Helo, Sevann

Abstract Introduction Glans ischemia and subsequent necrosis is a rare but devastating complication of inflatable penile prosthesis (IPP) placement. Differentiating true glans ischemia from severe ecchymosis is often difficult to distinguish, yet it remains paramount given the glans ischemia principle: “when in doubt, take it out.” Objective We present several clinical scenarios and associated postoperative images wherein there was concern for post-IPP glans ischemia based on initial clinical examination. In addition, we review pertinent clinical factors that can be used to help distinguish between greater than “average” glans ecchymosis and true ischemia. Methods We present four cases from 2025 and describe clinical factors likely responsible for increased glans discoloration. Results Traditional risk factors for glans ischemia are constrictive IPP wrap, vasculopathy, use of prolonged large bore catheters, and concomitant surgery (circumcision, distal counter-incision, urethral/neurovascular bundle mobilization). Case 1 was a patient with a history of radiation for prostate malignancy who had notably hypervascular corpora intraoperatively. On postoperative day (POD) #1, the urethral meatus was ecchymotic along with patchy ecchymosis throughout the glans. The Kerlix wrap can be seen around the penile shaft up to the corona. Removing the constrictive wrap and increasing room lighting revealed a well-vascularized glans with spotty ecchymosis likely from passage of the Keith needles during deployment. Case 2 was another patient examined on POD1 after uneventful IPP placement under local anesthesia. Note the similar level of ecchymosis involving the scrotum. Case 3 is another patient examined POD1 from a penoscrotal IPP that required multiple firing attempts with the Keith needle. Again, multifocal areas of patchy ecchymosis are interspersed with areas of normal appearing glans. The patient’s skin color was also similar in appearance to the areas of ecchymosis, requiring careful attention to detail to differentiate. Finally, Case 4 is an image on POD0 after uneventful IPP. The patient required several Keith needle passes because Furlow tool severed suture. Notably, decision was made to leave the penile implant in place in all cases. The penile wrap and/or catheter was removed and lighting was optimized to evaluate for clinical change. No patient reported paresthesia or pain out of proportion to the clinical examination. All glans were warm to the touch. Rates of glans bruising at POD3 for 298 implants performed since 2024 under local anesthesia, with bruising scored 0-4, were as follows: 0: 3.7% 1: 48.7%, 2: 25.5% 3: 21.1% 4: 0.3%. This demonstrates high rates of glans bruising with local anesthesia. We speculate that the increased rate of glans bruising may be attributed to the aggressive nature of the local anesthesia block, which can result in vasodilation and ecchymosis due to needle trauma and increased vascular permeability. Conclusions IPP cylinder deployment requiring multiple Keith needle punctures, constrictive post-op penile wrap, hypervascular corpora, exam/images with poor lighting, extensive bruising in other areas, and IPPs performed under local anesthesia appear may contribute to glans discoloration that mimics ischemia. A detailed physical exam and close clinical monitoring are essential when postoperative glans discoloration is observed. Disclosure No

Abstract Introduction Proximal perforation in complex penile prosthesis placement is well recognized. If recognized, suture sling repair amongst other techniques is our favored approach. Unrecognized proximal perforation often results in unilateral or bilateral perineal bruising, often with eventual proximal device migration and palpability of the proximal device in the buttock. Objective We present a series of 5 cases in which the suture sling technique was utilized for known proximal perforation, with subsequent need for immediate or delayed revision. Methods We assessed all cases performed at Mayo Clinic since 2018 that resulted in a known suture sling complication amongst 3 high volume implanters. We identified 5 cases in which the suture sling technique required revision surgery. All patients underwent cross sectional imaging for further evaluation. Results Patients were males aged 59 to 89 with erectile dysfunction. There were no consistent factors amongst the 5 cases that may have predicted suture sling complication. The majority of cases were inflatable penile prostheses (4/5), were prosthesis revision cases (3/5), utilized the penoscrotal approach (4/5), were Coloplast devices (4/5), utilized rear tip extenders (3/5), utilized Prolene suture sling (3/5), and returned to OR within 2 days for revision (3/5). The majority of the complications (4/5) involved excessive proximal cylinder length that were palpable on examination of the buttocks or near the rectum (one felt on rectal exam). One case demonstrated improper anchoring of the device not allowing proximal seating and thus S shaped deformity. We noted medial cylinder deviation on all imaging, as corporal perforation was always medial to the true corporal path. Conclusions When performing suture slings, surgeons should be very wary of oversizing. The medial cylinder path and prior surgical capsule may mislead surgeons when choosing appropriate cylinder length. If perforated, we advocate against rear tips and for under sizing in general, as proximal anchoring is reliant upon the suture, not a true corporal boundary. Similarly, the device should be fully inflated and proximally seated on palpation prior to tying down the sling to avoid S deformities. Disclosure No

Abstract Introduction Infection following inflatable penile prosthesis (IPP) placement is an uncommon yet serious complication, and its management poses significant clinical challenges. IPP infection management strategies continue to evolve, however, multicenter and robust studies evaluating and describing current practice patterns are lacking. Objective Using a large cohort from tertiary IPP referral centers in the United States to evaluate current infection management practice patterns and to identify factors that could predict the approach to managing IPP infections. Methods We queried a retrospective 14-center multi-institutional database for patients with IPP infections between April 2017 and January 1/2025. Patients were categorized by infection management strategy, which included device explant, malleable salvage, and 3-piece IPP salvage. Patient characteristics were compared using chi-square and independent t-tests. Multinomial analysis was performed to investigate patient and perioperative factors associated with management strategy at the time of infection. Results Among 2,934 cases, 85 (2.9%) patients developed IPP infection at a median of 40 (22-78) days after IPP implantation. Infections occurred after primary IPP surgery in 59 (69%), revision in 25 (29%), and after infection salvaged with IPP in 1 (1%). Infections were managed with device explant in 32 (38%), malleable salvage in 43 (51%), and IPP salvage in 10 (12%). A significantly higher proportion of non-White patients underwent salvage (either with malleable or IPP) compared to White patients (p=0.01). Multinomial regression showed no association between patient and perioperative characteristics and infection management (p>0.05). Conclusions In this multi-institutional cohort of experienced implanters, infections were most commonly managed with malleable salvage. Patient and perioperative factors did not predict management approach, suggesting that the decision between explanation and salvage is primarily driven by individual surgeon preference. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston scientific

Abstract Introduction The EROS (Erectile Restoration Outcomes and Satisfaction) registry provides prospective questionnaire-based follow-up after IPP was founded in 2020 at the Mayo Clinic, Rochester. Objective We sought to assess general trends in the open-ended responses portion of the questionnaire. Methods Data were collected from 2020 to 2025, with a total of 568 responses. The survey included six open-ended questions pertaining to lifestyle change since IPP, reasons not to repeat the procedure, impediments to use, dissatisfaction, what patients wish they had known more about the procedure, and other recommendations. Evaluable data included 6-month responses from Rochester, Jacksonville, and Phoenix. Results Open-ended feedback was given by 66% of patients on what they wished they had known, 54% gave other recommendations, 38% gave lifestyle feedback, 7% elaborated upon reasons not using, 3% on reasons for dissatisfaction, and 2% on reasons they would not repeat IPP. There was an overall very positive response (“Significant Improvement”, n=74.3%) from those who underwent the IPP placement, with some patients reporting that it was far more convenient than other forms of treatment, and even increased spontaneity in their sexual lives, leading to improved relationships. Among the reported responses are increased confidence (n=39.4%), increased sexual activity (n=13.3%), and improved health and exercise levels (n=6.6%). When questioning patients on why they would not repeat the procedure and what their sources of dissatisfaction were, of those who responded to each question (n=12, n=16), the most report complaint was exaggeration of pre-existing curves (n=41.7%, n=25.0%), particularly due to Peyronie’s disease. When questioned about what prevents use, the main response was partner-related or due to personal problems (n=45.2%). The patients did not have many recommendations but hoped for a better way to deflate and inflate the device (n=20.4%) and reported adequate pre-operative education and use of the pump. The table below outlines the categories of responses and the percentage of each keyword reported per question type. Conclusions In addition to standard pre-operative IPP counseling, providers should provide additional focus on potential difficulty with device inflation/deflation, length loss (IPP not in glans), pain/ recovery expectations, potential of new or worsened curve (erect or flaccid), and potential change in sensation. IPP satisfaction is high, as only 2% of patients gave responses on why they would not repeat the IPP, with many men expressing an increased level of overall confidence. Disclosure No

Abstract Introduction Many couples who do not achieve pregnancy with intrauterine insemination (IUI) subsequently pursue in vitro fertilization (IVF). While the impact of semen parameters on IUI outcomes is well established, it remains unclear whether characteristics of sperm following IUI preparation predict future IVF success. Many couples who do not achieve pregnancy with intrauterine insemination (IUI) subsequently pursue in vitro fertilization (IVF). While the impact of semen parameters on IUI outcomes is well established, it remains unclear whether sperm characteristics following IUI preparation predict future IVF success. Here we study a novel, clinically accessible marker of sperm quality – percent change in total motile sperm (TMS) after IUI sperm wash-that may predict fertilization and blastulation outcomes in subsequent IVF cycles. Objective This aims to evaluate the association between changes in total motile sperm (TMS) after IUI sperm wash and fertilization rates in subsequent IVF cycles.This study aims to evaluate the association between changes in TMS after IUI sperm wash and fertilization and blastulation rates in subsequent IVF cycles. Methods In this retrospective study, we identified couples at a single academic center who failed to achieve a live birth following IUI and subsequently underwent IVF with the same partner. To minimize confounding, only couples with a diagnosis of unexplained infertility or male factor infertility were included. In patients who underwent multiple IUIs (median of 2), the cycle with the greatest percent decrease in TMS was selected for analysis. Additional predictive variables of female partner age, male partner age, pre-wash TMS, and insemination method were assessed. A stepwise variable selection method was utilized to identify predictors of fertilization rate and complete blastulation failure, with linear and logistic regression models of selected variables developed, respectively. Results From the cohort of 388 couples, the median fertilization rate during IVF was 56% (IQR 43%–70%). Thirteen percent of couples experienced complete blastulation failure. Change in TMS was selected as a predictor of both fertilization rate and blastulation failure. A 10% greater decline in TMS after IUI sperm wash was associated with a 1.02% lower fertilization rate (p=0.052), after adjustment for insemination method. A 10% greater decrease in TMS was associated with a 1.22-times (95% CI 1.04, 1.48) increased odds of blastulation failure (p=0.023) after adjusting for female partner age. Conclusions A greater percent decrease in TMS following IUI sperm wash is associated with lower fertilization rates and a higher odds of blastulation failure in subsequent IVF cycles. These findings support the hypothesis that significant declines in TMS after sperm preparation may reflect underlying sperm quality defects not detected by routine semen analysis, yet still relevant to fertility outcomes. By identifying sperm quality issues not apparent on standard semen analysis, these findings offer a new tool for risk stratification and counseling of couples transitioning from IUI to IVF. Disclosure No

Abstract Introduction 0.05% Chlorhexidine Gluconate (CHG) has gained popularity as an irrigant and dip for inflatable penile prosthesis (IPP) surgery. Prior in vitro data is conflicting on the impact of CHG use with hydrophilic coated devices. Objective We sought to identify possible associations between CHG use and hydrophilic IPP infection rate. Methods We conducted a retrospective cohort study of 2,933 patients undergoing IPP implantation across 14 referral centers. Data collection spanned from January 1, 2017 to March 1, 2024. Each surgeon contributed patients who underwent IPP implantation with CHG used as an irrigant and/or dip as well as an equal number of consecutive control patients without CHG use. The primary outcome was IPP explant for postoperative infection. Univariable analysis was used to compare patient demographics, and logistic regression analysis was performed to assess factors associated with infection. Results Hydrophilic devices were implanted in 2,150 patients. Median follow-up for non-CHG patients was 13 months (IQR 18) and four months (IQR 9) for CHG patients. The incidence of infection with intraoperative CHG use was significantly higher compared to those without CHG use (4.6%, 46/1,001 vs. 2.1%, 24/1,148, p<0.001). On multivariable logistic regression analysis, intraoperative CHG use was associated with infection (OR 2.07, 95% CI 1.24-3.47, p=0.01). Additional variables associated with infection included immunosuppression, prior IPP infection, prior priapism, and revision surgery (p<0.01, Table). On subgroup analyses, the increased infection risk of CHG was most clear when CHG was used as both irrigation and dip (OR 2.03, 95% CI 1.19-3.46, p=0.01) and when CHG was used during revision surgery (OR 3.36, 95% CI 1.15-9.82, p=0.03). Conclusions In a large multi-institutional cohort, intraoperative CHG use was associated with an elevated incidence of hydrophilic IPP infection. Providers may take these findings into consideration when performing IPP surgery with hydrophilic devices, especially during revision surgery. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast Corporation and Boston Scientific

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.

Abstract Background Concerns exist regarding inflatable penile prosthesis (IPP) placement after transcorporal artificial urinary sphincter (TC-AUS) surgery due to potential risk of damaging the AUS cuff during corporal dilation and device placement. Aim To evaluate perioperative complications, infections, revision rates, and device longevity in patients undergoing IPP placement following prior TC-AUS surgery. Methods We present a case series of men who underwent IPP surgery with an existing TC-AUS in place. A retrospective review was conducted of all patients who underwent TC-AUS placement at a single tertiary institution between 2015 and 2025. Patients who subsequently received IPP surgery were identified. Standard IPP techniques were used with additional precautions to protect the AUS, including use of electrocautery instead of sharp dissection and contralateral reservoir placement. Demographics, operative details, complications, infections, revision events, and device survival were collected through review of operative notes and patient records. Outcomes Primary outcomes included intra-operative difficulties, perioperative complications, infection and erosion rates, and revision or failure rates for both the TC-AUS and IPP devices. Results Among 757 TC-AUS placements, 17 patients subsequently underwent IPP surgery. Seven patients (41%) had a history of pelvic irradiation. The median operative time for IPP placement was 83 minutes (interquartile range [IQR] 68-87), and median follow-up was 31.5 months (IQR 11.2-40.6). All reservoirs were positioned contralateral to the AUS reservoir. A 12 Fr catheter was left postoperatively in 10 patients (59%) for <24 hours. Proximal corporal dilation was noted to be challenging in 3 patients (18%) but dilation was completed without cuff injury or corporal perforation. One patient (6%) had TC-AUS cuff erosion 9.5 months after IPP surgery; one patient (6%) experienced TC-AUS device infection 11.5 months after IPP surgery when his AUD pump eroded through the scrotum. Four patients (24%) developed AUS mechanical failure due to cuff leak at a median of 31.9 months after IPP placement (39.9 months post-AUS). Clinical implications IPP implantation following TC-AUS can be performed safely using careful surgical technique, though vigilance for later AUS mechanical failure is warranted. Strengths and limitations This study represents one of the largest single-institution series evaluating IPP after TC-AUS and includes detailed operative and follow-up data. However, its retrospective design, small cohort size, and limited follow-up duration restrict generalizability. Conclusion IPP placement after TC-AUS appears safe, with low infection and erosion rates, though AUS cuff leaks may occur more frequently than when either device is implanted alone.