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Introduction: Various alternative placements of inflatable penile prosthesis (IPP) reservoirs have been previously documented, differing from the traditional retroperitoneal placement in the Space of Retzius. Pelvic trauma, history of surgery in the pelvic region, and atypical anatomy can necessitate an alternative location for implantation of the IPP reservoir. The midline placement of the IPP reservoir provides numerous advantages in outcomes, patient experience, and versatility of implantation. This video demonstrates the surgical procedure for midline placement of the IPP reservoir. Objective: We outline a surgical technique to place the IPP reservoir in an alternative midline location. Methods: The patient was instructed to void his bladder prior to the procedure to circumvent Foley catheter insertion. A 2.5 cm-wide horizontal incision was made 2 finger widths cranially to the dorsal aspect of the base of the penis. The surgeon's index finger was used for blunt dissection along the linea alba above the pubic tubercles. A tonsil clamp is used to pierce the rectus fascia at the midline, below the arcuate line, to leave a defect just wide enough to accommodate a 70 mm nasal speculum. The surgeon's finger is used to assess the space to determine if a 9/10 mm Hegar dilator is necessary to expand the avascular space by sweeping it parallel to the fascia. The speculum is inserted and positioned with the blades pointed cranially parallel to the facial axis and the handles pointed superiorly. The reservoir is prepared and delivered into this space using a metal pediatric Yankauer suction tip through the open blades of the nasal speculum. A syringe filled with saline solution is connected to the reservoir tubing, and the fluid is transferred completely to the reservoir and the tubing is clamped. The tubes originating from the reservoir and implant cylinders are both clamped, trimmed to length, and connected to each other in a watertight fashion to permit the bidirectional flow of saline solution. Proper IPP cylinder inflation is tested prior to closing the incision. Results: The reservoir is thus safely deployed cranially to the pubic bone and avoids interfering with the urinary bladder. No complications were observed in this patient, and he was discharged on the same day. Conclusions: The midline surgical placement of the reservoir during the infrapubic implantation of an inflatable penile prosthesis is a safe and effective alternative placement for patients with prior pelvic surgery, injuries, or atypical pelvic anatomy. Patients with compromised pelvic, abdominal, or inguinal regions due to hernia repair, patulous inguinal rings, or dense lateral pelvic scarring stand to benefit the most from this reservoir placement. This procedure outlines the surgical steps of midline reservoir placement for new IPP implantation or relocation during a revision procedure. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Penile girth enhancement (PGE) has gained significant popularity and is in high demand among individuals seeking to improve their sexual experiences and self-confidence. Perception of penile length and girth are integral components of the male psyche. Unfortunately, current treatment options for motivated patients looking to enhance penile girth fall short of patient and clinical expectations. While the safety of penile augmentation methods has been a subject of debate, hyaluronic acid (HA) fillers have demonstrated proven efficacy and safety, offering potential solutions for those interested in PGE. Advancements in the field of penile cosmetics with HA has led to the development of the UroFill™ patented technique for PGE. Objective: To assess the safety and efficacy of injecting HA using the UroFill™ technique for PGE. Methods: We performed a retrospective analysis of men undergoing penile girth enhancement with FDA-approved HA fillers between October 2021 and March 2023. Patients completed a series of validated questionnaires including the COPS-P, IIEF, and BAPS. Peri- and post-procedure adverse events were closely monitored. Physician follow-up appointments and patient questionnaires were utilized to identify and document these events. The determination of unsatisfactory cosmetic outcomes and the need for revision was made by the treating physician in consultation with the patient. The UroFill™ standardized technique was employed for all injections. Results: A total of 300 men (mean age: 37, range 21-80) received treatment using the UroFill™ standardized technique. 4,879 injections were performed over this time. Mean injection volume was 16.5 cc (range: 4-78cc) of HA once treatment had been completed. The study observed an average of 3.85 injection sessions (range: 1-44 sessions) and 5.25 post-injection modeling sessions (range 0-55) per patient. After receiving HA dermal fillers, patients experienced local injection site reactions such as bruising, tenderness, swelling, and erythema. These events were generally mild in intensity, and no patient reported bruising lasting longer than 7 days. None of the patients in this cohort required removal of filler. Adverse reactions were limited to 8 cases of localized skin infections which were successfully treated with conservative antibiotic therapy. All localized skin infections were a result of premature sexual intercourse or shaving in the area following injection. Patients reported high levels of satisfaction with 272/300 (91%) reporting "completely satisfied" or "mostly satisfied". Mean filler retention was 90% after 12 months. Conclusions: This study provides evidence that the UroFill™ standardized technique for penile girth enhancement using HA fillers is both safe and efficacious. With no instances of filler removal and successful management of adverse reactions, the safety profile of HA fillers is further supported. These findings reinforce HA's potential for sustainable penile enhancement. It is essential these procedures be performed in the described fashion by qualified urological professionals. Disclosure: Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific, UroFill. [ABSTRACT FROM AUTHOR]

Significant racial disparities in survival for renal cell carcinoma (RCC) exist between white and black patients. Differences in access to care and comorbidities are possible contributors. To investigate if racial disparities persist when controlling for access to care, we analyzed data from a single-payer healthcare system. As part of a case-control study within the Kaiser Permanente Northern California system, pathologic and clinical records were obtained for RCC cases (2152 white, 293 black) diagnosed from 1998 to 2008. Patient demographics, comorbidities, tumor characteristics, and treatment status were compared. Overall survival and disease-specific survival (DSS) were calculated by the Kaplan-Meier method. A Cox proportion hazards model estimated the independent associations of race, comorbidity, and clinicopathologic variables with DSS. We found that compared to white patients, black patients were diagnosed at a younger age (median 62 vs. 66 years, P < 0.001), were more likely to have papillary RCC (15% vs. 5.2%, P < 0.001), and had similar rates of surgical treatment (78.8% vs. 77.9%, P = 0.764). On multivariate analysis, advanced American Joint Committee on Cancer (AJCC) stage, lack of surgical treatment, larger tumor size, and higher grade were predictors of worse DSS. Race was not an independent predictor of survival. Therefore, we conclude that within a single healthcare system, differences in characteristics of black and white patients with RCC persist; black patients had different comorbidities, were younger, and had decreased tumor stage. However, unlike other series, race was not an independent predictor of DSS, suggesting that survival differences in large registries may result from barriers to healthcare access and/or comorbidity rather than disease biology. [ABSTRACT FROM AUTHOR]

Background: The ventral and distal aspects of the corpora cavernosa are the thinnest, increasing the likelihood of cylinder extrusion or crossover complications pertaining to inflatable penile prosthesis procedures. A double distal corporal anchoring double stitch can be used to robustly secure impending lateral extrusions and crossovers of implant cylinders. It is a novel, effective corrective measure for the uncommon complication of migrated cylinders in inflatable penile prosthesis placement. Aim: To describe the surgical indications and technique for the double distal corporal anchoring fixation stitch for lateral penile implant cylinder extrusion. Methods: We discuss a double-stitch technique that is performed following corporoplasty and capsulotomy. A lateral incision is made subcoronally on the affected side to identify the crossover or lateral extrusion. The cylinder is repositioned properly within the native corpora to prevent further cylinder migration. Two 2-0 Ethibond sutures are threaded through the distal cylinder eyelet, and each suture is delivered through the glans with a Keith needle and tied off. An incision is made in the glans, and 1 arm of each suture is tied with the other to create a bridge between the sutures that can be positioned deep within the skin of the glans. Outcomes: Over the past 4 years, 66 patients with lateral cylinder extrusion underwent the double distal corporal anchoring fixation stitch procedure, with overall improved satisfaction (97%). Only 2 patients had surgical complications. One patient experienced repeated lateral extrusion of the penile implant cylinders 6 weeks following the double-anchoring stitches procedure. The second patient developed a painful suture granuloma that necessitated excision, which resolved this issue, and the penile implant cylinder remained in the proper position over a year later. Clinical Implications: This technique ensures the secure fixation of the affected cylinders in the surgical capsule by creating a bridge between 2 sutures holding each repositioned cylinder in place, and the ensuing fibrotic reaction helps to fixate the extruded cylinder within the midglandular tissue. Strength and Limitations: This surgical technique describes the double distal corporal anchoring stitch for lateral penile implant cylinder extrusion. Further studies are warranted to validate long-term outcomes and satisfaction. Conclusion: The double distal corporal anchoring fixation stitch is a safe and efficacious method to secure cylinders in the proper surgical capsule during revision procedures to correct distal crossovers or laterally extruded penile prosthesis implants. [ABSTRACT FROM AUTHOR]

Background: Corporal fibrosis is known to result from prolonged priapism; however, the impact of the timing of penile prosthesis placement after priapism on complication rates is poorly understood. Aim: We sought to evaluate the impact of timing of inflatable penile prosthesis (IPP) placement on complications in men with a history of ischemic priapism. Methods: We performed a multicenter, retrospective cohort study of patients with a history of priapism undergoing IPP placement by 10 experienced implantation surgeons. We defined early placement as ≤6 months from priapism to IPP. We identified a 1:1 propensity-matched group of men without a history of priapism and compared complication rates between men who had early placement, late placement, and no history of priapism. Outcomes: Our primary outcome was postoperative noninfectious complications, and secondary outcomes included intraoperative complications and postoperative infection. Results: A total of 124 men were included in the study with a mean age of 50.3 ± 12.7 years. A total of 62 had a history of priapism and 62 were matched control subjects. The median duration of priapism was 37 (range, 3-168) hours and the median time from ischemic priapism to IPP placement was 15 months (range, 3 days to 23 years). Fifteen (24%) men underwent early (≤6 months) IPP placement at a median time of 2 months (range, 3 days to 6 months) following the ischemic priapism event. The remaining 47 (76%) underwent placement >6 months following priapism at a median time of 31.5 months (range, 7 months to 23 years). The complication rate in the delayed placement group was 40.5% compared with 0% in the early placement group and control group. Cylinder-related complications such as migration or leak accounted for 8 (57%) of 14 of the postoperative noninfectious complications. Full-sized cylinders were used in all patients who had a cylinder related complication. Clinical Implications: Priapism patients should be referred to prosthetic experts early to decrease complication rates in those needing an IPP. Strengths and Limitations: This is a multicenter study from experienced prosthetic urologists but is limited by the retrospective nature and small number of patients in the early placement group. Conclusion: IPP complication rates are high in men with a history of ischemic priapism, especially when implantation is delayed beyond 6 months. [ABSTRACT FROM AUTHOR]

Objective: To evaluate trends in the utilization of active surveillance (AS) in a nationally representative cancer database. AS has been increasingly recognized as an effective strategy for patients with small renal masses but little is known about national usage patterns.Methods: We identified patients with clinical T1a renal masses within the National Cancer Database in 2010 through 2014. Patients were classified according to initial management strategy received including AS, surgery, ablation, or other treatment. We characterized time trends in the use of AS vs definitive therapy and examined clinical and socio-demographic determinants of AS among patients with small renal masses using multivariable logistic regression models.Results: We identified 59,189 patients who satisfied the inclusion criteria. Of the total cohort, 1733 (2.9%) individuals received initial management with AS, while 57,456 (97.1%) received definitive treatment. Surveillance rates remained below 5% in all years. On multivariate analysis, patient age (OR: 1.08, 95% CI 1.08-1.09), smaller tumor size of <2 cm vs ≥2 cm (OR: 2.43, 95% CI: 2.20-2.7, P < .0001), management at an academic center vs community center (OR: 2.05, 95% CI: 1.83-2.29), and African American vs Caucasian race (OR: 1.56, 95% CI:1.35-1.80) were independently associated with use of AS as initial management.Conclusion: In a representative national cohort of patients with small renal masses, we observed clinical and facility-level differences in the utilization of active surveillance in patients with T1a renal masses. Further investigation is warranted to better understand the forces underlying initial management decisions for patients with small renal masses. [ABSTRACT FROM AUTHOR]

Objectives: Kidney masses suspicious for malignancy are frequently detected by cross-sectional imaging; however, little is known about the burden of surgical treatment for tumors found to be benign following excision.Material and Methods: We queried the National Inpatient Sample to identify records of individuals who received surgical treatment for renal neoplasms between 2004 and 2014. We characterized temporal treatment trends, patient demographics, treatment related complications, and charges.Results: We identified 7,099 (8.5%) and 76,892 (91.5%) patients who were treated for benign and malignant tumors, respectively. Benign masses accounted for 14.8% of partial and 5.5% of radical nephrectomies. The rates of surgery for benign tumors have remained steady (P = 0.058). The frequency of inpatient death was higher in those with malignant disease (0.63% vs. 0.18%, P < 0.0001). Median length of stay was longer for individuals with malignant renal tumors (4.86 vs. 4.12 days, P < 0.0001). The total discharge bill adjusting for inflation for benign or malignant renal surgery increased each year (R2 = 0.428, R2 = 0.719, P = 0.001, P = 0.0311, respectively). As of 2014, the estimated national inpatient cost of management for benign renal tumors was $153 million dollars ($55,573/individual).Conclusions: 8.5% of inpatient renal surgical admissions are performed for benign masses. There has been a trend toward decreased operative management for benign renal tumors over time. Surgical management remains a significant economic burden. Efforts to prospectively evaluate modalities for pretreatment identification should be further pursued. [ABSTRACT FROM AUTHOR]

Background: Variations in climate have been associated with a greater risk of surgical site infections, urinary tract infections, and changes in the skin microbiome; however, limited data exist on the impact of climate on inflatable penile prosthesis (IPP) infections., Aim: We sought to evaluate the impact of climate on the risk of IPP infections in a large international, multicenter cohort., Methods: We performed a multi-institutional, retrospective study of patients undergoing IPP surgery. We then evaluated whether the month or season, during which surgery was performed, affected device infections. Implant infections were defined as infections requiring device explantation. A univariate logistic regression analysis was undertaken., Outcomes: Our primary outcome was implant infection., Results: A total of 5289 patients with a mean age of 62.2 ± 10.8 years received IPP placement. There was a fairly even distribution of implants performed in each season. A total of 103 (1.9%) infections were recorded. There were 32 (31.1%) IPP infections in patients who underwent surgery in the summer, followed by 28 (27.2%) in the winter, 26 (25.2%) in the spring, and 17 (16.5%) in the fall. No statistically significant differences were recorded in terms of season (P = .19) and month (P = .29). The mean daily temperature (P = .43), dew point (P = .43), and humidity (P = .92) at the time of IPP placement was not associated with infection., Clinical Implications: These findings provide reassurance to prosthetic urologists that infection reduction strategies do not need to be tailored to local climate., Strengths and Limitations: Climate data were not directly recorded for each hospital, but rather based on the monthly averages in the city where the surgery was performed., Conclusion: The climate at time of IPP placement and time of year of surgery is not associated with IPP infection risk., (© The Author(s) 2024. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Glans hypermobility (GH) is a well-described clinical entity that can have significant implications for cosmesis and function, resulting in sexual dissatisfaction, penile pain, and early device erosion, with an estimated incidence of 0.04% to 10%. We developed a novel grading scale to assess GH severity intraoperatively during primary inflatable penile prosthesis (IPP) placement and describe a modified glanspexy technique to correct GH when encountered during IPP placement. 530 patients who underwent primary IPP placements from two high-volume prosthetic surgeons between February 2018 - November 2019 were retrospectively reviewed in order to identify the incidence of GH. Of these, 139 (26.2%) had hypermobility. Employing our new scaling system, grade 1, 2, and 3 GH was seen in 86 (16.2%), 29 (5.5%), and 24 (4.5%) cases, respectively. Increased implant size correlated with a decreased likelihood of GH incidence. Each increase in implant size by 1 cm decreased the incidence of detecting GH by 11.0% (OR = 0.89; p = 0.015). 11 patients underwent primary GH repair using our described technique. At one-year follow-up, one patient required repeat glanspexy for recurrent bothersome GH and a second patient developed a suture granuloma at the glanspexy incision requiring unilateral cylinder explant. Our modified glanspexy technique can be used to correct GH in any direction and is a useful tool for the prosthetic surgeon's armamentarium., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Purpose: Our aim was to determine if the AUA-recommended prophylaxis (vancomycin + gentamicin alone) for primary inflatable penile prosthesis surgery is associated with a higher infection risk than nonstandard regimens., Materials and Methods: We performed a multicenter, retrospective study of patients undergoing primary inflatable penile prosthesis surgery. Patients were divided into those receiving vancomycin + gentamicin alone and those receiving any other regimen. A Cox proportional-hazards model was constructed adjusted for major predictors. A subgroup analysis to identify the appropriate dosage of gentamicin was also performed., Results: A total of 4,161 patients underwent primary inflatable penile prosthesis placement (2,411 received vancomycin + gentamicin alone and 1,750 received other regimens). The infection rate was similar between groups, 1% vs 1.2% for standard vs nonstandard prophylaxis. In the multivariable analysis, vancomycin + gentamicin (HR: 2.7, 95% CI: 1.4 to 5.4, P = .004) and diabetes (HR: 1.9, 95% CI: 1.03 to 3.4, P = .04) were significantly associated with a higher risk of infection. Antifungals (HR: 0.08, 95% CI: 0.03 to 0.19, P < .001) were associated with lower risk of infection. There was no statistically significant difference in infection rate between weight-based gentamicin compared to 80 mg gentamicin (HR: 2.9, 95% CI: 0.83 to 10, P = .1)., Conclusions: Vancomycin + gentamicin alone for antibiotic prophylaxis for primary inflatable penile prosthesis surgery is associated with a higher infection risk than nonstandard antibiotic regimens while antifungal use is associated with lower infection risk. A critical review of the recommended antimicrobial prophylactic regimens is needed. Prospective research is needed to further elucidate best practices in inflatable penile prosthesis antimicrobial prophylaxis.

Introduction: Evidence has demonstrated that tumor size is related to adverse oncologic outcomes in small renal tumors (≤ 4 cm). We evaluated the association of adverse pathologic features (APF) with tumor size and survival in patients with a small renal mass (SRM)., Materials and Methods: We retrospectively reviewed the pathologic characteristics of 380 surgically resected SRMs from a single institution. APFs included lymphovascular invasion, coagulative necrosis, sarcomatoid/rhabdoid features, papillary type II histology, and perinephric fat/renal sinus invasion. The number and type of APFs were compared with tumor size. Survival analysis was performed using the Kaplan-Meier method., Results: There were 244 (64.2%) males and 136 (35.8%) females. The median age was 61 years, and median tumor size was 2.7 cm. The median follow up time was 65 months. A significant association was found between tumor size and presence of APFs (p = 0.018). At least 1 APF could be found in 22%, 32%, 36%, and 49% of tumors ≤ 1 cm, 1 cm-2 cm, 2 cm-3 cm, and 3 cm-4 cm, respectively. There were no differences in overall survival or recurrence free survival when compared by tumor size at diagnosis (p = 0.22 and 0.15 respectively). Compared to patients with ≤ 1 APFs, disease specific survival was worse for patients with ≥ 2 APFs (p < 0.002)., Conclusion: Our data support that aggressive tumor biology in a SRM is associated with greater size. In patients with a SRM, the decision to pursue active surveillance and the trigger for intervention should take tumor size and APFs into consideration as this may have future oncologic implications.