LAUSR

Advancements over the past four decades have improved inflatable penile prosthesis (IPP) reliability while minimizing the inherent risk of complications such as device infection [1]. The result has been consistently high patient and partner satisfaction rates in excess of 80–90% [2, 3]. Why are those 10–20% of patients dissatisfied? The reasons vary, but there is no doubt that the chief among these is concerns regarding penile morphometric changes such as length loss, which is reported by a significant proportion regardless of the type of prosthesis that is placed [4, 5]. To date, an approach to reliably restore a man’s penile length to the “glory days” before ED-onset remains elusive. This is not for lack of want, and a variety of pre-, intra-, and post-operative protocols have been described to optimize outcomes with varying results. In this month’s issue of International Journal of Impotence Research, Antonini et al. describe their outcomes with a protocol for length and girth preservation utilizing twice daily device cycling with vacuum erection device (VED) application after American Medical Systems (Boston Scientific, Marlborough, MA, USA; AMS); LGX700 IPP placement [6]. The protocol, as described, included prosthesis activation within 1–2 weeks followed by twice daily IPP inflation/ deflation for 10–15 minutes. The novel aspect of the protocol by Antonini et al. lies in the application of the VED postoperatively after IPP placement in order to supplement daily IPP cycling [6]. Starting at 3 weeks, patients were instructed to utilize a VED for 5 min twice per day with the device fully inflated for a period of 12 weeks. Patients followed up at 12, 24, and 48 weeks for subsequent evaluation. Not surprisingly, average penile length was shorter immediately after surgery, but with each subsequent timepoint the average penile length increased such that at 1 year after surgery the authors found that both penile length and girth were similar to the “erect” penis measurements obtained preoperatively. VED use has also been studied as a preoperative intervention to optimize outcomes in men with penile fibrosis prior to IPP placement and as postoperative therapy to prevent penile length loss after prostatectomy [7, 8]. In their discussion, Antonini et al. hypothesize that vacuum therapy after IPP placement allows the prosthesis to expand into the residual peripheral cavernosal tissue surrounding the cylinders, thereby preventing a “coffin-effect” from the pseudocapsule. While this hypothesis seems reasonable, an alternative hypothesis is that aggressive device cycling alone may be all that is necessary to provide the same benefits for length and girth expansion over time. Patient compliance was not reported and represents an important limitation. This has important implications, particularly in the absence of a control arm (i.e. those patients who did not use concurrent VED therapy), as we would expect to see a greater likelihood of “success” in those who used the VED more consistently if the treatment was indeed providing benefit beyond the twice daily inflation. Pyor et al. reported outcomes from three surgeons who utilized “optimal cylinder sizing” intraoperatively followed by an aggressive protocol of daily device activation, including maximal inflation for 60–120min starting at 6 months postoperatively after Coloplast (Humlebaek, Germany) Titan IPP placement [9]. This resulted in a significant increase in erect, flaccid, and stretched penile length and * Matthew Ziegelmann [email protected]