Citations

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 can be difficult but is critical, particularly in light of the adage, “when in doubt, take it out.” However, post-operative glans discoloration can be misleading and result in premature device explantation. Objective To present clinical cases and identify distinguishing features between true glans ischemia and pronounced post-operative ecchymosis, with emphasis on risk factors and evaluation techniques. Methods A retrospective case series was conducted on four IPP patients in 2025 who presented with significant glans discoloration concerning for ischemia. Key operative variables, physical exam findings, and postoperative images were reviewed. Additionally, a prospective database of 298 implants placed under local anesthesia since 2024 was analyzed for glans bruising severity on postoperative day (POD) 3, using a 0–4 scale. Results Common ischemia risk factors included tight circumferential wrap (e.g., Coban), vasculopathy (e.g., prior arterial bypass), prolonged catheterization, and concomitant procedures. Case 1: History of pelvic radiation with ecchymotic meatus and glans. Improved after wrap removal and better lighting. Case 2: Extensive ecchymosis and discoloration of glans and scrotum noted on POD1 after uneventful IPP under local. Case 3: Patchy glans discoloration after multiple Keith needle passes. Skin tone complicated assessment. Case 4: Severe glans bruising immediately post-op following multiple needle passes due to suture breakage. In all cases, the glans was warm, well-perfused, and not painful out of proportion to appearance. No patients required explantation. Glans bruising rates in 298 implants under local anesthesia were: 0 (3.7%), 1 (48.7%), 2 (25.5%), 3 (21.1%), 4 (0.3%), notably higher than with general anesthesia. Key Clinical Indicators: Favors Hematoma: • Vascular corpora • Small/no catheter • Bruising elsewhere • Wrap excluded glans • No blistering • No paresthesias • Glans warm to touch Favors Ischemia: • Avascular corpora • Large indwelling catheter • Minimal bruising elsewhere • Coban wrap on shaft • Blistering present • Pain or paresthesias • Glans cold to touch Conclusions Significant glans bruising can mimic ischemia, particularly in IPPs placed under local anesthesia. Factors such as multiple Keith needle passes, tight wrapping, and poor photographic lighting may contribute to this diagnostic confusion. Warm, non-painful glans with widespread ecchymosis are reassuring. Avoiding premature explantation requires thorough clinical assessment, device unwrapping, and close patient monitoring. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: UroFill, Coloplast, Boston Scientific, Rigicon

Abstract Introduction 0.05% Chlorhexidine Gluconate (CHG) has increasingly been used as an irrigant for inflatable penile prosthesis (IPP) surgery. Recent in vitro data shows mixed results regarding efficacy, but clinical data is lacking. Objective To explore the cultured organisms and infection characteristics of IPP infections with and without intraoperative CHG use from a large multi-institutional cohort. Methods We queried a retrospective multi-institutional database of patients who underwent IPP placement for cases resulting in IPP Infection. We stratified cases by intraoperative use of CHG as an irrigant or dip. We compared patient and infection characteristics using chi squared tests and independent t-tests. Culture data from IPP explant was reviewed for descriptive analysis. Results We identified 70 IPP infections, 43 with intraoperative CHG use. Patient demographics were similar between infection cohorts. (Table 1). Median time to infection was similar, 46.5 days in the CHG cohort and 34 days in the non-CHG cohort (p=0.518). Culture data were available for 57 (81.4%) patients. For CHG IPP infections, 8 had Escherichia coli cultured at time of explant and 6 grew methicillin sensitive Staphylococcus aureus. For non-CHG IPP infections, Staphylococcus epidermidis (4) and Pseudomonas aeruginosa (3) were the most common cultured organisms. A total of nine unique organisms were cultured for both CHG and non-CHG infections. Negative growth cultures were recorded for 2 patients in both the CHG and non-CHG infection groups. (Figure 1) Conclusions In a large, multi-institutional cohort, IPP infections after intraoperative CHG use were associated with a variety of cultured organisms, most commonly Escherichia coli and Methicillin sensitive Staphylococcus aureus. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast: Advisory board, speaker; Endo: Advisory board; Haleon: Advisory board; Halozyme: Advisory board, speaker; Masimo: Intellectual property; Softwave: Advisory board; Sprout: Consultant; Vertica: Research investigator; Xialla: Advisory board.

Abstract Introduction While most patients with Peyronie’s disease (PD) present with dorsal or lateral curvature, a significant number have ventral curvature (VC). These patients face limited treatment options, as they were excluded from initial clinical trials of collagenase clostridium histolyticum (CCH) due to safety concerns related to the proximity of the injection site to the urethra. However, urethral involvement is rare, as PD plaques develop in the tunica albuginea rather than the corpus spongiosum surrounding the urethra. Moreover, multiple prospective and retrospective studies have demonstrated favorable outcomes with CCH treatment in men with VC. Objective To evaluate the effectiveness and safety of CCH in men with PD and VC in a multicenter, real-world, retrospective study. Methods This is an ongoing phase 4, multicenter, retrospective review of medical records from 15 US physician sites. Eligible patients consisted of patients who are: age ≥18 years with a diagnosis of VC in PD with a palpable plaque that was treated with CCH from 2014 to the study start date at each site. Patients missing baseline (BL; pretreatment) or final (last measurement within 6 months of final CCH treatment) penile curvature measurements were excluded. Effectiveness endpoints included percentage change in VC from BL to last visit, mean change in VC (in degrees) from BL to last visit, and proportion of patients with ≥30% improvement in VC from BL to last visit. Safety was assessed as proportions of patients reporting treatment-related adverse events (TRAEs) throughout the study period. Results As of April 22, 2025, there were 116 patients with mean (SD) age of 58 (10.3) years who were eligible for analysis. Mean baseline VC decreased from 58 degrees to 37 degrees at last visit (37% improvement). An improvement in VC of ≥30% was seen in 73/116 (63%) of patients, with 81/116 (69.8%) experiencing ≥20% improvement. At least 1 TRAE was reported by 12 (10%) patients. TRAEs were mild-to-moderate in severity in 9 (75%) patients and unknown in 3 patients, with most events (14/17 [82%]) related to injection site reactions. As of the data cut, there were no treatment-related serious or treatment-related severe AEs, no reports of urethral involvement or injury, and no reports of corporal rupture. Conclusions Men with PD who present with ventral curvature represent an underserved patient population. Concerns about potential urethral injury pose a significant barrier to both minimally invasive and surgical treatments, thereby limiting available therapeutic options. These updated results from a multi-institutional real-world clinical cohort align with previous findings, and demonstrate that the clinical effectiveness and safety profile of CCH is consistent with the profile of CCH seen in other clinical presentations of PD. Disclosure Yes, this is sponsored by industry/sponsor: Endo USA, Inc Clarification: Industry initiated, executed and funded study Any of the authors act as a consultant, employee or shareholder of an industry for: Endo USA, Inc.

Abstract Introduction While previous research has explored overall satisfaction following IPP surgery, the specific relationship between final implant length and perceived satisfaction in both patients and their partners remains underexplored. Objective We aim to evaluate the association between IPP cylinder length and postoperative satisfaction in both patients and their sexual partners, and to determine whether perceived adequacy of length restoration correlates with overall sexual and psychosocial outcomes. Methods We initiated a registry of patients undergoing surgery for placement of a PP. After consent, perioperative study assessments and follow-ups were conducted. After surgery, patients were directed to fulfill a survey at 6 months and 12 months. Patients who fulfilled both items were included in the analysis. Results A total of 237 patients had a PP placement and completed the first survey and 158 the 12-month survey. The median IPP length was 22 cm (20-23). At 6 months, .189 patients (79.7%) reported moderate to high satisfaction, and this positive response was sustained at 12-months (n=132; 83.5%). At 6 months, 178 patients (75.1%) reported moderate to high partner’ satisfaction, and this positive response was sustained at 12-months (n=129; 81.6%). A regression analysis at 6 months showed a correlation of r=0.148 (p=0.029) and r=0.027 (p=0.743) at 12 months, implying that while significant statistically, it is not strongly related, and other factors are likely contributing to the response. Partner satisfaction showed a correlation of r=0.184 (p=0.008) at 6 months and r=0.032 (p=0.702) at 12 months, again showing no causal relationship between length of the IPP device with perceived satisfaction. A secondary analysis was performed in patients who had prostatectomy and were using vacuum devices before IPP placement (n=51). Of these, 12 (5.1%) reported decreased penile size during pre-op counseling. The median IPP length was 22 cm (19.5-23) and 21 cm (19.6-22) among patients who reported a decrease in size before IPP placement (p=0.574). There was no correlation between this statement and IPP length (p=0.572), nor satisfaction levels in both patients r=0.180 (p=0.221) and partners r=0.015 (p=0.921) at 6 months or 12 months r=0.060 (p=0.701) & r=0.078 (p=0.636). Conclusions IPP length showed a significant correlation but a weak association with patient and partner satisfaction. Our findings underscore the need for a multimodal approach when looking for patient and partner satisfaction and not only to perceived cosmesis. Comprehensive preoperative counseling should address these multidimensional aspects to better align expectations and outcomes. Disclosure Yes, this is sponsored by industry/sponsor: Coloplast Clarification: Industry funding only - investigator initiated and executed study

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.

Parkinson's disease (PD) is a progressive neurodegenerative disease with multiple manifestations including both motor and non-motor symptoms. One manifestation of PD that is often overlooked is the sexual dysfunction (SD) that patients may experience. Individuals with PD can experience impairment in sexual desire, arousal or lubrication, orgasm, ejaculation, pain and the physical aspect of intimacy. This article aims to provide an overview of the current practices in the evaluation and treatment of sexual dysfunction in men in the context PD. Note that this article focuses on the male population as it reviews the available American Urology Association practice guidelines many practitioners follow, which focus on the male population. Sexual dysfunction guidelines for the female population are much more limited, and future work should review the existing literature and gaps to provide a more robust understanding of sexual dysfunction in PD. PD represents a particularly vulnerable population for development of sexual dysfunction given the multifactorial nature of its manifestations. Given its profound impact on not only the patient, but their partner, it is important to be aware of the various manifestations of SD when evaluating individuals with PD. Through thorough history taking and targeted psychosexual evaluation, we as practitioners can ensure a more holistic and comprehensive approach to caring for individuals with PD.

Abstract Introduction Penile augmentation or penis enlargement surgery refers to any technique aimed at enhancing penile length or girth. These male enhancement surgical techniques can increase total penile length, either flaccid or erect, while others add to the penile shaft’s girth and/or glans size. Proposed strategies include physical methods such as various penile exercises, mechanical traction devices, and medical therapy, while surgical interventions include cosmetic and phallic reconstructive techniques and use of fillers, sleeves, grafts, and flaps to augment penile size. Objectives The International Consultation on Sexual Medicine (ICSM) consensus statements provide evidence-based recommendations and aim to guide a clinical framework in penile aesthetic and augmentation. Methods A comprehensive literature search was conducted to identify published literature relevant to penile augmentation or enhancement. Preliminary consensus was presented to the delegates attending the 5th ICSM meeting, and feedback was incorporated into the final document. Results Twenty new recommendations are provided with corresponding levels of evidence and grades of recommendation. Conclusions Due to the controversies and lack of longer-term data regarding penile augmentation and cosmetic procedures, comprehensive assessments and careful patient counseling weighing the pros and cons, as well as potential complications, are mandatory before embarking on any treatment. Surgeons should be experienced in anatomy and various surgical techniques, and it is important to individualize surgical options based on patient condition(s) and needs, surgeon expertise, and local resources.