Five Lessons in Prosthetic Urology the Clinician Should Learn Early in Their Career

Educational Objectives

The goal of this program is to improve outcomes for prosthetic urology. After hearing and assimilating this program, the clinician will be better able to:

1. Optimize timing of surgery for revision of complications related to inflatable penile prostheses.

2. Select appropriate candidates for prosthetic urologic procedures.

 

Summary

Treatment of patients with Peyronie disease: Dr. Scott invented prosthesis in 1973; equates to silicone balloon; lacked sufficient rigidity to overcome crookedness; adjunctive measures required to straighten penis; disassembly of penis most commonly performed in 1980s and early 1990s; complications severe; competing product released in 1983; layer of fabric added to silicone balloon; both products sufficiently rigid to correct crookedness; speaker began to model plaque instead of cutting; presented procedure and received considerable criticism; eventually published paper; speaker found correction durable and prosthesis not damaged by modeling after 7 to 8 yr; became gold standard

Disadvantages of modeling: correction still had crookedness immediately postoperatively; danger of driving cylinder into urethra; cylinders act as stent in penis; penis slightly crooked when flaccid but straight while erect

Adjunctive procedures to eliminate risk for urethral damage: include plication, scratch technique, return to plaque excision with placement of grafts, and multiple incisions without covering; techniques all effective for achieving straight penis; speaker states penis becomes straight with usage; will straighten completely in 8 to 12 mo if modeling stopped at 30 degrees

What speaker wishes he had known: initial straightening with all the newer techniques better than modeling; speaker has not damaged the urethra with any of the newer techniques

One scrotal incision to implant AUS: volume of sphincter procedures low (only ≈6000/yr in United States); tricky procedure through uncommonly used incision; speaker thought approach through scrotum potentially quicker and safer; performed procedure and reported at American Urological Association conference; received criticism that scrotal technique did not allow sufficiently proximal placement of cuff; speaker conceded cuff placed less proximally; speaker altered own standing position, altered positioning of patient, adjusted retractor, and used weighted vaginal speculum; achieved much lower placement of cuff; currently still not as popular as perineal incision; speaker next attempted to place both prostheses through single incision with good success; analyzed data and found patients with infections or other problems required removal of both implants; faced resistance from hospital administration and reimbursement issues from Medicare; subsequently abandoned double implantations except in unusual cases; currently stages implantations

What speaker wishes he had known: invented dual implantation through single incision, but stopped offering; currently prefers to place implants separately

Traditional retroperitoneal placement of reservoir: potential bad outcomes include damage to iliac vein with severe bleeding, bowel fistulas, and inadvertent placement of reservoir in bladder

Ectopic method: lockout valve developed around 2000; did not require space for reservoir; speaker experimented with placement of reservoir in abdominal wall with finger; reservoir always visible and palpable and sometimes herniated into scrotum; Dr. Perito began to place reservoirs ectopically through infrapubic incision with long nasal speculum; less visible, less palpable, and many fewer hernias; subsequent use of 14-inch grasping clamp allowed placement of reservoir much higher

What speaker wished he had known: approach through inguinal canal results in superficial placement in abdominal wall; lifting Scarpa’s fascia off pubic tubercle necessary to access transversalis fascia; ideal placement of reservoir submuscular on top of transversalis fascia; reservoir not visible or palpable; will not herniate; ectopic reservoir appropriate for any patient

Avoid rushing revision: open incision with draining blood, draining pus, draining urine, or draining fecal content requires immediate return to operating room; glans ischemia also requires immediate return; all other complications can wait; wait ≥3 mo to allow formation of capsule; complications that can wait include nondraining hematoma, visible reservoir, wound dehiscence with visible tubing but no obvious infection, and malposition of components

Patient selection: avoid impulsive surgeries; speaker now postpones difficult patients or refuses to operate; avoid patients with unrealistic expectations, who are excessively emotional about penis, or who desire a penis “as long as possible”; manage expectations; last surgeon to operate always answers to patient; select appropriate candidates

Readings

Osmonov D et al: High-submuscular vs. space of Retzius reservoir placement during implantation of inflatable penile implants. Int J Impot Res. 2020 Jan;32(1):18-23; Wilson SK and Simhan J: Is modeling an inflatable penile prosthesis obsolete for patients with Peyronie’s disease? Int J Impot Res. 2020 Jan 28; Wintner A and Lentz AC: Inflatable penile prosthesis: considerations in revision surgery. Curr Urol Rep. 2019 Mar 20;20(4):18; Yafi FA et al: Strategies for penile prosthesis placement in Peyronie’s disease and corporal fibrosis. Curr Urol Rep. 2015 Apr;16(4):21.

 

Disclosures

For this program, the following has been disclosed: Dr. Wilson is a consultant for AMT, Boston Scientific, INT:Med Devices, and Coloplast. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Wilson was recorded at 24th Annual Innovations in Urologic Practice, held September 13-15, 2019, in Santa Fe, NM, and presented by Grand Rounds in Urology. For information about upcoming CME opportunities from Grand Rounds in Urology, please visit Grandroundsinurology.com. The Audio Digest Foundation thanks the speakers and Grand Rounds in Urology for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

UR431402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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