Alan Wein: Hi, I'm Alan Wein from UroToday on the functional side, and it's my great pleasure to have today Tobias Köhler, who's a urologist at the Mayo Clinic. Today, Toby's going to talk to us about penile prostheses. He was part of a course that was given at the AUA and I've asked him to condense and reproduce his portion. So Toby, thanks so much for being with us and take it away.

Tobias Köhler: Thanks so much Dr. Wein, I really appreciate the honor of the invitation. All right, well thanks again everybody for your attention and our goal today is to talk about how we can practically improve penile implant outcomes.

We're going to divide into three simple sections: patient selection and pre-operative considerations, intra-op consideration, post-operative consideration.

Penile implant surgery is like most surgery. The most important thing to do, especially when you're starting your career and doing cases is to pick the right patients. These are different advice I've gotten from a lot of wise people. Dr. Steve Wilson says, "Never implant a stranger," so you should get to know your patients before you're doing an implant on them. A phrase that I like to utilize a lot is to under promise and over deliver in your outcomes for all surgeries. And when you think about pre-op counseling, I think a useful paradigm to talk to the patient about a best case, worst case, and most likely case scenario, really covering the gamut of what the outcomes could be. Also, when you're first starting on practice, we're all excited to do surgery because we just learn how to do it well. It's best to not start with train wrecks and do the straightforward cases first so you can establish a good reputation, gain confidence on great outcomes.

When we're picking patients for implants, but again, all surgeries, specifically Dr. Trost, my former colleague here at Mayo Clinic in Rochester and a great friend, came up with this mnemonic, the cursed patient or cursed penis. There's an acronym for characteristics that a patient may have that should make the hairs on the back of your neck stand up, make the red alarm bells go off. If patients are having a lot of these traits: being compulsive, unrealistic, going to several surgeons and getting different opinions, they feel very entitled, they deny reality of what's going on, or they have true psychiatric disorders. It may be best to not operate on those type of patients, or at least really document that you went over the risks of some benefits, but you can expect that the post-operative course is probably going to be rockier than for a more reasonable patient.

In addition to picking the right patient specifically for implants, there are several pre-operative considerations that I think are really worth thinking about. First of all, you really need to understand the patient's perception of his penis and where it is now relative to when he was 18 because that's how he's going to remember it. And if there's a new curve, because if there's a curve and you're surprised by it intra-operatively when you're doing implant, your game plan is going to be totally different. If you're not prepared, it's going to be a problem. Ask the patient, have they noticed a curve? Have they noticed shortening? Remember that shortening the penis is uniform Peyronie's. Basically, fibrosis symmetry in the penis, whereas fibrosis on one side of the penis, that's Peyronie's disease or curvature. So you have to know if that's present or not and if they do describe some shortening, have them use a vac erection device four to six weeks beforehand. That will help make the surgery easier, make the dilatation easier, okay?

The next thing I really want people to think about before they do their implant is you have to have a game plan as to where the penile implant reservoir is going to go. In the case of using a three-piece implant, the vast majority of the catastrophic outcomes from implant surgery comes from reservoir shenanigans, either iliac injury, colo fistula, vesical fistula, bladder injury, audible bleeding. These are a problem and so you have to know where the reservoir goes and if the patient has a hostile abdomen, they've had a previous cystectomy, they've had a robotic prostatectomy and they haven't reestablished a peritoneal veil, you need to know what you're going to do with the reservoir, and there's excellent approaches other than these traditional retropubic space. There's some muscular approaches, there's retroperitoneal approaches, but you just have to have a strategy in place.

Finally, if you are taking out an old device where the reservoir is somewhere but you don't know where it is because you didn't put it in, always get a CT scan. In the upper right of the slide, you'll see this is a reservoir placed by an outside surgeon. It's clearly intraperitoneal playing with bowel. So if you were to remove this willy-nilly from below, you may very well cause an unknown bowel injury. And of course, it's never wrong to make a counter incision to put the reservoir in. It's not a sign of weakness, it's a sign of strength to do what's necessary to take care of the patient.

The last thing I'd say probably that's very critical is think about the plumbing before the drywall. If a patient has untreated LUTS or incontinence, you need to fix this first before you put the implant in because if you put the implant in first and then do the endo-urologic procedures, you risk infecting a device, having your other injury to expose the device and other problems. So always plumbing before drywall.

Intra-operatively, we know from robust data that the best chance for success is the first IPP try, so this is your best chance to have an excellent outcome and get it right. When we talk about the factors that high-volume implanters will tell novices or first-time implanters or trainees, what do they consistently say? This is from the own personal experience in asking all the world's best implanters, they all say things like same operative setup every time, use a consistent and efficient approach. We recently proved that a more efficient operation leads to lower infection rates, so every minute extra you take to do an IPP surgery, the relative infection rate goes up 1%. So it's actually, time does matter for these type of surgeries, and we've seen this in other orthopedics for example as well. Have a specialized team that does the same thing every time, and have the device representatives available. They're invaluable resources that can really help getting the right volume, getting the right device, et cetera.

Intra-operative safety checks like we see pictured on the side of the slide, these field goal tests, these irrigation, they'll let you know if there's something amiss or if things are going well. Sometimes about one in seven times when you do standard implant, you're going to need specialized equipment, cavernotomes, Rossello dilators, specialized dilators. So you have to have those available. Again, you don't want to be surprised. You don't want there to be an abdominal incision where you don't know what's from, and that's somehow going to affect where the reservoir goes. You don't want there to be new Peyronie's when you put the implant in, so now you have to figure out what to do.

Another thing that's highly underutilized are narrow devices. A good implanter that does a lot of implants will typically use about one quarter of their cases. You should put a narrow device in. Why? Because sometimes the corpora are narrower than you think, and if you try to put a standard size device in, you'll struggle unnecessarily. And finally, use the right antibiotics, be familiar with their hospital antibiograms and use antifungals in the majority of patients. There's a lot of guidelines and advice you can have for anti-infectious processes.

I'm not going to belabor this slide, but I wanted to improve it. Basically when we talk about how we can prevent infection, there's many things we can do. And the green, yellow, red, blue are essentially proven unknown, proven to worsen, infection risk, et cetera, so look up these papers and you can see what successful implanters use to help mitigate infection.

Finally, post-operative strategies, a big mistake is to put in an implant and to rush to revision. There's only a few conditions where you actually need to go back right away and they're pictured on the slide. One, you've got this uniformly black glans with a blister. This is glans ischemia. It's typically not subtle. The patient will report a tremendous pain and discomfort and the best treatment for this is to remove the device immediately. If you try to get the patient by using other strategies and leave the device in, often results in catastrophic gangrene and loss of penis. If there's an obvious infection during pus and the patient is sick, take the device out. If there's stool or urine coming out with the incision, take the device out right away. Involve your surgical colleagues to help fix whatever shenanigans have occurred. Essentially, if you get these strange colors of the rainbow coming out of the penis or the incision, it's typically a bad sign, whether it's really brisk bleeding and bright red blood, or yellow urine, or white pus, or brown stool, or green bile heaven forbid, that's typically a bad thing.

All of their complaints, typically, you can give the patient the time to accommodate and adjust their complaints and it's typically fine. Little excess tubing that the patient notices, a little bulge of the device here or there typically is something that the patient will get used to and you can really mitigate risk by not having to re-operate because remember the first chance for success in the first try. The second and third try is when really infection rates and complication rates start to go up.

The last piece of advice I'd give is after device activation, give the patient a strategy to inflate their device and leave it inflated for five to 10 minutes a day. Patients who do this are actively involved in their care. They typically will have good studies that show they are happy with the length of their penis and they get very fast at using it.

Very often I see a patient that's afraid to use it because they think they're going to break it. I see them two years later in my clinic. I'm like, "How's the device?"

They're like, "Eh."

I ask them to inflate it for me, and they only get it to three or four out of 10 and they don't really know how to use it yet. So don't take that for granted that they really understand how to use it and really teach well, and make sure that they're cycling it and comfortable to cycle the device all the way from zero to 10 and vice versa.

So in summary, choose your implant patients very carefully. Use excellent counseling and under promise or deliver. Don't be surprised in the operating room and use a consistent approach with all necessary tools and resources available. Don't rush to revision with the notable exceptions that we went over. And above all, don't be afraid to ask for help from experienced implanters in all scenarios: pre-operatively, intra-operatively, or post-operatively. Please email me with questions. I would consider an honor to try to help you and that's all I have. Thanks for your attention.

Alan Wein: That was a terrific summary. At the end, those conditions that force you to go back and remove the entire device, how long do you have to wait after that? Let's say the glans returns to normal ultimately, all evidence of infection disappears. How long do you have to wait before you give it another try? And can you expect any issues because of having to remove the device with those conditions?

Tobias Köhler: Yeah, that's an interesting question. When you remove a device relatively quickly after it's in, for whatever reason, let's say it's for glans ischemia, if you wait six months from the time of removal to when you put it in, it's going to be a much more difficult surgery. The same thing holds true after a priapism, for example. So probably six months is the time in the body needs to really cement those corpora closed. And actually, the sooner you can go back in, that's safe to go in, is better. So for a post-priapism case, I strive to get in there if they want an implant. And it's justified within 30 days. As soon as you go beyond 30 days, you start to get more and more fibrosis and the case difficulty starts to escalate.

In the interim, after these emergent removals for whatever reason, have the patient use a vacuum device to keep the corpora soft and stretchy so that you avoid this corporal fibrosis and then your outcome should be better. And again, if you don't have to be a hero, if you are comfortable with virgin implants and you have to remove it for whatever reason, that's fine. But if you're not comfortable with a complex revision, send it to somebody else who is, if you don't have the corporal cavernotomes available, these kind of things, sometimes it's better to stick with the easier cases. You feel more comfortable to doing these complex revisions.

Alan Wein: Yeah, you've mentioned priapism. Are there any circumstances where you would recommend an implant right away? In other words, somebody shows up with priapism, just idiopathic, but it's obviously ischemic, it's not high flow. Are there any circumstances where you would forego the usual measures, the endless shunts, et cetera, and if something simple didn't work or recommend to the patient that they have, let's say an inflatable right then?

Tobias Köhler: They are. Well, the principle to put a device in right away at the time of priapism come from England where the NHS pays for it for sure, and they come with the priapism and they know that they did a lot of elegant MRI studies and biopsy studies showing that essentially the penis is kaput, dead after 36 hours of continuous priapism. That's in our new AUA guidelines, right? But the problem with that statement is that sometimes we're not entirely sure that it's been exactly 36 hours. Maybe the priapism resolved when they're in the outside ER with some irrigation or phenylephrine injections, but we pretty reliably know that the penis is not going to come back to life with a prolonged priapism, ischemic priapism. That being said, if there's shunt surgery where you're violating the distal corpora, it's probably not a good idea to put an implant in that setting.

Also, if there's a lot of puncturing and hematoma and potential for infection from all the work that's been done on the penis, I tend to try to not do the implant exactly at the time of that admission. In America, you need to get insurance approval for most of these guys anyway, and that typically, they don't like to give it in retrospect, they like to do it ahead of time, so waiting three weeks is totally fine and my most common move where I'll get insurance approval, I'll get an excellent consent, I'll have the patient really not be in this kind of crisis mode so they can really consider the risk and benefits of the surgery. I think that's the ideal time.

Alan Wein: Listen, those were great tips and great answers to the questions. We really appreciate those coming from an expert like yourself, and thank you so much for being with us.

Tobias Köhler: Thank you so much. Really appreciate the opportunity to spend some quality time with you.

Alan Wein: Great, thanks.