The 2020 Sexual Medicine Society of North America (SMSNA) Fall Scientific Meeting was held virtually and featured presentations by an expert panel offering personal tips on placement of inflatable penile prostheses (IPPs). IPPs have been placed since 1973, and many approaches, management methods and advances have been practiced. The panel presented contemporary preferred approaches, management of complex cases and billing advice for implanters.

Dr. Edward Karpman led the discussion first by highlighting his infrapubic approach to IPP in 12 steps. Intraoperatively, he administers pudendal blocks with a Marcaine® and Exparel® mixture, along with artificial erection with Marcaine to visualize deformities. He prefers the infrapubic approach due to the ability to make proximal corporotomies and the easier access to the external ring for reservoir placement. As demonstrated with surgical clips, the neurovascular bundle is easily identified and mobilized, and corporotomies are made proximal and lateral to the bundle for prosthesis placement. This approach allows the possibility of alleviating devastating reservoir complications and decreasing the need for rear tip extenders. Dr. Karpman also presented tips for accurate billing for IPP surgery. He highlighted the billing process in 3 parts: the preoperative, intraoperative and postoperative periods. He advised that all preoperative diagnostic tests and medications should be billed. The reimbursement rates were displayed, demonstrating the differences between the CPT codes, with the highest reimbursement seen with the “remove/replace infected IPP” procedure (CPT 54411). Underscoring appropriate CPT code choices such as difference in graft sizes or the use of plastic surgery codes for novel adjunct procedures allows the implanter to neither underbill nor overbill.

Dr. Faysal Yafi then presented his penoscrotal approach to penile prosthesis placement. His preference for this approach is due to better corporal exposure, lower risk of dorsal nerve injury, ease of pump placement and convenience for ventral and dorsal phalloplasty procedures. He also described his multimodal analgesia protocol including preoperative and postoperative acetaminophen, gabapentin and meloxicam, along with intraoperative pudendal and dorsal nerve blocks in an effort to decrease narcotic usage.¹ He carefully detailed the penoscrotal approach with the aid of videos. If plication is required, he prefers preplacing Essed-Schroeder plication 2-zero Ethibond® sutures. In addition to the penoscrotal approach, Dr. Yafi also demonstrated the mini-jupette sling placement for climacturia at the time of IPP placement. Climacturia occurs in about 20% to 64% of men after radical prostatectomy and 5.2% after radiation, which likely alludes to both neuronal and anatomical etiologies of the condition. The mini-jupette sling functions by coapting the urethra as a result of the stretched graft on IPP inflation. The corporotomy sites are made more lateral, and a Restorelle® mesh (his preferred material) is sutured to the medial edges of the corporotomies prior to the placement of the prosthesis. Due to the increasing public apprehension toward surgical mesh, he also demonstrated a technique utilizing autologous rectus fascia for the mini-jupette sling. Functional studies with retrograde urethral leak point pressure were assessed, showing pressures of 15 to 44 mm H₂O with the mini-jupette sling and inflated cylinders, similar to what is observed with Virtue® slings.

Although the majority of IPP procedures are relatively straightforward for the frequent implanter, difficult cases occur and present their own challenges. Dr. Dean Knoll presented advice for IPP placement in a hostile pelvis, which he defines as a pelvis that provides poor or no access to the inguinal ring for reservoir placement. He undertakes his IPP with an infrapubic approach, and reservoir placement is achieved through a horizontal incision through rectus fascia. The reservoir can then be placed in either submuscular or space of Retzius locations. In the implanted patient with concomitant Peyronie’s disease, which requires grafting, he makes an additional subcoronal incision for degloving purposes with the prosthesis inflated. The neurovascular bundle is mobilized and the most concave point is incised using cutting current of 20 W. A graft, 10% larger than the defect, is then sutured. Dr. Knoll further cautioned not to incise and graft in the setting of ventral curvatures, owing to the high risk of glanular necrosis.

To conclude the panel discussion, Dr. John Mulcahy presented on the IPP salvage procedure, which he first described in 1991. By 2003, he had performed 101 IPP salvage procedures with an 86% success rate. Advances have been made in this procedure over the years with salvage rates as high as 93% with semirigid rods. Additional contemporary changes to the Mulcahy washout include the use of antibiotics solution or saline, 1:10 dilution of Betadine® and pressure washing, while omitting the more toxic hydrogen peroxide. Contraindications to the salvage procedure are sepsis, ketoacidosis, genital necrosis, immunosuppression bilateral urethral erosion, and purulent or extensive cellulitis. Predictors of salvage failure include extensive cellulitis/purulence, virulent organisms and short incubation periods. In a 2017 study of infected IPPs from 25 centers, 153 cultures were positive with 35 different organisms, which were all susceptible to vancomycin, piperacillin/tazobactam and/or fluconazole.² Thus, this is the typical antibiotic cocktail he recommends, in addition to pre-salvage antibiotics for 48 to 72 hours when possible and postoperative Bactrim™ for 1 month. Dr. Mulcahy also described novel techniques for the management of cylinder aneurysm complications, which may at times require the addition of graft consolidation of the corpus cavernosum.

These articles are summaries of presentations made at the November 9–15, 2020 meeting of the Sexual Medicine Society of North America.