difference was observed between the two groups when comparing for total CD Grade 1-2 postoperative complications (p=0.028). Notably, 61.5% (n=8) in the penoscrotal group experienced a CD Grade 1-2 complication in the first 30 days postoperatively vs 10% (n=1) in the perineal group, most commonly surgical site pain. There was no statistically significant difference in CD Grade >3 postoperative complications between the two groups (p=0.617). There was also no significant difference found between the two groups when comparing for infection rates (p=0.603), AUS malfunction (p=1.00), or IPP malfunction (p=1.00). CONCLUSIONS: A single perineal incision for the placement of AUS/IPP synchronous implantation is a viable and effective option with similar device longevity compared to a penoscrotal approach. Low grade complications were found to be significantly improved with the perineal approach. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e502 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kirema Macharia More articles by this author Kyle Blum More articles by this author Travis Green More articles by this author Justin Mehr More articles by this author Leyla Akhverdiyeva More articles by this author Alex Leonard More articles by this author Run Wang More articles by this author Expand All Advertisement PDF DownloadLoading ...

V12-12 PENOSCROTAL DECOMPRESSION OF REFRACTORY ISCHEMIC PRIAPISM: SURGICAL TECHNIQUE

You have accessJournal of UrologyCME1 May 2022V12-12 PENOSCROTAL DECOMPRESSION OF REFRACTORY ISCHEMIC PRIAPISM: SURGICAL TECHNIQUE Nicholas Ottaiano, Ganesh Sanekommu, Christopher Koller, Wayne Hellstrom, Allen Morey, and Omer Raheem Nicholas OttaianoNicholas Ottaiano More articles by this author , Ganesh SanekommuGanesh Sanekommu More articles by this author , Christopher KollerChristopher Koller More articles by this author , Wayne HellstromWayne Hellstrom More articles by this author , Allen MoreyAllen Morey More articles by this author , and Omer RaheemOmer Raheem More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002638.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Outcomes after distal shunting have low rates of success in cases of refractory ischemic priapism lasting more than 48 hours. Current American Urological Association (AUA) guidelines recommend proximal shunting following a failed distal shunt; however, proximal shunting is no longer common practice due to the technically challenging nature of the procedure. METHODS: A 43 year old African American male presented to our institutional hospital from an outside hospital for refractory ischemic priapism lasting longer than 72 hours. Corporal blood gas analysis confirmed priapism of ischemic nature, penile duplex ultrasound confirmed an absence of blood flow. The remaining lab work (CBC, urine toxicology, and Hb electrophoresis) was negative. Corporal decompression via a penoscrotal approach was then performed in hopes of preserving the patient's erectile function. RESULTS: Penoscrotal decompression proved to be an effective and safe way of managing refractory ischemic priapism. The technique showed to produce favorable results while maintaining adequate sexual function. Longer follow up periods and a larger patient size is needed for future evaluation. CONCLUSIONS: Corporal decompression via a penoscrotal incision has recently emerged as a viable alternative to proximal shunting with favorable outcomes in select patients. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e970 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicholas Ottaiano More articles by this author Ganesh Sanekommu More articles by this author Christopher Koller More articles by this author Wayne Hellstrom More articles by this author Allen Morey More articles by this author Omer Raheem More articles by this author Expand All Advertisement PDF DownloadLoading ...