Penoscrotal Incision Research Articles

Outcomes related to penile prosthesis reservoir removal: a 7-year multi-institutional experience.

The 3-piece inflatable penile prosthesis (IPP) is the most widely used device for erectile dysfunction refractory to medications, containing a reservoir inserted into the retropubic space (RPS) or an alternative/ectopic space (AES). Indications for removal of the reservoir include malfunction, malposition, or infection. In revision cases without infection, reservoir removal is sometimes optional. We reviewed outcomes and complications related to reservoir removal from a large multi-institutional series. We retrospectively reviewed databases at 6 institutions over 7years. Patients with artificial urethral sphincter, urethral sling, or mini-jupette were excluded. Outcomes and complications related to IPP reservoir removal were analyzed. Data were collected, but only reservoir-related complications at surgery were included. Data were compared between the RPS and AES cohorts to evaluate differences with a χ2 test, with significance at P < .05. Of 215 cases, there were 172 RPS and 43 AES reservoirs. The mean patient age was 65.3years. An overall 131 procedures were due to malfunction and 49 to malposition of an IPP component; 35 were secondary to infection. Among those retained (n = 44), reasons included reuse, avoiding surrounding structure damage, and difficult dissection. Among those removed (n = 171), 15 required a counterincision. To determine the statistical difference between those removed from the RPS and an AES, the χ2 test result was P = .00059, indicating a significant difference in the need for a counterincision between the groups. Complications included bladder perforation (n = 1) in the RPS group and an avulsion of the epigastric vessels requiring abdominal exploration (n = 1) in the AES group. To determine the statistical difference between RPS and AES complications, the χ2 test result was P = .365, indicating no significant difference between the groups. Strengths include being a multi-institutional study with high-volume skilled implanters. Limitations include being a retrospective review, with implanters exclusively performing penoscrotal incisions and not utilizing an infrapubic approach. Last, there was a lack of long-term follow-up with these patients. Removal of an IPP reservoir remains safe, with few intraoperative complications. Surgeons should be aware of the inferior epigastric vessels during removal in an AES or be willing to perform a counterincision to avoid injury to surrounding structures. Surgeons should also obtain preoperative imaging to identify the specific location of the reservoir and adjacent anatomy. This is the first multi-institutional study reviewing outcomes related to reservoir removal during IPP revision or removal surgery.

Standardizing urethral stricture models in rats: a comprehensive study on histomorphologic and molecular approach.

To create a reproducible and standardized urethral stricture model in rats, evaluating both histomorphologic findings and gene expression data. In studies involving experimental animals, more standardization is needed for the creation of a urethral stricture model. Sixteen male rats were randomized into two groups. The Sham group (n:8) underwent only a penoscrotal incision, while the stricture group (n:8) had their urethras exposed through a penoscrotal incision, followed by electrocauterization to the corpus spongiosum. On the 15th day, blood and urethral tissues were harvested for histologic and molecular analyses. Histomorphologic, immunohistochemical, and reverse transcription polymerase chain reaction analyses were performed. The stricture group exhibited more severe and intense spongiofibrosis, inflammation, epithelial desquamation, and congestion in vascular structures compared to the controls (p < 0.05). The urethral tissue in the stricture group showed an increased ratio of inflammation parameters, including Collagen 1A1, Collagen 3A1, elastin, Transforming growth factor β1, α Smooth muscle actin, Platelet-derived growth factor α, and Platelet-derived growth factor β. Transforming growth factor β1, Platelet-derived growth factor α, and Platelet-derived growth factor β each correlated highly with the other six parameters (r > 0.60, p < 0.05). Developing electrocoagulation-induced urethral stricture in rats is a simple, reliable, inexpensive, and reproducible. Reporting histologic data with qualitative and semi-quantitative scoring will enhance data standardization, aiding reader understanding and analysis. Transforming growth factor β and Platelet-derived growth factor play key roles in fibrosis during stricture development. Incorporating these cytokines in urethral stricture animal model studies can demonstrate successful stenosis creation.

(165) Shaeer's Cavernotome: Core Your Way Through Corporal Fibrosis

Abstract Introduction Penile prosthesis implantation in scarred corporal bodies is one of the most challenging urologic procedures, with high risks of perforation and/or failure. Objective We present Shaeer’s Cavernotome (patent application number PCT/EG2021/050003). This is the forward-cutting cavernotome that relies on the principle of controlled coring rather than forward stabbing, with fibrous tissue accommodated into the hollow core, thereby high efficacy and low risk of perforation. Methods This is a prospective study involving 18 patients with severe corporal scarring. Surgery is performed through a peno-scrotal incision with an indwelling urethral catheter. Corporotomies are incised and a 2cm long core of fibrous tissue is excised with scalpel. Shaeer’s Cavernotome (ShC) is introduced and is lodged against the fibrous tissue. Coring proceeds with the stretched corpus or crus held between the thumb and index fingers of the non-dominant hand as a guide, ahead of the tip. ShC doubles as a sizer. Following coring, penile prosthesis implantation proceeds. Results Dilation of the corpora cavernosa was successful in 17 out of 18 patients. Average coring time was 8 minutes 3.2. Dilation was up to girth 13 Hegar in 12 patients, and 11 in 5. No perforations or infections were encountered Conclusions Shaeer’s Cavernotome is an instrument that facilitates penile prosthesis implantation in scarred corporal bodies. Full excavation of both corpora cavernosa is achievable in under 10 minutes, with low risk for perforation. Disclosure No.

(154) Corporal Tissue Ingrowth: A Rare but Operable Challenge in Revision Surgery for Inflatable Penile Prosthesis

Abstract Introduction Corporal tissue ingrowth into previously implanted cylinder is a rare but possible issue encountered during penile prosthesis (PP) revision surgery. To prevent cylinder aneurysms, a middle layer of woven and expandable polypropylene-like material was incorporated into the implant design in 1987. While the outer silicone layer usually prevents its contact with tissue, in cases of ruptured cylinders, there is a risk of cavernous ingrowth into the exposed woven layer. Collagen deposition within the inflammatory tongue of tissue can lead to significant difficulty in implant removal. Having a degree of suspicion about this phenomenon is important, especially as an implant may remain somewhat functional if the inner silicone layer remains intact. If encountered, its recognition is paramount in triggering operative countermeasures. To our knowledge, this is the only contemporary and second case series describing this phenomenon in English literature. Objective To highlight the existence of this difficult phenomenon in revision surgery and demonstrate our approach. Methods We report 3 patients over the past 3 years who underwent complex penile revision surgery. All had AMS penile implantation 10–15 years prior and presented with inability to inflate device. Each case began routinely through a vertical penoscrotal incision; however, the stuck cylinders were unable to be removed through the traditional corporotomy. Penoscrotal incision and corporotomy were extended until the location of ingrowth was identified. A combination of sharp and blunt dissection was required to liberate the cylinder from the surrounding corporal tissue. Care was taken to maintain a plane just outside the ruptured cylinder to prevent more proximal or distal injury to the tunica albuginea. Once liberated and new device implanted, corpora are closed in the usual fashion without the need for elaborate tunica albuginea reconstruction. Results All 3 patients had successful revision of impacted cylinder from the corpora through extension of the vertical penoscrotal incision. No secondary distal incision was necessary in these cases. Patients were followed for 6–12 months in which time all prosthesis remained functional and no deviation from the usual post-operative course was encountered. Conclusions Implanters should not shy away from maximizing exposure if ingrowth is suspected. The vertical penoscrotal incision was a versatile approach that could be easily extended and should be considered for suspected complex revision surgery. Furthermore, this phenomenon also adds credence to early revision surgery in the cases of device malfunction from suspected cylinder rupture. Despite the difficulty this issue poses, corporal tissue readily integrates into porous synthetic materials. This ability may be useful in future device development in the tissue engineering space. Disclosure No.

(026) Application of Gelatin Sponge as a Hemostatic Agent in Penile Prosthesis Implantation

Abstract Introduction Gelfoam® Sterile Compressed Sponge is a hemostatic that is directly applied to bleeding surfaces. This cost-effective hemostatic agent is prepared from purified porcine skin, Gelatin granules and Water for Injection. It is water insoluble, however is completely absorbed within 4–6 weeks with minimal scar formation. Gelfoam is available sterile for intra-operative use, and is applied in a multitude of surgical specialties. Objective In this work, we demonstrate for the first time the of Gelfoam to minimize the risk of bleeding in penile prosthesis implantation. Methods Eight cases received a three-piece inflatable implant (Rigicon Infla10®) through a peno-scrotal incision. Following cylinder insertion, corporotomies were closed by tying the stay sutures rather than water-tight sewing. Gelfoam was soaked in antibiotic-supplemented saline. Air bubbles were squeezed out followed by soaking. Gelfoam was then applied to the corporotomies, pump space and entry rout to the reservoir space. It was secured over the corporotomies by closing a pre-fashioned layer of Buck’s fascia. A suction drain was inserted. Mummy wrap was not used. Drain output was monitored and complications recorded. Results In two cases, drain output was an average of 80 cc’s in the first 24 hours, then 20 cc’s in the following 24 hours. However, in 6 cases, drain output was an average of 18 cc’s in the first 24 hours, mostly sero-sanguinous, then none in the following 24 hours. No cases of hematoma formation, infection, foreign body reaction, mass formation or hypersensitivity reaction were encountered. Conclusions The initial results of the current small case series demonstrate that Gelfoam is well-tolerated in penile surgeries, with possible value at minimizing post-operative bleeding, encouraging a multi-center larger study. Disclosure No.

(172) Managing Proximal Perforation of Inflatable Penile Prosthesis in Pelvic Trauma

Abstract Introduction Corporal perforation is a complication that occurs secondary to misdirected or over-aggressive dilation or weakened tunica albuginea. One major risk factor is corporal fibrosis, as the corpora is more difficult to dilate, and sharp dissection or counter-incisions may be required. Fibrosis is most commonly observed in patients with history of infection, priapism, Peyronie’s disease, or multiple revision surgeries. In the setting of pelvic trauma, normal anatomical landmarks can be altered leading to proximal perforation during dilation. Proximal corporal perforation first manifests as unequal corporal measurements intraoperatively or palpable malposition of the cylinder into the perineum. Objective Herein we discuss the case of a 24-year-old male with erectile dysfunction secondary to pelvic trauma who presents one year postoperatively with malposition of his right cylinder due to proximal migration from altered pelvic anatomy. We aim to describe our surgical techniques that can be utilized to correct proximal perforation. Methods Physical exam and preoperative imaging revealed grossly malpositioned right prosthetic cylinder. We utilized the prior transverse penoscrotal incision to deliver the scrotal pump from the surgical capsule. Given normal appearance of reservoir on imaging and duration from initial placement, only the scrotal pump and cylinders were exchanged. Bilateral cylinders were explanted through vertical corporotomies. Proximal measurements of 20cm on the left and 24cm on the right were consistent with corporal perforation. The Windsock procedure was performed by placing a 2–0 PDS suture from out to in through the tunica albuginea, through the right rear-tip extender, then in to out back through the albuginea of corporotomy. After copious irrigation of corporal space, new cylinders were placed using the modified rear tip extender. A new scrotal pump was placed in anterior dependent position. The device cycled properly in symmetric position bilaterally before all tissue layers were closed. Results The patient was observed overnight and discharged on post-operative day 1 after passing void trial. He was noted to be doing well at his post-operative clinic visit 6 weeks later and has been cleared for sexual activity. Conclusions We describe a patient with challenging anatomy due to extensive pelvic fracture leading to corporal perforation and proximal migration of a prosthetic cylinder. Due to lack of a normal pubic tubercle, we performed the Windsock sling procedure to provide posterior support of the right cylinder to prevent future proximal migration. An alternate approach is to secure the prosthesis tubing via sutures to the corporotomies is also presented. A critical intraoperative maneuver is evaluating for equal dilator depth alignment to recognize proximal perforation. These techniques can be applicable to other patients with altered anatomy secondary or in the setting of proximal corporal perforation. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

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

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

(140) Penile Length and Girth Restoration in Mb Peyronie: Less Invasive Approach for Complex Composite Graft Corporplasty and Implantation of Inflatable Penile Prosthesis

Abstract Introduction Peyronie's disease (PD) is a fibrotic disorder of the tunica albuginea. It is both a physically and psychologically devastating disorder that causes penile deformity, curvature, narrowing and shortening, which eventually compromise sexual function. Objective The presented technique is a less invasive approach that gives few complications, has a natural cosmetic outcome with preserved preputium, and high patient satisfaction. Methods In the period between December 2017 and May 2022, 65pts aged 33y to 78y underwent complex corporoplasty with inflatable penile prosthesis implantation. Mean penile curvature was 70 o (60 o -95 o ). Average penile shortening was 3.2cm (1 - 5.5cm), and girth narrowing 2.5cm (0 - 4cm). The surgical approach was thru penos-crotal incision, followed by direct dissection of NVB from tunica albuginea, penile eversion, composite corporoplasty (for transversal grafting 0.5mm thick porcine dermal graft, and for longitudinal graft composite semi-resorbable soft mash), and 3-piece inflatable penile prosthesis implantation. Postoperative vacuum drainage and compressive dressing were left in place for one week. Results Follow-up was 2-58 months (mean 21). Penile shape (corrected curvature, length and girth) was restored in all patients. In the first 4 weeks postoperatively 12pts had mild scrotal oedema; 8pts developed mild scrotal haematoma; 7pts developed penile skin oedema; 5pts had a transitory loss of sensitivity. All patients 5 weeks postoperatively started with sexual intercourse. All patients 12 weeks after surgery reported satisfactory aesthetical and functional results with no visible scaring related to surgery. Five pts (12-23 months after surgery) had prosthesis malfunction that needed reimplantation of the prosthesis. Conclusions Penile eversion thru peno-scrotal incision with preserving the prepuce for complex reconstructive surgery of PD is safe and gives the natural aesthetic appearance and good functional result with low complication rate. The high satisfaction rate for the patients is the most important aspect of this surgical method. Disclosure No

(241) Shaeer’s Cavernotome: A New Cavernotome to Facilitate Penile Prosthesis Implantation into Scarred Corporal Bodies

Abstract Introduction Penile prosthesis implantation into scarred corporal bodies is one of the most challenging prosthetic urology procedures, with high risks of corporal perforation, urethral laceration &amp; lack of success. Objective: We introduce a novel Cavernotome (patent application number PCT/EG2021/050003) which cuts the channel as it is passed forward. The instrument relies on controlled coring rather than forward stabbing, with resected tissue accumulated into the hollow core. Objective We introduce a novel Cavernotome (patent application number PCT/EG2021/050003) which cuts the channel as it is passed forward. The instrument relies on controlled coring rather than forward stabbing, with resected tissue accumulated into the hollow core. Methods After ethical committee approval, we utilized the cavernotome in 18 patients with severe corporal fibrosis. Scarring was due to penile prosthesis removal after infection in twelve patients, and neglected ischemic priapism in six. Surgical Procedure: Surgery is performed through a peno-scrotal incision with urethral catheter placed for identification. Corporotomies are 2-5 cm long depending on the implant to be used. A 2cm core of fibrous tissue is excised with scalpel or electrosurgical pencil. The appropriate size for Shaeer’s Cavernotome (ShC) is determined according to the maximum that fits in the fore mentioned excavated space, mostly size 11 Hegar. ShC is advanced proximally and distally in a screwing / coring motion, rather than the customary oscillating or forward thrusting motion. To prevent inadvertent direction, the stretched corpus is held between the thumb and index fingers of the non-dominant hand ahead of the tip. ShC doubles as a sizer with a ruler marked on the shaft. Following coring, the excavated corpora and crura are dilated with minimal resistance using Hegar or Brook’s dilators. Penile prosthesis implantation proceeds in the usual fashion. The surgical technique is available at VJPU: https://www.vjpu-issm.info/videos/peer-reviewed/1-penile-prosthesis-malleable-inflatable-penile-prosthesis-ipp/1-a-first-time-implant/item/198-shaeer-s-cavernotome Results Prosthesis implantation was successful in 17 out of 18 patients. In one patient, coring was not possible. the corpora were thinned out and calcified. Size 6 ShC could not be introduced. Corporal reconstruction was performed. Average coring time was 8 minutes. Dilation to 13mm Hegar in 12 patients, and 11mm in 5. The implant used was Rigicon Rigi10® (n=12), Rigicon Infla10® (n=2) and Coloplast Genesis® (n=3). No perforations or infections in the 17 successful implantations. Conclusions Shaeer’s Cavernotome is a new instrument that, in its initial study by the inventor, facilitates penile prosthesis implantation into scarred corporal bodies. Disclosure No

(347) Prediction of Post-operative Sexual Satisfaction after Penile Prosthesis Implantation (With and Without Penile Lengthening Procedures) Using Preoperative Penile Length Measurements

Abstract Introduction `- Penile prosthetic devices are the gold standard treatment of medication-resistant erectile dysfunction, however penile length reduction was reported as one of the main post operative disturbing complaints - Many lengthening procedures during penile prosthesis implantation (PPI) were described to increase postoperative sexual satisfaction. Objective `- To predict post-operative sexual satisfaction after PPI (with or without penile lengthening procedure) using preoperative penile length measurements. Methods `- This study was conducted in our urology department as prospective RCT, in the period between August 2018 till April 2020 - It included 61 male patients with organic ED who are candidates for PPI. - Patients were randomized to 2 groups; group A included 31 patients who underwent suspensory ligament release via penopubic Z-plasty, dorsal phalloplasty, suprapubic lipectomy, +/− ventral phalloplasty (in case of high scrotal insertion); group B included control patients who underwent PPI only via penoscrotal incision. - Measurement of preoperative and postoperative (after 3 months) penile lengths were done, including; the flaccid, visible stretched and functional stretched penile lengths. - Assessment of patients’ sexual satisfaction was done using the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) score adapted to penile prosthetic implant. - Patients with EDITS scores of 60-80 were considered satisfied, and those with EDITS scores of 80-100 were considered very satisfied. - Receiver operating curve (ROC) analysis was done to detect cutoff value for the preoperative stretched penile lengths (functional &amp; visible) that are predicted to aid the patient to reach a postoperative satisfaction of EDITS ≥90 in each group. Results `- The mean preoperative measurements showed no statistically significant difference between the two groups. - However, the mean postoperative measurements after 3 months demonstrated a statistically significant difference between the two groups. - The mean values of both overall EDITS and the EDITS resting state and malleability scores were higher in group A (91.92 ± 7.22 and 7.38 ± 0.78) Vs. (79.55 ± 15.55 and 5.32 ± 1.12) in group B (p &amp;lt; 0.001) - For EDITS satisfaction level, the percentage of the very satisfied patients [≥ 80] in group A (89.7%) was significantly higher than in group B (64.3%) (p= 0.045) - Also, for the EDITS resting state and malleability satisfaction level, the percentage of the very satisfied patients in group A (55.2%) was significantly higher than in group B (0.0%) (p &amp;lt; 0.001) - ROC curve was done for both groups In group A: - Functional stretched penile length: AUC 0.815 with a cutoff value of 12.75 cm yielding a 81.8% sensitivity and 71.4% specificity (p value = 0.013) - Visible stretched penile length: AUC 0.795 with a cutoff value of 10.75 cm yielding a 81.8% sensitivity and 71.4% specificity (p value =0.020) In group B: - Functional stretched penile length: AUC 0.927 with a cutoff value of 14.50 cm yielding a 77.8% sensitivity and 94.7% specificity (p value &amp;lt; 0.001) - Visible stretched penile length: AUC 0.892 with a cutoff value of 12.50 cm yielding a 66.7% sensitivity and 94.7% specificity (p value &amp;lt;0.001). Conclusions `- Preoperative measurement of functional and visible penile lengths can be of value in predicting post-operative sexual satisfaction after PPI (with or without concurrent penile lengthening procedures). Disclosure No

Shaeer's Cavernotome for Penile Prosthesis Implantation in Scarred Corpora Cavernosa.

Penile prosthesis implantation in scarred corporal bodies is one of the most challenging urologic procedures, with high risks of perforation and/or failure. We present Shaeer's Cavernotome (patent application number PCT/EG2021/050003). This is the forward-cutting cavernotome that relies on the principle of controlled coring and grinding rather than forward stabbing, with fibrous tissue accommodated into the hollow core, thereby ensuring high efficacy and low risk of perforation. This is a prospective study involving 18 patients with severe corporal scarring. Surgery is performed through a peno-scrotal incision with an indwelling urethral catheter. Corporotomies are incised and a 2-cm-long core of fibrous tissue is excised with a scalpel. Shaeer's Cavernotome is introduced and lodged against the fibrous tissue. Coring proceeds with the stretched corpus or crus held between the thumb and index fingers of the non-dominant hand as a guide, ahead of the tip. Shaeer's cavernotome doubles as a sizer. Following coring, penile prosthesis implantation proceeds. Dilation of the corpora cavernosa was successful in 17 out of 18 patients. Average coring time was 8 ± 3.2 minutes. Dilation was up to girth 13 Hegar in 12 patients, and 11 in 5. No perforations or infections were encountered. Shaeer's cavernotome facilitates penile prosthesis implantation in scarred corporal bodies. Full excavation of both corpora cavernosa is achievable in less than 10 minutes, with a low risk for perforation.

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.

No touch modified ectopic reservoir placement

IPP reservoir has been traditionally placed at the retropubic space of Retzius . Multiple severe complications have been reported with retropubic placement, including vascular, bladder and bowel injuries due to blind insertion of the reservoir through a puncture of the inguinal canal floor. Our technique for ectopic deep subcutaneous reservoir placement through penoscrotal incision under vision offers a safer and simpler alternative to the traditional reservoir placement with less complications. This technique was implemented by a single high volume surgeon in 52 patients with a median follow up of 1 year. Our technique is done by covering the surgical field by two Ioban drapes, after which a penoscrotal incision is made through the drapes. Next, hooks are placed to expose the area, and two W-shaped stay sutures are placed over both corporas. Blunt dissection by finger, assisted by Deaver, is done parallel to the corpora towards the ipsilateral shoulder. Reservoir space is made with sponge holder. The reservoir is inserted in the subcutaneous area surrounded by a pillow of fat with no surrounding major vessels nearby. Insertion of the reservoir using nine inch clamp. Closing of the tunnel used to insert the reservoir by absorbable suture to avoid prolapse. The rest of the surgery is done in the usual way One patient developed infection, which was treated by Mulcahy salvage removal of implant components and insertion of malleable implant. No patients experienced reservoir prolapse, reservoir herniation, or implant malfunction. Visible or palpable reservoirs were only noticed in thin patients and became significantly less visible two months after surgery. Deep subcutaneous insertion may be a safe, easy alternative location for reservoir placement in average and overweight patients, or in those with previous pelvic or abdominal surgery. The author declares that there is no conflict of interest.

Corporotomy localization in inflatable penile implant surgery: learning curve and comparing different surgical approaches in high volume surgeons

Inflatable penile prostheses (IPP) is a viable solution for patients with erectile dysfunction unresponsive to or with contraindications for conservative treatment. In contrast to rapporting of IPP design and material modifications, no data exist regarding the effect of different surgical approaches during IPP implantation on the corporotomy site. The purpose of the present multi-center study was to investigate different IPP implantation surgical approaches and their influence the corporotomy site, while the effect of learning curve on the corporotomy site was also evaluated. Data was collected from 6 high-volume IPP surgeons. Surgical notes were searched for incision site, proximal and distal corporal length measurement, total length measurement, total cylinder length, length of rear tip extenders (RTE), surgery time, type of implant and reservoir placement while postoperative complications were also reported. The association between proximal/distal corporal length, the recorded covariates and infectious complications were examined. 1757 patients with virgin 3-piece IPP implantation were included in the analysis. The proximal/distal ratio averaged at 0.829 (SD ±0.293) in penoscrotal incisions (N=782), 0.687 (SD± 0.245) in infrapubic (N=1664) and 0.724 (SD± 0.179) in subcoronary (N=972) incisions. No significant differences where observed in the three highest volume surgeons. Correcting for significant covariates (diabetes mellitus, RTE, age) did not change this outcome. In the three highest volume surgeons, a more proximal incision resulted in significantly less RTE use. There was no difference in infectious complications with different surgical techniques (p = 0.280). Focusing on the data of the principal center, we found a decrease in the proximal/distal ratio of 8.41% per additional year of experience. We were unable to draw a firm conclusion about the difference in corporotomy site between different surgical approaches as such, but we found no significant difference between the highest volume surgeons using different techniques. Nevertheless, a significant effect of experience on the proximalization of the corporotomy was reported. none

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.

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 ...

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 ...

The Efficacy of Suspensory Ligament Release and Pubic Lipectomy Via Penopubic Z Plasty During Penile Prosthesis Implantation in Improving Sexual Satisfaction: A Prospective Randomized Controlled Trial

The utility of penile suspensory ligament release (SLR) in the setting of penile prosthesis implantation (PPI) has received limited attention in the literature. To assess the efficacy and safety of penile SLR release, pubic lipectomy (PL), and the utility of penopubic Z-plasty (ZP) during malleable PPI in improving sexual satisfaction compared to that achieved with the conventional method. Between August 2018 and April 2020, 61 patients with refractory erectile dysfunction were prospectively randomized into 2 groups; group A included 31 patients who underwent PPI with SLR and PL via ZP, and group B included 30 patients who underwent conventional PPI via a penoscrotal incision. Penile length was assessed at 3 months, and sexual satisfaction was assessed up to 1 year after PPI using both validated and non-validated tools. The median operative time was higher in group A than in group B (170 min; interquartile range [IQR] [160-190] vs 97.5 min; IQR [90-110] P < .001).The median pre- to postoperative differences in functional and visible penile lengths for group A were 1.5 cm; IQR [0-2] and 2.5 cm; IQR [1-3.5], respectively, while those in group B were both 0 cm; IQR [-1 to 0] P < .001). Group A patients reported higher scores in the International Index of Erectile Function satisfaction domains than the group B patients did (13; IQR [12-14] and 9; IQR [8-10] vs 11; IQR [9.5-12] and 8; IQR [6.5-8.5], respectively, P < .001). Moreover, the postoperative Erectile Dysfunction Inventory of Treatment Satisfaction score was higher in group A than that in group B (95.40; IQR [91-97.7] vs 85.20; IQR [72.7-91], respectively, P < .001). Common complications in group A were penile edema (77.4%), penile instability (9.7%) and glans numbness (9.7%). The benefit in patient satisfaction following SLR and PL via ZP during PPI may outweigh the incremental increase in complications. To our knowledge, this is the first prospective randomized controlled study to evaluate the efficacy and safety of SLR, PL, and ZP during PPI. However, because an optimal tool for assessing sexual satisfaction after PPI is lacking at this time, we alternatively adopted the most used assessment tools. Further, our data applies only to malleable penile prosthesis. SLR and PL via ZP during PPI resulted in a substantial improvement of the patients' sexual satisfaction without serious complications.

Sub-Coronal Inflatable Penile Prosthesis Placement: Patient Satisfaction and Outcomes

ABSTRACT Introduction Placement of an inflatable penile prosthesis (IPP) is a common surgical treatment of multiple disorders of male sexual function, including erectile dysfunction (ED) and Peyronie's disease (PD). The infra-pubic and peno-scrotal approaches have classically been favored for IPP placement since the first description of IPP placement in 1973 given reliably good outcomes. A sub-coronal incision was then described in 2016 for the implantation of a multicomponent IPP. The benefits of a sub-coronal approach to IPP placement includes exposure and access to the entire pendulous penis back to the mid bulb to allow for additional reconstructive procedures, such as plaque incision and grafting for Peyronie's disease, which previously would require an additional incision. Objective Although the sub-coronal approach has been described to be operatively feasible with advantageous operating times, the aim of this project is to report outcomes of the sub-coronal approach, such as patient satisfaction, rate of revision, infection, and wound complications. Methods A retrospective chart review from 5/11/2012 to 12/28/2020 was conducted on IPP placements performed at a single, tertiary-care institution to identify patients with IPPs placed via a sub-coronal approach. Data was collected at most recent follow-up date to determine outcomes measures such as satisfaction and complication rates. Results Forty-six patients had IPPs placed through a sub-coronal incision. Mean time to follow-up was 9.81 months (0.46-45.6 months). Of these patients, 22 (47.8%) explicitly expressed satisfaction with the procedure at follow-up. Four (8.7%) had wound complications. Additionally, only one (2.2%) experienced a post-operative prosthetic infection. Revision was performed in 3 IPPs (6.5%). One revision was performed to primarily release prothesis tubing that had become adherent to the left base of penile shaft, which was causing patient discomfort. The same revision served additional cosmetic purpose to reduce redundant skin along the patient's circumcision line. The other two revisions were performed for prosthesis malfunctions: one prosthesis acquired “buckling” leading to a ventral curvature requiring release of scar contraction, and the other prosthesis developed a proximal aneurysm requiring removal and replacement. Conclusions The sub-coronal approach for placement of an IPP is a promising alternative to the infra-pubic and peno-scrotal incisions with high patient satisfaction, low complication, and low revision rates. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast

Corporal Excavation and Grafting for Inflatable Penile Prosthesis Implantation in Severe Corporal Fibrosis

ABSTRACT Introduction Inflatable Penile Prosthesis (IPP) insertion becomes substantially more difficult in men with severe corporal fibrosis due to the need for dilation through scar tissue and decreased diameter of the corporal bodies. In this setting, traditional strategies of dilation have increased risk of urethral and glanular perforation given obliteration of normal dilation planes. This is a rare, but significant surgical challenge whose body of evidence contains few studies with small cohorts. Objective To describe and analyze our institution's experience with complex IPP placement in patients with severe corporal fibrosis using corporal excavation and/or grafting. Methods We performed a retrospective review of all patients with severe corporal fibrosis who underwent IPP placement using a technique of corporal excavation and/or grafting between 01/2006—05/2021. Corporal excavation involved a penoscrotal incision extending the full length of penile shaft for complete exposure of the corpus spongiosum and direct excision of the entire central fibrotic core. Corporal grafting involved sewing grafts in areas of the corporal implant bed that remained severely narrowed after excavation to accommodate the IPP cylinder(s). Our two primary outcomes were (1) post-operative complications and (2) surgical success, which was defined as erections sufficient for intercourse in the absence of post-operative complication requiring re-operation. Results Ten cases meeting inclusion criteria were identified with 1 involving corporal excavation only, 4 involving grafting only, and 5 involving corporal excavation and grafting. In all cases, severe fibrosis was due to trauma (n=3), priapism requiring corporal shunting (n=3) or prior IPP infection and explant (n=4). All were implanted with an AMS-700 three-piece IPP and five patients required insertion of a reduced diameter IPP. Five out of 9 (55.6%) cases involving grafting used a Tutoplast pericardium allograft and 4/9 (44.4%) cases used a Gore-Tex synthetic graft. When graft was used, the median area used was 10.0 centimeters (IQR 4.5-11.8). Median operative duration was 315 minutes (IQR 243.75-370.5). Median post-operative hospital stay was 1 day. Post-operative complications included 2 (20%) cases of infection requiring antibiotics and 1 (10%) case of post-operative neuropathic pain/distal glans numbness. Median follow-up duration was 3.8 months (IQR 1.5-65.7) across all groups, with surgical success seen in 3/4 (75%) grafting cases, 1/1 (100%) excavation cases, and 5/5 (100%) simultaneous excavation and grafting cases. Failure was seen in one case due to penile shortening that required a penile lengthening procedure and IPP upsizing 10 months post-operatively. Conclusions IPP insertion in the setting of corporal fibrosis is complex. Downsized cylinders may be required due to contracture of the tunica albuginea. However, patients with corporal fibrosis may safely undergo IPP placement with good intermediate term outcomes using corporal excavation and/or grafting. Disclosure No