Search

William Costerton, the pioneer of bacterial biofilm research and Wilson published a review of this subject in 2012. Recent events and false claims have prompted an update for urologists regarding the science of penile implant biofilm. The recent biofilm literature has been investigated and new conclusions regarding penile implant biofilm physiology are clarified in this review. The timeline of biofilm formation is as follows. The wound is contaminated upon incision, and the inoculum of bacteria ceases with incision closure. Almost immediately planktonic bacteria attach to the implant and secrete biofilm which alters the host’s ability to eradicate the bacteria. Infection retardant coatings impair clinical infection by common skin organisms including coagulase negative staphylococci, the most frequent offenders. In the modern era of availability of infection retardant coated implants, the increasingly rare penile implant infections are now usually caused by more virulent bugs. Antibiotic elution from the surface of the implant is a tiny dose and only truly helpful in the first 24 h. AMS and Coloplast infection retardant coatings reduce infection equally and contemporary primary implant infections are far lower in experienced implant surgeons’ practices.

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 By the turn of this century all of the unitary and two-piece inflatables had been withdrawn from the market except the Ambicor two-piece inflatable penile prosthesis.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.

The Penuma® implant is a medical-grade silicone implant surgically inserted subcutaneously to provide cosmetic improvement of the penile aesthetic. The principal author was invited to provide an update on the usage of the Penuma® implant for penile aesthetics. He collected as yet unpublished data, which is undergoing synchronous submission to Urologic meetings and peer-reviewed publications by a variety of authors for this communication. The objective of this article is to provide updated information regarding the Penuma® aesthetic penile implant. A new scrotal method of implantation named "concealed" is emerging. Through physician comparison of various factors prior to and after the scrotal method intervention, early findings suggest this approach seems to have less visible scar, is quicker and is followed by less seroma formation. As the device is now surgically implanted by surgeons other than its inventor, new developments have appeared authenticating the original published paper in 2018. Patients were contacted via phone and were asked five questions regarding satisfaction with the responses recorded. This new multicenter study shows findings of high patient and partner satisfaction coupled with acceptable adverse outcomes similar to the single-surgeon study. A new penile rehabilitation program has been developed with the aim for the penis appearance to be restored to its pre-operative state if the Penuma® is removed. 12 patients who underwent penile implant removal were followed for 6 months while participating in the penile rehabilitation program. The discipline worked in patients who desired removal for dissatisfaction and is currently under evaluation in patients who require device removal for medical reasons, e.g., infection or suture-related issues. Through new developments, the acceptance of Penuma® in the prosthetic community seems to be further solidified.

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.

William Costerton, the pioneer of bacterial biofilm research and Wilson published a review of this subject in 2012. Recent events and false claims have prompted an update for urologists regarding the science of penile implant biofilm. The recent biofilm literature has been investigated and new conclusions regarding penile implant biofilm physiology are clarified in this review. The timeline of biofilm formation is as follows. The wound is contaminated upon incision, and the inoculum of bacteria ceases with incision closure. Almost immediately planktonic bacteria attach to the implant and secrete biofilm which alters the host's ability to eradicate the bacteria. Infection retardant coatings impair clinical infection by common skin organisms including coagulase negative staphylococci, the most frequent offenders. In the modern era of availability of infection retardant coated implants, the increasingly rare penile implant infections are now usually caused by more virulent bugs. Antibiotic elution from the surface of the implant is a tiny dose and only truly helpful in the first 24 h. AMS and Coloplast infection retardant coatings reduce infection equally and contemporary primary implant infections are far lower in experienced implant surgeons' practices.

Achieving a thriving sexual medicine practice with a high volume of penile implants is both challenging and rewarding for the prosthetic surgeon. It is not an easy feat to accomplish. Techniques of practice building from physician referrals and marketing to the patient have changed remarkably in the era of social media. Peer-to-peer continues to be a critical source of physician referrals, but methods of "getting the word out" to patients have drastically altered. Internal marketing to one's own patients and external passing of information to prospective clients requires a robust presence on the internet. This workshop will focus on the achievement of high-volume implant practices in the age of the World Wide Web. Despite accomplishing this triumph through use of digital media, it is important to continue personal attainments to maintain your ethical image amongst your physician peers and the general public.

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.

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.

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.

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.

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 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.

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.

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.

In the previous workshop we described cylinders out of place due to flawed and unrecognized surgical movements piercing tissue planes that months later are subsequently exploited by the cylinders during sexual intercourse. This workshop completes the trilogy of cylinders out of place. The fourth workshop cataloged fixes of cylinders out of place intraoperatively and the fifth workshop showed the current surgical revision operations to address the cylinders once they have migrated. This sixth workshop will address correction of the implanted penis that is distorted by hypermobile glans, incorrectly measured or crossed over cylinders.

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.

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.

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...

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!