Bruce B. Garber

Outcomes of Abdominal Wall Reservoir Placement in Inflatable Penile Prosthesis Implantation: A Safe and Efficacious Alternative to the Space of Retzius

INTRODUCTION Inflatable penile prosthesis (IPP) surgery is a successful therapeutic option for men with erectile dysfunction. Traditional placement of the reservoir in the retropubic space of Retzius is associated with the rare occurrence of significant complications including bladder, bowel, and vascular injury. An alternative site, posterior to the abdominal wall musculature, has been identified as a potentially safer location for reservoir placement. AIMS The aim of this study was to describe our technique of abdominal reservoir placement during infrapubic IPP surgery and present our outcomes data. METHODS We retrospectively reviewed our experience with abdominal reservoir placement during virgin IPP cases. Reservoirs placed anterior and posterior to transversalis fascia were analyzed separately. MAIN OUTCOME MEASURE The main outcome measures was assessment of reservoir-related complications including palpable reservoir, reservoir herniation, and injuries to bowel, bladder, or major blood vessels. RESULTS There were no injuries to bowel or major blood vessels with abdominal reservoir placement posterior or anterior to the transversalis fascia in properly segregated patients. CONCLUSION Abdominal reservoir placement is a safe and simple surgical method that can be recommended for most men undergoing IPP placement. Men with a history of pelvic surgery can have the reservoir placed between the rectus abdominis musculature and transversalis fascia, while other men can have the reservoir placed between transversalis fascia and peritoneum in order to avoid a palpable reservoir. By applying this protocol, the catastrophic injuries that occur rarely with retropubic reservoir placement can be reliably avoided.

Inflatable penile prostheses for the treatment of erectile dysfunction

Male erectile dysfunction is a common medical condition. Recent advances in our understanding of corpora cavernosa physiology have resulted in three effective oral medications (sildenafil, vardenafil and tadalafil – all phosphodiesterase type 5 inhibitors), which can effectively treat many men with erectile dysfunction. However, a large number of men are not adequately treated by these medications due to their cost, side effects, contraindications or lack of a satisfactory erectile response. For men who do not respond to less invasive therapy, an inflatable penile prosthesis can provide an excellent alternative. This article will review and critique the currently available inflatable penile prostheses in the treatment of erectile dysfunction.

Inflatable penile prostheses for the treatment of erectile dysfunction: an update

Male erectile dysfunction (ED) is a common medical condition. Three oral medications (sildenafil, vardenafil and tadalafil, all phosphodiesterase type 5 inhibitors) have been developed and approved for the treatment of ED by the US FDA. Extensive worldwide marketing of these medications has raised public awareness of ED, and allowed many previously untreated men to seek and receive effective therapy. A variety of other ED treatments are available and approved by the FDA, including vacuum-constriction devices and intracavernous or intraurethral alprostadil. However, roughly 30–40% of men with ED are not adequately served by these treatments due to their cost, side effects, contraindications, the need to ‘time’ sexual activity, or lack of satisfactory erectile response. For men who do not respond to less invasive therapy, an inflatable penile prosthesis can provide a satisfying and effective alternative. This article will review and critique the inflatable penile prostheses that are currently available in the USA and the EU for the treatment of ED.

Coloplast Titan Inflatable Penile Prosthesis with One-Touch Release Pump: Review of 100 Cases and Comparison with Genesis Pump

INTRODUCTION In 2008 Coloplast Corporation modified their Titan inflatable penile prosthesis (IPP) with a new One-Touch Release (OTR) pump, in an attempt to facilitate device deflation. There is currently little published data concerning this new pump. AIM The aim of this pilot study was to assess initial patient and physician experience with the Titan OTR pump. METHODS Retrospective chart review was used to assess the functionality and surgeon experience with 100 consecutive patients implanted with a Titan OTR pump, compared with 100 prior consecutive patients implanted with a Titan Genesis pump. MAIN OUTCOME MEASURES The ease of implantation of the OTR pump, the number of required postoperative inflate/deflate teaching visits, and OTR pump functionality were assessed and compared with that of the prior Genesis pump. RESULTS The mean length of follow-up in the Genesis group (N = 100) was 20.8 months, and mean length of follow-up in the OTR group (N = 100) was 8.4 months. There was one device infection in each group. The average number of postoperative teaching sessions needed to teach the patient how to operate the device was 1.87 in the Genesis group, and 1.19 in the OTR group (P < 0.001). The range of teaching visits was 1-5 in the Genesis group, and 1-3 in the OTR group (P < 0.001). No pump malfunctions were seen in either group. Subjectively, the OTR pump was just as easy to implant as the Genesis pump. In addition, the OTR pump was subjectively easier for the surgeon and the patient to deflate, and just as easy to inflate, compared with the Genesis pump. CONCLUSIONS This pilot study revealed that the OTR pump functioned as specified by the manufacturer. With short-term follow-up, no pump malfunctions were detected. The OTR pump was associated with a statistically significant reduction in the number of postoperative teaching sessions required for the patient to properly operate the device. It was subjectively just as easy to implant and inflate, and easier to deflate, compared with the Genesis pump.

Delayed Postoperative Hematoma Formation after Inflatable Penile Prosthesis Implantation

INTRODUCTION Infrequent but serious postoperative complications following inflatable penile prosthesis (IPP) insertion include infection, malfunction, and bleeding. Although prior publications report methods to reduce immediate postoperative bleeding, there is little in the literature concerning the etiology, diagnosis, imaging, and management of delayed bleeding after IPP insertion. AIM The aim of the study was to review cases of delayed postoperative bleeding following IPP insertion in a large single-surgeon series. METHODS We carried out a retrospective chart review of 600 patients implanted with a Coloplast Titan IPP with One-Touch Release pump by a single surgeon, and analyzed cases of delayed postoperative bleeding. MAIN OUTCOME MEASURE The main outcome measure was an analysis of the incidence, causes, diagnostic methods, treatment, and final outcome of these cases. RESULTS Three out of 600 consecutive patients (0.5%) developed a delayed (defined as >5 days postoperative) hematoma following IPP insertion. All patients presented postoperatively with a swollen surgical site, and all were evaluated with a pelvic computed tomography scan to completely define the extent of the hematoma. Two patients developed a delayed hematoma because of excessive physical activity; the remaining patient bled because of premature administration of enoxaparin sodium (Lovenox) by his cardiologist. All three patients were successfully treated with hospital admission, intravenous antibiotics, wound exploration, hematoma evacuation, and antibiotic washout. All three IPPs were successfully salvaged; none developed peri-prosthetic infection. CONCLUSIONS The incidence of delayed postoperative hematoma following IPP surgery was 0.5% in our series of 600 cases. All cases were successfully managed with intravenous antibiotics, hematoma evacuation, and antibiotic washout. Because of the low incidence of this complication, definitive statements concerning prevention and management cannot be made. However, we now recommend avoiding postoperative anticoagulants for at least 5 days if possible, and avoiding vigorous physical activity for at least 3 weeks.

Inflatable Penile Prosthesis Insertion in Men with Severe Intracorporal Fibrosis

Objectives: To retrospectively review a series of men who underwent attempted inflatable penile prosthesis (IPP) insertion into severely scarred corpora, and to analyze the surgical techniques and instruments that contributed to a successful outcome. Patients and Methods: All IPP procedures done by a high-volume prosthetic surgeon during a 5-year period were retrospectively reviewed. Fourteen patients with severe intracorporal fibrosis underwent 15 attempted IPP insertion procedures, and are the subject of this review. Results: A standardized surgical approach was employed for all patients. Thirteen of the 15 procedures were successful (i.e., an IPP was inserted, with satisfactory cylinder position). One procedure failed due to corporal obliteration. One patient underwent an initial failed attempt, but was successfully implanted 10 months later. Two of the 14 patients (14%) developed peri-prosthetic infection and were explanted. Conclusion: IPP insertion into scarred corpora is difficult and occasionally impossible. We have developed a standardized surgical approach for these cases, using limited corporal excavation, followed by the use of sequential Uramix and then Carrion-Rossello cavernotomes, that we feel has improved our chance of a successful implant. However, due to the rarity of these cases, it is not possible to make definitive statements concerning the optimal surgical technique.

Prostate cryoablation in patients with multiple-component inflatable penile prostheses.

OBJECTIVE To evaluate and assess any inflatable penile prosthesis (IPP)-related complications in patients with organ-confined prostate cancer treated definitively with third-generation, ultrasound-guided prostate cryoablation. MATERIAL AND METHODS From November 2003 to October 2010, we identified 100 consecutive patients with clinically organ-confined prostate cancer who were treated with targeted cryoablation as primary or salvage therapy by a single surgeon. Review of these patients revealed 13 who had previously been diagnosed with organic erectile dysfunction and had been implanted with a multiple-component IPP by the same surgeon. To assess IPP complications related to the cryoablation procedure, we retrospectively reviewed events occurring within a 6-month postoperative follow-up period. RESULTS For the entire series, the patient ages ranged from 42-84 years (mean 68). Of the 13 patients with IPPs, no device-related complication (eg, IPP infection, erosion, or malfunction) was found. No patient required IPP revision or removal. CONCLUSION Patients with organ-confined prostate cancer who also have a multiple-component IPP may safely undergo ultrasound-guided prostate cryoablation as definitive therapy. Cryoprobe and thermocouple placement must be carried out carefully, using ultrasound guidance. To avoid IPP reservoir injury, suprapubic tube placement should be avoided.

Use of BioPatch® (Protective Disk with Chlorhexidine Gluconate) in Closed-Suction Drainage for Penile Implant Surgery.

Background: The use of closed-suction drains after penile implant surgery remains controversial. The use of BioPatch®, a protective disk with chlorhexidine gluconate, may reduce the incidence of drain-related infections, one of the feared complications of drains. The aim of this study is to describe a novel use of BioPatch® in penile implant surgery as well as additional techniques that may potentially minimize infection rates. Methods: A description of operative technique and a review of the literature will be presented. A novel approach to penile implant surgery that may reduce infection rates is described. Results: A simple technique is described for surgeons considering implementation of closed-suction drains after penile implant surgery. Conclusion: Although randomized controlled studies looking at drain placement following penile implant surgery are lacking, the addition of BioPatch® and the implementation of surgical techniques as described are potentially helpful in preventing infection following this surgery.