Practical Considerations in Inflatable Penile Implant Surgery

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.

Factors Impacting Postoperative Opioid Use Among Patients Undergoing Implantation of Inflatable Penile Prosthesis

Introduction Surgical treatment of erectile dysfunction (ED), particularly inflatable penile prosthesis (IPP) implantation, is a key intervention for patients unresponsive to conservative therapies. Delivering this care efficiently within elective services is essential, especially as surgical backlogs and resource constraints challenge healthcare systems. Centralised tertiary centres often struggle with emergency care pressures, potentially impacting elective surgery throughput. This study evaluates theatre efficiency and patient outcomes in IPP surgery across two hospital models: a large tertiary centre and a dedicated elective “cold-site”. The standalone “cold-sites” were designed to deliver high-volume elective surgical care while being insulated from the demands of emergency care pressures. Objective To compare surgical delivery of inflatable penile prosthesis implantation and other andrology surgeries using theatre efficiency metrics between a tertiary and cold-site hospital setting, with emphasis on theatre utilisation, patient experience, and system-based delays. Methods A retrospective observational study analysed all full-day urology theatre sessions led by two high-volume andrology surgeons over two 18-month periods: Period 1 (Oct 2018–Feb 2020, tertiary centre) and Period 2 (Oct 2023–Feb 2025, cold-site hospital). These timeframes were selected to minimise COVID-19-related bias. Metrics included theatre utilisation, case volume, proportion of IPP/andrology cases, delays, cancellations, day-case rates, 30-day readmissions, and IPP-specific patient satisfaction scores. Results In Period 1 (tertiary centre), 71 theatre sessions were conducted with 202 cases and 67.3% being andrology-related. Theatre utilisation averaged 34.61%. In Period 2 (cold-site), 82 sessions were recorded with 340 cases, of which 79.9% were andrology procedures. Theatre utilisation improved to 81.2%, with a day case rate of 73.5%. Delayed starts occurred in 30 sessions (mean 21.8 minutes), and 19 sessions overran (mean 36.9 minutes). There were 32 on-the-day cancellations, and the 30-day readmission rate was 1.18%. Patient experience survey data for 61 IPP implantation patients during 2024 revealed strong satisfaction levels: * Pre-operative: 4.81 / 5 * Day of surgery: 4.73 / 5 * Post-operative: 4.58 / 5 These outcomes reflect a patient-centred care model enhanced by the cold-site's dedicated elective infrastructure. Conclusions Cold-site elective surgery delivery for erectile dysfunction, mainly IPP implantation, demonstrated markedly improved efficiency and patient satisfaction compared to a tertiary hospital setting. Higher throughput, better theatre utilisation, and reduced disruption from emergency pressures underpin these findings. The results support broader adoption of ring-fenced elective surgical pathways to improve access, efficiency, and patient experience in surgical management of erectile dysfunction. Disclosure No

Inflatable penile prosthesis (IPP) surgery offers a high satisfaction rate and low rate of complications when performed by experienced surgeons. However, reservoir placement, either in the space of Retzius (SOR), or alternative/ectopic locations, may lead to an array of serious complications that may require revision surgery. To review the prevalence and management options for non-infectious intraoperative and postoperative complications related to prosthetic reservoirs. A Medline PubMed search was used to identify articles related to IPP reservoir-related complications including bladder and bowel injury, vascular injury, autoinflation, herniation, palpability, leakage, and tubing torsion. Rates and types of reservoir-related complications during and after IPP surgery. Non-infectious reservoir-related complications in the intraoperative setting include injury to pelvic structures such as bladder, bowel, and blood vessels. In the postoperative setting, patients may experience autoinflation and reservoir herniation that might require revision surgery. Patients undergoing alternative reservoir placement (ARP) may complain of reservoir palpability and premature mechanical failure secondary to reservoir leakage or tubing torsion. Although most surgeons continue to use the SOR as the main location for reservoir placement, ARP has gained popularity owing to its low risk of bother, minimal loss of functionality, and safety advantages in patients with history of pelvic surgery. Both reservoir placement in the SOR and ARP carry a low rate of complications while maintaining a high satisfaction rate. Clavell-Hernández J, Shah A, Wang R. Non-Infectious Reservoir-Related Complications During and After Penile Prosthesis Placement. Sex Med Rev 2019;7:521-529.

Experience With Prophylactic Gentamicin During Penile Prosthesis Surgery: A Retrospective Comparison of Two Different Doses

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

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

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

Risk of Postoperative Thromboembolism in Men Undergoing Urological Prosthetic Surgery: An Assessment of 21,413 Men.

Despite significant scientific advances in the modern three-piece inflatable penile prosthesis implant surgery, it is not without surgical risks and can carry additional cosmetic and psychosocial consequences in poorly selected and consented individuals. To address this problem, an international group of key opinion leaders and high-volume prosthetic surgeons reviewed the current guidelines and clinical evidence, discussed their experiences, and formed a consensus regarding inflatable penile prosthesis surgery. The findings of this consensus panel were presented at the 17th biennial Asia Pacific Society of Sexual Medicine scientific meeting. The experts concluded that proper patient selection, informed consent and strict adherence to safe surgical principles are important to optimize clinical outcomes. Furthermore, most intraoperative complications, if recognized, can be addressed intraoperatively to enable placement of the device at the time of initial surgery. Men with significant corporal fibrosis due to Peyronie's disease, prior prosthesis explantation and priapism, and men who have undergone construction of a neophallus, as well as men who receive concurrent continence surgery, are complex cases requiring additional care and advanced techniques to obtain optimal surgical outcomes. Variability in patient care - in terms of postoperative antibiotic use, pain management, scrotal care, and cycling of the penile prosthesis implant - must be reduced to enable optimization and assessment of outcomes across patient groups.

Introduction Patients who desire concomitant sterilization and treatment for medically refractory erectile dysfunction may benefit from a combined surgical approach involving vasectomy and inflatable penile prosthesis (IPP) placement. Traditional surgical methods often require separate incisions for each procedure, which increases overall patient recovery time and introduces potential complications associated with multiple incisions. This video details a minimally invasive no-scalpel vasectomy technique performed concurrently with 3-piece IPP placement through a single incision. Objective We demonstrate a surgical method that combines the no-scalpel vasectomy and 3-piece IPP placement through a single midline infrapubic incision. This approach aims to reduce the number of incision points, minimize surgical trauma, and optimize the recovery process for patients who undergo both procedures. Methods A 50 year-old male patient with a history of medically refractory erectile dysfunction and penile vascular disease requested sterilization and IPP implantation. Preoperative preparations included a detailed discussion of risks and benefits, home oral antibiotics, and a Hibiclens shower. The patient was placed under IV sedation and prepped in a sterile fashion. A Foley catheter was not needed as the patient voided his bladder to completion prior to the procedure. Local anesthesia was first administered via a pudendal nerve block through Alcock’s canal with 5 cc’s of mixed ropivacaine and lidocaine solution on either side. This was followed by a neurovascular bundle block and incisional block, followed by a fan block at the site of reservoir placement. A small midline infrapubic incision was made superior to the penopubic junction, only wide enough to accommodate the IPP pump. The spermatic cord and vas deferens were identified and delivered through the incision using a ring vasal clamp. The vas deferens on either side was transected and the ligated ends were secured in different fascial planes. Following the completion of the vasectomy, implantation of the IPP was performed through the same midline incision. Results The patient tolerated the procedure well with minimal blood loss. Postoperative pain was managed effectively, and the patient was able to ambulate without issues. The patient was discharged the following day and experienced no complications at the two week follow up visit. A post-vasectomy semen analysis performed at eight weeks confirmed complete sterility with non-motile sperm count under 100,000 per mL, meeting the American Urological Association guidelines. Conclusions The combined no-scalpel vasectomy and 3-piece IPP placement using a single midline infrapubic incision is a viable and effective approach for patients desiring both sterilization and treatment for erectile dysfunction. This method minimizes the number of surgical incisions required, reduces cumulative recovery time, and offers a convenient and streamlined surgical approach for these consecutive procedures, to the benefit of both patients and urologists. Disclosure No.

Inflatable penile prosthesis (IPP) surgery is an effective treatment for erectile dysfunction (ED), but infections pose a significant threat to its success. Current guidelines lack antifungal recommendations, despite rising fungal infection rates post-IPP surgery. This review examines epidemiology, risk factors (including diabetes mellitus, immunosuppression, and obesity), and pathogenesis, highlighting the role of biofilm formation in device contamination. Clinical manifestations vary from acute to delayed, with fungal biofilms presenting challenges in diagnosis. Prophylactic strategies, including broad-spectrum antibiotics and antifungals, are crucial, with evidence suggesting a 92% reduction in infections. With fungal infections showing lower salvage rates, management involves culture-guided treatment, irrigation, and oral antibiotics. Future research aims to understand biofilm mechanisms and develop biomaterials to reduce infection rates. Implementing antifungal therapy, along with standard practices like the no-touch technique and antibiotic dips, is crucial in preventing IPP infections.

To discuss emerging alternative strategies for reservoir placement during inflatable penile prosthesis surgery. Innovations in penile prosthesis design have facilitated the development of various alternative approaches for reservoir placement. Avoiding the space of Retzius is particularly appealing in patients with a history of pelvic surgery and/or radiation. The high submuscular technique utilizes a low-profile reservoir in combination with the implant's lockout valve to allow for safe placement in the potential space between the anterior abdominal wall musculature and the transversalis fascia, far cephalad from the external inguinal ring and without the need for a counter-incision. Multiple recent publications have demonstrated the safety and efficacy of the high submuscular technique. High submuscular inflatable penile prosthesis reservoir placement is a safe and effective alternative to placement within the space of Retzius.

Introduction Frailty, an approximation of a patient’s reserve resulting from age-associated decline across multi-organ systems, has been shown to be an independent predictor of adverse outcomes. Amongst penile prosthesis surgery however, frailty is an underutilized risk factor with conflicting data regarding its impact on surgical outcomes. Objective To evaluate the association between the modified Frailty Index (mFI) and adverse outcomes following inflatable penile prosthesis (IPP) surgery. Methods A retrospective chart review of men who underwent IPP surgery between 1/1/13 and 7/31/20 at a single-institution was conducted. Patient frailty was defined using the mFI, a previously validated measure, which consists of 11 patient characteristics. Each variable is allotted 1 point with aggregate scores ranging from 0 (no frailty) to 11 (highest degree of frailty). Complications were defined as mechanical failure, erosion, infection, hematoma, intractable pain, or other (ex. herniated reservoir, pump revision). Logistic regression was used to determine the association between mFI and complications after controlling for predetermined covariates. Results The final cohort consisted of 337 IPP patients with a median age of 64.6 years (IQR 58.5-68.4) and a median time from surgery to data collection of 66.6 months (IQR 39.0-85.4). The overall complication rate was 9.8% (n=33) with 63.6% of those (n=21) requiring a surgical intervention (ex. explant, remove/replace, revision). The median mFI for patients with a complication was 2 (IQR 1-3) while the median mFI for those without a complication was 1 (IQR 1-2) (Table 1). When adjusting for confounding variables on multivariable analysis, mFI was not associated with either overall (p=0.20) or operative complications (p=0.69) (Table 2). Conclusions While specific frailty metrics such as handgrip strength have been shown to be associated with complications following IPP placement, our results suggest that overall mFI was not associated with adverse outcomes following IPP surgery. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

A Modified Surgical Technique for Reservoir Placement During Inflatable Penile Prosthesis Implantation