Kohler, Tobias S

Abstract Objective . Penile vibro-elastography (PVE) is complicated by reverberant shear wavefields from the cylindrical geometry of the corpus cavernosum (CC), which bias shear wave speed (SWS) estimates. This study evaluated local phase velocity imaging with wavefield-based filtering (LPVI-WBF) for CC stiffness assessment in post-prostatectomy erectile dysfunction (ED), compared against phase gradient (PG) and time-of-flight (TOF) methods. Approach . Six patients with post-prostatectomy ED underwent PVE at four longitudinal visits (902 acquisitions). SWS was estimated in flaccid and erect states at 100, 150, and 200 Hz using LPVI-WBF, PG, and TOF. Wavefield composition was quantified via the standing wave index. Simulations evaluated accuracy and frequency stability under clean and reverberant conditions. Main results . Reverberant components dominated penile acquisitions, with traveling wave energy absent in 59% of acquisitions and mean standing wave fraction of 57 ± 17%. LPVI-WBF was the only method producing physiologically consistent estimates, with erect SWS exceeding flaccid (3.59 ± 0.48 vs 3.25 ± 0.58 m s −1 , p < 0.0001). PG and TOF yielded reversed results ( E < F, p < 0.0001). The dispersion exponent was near-zero for LPVI-WBF ( α = 0.048, p = 0.21), consistent with weakly viscoelastic tissue, while PG ( α = 0.184) and TOF ( α = 0.321) showed significant frequency dependence from reverberant contamination. Simulations confirm PG accuracy in clean wavefields but collapse under reverberant ones. Significance . LPVI-WBF produced SWS estimates consistent with expected CC biomechanics across all patients and frequencies, a criterion PG and TOF failed to satisfy. Phantom validation and multi-directional wavefield simulation are needed to establish accuracy.

Abstract Introduction Inflatable penile prosthesis (IPP) implantation is a common and effective surgical treatment for erectile dysfunction. However, the presence of comorbidities and the use of anti-thrombotic therapy (AT) can complicate surgical decision-making. Due to the correlation between erectile dysfunction and cardiovascular disease, the preoperative comorbidities of surgical patients are important to examine. Objective The goal of this study was to assess the outcomes of IPP implantation in men on active AT therapy compared to a non-AT therapy cohort. Methods A retrospective analysis from 2015 to 2023 was conducted using data from three high-volume implant centers. The study focused on men who underwent three-piece IPP placement. Demographics, comorbidities, secondary procedures, drain information, and complications were recorded. The three centers each have different techniques and approaches to the surgery. Center 1 utilizes a penoscrotal approach, never places a drain, and places the reservoir in an ectopic location. Center 2 utilizes an infra-pubic approach, places a drain which remains in place for 3 days, and utilizes various reservoir locations depending on patient profile. Lastly, center 3 utilizes a penoscrotal approach, places a drain with removal when output is less than 50 mL over 8 hours, and places the reservoir in an ectopic location. Outcomes were analyzed using multivariate and univariate analysis. Results A total of 210 patients on active AT therapy and 128 non-AT patients were included. The AT and non-AT groups showed significant differences in baseline comorbidities, with the AT group exhibiting higher rates of cardiovascular disease, hypertension, and thrombosis (p&lt;0.05). Among patients on anti-thrombotic therapy, 27.6% required revision surgeries and had increased rates of ectopic reservoir placement compared to the non-AT group (p&lt;0.001). Despite these differences, there were no statistically significant variations in overall complication rates between the two groups. Drain output was notably higher in the AT cohort on postoperative days 1 (mean 110.5 cc vs 60 cc, p&lt;0.001) and 2 (mean 78 cc vs 20 cc, p&lt;0.001); however, hematoma rates remained comparable between both groups (p=0.667). Importantly, neither the type of anti-thrombotic therapy nor the surgical approach used appeared to influence postoperative outcomes. Eleven patients (5.2%) experienced complications in the AT arm and 5 patients (3.9%) experienced complications in the non-AT arm (p=0.793). Conclusions IPP implantation is feasible and safe in men on active anti-thrombotic therapy when performed in high-volume centers with appropriate perioperative management. Further studies with larger cohorts and longer follow-up are needed to refine protocols and determine long-term outcomes for these high-risk patients. Disclosure No

Abstract Introduction The opioid epidemic has encouraged increased efforts to minimize postoperative opioid use, particularly in urologic procedures. While short-acting local anesthetics are often used in inflatable penile prosthesis (IPP) placement, their effects diminish quickly, potentially leading to higher opioid requirements. Liposomal bupivacaine (LB), a long-acting local anesthetic, may reduce opioid requirements, but its cost and limited prospective data in IPP patients warrant further investigation. Objective To compare the efficacy of long-acting liposomal bupivacaine with short-acting ropivacaine in reducing postoperative pain and opioid consumption following inflatable penile prosthesis (IPP) placement. Methods This randomized controlled trial enrolled adult males undergoing primary IPP placement via a penoscrotal approach. Participants were randomized to receive either LB (20 mL Exparel + 20 mL bupivacaine 0.25%) or ropivacaine (40 mL of 0.5%) as part of a standardized multimodal analgesia protocol. All patients received acetaminophen, gabapentin, and meloxicam perioperatively, with oxycodone prescribed as needed postoperatively (figure 1). The primary outcome was postoperative opioid consumption measured in oral morphine equivalents (OME). Secondary outcomes included pain and anxiety scores assessed on postoperative days (POD) 3, 7, and 14 using visual analog scales. Results Only 13 patients completed the study due to difficulties in recruitment (9 in the long-acting group, 4 in the short-acting group). The long-acting group demonstrated consistently lower opioid consumption at all follow-up points. On POD 3, the median cumulative OME was 7.5 vs. 41.25 in the short-acting group. By POD 14, cumulative OME was 15.0 vs. 93.75. (Figure 2) Pain scores followed a similar pattern, with the long-acting group reporting lower median scores on POD 3 (4 vs. 6) and POD 7 (4 vs. 6). Anxiety scores were also lower in the long-acting group throughout the follow-up. Use of non-opioid analgesics was similar across both groups. Conclusions Despite a limited sample size, this trial showed consistent trends favoring LB over ropivacaine for reducing opioid use and pain following IPP placement. These findings suggest potential clinical benefit but require validation in larger, multicenter studies. The trial also illustrates the difficulty of conducting randomized studies when institutional practices strongly favor one approach. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Endo pharmaceuticals.