Citations

Abstract Introduction We report outcomes for patients in which the IPP became unusable by the patient because of pump difficulties or inadequate fluid volume in the IPP system. Objective We sought to assess outcomes of penile implant single component exchange or fluid instillation in a cohort of patients, challenging the entire device replacement dogma. Methods 17 patients underwent single component exchange by a single surgeon. CT scan was obtained to ensure device integrity, assess for air in the system, and to delineate device details. In cases of pump difficulties, the old pump was removed and replaced with a “classic” Genesis Coloplast pump regardless of initial device brand (“Frankenstein” if brands are mixed). Patients are taught pump rocking techniques and have > 6 months of difficulty before exchange. Patients are warned of auto-inflation as there is no lock out valve in the Genesis pump. For fluid addition to the system, the two old connector collars are separated and sometimes re-used after saline is added to only the cylinders. We never add fluid to the reservoir using a piston syringe for fear of reservoir capsule rupture into adjacent structures. Revisions were copiously irrigated, as of 2022, with Irrisept. Results Pump exchange: 14 patients underwent single component pump exchange secondary to inability for the patient to be able to adequately cycle the device (11 AMS MS, 1 Coloplast Touch). Remarkable differences were noted in pump cycling between office exam (difficult), exam under anesthesia prior to incision (sometimes difficult), and once the pump is removed from its capsule (universally easy). Complications of these 14 patients include 1 fungal infection requiring replacement with a malleable device and one repeat pump exchange (AMS MS - AMS MS - Genesis). Two patients noted non-bothersome minor auto-inflation. The single Coloplast case had a remarkably thickened capsule after a likely low grade infection. All patients can successfully use their devices now. Fluid Addition: Three patients underwent fluid addition to the system. One had a significant proximal aneurysm for which we added 35 ml. A different case had both a pump exchange and 30 ml added to the system as the initial reservoir appeared to have folded cordoning off fluid. The final fluid addition occurred 18 months after initial Coloplast 22+2 cm placement in which the patient very aggressively cycled the device and could not obtain 10/10 erection. 30 ml was added to the system totaling 140 cc. All patients have done well with fluid addition with mean time since surgery of 1 year. Conclusions Pump exchange with genesis pump or simple fluid addition to the system are safe and feasible and successfully restores IPP functionality. The Frankenstein strategy is a viable alternative, although patients must be counseled that auto-inflation may occur. With modern day irrigation techniques and CT confirmation of fluid system integrity, the dogma to replace the entire device may actually carry higher morbidity in some patients. Disclosure No

Abstract Introduction Erectile dysfunction (ED) stems from a variety of etiologies and often requires a multidisciplinary approach to optimize patient care. Objective We sought to assess attitudes and confidence regarding the treatment of erectile dysfunction across different provider types. Methods Responses were obtained through an anonymous, email-based survey of our institution's providers in the disciplines of urology, internal medicine, and family medicine. We created a novel tool of 25 5-point Likert scale questions regarding ED treatment. Data were analyzed through descriptive statistics and Fisher’s exact test and sorted by respondent specialty. Ethical Committee approval was obtained before study. Results 138 health care providers returned surveys, including 58 internists (IM), 47 family physicians (FP), and 33 urologists (GU). FP and IM responses showed significant overlap with a few key statistically significant differences. In general, IM was much more positive in VED, penile implant as an option, penile implant satisfaction, and penile implant risk. 37% of IM agreed or strongly agreed inflatable penile prosthesis risk is low vs 6% FP (p = .0032). IM also more strongly supported team-based care and referral to specialists IM 71% vs. 51% FP (p = .0012). (Figures) When comparing GU versus FP + IM 24/25 questions revealed statistically significant differences revealing greater GU confidence and knowledge about ED with only the importance of a team-based approach not differing. Noteworthy points include 46% vs. 18% confidence for a detailed sexual history for GU vs. FP + IM (all other points % and same provider sequence). IIEF usage and familiarity were 61 vs. 3 and 88 vs. 18, respectively. 100 and 85 strongly/agreed that good options remained after pills failed. Regarding inflatable penile prosthesis, agreement or strong agreement for patient willingness to undergo surgery for ED 67 vs. 13; patient satisfaction 91 vs. 25, partner satisfaction 80 vs. 25; and would repeat surgery or recommend to a friend was 82 vs. 17. Finally, and perhaps most notably 83 vs. 11 of providers were aware that Medicare covered implants. (Figures). Conclusions Conclusions This survey reveals significant knowledge gaps for treatment options and outcomes for ED. Targeted provider education, particularly about penile prostheses, could optimize patient care. Disclosure No

Abstract Introduction Erectile dysfunction continues to be a concern for patients and physicians after surgical treatment of prostate pathology. Objective To analyze doppler diagnosis on patients who underwent prostate surgery for benign or malignant pathology of the prostate. Methods We retrospectively analyzed all patients who underwent either robotic assisted prostatectomy (RALP), open retropubic prostatectomy (RRP), endoscopic procedures such as greenlight procedure, laser resection of the prostate or transurethral resection of the prostate (TURP); and High Intensity Focused Ultrasound (HIFU) treatment for prostate pathology and who underwent intracavernous injection followed by Color Doppler Duplex Ultrasound (CDDU) at our institution between 2005 and 2019. CDDU findings were recorded following injection of low dose alprostadil (10-20 mcg) and again after a period of privacy and visual sexual stimulation. CCDU findings including peak systolic velocities (PSV), and resistive indices (RIs) were recorded. Arterial insufficiency (AI) was defined as either a post-stimulation PSV < 25 with any RI or a PSV 25-34.9 with RI≥0.9. Cavernous Venous Occlusion Disease (CVOD) was defined as post-stimulation PSV ≥35 with RI < 0.9. Mixed was defined as post-stimulation PSV 25-34.9 with RI < 0.9. Vascular normal was defined as post-stim PSV ≥ 35 with RI ≥ 0.9. Results 380/1917 (19.8%) patients had a past surgical history of prostate surgery. 111/380 (29.2%) underwent RRP, 168/380 (44.2%) patients underwent RALP, 85/380 (22.3%) underwent endourological resection of the prostate and 2/380 (0.5%) patients underwent HIFU. Median age for the RALP group was 60.5 (IQR 23.7-82.8), RRP group was 64.2 (29.7-87.7), endourological resection of the prostate 64.6 (30.8 – 85.6) and HIFU 65.0 (46.9-79.4). 87.1% of patients who had an endoscopic procedure were using phosphodiesterase-5 inhibitors at the time of CDDU. CVOD was the most common etiology of ED in patients who underwent RRP (28.8%) and Endourological procedures of the prostate (32.9%); In patient who underwent RALP the most common etiology of ED was noted to be AI (28.6%), however none of these values were statistically significant (p=0.428). Conclusions There is no difference in etiology of ED in patients who underwent open, robotic or endoscopic manipulation of the prostate as shown by CDDU. Disclosure No

Abstract Introduction Penile prosthesis placement in men on active anti-coagulation (AC) is controversial. The bleeding risk of continued blood thinners must be weighed against the increased thrombotic risk for patients when stopping them. Previously utilized techniques to decrease complication rates from AC include the use of a malleable implant only, leaving the IPP partially inflated for hemostasis, and placement of a drain. Objective We sought to assess outcomes of penile implant placement in men on clopidogrel, warfarin, apixaban, enoxaparin, and rivaroxaban in a multi-institutional study. Methods Data from 3 high volume implant centers were retrospectively obtained. Demographic characteristics, comorbidities, case information including secondary procedures, placement of drain, drain output, and complications were recorded. Data on patients with aspirin any dose alone were not included as all 3 centers do not routinely discontinue ASA at time of penile implant. One center never placed drains and used a penoscrotal approach, one center left a drain at least one day and removed when output was < 50 ml/8 hours and used a penoscrotal approach, and the last center placed a drain for 3 days and utilized an infra-pubic approach. Results 202 patients were continued on AC throughout surgery. 112 patients were on clopidogrel, 35 warfarin, 38 apixaban, 1 enoxaparin, 15 rivaroxaban, and 1 on combination therapy with clopidogrel and enoxaparin. AC requirement included peripheral vascular disease (55%), CHF (11%), cardiac stents (11.6%), DVT/PE/history of thrombosis (7%), atrial fibrillation (11%), cardiac valves (2.2%), stroke (1.3%), and preventive (0.9%). Nine patients on AC (3.98%) experienced complications including 4 significant events (1.9%): 1 major retropubic bleed requiring transfusion, 3 IPP infections and 5 minor events: 3 minor hematomas, 1 minor wound dehiscence and 1 CT negative stroke event. Drain outputs for the 3 day center averaged 113 ml, 81 ml and 30 ml of output per day respectively with a total average output average of 223 ml and experienced no hematomas nor infections. Drain output for the center with removal when < 50 ml/8 hours averaged 121 ml with the majority or patients having the drain for only one day. Drain output was significantly higher than historical non AC controls (121 vs. 72 ml p=.001) but there was no difference in hematoma rate. Three hematomas and 1 infection occurred in this group. AC type, revision surgery, scrotoplasty, or reservoir technique did not affect outcomes nor drainage (P>.05). Complication rate (IPP infection and hematoma rate) where not different when compared to large cohorts from respective institutions. Conclusions Our data shows a 1.9% rate of major complications in patients undergoing IPP placement on anticoagulation in high volume implant centers. Although this approach appears feasible and similar in complication rates in men not on AC, careful consideration of the risk benefit ratio should be undertaken. Our data indicate closed suction draining for 3 days may be warranted. Additionally, the retropubic bleed case argues for only submuscular reservoirs placed under direct vision which minimizes occult bleeding risk. In the majority of cases, elective IPP surgery should be delayed until it is safe to discontinue anticoagulation therapy. Disclosure No

Abstract Introduction The AUA Census offers broad insight into urology, however, there is limited information reported regarding sub-specialists. We designed a survey to capture similar data among urologists who treat male sexual health, including demographics, clinical practice characteristics, and job satisfaction. Objective To characterize the demographics, practice characteristics and job satisfaction of providers who treat male sexual health. Methods A survey was developed and distributed to all relevant professional urological societies for male sexual health providers, including GURS, ISSM, SMSNA and SUPS. Averages, modes, counts, and ranges were examined. The survey remains open and additional responses are expected. Preliminary analysis as of June 15, 2022, yielded 76 responses; 58 were complete. Results The survey remains open and additional responses are expected. Preliminary analysis as of June 15, 2022, yielded 76 responses; 58 were complete. Demographics: The average age of respondents is 42 years old. 52 (89.6%) respondents self-identify as male, 6 (10.4%) as female. 67% of respondents identify as white (n=39), 7% identify as Asian (n=4), 7% identify as Black or African American (n=4), 2% identify as American Indian/Native American or Alaskan Native (n=1) and 17% preferred not to select a race or selected “other” (n=10); respondents were able to select more than one racial identity. 16% of respondents identified themselves as having Hispanic ethnicity (n=9). 84% of respondents are married (n=49) with 21% divorced or currently going through a divorce (n=12). On average, respondents have 1.5 children (range: 0-3, mode: 2). Work-life: The majority (58%) of respondents work in academic practice (n=34). 19% work in private practice (n=11). Employed physician, multispecialty, solo and hybrid private-VA practices make up the remaining 22% (n=4, 5, 3, 1 respectively). 72% of respondents practice in cities with a population greater than 500,000 (n=42), 12% work in cities with populations between 100,000 – 500,000 (n=7), 14% serve towns of less than 100,00 (n=8). Satisfaction: The survey asked providers binary yes/no questions about career satisfaction. 88% affirmed “I would pursue this career again” (yes, n=51; no, n=7). 69% affirmed “I am satisfied with my current level of compensation” (yes, n=40; no, n=18). 52% affirmed “I am satisfied with my current work-life balance” (yes, n=30; no, n=28). Female responders were significantly more likely to indicate that they are dissatisfied with work-life balance (p=0.0074).100% of female respondents reported dissatisfaction compared to 42% of males. Conclusions To our knowledge, this survey is the first survey exclusively of male sexual health providers. Among survey respondents, the average practitioner is white, male, and married with two children under 18. They are in the first half of their career at an academic institution in an urban area. Although nearly 90% would choose their career again, 50% are dissatisfied with work-life balance. Gender has a significant impact on satisfaction. While averages reflect low diversity within the field, they suggest that gender parity is on track with national trends while racial and ethnic diversity may exceed that of general urology (ref 1). Disclosure No

Abstract Introduction Inflatable penile prosthesis (IPP) placement is associated with high postoperative patient satisfaction. Patients often express concerns about postoperative penile length. There is scant evidence in the literature of clinical and surgical factors that predict IPP length. Objective To evaluate predictors of cylinder length for men undergoing primary IPP placement in a large multicenter cohort. Methods Patients undergoing primary IPP placement for treatment of erectile dysfunction at 16 high-volume implant centers were included. All patients had preoperative demographics, surgical characteristics, and device length retrospectively collected at their respective institutions and combined for analysis. Descriptive statistics were reported for the full group. Univariate analysis was utilized to isolate variables significantly associated with device length and all variables reaching p<0.1 were included in linear regression modeling. Results 3,953 men underwent primary IPP placement. The mean age was 61.8±10.4 years and BMI was 29.8±4.2 kg/m2. The mean total device length was 20.6±2.1cm. 1291 (32.7%) had diabetes mellitus, 641 (16.2%) were smokers, 705 (17.8%) had a prior radical prostatectomy, 195 (4.9%) had prior radiation, 549 (13.9%) had Peyronie’s disease, and 884 (22.4%) had a history of intracavernosal injections. In univariate analysis, BMI (B=0.05, 95%CI 0.04 to 0.07, p<0.001), a history of Peyronie’s disease (20.4 vs 20.6cm, p=0.02), and use of intracavernosal injection (20.7 v 20.9cm, p=0.02) were predictors of shorter total device length. Use of rear tip extenders (20.7 v 20.0cm, p<0.001), penoscrotal approach (21.0 v 20.3, p<0.001), and single corporal dilation (20.8 v 20.4cm, p<0.001) were associated with longer length. In multivariable analysis, a history of Peyronie’s disease (B=-0.29, 95%CI -0.47 to -0.11, p=0.002) and greater BMI (B=0.05, 95%CI 0.03 to 0.07, p<0.001) were predictors of shorter total device length. Independent predictors of longer device length were penoscrotal approach (B=-0.85, 95%CI -1.03 to -0.65, p<0.001), rear tip extender use (B=1.00, 95%CI 0.84 to 1.17, p<0.001), and single corporal dilation (B=-0.5, 95%CI -0.67 to -0.34, p<0.001). Conclusions In this series, Peyronie’s disease and greater BMI are independent predictors of shorter IPP device length, while use of rear tip extenders, single corporal dilation, and penoscrotal approach are independent predictors of longer device length. These results are important in counseling patients regarding expectations of postoperative length. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Intuitive Surgical, Fidelis, Urofill, Boston Scientific, Endo Pharma, Coloplast, Cynosure, Antares Pharma, Clarus Pharmaceuticals, Acerus Pharma

Abstract Introduction Perception of penile curvature (PC) varies widely, and correction of PC is in the eye of the beholder. Objective We sought to investigate if patients with Peyronie’s Disease (PD) had differing opinions on correction of PC compared to general andrology (AD) patients without PD and general urology (URO) patients. Methods A cross-sectional survey was administered to adult patients in andrology and general urology clinics at 3 geographically separate institutions. Patients were grouped with having PD vs AD vs URO conditions. The survey consisted of unlabeled images of penis models with varying degrees of PC (range 10-90°). Respondents were asked to select the images they would want surgically corrected. Univariable and multivariable analyses were performed to identify demographic variables associated with willingness to consider correction. Results Ninety-four PD, 106 AD, and 302 URO patients were recruited. When comparing the 3 groups, besides obvious gender differences with PD patients, PD patients were less in 25-34 age range and more in 55-64 age range (p=0.01 and p=0.007). PD was less represented in Mid-Atlantic (p<0.001). 8% of PD, 12% of AD, and 20% of URO patients chose not to surgically correct any degree of PC (p=0.001). Among those who endorsed willingness to surgically correct PC, the average threshold for correction was 52.5° (SD 13) for PD, 37.2° (SD 29.5) for AD, and 51.0° (SD 19.9) for URO patients. When comparing PD patients with AD patients, no difference in the decision to surgically correct was found (p=0.42). This was also found to be the case when comparing PD with URO (p=0.46) and PD+AD patients vs URO (p=0.67). On univariable analysis, among AD patients, those ages 55-64 were more willing to undergo PC correction at lower degrees of PC (p=0.03) but did not hold up on multivariable analysis (p=0.40). No other demographic factors among PD and AD groups were found to have an impact on willingness to undergo PC correction (Table 1). Conclusions No significant differences were seen in the decision to surgically correct PC when comparing the perspectives of patients with PD, AD, and URO. Roughly 10% of all of these patients would defer on surgical management of any degree of PC. Despite having PC, no demographic differences were seen among PD patients’ willingness to correct PC. Disclosure No

Abstract Introduction Predictors of intraoperative corporal perforation and delayed cylinder complications in inflatable penile prosthesis (IPP) placement have not been well-delineated in the literature. Inflatable penile prosthesis (IPP) can offer high satisfaction rates of patients, but this procedure is not without complications that can be encountered intraoperatively and postoperatively. Particularly, predictors of intraoperative corporal perforation and delayed cylinder complications in IPP placement have not been well-delineated in the literature. Objective We evaluated our retrospective multi-institutional database of IPP surgeries performed by expert implant surgeons to identify risk factors that are predictive of the development of these non-infectious complications. Methods IPP cases performed by sixteen international implanters from 2016-2021 were identified. All primary and revision cases were included. Salvage cases for infection were excluded. Demographic characteristics, intraoperative variables, and postoperative outcomes were assessed. Poor corporal integrity (PCI) was defined as intraoperative corporal complications (proximal and/or distal perforation of the corpora, corporal crossover) or postoperative corporal complications (cylinder erosion, extrusion, impending erosion, or deformity). Risk factor analysis and multivariate analysis were performed to identify predictors of PCI. Results A total of 5406 IPP cases across 16 separate institutions were assessed. There were 163 (3.0%, mean age 64) cases of PCI. Of the 156 complications that occurred, 101 (64.7%) occurred intraoperatively, while 55 (35.3%) occurred postoperatively. The rates of diabetes (p=0.669), vascular disease (p=0.054), and history of intracavernosal injections (p=0.111) all had no statistically significant effect on corporal integrity. Patients with PCI tended to have hypertension (p=0.045), current smoking (p=0.03), history of IPP infection (p<0.001), and history of shunt for priapism (p<0.001). On multivariate analysis, predictors of PCI include hypertension (OR 1.64 (1.09-2.47), p=0.018), history of IPP infection (OR 4.41 (2.52-7.84), p<0.001), and age (OR 1.02 (1.00-1.04), p=0.027). Obesity was found to be protective (OR 0.63 (0.42-0.95), p=0.027). Conclusions Our multicenter analysis found that hypertension, current smoking, history of IPP infection and age were risk factors for complications associated with poor corporal integrity. Recognizing these risk factors preoperatively can allow for improved patient-specific counseling and changes in surgical strategy to potentially prevent these complications. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast and Boston Scientific.

Abstract Introduction In primary implant patients without significant corporal fibrosis, penile implant surgical technique varies in implementation of either single dilation (SingD) or sequential dilation (SeqD). Vigorous debate exists regarding both methods, but there is no robust evidence supporting one technique over the other in the literature. Objective We compared the rates of intraoperative complications and postoperative outcomes from a large international database of inflatable penile prostheses (IPP) performed by expert implant surgeons to determine if there were any significant differences in rates between SingD and SeqD. Methods We analyzed IPP cases performed by international implanters from 2016-2021. All primary implant cases were included, while revision cases, salvage operations, and patients with evidence of corporal fibrosis were excluded. Intraoperative complications and postoperative noninfectious outcomes were assessed between the two groups. These included proximal/distal perforation and cylinder crossover. Results After exclusion based on aforementioned criteria, we identified 3045 patients who underwent IPP. After 1:1 propensity matching of both groups, we analyzed 572 patients who underwent SingD and 572 patients who underwent SeqD. Between the two groups, more men of non-Caucasian race underwent SingD vs SeqD (p<0.001). There was a significant difference in cylinder length in the SeqD group vs the SingD group (20cm ± 1.5 vs. 20 cm ±2 respectively, p=0.018). There were 8 (0.7%) intraoperative complications in total, 7 in the SeqD group and 1 in the SingD group (p=0.034). Of these intraoperative complications, 3 (37.5%) patients who underwent SeqD sustained a proximal perforation, 3 (37.5%) sustained distal crossover, and 1 (12.5%) sustained proximal crossover. 1 patient (12.5%) with intraoperative complication who underwent SingD sustained a proximal perforation. Postoperatively, 78 (82%) of complications were in the SeqD group and 17 (18%) in the SingD group (p<0.001). Of these postoperative complications, there were 15 patients with bleeding or hematoma, of which 14 were in the SeqD group vs 1 in the SingD group (p<0.001). Of the 35 patients who were noted to have device-related malfunction, 29 underwent SeqD and 6 underwent SingD (p<0.001). Postoperative complications were more related to technical error in the SeqD vs the SingD group (11 patients and 1 patient respectively, p<0.011). On multivariate analysis, prior radical prostatectomy was predictive of intraoperative complications (OR 4.59 with IQR 1.39-15.16, p=0.024), while larger cylinder size seemed to be protective (OR 0.66 with IQR 0.50-0.89, p=0.006). On multivariate analysis, SeqD was predictive of postoperative complications (5.16 with IQR 3.01-8.83, p<0.001), as was history of priapism (4.15 with IQR 1.30-13.29, p=0.017). Patients who undergo SeqD may be calibrated by the surgeon to have more complex corpora, which could explain higher complication rates. We identified 3045 patients who underwent IPP. Conclusions In our international multicenter assessment of primary IPPs without corporal fibrosis performed by expert surgeons, patients undergoing single dilation appear to have slight benefit in total cylinder length. Sequential dilation may confer greater risk of intraoperative and postoperative complications, including bleeding and hematoma. Single dilation is a safe technique for primary inflatable penile prosthesis. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast and Boston Scientific