To determine whether preoperative partner involvement at clinic appointments is associated with deviation from a standardized postoperative care pathway for patients undergoing an inflatable penile ...prosthesis placement.
This is a retrospective study of 170 patients undergoing primary inflatable penile prosthesis placement performed by a single surgeon between 2017 and 2020. A standardized postoperative clinical pathway was used, including planned follow-up visits at 2 weeks (for wound check and device deflation) and 6 weeks (for device teaching). Patient characteristics, including demographics, partner involvement, and the number of follow-up visits were obtained from the medical record. Logistic regression modeling was performed to determine whether partner involvement was associated with unanticipated follow-up visits.
Partners were involved in preoperative visits for 92 patients (54%). Additional unplanned follow-up visits were observed for 58 patients (34%) between 0 and 6 weeks and for 28 patients (16%) after 6 weeks from surgery. Partner involvement was associated with reduced odds of unanticipated follow-up visits, both between 0 and 6 weeks (odds ratios 0.37, 95% CI 0.18-0.75) and after 6 weeks (odds ratios 0.33, 95% CI 0.13-0.81) in adjusted models.
Having a patient’s partner involved during the preoperative period is associated with a significant reduction in unanticipated follow-up. We would recommend that urologists routinely encourage patients considering the insertion of a penile prosthesis to involve their partners in perioperative visits. Further research needed is needed to determine how to best support patients during surgical decision-making and through the postoperative period.
Penile prosthesis (PP) insertion in the setting of corporal fibrosis can be challenging and a variety of techniques have been described to accomplish this, however the necessity of these maneuvers is ...debatable. Our objective was to investigate techniques and outcomes of PP placement in patients with corporal fibrosis at tertiary referral centers. Multicenter outcomes of 42 patients (mean age 53.4 ± 1.9 years) with corporal fibrosis who underwent placement of PP over a 10-year period were reviewed. The most common etiology of corporal fibrosis was prior PP explant due to either infection (40.5%) and/or erosion (16.7%). Fourteen patients (33.3%) had a history of priapism, 5 (11.9%) of which had one or more distal surgical penile shunts. Techniques used for PP placement included: sequential dilation (8-12 mm) with standard dilators in 15 (35.7%), dilation with cavernotomes in 25 (59.5%) and limited sharp corporal excision and dilation with cavernotomes in 1 (2.4%). Narrow cylinders were employed in ten patients (23.8%). Major complications occurred in one patient (2.4%) who underwent explant for infection and distal erosion. Most patients with corporal fibrosis can undergo successful placement of a PP using standard dilators or cavernotomes. Sharp corporal excision and other measures are rarely required.
A lack of uniformity exists for insurance payer coverage for all categories of penile prostheses (PP). We sought to determine common insurance coverage criteria and barriers to implantation across ...common insurance plans from healthcare referral regions (HRR) nationwide. Coverage criteria and stipulations were reviewed regarding erectile dysfunction (ED) etiology, ED duration, contributing comorbid conditions, medications, drug use, diagnostic tests, use of procedures and prior interventions. Seventy of 100 plans included coverage criteria. 36.1% provided coverage only in cases of gender dysphoria. 27.7% required documentation of trial, contraindication or intolerance to pharmacologic therapy, with varying descriptors of what this entailed. 13.8% required at least consideration of prior pharmacologic therapy. 4.2% required trial or contraindication to classic second-line therapies. 25.0% stated that ED must be organic. Psychogenic ED was covered by 12.5% of plans. Eleven plans required at least 6 or 12 months of symptoms. Laboratory evaluation to rule out hypogonadism or hyperprolactinemia was required by five plans. Insurance coverage criteria for PP placement were highly variable by state and plan. Coverage is provided for PP implantation in most cases for ED of organic etiology following failure of pharmacologic therapy when contributing comorbidities are optimally managed.
Historically, management of inflatable penile prosthesis infection was explantation of the device with delayed reimplantation at a later date. In 1991, this paradigm was challenged when early ...attempts at washout and immediate salvage proved successful. The clinical experiences and data generated over the past 30 years have allowed implanters to refine their salvage procedures to improve patient outcomes. In this article, we review the original Mulcahy technique for salvage and discuss updates to this protocol based on recent data.
To characterize penile prosthesis surgery utilization and assess for regional differences in the use of this procedure across the United States.
We examined penile prosthesis surgeries (inflatable ...and semirigid implants) in Medicare beneficiaries with erectile dysfunction (ED) for the years 2006 through 2014. Adjusted utilization rates were calculated per 1000 beneficiaries accounting for age and race. Utilization rates were examined nationally and by hospital referral region (HRR).
The national adjusted rate of penile prosthesis surgery declined from 5.41 per 1000 beneficiaries in 2006 to 3.74 per 1000 beneficiaries in 2014. The number of beneficiaries diagnosed with ED outpaced the number of patients undergoing surgery. Regional variation was observed; a 12-fold difference in 2014 (1.9/1000 in Norfolk, VA to 24.2/1000 in Miami, FL). Adjustment of 2014 data by urology provider density reduced variation between HRRs, and as a result a 3.5-fold difference was observed. Over 60% of HRRs performed 0 to <11 surgeries.
The rate of penile prosthesis surgery is declining amongst Medicare beneficiaries with ED. Significant regional variation exists in the utilization of penile prosthesis surgery. This variation may be explained by a series of urologist and patient-specific factors, including provider density. Penile prosthesis surgery in Medicare beneficiaries is likely highly dependent on where these patients seek care.
Scientific literature has experienced a significant growth in the number of authors per publication each year. Erectile dysfunction (ED) is one of the most common urologic conditions, accounting for ...over 2.9 million outpatient visits per year. Given the prevalence of ED and the large literature base available on this condition, bibliometric analysis of the ED literature could provide urologists and sexual medicine specialists with a better understanding of publication trends in this topic area.
The purpose of this study was to investigate trends in authorship, citations, and impact score for ED original and review articles published in urology and sexual medicine journals.
We analyzed ED original research and review articles indexed in MEDLINE between January 1, 2006, and December 31, 2016. Descriptive statistics were used to evaluate the mean number of authors for articles by journal type and time period (2006 vs 2016). Linear regression was used to examine the relationship between number of authors, number of citations, and relative citation ratio (RCR).
The primary outcomes of interest included mean number of authors, citations, and RCR per manuscript by journal type and time period.
A total of 3,516 articles were analyzed, 2,938 (83.6%) original and 578 (16.4%) review articles. The mean number of authors among ED publications increased from 4.8 in 2006 to 6.4 in 2016, a 34.4% increase. Original articles had a greater mean number of authors compared to review articles (6.0 vs 4.3, P < .001). The mean number of authors for original articles significantly increased from 5.0 in 2006 to 7.0 in 2016 (P < .001), an increase of 38.9%. A positive linear relationship was observed between mean number of authors and number of citations per manuscript (r = 0.015, P < .01) as well as RCR (r = 0.37, P < .0001). The largest authorship increases were observed in European Urology (78.8%), BJU International (78.6%), and Journal of Sexual Medicine (58.1%).
Authorship trends should be taken into consideration when urologists and sexual medicine experts review ED articles for the purpose of informing patient care.
Primary strengths include a large literature base spanning multiple years for analysis and a systematic literature search to identify relevant ED literature. Findings are limited to ED literature published in the urology and sexual medicine journals analyzed.
The number of authors per ED manuscript has significantly increased over time, most notably among original research articles. Increasing authorship was associated with more citations and higher RCR in the ED literature.
Rezaee ME, Johnson HA, Munarriz RM, et al. Bibliometric Analysis of Erectile Dysfunction Publications in Urology and Sexual Medicine Journals. J Sex Med 2018;15:1426–1433.
Purpose of Review
The purpose of this review is to critically analyze and summarize recent studies in the area of penile prosthesis surgery outcomes with a focus on infection prevention in high-risk ...patients.
Recent Findings
Reduction of surgical time in complex prosthesis surgery may reduce infection risk. Concomitant implant surgery is not associated with increased infection risk. Certain immunocompromised patients may be more likely to have penile implant infections, but these may not include patients with well-controlled HIV, well-controlled diabetes, or transplant recipients. Substance abuse is correlated with increased risk of infection after penile implant surgery. Careful patient selection and preoperative optimization can reduce infection risk in spinal cord injury patients.
Summary
In the last 5 years, there have been several important studies investigating the risk of penile prosthesis infection in complex patients, clarifying which patient categories are at increased risk and how that risk can be mitigated.
Defining the risks associated with diabetes mellitus in patients undergoing penile prosthesis implantation remains controversial. Our study aims to assess whether preoperative hemoglobin a1c and ...preoperative blood glucose levels are associated with an increased risk for postoperative infection in diabetic men. We performed a retrospective review of 932 diabetic patients undergoing primary penile prosthesis implantation from 18 high-volume penile prosthesis implantation surgeons throughout the United States, Germany, Belgium, and South Korea. Preoperative hemoglobin a1c and blood glucose levels within 6 h of surgery were collected and assessed in univariate and multivariate models for correlation with postoperative infection, revision, and explantation rates. The primary outcome is postoperative infection and the secondary outcomes are postoperative revision and explantation. In all, 875 patients were included in the final analysis. There were no associations between preoperative blood glucose levels or hemoglobin a1c levels and postoperative infection rates; p = 0.220 and p = 0.598, respectively. On multivariate analysis, a history of diabetes-related complications was a significant predictor of higher revision rates (p = 0.034), but was nonsignificant for infection or explantation rates. We conclude preoperative blood glucose levels and hemoglobin a1c levels are not associated with an increased risk for postoperative infection, revision, or explantation in diabetic men undergoing penile prosthesis implantation.
Modern-day penile prostheses use infection retardant coating to decrease rates of postoperative infection, subsequently reducing explantation and revision rates as well. The Coloplast Titan models ...are dipped into antimicrobial solutions right before implantation, and the components used for dipping can be tailored toward the patient.
To compare infection, explantation, and revision rates among different dipping solutions used before implantation for patients with diabetes receiving a Coloplast Titan implant.
We systematically reviewed 932 patients with diabetes receiving a primary penile implant across 18 different centers from the period April 2003 to August 2018. Of those patients, 473 received a Coloplast device, whereas 459 received an AMS device. Data regarding the type of antimicrobial solution used before implantation were recorded for 468 patients receiving a Coloplast Titan, including whether or not they suffered a postoperative infection and if they underwent explantation and/or revision. Outcome rates were compared using Fisher's exact and Pearson's chi-square tests, and logistic regression modeling was performed to account for covariates.
The main outcome measures of this study were postoperative infection, explantation, and revision rates.
Of the total 932 patients reviewed, 33 suffered a postoperative infection. Of 468 patients receiving Coloplast implants, there was a 3.4% infection rate. The most commonly used antibiotic combination before dipping was vancomycin + gentamicin (59.0%). There was a significantly lower rate of postoperative infection, explantation, and revision when vancomycin + gentamicin was used than those associated with the use of all other dipping solutions (1.4% vs 6.4%; P = .004, 1.1% vs 8.3%; P < .001, and 2.5% vs 12.5; P < .001, respectively). After adjusting for age, body mass index, preoperative blood glucose level, and hemoglobin A1c, the use of other dips was an independent predictor of postoperative infection (odds ratio: 0.191; P = .049). The inclusion of rifampin in the dipping solution trended toward being a significant risk factor for infection (P = .057). Including antifungals in the dipping solution did not affect infection (P = .414), explantation (P = .421), or revision (P = .328) rates.
Vancomycin + gentamicin was the most efficacious combination of antibiotics used for dipping in terms of preventing postoperative infection and subsequent explantation and revision.
Data were sampled across multiple institutions providing a large sample that may be more representative of the population of interest. A key limitation of the study was its retrospective nature, which prevented us from controlling certain variables.
The use of rifampin did not provide the same type of protection, possibly representing a shift in resistance patterns of common bacteria responsible for device infection. Towe M, Huynh LM, Osman MM, et al. Impact of Antimicrobial Dipping Solutions on Postoperative Infection Rates in Patients With Diabetes Undergoing Primary Insertion of a Coloplast Titan Inflatable Penile Prosthesis. J Sex Med 2020;17:2077-2083.
Purpose of Review
To describe recent advances in infection prevention strategies for penile prosthesis surgery.
Recent Findings
Improvements in surgical technique, antibiotic prophylaxis, prosthetic ...device design, and patient selection have globally reduced penile prosthesis infection rates. However, current societal antibiotic prophylaxis guidelines may fail to cover all organisms implicated in penile prosthesis infections, particularly fungal and anaerobic pathogens.
Summary
Although significant strides have been made in reducing penile prosthesis infections, further education and research efforts are needed to continue to prevent this infrequent, but devastating complication. This review discusses recent advances in penile infection understanding and prevention.
