Stress urinary incontinence and ED are common patient ailments treated in a urologist’s office, and its concomitant presentation can be seen in specific patient populations, such as those who undergo robotic-assisted prostatectomy for prostate cancer . Specifically, in post-prostatectomy patients, for instance, the PIVOT study showed at 2-year follow-up, 17% of patients had SUI or required indwelling catheter. Rates of postoperative ED following RP can range from 14–90% in the literature, with a large variance between institutions [22–24]. Therefore, dual presentation of symptoms are not uncommon. Depending on the severity, surgical correction may be indicated with either a IPP and a AUS or urethral sling.
Combination prostheses therapy for ED and incontinence has been previously reported in the literature as both feasible and effective [15, 20, 25, 26]. Wilson and colleagues reported the first instance of dual IPP and AUS implantation through a single transverse scrotal incision. Further work by Sellers and colleagues reported dual implantation of an IPP and AUS through a single penoscrotal incision compared to individual implantations to reveal a reduction in both operative time and $7,000 in cost savings . Then in 2005, the first reported technique of concomitant penile prosthesis and bulbourethral sling implantation was published involving a perineal incision for a sling and a separate penoscrotal incision for the IPP. Our group in 2010 modified this dual implantation procedure with the placement of the IPP through the same perineal incision that is normally created for sling and AUS implantation where we found no significant difference in operative time, EBL, or postoperative hospital stay when compared with individual incision procedures and a cost savings of over $9,000 when performing the simultaneous implantation.
In our current study, we build upon our previous work , and looked at an extended follow-up time of 49 months in a larger patient cohort where 24 patients underwent synchronous implantation via perineal incision and 14 via penoscrotal incision. Among the perineal incision cohort, 8 patients underwent AUS/IPP operation and 16 underwent male sling/IPP operation and for the penoscrotal incision cohort, all 14 patients underwent AUS/IPP operation. Demographically, the two groups were similar and exhibited no significant difference in age, BMI, or comorbidities. Notable findings included no significant difference in the rate of patients with complications between the two groups as well as no difference in treatment satisfaction scores. There was a significant difference in median follow-up time (IQR) between the two groups, 26.03 months for the perineal group and 72.02 months for the penoscrotal group (p = 0.035). This difference may be due to our limited sample size and attempting to contact these patients to obtain extended follow-up information may be beneficial for longer-term device satisfaction rates.
The benefits of undergoing a single incision for dual implantation of devices can be thought of as both clinically and financially advantageous to the patient. Clinically, using a single incision minimizes risk of infection, decreased pain, and lowers the comorbidity of the procedure. Financially to the patient, undergoing a single setting implantation of dual devices results in a single fee for anesthesia and postoperative care (nursing, medications, and hospital stay charges). In addition, at our follow-up, there seems to be no significant difference in device durability despite the alternative approach. Since perineal incision is used for most AUS and sling procedures, surgical approach for synchronous penile implant should then be tailored accordingly to avoid any additional incision.
The evident limitations of this report are the retrospective manner of data collection, and the size of the study groups. However, our technical approach with a single perineal incision is unique and the procedure is well tolerated by the patients, without any increased risk of complications. We believe that the advantages of performing these procedures in a single event are a single exposure to anesthesia and its associated risks, presence of a single incision, cost efficiency and comparable complication and treatment outcomes.