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The purpose of this study is to investigate the relationship between inflatable penile prosthesis (IPP) infection, time of year, climate, temperature and humidity. This is a retrospective IRB-approved analysis of 211 patients at 25 institutions who underwent salvage procedure or device explant between 2001 and 2016. Patient data were compiled after an extensive review of all aspects of their electronic medical records. Climate data were compiled from monthly norms based on location, as well as specific data regarding temperature, dew point, and humidity from dates of surgery. Rigorous statistical analysis was performed. We found that penile prosthesis infections occurred more commonly in June (n = 24) and less frequently during the winter months (n = 39), with the lowest number occurring in March (n = 11). One-hundred thirty-nine infections occurred at average daily temperatures greater than 55 °F, compared to 72 infections at less than 55 °F. The incidence rate ratio for this trend was 1.93, with a p-value of

INTRODUCTION AND OBJECTIVE:Inflatable penile prosthesis (IPP) is a well-established treatment for medically refractory erectile dysfunction. Infection is the most dreaded complication and the major...

Introduction and Objectives Implantation of a penile prosthesis in a patient with significant corporal fibrosis can pose a significant challenge to the surgeon, necessitating the knowledge of specific techniques used to dilate and close aggressively scarred corpora. The objective of our instructional video is to discuss 2 techniques used to approach corporal fibrosis: proper and safe use of cavernotomes for dilation and use of narrower prostheses. Methods In this video, we present a 53-year-old man with a history of priapism 3 years ago that lasted 4 days in the setting of trazodone use. He was managed with corporal irrigation and subsequently developed severe erectile dysfunction. Notably, the patient had a history of sickle cell anemia, and on physical examination was noted to have densely fibrotic corpora. After extensive counseling regarding options, he chose a penile implant. The surgical was planned using the “no touch technique.” After the corporotomies were made, we began dilating the corpora. Hegar dilators and Dilamezinsert were attempted at first but met significant resistance. We switched to cutting cavernotomes and were able to dilate up to 11-Fr distally and up to 13-Fr proximally. The proper use of cavernotomes is highlighted in our video, with care being taken to aim the cutting edge of the cavernotome laterally away from the urethra. We also used the narrowest inflatable prosthesis available to us (Coloplast Titan narrow-base) and describe the narrower devices available in inflatable and malleable forms as an option for less-than-ideally dilated corpora. The pump and reservoir placement was completed uneventfully. Results The patient was admitted overnight for observation and check of a complete blood count given his history of sickle cell anemia. He was able to be discharged after 23 hours of observation. The patient presented to the clinic 4 weeks later for pump activation. He was able to achieve good rigidity and had a penile length adequate for penetration after maximal activation. Conclusion This video discusses the approach to penile prosthesis placement in patients with significant corporal fibrosis. It highlights the proper use of cutting cavernotomes and the availability of narrow-diameter prostheses, both malleable and inflatable.

We report a case of malfunction of an inflatable penile prosthesis (IPP) after prostatic urethral lift (PUL) necessitating surgical intervention. A 70 year-old male underwent PUL for benign prostatic hyperplasia after IPP implant for organic erectile dysfunction. After PUL, the patient experienced IPP malfunction where he underwent subsequent IPP removal and replacement. A pinhole defect was noted in the reservoir upon removal attributable to PUL. Performing PUL before IPP implantation should be considered in light of potential iatrogenic PUL needle deployment injury.

FIGURE 1 The “no touch” enhancement to the placement of a virgin inflatable penile prosthesis decreases the infection rate to 0.46%. An additional step to the “no touch” technique aids in the reduction of potential postoperative hematoma formation. Two well-documented methods of preventing a postimplant scrotal hematoma are a closed-suction drain and a “mummy wrap.” A novel technique to facilitate reliable and safe cylinder placement with minimal postoperative scrotal swelling is described along with patient outcomes. © 2014 International Society for Sexual Medicine

Objective To explore whether a “no touch” enhancement to the surgical technique of inflatable penile prosthesis (IPPs) implantaion will further decrease infection rates. Materials and Methods A single surgeon performed 2347 IPPs between January 2002 and June 2011. Patients receiving each manufacturer's implants were stratified for age and diabetes. Since 2003, infection retardant–coated IPPs were implanted through the standardized penoscrotal approach. Since 2006, the “no touch” enhancement was added to the surgical procedure. Infection rates in the noncoated IPP, coated IPP with standard technique, and coated IPP implanted with “no touch” enhancement were calculated and subjected to statistical analysis. The two company's implants were scrutinized for their individual infection rates in each group. Results Patients in all the groups were similar for age and diabetes. 132 noncoated implants had an infection rate of 5.3%. In the years 2003-2005, 704 coated devices had a statistically significant improvement in incidence of infection to 2%. In the years 2006-2010, the “no touch” technique enhanced the standard surgical procedure in 1511 patients. Only 7 infections were seen yielding an infection incidence of 0.46%. There was no difference in the two manufacturer's infection rates. Differentiation between virgin and revision operation displayed no bias in the infection rate. Conclusion Infection-retardant coatings lower the risk of infection from 5.3% to 2%. The “no touch” enhancement to the surgical procedure further decreases the rate of infection to 0.46%. Neither manufacturer showed statistical superiority in survival from revision for infection.

Introduction Over 25% of the more than 725,000 cases of nosocomial infection in the United States are related to an implantable device. Despite the standard typical strategies available, infection rates for breast implants, cerebrospinal shunts, and penile implants remain unacceptably high. This paper will review use of a “no-touch” technique in varied surgical procedures from orthopedic fracture repair, cerebrospinal fluid shunt placement, and breast reconstruction/augmentation to penile prosthesis implantation. Aim One of our aims was to investigate whether the “no-touch” concept was unique to the field of penile implants and if similar results were obtained in other subspecialties. The other was to examine whether the low infection rate initially obtained with the “no-touch” technique was maintained for a larger number of penile implant procedures. Methods The literature was reviewed for the use of the “no-touch” technique in procedures as varied as orthopedic fracture repair, cerebrospinal fluid shunt placement, breast reconstruction/augmentation, and penile prosthesis implantation. In addition, a single surgeon's experience with 3342 penile implant surgeries with and without the use of the “no-touch” technique was reviewed. Main outcome measure Penile implant infection rate was examined for 3342 consecutive cases between January 2002 and December 2014. Infection of standard technique was compared with rate of infection with antibiotic impregnated devices and starting in 2006 with the addition of the “no-touch” enhancement. Results Literature review revealed that the “no-touch” technique decreased postoperative cerebral shunt infection from 9.1% to 2.9%. Breast implant reconstruction surgical site infection decreased from 19% to none with the “no-touch” technique. Penile implant infection rate fell from 5.3% in 2002 to 1.99% with the use of antibiotic impregnated devices and to 0.44% with the addition of the “no-touch” technique. Conclusion Use of a “no-touch” technique involving a mechanical barrier makes a difference in preventing infection of an implantable device.

Since its introduction in 1996 Mulcahy salvage has significantly improved outcomes for the removal and replacement of infected inflatable penile prostheses. Long-term followup data of Mulcahy salvage show an infection-free rate of 82%. A multicenter retrospective analysis of the malleable implant salvage technique was conducted to assess infection outcomes and the feasibility of conversion from malleable device back to inflatable penile prosthesis.This is a retrospective, institutional review board exempt, multi-institution study of 58 patients who underwent Mulcahy salvage with inflatable penile prosthesis removal and replacement with malleable prosthesis. Patient operative notes and charts were extensively reviewed to compile study data.Between 2002 and 2014 a total of 58 patients underwent infected inflatable penile prosthesis removal and replacement with a malleable prosthesis via Mulcahy salvage. Of these patients 54 (93%) have remained infection-free postoperatively. Average patient age was 56.4 years and average operative time was 148 minutes. Postoperative followup (as of May 2015) ranged from 1 month to 84 months. Of the 54 patients 37 retained the malleable prosthesis and 17 (31%) subsequently underwent replacement with an inflatable penile prosthesis. This occurred on average 6.7 months after Mulcahy salvage. Four patients had persistent infection after Mulcahy salvage with the malleable prosthesis and underwent explantation.This retrospective analysis of Mulcahy salvage procedure and replacement of inflatable penile prosthesis with malleable prosthesis shows a high infection-free rate. Additionally, 17 of the 54 patients who remained infection-free were able to successfully undergo subsequent removal of the malleable prosthesis and replacement with an inflatable penile prosthesis. Further prospective studies are needed to compare salvage with malleable vs inflatable penile prosthesis.

The coordinated performance of a surgical procedure requires the combination of honed technical skills acquired through graduated experience and the retained cognitive information concerning anatomy and the particular disease entity. The completeness of the surgeon’s visual understanding of the three-dimensional anatomic relationships involved in the procedure directly impacts the rhythm of the operation, the speed, the freedom from complications, and the successful completion. Years ago a senior surgeon gave the advice to sit back the night before a major operation and mentally visualize each step, anticipate anatomic variations or anomalies, and develop strategies to avoid or cope with surgical complications. It is advice well taken. An additional adage is that it is better to avoid complications than to be known as a master at successfully correcting your own errors. Surgical anatomy is truly the study of relationships-musculoskeletal, facial, vascular, and the juxtaposition of organs. This article concentrates on the anatomy important to renal procedures, both as a guideline for a specific surgical approach and as a map for orderly removal or repair of the kidney. The article is primarily visual; the reader should concentrate on the figures, attempting to reconstruct them in a threedimensional fashion, positioning the kidney within.

Two patients following bladder exstrophy repair presented for final cosmetic reconstruction with the characteristic lower abdominal midline scar, bisected mons pubis, and laterally displaced labia majora. Tissue expanders were used to obtain additional skin and subcutaneous tissue. After adequate serial expansion, the expanders were removed, scar tissue excised, and primary approximation of healthy tissues performed. A tension free closure and esthetically pleasing midline incision, mops pubis, and vulva were obtained.

Objectives. To evaluate patient and female partner responses on the efficacy of, and overall satisfaction with, tadalafil to treat erectile dysfunction using sexual encounter profile (SEP) diaries. Methods. Data were pooled from four double-blind, placebo-controlled, 12-week trials that included 746 couples. Patients were randomized to placebo or tadalafil 10 or 20 mg. Efficacy was evaluated by the mean per-patient/per-partner percentage of “yes” responses to patient SEP questions 1, 2, and 5 and partner SEP questions 1 to 3 (erection achievement, penetration, and overall satisfaction with the sexual experience, respectively) for tadalafil versus placebo. For each SEP question, the number of postbaseline intercourse attempts when each couple agreed on the outcome was tabulated and divided by the total number of postbaseline attempts to calculate the mean percentage of agreement by couple. The overall satisfaction with successful postbaseline intercourse attempts was determined. Results. Tadalafil significantly improved the responses for the patient and partner-evaluated SEP questions (P 0.001, both doses versus placebo). Partners tended to report greater overall satisfaction than patients at baseline and postbaseline. The mean percentage of agreement by couple was approximately 98% for erection achievement and penetration and 85% for overall satisfaction. For successful intercourse attempts, patients and partners treated with tadalafil reported more overall satisfaction than those treated with placebo (P 0.05, tadalafil versus placebo comparisons). Conclusions. Partners reported significantly improved overall sexual satisfaction and corroborated the man’s report of improved erections and penetration ability with tadalafil 10 mg or 20 mg. Men reported improved erection achievement, penetration, and overall satisfaction with the sexual experience after taking tadalafil. UROLOGY 68: 631–635, 2006. © 2006 Elsevier Inc.