Piraino, Javier

Abstract Background Multiple guideline-based surgical treatment options for Peyronie’s disease (PD) exist, including penile plication and plaque incision or excision and grafting. Surgical incision type may differ depending upon location and severity of curve, planned concomitant procedures, and surgeon preference. Aim To evaluate postoperative wound complications comparing outcomes between ventral and subcoronal incisions in patients undergoing tunica albuginea plication (TAP) and plaque incision or partial excision and grafting (PG) for PD. Methods A single-surgeon, single-center retrospective chart review was conducted on all patients undergoing TAP or PG from 2019 to 2023. Patient demographics, including previous PD treatments, were recorded. A Mann–Whitney U test was utilized to determine differences in wound complication rate, median curvature improvement, and remaining postoperative curvature between ventral and subcoronal approaches. Outcomes Wound complication was classified as any dehiscence and/or wound exudate suspicious for infection within the first 3 months postoperatively. A secondary analysis was performed comparing these outcomes between TAP and PG. Results In the analysis, 189 patients were included, including PD straightening surgery, including 125 patients who underwent TAP (66%) and 64 patients (34%) who underwent PG. Among all cases, 49.7% underwent ventral incision (N = 94) and 50.3% (N = 95) underwent subcoronal incision. A total of 12 patients (6.3%) experienced a wound-related complication postoperatively (range 3-23 days), including 9/94 (9.6%) in the ventral incision cohort and 3/95 (3.2%) in the subcoronal cohort (P = 0.081). All the patients were treated with oral antibiotics and two patients required closure under local anesthesia (both in the ventral incision cohort). Secondary analysis did not reveal any significant difference in outcomes between TAP and PG cohorts with respect to wound complications. Clinical Implications While we did not identify a statistically significant difference, most of our wound complications, including infection and/or dehiscence, were seen in those undergoing a ventral penile raphe incision. Despite this, the rate of wound complications with either incisional approach as low. Strengths and Limitations Our report represents a large cohort of patients treated with surgical straightening for PD, and to our knowledge is one of the first to compare wound complications between ventral and subcoronal incisions. Limitations include the retrospective single-surgeon series without randomization, lack of power analysis, and heterogenous classification of wound complications. Conclusion Both ventral penile raphe and subcoronal (degloving) incisions can be considered for penile straightening procedures to correct PD curvature deformity with a low risk for serious wound-related complications.

Abstract Background Chlorhexidine gluconate (CHG) (0.05%) has recently been suggested as a dip and irrigation solution at time of inflatable penile prosthesis (IPP) surgery. Aim This study evaluated infection rates before and after implementing CHG protocol while investigating concurrent risk factors contributing to post operative infections. Methods A retrospective, consecutive cohort study was performed that included patients who underwent insertion of a Coloplast Titan IPP including both virgin and revision cases between 2021 and 2024. Cases performed from January 2021 to August 2022 utilized rifampin/gentamicin for dip and vancomycin/gentamicin for irrigation (ABX), whereas those from October 2022 to May 2024 utilized CHG for both dip and irrigation. Perioperative risk factors including dip and irrigation solution used at time of surgery were compared between groups. Outcomes We defined the incidence of postoperative infection and risk factors associated with infection in each group. Results The incidence of infection was significantly higher in the 0.05% CHG group (13/377) compared to the ABX group (0/320) (P < .001). When analyzed separately by subgroup, virgin cases treated with CHG for dip and irrigation demonstrated a significantly higher infection rate (7/315) compared to those in the ABX group (0/280) (P = .012). Similarly, in revision cases, the CHG group also exhibited a significantly higher infection rate (0/40) than the ABX group (6/62) (P = .043). Univariable analysis of the CHG cohort identified three significant risk factors for infection: diabetes mellitus (DM), extended operative time (OP), and revision surgery (P = .003, .001, and < .001, respectively). Multivariable regression analysis revealed that patients with DM had a 5.7-fold increased risk of infection (OR: 5.70, P = .004), while those undergoing revision surgery faced a 5.3-fold higher risk (OR: 5.26, P = .004). Additionally, each minute increase in OP was associated with a 1% higher infection risk (OR: 1.01 per minute, P = .007). These associations remained significant after adjusting for all variables in the model. Clinical Implications Prosthetic surgeons should be cautious about adopting 0.05% CHG for both dip and irrigation in the absence of strong clinical evidence demonstrating its non-inferiority to antibiotic solutions. Strengths and Limitations This is the first clinical study reporting infection rates after IPP surgery using 0.05% CHG for both dip and irrigation. While retrospective and non-randomized, we present a relatively large sample size of patients. Conclusions Our findings identify four risk factors for penile prosthesis infection: usage of the 0.05% CHG solution for dip and irrigation solution of Coloplast hydrophilic-coated devices, DM, revision surgery, and extended OP.

Abstract Background The 3-piece inflatable penile prosthesis (IPP) is the most widely used device for erectile dysfunction refractory to medications, containing a reservoir inserted into the retropubic space (RPS) or an alternative/ectopic space (AES). Indications for removal of the reservoir include malfunction, malposition, or infection. In revision cases without infection, reservoir removal is sometimes optional. Aim We reviewed outcomes and complications related to reservoir removal from a large multi-institutional series. Methods We retrospectively reviewed databases at 6 institutions over 7 years. Patients with artificial urethral sphincter, urethral sling, or mini-jupette were excluded. Outcomes Outcomes and complications related to IPP reservoir removal were analyzed. Data were collected, but only reservoir-related complications at surgery were included. Data were compared between the RPS and AES cohorts to evaluate differences with a χ2 test, with significance at P < .05. Results Of 215 cases, there were 172 RPS and 43 AES reservoirs. The mean patient age was 65.3 years. An overall 131 procedures were due to malfunction and 49 to malposition of an IPP component; 35 were secondary to infection. Among those retained (n = 44), reasons included reuse, avoiding surrounding structure damage, and difficult dissection. Among those removed (n = 171), 15 required a counterincision. To determine the statistical difference between those removed from the RPS and an AES, the χ2 test result was P = .00059, indicating a significant difference in the need for a counterincision between the groups. Complications included bladder perforation (n = 1) in the RPS group and an avulsion of the epigastric vessels requiring abdominal exploration (n = 1) in the AES group. To determine the statistical difference between RPS and AES complications, the χ2 test result was P = .365, indicating no significant difference between the groups. Strengths and Limitations Strengths include being a multi-institutional study with high-volume skilled implanters. Limitations include being a retrospective review, with implanters exclusively performing penoscrotal incisions and not utilizing an infrapubic approach. Last, there was a lack of long-term follow-up with these patients. Conclusions Removal of an IPP reservoir remains safe, with few intraoperative complications. Surgeons should be aware of the inferior epigastric vessels during removal in an AES or be willing to perform a counterincision to avoid injury to surrounding structures. Surgeons should also obtain preoperative imaging to identify the specific location of the reservoir and adjacent anatomy. This is the first multi-institutional study reviewing outcomes related to reservoir removal during IPP revision or removal surgery.

Abstract Introduction Penile fracture is traditionally considered a surgical emergency warranting immediate repair with the goal to maximize long-term erectile function and minimize penile curvature. Nonetheless, consensus on the optimal timing for penile fracture repair remains to be elucidated and is the subject of continued research efforts. Objectives This review aims to summarize the contemporary literature pertaining to optimal timing of penile fracture repair and associated outcomes. Methods We queried PubMed/MEDLINE and Google Scholar for relevant articles published between 2012 and 2022 to evaluate the most recent literature on the queried topic of early vs delayed intervention for penile fracture. All examined review articles were published within the last decade but may have included analyses of studies published prior to 2012. Reference lists of articles and reviews were manually reviewed to identify additional relevant articles. Results We identified 16 articles that met inclusion criteria: 12 primary articles and 4 systematic reviews or meta-analyses. Importantly, definitions of early and delayed intervention varied greatly among studies, making quantitative comparison challenging. In summary, 6 primary studies and 2 systematic review articles favored early intervention. There were also 6 primary studies and 2 systematic review articles suggesting equivocal outcomes between early and delayed repair. No articles demonstrated improved outcomes with delayed repair relative to early intervention. Conclusion Surgical intervention for penile fracture remains the gold standard, with superior long-term sexual and functional outcomes when compared with conservative management. Optimal timing of penile fracture repair remains to be elucidated with data limited by low incidence, resulting in small case series and a lack of randomized controlled trials. Nonetheless, recent data suggest that a brief delay in surgical intervention for patients presenting with penile fractures does not affect long-term sexual and functional outcomes.

Abstract Introduction Treatment recommendations for Peyronie's Disease (PD) differ based on whether a patient is in the acute/active versus chronic/stable phase of the disease, yet there are no agreed upon criteria for defining these clinical entities. Objectives To review the criteria used to define acute and chronic phase PD in modern PD intervention studies Methods We performed a search engine review to identify indexed publications for PD intervention studies and review articles / meta-analyses from the year 2011-2020. Outcomes results were catalogued and summarized across articles. As a result of the substantial heterogeneity of outcome measures and follow-up intervals, meta-analytic techniques were not applied to the data analysis. Results We identified a total of 104 studies that met inclusion criteria and had available information for review (n = 79 primary intervention studies; n = 25 review articles/meta-analyses/guidelines). Among the queried studies, we were unable to identify a consensus with respect to the criteria used to define acute and chronic phases of PD. 33% of primary intervention studies did not specifically define their criteria for acute and chronic phase PD, despite referencing these populations as part of the inclusion criteria in many instances. Studies used heterogenous criteria including total symptom duration, duration of “stable” symptoms, and presence/absence of pain. Conclusion Due to varying definitions across the literature, we were unable to create a standardized definition of acute and chronic phase Peyronie's in terms of time. Our findings emphasize the need for greater consensus in defining the treatment cohorts with future studies that assess treatment for men with PD.