Surgical Technique For Placement Research Articles

EC-IC bypass for occlusion of the internal carotid artery

There are barely any alternative treatment options to the drug treatment of hemodynamically caused cerebral ischemia, as in occlusion of the internal carotid artery. For secondary prevention of an ischemic stroke due to carotid occlusion and hemodynamic instability, extracranial-intracranial (EC-IC) bypass surgery can be an important option in selected patients. The development, study situation, indications and surgical technique for placement of an EC-IC bypass in cases of occlusion of the internal carotid artery are presented. With appropriate expertise and strict selection of patients, the placement of an EC-IC bypass enables stabilization of cerebral perfusion with a low rate of complications. The study situation is controversially discussed; nevertheless, surgical treatment in a specialized neurovascular center should at least be considered.

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

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

Punch vs open surgical techniques for placement of bone-anchored hearing implants: a systematic review and meta-analysis of skin reactions and operating time.

Several authors have reported their experience with the punch technique as compared to open surgical methods for bone-anchored hearing implants (BAHI). However, no study has attempted to aggregate current evidence. We aimed to compare post-operative skin complications and operating time between punch and open surgical techniques of BAHI via a systematic review and meta-analysis. Databases of PubMed, Embase, Scopus, BioMed Central, Ovoid, and CENTRAL were screened up to 15th February 2020 to include studies comparing punch and open surgical technique for BAHI. Eight studies were included. Punch technique was compared with dermatome and linear incision techniques with and without soft tissue reduction. There was no difference in normal-to-moderate skin reaction between the punch and open surgical techniques (OR: 0.86 95% CI 0.23, 3.28 I2 = 0%). The incidence of adverse skin reactions were also not different between the two groups. Meta-regression for different follow-up periods did not demonstrate any statistically significant results. Our results also indicated that punch technique requires less operating time, however, the inter-study heterogeneity in the analysis was very high. Similar results were seen on sub-group analysis based on the type of open surgical technique. There may be no difference in skin tolerance between the punch technique and open surgical techniques. Operating time may be significantly reduced with the punch technique. Strong conclusions cannot be drawn owing to a limited number of studies. Further large-scale randomized trials are required.

Dorsal root ganglion stimulation for treatment of complex regional pain syndrome of the foot.

This is a case of a 54-year-old man presenting with complex regional pain syndrome (CRPS) type 1 of the right lower extremity, which was most debilitating in the plantar aspect of the right foot. The patient had prior treatment with thoracic spinal cord stimulation; however, the foot pain remained intractable. Given that his pain was predominantly in his foot and remained debilitating despite thoracic spinal cord stimulation, it was recommended that the patient undergo a trial of dorsal root ganglion (DRG) stimulation. The surgical technique for placement of dorsal root ganglion stimulators is demonstrated in this operative video.The video can be found here: https://youtu.be/_1xMxFZa6tU

Surgical technique for placement of the automated low flow ascites pump (Alfapump).

Approximately 10% of patients with ascites associated with cirrhosis fail to respond to dietary rules and diuretic treatment and therefore present with refractory ascites. In order to avoid iterative large-volume paracentesis in patients with contraindication to TIPS, the automated low flow ascites pump system (Alfapump) was developed to pump ascites from the peritoneal cavity into the urinary bladder, where it is eliminated spontaneously by normal micturition. This manuscript reports the surgical technique for placement of the Alfapump.

Dilatable pulmonary artery banding for ventricular septal defect: surgical technique and case report of three cats

Pulmonary artery banding (PAB) is a viable but underreported palliative option for hemodynamically significant ventricular septal defect in small animals. A significant challenge associated with PAB is judging the degree of band tightening, which can be further complicated when animals are immature and still growing at the time of PAB. If a pulmonary artery band is overtightened or becomes progressively too tight after surgery, the result can be reversal of shunt flow with potentially devastating consequences. Placement of a band that could be percutaneously dilated using a balloon catheter affords a minimally invasive option for partially or completely relieving the band should it become too tight after PAB. This report describes a surgical technique for placement of a dilatable pulmonary artery band, reviews guidelines for tightening the band, and reports the outcome of three cats undergoing the procedure. All three cats showed evidence of reduced hemodynamic load after PAB for a period of up to three years after PAB.

Comparison of Percutaneous versus Open Surgical techniques for placement of Peritoneal Dialysis Catheters

Background: Nephrologists have used percutaneous placements of peritoneal dialysis catheters (PDCs) with or without fluoroscopic guidance. PDCs are also placed using mini-laparotomy and laparoscopic techniques by surgeons. Percutaneous PDC placement by nephrologists is a simple, non-invasive technique with minimum intraoperative morbidity. We compared operative and immediate complications of PDCs using percutaneous versus open surgical mode of insertion.
 Methods: Data of all patients entering into CAPD programme in our center between July 2011 to July 2015 was collected. A total of 377 PDCs had been inserted over 48 months in 358 patients. Of 377 catheters inserted, 224 had been inserted by percutaneous method and 153 by surgical technique.
 Results: Wound hematoma developed in 3.5% of percutaneously placed catheters vs 2.6% of catheters placed by surgical technique, p-0.061. Haemorrhagic effluent was seen in 4.46% of percutaneously placed catheters vs 3.92% of surgically placed catheters, p-0.068. Bowel injury occurred in 1.33% of percutaneously placed catheters vs 0.65% of surgically placed catheters, p-0159. Dialysate leak occurred in 2.6% of catheters placed percutaneously vs 6.5% of catheters placed by surgical technique, p-0.068. Percutaneous PDC allowed a significantly shorter hospital stay, smaller wound size and less break-in period
 Conclusions: Percutaneously placed CAPD catheters by nephrologists ensues significantly less hospital stay, small sized incision, lesser break-in period and less post-surgical morbidity as compared with surgically placed catheters. Percutaneous PDC placement is minimally invasive, safe, less time consuming and dependable peritoneal access technique.

Surgical technique for placement of the Melody valve in a dilated right ventricular outflow tract

Surgical technique for placement of the Melody valve in a dilated right ventricular outflow tract

Surgical placement of a wireless telemetry device for cardiovascular studies of bovine calves

Background: Domestic cattle ( Bos taurus) are naturally susceptible to hypoxia-induced pulmonary arterial hypertension; consequently, the bovine calf has been used with considerable success as an animal model of the analogous human condition. Studies to date, however, have relied on instantaneous measurements of pressure and cardiac output. Here, we describe the surgical technique for placement of a fully implantable wireless biotelemetry device in a bovine calf for measurement of pulmonary arterial and left ventricular pressures, right ventricular output, and electrocardiogram. Methods: Three, 2-month old bovine calves underwent left-sided thoracotomies. A transit-time flow probe was placed around the pulmonary artery and solid-state pressure catheters inserted into the pulmonary artery and left ventricle. Biopotential leads were secured to the epicardium. The implant body was secured subcutaneously, dorso-caudal to the incision. Results: The implant and sensors were successfully placed in two of the three calves. One calf died from ventricular fibrillation following left ventricular puncture prior to pressure sensor insertion. Anatomical discrepancies meant that either 4 th or 5 th rib was removed. The calves recovered quickly with minimal complications that included moderate dyspnea and subcutaneous edema. Conclusions: Left thoracotomy is a viable surgical approach for wireless biotelemetry studies of bovine calf cardiovascular function. The real-time, contemporaneous collection of cardiovascular pressures and output, permits pathophysiological studies in a naturally susceptible, large animal model of pulmonary arterial hypertension.

Surgical placement of a wireless telemetry device for cardiovascular studies of bovine calves.

Background: Domestic cattle ( Bos taurus) are naturally susceptible to hypoxia-induced pulmonary arterial hypertension; consequently, the bovine calf has been used with considerable success as an animal model of the analogous human condition. Studies to date, however, have relied on instantaneous measurements of pressure and cardiac output. Here, we describe the surgical technique for placement of a fully implantable wireless biotelemetry device in a bovine calf for measurement of pulmonary arterial and left ventricular pressures, right ventricular output, and electrocardiogram. Methods: Three, 2-month old bovine calves underwent left-sided thoracotomies. A transit-time flow probe was placed around the pulmonary artery and solid-state pressure catheters inserted into the pulmonary artery and left ventricle. Biopotential leads were secured to the epicardium. The implant body was secured subcutaneously, dorso-caudal to the incision. Results: The implant and sensors were successfully placed in two of the three calves. One calf died from ventricular fibrillation following left ventricular puncture prior to pressure sensor insertion. Anatomical discrepancies meant that either 4 th or 5 th rib was removed. The calves recovered quickly with minimal complications that included moderate dyspnea and subcutaneous edema. Conclusions: Left thoracotomy is a viable surgical approach for wireless biotelemetry studies of bovine calf cardiovascular function. The real-time, contemporaneous collection of cardiovascular pressures and output, permits pathophysiological studies in a naturally susceptible, large animal model of pulmonary arterial hypertension.

Biomechanical Three-Dimensional Finite Element Analysis of Single Implant–Supported Prostheses in the Anterior Maxilla, with Different Surgical Techniques and Implant Types

The aim of this study was to use three-dimensional finite element analysis to analyze the stress distribution transferred by single implant-supported prostheses placed in the anterior maxilla using different connections (external hexagon, internal hexagon, or Morse taper), inclinations of the load (0, 30, or 60 degrees), and surgical techniques for placement (monocortical/conventional, bicortical, or bicortical with nasal floor elevation). Nine models representing a bone block of this region were simulated by computer-aided design software (InVesalius, Rhinoceros, SolidWorks). Each model received one implant, which supported a cemented metalloceramic crown. Using FEMAP software, finite elements were discretized while simulating a 178-N load at 0, 30, and 60 degrees relative to the long axis of the implant. The problem was solved in NEi Nastran software, and postprocessing was performed in FEMAP. Von Mises stress and maximum principal stress maps were made. The von Mises stress analysis revealed that stress increased with increasing inclination of the load, from 0 to 30 to 60 degrees. Morse taper implants showed less stress concentration around the cervical and apical areas of the implant. The bicortical technique, associated or not with nasal floor elevation, contributed to decreasing the stress concentration in the apical area of the implant. Maximum principal stress analysis showed that the increase in inclination was proportional to the increase in stress on the bone tissue in the cervical area. Lower stress concentrations in the cortical bone were obtained with Morse taper implants and the bicortical technique compared with other connections and surgical techniques, respectively. Increasing the inclination of the applied force relative to the long axis of the implant tended to overload the peri-implant bone tissue and the internal structure of the implants. The Morse taper connection and bicortical techniques seemed to be more favorable than other connections or techniques, respectively, for restoring the anterior maxilla.

P.092 Ommaya reservoir placement for intraventricular chemotherapy: a retrospective case series in the image-guidance era

Background: In 1963, Ayub Ommaya proposed a surgical technique for placement of a subcutaneous reservoir and pump to allow access to intraventricular cerebrospinal fluid (CSF). Currently, the most common indication for Ommaya reservoir insertion in adults is for patients with hematologic or leptomeningeal disorders who require repeated injection of chemotherapy into the CSF space. Historically, the intraventricular catheter has been inserted blindly based on anatomical landmarks. The purpose of this study was to determine short-term complication rates from Ommaya reservoir placement in the image-guidance era. Methods: We retrospectively evaluated all operative cases of image-guided Ommaya reservoir insertion from 2004-2014 by the senior author (JFM). Patient demographic data and peri-operative complications were collected. Results: We identified 28 patients over the study period (43.3+/-17.3 years; 64.3% male). Indications for placement included acute lymphoblastic leukemia, diffuse large B-cell lymphoma, and leptomeningeal carcinomatosis. There was one asymptomatic peri-operative intracranial hemorrhage (3.6%), and one early infection (3.6%). All catheters were well-positioned and functional. Conclusions: In our retrospective single-centre case series, all catheters were placed accurately. Our results support routine use of intra-operative image guidance for proximal catheter insertion in elective Ommaya reservoir placement for intraventricular chemotherapy.

Treatment of severe tracheobronchomalacia: Ten-year experience

IntroductionPaediatric tracheobronchomalacia is a rare but potentially serious condition. Severe tracheobronchomalacia requires intervention or operation. This is an evaluation of a ten-year experience at an institution. MethodsIn this retrospective study all patients were included that required an intervention for severe tracheobronchomalacia from 2003 to 2012. Symptoms, aetiology, comorbidities, localisation of the malacia, age at diagnosis, therapeutic measures and associated complications were evaluated. ResultsForty-four patients with severe tracheobronchomalacia underwent intervention/operation. The predominant aetiology was vascular compression in 48%. The majority of patients had complex comorbidities, most importantly cardiac pathology in 66%. The median age at diagnosis was 3 months. A total of 17 aortopexies, 21 tracheostomies and 25 stent placements were performed. The mean follow-up was 2.6 years. Severe complications occurred in 12 patients. The most common complications were stent obstruction/fracture and tracheostomy tube obstruction. ConclusionThe management of severe tracheobronchomalacia is complex and the population of patients is very heterogeneous. Therefore the treatment has to be adapted for each patient individually. The decision strategies are discussed in this article. The surgical techniques for placement and safe removal of expandable bare metallic stents employed in our institution are presented. A multidisciplinary team of ENT surgeons, Intensivists, Cardiologists and Cardiac surgeons is of great importance.

Anthropometry of the Vertebral Pedicles of the Thoracic Spine without Pathology in Mexican Patients of a Public Institution in the Metropolitan Area

Introduction The anatomy of the pedicles is complex and vary according to the region valued. For proper placement of a transpedicular screw requires a high knowledge of the anatomy of the pedicle and the different surgical techniques for placement. Tomography is the best radiological tool for measuring various parameters of the pedicles. The purpose of this study was to determine, through tomography, thoracic pedicle anthropometry of the Mexican population and its variations according to sex, with the aim of providing irrefutable anatomical information for the development of techniques, materials, and tools more specific to our population pedicle fixation. Methods This study is a descriptive, retrospective, and observational study. The source collection and measurement were performed on CT chest scan of Unit Trauma Hospital “Dr. Victorio de la Fuente Narv·ez,” between January 2012 and June 2013, on computer tomographic Siemens Somatom and General Electric of 16 cuts, which were made in Mexican patients without lesions in the thoracic spine, with an age range of 18 and 60 years, who had axial, sagittal, and coronal to no more than 3 mm in T1 to T12 levels in the left and right pedicles. The sample size was calculated using tables Hulley, given a universe of 1,620 thoracic CT, with a confidence level of 95% amplitude interval 0.15, an expected ratio of 0.15, and a β 0.20, determined a sample of 122 scans. Measurements (axial and sagittal diameter, coronal morphology, axial, and sagittal angulation) were performed by two observers and the involvement of a third when discordance of more than 10% between the first two was found. Data analysis was performed with SPSS version XVII, using descriptive statistics and weighted Kappa. Results The pedicles were of smaller diameter T5, with 2.03 ± 0.94 mm in men and 1.66 ± 0.77 mm in women. The smallest sagittal diameter was found in T2, with 1.95 and 10.15 ± 9.27 ± 2.60 mm, respectively. The angle was increased axial T1, averaging 32.70 ± 4.37ʃ. The sagittal angle of thoracic pedicle showed greater angles from T4 to T10. Predominated teardrop at T1–T3, the elongated drop in T4–T5 and T11–T12, and kidney-shaped in T6–T10. Conclusions Women may be less than the male population values. From T3 to T9 pedicles are smaller than the diameter of the screws that are included in the market. Therefore, anteroposterior, lateral, and axial assessment of each vertebral body to the pedicle screws placement necessary; we also seek new screw placement techniques as described in-out-in, and use technology such as neuronavigation, to continue to benefit from the biomechanical properties of transpedicular instrumentation both to the surgeon and the patient.

The S-Tunnel for tunnelled dialysis catheter: an alternative approach to the prevention of displacement.

Vascular access has been described in the literature anywhere from the 'Achilles Heel' to the 'Cornerstone' of haemodialysis. Displacement of a central venous catheter is not an uncommon occurrence. We discuss an alternative method of placement for the tunnelled central venous catheter to prevent displacement in those patients with excess anterior chest wall soft tissue. A new surgical technique for placement of a tunnelled central venous catheter was developed in an attempt to reduce the number of displacements. This involved the creation of a second tunnel at a 90° angle to the original retrograde tunnelled path. The authors have currently placed five 'S-Line' tunnelled central venous catheters with no reports of displacement or line infection over a period of 18 months. The 'S-Line' offers a simple, straightforward and most importantly safe method to reduce the incidence of tunnelled right internal jugular central venous catheter displacement.

New technique for open placement of paddle-type spinal cord stimulator electrode in presence of epidural scar tissue.

The objective of this study is to present a novel surgical technique for safe placement of paddle-type spinal cord stimulation (SCS) electrode in the presence of epidural scar tissue. We developed a new surgical technique for placement of paddle-type SCS electrode in presence of epidural scar tissue when conventional placement methods had failed. The technique involves creating a laminotomy trough to provide an adequate window for dissection of scar tissue to ensure safe placement of the electrode. We have applied this technique in eight patients. Safe placement of SCS electrode was achieved in all eight patients without any complications. All electrodes were placed between T8 and T10 levels, and we were able to place the electrodes in the midline and achieve adequate coverage in all cases. SCS is a widely accepted treatment modality for chronic neuropathic pain. Placement of paddle electrode can be challenging, usually because of the presence of epidural scar tissue. There have been reported cases of spinal cord injury related to paddle electrode placement. We present a novel technique that allows for safe placement of a paddle-type SCS electrode in more challenging surgical circumstances, including the presence of epidural scar tissue.

Two-Step Technique for Posterior Optic Buttonholing of Intraocular Lens

This study aims to describe a two-step surgical technique for placement of a posterior chamber intraocular lens (IOL) in cases with crystalline lens subluxation resulting from non-progressive zonular dialysis. The first stage entails a phacoemulsification with creation of a 4-mm posterior capsular opening using an automated vitrector. The second stage performed 6 weeks later includes an anterior vitrectomy and injection of a foldable three-piece IOL in the sulcus. The haptics of IOL are positioned in the sulcus while the optic is pushed behind the posterior capsular opening therefore "buttonholing" the IOL. Seven eyes of seven patients with posttraumatic zonular dialysis were operated using this technique. Follow-up of all cases revealed a well-centered IOL with good postoperative visual acuity (20/20 to 20/80). Our two-stage surgical technique precludes the insertion of capsular tension ring in cases with non-progressive zonular dialysis. The technique is recommended in the presence of less than or equal to 6 clock hours of zonular dialysis with preexisting posterior capsular tear or herniation of vitreous in the anterior chamber.

Surgical outcomes analysis of pediatric peritoneal dialysis catheter function in a rural region

PurposeThe purpose of this study was to analyze the experience with peritoneal dialysis (PD) at a high-volume, single center institution that supports a rural population. MethodsFrom 2000 to 2010, 88 children (median age: 1.98 years, [range: 2 days–20.2 years]) received 134 PD catheters for the management of acute and chronic renal failure. The primary outcome of interest was the incidence of primary PD catheter failure (replacement or revision within 60 days). Operative technique, longitudinal outcomes, and time intervals to transplantation were analyzed. ResultsMedian time to transplant from the institution of dialysis was 1.4years [range: 0.3–6.4years]. Primary catheter failure occurred in 24.6% of cases. Infants less than 6months of age demonstrated an increased incidence of primary catheter failure (p=0.02). The operative technique for catheter placement was not associated with the incidence of primary failure. Postoperative complications included peritonitis (22.7%), omental plugging (11.9%), pericatheter drainage (9.0%), and exit site infection (3.0%). ConclusionPeritoneal dialysis provides a safe and effective renal replacement therapy for regional pediatric centers that serve a rural population. However, primary catheter failure rates remain high at 24.6%. The surgical technique for placement had no effect on this failure rate in our patient population. Infants less than 6months of age are at increased risk for primary catheter failure and warrant intensive surveillance.

Zygomatic implants: a critical review of the surgical techniques

The purpose of the present study is to identify and describe the different surgical techniques for placement of zygomatic implants reported in the literature and discuss the differences between them. An electronic search was undertaken in July 2011. The titles and abstracts from these results (n = 130) were read for identifying studies, which reported different surgical techniques for placement of zygomatic implants, which resulted in 41 articles. Five different surgical approaches were identified: (1) the classical approach, (2) the sinus slot technique, (3) the exteriorized approach, (4) the minimally invasive approach by the use of custom-made drill guides, and (5) the computer-aided surgical navigation system approach. When the maxilla is severely resorbed, the concavity formed by the ridge crest is small, and the original classical technique should be used. When maxillary resorption generates a large concavity, it would be better to exteriorize the zygomatic implant. The externalized technique has fewer surgical steps than the classical and sinus slot methods, is less invasive, and reduces surgical time. It is recommended that utilization of the sinus slot technique together with the CT-based drilling guide would enhance the final results. Although the technique that uses the computer-aided surgical navigation system approach may produce an improved precision in the clinical procedure, its use is expensive, prolongs the operation time, and is limited to centers that have the necessary equipment for the surgery. Preference for one technique over the other should take into consideration the concavity formed by the ridge crest, maxillary sinus, and region of implant insertion in the zygomatic bone.

Advances in Prosthetic Urology

The inflatable penile prosthesis (IPP) has become the gold standard treatment for erectile dysfunction among men refractory to medical therapies. Among the many treatments for erectile dysfunction, implantation of a penile prosthesis has been associated with high patient satisfaction rates and low mechanical failure rates. In this special issue, seven articles are presented, including primary research, reviews, and methodological reports, to highlight outcomes related to patient satisfaction with IPPs, advances in surgical placement techniques, and methods for penile size enhancement concomitant with implant placement. The safety and efficacy of the IPP have been well documented, but in spite of this, urologists may be reluctant to offer an IPP to older patients due to various concerns, including impaired dexterity of older patients and their ability to operate an inflatable device. To determine the outcomes of and satisfaction with the multicomponent IPP in the elderly male, Villarreal and Jones retrospectively assessed patients using chart review and telephone interview. To analyze overall patient satisfaction with IPPs with a consistent approach, Bernal and Henry conducted a review of the literature over the past 20 years. Nine articles met inclusion criteria for analysis and data collation. Despite the fact that varied metrics were used to determine patient satisfaction, they found that patients in general were very satisfied with their three-piece IPPs and restoration of sexual function, and they identified common reasons for patient dissatisfaction. The number one patient complaint after IPP placement is loss of penile length. One IPP company has recently remade a product that has longer length cylinders than those formerly available. However, traditionally, longer cylinders were believed to lack axial rigidity. Henry et al. present a prospective, multicenter research study, performed on the new product to address this concern. In a methodology report, Hakky et al. present an overview of various techniques performed concomitantly with IPP placement surgery to enhance penile length and girth. Outcomes can be improved by combining the use of adjunct surgical techniques; these adjuvant procedures are a key addition in the armamentarium for the serious implant surgeon. In two methodological articles, surgical techniques and outcomes are described related to surgical treatment of erectile dysfunction. First, Martinez et al. describe common surgical techniques for treatment of Peyronie's disease, a clinical condition that interferes with erectile function. Despite attempts to uncover the pathophysiology behind Peyronie's disease, it remains an enigma, with a reported incidence that is rising, in part because more men come forth to seek treatment. Second, Karpman reports on a streamlined approach for infrapubic placement of an IPP. A better understanding of operative techniques and recent clinical outcome studies have led to an evolution of the original infrapubic approach with significant contributions by Dr. Perito as discussed in the erratica. Small incisions and efficient operative maneuvers can shorten operative times and expedite postoperative recovery. Finally, Henry et al. present a review of outcomes for subarachnoid versus general anesthesia during IPP surgery. The leading patient complaint during the perioperative period for penile prosthesis implantation is postoperative pain, while emesis and urticaria also affect the procedure's perceived success. This paper retrospectively reviews 90 consecutive, primary inflatable penile prosthetic operations performed by a single surgeon at one private medical center. As erectile dysfunction is highly prevalent in our society, increasing with age, and life expectancy continues to increase, continued research and development regarding IPPs remain an important area of work. Gerard D. Henry Andrew C. Kramer Rafael E. Carrion Brian Christine