Penile Prosthesis Implantation in Patients With Peyronie's Disease: Results of the PROPPER Study Demonstrates a Decrease in Patient-Reported Depression

Re: Simultaneous Penile Lengthening and Penile Prosthesis Implantation in Patients with Peyronie's Disease, Refractory Erectile Dysfunction, and Severe Penile Shortening

Outcomes following penile prosthesis implantation in patients with a history of total phallic construction are not well described. The aim of this study was to evaluate outcomes following neophallus penile prosthesis placement. Retrospective review penile prosthesis placement in patients with prior total phallic construction. GORE-TEX® (Gore Medical, Flagstaff, AZ) sleeve neotunica construction was utilized in all patients. Success defined as patient sexual activity with a functioning prosthesis. Thirty-one patients underwent neophallic prosthesis implantation at a mean 35.6 years of age. Prosthesis placement occurred at an average 56.3 months following phallic construction and follow-up was a mean of 59.7 months. Malleable prostheses were placed in 21 patients and inflatable in 10; implants were bilateral in 94%. Six percent experienced operative complications including a bladder injury (1) and phallic flap arterial injury (1). Postoperative complications occurred in 23% at a median 5.5 months following placement. Five prostheses were explanted secondary to infection or erosion and two additional required revisions. Of the explanted prosthesis two were later replaced without further complication. Eighty-one percent of patients were sexually active following prosthesis placement. Penile prosthesis placement is possible in patients with prior penile reconstruction/phallic construction. Although complications rates appear to be elevated in this population compared with historic controls of normal anatomic men, the majority of patients in this series were sexually active following prosthesis placement. This demonstrates the utility of prosthesis implantation in these difficult patients.

V1584 TRANS-SCROTAL PLICATION FOR PEYRONIE'S DISEASE WITH SYNCHRONOUS PENILE IMPLANT

Introduction There are a variety of treatment modalities available to treat Peyronie’s disease (PD), including collagenase clostridium histolyticum (Xiaflex) injections. Patients with concomitant erectile dysfunction (ED) and PD are best served by insertion of an inflatable penile prosthesis (IPP) in order to adequately treat both conditions. Many PD patients may undergo other PD treatments, including Xiaflex, prior to IPP implantation. Little data exists regarding whether Xiaflex treatments prior to IPP placement influence changes in penile curvature during and after IPP surgery with manual modeling. Objective The primary objectives were assessing the impact of pre-treatment with Xiaflex on penile curvature immediately after IPP implantation and after manual modeling. The secondary objective was change in penile curvature postoperatively. Methods All IPP patients with known preoperative penile curvature with and without a history of Xiaflex injections undergoing IPP placement by a single surgeon from January 2017 to June 2023 were included in this IRB-approved (IRB 00031589) retrospective series. All patients had a 3-piece Coloplast Titan Touch IPP (Coloplast, Minneapolis, MN, USA) ranging 16-24 cm in length (mean 19.8 ± 1.9 cm) with 0-3 cm rear tips (mean 1.4 ± 0.9 cm). Goniometer was used to assess curvature during preoperative intracavernosal injection and duplex Doppler ultrasound, at multiple points intraoperatively, and postoperatively at 2 weeks, 6 weeks, and 6 months. Results Sixty-one patients were included. Preoperative curvature was 35° ± 17° (10° to 70°) for the Xiaflex cohort (n = 11) and 41° ± 15° (20° to 80°) for the Xiaflex naïve cohort (n = 50). At the time of IPP placement, patients previously treated with Xiaflex had a 19° ± 12° absolute reduction in penile curvatures, corresponding to a 45% ± 36% improvement, while Xiaflex naïve patients had a 20° ± 13° absolute reduction and 54% ± 23% improvement. Similar mean curvature reductions were seen with IPP placement regardless of curvature direction. There was little difference in change in curvature after modeling between the Xiaflex (11° ± 3°, 63% ± 23%) and Xiaflex naïve patients (14° ± 9°, 70% ± 20%). Interval assessments postoperatively were also comparable. Conclusions Preoperative treatment of PD with Xiaflex does not impede nor significantly improve curvature correction with IPP implantation and manual modeling. Similar changes in penile curvatures were seen in both groups regardless of curvature direction, modeling, or postoperative interval. In patients with severe PD, Xiaflex may be a useful tool to improve preoperative penile curvatures such that they may be more easily correctable with an IPP. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, MenMD.

The surgical treatment of disorders of male sexual function requires specific exposure to correct the underlying problem safely and efficiently. Currently, sub-coronal exposure is used for treatment of phimosis, Peyronie's disease plaque (PDP), and semirigid penile prosthesis insertion. Infra-pubic and scrotal incisions are used for inflatable penile prosthesis (IPP) placement. However, men who present with several disorders might require multiple procedures and surgical incisions. To report a prospective review of our surgical experience and outcomes with a single sub-coronal incision for IPP placement with a modified no-touch technique. This approach allows for access to the entire corporal body for multiple reconstructive procedures. Two hundred men had IPPs placed through a sub-coronal incision using our modified no-touch technique. The penis was degloved to the level of the penoscrotal junction and the dartos muscle was everted and secured to the drapes. This allowed exclusion of the scrotal and penile skin from the operative field. After artificial erection, the patient's corpora were inspected for PDP and other abnormalities. Penoscrotal IPP models were placed in all cases with insertion proximal to the penoscrotal junction. After placement of the IPP, the abnormalities were repaired. Feasibility of the procedure, operative times, complication rate, utilization of accessory, reconstructive procedures, and post-operative penile length. Of the 200 men who had IPP placement, 92 had PDP that was treated, 106 (53%) consented to circumcision, 24 (12%) had their reservoir placed ectopically, and 31 (16%) had a prosthesis exchanged through the sub-coronal technique. Mean operative time was 73 minutes (39-161 minutes). Specialists in the surgical treatment of disorders of male sexual function can perform multiple procedures safely and easily through a modified no-touch single sub-coronal incision. This approach allows access to the entire corporal body, providing excellent visibility and allowing the surgeon to perform multiple penile reconstructive surgeries through a single incision.

Introduction Intraoperative manual modeling during inflatable penile prosthesis (IPP) placement for Peyronie’s disease (PD) was first described by Wilson and Delk in 1994. Early adoption was slow, partly due to the quoted 4% urethral perforation rate. In the last 30 years, modeling has been confirmed as a safe and effective technique during IPP implantation for PD. Despite widespread use, significant questions about technique persist, including the number and duration of modeling cycles, and their impact on outcomes. Comparative data among different types of IPP devices is also lacking. Objective To evaluate the efficacy and safety of intraoperative manual modeling during IPP implantation for PD. We analyzed the relationship between modeling technique (number and duration of cycles), curvature correction, device type, and clinical outcomes, including residual curvature, satisfaction, and complications. Methods A retrospective review was conducted of 93 patients who underwent IPP placement with standard intraoperative manual modeling by a single surgeon. Patients who underwent concurrent plication or grafts were excluded from the study. Variables analyzed were pre- and postoperative curvature (intraoperative and 6 months), modeling cycles and duration, device type, patient satisfaction, and complications. Modeling success was defined as <15 degrees final curvature. Logistic regression was used to identify predictors of success. Results The median preoperative curvature was 40° (range 25–75), with a median of 2 modeling cycles (range 1–4) and an average of 65 seconds per cycle (range 60–90). Postoperative curvature had a median of 10° (range 0–30). Most patients (62.0%) underwent 2 modeling cycles, while 18.5% had either 1 or 3 cycles, and only one patient required 4. Curve direction was predominantly dorsal (68.5%), followed by left (15.2%), ventral (9.8%), and right (4.4%). The vast majority (92.4%) received Coloplast Titan implants, with only a few receiving Titan Narrow Base (4.4%) or AMS 700 CX (3.3%) devices. 75% of patients achieved a curvature of <15°, with no intraoperative urethral or device injuries. At 6-month follow-up, 94.1% of patients reported satisfaction, and none required revision surgery. However, 13% showed increased curvature at 6 months postoperative compared to immediate intraoperative results. Thirty-four patients (37.0%) achieved complete straightness intraoperatively (0°), while 47.8% had a residual curve ≤15°, and 15.2% had a curvature between 16° and 30°; no patients had residual curvature >30°. In logistic regression analysis, increased BMI was significantly associated with lower likelihood of successful modeling (OR: 0.81, p=0.015). Age (OR: 0.94, p=0.062) and prior robotic-assisted laparoscopic prostatectomy (OR: 0.23, p=0.069) showed trends toward significance but did not meet statistical thresholds, likely due to limited sample size. Conclusions Manual intraoperative modeling at the time of IPP placement is a safe and effective procedure for the correction of penile curvature in PD with a 75% success rate and no intraoperative complications. Most patients experienced a marked decrease in curvature, and nearly all were satisfied at follow-up. Increased BMI was independently associated with reduced modeling success, potentially indicating a biomechanical or technical constraint in this population. Further studies are needed to refine modeling protocols and to assess long-term durability and patient-reported outcomes. Disclosure No

The treatment of erectile dysfunction (ED) using penile prosthesis implantation (PPI) has recently garnered significant interest, but reports of bibliometric analyses of studies on PPI have yet to appear. Therefore, the purpose of this study is to use visualization techniques to statistically and qualitatively assess the state of knowledge, current research topics, and trends in this field. The Science Citation Index-Expanded (SCI-E) from the Web of Science Core Collection (WoSCC) was searched for publications about PPI from the inception of the database to 2023. VOSviewer (version 1.6.19), CiteSpace (version 6.2. R2), and Excel (version 2021) were used for the data analysis. The results show a total of 1015 original articles and reviews on PPI published over this nearly 50 years, with an increasing trend in the number of studies published each year. The United States is the country with the most published studies (n = 578). Mayo Clinic is the organization with the most publications overall (n = 46). The Journal of Sexual Medicine has the most publications (n = 184). The most prolific author is Wilson, Steven K (n = 31). The most commonly used terms were erectile dysfunction (n = 509), penile prosthesis (n = 332), implantation (n = 207), satisfaction (n = 201), surgery (n = 200), infection (n = 134), outcomes (n = 128), Peyronie's disease (n = 121), men (n = 115), and experience (n = 109). Current research focuses on four main areas: complications of PPI, the current status of inflatable penile prosthesis (IPP), the use of PPI in radical prostatectomy and Peyronie's disease populations, and patient satisfaction after PPI. Improving patient satisfaction with PPI through improved mechanical design and surgical techniques is a key concern for future research.

152 Multi-Center Experience Utilizing Collagen Fleece for Plaque Incision with Grafting to Correct Residual Curvature at Time of Inflatable Penile Prosthesis Placement in Peyronie's Disease Patients

Penile prosthesis (PP) is the mainstay of treatment in Peyronie's disease (PD) with co-existent refractory erectile dysfunction (ED). This study aimed to assess the clinical outcomes of patients who underwent PP as the first-line surgical treatment in PD without ED. A total of 636 patients underwent PP for PD from 2012 to 2022, but only 168 patients who underwent PP as first-line surgical management for PD with or without ED were included in the study. The mean (SD) age of 168 patients was 56.3 years (12.4). The mean curvature of the "PD with ED" group and the "PD without ED" group were 38.2 (5.6) degrees and 42.2 (5.9) degrees. The median (IQR) follow-up was 56.0 months (34.5- 61.4). Most (86.9%) patients underwent 3-piece inflatable PP. An important finding is that 33 patients (19.6%) without ED had undergone PP. Mechanical failure requiring revision surgery was less common in the 'without ED' group than in the ED group (6.8% vs. 10.2%, p 0.04). Most PD patients without ED (87.9%, 29/33) and with ED (88.9%, 120/135) were "satisfied" after PP implantation at six months, as defined by a score of ≥4 on a 5-point Likert scale. If surgery is offered in PD, PP may be considered a safe and effective first-line surgical treatment regardless of the ED, given the acceptable complications and high satisfaction rates. However, this new concept warrants further research.

Erectile dysfunction (ED) frequently accompanies Peyronie's disease (PD) and changes the therapeutic approach. To evaluate a single-center experience with inflatable penile prostheses (IPP) in men with medication refractory ED and PD. Ninety men underwent placement of an IPP with straightening maneuvers as necessary to address their deformity and ED. Preoperative assessment included International Index of Erectile Function-erectile function domain (IIEF-EF) and duplex ultrasound to confirm ED and measure erect deformity. Postoperative assessment included a modified Erectile Dysfunction Index of Treatment Satisfaction (EDITS) questionnaire, as well as office visits at 1, 6, and every 12 months thereafter. Complete chart review was performed with mean follow-up of 49 months. Mean preoperative IIEF-EF score was 11. Full rigidity was not obtained in any patient during duplex ultrasound. Mean curvature at maximum erection was 53°. There were seven mechanical failures requiring device replacement, two revision surgeries for pump or reservoir malposition, one infected device, and two corporoplasties for distal tunica erosion. Postoperative office assessment revealed a functionally straight (i.e., <20°) erect penis and a properly positioned as well as operational device in all patients. The modified EDITS questionnaire was returned by 56 (62%). Overall, 84% of patients were satisfied with their outcome, yet only 73% were satisfied with their straightness. Patient perceived postoperative curvature correction stabilized quickly and was complete by 3 months in 84% of patients. Satisfaction with ease of inflation, deflation, and concealability was 84%, 71%, and 91%, respectively. Coital activity was reported by 91% of men in this group. In men with PD and ED, IPP placement allowed reliable and satisfactory coitus for the great majority of men. Mechanical failure was 7%. Men with PD undergoing IPP placement should be counseled regarding potential penile length loss and residual curvature, neither of which appeared to interfere with coitus but may reduce satisfaction.

Introduction Patients with post-prostatectomy erectile dysfunction (ED) and stress urinary incontinence (SUI) often require dual prosthetic implants. A single-incision penoscrotal approach enables simultaneous AUS and inflatable penile prosthesis (IPP) placement, reducing operative time and morbidity. Objective To demonstrate a streamlined surgical technique for simultaneous AUS and IPP implantation via a single penoscrotal incision in a patient with dual dysfunction after radical prostatectomy. Methods A male patient with persistent SUI and ED underwent combined AUS and IPP placement. The procedure was performed through a midline penoscrotal incision. Following corporal dilation and IPP cylinder placement, the bulbar urethra was exposed, and an AUS cuff was positioned. The IPP pump and AUS pump were placed in the scrotum, and the reservoir and pressure-regulating balloon were inserted through the same incision. Results The surgery was completed without complications. The single-incision technique allowed efficient access to both prosthetic spaces. At follow-up, the IPP was activated at 4 weeks and the AUS at 6 weeks. The patient reported significant improvement in both erectile function and continence, with high satisfaction and no postoperative complications. Conclusions The combined penoscrotal approach for AUS and IPP placement is a practical and effective solution for patients requiring dual prosthetic intervention. This video highlights operative steps and pearls to assist surgeons in adopting this single-incision strategy. Disclosure No

AUA-recommended Antibiotic Prophylaxis for Primary Penile Implantation Results in a Higher, Not Lower, Risk for Postoperative Infection: A Multicenter Analysis.

1817 CONCORDANCE BETWEEN PATIENT AND PHYSICIAN ASSESSMENT OF PEYRONIE'S DISEASE DEFORMITY

Up to 20–30% of patients with Peyronie’s disease (PD) suffer from some degree of erectile dysfunction (ED). When medical management fails, the surgical approach towards those with PD and ED relies on the penile prosthesis. Graft material has advanced in recent years, and hemostatic patch material has emerged as a promising, easy to use, and cost-effective approach. Intracorporal techniques that obviate the need for neurovascular bundle mobilization have recently been described, and can be considered a frontier for further investigation. A thorough literature review was performed using the PubMed online database with query: “Penile Prosthesis” and “Peyronie’s disease” with “Plaque excision,” “Plaque incision,” “Tunica albuginea plication,” “Modeling,” and “Excision and grafting.” While the three-piece inflatable penile prosthesis (IPP) is commonly used, malleable implants may also achieve success where three-pieces are unavailable or not appropriate for use. When implant alone does not correct the deformity, manual modeling is a mainstay in treating residual curvature. Tunica plication, incision, and excision/graft techniques are required in patients with more severe/complicated plaques.

Practical Considerations in Inflatable Penile Implant Surgery