Caroline J. Simmons

Centers of Excellence Concept and Penile Prostheses: An Outcome Analysis

PURPOSE Outcome analysis has shown that the center of excellence concept, in which all of a specific type of surgery is done by 1 surgeon rather than by multiple surgeons in a group, provides superior outcomes for total joint replacement, radical cancer and heart valve surgery. We compared penile prosthesis implantation outcomes between the center of excellence and multiple surgeon approaches in a large, single specialty urological surgical practice. MATERIALS AND METHODS Between February 2001 and August 2004 a total of 57 penile prostheses were implanted by 10 surgeons at a large urology practice (multiple surgeon group). Between July 2004 and April 2005 a total of 57 penile prostheses were placed by a single surgeon (center of excellence group). Chart review of the 2 patient groups was performed. RESULTS The patient groups showed no statistical differences in age, race, cause of impotence or percent with diabetes. The median cylinder length of prostheses placed by the center of excellence surgeon was 2 cm greater than the length of the cylinders placed by the multiple surgeon team (p <0.0001). Excluding cases requiring additional procedures the median placement time was considerably shorter for the center of excellence surgeon than for the multiple surgeon team (34 vs 94 minutes, p <0.0001). There were 8 iatrogenic failures (infection, erosion and poor positioning) requiring surgical removal in the multiple surgeon group but none in the COE group (p <0.05). Although followup for the multiple surgeon team was longer, Kaplan-Meier revision-free survival curves showed significantly longer survival for the center of excellence group (log rank test p = 0.0283). CONCLUSIONS The center of excellence concept in penile prosthesis surgery appears to deliver superior surgical outcomes in terms of shorter operative time, longer cylinders and fewer iatrogenic complications.

Perineal Approach for Artificial Urinary Sphincter Implantation Appears to Control Male Stress Incontinence Better Than the Transscrotal Approach

PURPOSE Traditionally cuff placement of an artificial urinary sphincter is done through a perineal approach. A new approach through a penoscrotal incision or transscrotal approach is reportedly more rapid and easier than the traditional incision. These 2 approaches were evaluated to determine which one controlled male stress urinary incontinence better. MATERIALS AND METHODS We performed a retrospective chart review of 94 patients who underwent artificial urinary sphincter placement procedures from April 1987 to March 2004. RESULTS A total of 126 artificial urinary sphincter cuffs (120 procedures, including double cuff placement in 6) were placed in 94 patients with 63 placed penoscrotally and 63 placed perineally. Of the double cuff placements 1 was perineal and 5 were transscrotal. In patients with a single initial or revision cuff the self-reported completely dry rate was 28.6% with the penoscrotal approach and 56.5% with the perineal approach (p = 0.01), while for initial cuffs only the dry rate was 28.0% and 56.7% for the penoscrotal and perineal approach, respectively (p = 0.03). Five of 28 patients (17.9%) with initial penoscrotal placement later underwent tandem cuff placement for continued incontinence, whereas only 1 of 32 (3.1%) with initial perineal placement later had a tandem cuff added (p = 0.06). There was no difference in the estimated failure-free survival (failure for any reason) of the device. CONCLUSIONS When the artificial urinary sphincter cuff is placed through a perineal approach, there appears to be a higher completely dry rate and fewer subsequent tandem cuff additions than when the artificial urinary sphincter cuff is placed through a penoscrotal incision.

A Multicenter Study on the Perineal Versus Penoscrotal Approach for Implantation of an Artificial Urinary Sphincter: Cuff Size and Control of Male Stress Urinary Incontinence

PURPOSE In a single center retrospective study we previously reported superior dry rates and fewer artificial urinary sphincter revisions when the sphincter cuff was placed via the traditional perineal approach compared with a penoscrotal approach. A multicenter study was performed to compare the approaches further and explain the disparity in outcomes. MATERIALS AND METHODS We performed a retrospective review of 158 patients who underwent these procedures from April 1987 to October 2007 at 4 centers. RESULTS During 184 surgeries in 158 patients 201 artificial urinary sphincter cuffs were placed (90 penoscrotal and 111 perineal). Among patients with known followup the completely dry rate for single cuff artificial urinary sphincters was 17 of 62 (27.4%) in the penoscrotal group and 41 of 93 (44.1%) in the perineal group (p = 0.04). Continued incontinence necessitated subsequent tandem cuff in 7 of the 62 (11.3%) penoscrotal cases compared to only 5 of the 93 (5.4%) perineal cases. Cuff size in the penoscrotal group was 5.0 cm in 1 patient (1.1%), 4.5 cm in 11 (12.2%) and 4.0 cm in 78 (86.7%). Cuff size in the perineal group was 5.5 cm in 1 patient (0.9%), 5.0 cm in 8 (7.2%), 4.5 cm in 30 (27.0%) and 4.0 cm in 72 (64.9%). CONCLUSIONS There appears to be a higher completely dry rate with fewer subsequent tandem cuff additions with the perineal approach compared to the penoscrotal approach. This disparity may be explained by a more proximal artificial urinary sphincter cuff placement in the perineal group as evidenced by a larger cuff size.