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The history of the development of today’s very dependable three-piece inflatable penile prostheses is fascinating. In its infancy, the three piece was plagued with frequent revisions and a relatively complex insertion and consequently unitary and two-piece prostheses flourished with the implanting urologists. While the surgery was less difficult because these devices did not require the dreaded reservoir insertion, they often proved unsatisfactory to patients in flaccidity, erection and longevity. By the turn of this century all of the unitary and two-piece inflatables had been withdrawn from the market except the Ambicor two-piece inflatable penile prosthesis. This paper covers the history of the various unitary and 2-piece inflatable models before examining a critical question: is the Ambicor 2-piece still a needed implant today?

This workshop completes the trilogy of nuances of the various incisions used to place an inflatable penile prosthesis (IPP). Infrapubic placement was the original technique employed 50 years ago for the very first IPP surgeries. The historical perspective of the development of implantation incisions and the original Scott prosthesis highlighted in this work should be fascinating to today’s younger prosthetic urologists. The developing surgeon should also find some surprising maneuvers considered important technique nuances from the highest volume infrapubic implanter in the world. Among the wonders of the infrapubic approach covered are: The surgery is conducted without the aid of an in-dwelling Foley catheter or post-operative inflation. Hydrodistension of the corpora substitutes for corporal dilatation. The “chicken choke” protects the urethra from damage. Closed suction drainage is employed despite minimal scrotal dissection. Motivated patients may use their new device as early as 14 days after implantation.

The use of semirigid rod penile prosthesis for the management of erectile dysfunction was first described over 85 years ago. Since then, there have been numerous design advancements leading to improved overall durability, concealability, rigidity, and natural feel. However, the inflatable penile prosthesis (IPP) still has a higher patient satisfaction rate and is currently the most commonly inserted prostheses in the United States. There are still certain situations and conditions where the simplicity of a rod may be preferred over an IPP. A pair of semirigid rods has been shown to have less risk of malfunction and need for revision surgery. In addition, patients with poor manual dexterity, those undergoing a salvage for infection prosthesis and those with a prolonged (> 48 h) priapic episode may be better served with a rod than an IPP. Finally, in patients compromised by infection or priapism, the rods can later successfully be exchanged for an IPP with potentially longer, wider cylinders with resultant greater patient satisfaction.

BackgroundInfection after the penile prosthesis can be devastating to both the patient and surgeon with various complications and consequences. After introduction of antibiotic-coated implants, the rate of infection has dramatically decreased, but still we see uncommon organisms causing infection. We present a first case report of penile prosthesis infection by brucellosis due to raw milk ingestion. To our knowledge, this is the first reported case of brucellosis penile prosthesis infection.Case presentationWe present a first case report of penile prosthesis infection by brucellosis due to raw milk ingestion. A 75-year-old, diabetic male patient presented with penile prosthesis infection 5 months post-penile exchange surgery due to mechanical malfunctioning of 2-piece penile prosthesis which was inserted 11 years ago. The initial treatment with broad spectrum antibiotics did not subside the infection. After diagnosis of brucellosis, the antibiotic was changed to anti-brucellosis (Rifampicin + Tetracycline). The patient improved dramatically and was discharged home with smooth follow-up course.ConclusionBrucellosis can cause infection of penile prosthesis and can be treated with anti-brucellosis antibiotics without necessitating surgical intervention and removal of prosthesis.

In a special miniseries highlighting the different surgical techniques to the inflatable penile prosthesis (IPP), Wilson’s Workshop seeks to bring forth skill considerations for the modern implanter. Each work is authored by a highly regarded surgeon who has truly honed the art of their respective approach. Today, most implanters are comfortable with either the penoscrotal or suprapubic incision. The following work directs the spotlight onto a much newer and less known technique, IPP implant via the subcoronal incision. SHP leads the Urology Center of Excellence in Seoul, South Korea, and has implanted more than 700 IPPs using the subcoronal approach since 2015. Here, he will share the clinical pearls of this novel incision gathered through trial and error over many repetitions. We are hopeful that this work will peak the interest of inquisitive minds and help disseminate improved implant techniques.

The inflatable penile prosthesis was first implanted with a large vertical suprapubic incision. Nowadays, three surgical approaches are utilized: penoscrotal, infrapubic, and subcoronal. Globally the penoscrotal approach is used most often. Our first author describes nuances of the high transverse scrotal incision technique gained over 48 years of experience. Many of these methods will interest the reader because they are divergent from the common practice of implanters across the world. These distinctions are designed to diminish the risk of infection, speed up the surgery, and improve outcomes for both the patient and his surgeon.

The single most important factor in the reduction of penile implant infections has been the infection retardant coatings. Virtually every inflatable penile prosthesis (IPP) sold for the last 15 years in America has been coated and the device infection rate has dropped over 50% to less than 1% in experienced implanter practices. The vast majority of penile implants are contaminated with bacteria at time of surgery and the bacteria live within the implant spaces in a quiescent fashion protected by a biofilm secreted by the organisms that makes them impermeable to antibiotics or the body’s defense mechanisms. Only very rarely do the bacteria cause a clinical infection. Medicine has no clue why this atypically happens. There are new recommendations for systemic prophylactic antibiotics—a testimonial to the changing face of the bacteria causing device infection. New washout solutions are being utilized and new salvage guidelines are being studied.

The artificial urinary sphincter, known as AMS 800, has been the gold standard for treating moderate to severe stress urinary incontinence in males for 40 years. Yet, the number of sphincters done globally is quite small and the majority of urologists doing them are infrequent implanters. Estimates for 2019 showed half of implanters did only one implant that year and worldwide only around 13,000 implantations were performed. The traditional two-incision technique of perineal exposure for cuff placement and abdominal incision for pump and pressure regulating balloon persists as the most common technique to surgically place an artificial urinary sphincter. Present estimates are that upwards of 80% are done via the perineal approach and that approach is the highly favored incision of large volume centers. The scrotal one-incision approach was invented by Wilson 20 years ago and was aimed at making the implantation of a sphincter quicker, easier and safer for the occasional implanter. These physicians perform 1-2 devices per year, comprise 60% of implanters who perform the surgery yearly, and implant 22% of all implanted devices. Our article targets these infrequent inserters discussing the history of the two techniques and what the authors have learned about the advantages and hazards of the one scrotal incision procedure over the last two decades.

Although the artificial urinary sphincter (AUS) is widely regarded as the "gold standard" for surgical correction of male stress urinary incontinence, long-term durability for symptom control is variable. A significant number of men will experience a decline in device-related improvement over time. With erosion of initial success, men sufficiently bothered by recurrent incontinence not caused by device malfunction may seek surgical revision. Secondary surgery requires careful consideration on the part of the prosthetic urologist and a keen awareness of sound surgical techniques. The armamentarium for revision has traditionally consisted of strategies involving cuff downsizing and/or relocation, modification of the pressure regulating balloon, urethral wrapping, addition of a tandem cuff, or use of transcorporal cuff placement. These options will be presented in view of their evidence and theoretical advantages and disadvantages. In addition, we will discuss a newer approach of growing popularity that serves to challenge existing dogma and shift the paradigm of AUS revision surgery.

The constant refrain for patients seeking penile implant is, “can you make it bigger?” It is a different request when the patient is young and fully potent compared with the mature individual suffering from erectile dysfunction (ED) for whom conservative therapies don’t work. The purpose of this workshop is to review strategies to make the ED patient undergoing inflatable penile prosthesis (IPP) have an enhanced penile appearance by having more of his phallus visible outside his body. Our common procedures are to use a combination of vacuum device preparation, oversizing the cylinders 1–2 cm, and daily aggressive cycling of the device for at least 6 months following implantation. More complex surgical solutions are also covered.

Erectile dysfunction (ED) and stress urinary incontinence (SUI) are known bothersome sequelae to radical prostatectomy. In recent years, additional attention has been placed on another less commonly described and reported side effect to this surgery, climacturia. While various noninvasive and surgical interventions have been described for the management of climacturia, until recently, none has provided reliable and meaningful results. In the past few years, the Mini-Jupette sling has gained popularity as an adjunct to inflatable penile prosthesis placement in patients with concomitant ED and climacturia. Recent data have also suggested its feasibility in patients with mild SUI. While the original technique described by Pr. Andrianne has shown long-term, reproducible, and safe results, innovative modifications such as the use of autologous rectus fascia, the Male Urethral Mini-Sling and the Mayo Clinic modified Mini-Jupette sling have also been suggested, proof of widespread interest amongst clinicians toward achieving the optimum surgical technique.

It is safe to say that the overwhelming majority of cylinders out of place result from surgeon error at the time of implantation. There are some instances where patient comorbidities could increase the difficulty of accurate development of cylinder insertion or space. Most of the time the operator recognizes his instrument out of place and corrects it intraoperatively. Other times the surgeon makes a flawed movement with a sharp instrument piercing some tissue. When the cylinder is placed initially and inflated the wayward position is usually not evident. However, in the postoperative period, the inaccurate position of the cylinder(s) can become readily apparent. The reader will notice this repeatedly stressed in Wilson's Workshop-over 90% of cylinders that are out of position can be diagnosed or prevented if one utilizes the two safety checks outlined below.

Corporal fibrosis is a process that involves excessive deposition of scar tissue in response to infection, trauma, or ischemia. It does not occur merely as a result of previous IPP surgery. Excessive development of corporal fibrosis is certain after extraneous and disastrous events such as priapism or the removal of a device for infection. The usual surgical planes and spaces are obliterated by proliferation of scar both in the tissues overlying the corpora and the space within the corpora previously occupied by erectile tissue. To maximize success, specialized instruments, downsized cylinders, and lots of experience are necessities. Prosthetic urology produces, for the most part, happy patients. Fibrosis guys, to a man are not happy. Let the expert have the unhappy patient!

Background: Penile prosthesis implantation represents the gold standard of treatment for severe or medically refractory erectile dysfunction (ED). We sought to address the paucity of currently available literature about global penile prosthesis usage in regard to geography, patient age, surgical approach, implanter volume, and etiology of ED. Methods: From device manufacturer information, we compiled data on over 63,000 implants performed worldwide. Data was grouped and then analyzed to examine trends in penile implantation between the years of 2005–2012. Results: The number of implants was seen to steadily increase over the study period. Of the 63,013 total procedures recorded, 85.9% were performed within the United States. 60–78% of procedures were done using the penoscrotal (PS) approach, with only Belgium/Netherlands as an outlier with an infrapubic (INF) majority. The US was notable for having an increasing number of implanters doing 16–30, 31–50, or >100 implants yearly. Etiology of ED worldwide was variable, but “organic,” post-prostatectomy, and diabetes accounted for the vast majority of cases worldwide. Conclusions: Penile prosthesis implantation is an increasing practice, as evidenced by a steady increase in the number of implants performed over a 7-year study period. Acceptance of this treatment option for ED is variable by region with the US leading the annual number of implantations by a wide margin. Worldwide, there appears to be a predominance of surgeons placing implants via the PS approach.

We report a novel solution for patients suffering from adult acquired retractile penis. Three patients complained of retractile penis (when standing) and/or prepubic recession. Physical examination confirmed the shaft of the penis was buried with only the glans visible. All three patients reported lower levels of self-confidence, self-esteem, and sexual confidence prior to their procedure. The three patients received surgical treatment with the insertion of a subcutaneous soft silicone penile implant and two of the three also received removal of the suprapubic fat pad. Over one year post operatively, the penile shaft and glans was visible and appeared natural. All patients reported an increase in self-confidence and self-esteem. The insertion of a subcutaneous soft silicone penile implant may prove to be a viable solution to reverse retractile penis and to increase patient quality of life when compared to more invasive current surgical treatments.

Penile prosthesis infection remains a rare but devastating complication of implantation. Historically, management of device infection was always extirpation. While certainly effective, device removal leaves an unhappy patient with a shortened penis. In this last part of a three-part series on the topic of penile prosthesis infection, we seek to highlight new and emerging ideas of infection management which have allowed surgeons the option of preserving the implanted status in select patients.

Since penile prostheses only provide axial rigidity, correction of penile deformity and enlargement of the visible penis during implant surgery may be desired. Evolving techniques of tunica expansion have made it possible to avoid grafting and preservation of the cylindrical appearance without bulges and indentations. After two decades of devising individualized solutions for patients and continuous enhancements of existing surgical solutions, Dr. Paulo Egydio has arrived at his Tunica Expansion Procedure (TEP). This strategy is his newest iteration of a lengthening techniques without grafting accompanied by penile prosthesis implantation. The TEP Strategy permits surgeons to use their own intuitive reasoning to determine the best pattern of multiple, small, staggered incisions to promote length and girth enlargement.

To assess outcomes of a variant of traditional modeling ("optimal modeling," OM) in patients with residual curvature following prosthesis implantation.We performed a retrospective review of all patients who underwent penile implant insertion. Patients with30° of residual curvature after cylinder placement and inflation underwent OM and were compared 1:1 to a demographically-matched cohort who received implantation without ancillary straightening. Optimal modeling was performed by forcibly bending the erect penis in the direction opposite the point of maximal curvature while maintaining glanular pressure to prevent urethral injury. This was performed for 90-second intervals for as many cycles as necessary to achieve15° curvature.Eighty patients were included in the final analysis; 40 (50.0%) underwent optimal modeling while 40 (50.0%) did not need additional straightening following surgery. The mean premodeling curvature was 47.8° (range 30°-90°) while post-modeling curvature improved to a mean of 10.6° (range 0°-30°, P.001); 87.5% of patients had15° of residual curvature. Patients in the OM cohort experienced longer operative times (82.7 vs 75.8 min, P = .15). No patient in either group experienced an intraoperative or postoperative complication at a mean follow-up of 29.9 months.Although many prosthetic urologists forego manual modeling in cases of moderate-severe penile curvature, our contemporary series shows it to be both safe and effective. OM may preclude the need for more time-consuming and complex surgical procedures.

The penoscrotal (PS), infrapubic (IP), and subcoronal (SC) incisions are used for inserting an inflatable penile prosthesis (IPP). Each surgical approach has its advantages and disadvantages and experts continue to debate which technique has the best outcomes. We performed a critical review of the published English-language studies up to April 2020 investigating the PS, IP, or SC approach for IPP placement. The PS approach is the most frequently used incision. The available data do not suggest a difference between PS and IP approach in size of the implanted prostheses, achieved penile length, patient satisfaction, infection rate, and risk of urethral injury. The risk of dorsal nerve injury, even if low, seems to be greater for IP approach. IP technique is associated with shorter operative time and earlier use of IPP compared with PS approach. Despite limited available data it is reasonable to assume that SC approach, compared with other approaches, has longer operative time and similar infection rate. The time to device activation with SC technique could be similar to the IP approach, but there is only minimal data that can confirm this hypothesis.

Inflatable penile prosthesis (IPP) infections are undeniably devastating for patient and surgeon alike. While less common in this modern era, the landscape of prosthesis infection is shifting. Continued examination of risk factors for infection and re-evaluation of common practices remain critical should we aim to advance the field. Quality research on this topic is limited by several factors, among which small sample size and lack of coordinated effort pose the most precarious of challenges. Nonetheless, careful analysis of available data in conjuncture with judicious utilization of established research from other prosthetic fields can help us better grasp the issue at hand. In this review, we aim to do exactly that—to examine available evidence in an effort to discern fact from fiction. In this first part of the three part series, we aim to summarize our understanding of the pathogenesis behind prosthesis infections, explore known preoperative risk factors, and discuss intraoperative considerations for infection prevention. In the second part of this series, we will examine the game changing effect of infection retardant implant coatings. Part three of the series details postoperative prevention strategies, reviews salvage techniques, and discusses additional key considerations.

If the surgeon makes a flawed and unrecognized movement with an instrument during implantation surgery, the cylinder subsequently may migrate into an unexpected position with inflation and thrusting post operatively. The out of position cylinder is now evident to the patient or symptomatic with discomfort. This 5th Wilson's Workshop will describe our recommended surgeries for correction of out of place cylinders and illustrate the simplest, safest and least invasive.

INTRODUCTION AND OBJECTIVE:The most dreaded complication of penile prosthesis (PP) implantation is device infection. Infection retardant coatings, changes in prep solutions and enhancement of surgi...

Removal of an infected penile implant often results in corporeal fibrosis, irreversible penile shortening and dissatisfaction with future implant surgery. Salvage surgery may avoid these problems but to our knowledge no study to date has evaluated these specific end points. We evaluated patients who presented to our center with an infected implant to determine the impact of salvage surgery on penile length.We evaluated consecutive patients undergoing removal of an infected penile prosthesis with immediate salvage or delayed reimplantation using a comprehensive, prospective database. Total corporeal length prior to and following immediate salvage or delayed reimplantation were compared. The impact of patient age, comorbidities, bacterial species, initial penile length and time to reimplantation on subsequent total corporeal length was evaluated.The cohort consisted of 40 patients. Overall 81% of salvaged cases were successful, resulting in a mean 0.6 cm (95% CI 0.20 to 1.1) reduction in total corporeal length. Delayed reimplantation resulted in a mean 3.7 cm (95% CI 2.9-4.5) total corporeal length loss. In patients who underwent delayed reimplantation the total corporeal length reduction was directly proportionate to the initial penis size of the patient. No statistically significant impact on penile length was attributable to patient age, diabetes, bacterial species or time to reimplantation.When possible, salvage surgery should be offered to patients with an infected penile implant. Our data confirmed that successful salvage surgery preserves penile length. When a device is explanted and replaced at a later date, patients can expect to lose 15% to 30% of penile length irrespective of age, diabetes, type of infecting organism and time to reimplantation.

Background After radical prostatectomy (RP), erectile dysfunction, often necessitating the need for inflatable penile prosthesis (IPP) insertion, and urinary incontinence and climacturia can ensue. Aim To assess the efficacy and safety of the mini-jupette, a mesh used to approximate the medial aspects of the 2 corporotomies at the time of IPP insertion, for the management of climacturia and urine leakage in patients with minimal incontinence. Methods We conducted a pilot multicenter study of patients with post-RP erectile dysfunction and climacturia and/or mild urinary incontinence (≤2 pads/day [ppd]) undergoing IPP insertion with concomitant placement of a mini-jupette graft. Outcomes Pre- and postoperative erectile function, continence and climacturia, and overall surgical outcomes were assessed. Results 38 patients underwent the mini-jupette procedure. The mean age of the population was 65.3 years (SD = 7.7). 30 had post-RP climacturia and 32 patients had post-RP incontinence (mean = 1.3 ppd, SD = 0.8). 31 patients received Coloplast Titan, 4 received AMS 700 LGX, and 3 received AMS 700 CX IPPs. Mean corporotomy size was 2.9 cm (SD = 1.0). Mean graft measurements were 3.2 cm (SD = 0.9) for width, 3.3 cm (SD = 1.3) for length, and 11.0 cm2 (SD = 5.1) for surface area. At a mean follow-up of 5.1 months (SD = 6.9), there were 5 postoperative complications (13.2%) of which 4 required explantation. Climacturia and incontinence were subjectively improved in 92.8% and 85.7%, respectively. Mean ppd decreased by 1.3 postoperatively. Clinical Implications The Andrianne mini-jupette is a feasible adjunct to IPP placement that can be used for subsets of patients with post-RP climacturia and/or minimal incontinence. Strengths and Limitations Strengths of this study include the novel nature of this intervention, the multi-institutional nature of the study, and the promising results demonstrated. Limitations include the retrospective nature of the study and the heterogeneity of the techniques and grafts used by different surgeons involved. Conclusion Longer follow-up and larger patient cohorts are needed to confirm the long-term safety and benefits of this intervention.

Optimizing outcomes with placement of inflatable penile prostheses (IPPs) can be challenging, especially in inexperienced hands. In this article, we outline Dr. Köhler’s penoscrotal penile prosthesis surgical approach. We also highlight patient selection, post-operative care and complications.

The most common reasons for revision surgery of penile prostheses include mechanical failure, infection and patient dissatisfaction. While revisions for mechanical failure and patient dissatisfaction are relatively routine surgical procedures, penile prosthesis implantation in previously failed settings is daunting, even for the experienced implanter. The surgical planes are altered and obliterated by scar. To maximize success, specialized instruments, downsized implants and lots of experience are necessities. Even experienced implanters without these assets have a high complication rate. Even if a surgical victory is achieved for the surgeon, the patient may be unhappy about his loss of length. This chapter is meant as a guide to the focused implanter for navigating the tricky pathways of redo of multi component prosthetics. We hope to help the reader prevent mistakes and reward realistic patient expectations in this difficult surgery on discouraged patients.

Inflatable penile prosthesis is the definitive operative intervention utilized for treatment of erectile dysfunction. There are a handful of surgical approaches to perform this operation in a safe and efficient manner. The aim of this review article is to discuss the surgical approaches described in the literature, and describe the preferred approach of authors. Ultimately, the surgical approach utilized by the prosthetic surgeon depends upon their training, patient factors, and surgeon preference.

Following publication of the original article [1], the authors identified an error in an author’s name.

The most dreaded complication of penile prosthesis (PP) implantation is device infection. We sought to assess whether inadequate cleaning and sterilization of the reusable Furlow inserter may represent one of the last etiologies of infection in PP patients. We performed a prospective analysis of cultures of the Furlow inserter used for PP surgeries from seven centers between May 1st and June 30th, 2019. Once the Furlow was received for surgery, the surgical team inspected the device for assembly status (disassembled or not) and the presence of visible stains, pieces of tissue or discoloration on either the interior of the barrel or the plunger. Swab aerobic and anaerobic bacterial and fungal cultures were then obtained from the internal component, after removal from the external component if assembled, and after introduction and immediate removal from the external component if disassembled. A total of 83 Furlow devices were cultured. Median age of surgical instrument was 4 years (2–10 years). Methods of sterilization included autoclave, wet autoclave, steam, and Sterad. Median time from sterilization was 3 days (1–22). On initial presentation, 79 devices were disassembled (95.1%) and 4 devices were still assembled (4.9%). Three external components were discolored (3.6%), while internal components demonstrated two stains (2.4%) indicative of improper cleaning which were thought to be residual blood products. Overall, 2/83 (2.4%) devices revealed positive swab cultures for Staphylococcus epidermidis. Swab cultures were negative for fungi and anaerobic bacteria. This patient cohort will continue to be followed to see if device infection occurs but it is unlikely to be meaningful since contaminated Furlows were discarded. Improper cleaning and/or sterilization of the Furlow Insertion Instrument may represent a source of infection for patients undergoing PP implantation.

Objective To investigate patients for positive culture rates with or without infection retardant coatings (IRC) penile prostheses (PPs) and to examine changes in culture positive isolates found in patients presenting overt clinical infection. Methods Cultures were obtained from PPs immediately upon surgical exposure of the pump. 236 patients were broken down into 2 groups, with each further divided into 2 groups. The noninfected group included 208 patients: 133 with uncoated PPs and 75 with IRC implants. The infected group included 28 patients: 16 with uncoated PP and 12 with IRC inflatable penile prostheses (IPP). Additionally, sensitivity to the combination of tetracycline and rifampin were evaluated on all cultures. Results In the noninfected group, culture positive isolates were found in 85 patients with uncoated PP's and in 32 patients with IRC implants [P value = 0.0003]. Cultures positive for Staphylococcus genus were found in 75 uncoated PP patients, while 20 patients with IRC implants had an isolate of this genus. In the infected group, culture positive isolates were found in 7 patients with uncoated PP and 6 patients with IRC IPPs [P value = 1.000]. Positive cultures for Staphylococcus genus were found in 6 patients with uncoated PP, while 3 patients with IRC IPP had an isolate of this genus. All bacterial isolates were sensitive to the combination of tetracycline and rifampin. Conclusion Positive bacterial cultures have been shown to be present on clinically uninfected IPPs at time of revision surgery. Culture isolates grown from patients with IRC IPPs reveal a nontraditional bacterial profile: fewer cultured isolates of Staphylococcus genus.

[Yafi, Faysal A.] Univ Calif Irvine, Irvine, CA USA. [Andrianne, Robert] Univ Hosp Liege, Liege, Belgium. [Alzweri, Laith; Hellstrom, Wayne J. G.] Tulane Univ, New Orleans, LA 70118 USA. [Brady, Jeffrey] Florida Urol Associates, Orlando, FL USA. [Butcher, Michael] Pk Nicollet Sexual Hlth Clin, St Louis Pk, MN USA. [Chevalier, Daniel] CHU Nice, Nice, France. [DeLay, Kenneth J.] Adv Urol Inst, Tallahassee, FL USA. [Faix, Antoine] Clin Beau Soleil, Montpellier, France. [Hatzichristodoulou, Georgios] Julius Maximilians Univ Wurzburg, Wurzburg, Germany. [Jenkins, Lawrence] Ohio State Univ, Columbus, OH 43210 USA. [Kohler, Tobias S.] Mayo Clin, Rochester, MN USA. [Osmonov, Daniar] Univ Hosp Schleswig Holstein, Kiel, Germany. [Park, Sun Hung] Sewum Prosthet Urol Ctr Excellence, Seoul, South Korea. [Schwabb, M. David] Lincoln Med Ctr, Bronx, NY USA. [Valenzuela, Robert] Mt Sinai Hosp, New York, NY 10029 USA. [van Renterghem, Koenraad] Jessa Hosp, Hasselt, Belgium. [Wilson, Steven K.] Inst Urol Excellence, La Quinta, CA USA.

Objective To examine possible etiology and treatment outcomes in 21 patients with glans necrosis following penile prosthesis implantation. Methods Glans necrosis typically presented with a dusky glans on the first postoperative day following prosthesis implantation. Results The blood supply to the glans penis consists of the dorsal arteries and the terminal branches of the spongiosal arteries. Using the cohort in our study, we compiled preoperative comorbidities and adjunctive surgical maneuvers that might compromise glans vascularity, leading to glans necrosis. Preoperative risk factors were arteriosclerotic cardiovascular disease (90%), diabetes mellitus (81%), smoking (81%), previous prosthesis explantation (57%), and previous radiation therapy (48%). The most prevalent intraoperative and postoperative factor was subcoronal incision for reasons as simple as coincident circumcision or as complex as for penile degloving (86%). Other factors detected were penile wrapping with an occlusive elastic bandage (62%), use of a sliding technique for penile lengthening (33%), and coincident distal urethral injury repair (29%). Seventeen patients (81%) managed expectantly with preservation of implanted prosthesis sustained significant glandular loss. Four patients managed with immediate prosthesis removal healed without sequelae. Conclusion Patients with preoperative risk factors undergoing penile prosthesis implantation should avoid high-risk adjunctive surgical maneuvers. Upon development of signs of glans necrosis postoperatively, in the setting of these high-risk factors, immediate implant removal may prevent subsequent glans necrosis.

Introduction The traditional surgical approach for revision of a malfunctioning artificial urinary sphincter (AUS) includes removal and replacement of all device components, identical to that employed in the setting of an infected or eroded AUS. Aims To describe outcomes of our technique in which we intentionally leave behind the original pressure‐regulating balloon (PRB) at time of AUS revision in a clinically non‐infected setting. Methods We retrospectively reviewed our combined institutional series of 35 patients who underwent 36 AUS revisions in which the original pressure‐regulating balloon was left undisturbed. We removed and replaced the defective cuff and pump through a single peno‐scrotal incision for most patients requiring revision of a non‐infected AUS. The new PRB was then placed on the opposite side through this single incision. Main Outcome Measures Assessment of outcomes, complication, and infection rate of this surgical series. Results All of the patients had the original pressure‐regulating balloon placed through an inguinal counter‐incision. Mean follow‐up time was 14 months (2−33 months). Overall complication rate for the revision series was 11%. No infections or complications occurred secondary to the retained PRB. Conclusion Follow‐up of our series provides evidence that retention of the original PRB at the time of non‐infected AUS revision is safe. Potential advantages include elimination of a counter incision and technically challenging exploration. By eliminating these aspects, the potentially resultant decreased operative time may help counter the theoretical yet unproven risk of infection from leaving the old PRB in place. Kohler TS, Benson A, Ost L, Wilson SK, and Brant WO. Intentionally retained pressure‐regulating balloon in artificial urinary sphincter revision. J Sex Med 2013;10:2566–2570.

Modeling (Wilson et al.) allows surgeons to correct most if not all Peyronie’s related curvatures when placing a penile prosthesis without having to use invasive and time-consuming procedures. The accepted rate of urethral disruption from modeling is nearly 5%. To diminish the possibility of this potential complication, the scratch procedure for internal disruption of the Peyronie’s plaque is used as an adjunct to modeling. The procedure can also be used to rid the implanted penis of any hour-glass defects commonly found prior to implantation in Peyronie’s patients. Normal erect penis without fibrous plaque

Introduction: The inflatable penile prosthesis (IPP) has been used to treat erectile dysfunction for 40 years. Loss of penile length following IPP remains the single biggest patient complaint. We describe a preoperative and postoperative patient preparation protocol to assist in setting realistic patient expectations and decreasing the complaint of reduced penile length. Materials & Methods: 750 Patients are instructed to use a vacuum erection device for 10 minutes each day for up to 2 months prior to IPP implant. After two months, maximization of cylinder length is accomplished regardless of IPP manufacturer. Cylinders are left partially inflated in the post-operative period and daily inflation for 3 months immediately upon patient tolerance. The average implanted cylinder length has increased dramatically with the preoperative vacuum usage when compared to the authors’ previous implantations and when compared to the national average of implanted cylinders obtained from one manufacturer. Results: Preoperative use of the vacuum device has allowed maximization of cylinder length. After the vacuum program, patients tend to experience less pain following implantation allowing earlier device instruction cycling and use. The average implanted cylinder length continued to increase annually for the first 5 years as the protocol evolved and seems to have remained stable for the last five years. Conclusions: Preoperative vacuum usage and postoperative capsule management has nearly eliminated patient complaints of reduced penile length. We believe this to be the result of larger size cylinders being implanted when compared to our previous implantations absent of the patient participation protocol.

Introduction Although infection rates have decreased with the use of antibiotic-coated implants and other enhancements, the risk of infection is still considered a serious concern in penile implant revision surgeries. Aim To review the literature for advances made in inflatable penile prosthesis (IPP) revision surgery and organisms found at the time of revision, the significance of biofilm in prosthetic infection, and the bacteriology of infection. Methods PubMed was reviewed for articles spanning the past three decades that discussed micro-organisms and biofilm in relation to penile implant revision surgery. Main Outcome Measures All articles were reviewed for evidence of bacteria found at revision IPP surgeries and any improvements made in surgical techniques and prosthesis enhancements. Results During the period examined, several improvements have lowered the rate of infection in penile implant surgery: notably, antibiotic-coated IPPs, revision washout, and alcohol-based skin preparations. The biofilm composition on clinically uninfected and infected IPPs appears to have changed over time. The abundance of staphylococcal species—particularly coagulase-negative organisms—in positive cultures has decreased in infected implants, and clinically uninfected implants also have shown a decrease in the proportion of staphylococcal species. Conversely, other isolates such as fungi, Escherichia coli, and Enterococcus species have increased in clinically uninfected and infected implants, and there has been an overall increase in unique isolates that form the biofilm. Conclusion A multitude of enhancements has decreased the presence of micro-organisms and the subsequent formation of biofilm. Nevertheless, the formation of biofilm on penile implants has been noted more frequently in the past decade, and the microbial composition of biofilms seems to be changing. Dawn LE, Henry GD, Tan GK, Wilson SK. Biofilm and Infectious Agents Present at the Time of Penile Prosthesis Revision Surgery: Times Are a Changing. Sex Med Rev 2017;5:236–243.

This systematic review was done to compare the effectiveness of infection retardant coated inflatable penile prostheses vs noncoated devices.We systematically reviewed PubMed® and Galileo® to identify all relevant case studies. The postoperative infection incidence rate was compared for coated and noncoated inflatable penile prostheses to determine whether coating the implant affects the rate of surgical implant infection.Included in analysis were 14 clinical case studies in a total of 9,910 patients with a first time implant, including 5,214 inflatable penile prostheses without an infection retardant coating and 4,696 coated inflatable penile prostheses impregnated with minocycline/rifampin (3,158), rifampin/gentamycin immersion (181), vancomycin/gentamycin immersion (181) and a hydrophilic coating only (1,176). For noncoated vs coated prostheses the infection rate was 2.32% vs 0.89% (p0.01), including 0.63%, 0.55%, 4.42% and 1.11% for minocycline/rifampin, rifampin/gentamycin immersion, vancomycin/gentamycin immersion and hydrophilic coatings, respectively.This analysis documents a significant advantage of using coated compared to noncoated inflatable penile prostheses to prevent postoperative device infection. Infection retardant coatings that allow antibiotics to elute off the device components decrease the incidence of device infection by approximately 50%. Future studies must address novel techniques, such as preventing bacterial adhesion, to further decrease infectious etiologies.

Introduction When a clinically uninfected penile prosthesis has malfunctioned, removal of the broken prosthesis and simultaneous replacement with a new prosthesis is generally accepted as the treatment of choice. During prosthesis replacement, questions inevitably arise as to whether or not a washout of the implant spaces with saline or antiseptic solution should be undertaken. Since removal of the reservoir from the retropubic space is often challenging, the operating surgeon must decide whether to remove all the components or leave the reservoir in situ. Aim To present strategies for optimal outcomes in inflatable penile prosthesis revision surgery. Methods We review the current literature to find evidence regarding indications and support for washout procedures, strategies to achieve the lowest infection rates, and the need for total vs. single prosthesis component removal at the time of revision surgery. For illustration, we present the case of a clinically uninfected, malfunctioning penile prosthesis that requires replacement. Main Outcome Measures Survival from revision surgery for infection and medical complication based on published literature in peer‐reviewed journals. Results Recent peer‐reviewed publications were summarized for guidance in addressing the dilemmas of revision surgery. Conclusions Penile prosthesis revision in a clinically uninfected patient has a higher infection rate than a first‐time implantation. The combination of infection‐retardant coated components, vigorous washout, proper preparation of skin incision site, use of perioperative antibiotics, and avoiding contact between the patient's skin and the implant will lower infection rates. Compared with single‐component exchange, complete component removal appears to confer advantages related to future infection and malfunction. More work is needed to establish optimal strategies for handling reservoirs since clinical experience shows minimal risk of future infection in retained reservoirs. Hinds PR, Wilson SK, and Sadeghi‐Nejad H. Dilemmas of inflatable penile prosthesis revision surgery: What practices achieve the best outcomes and the lowest infection rates? J Sex Med 2012;9:2483–2492.

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 This study was conducted to determine how long after inflatable penile prosthesis (IPP) surgery patients attempt sexual intercourse and the frequency of subsequent relations. We also examined survival-related factors for the AMS 700 CX, Mentor Alpha 1, and Mentor Alpha Narrow Base. Aims The aim was to survey men who received IPPs and collect information about their return to sexual function and frequency of use, and to assess the resilience of their devices. Methods Phase I involved retrospective chart review of 1,298 virgin IPP surgeries performed by one surgical team from January 1992 to December 1998. Phase II included 330 subjects selected by stratified, systematic, random sampling from phase I patients. Data were collected by computer-assisted telephone interview, using a 27-question survey. All patients had been instructed to wait 4 weeks before using the implant and were taught how to inflate/deflate their prostheses at the 4-week postsurgical visits. Main Outcome Measures The survey examines the length of time after surgery for men to resume sexual function. In the same study, information was garnered about mechanical durability of the device. Results Among phase I subjects, the 5-year survival rate was 83% (N = 1,069) for IPP revision for any reason. Of the 330 phase II subjects, 248 (75%) were successfully contacted; 199 (80%) responded to the full survey and 49 (20%) responded to selected parts of the survey. Sexual intercourse was resumed postoperatively at 1–4 weeks for 41% (78/190), at 5–6 weeks for 31% (59/190), at 7–8 weeks for 16% (30/190), and at >8 weeks for 12% (23/190) of the patients. More than 60% of patients reported using their IPP at least once weekly. Conclusions The three-piece IPP has excellent 5-year survival rates. Most patients return to sexual activity relatively quickly, with high frequency of usage of their prostheses. Henry GD, Brinkman MJ, Mead SF, Delk JR II, Cleves MA, Jennermann C, Wilson SK, and Kramer AC. A survey of patients with inflatable penile prostheses: Assessment of timing and frequency of intercourse and analysis of implant durability. J Sex Med 2012;9:1715–1721.