Brian Christine

North American Consensus Document on Infection of Penile Prostheses

OBJECTIVE To issue a consensus document on the prevention, management, and research of infection associated with penile prostheses, as neither professional associations nor governmental entities have issued guidelines that are specific to this infection. METHODS Sixteen North American experts on infection of penile prostheses were identified and assembled to select and discuss certain issues related to infection of penile prostheses. After performing an extensive search of clinically important issues in published reports, the 16 experts met twice in person to finalize the selection, discuss the issues that were deemed most important, and issue pertinent recommendations. RESULTS Although many subjects relevant to infection of penile prostheses were initially identified, the experts selected 10 issues as currently being the most important issues and for which there exists some support in the published data. The examined issues involved prevention, management, or research of infections associated with penile prostheses. CONCLUSION In the absence of pertinent guidelines, the consensus document issued by experts in the field of prosthetic urology is anticipated to improve the quality of patient care, streamline the prevention and management of infected penile prostheses, and stimulate collaborative research. Although this consensus document could serve as best practice recommendations, the lack of adherence to these recommendations would not indicate improper care.

Treatment of Recurrent Urinary Incontinence After Artificial Urinary Sphincter Placement Using the AdVance Male Sling

OBJECTIVES We report on the use of the AdVance male sling to treat men who had an artificial urinary sphincter placed and subsequently developed recurrent urinary incontinence. METHODS Nineteen men who had undergone placement of an artificial urinary sphincter for post prostatectomy urinary incontinence, and who had developed recurrent incontinence, were treated by placing an AdVance sling. Self-reported pad use preoperatively was 2-5 pads per day. RESULTS All 19 patients (100%) reported improvement in their incontinence as documented by decreased pad use. Of these men, 15 (79%) became dry, using no further pads, and four (21%) decreased pad use to 1 pad per day. Of the 15 dry patients, 8 remained dry without reactivation of the artificial sphincter (53%); the other 7 maintained complete continence with a combination of the sling and an activated artificial sphincter. CONCLUSIONS Men who suffer from recurrent urinary incontinence secondary to cuff compression atrophy can be made continent by the placement of a male sling. The technique of sling placement requires no special modification in these patients. By not revising the artificial urinary sphincter the capsule surrounding the device is not violated, which may decrease the risk of postoperative infection. In addition, the patient may not need to rely upon the use of his artificial sphincter to maintain continence.

The Who, How and What of Real-World Penile Implantation in 2015: The PROPPER Registry Baseline Data

PURPOSE To date, the published data on patients treated with penile implantation generally consist of small series of single surgeon, retrospective experiences rather than prospective or large, multicenter evaluations. This study establishes a baseline of data collection from the PROPPER (Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration). The PROPPER is the first large, prospective, multicenter, multinational, monitored, and internal review board approved study of real-world outcomes for patients with penile implants. MATERIALS AND METHODS Data from the PROPPER study were examined to determine patient baseline characteristics and primary and secondary etiologies before treatment of erectile dysfunction. Data include type and size of implant received, surgical steps/techniques used during implantation, and duration of hospital stay. RESULTS Through April 2, 2015 a total of 1,019 patients were enrolled in the study at 11 sites, with radical prostatectomy being the predominant etiology in 285 (28%). Of those 285 patients treated with radical prostatectomy 280 (98.2%) received an AMS 700™. Of these patients 65.0% (182 of 280) had placement of the reservoir in the traditional retropubic space vs 31.8% (89 of 280) in a submuscular location. Of those patients not treated with radical prostatectomy receiving an AMS 700, fewer underwent reservoir placement in the submuscular location (17.7%, 124 of 702, vs 80.9%, 568 of 702; p <0.001). Of those patients receiving an AMS 700, those treated with radical prostatectomy and those with diabetes had more outpatient admissions (less than 24 hours, 56.8% and 52.1%, respectively) compared to those with cardiovascular disease and Peyronies disease (42.0% and 35.6%, respectively, p <0.001). CONCLUSIONS This first-of-its-kind, large, prospective, multicenter study reveals most penile implant cases in North America receive an inflatable penile prosthesis and that radical prostatectomy is the most common primary etiology of penile implant surgery. Moreover, patients treated with radical prostatectomy were more likely to have the reservoir placed in a submuscular location, have a longer operating room time and be admitted to the hospital overnight compared with other patient groups.

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 Peyronies disease, a clinical condition that interferes with erectile function. Despite attempts to uncover the pathophysiology behind Peyronies 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 procedures 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

JSM HIGHLIGHTSConcomitant Treatment of Erectile Dysfunction and Postprostatectomy Stress Urinary Incontinence (CME)

A man presented to our clinic for the treatment of persistent postprostatectomy stress urinary incontinence (SUI). He had undergone a robotic-assisted radical prostatectomy 15 months previously for Gleason’s grade 6/10 prostate adenocarcinoma. At the time of prostatectomy, his prostate specific antigen (PSA) was 4.6. The PSA had remained undetectable since surgery, and the patient had required no adjuvant treatment for his malignancy. However, SUI had not resolved with the patient reporting the use of 2–3 protective pads per day. In fact, since 10 months postsurgery the degree of the incontinence had not significantly improved despite conservative measures. Query as to the patient’s erectile function status revealed that he had used phosphodiesterase type 5 inhibitors prior to the prostatectomy with moderate success. Since surgery, oral therapy was ineffective. Penile injection therapy had been attempted butwas felt to be inconvenient by the patient and his partner. The use of a vacuum erection device provided an erection that the patient felt was inadequate for sexual intercourse. Workup for the urinary incontinence consisted of 24-hour pad weight testing, urodynamic studies, urinalysis, and flexible cystoscopy in the clinic. Pad weight for 24 hours was 120 g. The patient reported typically using 1–2 protective pads per day. Urodynamics confirmed the presence of SUI and an absence of detrusor instability; voiding pressures were not elevated and the postvoid residual urine volume was 0 cc. During cystoscopy, no urethral stricture or bladder neck contracture were seen. The resting tone of the external sphincter was normal. The patient demonstrated the ability to produce a robust, circumferential contraction of the external sphincter, and after cystoscopy he could completely interrupt his urinary stream.Urinalysis was negative for infection. Based on the findings listed above, the patient was felt to suffer from postprostatectomy incontinence of moderate severity that would be amenable to treatment with a transobturator male sling. In addition, he was offered concomitant placement of an inflatable penile prosthesis (IPP) to permit a functional erection. He readily agreed, following a detailed informed consent, and underwent the combined procedure. On the day of surgery, the patient received vancomycin 1 g intravenous (IV) and gentamicin 100 mg IV prior to skin incision. The patient was placed in lithotomy position with the hips flexed at 90 degrees and remained in lithotomy position throughout the case. Skin preparation was with chlorhexidine. A 14 French foley catheter was placed into the bladder. An AdVance male sling (American Medical Systems, Minneapolis, MN, USA) was implanted through a midline perineal incision as the first stage of the combined implant. The technique of sling implantation during the combination procedure was no different than that of a stand-alone sling surgery. After the male sling had been placed, we proceeded with implantation of a 700 CX IPP (American Medical Systems) through a transverse scrotal incision. The patient remained in lithotomy position for the IPP. The legs can be lowered slightly if the surgeon prefers; the surgeon stands between the patient’s legs for the IPP. The surgical technique for the IPP was standard with no modifications required because of sling placement. The reservoir was placed through the external inguinal ring, and filled with the appropriate volume of saline. The pump was placed into a dependent position in the scrotum using a nasal speculum to make an anterior, subDartos space for the pump. Following connection

Concomitant Treatment of Erectile Dysfunction and Postprostatectomy Stress Urinary Incontinence (CME)

A man presented to our clinic for the treatment of persistent postprostatectomy stress urinary incontinence (SUI). He had undergone a robotic-assisted radical prostatectomy 15 months previously for Gleason’s grade 6/10 prostate adenocarcinoma. At the time of prostatectomy, his prostate specific antigen (PSA) was 4.6. The PSA had remained undetectable since surgery, and the patient had required no adjuvant treatment for his malignancy. However, SUI had not resolved with the patient reporting the use of 2–3 protective pads per day. In fact, since 10 months postsurgery the degree of the incontinence had not significantly improved despite conservative measures. Query as to the patient’s erectile function status revealed that he had used phosphodiesterase type 5 inhibitors prior to the prostatectomy with moderate success. Since surgery, oral therapy was ineffective. Penile injection therapy had been attempted butwas felt to be inconvenient by the patient and his partner. The use of a vacuum erection device provided an erection that the patient felt was inadequate for sexual intercourse. Workup for the urinary incontinence consisted of 24-hour pad weight testing, urodynamic studies, urinalysis, and flexible cystoscopy in the clinic. Pad weight for 24 hours was 120 g. The patient reported typically using 1–2 protective pads per day. Urodynamics confirmed the presence of SUI and an absence of detrusor instability; voiding pressures were not elevated and the postvoid residual urine volume was 0 cc. During cystoscopy, no urethral stricture or bladder neck contracture were seen. The resting tone of the external sphincter was normal. The patient demonstrated the ability to produce a robust, circumferential contraction of the external sphincter, and after cystoscopy he could completely interrupt his urinary stream.Urinalysis was negative for infection. Based on the findings listed above, the patient was felt to suffer from postprostatectomy incontinence of moderate severity that would be amenable to treatment with a transobturator male sling. In addition, he was offered concomitant placement of an inflatable penile prosthesis (IPP) to permit a functional erection. He readily agreed, following a detailed informed consent, and underwent the combined procedure. On the day of surgery, the patient received vancomycin 1 g intravenous (IV) and gentamicin 100 mg IV prior to skin incision. The patient was placed in lithotomy position with the hips flexed at 90 degrees and remained in lithotomy position throughout the case. Skin preparation was with chlorhexidine. A 14 French foley catheter was placed into the bladder. An AdVance male sling (American Medical Systems, Minneapolis, MN, USA) was implanted through a midline perineal incision as the first stage of the combined implant. The technique of sling implantation during the combination procedure was no different than that of a stand-alone sling surgery. After the male sling had been placed, we proceeded with implantation of a 700 CX IPP (American Medical Systems) through a transverse scrotal incision. The patient remained in lithotomy position for the IPP. The legs can be lowered slightly if the surgeon prefers; the surgeon stands between the patient’s legs for the IPP. The surgical technique for the IPP was standard with no modifications required because of sling placement. The reservoir was placed through the external inguinal ring, and filled with the appropriate volume of saline. The pump was placed into a dependent position in the scrotum using a nasal speculum to make an anterior, subDartos space for the pump. Following connection

Inflatable penile prosthesis implant length with baseline characteristic correlations: Preliminary analysis of the PROPPER study

Background “Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration” (PROPPER) is a large, multi-institutional, prospective clinical study to collect, analyze, and report real-world outcomes for men implanted with penile prosthetic devices. We prospectively correlated co-morbid conditions and demographic data with implanted penile prosthesis size to enable clinicians to better predict implanted penis size following penile implantation. We present many new data points for the first time in the literature and postulate that radical prostatectomy (RP) is negatively correlated with penile corporal length. Methods Patient demographics, medical history, baseline characteristics and surgical details were compiled prospectively. Pearson correlation coefficient was generated for the correlation between demographic, etiology of ED, duration of ED, co-morbid conditions, pre-operative penile length (flaccid and stretched) and length of implanted penile prosthesis. Multivariate analysis was performed to define predictors of implanted prosthesis length. Results From June 2011 to June 2017, 1,135 men underwent primary implantation of penile prosthesis at a total of 11 study sites. Malleable (Spectra), 2-piece Ambicor, and 3-piece AMS 700 CX/LGX were included in the analysis. The most common patient comorbidities were CV disease (26.1%), DM (11.1%), and PD (12.4%). Primary etiology of ED: RP (27.4%), DM (20.3%), CVD (18.0%), PD (10.3%), and Priapism (1.4%), others (22.6%). Mean duration of ED is 6.2¡À4.1 years. Implant length was weakly negatively correlated with White/Caucasian (r=−0.18; P<0.01), history of RP (r=−0.13; P<0.01), PD as comorbidity (r=−0.16; P<0.01), venous leak (r=−0.08; P<0.01), and presence of stress incontinence (r=−0.13; P<0.01). Analyses showed weak positive correlations with Black/AA (r=0.32; P<0.01), CV disease as primary ED etiology (r=0.08; P<0.01) and pre-operative stretched penile length (r=0.18; P<0.01). There is a moderate correlation with pre-operative flaccid penile length (r=0.30; P<0.01). Conclusions Implanted penile prosthesis length is negatively correlated with some ethnic groups, prostatectomy, and incontinence. Positive correlates include CV disease, preoperative stretched penile length, and flaccid penile length.