Undergoing Inflatable Penile Prosthesis Implantation Research Articles

Downstream Revenue Realized by Facilities Placing Inflatable Penile Prosthesis in Medicare Beneficiaries to Treat Erectile Dysfunction

ObjectivesTo quantify the incremental downstream revenue generated from subsequent treatment of men who received an inflatable penile prosthesis (IPP) to treat erectile dysfunction (ED), compared to men without ED. MethodsThe 100% Medicare Standard Analytic Files were used to conduct a retrospective claims analysis of the 5-year revenue generated by patients receiving IPP to treat their ED, compared to a propensity-matched cohort of men without ED. Men aged 65 years or older with ED who underwent IPP implantation (Current Procedural Terminology® 54405) in a hospital outpatient setting between January 1, 2016 and December 31, 2021, and who had continuous Medicare Parts A and B enrollment for 12 months pre-index IPP and five years post-index IPP discharge date were included in the study. Men without ED but with comparable characteristics were identified and used as a comparator group. Revenue received by hospitals from Medicare was defined as the sum of payments for patient services, other payor-paid amounts, patient deductibles, copayments, and coinsurance. Revenue was inflated to 2022 US dollars. The mean values and their corresponding standard deviations (SD) are reported. ResultsAfter matching, there were 2,905 men with ED who received an IPP and 7,462 men without ED. The IPP cohort showed a significantly higher 5-year cumulative revenue (mean=$34,571 [SD=$50,234]) compared to the men without ED (mean=$3,189 [SD=$11,527]). When stratified by diagnosis type, the differences in revenue were $10,258 for circulatory disease, $2,646 for diabetes, $2,013 for urology, and $1,043 for prostate cancer. Significantly more IPP patients had at least one health encounter for these conditions over the 5-year follow-up period than their matched controls (55.0% versus 7.8% for circulatory, 46.7% versus 16.8% for urology, 19.3% versus 3.6% for diabetes, and 19.0% versus 3.0% for prostate cancer). ConclusionsMen with ED who received IPP generated substantially higher revenue for the healthcare system over a 5-year period, nearly ten times as much, compared to men without ED, excluding the initial cost of the IPP procedure. The presence of ED, coupled with IPP usage, is associated with significantly increased healthcare revenue across a range of medical conditions compared to men without ED. These findings emphasize the financial implications for advanced ED programs to improve access to necessary care for these patients. Healthcare facilities may leverage these insights to effectively allocate resources to deliver critical healthcare to men with ED.

(242) Medicare Beneficiaries with Erectile Dysfunction Who Receive Inflatable Penile Prosthesis: A Real-World, Downstream Revenue Analysis

Abstract Introduction Erectile dysfunction (ED) has a significant negative impact on the quality of life of patients, while also presenting challenges due to the limited access to effective treatment options. Given ED is recognized as a precursor for other chronic health conditions, increasing patient access to ED treatment through men’s health programs may provide economic benefits to a healthcare system through revenue generated from subsequent patient care for other comorbidities. Objective This study quantified the incremental downstream revenue generated from treating men with ED with an inflatable penile prosthesis (IPP) compared to men without ED. Methods This retrospective study used the 100% Medicare Standard Analytical Files to identify men aged 65 years or older with ED who underwent IPP implantation (Current Procedural Terminology 54405) in a hospital outpatient setting between January 1, 2016 and December 31, 2021. To capture 5-year downstream revenue, patients were required to have continuous Medicare Parts A and B enrollment for 12 months pre-index IPP and five years post-index IPP discharge date. Propensity score matching (PSM) was used to match men with ED who received an IPP to men without ED based on demographic and clinical characteristics. Revenue was defined as the sum of the payment for patient services received by hospitals from Medicare, other payor paid amounts, and patient deductibles, copayment, and coinsurance. The total revenue generated was estimated as follows: 1-year pre-IPP, 1-year post-IPP, and 5-year cumulative post-IPP. The 1-year and 5-year downstream revenue was captured post-IPP discharge date and excluded the revenue generated from the index IPP encounter. Revenue was inflated to 2022 US dollars. The mean values and their corresponding standard deviations (SD) were reported. Results Before PSM, the study identified 3,367 men with ED who received IPP and 10,609 men without ED or IPP (mean age: 70; White: 77% vs 79%; Southern region: 53% vs 45%; and Elixhauser comorbidity index score ≥3: 21% vs 20%). Among men undergoing IPP, the average revenue generated was $6,152 (SD: $12,934) at 1-year pre-IPP and $7,898 (SD: $17,794) at 1-year post-IPP. After PSM, the men with ED who received IPP showed a significantly higher 5-year cumulative revenue (n=2,905; mean=$34,571 [SD=$50,234]) compared to the men without ED (n=7,462; mean=$3,189 [SD=$11,527]), respectively. The 5-year cumulative average revenue varied by type of diagnosis: circulatory disease (n=1,597; cost difference=$10,258), urology (n=1,358; cost difference=$2,013), diabetes diagnosis (n=562; cost difference=$2,646), and prostate cancer diagnosis (n=551; cost difference=-$1,043). All statistical analysis results post-PSM are significant at p-value less than 0.05. Conclusions Men with ED who received IPP generated substantially higher revenue for the healthcare system over a 5-year period, nearly ten times as much, compared to men without ED, excluding the initial cost of the IPP procedure. These findings emphasize the financial implications of implementing an advanced ED program aimed at improving access to necessary care for these patients. Healthcare facilities can leverage these insights to effectively allocate resources to deliver critical healthcare to men with ED. Disclosure Yes, this is sponsored by industry/sponsor: Boston Scientific. Clarification: Industry initiated, executed and funded study. Any of the authors act as a consultant, employee or shareholder of an industry for: This study was funded by Boston Scientific. Abimbola O. Williams, Sirikan Rojanasarot, Gregory Moore, Alysha M. McGovern, Liesl M. Hargens, and Erin Turner are employees of Boston Scientific. Paurush Babbar is a practicing urologist at The Urology Group in Cincinnati, Ohio and discloses no financial interests. Andrew Sun is a practicing urologist at Urology Partners of North Texas and serves as a consultant for Boston Scientific, Endo Pharmaceuticals, and Marius Pharmaceuticals. Paurush Babbar and Andrew Sun were not compensated for their participation in this study.

(542) Socioeconomic Status is Not Associated with Complications or Patient Satisfaction Following Inflatable Penile Prosthesis Surgery

Abstract Introduction Prior studies have demonstrated that patient socioeconomic background and neighborhood status are associated with health care outcomes. Understanding how a patient’s environment and local community status affect clinical outcomes can vastly impact surgical care, patient education and counseling, as well as surgical outcomes. The Area Deprivation Index (ADI), is a validated measurement evaluating the differences in socioeconomic status between various neighborhoods both on a state and national level. ADI incorporates a composite score of patient income, education level, employment status, and housing quality. No prior studies have looked at how a patient’s socioeconomic status and geographic residence affect postoperative outcomes and patient satisfaction following implantation of inflatable penile prosthesis (IPP). Objective To understand how a patient’s socioeconomic status as measured by the ADI affects overall surgical outcomes and patient satisfaction following IPP placement. Methods Men that underwent a new IPP placement between 6/1/13 and 3/31/22 were included in the study. Using the Neighborhood Atlas National® (Madison, WI), national ADI percentiles (1-100) were calculated for each patient using their home address at the time of surgery. Higher ADIs represent a more disadvantaged socioeconomic status while lower ADIs represent a more advantaged socioeconomic status. Complications were defined as mechanical failure, urethral erosion, infection, intractable pain, or other (ex. hematoma, herniated reservoir, pump revision). A patient satisfaction phone questionnaire was administered measuring overall satisfaction (Likert scale). In order to reduce recall bias and allow for adequate follow-up, the phone questionnaire was limited to men who underwent IPP placement between the 2016-2020. Multivariable logistic regression and multivariable ordinal logistic regression were used to identify the association between ADI and surgical complications and patient satisfaction, respectively. Results A total of 430 men who underwent IPP implantation from 2013 to 2022 were identified and data were retrospectively collected. The final cohort consisted of 83% (n=355) Caucasian men with the median age of 65 (IQR 58-69). The overall complication rate was 11.2% (n=48). Of the 48 total complications, 22 (5.1%) required surgical intervention (mechanical problem n=7, urethral erosion n=1, infection n=9, pain n=1, other n=4). The median national ADI for patients with a complication was 57 (IQR 33-72) compared to 60 (IQR 42-76) in those patients without a complication (p=0.32). A total of 163 men completed the satisfaction phone questionnaire and 70% (n=114) of men stated that they were either very satisfied or satisfied with their IPP. The median ADI for patients who were satisfied was 64 (IQR 43-80) compared to 60 (IQR 42-76) in those patients who were not satisfied (p=0.45). On multivariable analysis, national ADI was not associated with postoperative complications (p=0.57) (Table 1) or with patient satisfaction (p=0.39) (Table 2). Conclusions While living in a disadvantaged neighborhood has been associated with poor health outcomes in other areas of medicine, we found no association between a patient’s socioeconomic status and complications or satisfaction following IPP placement. Regardless of a patient’s geographic residence, patients pursuing an IPP can expect comparable outcomes and overall satisfaction rates suggesting that implant consideration should not be influenced by socioeconomic status. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

(502) Arista™ Hemostat Associated with Decreased Odds of Infection and Reoperation Following Inflatable Penile Prosthesis Surgery in a Diverse, Multiethnic Academic Center

Abstract Introduction Using hemostatic agents to manage intraoperative bleeding or assist in surgical closures is well established practice. Currently, several hemostatic agents such as Arista™, Surgiflo®, and Surgicel® are available for surgeon use when placing inflatable penile prosthesis (IPP). However, the effect of these agents on postoperative infection remains to be seen. Thus, we conducted a study to compare postoperative infection and reoperation rates of Arista™ to other hemostatic agents. Objective Primary objective was to determine if use of Arista™, when compared to other hemostatic agents, was associated with decreased rates of infection and reoperation in patients from a diverse, multiethnic population undergoing a primary IPP implantation. Methods A single institution retrospective study of patients who underwent IPP implantation between December 2015 and February 2022 from a single surgeon was conducted. Patients were sorted into groups based on use of intraoperative hemostatic agents. Demographic data, intra- and peri-operative patient characteristics, reoperation, and post-operative infection information was extracted from electronic medical records. Results A total of 434 patients undergoing primary IPP (95.4% Coloplast and 4.6% AMS devices) met inclusion criteria; of which, 158 (36.4%) received Arista™ and 276 (63.6%) received other hemostats such as Surgiflo®, and Surgicel®. There was no significant difference between age, race, preferred language, BMI, or smoking status between the Arista™ and other hemostat groups. Cardiovascular disease (CVD) and diabetes were prevalent in 76.7% and 56.3% of our sample, respectively. A vast majority (84%) of CVD patients had concomitant diabetes. Median Operative time was significantly shorter in the other hemostat group compared to the Arista™ group (62 minutes vs. 75, P <0.001). There was no significant difference in post-operative instances of urinary retention, emergency department visits, or readmission between the two hemostat groups. Multivariable model controlling for age and CVD (Table 1) revealed that Arista™ was associated with significantly decreased odds of postoperative infection and reoperation when compared to other hemostats (OR = 0.36; 95% CI (0.14 – 0.97), P=0.04). Conversely, active smoking were associated with significantly higher odds (OR = 3.92; 95% CI (1.39 – 11.04), P=0.01). Conclusions Our retrospective study indicates that use of Arista™, regardless of patient CVD status, may lead to decreased infections and subsequent reoperations. Prospective randomized control trials should be pursued to adequately assess the benefits of Arista™ compared to other hemostatic agents. Disclosure No

To drain or not to drain an inflatable penile prosthesis implantation? A multi-institutional experience tracking scrotal hematoma and infection occurrence

ABSTRACT Introduction Although the placement of a drain after inflatable penile prosthesis (IPP) implantation has become a current recommendation by many surgeons, some institutions still disagree believing drainage to be a potential source of infection. Objectives We hereby present our data to defy this belief and to add to the body of evidence supporting postoperative (PO) drainage. Furthermore, we attempt to define the optimal duration for drainage. Methods Our subjects underwent IPP implantation by three European high volume surgeons. All implantations were performed via the penoscrotal access using the Coloplast Titan Touch device. Only patients without a previous penile implantation were included. We divided our patients into 3 groups: Group 1: no-drain (n=60), Group 2: 24-hour drain (n=60) and Group 3: 72-hour drain (n=60). All patients received similar perioperative antibiotics accordingly to clinical guidelines. Surgical outcomes such as presence or absence of PO scrotal hematoma and infection were evaluated and compared between the 3 groups. We defined hematoma as a scrotal swelling correlated with evidence of scrotal free floating fluid on ultrasound examination. The ultrasound was done after 24 hours and on the 3rd and 10th PO days. Overall PO follow up was for 80 days. Results There were no significant differences in age, BMI, operative time, medical comorbidities among our study groups. The patients from Group 3 developed significantly less hematoma compared to Groups 1 and 2. The exact distribution of hematoma incidence was greatest in Group 1: n=12 (20%, p=0.005) followed by Group 2: n=8 (13.3%, p=0.05) and least in Group 3: n=1 (1.7%, p=0.002). Four patients in the no-drain group (6.7% p=0.005) developed IPP associated infection requiring device removal. All four had a hematoma prior to the infection. Groups 2 and 3 were infection-free. Conclusion Prolonged drainage up to 72 hours after virgin IPP implantation significantly reduces hematoma rates without the increased risk of drain-associated infections. Moreover, we believe that the development of a scrotal hematoma, by itself, may be a potential cause for surgical site infection. Disclosure Work supported by industry: no. A consultant, employee (part time or full time) or shareholder is among the authors (Coloplast).

To Drain or Not To Drain an Inflatable Penile Prosthesis Implantation? A Multi-institutional Experience Tracking Scrotal Hematoma and Infection Occurrence

ABSTRACT Introduction Although the placement of a drain after inflatable penile prosthesis (IPP) implantation has become a current recommendation by many surgeons, some institutions still disagree believing drainage to be a potential source of infection. Objective We hereby present our data to defy this belief and to add to the body of evidence supporting postoperative (PO) drainage. Furthermore, we attempt to define the optimal duration of drainage. Methods Our subjects underwent IPP implantation by four European high volume surgeons. All implantations were performed via the penoscrotal access. Only virgin cases were included. We divided our patients into 3 groups: Group 1: no-drain (n=60), Group 2: 24-hour drain (n=60) and Group 3: 72-hour drain (n=60). All patients received similar perioperative antibiotics according to clinical guidelines. Surgical outcomes such as presence or absence of PO scrotal hematoma and infection were evaluated and compared between the 3 groups. We defined hematoma as a scrotal swelling correlated with evidence of scrotal free floating fluid on ultrasound examination. The ultrasound was done after 24 hours and on the 3rd and 10th PO days. Overall PO follow up was for 80 days. Results There were no significant differences in age, BMI, operative time, medical comorbidities among our study groups. The patients from Group 3 developed significantly less hematoma compared to Groups 1 and 2. The exact distribution of hematoma incidence was greatest in Group 1: n=12 (20%, p=0.005) followed by Group 2: n=8 (13.3%, p=0.05) and least in Group 3: n=1 (1.7%, p=0.002). Four patients in the no-drain group (6.7% p=0.005) developed IPP associated infection requiring device removal. All four had a hematoma prior to the infection. Groups 2 and 3 were infection-free. Conclusions Prolonged drainage up to 72 hours after virgin IPP implantation significantly reduces hematoma rates without the increased risk of drain-associated infections. Moreover, we believe that the development of a scrotal hematoma, by itself, may be a potential cause for surgical site infection. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast

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

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

PD20-07 A DESCRIPTIVE ANALYSIS OF POST-OPERATIVE URINARY RETENTION (POUR) IN PATIENTS UNDERGOING IMPLANTATION OF INFLATABLE PENILE PROSTHESIS: A SINGLE CENTER EXPERIENCE

You have accessJournal of UrologySexual Function/Dysfunction: Surgical Therapy I (PD20)1 Apr 2020PD20-07 A DESCRIPTIVE ANALYSIS OF POST-OPERATIVE URINARY RETENTION (POUR) IN PATIENTS UNDERGOING IMPLANTATION OF INFLATABLE PENILE PROSTHESIS: A SINGLE CENTER EXPERIENCE Johnathan Drevik*, Jacob Lucas, Jay Simhan, and Joshua Cohn Johnathan Drevik*Johnathan Drevik* More articles by this author , Jacob LucasJacob Lucas More articles by this author , Jay SimhanJay Simhan More articles by this author , and Joshua CohnJoshua Cohn More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000870.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The rates of Post-operative urinary retention (POUR) following inflatable penile prosthesis (IPP) are not well defined but are of interest given the potential implications for length of stay and feasibility of outpatient surgery. Herein we attempt to characterize and identify potential risk factors for POUR after IPP. METHODS: We reviewed all patients who underwent IPP implantation by a single surgeon (JS) from January 2014 to December 2018 with data regarding POUR. A Foley catheter was placed at the start of each case and the bladder emptied prior to removal at the end of the procedure. Post-void residuals (PVR) were checked after the first void post-operatively, and indwelling catheterization or intermittent catheterization performed for PVR >350 mL or symptomatic retention at lesser volumes. We compared patients who experienced post-operative urinary retention (POUR), defined as need for urinary catheterization at any time postoperatively, to patients who did not experience post-operative urinary retention (N-POUR). Patients were excluded if they underwent a concomitant procedure or had a diagnosis of neurogenic bladder. RESULTS: A total of 200 patients comprised the study population, of whom 53 (26.5%) experienced POUR and 147 (73.5%) did not. There were no differences between groups with regards to age, race, BMI, ASA, or other comorbidities (Table 1). Patients who experienced POUR had a median retained volume of 546 cc (25-75 IQR 378.0-693.5 cc). Among men with POUR, 33 (62.3%) had resolution of their urinary retention prior to discharge, while the remainder 20 (37.7%) were discharged with a Foley catheter. The rate of POUR was significantly lower in patients with a prior history of radical prostatectomy (10.7% vs 32.6%, p<0.001). On multivariable analysis, absent history of prostatectomy (OR 2.9, 95%CI 1.1-8.0, p=0.03) was found to be an independent risk factor for POUR. CONCLUSIONS: In our series, ∼25% of patients undergoing implantation of IPP developed POUR requiring catheterization. It is likely that bladder outlet obstruction and/or detrusor underactivity—which share similar risk factors as vasculogenic ED—result in POUR following IPP placement. Clinicians should carefully counsel patients regarding their risk. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e449-e450 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Johnathan Drevik* More articles by this author Jacob Lucas More articles by this author Jay Simhan More articles by this author Joshua Cohn More articles by this author Expand All Advertisement PDF downloadLoading ...

Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice

BackgroundThe definitive treatment for erectile dysfunction is the surgical implantation of a penile prosthesis, of which the most common type is the 3-piece inflatable penile prosthesis (IPP) device. IPP surgery in outpatient freestanding ambulatory surgical centers (ASC) is becoming more prevalent as payers and health systems alike look to reduce healthcare costs. AimTo evaluate IPP surgical outcomes in an ASC as compared to contemporaneously-performed hospital surgeries. MethodsA database of all patients undergoing IPP implantation by practitioners in the largest private community urology group practice in the United States, from January 1, 2013 to August 1, 2019, was prospectively compiled and retrospectively reviewed. Cohorts of patients having IPP implantation performed in the hospital vs ASC setting were compared. Main Outcome MeasureThe primary outcome measure was to compare surgical data (procedural and surgical times, need for hospital transfer from ASC) and outcomes (risk for device infection, erosion, and need for surgical revision) between ASC and hospital-based surgery groups. ResultsA total of 923 patients were included for this analysis, with 674 (73%) having ASC-based surgery and 249 (27%) hospital-based, by a total of 33 surgeons. Median procedural (99.5 vs 120 minutes, P < .001) and surgical (68 vs 75 minutes, P < .001) times were significantly shorter in the ASC. While the risk for device erosion and need for surgical revision were similar between groups, there was no higher risk for prosthetic infection when surgery was performed in the ASC (1.7% vs 4.4% [hospital], P = .02), corroborated by logistic regression analysis (odds ratio 0.39, P = .03). The risk for postoperative transfer of an ASC patient to the hospital was low (0.45%). The primary reason for mandated hospital-based surgery was medical (51.4%), though requirement as a result of insurance directive (39.7%) was substantial. Clinical ImplicationsIPP implantation in the ASC is safe, has similar outcomes compared to hospital-based surgery with a low risk for need for subsequent hospital transfer. Strengths & LimitationsThe strengths of this study include the large patient population in this analysis as well as the real-world nature of our practice. Limitations include the retrospective nature of the review as well as the potential for residual confounding. ConclusionASC-based IPP implantation is safe, with shorter surgical and procedural times compared to those cases performed in the hospital setting, with similar functional outcomes. These data suggest no added benefit to hospital-based surgery in terms of prosthetic infection risk.Weinberg AC, Siegelbaum MH, Lerner BD, et al. Inflatable Penile Prosthesis in the Ambulatory Surgical Setting: Outcomes From a Large Urological Group Practice. J Sex Med 2020;17:1025–1032.

An update on oxidized regenerated cellulose (fibrillar™) in reducing postoperative corporal bleeding following inflatable penile prosthesis surgery.

Scrotal hematoma formation is a dreaded complication of penile prosthesis surgery that increases patient pain and healthcare costs, as well the risk for eventual device infection and failure. The efficacy of hemostatic agents in reducing the incidence of scrotal hematoma development has not been extensively studied in urologic prosthetic surgery. In this paper we further evaluate our experience with oxidized regenerated cellulose (ORC; Surgicel Fibrillar™) as an adjunct to standard hemostatic practices in inflatable penile prosthesis (IPP) implantation. From April 2016 onward, intracorporal ORC pledgets were placed during corporotomy closure in all patients undergoing IPP implantation or revision by a single surgeon using an identical surgical technique. Perioperative parameters and outcomes-primarily postoperative cumulative drain output, secondarily patient phone calls in the postoperative period-were compared among successive cases with ORC (April 2016 to February 2019) and without ORC (April 2013 to March 2016). A total of 274 men underwent IPP implantation during the study period; 175 (64%) had ORC included in their corporotomy closures. Median drain output was significantly reduced in the ORC patients relative to the non-ORC group (50 vs. 65 mL; P=0.0001). A significant reduction in patient-initiated phone calls regarding scrotal pain, swelling, or discomfort in the first 4 weeks following surgery was also observed in the ORC group (average 0.69 vs. 1.1 calls per patient; P=0.03). A total of 9 patients underwent IPP explantation during the study period, all due to device infection; 5 of these were in the ORC group, while 4 were in the non-ORC group (P=0.73). ORC use did not constitute any additional infection risk. Bilateral incorporation of ORC pledgets during corporotomy closure in IPP surgery significantly decreases postoperative scrotal drain output, a well-documented risk factor for scrotal hematoma formation.

Intraoperative Intracavernosal Liposomal Bupivacaine (Exparel) Injection Does Not Affect Systemic Hemodynamics

IntroductionThe systemic effect of intracavernosal liposomal bupivacaine (Exparel) injection during inflatable penile prosthesis (IPP) implantation on systemic hemodynamics has not been clarified. AimTo evaluate whether intraoperative intracavernosal Exparel injection affects systemic hemodynamics. MethodsWe studied 56 consecutive patients who underwent IPP implantation under general anesthesia using the transverse scrotal approach. Exparel [10 mL of 1.3% (13.3 mg/mL)] was instilled bilaterally intracavernosally via a 25-gauge needle around 30 min after starting the surgery. All patients graded their postoperative pain using a standard 10-point scale. Main Outcome MeasurePerioperative vital signs at defined time intervals and postoperative pain were monitored. The degree of postoperative pain were analyzed using a standard 10-point scale. ResultsMedians and interquartile ranges (IQRs) of the patients' age [64 years (57.3–69.3)], operation time [85 min (78–96)], and estimated blood loss [75 mL (29–100)] were recorded. Although the median preoperative systolic noninvasively measured blood pressure of 131 mm/Hg (IQR: 122–139) fell by 25% to 98 mm/Hg (IQR: 90–100) (P < .001) after anesthesia started, there was no significant decrease in blood pressure between before and after Exparel injection. The perioperative pulse rate and pulse oximetry oxygen saturation were stable. Neither arrhythmia nor convulsion occurred. Patients reported postoperative pain as 0 (IQR: 0–2.25) on a scale of 0–10. Clinical ImplicationsIntraoperative intracavernosal Exparel injection is safe and effective in patients undergoing IPP implantation surgery. Strength & LimitationsThis is the first report to describe systemic hemodynamics of intracavernosal Exparel injection. Limitations are lack of blood concentration of Exparel at various time points and long-term follow-up for pain assessment. ConclusionAlthough limited by a lack of the blood concentration of Exparel and short follow-up for pain assessment, we concluded that intraoperative intracavernosal Exparel injection does not affect systemic hemodynamics.Taniguchi H, Mulhall JP. Intraoperative Intracavernosal Liposomal Bupivacaine (Exparel) Injection Does Not Affect Systemic Hemodynamics. J Sex Med 2020;17:526–530.

A Multi-institutional Assessment of Multimodal Analgesia in Penile Implant Recipients Demonstrates Dramatic Reduction in Pain Scores and Narcotic Usage

IntroductionDespite the pain associated with inflatable penile prosthesis (IPP) implantation, there has been a lack of standardized, nonopioid pain control regimens described to date. AimTo assess the effectiveness of a multimodal analgesic regimen in patients undergoing implantation of an IPP compared with patients treated with an opioid-only regimen. MethodsA large, multicenter patient cohort undergoing IPP implantation whose pain was managed using a multimodal analgesia (MMA) protocol (preoperative and postoperative acetaminophen, meloxicam orcelecoxib, and gabapentin and intraoperative dorsal and pudendal nerve blocks) was compared with a matched cohort of patients managed via an opioid-only protocol. Both groups were compared with respect to visual analog score (VAS) and opioid usage (total morphine equivalents [TME]) in the post-anesthesia care unit (PACU), postoperative day 0 (POD0) and postoperative day 1 (POD1), and in the immediate postdischarge period. Narcotic usage on discharge and follow-up were assessed and compared. Main Outcome MeasurePostoperative pain scores and narcotic usage are the main outcome measures. Results203 patients were eligible for final analysis: 103 (50.7%) patients receiving MMA medication and 100 (49.3%) patients receiving opioids only. The VAS was significantly lower in the multimodal group in PACU (median 0.0 vs 2.0, P = .001), POD0 (median 3.0 vs 4.0, P = .001), and POD1 (median 3.0 vs 4.3, P = .04). Patients in the multimodal group also used fewer narcotics in PACU (median 0.0 vs 4.0 TME, P = .001), POD0 (median 7.5 vs 12.5 TME, P < .001), and POD1 (median 7.5 vs 13.5 TME, P = .01). Despite being discharged with fewer narcotics (median 20.0 vs 30.0 tablets, P < .001), a smaller proportion of patients in the MMA cohort required narcotic refills (10.7% vs 28.0%, P = .001). There were no narcotic- or MMA medication–related side effects in the entire cohort. Clinical ImplicationsMMA confers significant improvement in pain management while also providing a significant reduction in narcotic usage in patients undergoing implantation of IPP. Strength & LimitationsThis is the 1st large multi-institutional assessment of a multimodal analgesic regimen in urologic prosthetic surgery. The analgesic regimen targets several pain pathways that provide excellent pain control throughout the recovery process. Limitations include retrospective design and lack of standardization of the nonsteroidal anti-inflammatory drug type within the multimodal analgesic regimen. ConclusionThe use of a MMA protocol significantly reduces postoperative pain measures in penile implant recipients and further reduces both inpatient and outpatient narcotic usage without any discernable side effects.Lucas J, Gross M, Yafi F, et al. A Multi-institutional Assessment of Multimodal Analgesia in Penile Implant Recipients Demonstrates Dramatic Reduction in Pain Scores and Narcotic Usage. J Sex Med 2020;17:518–525.

Neurogenic bladder is an independent risk factor for complications associated with inflatable penile prosthesis implantation.

Men with neurogenic bladder (NGB) often have concomitant erectile dysfunction and may be considered for inflatable penile prosthesis (IPP) placement. However, it is unclear if NGB is a risk factor for complications associated with IPP placement. The aim of this study is to compare surgical outcomes after IPP placement in a contemporary cohort of patients with NGB to that of a non-neurogenic control group. To accomplish this, consecutive records of patients who underwent IPP implantation between 2007 and 2018 were retrospectively reviewed. Patients with a known neurologic lesion and documented NGB by clinical or urodynamic criteria were compared with a non-neurogenic control group of men with erectile dysfunction. We found that patients in the NGB cohort were younger (median age 48 vs. 62 years, p < 0.001) and less likely to void spontaneously prior to surgery (3% vs. 97%, p < 0.001). The most common cause for NGB was spinal cord injury (46%). There was a 24.3% overall rate of complication (infection, erosion, or mechanical failure) in the NGB cohort compared with a 7.5% rate in the non-neurogenic control group (p = 0.001). On multivariate logistic regression modeling, NGB (OR 3.47; 95% CI 1.13-10.71; p = 0.03) was independently associated with risk of IPP complication. First time penile prosthesis was associated with lower risk of IPP complication (OR 0.25 95% CI 0.09-0.71; p = 0.01). In conclusion, patients with NGB are at increased risk for complications after IPP placement. Patients should be counseled accordingly, and all efforts should be made to stabilize bladder function prior to surgery.

293 Satisfaction with Inflatable Penile Prosthesis in Patients with History of ischemic Priapism

Prolonged episodes of ischemic priapism result in significant corporal fibrosis and ultimate loss of erectile function. Implantation of penile prosthesis is a well-established treatment for erectile dysfunction (ED) related to priapism. However, questions regarding optimal device choice and timing of the surgery remain incompletely answered. This report presents surgical and patient-reported outcomes following inflatable penile prosthesis (IPP) implantation in patients with prior history of ischemic priapism. Consecutive records of patients who underwent IPP implantation at our institution between May 2007 and January 2018 were queried retrospectively. Medical records of patients with a history of ischemic priapism who underwent IPP implantation were evaluated. Patient demographics, pre-operative workup, intra-operative maneuvers and post-operative follow-up data were analyzed with use of standard statistics. Patient satisfaction was assessed using a phone-administered EDITS (Erectile Dysfunction Inventory of Treatment Satisfaction) questionnaire. Records of nineteen men were identified. Average patient age was 41 years (range: 21-86yo) and twelve men (63.2%) were African-American. Six men had history of sickle cell disease. Two out of nineteen men underwent an immediate prosthesis implantation. Thirteen men had significant intra-cavernosal fibrosis and required complex reconstructive maneuvers. Only one patient (in the immediate IPP group) necessitated prosthesis removal due to infection. Five out of seventeen (29%) living patients responded to the EDITS questionnaire. Four out of the five patients were overall very satisfied with the treatment while one was very dissatisfied. This was further confirmed with the mean EDITS index score of 67.3, ranging from 6.8 to 100 (indicating extremely low and extremely high treatment satisfaction, respectively).

045 Combined Urethral Surgery at Time of Penile Prosthesis Implantation does not Increase Risk of Device Infection

Urethral surgery for stricture disease or urethral trauma sustained at the time of inflatable penile prosthesis (IPP) implantation is thought to significantly increase rates of device infection. The classic teaching requires procedure abortion, urethral repair and a future, delayed IPP implantation. We report our experience with patients who had urethral surgery at the time of IPP implantation in order to further elucidate potential risk factors associated with device complications. Consecutive records of patients who underwent IPP implantation at our institution between May 2007 and March 2017 were queried retrospectively. Medical records of patients with a history of urethral surgery at the time of IPP implantation were evaluated. Patient demographics, pre-operative workup, intra-operative maneuvers and post-operative follow-up data were analyzed with use of standard statistics. Records of thirteen men were identified. Average patient age was 63.9 years (range: 40-81yo), and 11 of men (84.6%) were Caucasian. Two men who sustained intra-operative urethral injuries underwent complex repairs with suprapubic tube (SPT) placement. The remaining eleven men had stricture disease and required either stricture dilation, incision or urethroplasty. IPP revision (explantation/ implantation) was performed in two of the men undergoing urethral dilation for stricture disease. There were no device infections or erosions. (Table 1)

Experience with AMS 700 LGX penile prostheses for preserving penile length in Korea

BackgroundThe purpose of this study was to report the outcomes of patients who underwent penile implantation with AMS 700 LGX inflatable penile prosthesis (IPP) in a single center by a single surgeon.MethodsA total of 342 patients with erectile dysfunction who underwent AMS 700 LGX IPP implantation between October 2014 and April 2016 were included in this study. All patients were evaluated using the International Index of Erectile Function questionnaire preoperatively and at 3, 6, and 12 months postoperatively. We also investigated the mean stretched flaccid penile length before and after surgery as well as the complications related to and the mechanical reliability of the IPP.ResultsThe questionnaire scores at 12 months were statistically significantly higher than the baseline scores. The mean stretched flaccid penile length was 11.1 ± 0.8 cm at baseline and was longer at 3 (11.9 ± 0.9 cm, P < 0.001), 6 (12.0 ± 0.9 cm, P < 0.001), and 12 (12.2 ± 0.7 cm, P < 0.001) postoperatively. There were no intraoperative or perioperative complications. However, one patient had infection and 10 patients developed mechanical failure during the follow-up duration.ConclusionsThe results of our study suggest that the AMS 700 LGX IPP could be used to prevent penile shortening in patients undergoing IPP implantation. Furthermore, erectile function and patient satisfaction were improved excellently.

MP84-06 PROSPECTIVE TRIAL COMPARING PENOSCROTAL VERSUS MINIMALLY INVASIVE INFRAPUBIC APPROACH FOR INFLATABLE PENILE PROSTHESIS PLACEMENT: A SINGLE-CENTRE MATCHED PAIRED ANALYSIS.

You have accessJournal of UrologySexual Function/Dysfunction: Penis/Testis/Urethra: Benign Disease & Malignant Disease II1 Apr 2018MP84-06 PROSPECTIVE TRIAL COMPARING PENOSCROTAL VERSUS MINIMALLY INVASIVE INFRAPUBIC APPROACH FOR INFLATABLE PENILE PROSTHESIS PLACEMENT: A SINGLE-CENTRE MATCHED PAIRED ANALYSIS. Pietro Grande, Gabriele Antonini, Cristiano Cristini, Ettore De Berardinis, Giuseppe Gentile, Giovanni Di Lascio, Andrea Lemma, and Giovanni Battista Di Pierro Pietro GrandePietro Grande More articles by this author , Gabriele AntoniniGabriele Antonini More articles by this author , Cristiano CristiniCristiano Cristini More articles by this author , Ettore De BerardinisEttore De Berardinis More articles by this author , Giuseppe GentileGiuseppe Gentile More articles by this author , Giovanni Di LascioGiovanni Di Lascio More articles by this author , Andrea LemmaAndrea Lemma More articles by this author , and Giovanni Battista Di PierroGiovanni Battista Di Pierro More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2774AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Currently, approximately 80% of inflatable penile prosthesis (IPP) are placed by penoscrotal approach (PSA), although no superiority of this technique compared to infrapubic approach has ever been demonstrated.The aim of this study was to compare perioperative results, safety and efficacy profile in patients receiving inflatable penile prosthesis(IPP) via PSA or minimally invasive infrapubic approach(MIIA) for erectile dysfunction. METHODS Data were prospectively collected in our password-secured institutional database of implanted patients. A matched-pair analysis was performed including 42 patients undergoing IPP implantation via PSA(n=21) or MIIA(n=21) between 2011 and 2016. Excluded from the study were those patients with urinary incontinence, simultaneous surgery for congenital or acquired recurvatum, previous urethral or penile surgery and lack of follow-up data. All patients were invited to fill in validated self-administered questionnaires to evaluate various aspects of post-prosthesis sexual life. Specifically, questionnaires included: the International Index of Erectile Function(IIEF), Erectile Dysfunction Inventory of Treatment Satisfaction(EDITS) and Quality of Life and Sexuality with Penile Prosthesis (QoLSPP) questionnaires. RESULTS Mean(SD) operative time was 128(40.6) min in group PSA and 91(43.0) min in group MIIA(p=0.041). Complications occurred in 3 (14%) and 2 (10%) patients in groups PSA and MIIA(p=0.832). Overall, no differences were observed concerning the device utilization (p=0.275). However, in group MIIA 4 (19%) patients were able to resume sexual activity prior to 4 postoperative weeks, while in group PSA no patient was (p=0.012). Mean(SD) scores for questionnaires were similar between groups PSA and MIIA: IIEF [20.9(7.3) vs 20.7(4.8); p=0.132], patient EDITS [76.0(25.6) vs 74.7(20.8); p=0.256] and partner EDITS [72.5(29.1) vs 73.1(21.4); p=0.114]. Similarly, QoLSPP showed comparable results among the groups PSA and MIIA: functional domain [3.9(1.4) vs 4.0(1.2); p=0.390], personal [4.0(1.2) vs 4.1(1.0); p=0.512], relational [3.7(1.5) vs 3.9(1.2); p=0.462] and social [4.0 (1.2) vs 3.9 (1.2); p=0.766]. CONCLUSIONS Penoscrotal and minimally invasive infrapubic approaches demonstrated to be safe and efficient techniques for IPP implantation, leading to high level of both patients and partners satisfaction. Additionally, the minimally invasive infrapubic approach showed a shorter operative time and a tendency for a faster return to sexual activity. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1126-e1127 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Pietro Grande More articles by this author Gabriele Antonini More articles by this author Cristiano Cristini More articles by this author Ettore De Berardinis More articles by this author Giuseppe Gentile More articles by this author Giovanni Di Lascio More articles by this author Andrea Lemma More articles by this author Giovanni Battista Di Pierro More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Oxidized Regenerated Cellulose (Fibrillar) Reduces Risk of Postoperative Corporal Bleeding Following Inflatable Penile Prosthesis Surgery

To report our initial experience with oxidized regenerated cellulose (ORC; Surgicel Fibrillar) as a hemostatic adjunct during inflatable penile prosthesis (IPP) surgery. Beginning in April 2016, ORC pledgets were placed within the corporotomy closures of all men undergoing IPP insertion. Perioperative characteristics and outcomes including cumulative postoperative drain output were evaluated among consecutive cases with (April 2016 to October 2016) and without ORC (December 2015 to March 2016) using an identical surgical technique by a single surgeon. During the study period, 64 men underwent IPP implantation, of whom 32 (50%) received ORC. There was a significant reduction in median drain output relative to controls (33 mL vs 65 mL; P = .01). Postoperatively, ORC use was associated with a reduction in the number of patient phone calls for scrotal-related concerns in the immediate postoperative period (average 0.5 vs 1.1; P = .03). There were 3 IPP explantations in the non-ORC group (2/3 for infection)-one of which was directly related to an infected hematoma. After controlling for other clinical features, the use of ORC (β -32, 95% confidence interval: -61 to -5; P = .02) was independently associated with a reduction in drain output. ORC use during IPP corporotomy closure reduces postoperative drain output, a known risk factor for hematoma-related complications.

HP-09-001 The role of the Tachosil and SIS as grafts after inflatable penile prosthesis implantation and plaque incision: Surgical and functional outcomes from a single center prospective comparative study

Among the straightening manoeuvres aiming to correct a residual curvature in Peyronie’s disease (PD) after inflatable penile prosthesis (IPP) implantation, Plaque incision with grafting (PIG) has been widely described in the scientific literature. However, it is still under debate the definition of the best graft to apply after this procedure. The aim of our study is to compare the surgical and functional outcomes in 2 groups of patients underwent IPP implantation and PIG for residual curvature using 2 different grafts: SIS-small intestinal submucosa (Group A) and Tachosil (Group B). From January 2007 to January 2015, 60 consecutive patients affected by PD with concomitant erectile dysfunction (ED) and penile curvature, underwent IPP implantation (AMS 700 CX) and PIG. SIS (A) was used as a graft in 34 cases whereas Tachosil was applied respectively in the remnants. The main difference between the two grafts was that the SIS was fixed to the albuginea’s incision margins with a running 3-0 Vycril suture. On the other hand the Tachosil was directly applied on the albugineal defect. The Buck’s fascia was reconstructed in both cases to control any possible haematoma. We selected as variables for the surgical outcomes the intraoperative complications, the hospital stay, the postoperative complications (haematoma, infections, prosthetic mechanical failures, recurrent curvatures). Nevertheless, the IIEF questionnaire was administered to all patients before and 12 months after surgery to Assess the functional outcomes of the procedure.

Inflatable penile prosthesis technique and outcomes after radial forearm free flap neophalloplasty

The aim of this study was to describe the technical aspects and short-term outcomes of inflatable penile prosthesis (IPP) implantation after neophallus reconstruction at a single institution. Nine men with previously constructed radial forearm neophalli underwent IPP implantation. The etiologies of their penile anomaly were bladder exstrophy complex in five, disorder of sexual differentiation in two and genital obliteration secondary to ballistic trauma in two. Median follow-up was 9.6 months (range 1.5-139.7). The records for these patients were retrospectively reviewed and outcomes recorded. Mean age was 23.6 (range 18-31) years, and mean time interval from neophalloplasty to IPP implantation was 22.1 months (range 3-48). In all cases, 3-piece IPPs were employed, with eight of patients having one cylinder implanted in the native corporal body and extending into the neophallus. Mean surgical time was 222 min (range 142-409). Median length of implanted device was 22 cm. No intraoperative complications were observed. At the most recent follow-up, six patients (66.7%) had functional devices, with acceptable surgical outcomes. Three patients (33.3%) sustained device infections, and three (33.3%) sustained cylinder erosion. In three patients in whom neo-tunica albuginea were fashioned by ensheathing the cylinder with allograft human dermal tissue matrix, no erosions occurred. One patient underwent two revisions, the first for the associated erosion and infection and the second for genital pain, and was left with a semi-rigid prosthesis. IPP implantation affords the best opportunity for functionality for patients with a radial forearm free flap neophallus. Caution must be taken to ensure viability of the neophallus intraoperatively, and protocols to minimize the risk of infection should be followed. Fashioning neo-tunica albuginea using graft material may reduce risk of erosion.