-
[show abstract]
[hide abstract]
ABSTRACT: Congenital penile curvature results from disproportionate development of the tunica albuginea of the corporal bodies and is not associated with urethral malformation. Patients usually present after reaching puberty as the curvature becomes more apparent with erections, and severe curvature can make intercourse difficult or impossible, at which point surgical repair is recommended. Excellent outcomes can be expected with surgical intervention. The three most commonly used repair techniques are the original Nesbit procedure, modified Nesbit procedure, and plication. Nesbit and modified Nesbit techniques require that an incision is made in the tunica albuginea while plication techniques utilize plicating sutures without an incision. While Nesbit and modified Nesbit techniques are more complex operations, these generally result in less recurrences and more satisfactory outcomes as opposed to the quicker and simpler plication technique.
Current Urology Reports 06/2012; 13(4):290-7.
-
[show abstract]
[hide abstract]
ABSTRACT: The male transobturator AdVance™ sling is a viable option for mild to moderate post-prostatectomy incontinence. As this treatment is relatively new, our study provides an analysis of efficacy through patient reported outcomes and pad use.
A telephone survey and chart review were conducted on all patients receiving a sling before 2010 by either of 2 surgeons at a large academic institution. The survey included the Patient Global Impression of Improvement and Severity instruments, pad use characteristics before and after sling surgery, and items assessing durability of efficacy. Patient determined (subjective) success was very much or much better on the Patient Global Impression of Improvement without subsequent incontinence therapy. Quantitative success was defined as a decrease to 2 or fewer pads per day. We assessed therapeutic durability in a subanalysis of patients interviewed twice, first in a prior study.
From initial office followup to 2 years, quantitative success decreased from 87.3% to 62.5% and pad use doubled from a mean±SD of 0.8±1.7 to 1.7±2.5 pads per day. Patient determined success was 53.6% at 2 years. A subgroup of 25 patients interviewed at 7 and 29 months after sling surgery had quantitative success significantly decrease by 20% (p=0.03), subjective success decrease by 4% (p=0.56) and pad use significantly increase (p=0.01) from 1.4±2.2 to 2.3±3.2 pads per day.
Most patients receiving the AdVance sling did see improvement in post-prostatectomy incontinence and a decrease in pad use, but in 20% of patients this benefit decreased with time. Nevertheless, patients remained satisfied and perceived the treatment as successful.
The Journal of urology 02/2012; 187(4):1331-5. · 4.02 Impact Factor
-
Drogo K Montague
[show abstract]
[hide abstract]
ABSTRACT: Penile prosthesis implantation, the oldest of the modern treatments for erectile dysfunction (ED), still plays an important role despite the advent of less invasive alternatives. For some men with ED, penile prosthesis implantation is the only effective or acceptable treatment. Penile prosthesis implantation remains a viable option in the contemporary management of ED as evidenced by annual penile prosthesis implantation cases in the United States rising from 17,540 in 2000 to 22,420 in 2009. Improvements in prosthesis design and implantation techniques have resulted in significant increases in device survival and patient satisfaction.
Urologic Clinics of North America 05/2011; 38(2):217-25. · 1.82 Impact Factor
-
Drogo K Montague
Nature Reviews Urology 04/2010; 7(4):187-8. · 4.41 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Objective measures show the AdVance() sling provides some benefit in post-prostatectomy incontinence. To our knowledge no validated, patient determined outcomes have been used to assess this procedure. We described the patient perceived effectiveness and postoperative complications.
A retrospective chart review was followed by a telephone survey consisting of the Patient Global Impression of Improvement, Patient Global Impression of Severity, and questions about recommending the surgery, daily pad use and complications. Successful outcomes were Patient Global Impression of Improvement responses of very much better or much better without further incontinence treatment. Objective success is defined as pad-free or a reduction to 2 or less pads daily.
A total of 35 patients received the sling a median of 25 months after prostatectomy. Telephone surveys were administered a mean of 35 weeks after the sling procedure and 33 patients were contacted. Of the cases 18 (51.4%) and 21 (60%) were patient determined and objective successes, respectively. Of the patients with subjective treatment failure 3 would recommend the surgery to a friend and 12 were undecided or would not. Furthermore, no patients with subjective treatment failure were pad-free and 10 (58.8%) had pads that were mostly wet on changing. For the entire population a reduction in median daily pad use from 2.5 to 1 was observed as well as a strong association (p <0.01) between Patient Global Impression of Improvement and Patient Global Impression of Severity responses. Three individuals pursued further treatment with bulking agents and 3 had retention that resolved.
The AdVance sling is safe, and demonstrates similar subjective and objective outcomes. The procedure can benefit some individuals with post-prostatectomy incontinence and, therefore, may be another treatment option for this condition.
The Journal of urology 11/2009; 183(1):247-52. · 4.02 Impact Factor
-
Drogo K Montague
European urology 09/2009; 56(6):934-5; discussion 935-6. · 7.67 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Penile prosthesis implantation is suitable treatment for men with erectile dysfunction when nonsurgical treatment options fail or are otherwise unsatisfactory. Three-piece inflatable penile prostheses closely approach the ideal of producing normal penile flaccidity and erection. Nevertheless, even in men with normal corpora cavernosa, many report their prosthetic erection is shorter than their former natural erection. This is due to the lack of glans tumescence and the use of penile cylinders, which only expand in girth. Using girth- and length-expanding cylinders can decrease the loss of penile length frequently seen with prosthesis implantation. Some penile prosthesis recipients have abnormal corpora following radical prostatectomy or after removal of an infected penile prosthesis, or as the result of Peyronie's disease, obesity, or ischemic priapism. In these men with abnormal corpora, associated penile-lengthening procedures can be combined with penile prosthesis implantation. However, experience is limited with these combined procedures.
Current Urology Reports 12/2008; 9(6):483-6.
-
[show abstract]
[hide abstract]
ABSTRACT: Some surgeons will not offer a three-piece inflatable penile prosthesis (IPP) to patients who have undergone retropubic surgery because of a perceived increase in intraoperative risk during reservoir placement into the retropubic space.
Of 942 consecutive patients undergoing IPP placement from 1986 to 2006, 115 had undergone radical prostatectomy before placement of an American Medical Systems Ultrex (n = 73), CX (n = 34), or CX-M (n = 8) device. Intraoperative and follow-up data for all patients were collected in an institutional review board-approved database.
All 115 IPP placements were completed as planned and without intraoperative complications, including no injury to the bladder or iliac vessels. An increased amount of scarring often made the fascia more difficult to perforate, but blind entrance into the retropubic space was performed successfully in all cases. Three prosthetic infections (2.6%) and eight mechanical failures (7%) occurred during a median follow-up of 3.3 years. The estimated probability of no infection or mechanical failure at 3 years in this patient cohort was 97.0% and 95.5%, respectively.
Retropubic placement of the reservoir of a three-piece IPP was accomplished without intraoperative complications in 115 consecutive postprostatectomy patients, with more than 90% of devices free of mechanical failure at 5 years. Because three-piece IPPs can be placed safely and have been associated with the greatest patient and partner satisfaction rates, we do not believe that prostatectomy should be a contraindication for placement of the retropubic reservoir of a three-piece IPP through a transverse scrotal incision.
Urology 10/2007; 70(3):539-42. · 2.43 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We determined the long-term mechanical reliability of the AMS 700CX/CXM inflatable penile prosthesis in men with organic erectile dysfunction.
A total of 455 consecutive patients underwent implantation of an AMS 700CX/CXM inflatable penile prosthesis between April 1986 and July 2004. Using telephone interviews and mailed questionnaires we obtained followup on 380 of 455 patients (83%). Data were obtained with regard to 2 end points, including overall failure and mechanical failure caused by any malfunctioning component.
Followup was 0.49 to 231 months (median 91.5). Ten-year Kaplan-Meier estimates of overall and mechanical survival were 74.9% (95% CI 69.2 to 81.1) and 81.3% (95% CI 75.7 to 87.3), respectively.
To our knowledge this is the longest followup of any inflatable penile prosthesis showing overall and mechanical survival by Kaplan-Meier estimates.
The Journal of Urology 01/2007; 176(6 Pt 1):2599-601; discussion 2601. · 3.75 Impact Factor
-
Nature Clinical Practice Urology 07/2006; 3(6):290-1. · 4.07 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Penile prosthesis implantation in men who have fibrotic corpora as the result of ischemic priapism or previous removal of an infected penile prosthesis poses a significant challenge to the implanting surgeon. We describe a new technique, corporeal excavation, to meet this challenge.
The operative approach is through an inverted T penoscrotal incision that affords exposure of nearly the entire corpus cavernosum on each side. Extended corporotomies are made on the ventral aspect of each corpus cavernosum, and a plane of dissection between the fibrotic corporeal tissue and the inner surface of the tunica albuginea is established, resulting in core removal of nearly all fibrotic intracorporeal tissue. Cylinders are laid into the empty corporeal bed, and the tunica albuginea is closed primarily. Nine patients were identified who had undergone this procedure. The operative notes and medical records were reviewed, and telephone interviews were done for follow-up when patients had not been recently seen in the clinic.
Successful outcomes were achieved in all 9 patients. Corporeal excavation permits penile prosthesis implantation in men with severe intracorporeal fibrosis usually resulting from priapism or previous removal of infected penile prostheses.
Urology 06/2006; 67(5):1072-5. · 2.43 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Artificial urinary sphincter (AUS) implantation is most often performed to treat urinary incontinence following radical or
subtotal prostatectomy. In these cases, the cuff of the AUS is placed around the bulbous urethra. This device can also be
implanted to treat urinary incontinence associated with myelodysplasia in men, women, or children or to treat urinary incontinence
caused by intrinsic sphincter deficiency in women. In these cases, the cuff is implanted around the bladder neck. This chapter
details the implantation of the AUS with cuff placement around the bulbous urethra.
12/2005: pages 435-441;
-
The Journal of Urology 08/2005; 174(1):230-9. · 3.75 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Despite the recent development of effective oral agents for the treatment of erectile dysfunction, penile prosthesis implantation remains an effective and acceptable treatment for the significant number of men who fail to respond to nonsurgical therapy. The most serious complication that can affect the use of most prosthetic devices is infection. In penile prostheses, this can be devastating and frequently results in removal of the device despite aggressive antibiotic therapy. In recent years, new strategies have been developed in an attempt to minimize this risk. This review focuses on one such method, namely the use of an antibiotic coating on the device. It reviews recent published data regarding the effectiveness of such devices at decreasing infection rates.
Current Urology Reports 12/2004; 5(6):460-6.
-
The Journal of Urology 08/2004; 172(1):290-4. · 3.75 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To assess the efficacy and factors associated with successful treatment of sildenafil citrate for erectile dysfunction after radical prostatectomy (RP).
Of the 470 patients who underwent RP at our institution between July 1998 and January 2000, 227 (48%) sought treatment for erectile dysfunction, and 174 (37%) were prescribed sildenafil citrate. The starting dose was 50 mg, which was increased to 100 mg if the patient did not have a positive response. Of the 174 patients, 104 (59.8%) had undergone a bilateral nerve-sparing (NS) procedure, 28 (16.1%) had undergone a unilateral NS procedure, and 42 (24.1%) had undergone a non-NS procedure. Erectile function was assessed by the abridged five-item version of the International Index of Erectile Function questionnaire, referred to as the Sexual Health Inventory for Men (SHIM), at baseline and 1 year after sildenafil use. The patients' charts were retrospectively reviewed to find factors associated with a successful outcome, which was defined as successful vaginal intercourse. Association with success was assessed by chi-square analysis and the Cochran Armitage test for trend. Bonferroni correction for multiple comparisons was used, with an overall significance level of 0.05 for each factor assessed.
The mean age was 60.1 +/- 6.25 years, and the mean interval from RP to drug use was 3 months. After treatment with sildenafil, 100 (57%) of 174 patients responded to the drug: 79 (76%) of 104 in the bilateral NS group, 15 (53.5%) of 28 in the unilateral NS group, and 6 (14.2%) of 42 in the non-NS group. SHIM analysis showed that the magnitude of the improvement was greater in the bilateral NS group (19.97 +/- 1.12) than in the unilateral NS (15.89 +/- 3.38) or non-NS (10.06 +/- 2.0) groups (P <0.020). Four factors were significantly associated statistically with a successful outcome: the presence of at least one neurovascular bundle, a preoperative SHIM score of 15 or greater, age 65 years old or younger, and interval from RP to drug use of more than 6 months (P <0.001).
The efficacy of sildenafil citrate after RP correlated with the degree of neurovascular bundle preservation, preoperative erectile function status, age, and interval before starting treatment.
Urology 05/2004; 63(5):960-6. · 2.43 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To assess whether long-term users of intracavernous (IC) injections after radical prostatectomy can switch to oral therapy with sildenafil citrate.
Forty-nine patients (mean age 60.9 years) with erectile dysfunction after radical prostatectomy were identified as long-term users of IC injections (3.7 +/- 1.9 years). These patients received open-label treatment with sildenafil citrate (50 to 100 mg) for a minimum of 4 weeks or five attempts. The primary outcome measure of our study was assessed by the Sexual Health Inventory of Men (SHIM) questionnaire (International Index of Erectile Function-5 [IIEF]). A successful switch was prospectively defined as erection sufficient for vaginal penetration after sildenafil use and compliance to therapy. Patients were designated as responders or nonresponders on the basis of their ability to achieve vaginal penetration.
Of 49 patients, only 36 agreed to receive oral open-label sildenafil (50 to 100 mg) for a minimum of 4 weeks or five attempts. Prostaglandin E1 (PGE1) was used in 70% and triple therapy (PGE1, papaverine, and phentolamine) in the remaining 30%. Of the 36 patients, 15 (41%) successfully switched to sildenafil and discontinued IC injections. When the results were stratified by the type of IC solution, patients with high-dose triple therapy had a poor success rate of switch (7%) compared with patients using PGE1 treatment (67%). Of the 36 patients, 14 (38%) found sildenafil ineffective and continued using IC injections. Patients who switched to oral therapy had had a greater (P <0.001) total mean SHIM (IIEF-5) score with IC injections than those who did not switch (12.3 +/- 7.8 versus 20.0 +/- 4.9). Of the 36 patients, 7 (19%) found sildenafil alone to be suboptimal but continued using it, enhancing the efficacy of IC injections alone. The three predictive factors for a successful switch were high preoperative SHIM (IIEF-5) score, high post-IC injection SHIM score, and type of IC medication used (PGE1 alone versus high-dose triple therapy).
Long-term users of IC injection therapy can potentially switch to sildenafil citrate with acceptable sexual satisfaction. Patients will accept a lower degree of sexual satisfaction as measured by the IIEF-5 (SHIM) score if oral therapy is effective.
Urology 03/2004; 63(3):532-7; discussion 538. · 2.43 Impact Factor
-
The Journal of Urology 11/2003; 170(4 Pt 1):1307-8. · 3.75 Impact Factor
-
The Journal of Urology 11/2003; 170(4 Pt 1):1318-24. · 3.75 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To evaluate the long-term effect and safety of sildenafil citrate for the treatment of erectile dysfunction after radical prostatectomy (RP).
The study consisted of 91 patients with erectile dysfunction from our institution who received oral sildenafil citrate after RP. We surveyed these patients using a self-administered questionnaire during the first year of sildenafil citrate use to determine treatment satisfaction, patient compliance, and safety. Those who had responded positively to the drug were surveyed again 3 years later (n = 48). Sildenafil citrate was prescribed at a dose of 50 mg and increased to 100 mg if needed. Data were collected from a self-administered questionnaire using the abridged five-item version of the International Index of Erectile Function questionnaire, referred to as the Sexual Health Inventory of Men, and the Erectile Dysfunction Inventory of Treatment Satisfaction. The patients were stratified according to the type of nerve-sparing (NS) RP procedure they underwent: bilateral NS, unilateral NS, and non-NS.
At 3 years, 31 (71%) of the 43 patients who had returned the second surveys were still responding to sildenafil. Of these 31 respondents, 10 (31%) had augmented their dose from 50 to 100 mg. The dropout rate was 27%; 6 of 12 had discontinued because of the return of natural erections, 5 because of a loss of efficacy, and 1 because his spouse had died. No differences were found in the 1-year and 3-year five-item International Index of Erectile Function (Sexual Health Inventory of Men) and Erectile Dysfunction Inventory of Treatment Satisfaction scores between the NS groups. The most common side effects at 3 years were headache (12%), flushing (10%), and blue or blurred vision (2%). No patient discontinued the drug at 3 years because of side effects.
The results of this study indicate that the vast majority of patients with erectile dysfunction after RP who initially respond to sildenafil continue to do so at 3 years and are satisfied and compliant with the treatment regimen.
Urology 08/2003; 62(1):110-5. · 2.43 Impact Factor
