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The history of the development of today's very dependable three-piece inflatable penile prostheses is fascinating. In its infancy, the three piece was plagued with frequent revisions and a relatively complex insertion and consequently unitary and two-piece prostheses flourished with the implanting urologists. While the surgery was less difficult because these devices did not require the dreaded reservoir insertion, they often proved unsatisfactory to patients in flaccidity, erection and longevity. By the turn of this century all of the unitary and two-piece inflatables had been withdrawn from the market except the Ambicor two-piece inflatable penile prosthesis. This paper covers the history of the various unitary and 2-piece inflatable models before examining a critical question: is the Ambicor 2-piece still a needed implant today?

The artificial urinary sphincter, known as AMS 800, has been the gold standard for treating moderate to severe stress urinary incontinence in males for 40 years. Yet, the number of sphincters done globally is quite small and the majority of urologists doing them are infrequent implanters. Estimates for 2019 showed half of implanters did only one implant that year and worldwide only around 13,000 implantations were performed. The traditional two-incision technique of perineal exposure for cuff placement and abdominal incision for pump and pressure regulating balloon persists as the most common technique to surgically place an artificial urinary sphincter. Present estimates are that upwards of 80% are done via the perineal approach and that approach is the highly favored incision of large volume centers. The scrotal one-incision approach was invented by Wilson 20 years ago and was aimed at making the implantation of a sphincter quicker, easier and safer for the occasional implanter. These physicians perform 1-2 devices per year, comprise 60% of implanters who perform the surgery yearly, and implant 22% of all implanted devices. Our article targets these infrequent inserters discussing the history of the two techniques and what the authors have learned about the advantages and hazards of the one scrotal incision procedure over the last two decades.

Introduction Modern penile implants were introduced to the marketplace more than 40 years ago and were the first effective treatment of organic erectile dysfunction. The original devices were effective in restoring erections but were prone to early malfunction. Aim This article describes the penile implants tested in clinical trials and chronicles the changes implemented by penile implant vendors in perfecting their products to improve device longevity, ease of use, and patient satisfaction. Methods The narrative is divided into six sections, three for inflatable implants and three for the semirigid rod-type devices. The inflatable category includes the three-piece inflatable, the two-piece inflatable, and unitary or self-contained inflatable prostheses. The semirigid rod types consist of soft semirigid, malleable, and mechanical implants. Main Outcome Measures These include ease of use, longevity of function, and patient and partner satisfaction. These parameters determine the success or failure of a particular product. Results Those devices producing the best rigidity and flaccidity (ie, the three-piece inflatables) have increased in popularity and hold the largest market share. Implants not performing well in providing these two qualities have a smaller sales volume or have been discontinued. Conclusion Penile implants have provided a predictable and reliable way for restoring erections in those patients in whom more conservative measures have failed. Vendors have reinforced or eliminated areas of these devices that were prone to wear and have made them easier to operate. The currently available models have very good durability and patient satisfaction.

Background Diabetic patients may be more prone to penile-implant infections than other men. Objective We sought to determine whether revision surgeries due to infection were less common in diabetic men after implantation of an inflatable penile prosthesis (IPP) impregnated with minocycline and rifampin (M/R) versus a nonimpregnated prosthesis. Design, setting, and participants Infection-related revisions for M/R-impregnated and nonimpregnated implants were compared during a retrospective review of patient-implant and removal data recorded in the manufacturer's database. The data set included men with diabetes as an etiology of erectile dysfunction and who were implanted with their first IPPs between 2001 and 2008. Intervention All men received three-piece IPPs. Measurements The number of first revisions due to infection reported at any time during the study period were summarized for each group. Freedom from infection-related revisions for initial M/R-impregnated implants were compared to nonimpregnated implants with ≤84 mo of follow-up using life-table survival analysis. Infection-free survival was also compared for diabetics versus nondiabetics. Results and limitations Mean age was 59.1 yr for the 6071 diabetic men in the M/R-impregnated group. The nonimpregnated group included 624 diabetics with a mean age of 57.6 yr. Initial revisions due to infection were reported for 1.47% of M/R-impregnated versus 4.17% of nonimpregnated implants. At 7 yr, the rate of infection-related revisions was significantly lower for M/R-impregnated (1.62%) than for nonimpregnated implants (4.24%; log-rank p p =0.0052). Conclusions This long-term evidence from the largest known database of diabetic IPP recipients establishes that the use of an antibiotic-impregnated IPP can decrease revisions due to infection. Reducing the incidence of this devastating complication represents a significant medical advance in erectile restoration for diabetic patients.

Although some studies suggest that most infections associated with inflatable penile prosthesis implantation develop within year 1 after surgery, device related infections have been reported 5 years after implantation or later and the infection risk with time is not well characterized. We previously reported a statistically significantly lower infection rate for original inflatable penile prostheses impregnated with antibiotic treatment with minocycline and rifampin vs nonimpregnated inflatable penile prostheses at 1-year followup. Long-term data are now available on infection revision after initial implantation of antibiotic impregnated vs nonimpregnated prostheses.We retrospectively reviewed patient information forms voluntarily filed with the manufacturer after the initial implantation of more than 39,000 inflatable penile prostheses to compare the revision rate due to infection for antibiotic impregnated vs nonimpregnated implants between May 1, 2001 and December 31, 2008. Life table analysis was used to evaluate device survival from revision surgery.On life table survival analysis initial revision events due to infection were significantly less common in the impregnated vs the nonimpregnated group (log rank p0.0001). At up to 7.7 years of followup 1.1% of 35,737 vs 2.5% of 3,268 men with impregnated vs nonimpregnated implants underwent initial revision due to infection.To our knowledge this long-term outcome analysis provides the first substantial clinical evidence of a decrease in costly infection related revision using an antibiotic impregnated inflatable penile prosthesis.

Penile implants remain a mainstay in treating erectile dysfunction (ED). Despite competing therapies, the number of devices implanted has increased each year. Implant infection continues to be a problem, but recent advances in antibiotic-coated devices and copious use of antiseptic irrigation have reduced the incidence. When confronted with an implant infection, a salvage procedure has gained acceptance that involves immediate replacement of the infected implant after antiseptic washing of the implant cavities. This procedure minimizes shortening of the implant erection and facilitates placement of cylinders in corporal bodies. Among patients and health care providers, satisfaction with penile implant remains the highest for all ED treatments.

Penile implants became popular with the introduction of effective models more than 30 years ago. Today they play a secondary but definitive role in the treatment of erectile dysfunction at times when more conservative therapies have failed. Improvements in reducing the incidence of infection, treating infection with antiseptic washes, enhancing device longevity, and instituting new techniques to manage complicated implantation procedures have made them more acceptable to patients. Although penile implants are the least often chosen and most invasive treatment for erectile dysfunction, they have the highest satisfaction rate--in the range of 80% to 90%--among both patients and partners.

Introduction There are few published guidelines for the management of sexual dysfunctions in men and women, despite the prevalence and lack of attention to these problems. Disorders of sexual function in men include erectile dysfunction, orgasm/ejaculation disorders, priapism, and Peyronie's disease. Aim To provide evidence-based and expert-opinion consensus guidelines for the clinical management of men's sexual dysfunctions. Methods An International Consultation in collaboration with major urological and sexual medicine societies assembled over 200 multidisciplinary experts from 60 countries into 17 consultation committees. Committee members established the scope and objectives for each chapter. Following intensive review of available data and publications, committees developed evidence-based guidelines in each area. Main Outcome Measure New algorithms and guidelines for assessment and treatment of men's sexual dysfunction were developed. The Oxford system of evidence-based review was systematically applied. Expert opinion was based on systematic grading of the medical literature, in addition to cultural and ethical considerations. Results Recommendations and guidelines for men's sexual dysfunction are presented. These guidelines were developed as evidence-based, patient-centered, and multidisciplinary in focus. For the clinical assessment and diagnosis of ED, a basic evaluation was recommended for all patients, with optional and specialized testing reserved for special cases. A new treatment algorithm is proposed. This algorithm provides a clinically relevant guideline for managing ED in the large majority of men. New treatment guidelines and algorithms are provided for men's orgasm and ejaculation disorders, including premature ejaculation, retrograde and delayed ejaculation. Finally, expert opinion-based guidelines for the clinical management of priapism and Peyronie's disease are provided. Conclusions Additional research is needed to validate and extend these guidelines. Nonetheless, this summary encompasses the recommendations concerning men's sexual dysfunctions presented at the 2nd International Consultation on Sexual Medicine in Paris, France, June 28–July 1, 2003.

Penile implants hold a major position in the treatment algorithm for patients with erectile dysfunction who find medications and vacuum erection devices ineffective or unsatisfactory. As with any surgical procedure, adverse events may occur. The infection rate associated with implant placement has been lowered to the range of 1 % or less due to multifactorial improvements including no-touch techniques, the use of antibiotic-coated devices, and improved quality measures in the operating room. Urologists have been proactive in employing techniques and procedures which minimize loss of erectile length, hence enhancing patient satisfaction. Flat reservoirs have been developed and techniques of placing these to avoid problems in the space of Retzius have reduced complication rates as well. Device reliability has improved to the point that penile implants are among the most durable mechanical surgical products that contribute to patient and partner satisfaction, which is by far the greatest among all the treatments of erectile dysfunction.

This procedure may be considered when inserting a semi-rigid prosthesis in men with a scrotal web, requiring only a single scrotal skin incision to achieve both subcoronal corporotomies and a reduction scrotoplasty. The reduction scrotoplasty procedure might enhance patient perception of penile length and improve overall satisfaction with penile implant surgery. Using the scrotal skin incision prevents the need for circumcision but allows for minimal-sized subcoronal corporotomies, and permits a multilayered closure with nonoverlapping suture lines. Artificial erection is developed with saline via butterfly needle using a penile tourniquet. A penoscrotal incision is used to avoid circumcision and to remove scrotal web Typical location of incision for circumcision Scrotal web

Almost four decades ago, modern penile implants were introduced as a treatment of erectile dysfunction. Infection associated with placement of an implant is a feared complication, and fortunately, has become less common due to a number of measures, including antibiotic-coated devices and chlorhexidine–alcohol skin preparation. When an infection around an implant occurs, the device should be removed. An option, termed a salvage (or rescue) procedure, is cleansing the wound with a series of antiseptic solutions and replacing a new prosthesis during the same procedure, with success in the range of 85%. The alternative is to return at a later date to replace the implant. However, the latter approach is associated with a difficult insertion, a shorter erection, and a less satisfied patient. Most patients elected the salvage approach because they were highly motivated to continue sexual activity to have the implant placed initially.

Introduction Urinary incontinence impairs sexual functioning and sexual satisfaction. Traditional artificial urinary sphincter (AUS) implantation requires perineal incision for cuff placement and a second inguinal incision for reservoir and pump placement. We believed AUS could be placed easier and quicker through one scrotal incision. Aim In an effort to effect more proximal placement of the cuff while keeping the advantages of the one scrotal incision technique, we report enhancements to the original surgical technique. Methods Thirty patients have been operated upon using the enhanced technique. A modification of the SKW retractor system (AMS) facilitates deep bulbar exposure. Twenty patients were first time implantations and 10 were revisions with five of the revisions having had the original AUS placed by traditional two-incision technique. Two of the first time AUS patients received an inflatable penile prosthesis through the same incision. Main Outcome Measures We evaluated site of cuff placement, sizes of cuffs used, postoperative continence status. Results All of the virgin AUS required dissection of the bulbocavernosus muscle prior to cuff placement. In scrotally placed revisions, replacement cuffs were situated considerably proximal (4.5–7.5 cm) to the original cuff site. The perineal placed revisions were accomplished through a scrotal incision with replacement of two cuffs in the same site and the three other patients immediately distal. No intraoperative complications were seen. One patient developed scrotal hematoma requiring drainage. Only 15 patients are available for follow-up and all are socially continent (one pad or less). Conclusions Transscrotal approach is used safely and efficiently for penile implants and AUS implantation. The new enhancements to the one-scrotal incision technique allow more proximal cuff placement as evidenced by the bulbocavernosus muscle dissection and use of larger cuffs. Continence rate is similar to rates achieved with perineal placement of cuff found in the literature. Wilson SK, Aliotta PJ, Salem EA, and Mulcahy JJ. New enhancements of the scrotal one incision technique for placement of artificial urinary sphincter allow proximal cuff placement.

Placement of an inflatable penile prosthesis in a patient with scarred corporal bodies secondary to priapism or removal of a previously infected implant is a formidable surgical challenge; use of downsized implants has improved chances of successful reimplantation. Nevertheless, patients are frequently dissatisfied with the resulting short penises.This study investigates the use of downsized inflatable penile prosthesis cylinders as tissue expanders in patients with corporal fibrosis.Corporal length and width were calibrated before implantation of downsized prostheses and after 1 year of their use as tissue expanders.Thirty-seven patients had insertion of Mentor Narrow Base (18), AMS CXM (9), or AMS CXR (10) into scarred corporal bodies. Etiology was previously infected and removed implant (29) or priapism (8). In each of these cases it was not possible to dilate to 12 mm in order to place standard-sized cylinders. Patients were encouraged to inflate their implant for up to 3 hours daily. After several months intracorporal stretching occurred. The patients were reoperated; corporal length and width were recalibrated.Upon reoperation, it was possible to pass dilators of 12 mm width proximally allowing the substitution of standard-sized AMS 700 CX (23), Mentor Alpha 1 (10), or Mentor Titan (2). Additionally, corporal length measurements in the previously infected patients increased an average of 2.2 cm allowing placement of longer cylinders. Although priapism patients did not show this phenomenon of corporal lengthening, the implant space widened enough to permit replacement with standard-size cylinders improving girth, rigidity, and appearance.Wider and sometimes longer cylinders can be substituted in patients with corporal fibrosis that required implantation with downsized cylinders because of fibrotic corpora. Prolonged inflation over an 8- to 12-month period results in expansion of the cylinder cavity, permitting standard-sized cylinders in all patients.

Introduction Penile prostheses, introduced as the first effective organic treatment for erectile dysfunction over three decades ago, have an important role in the treatment of erectile dysfunction when other nonprosthetic treatment options have proven unsatisfactory. Although they are the least chosen and most invasive treatment option, they have the highest satisfaction rate of all available ED options and provide a predictable and reliable result. Aim To provide recommendations/guidelines concerning state-of-the-art knowledge for utilization of the penile prosthesis in the management of men with erectile dysfunction. Methods An International Consultation in collaboration with the major sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. There were 10 experts from seven countries concerning the Penile Implant for Erectile Dysfunction. Main Outcome Measure Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate. Results Recommendations/guidelines for penile prosthesis (hydraulic, semi-rigid and soft silicone) insertion for management of men with erectile dysfunction were updated. Consensed issues included: criteria for patient selection, informed consent procedures, strategies for preoperative preparation, operative incisions/technical considerations and outcome results in terms of patient satisfaction and device survival. Updated information was reviewed concerning therapies for device failures, device insertion in scarred corporal bodies and strategies for managing implant infections. Conclusions There is a need for more research in developing management strategies for insertion of penile prostheses in men with ED.

We present 5 cases involving reinsertion of an artificial urinary sphincter after either erosion or infection. All 5 patients now have socially acceptable urinary continence.

Objectives To assess the efficacy and safety of the double-cuff artificial urinary sphincter over a long-term period. Methods Ninety-five patient charts were reviewed from December 1986 to November 1995. Data on the degree of urinary incontinence and complications were compiled and tabulated. Results There were 10 cuff erosions (10.5%) and one infection (1.1 %) requiring removal of the double-cuff system, with one death from unrelated causes. Two patients in the erosion group had a double-cuff system reinserted at a later date. Eighty-six patients have a double-cuff system, with 97.6% remaining dry. Conclusions A tandemly placed double-cuff artificial urinary sphincter is safe and effective in the treatment of severe postprostatectomy urinary incontinence.

Purpose: We describe our experience with salvage of the infected penile prosthesis at initial presentation in 11 patients.Materials and Methods: All patients with prosthesis infection who presented since 1991 were considered for salvage surgery. Contraindications to a salvage operation included necrotic infections, diabetic patients with purulence in the corporeal bodies, rapidly developing infections and erosion of the device cylinders.Results: In 1 patient in this group a salvage attempt was repeated after re-infection, for an overall success rate of 91 percent. Mean followup for the group was 21 months (range 9 to 42). Staphylococcus epidermidis was the infecting organism in 75 percent of out patients.Conclusions: Our experience demonstrates the safety and advantages of the immediate salvage technique.

The research literature on the employment of various vasoactive drugs to induce penile erection has largely examined assessment and treatment techniques. One study specifically examined the duration of erection, or "orgasm latency," of the drug-induced erection. However, it did not determine the relation of this duration to pre-impotence duration. The intent of the present investigation was to make this determination. Subjects at a urology department impotence clinic were asked to estimate orgasm latency prior to impotence and with papaverine-induced erection. The mean orgasm latency prior to impotence was 9.9 minutes; with papaverine, 15 minutes. It is concluded that papaverine injection not only causes an erection but makes it last longer than naturally occurring erections.

Stress urinary incontinence in the male patient has been successfully treated with the artificial urinary sphincter. However, approximately 15% of the patients treated are still significantly wet despite some improvement with this device. These patients usually are almost totally incontinent before artificial sphincter implantation. Of 15 such patients 80% were rendered satisfactorily dry by adding a second sphincter cuff around the bulbous urethra. This double cuff technique increases the success rate with the AMS800 sphincter to greater than 95%.

Purpose: We reviewed our series of patients with an AMS700 Ultrex* penile prosthesis whose erectile deformities were corrected by replacement with AMS700CX cylinders.American Medical Systems, Minnetonka, Minnesota.Materials and Methods: Ultrex cylinders were replaced by AMS700CX cylinders in 7 men with erectile deformities.Results: Deformities were corrected successfully in all 7 patients. The penis is completely straight in 6 patients, while a mild 30-degree ventral curvature is present in 1.Conclusions: Erectile deformities with the AMS700 Ultrex penile prosthesis can be repaired successfully by replacement with the AMS700CX cylinders.

Hyperprolactinemia is a recognized cause of impotence. The discovery of elevatedprolactin levels in impotent men is very important since pharmacotherapy in this instance is highly successful. We review our experience with prolactin determinations in impotent men, and a population is defined that may benefit from routine prolactin determination. In our experience, the predominant symptom associated with hyperprolactinemia in men is loss of libido.

The Duraphase**Dacomed Corp., Minneapolis, Minnesota. penile prosthesis was implanted in 63 patients at 4 investigative sites during clinical trials. This device is a semirigid rod that is bendable and provides good support to the erection. Mechanical complications included 4 instances of cable breakage rendering the device nonfunctional. Of 57 patients questioned 55 were pleased with the results after 4 months. Ease of insertion and exceptional bendability are other features that make this device attractive.

A series of 7 patients undergoing percutaneous radiofrequency sacral rhizotomy to change a hyperreflexic to an areflexic bladder was reported in 1978. A patient from this original series was seen for treatment nine years later with successful preservation of good vesical capacity enabling him to use Crede maneuver and intermittent catheterization to evacuate his urine. In addition, there has been no recurrence of symptoms of autonomic dysreflexia during that period.

We report the results of a series of 79 patients who underwent placement of a unitary component penile prosthesis via a ventral penile skin incision in conjunction with distal ventral corporotomies. This approach facilitates the placement of semirigid and inflatable devices, and eliminates potential pitfalls of other incisions by limiting corporotomy length, avoiding dissection around neurovascular structures and allowing a multilayered closure with nonoverlapping suture lines.

We studied 9 patients with indwelling urethral catheters or who were using intermittent clean catheterization and who had received a penile prosthesis. A 56 per cent (5 of 9) incidence of urethral erosion was found in this population. Urethral erosion was a late complication, 80 per cent (4 of 5) of the time in our series, that usually presented several months after implantation of the prosthesis. We believe that the etiological factors that contributed to this disastrous complication were the friction and inflammation associated with catheterization. We currently construct a perineal urethrostomy in patients who desire a penile prosthesis and who perform intermittent catheterization. If intermittent catheterization is not feasible, insertion of a suprapubic tube is recommended. We additionally recommend insertion of an inflatable penile prosthesis, since this type is relatively soft most of the time and will not cause as much pressure at the end of the penis. Since instituting these procedures we have not encountered any erosion.

A technique for proximal reconstruction of the corpora cavernosa using a synthetic vascular graft fashioned into a cup is described. In 6 cases this procedure was critical and successful in the repair of the corpora cavernosa associated with the placement of a penile prosthesis.

The symptoms and physical findings in patients with transitional cell carcinoma of the prostate were similar to those in patients with prostatic adenocarcinoma. Usually the neoplasm was poorly differentiated and advanced when the diagnosis was first established. Osseous metastases were commonly osteolytic. Frequently, elevations of serum alkaline or acid phosphatase levels were associated with metastasis. Tartrate-inhibited fractions of the serum acid phosphatase were not elevated. The best form of treatment is radical ablation of the prostate and radiation therapy is next best. Because these neoplasms are not hormonally dependent, hormonal manipulation is not indicated. Prognosis for patients with this malignancy is guarded.

A case of massive leg edema resulting from overdistention is described. Remission of symptoms followed bladder decompression. Venous obstruction as the etiologic factor is supported by impedance plethysmography data before and after bladder decompression.

✓ Ten patients with neurogenic detrusor hyperreflexia were treated by percutaneous radiofrequency sacral rhizotomy. All had low-threshold involuntary micturition. The bladder capacity of seven patients was increased to over 290 cc during a follow-up interval of 3 to 18 months. This convenient percutaneous procedure is particularly suited for controlling detrusor hyperreflexia, which has frequent failures of initial treatment and late recurrence of symptoms.

The mechanical activity of the anal sphincter can be translated into electrical activity and recorded on graph paper or an oscilloscope. The activity of the anal sphincter may be extrapolated to activity of the external urethral sphincter because both are striated muscles innervated by the pudendal nerve that arises from S-2, S-3, and S-4. Stimulation of these nerves causes contraction of the sphincter muscles, and a deflection of the recording device occurs. This technique was employed intraoperatively in monitoring operations on the conus medullaris and sacral nerve roots in 10 patients with spinal dysraphism (age range, 3 weeks to 15 years). Their diagnoses were tethered conus, 4; lipomeningocele, 3; spinal hamartoma, 1; syringocele, 1; and sacral arachnoiditis, 1. With general anesthesia, and the patient in the prone position, an electrode-containing anal plug was inserted or two needle electrodes were inserted into the anal sphincter muscle. The electrodes were connected to the electromyography recording stylus of the urodynamic bladder diagnostic unit. During the spinal operation, whenever a structure could not be identified clearly, it was stimulated with the disposable electrical stimulator and, if oscillations of the stylus occurred (indicating contraction of the anal sphincter), the structure was preserved. This technique permitted spinal operations in these 10 patients without changes in neurological or urological function.

An infectious complication involving placement of a penile prosthesis is a disastrous event. A review of more than 300 devices placed between 1979 and 1984 at this center reveals an infectious complication rate of 8.3 per cent. Perioperative risk factors predisposing to infection included reoperation for technical failures, inadequate antibiotic coverage (specifically for Staphylococcus epidermidis), failure to perform a circumcision at the time of placement in uncircumcised patients and simultaneous placement with an artificial urinary sphincter device. No group of patients nor type of prosthesis was more susceptible to the development of a postoperative infection.

A case of lymphangioma of the scrotum is reported. The presenting symptoms of this unusual tumor are an increase in size of the lesion with tenderness or persistent lymphorrhea. Total surgical excision is the definitive treatment.

A 44-year-old man suffered a Busehke-Loewenstein tumor that was treated by distal penectomy. Ultrastructurally, this tumor showed widened intercellular spaces, prominent microvilli, decreased numbers of and incompletely developed desmosomes, decreased tonofilaments, cytoplasmic dense bodies, enlarged nucleoli and annular nuclear bodies. These ultrastructural features are quite similar to those of squamous carcinoma but are dissimilar to those of condyloma acuminatum and, to a lesser extent, verrucous carcinoma. These data suggest that electron microscopy may be useful in differentiating the neoplastic Busehke-Loewenstein tumor from large condyloma acuminatum.

A case of massive hydronephrosis secondary to a ureteral valve was discovered upon evaluation of mild trauma. The orderly diagnostic studies, including ultrasonography and antegrade pyelography, led to the correct diagnosis and appropriate therapy. Ultrasonography as a diagnostic tool in urology is discussed and characteristics of the 18 cases of ureteral valves reported to date are reviewed.

Sixty-two patients, age twelve years and under, were treated for incontinence due to neurogenic bladder secondary to spina bifida (58) or trauma (4) with a follow-up period of three to thirty-two months (mean, ten months). In early life, patients were managed with the Crede maneuver (18 patients). Older children were managed with intermittent clean catheterization (44 patients) with or without pharmacologic agents. Continence was achieved with intermittent clean catheterization in 77 per cent, thus enabling these children to be more acceptable to their peers and in many cases attend schools from which they had previously been excluded because of urinary incontinence. With the Crede maneuver, renal deterioration was noted in 11 per cent on follow-up IVP, and in 2 per cent of the patients on intermittent clean catheterization. Recurrent asymptomatic bacteriuria occurred in 33 per cent of those with the Crede maneuver and in 55 per cent of the patients using intermittent clean catheterization. The use of antibiotic bladder irrigations reduced this incidence to 5 per cent. All patients with renal deterioration except one responded to intermittent clean catheterization; this patient was treated with cutaneous vesicostomy. Urodynamic assessment was performed in 15 patients, and this diagnostic tool assisted in the therapeutic management of these children.

Varying degrees of vesicoureteral reflux in 193 ureters were followed conservatively. Prediction of in which ureters reflux would stop could not be made from an evaluation of the configuration and position of the orifice, the presence or absence of infection, the grade of the reflux or the age of the patient. The management of such patients is discussed.

We encountered 7 cases of significant penile curvature after placement of an inflatable penile prosthesis. In 3 cases curvature was present preoperatively owing to Peyronie’s disease and penile trauma, while in 4 it developed postoperatively owing to improper penile positioning. Curvature was straightened successfully by removal of small elliptical wedges of tunica albuginea of the corpus cavernosum from the convex surface of the curve and closing the defects created with 3-zero polydioxanone sutures. A subjectively gratifying result was achieved in each instance.

Recently the triple-layered CX or controlled expansion cylinders were introduced, which consisted of a middle layer of expandable monofilament knitted polypropylene-like material sandwiched between 2 silicone layers. These cylinders provide uniform nonaneurysmal expansion to a girth of 18mm. CX cylinders were implanted in 34 patients for a variety of situations. The results have been gratifying in each case and patient satisfaction has been high.

The Hydroflex* penile prosthesis has been implanted in 100 patients with a 1 to 3½-year followup. Patient dissatisfaction among the earlier implants was high due to inadequate girth and support during intercourse and difficulty with inflation and deflation of the device. As experience was gained in patient selection and sizing of the cylinders, patient satisfaction improved considerably. The mechanical reliability of this device has been good to date.