LAUSR

Performing prosthetic surgical procedures in urology and more specific penile implant surgery is so much more than just a surgical act. The final goal should be delivering high quality of care which implies ultimately the patients benefit. Thus, much more focus should be given on attempts to improve this outcome. Most of the available literature on penile implant surgery is mainly based on case series, a fact which led to present guidelines being by definition empirical. Therefore, objective evidence-based conclusions are lacking in order to allow us to report more robust outcomes. In this perspective, the article “Surgeons variations in the perioperative evaluation of penile prosthesis patients” by Barham et al. [1] could be one stone contributing to build a wall of evidence-based guidelines regarding penile implant surgery. The importance of the present study cannot be underestimated. The authors finger point many important messages and they do that by conducting a broad survey on 122 urologists and by evaluating numerous interesting parameters: surgeon sexes, geographical factors, training background, number of cases performed, sexual orientation of patients, kind of sexual activity, etc. Their conclusion that there is “much room for improvement” seems completely justified. It has been nearly 50 years since the first inflatable penile implant by Scott et al. was available on the market in 1973 [2]. Nevertheless, during these five decades many questions regarding penile implant surgery optimization remain unanswered. First of all a solid penile implant surgery training program is absent and, as in almost all surgical training programs, the Halsted principle of “see one, do one, teach one” is still the gold standard. Therefore, we started in 2021 a brand new surgical training program named “Surgical Academy for Penile Implant Surgery” within the European Society for Sexual Medicine [3]. This academy consists of two main levels. The first broad accessible level consists of three webinars with lectures from key opinion leaders covering the whole spectrum of penile implant surgery. More particularly, knowledge of available devices, instrumentation and surgical techniques, indications for penile implant surgery, pre-and postoperative care, complications management and implanting the difficult patient are fields analyzed. The article by Barham et al. [1] by focusing on how to standardize perioperative care in this patient population can be a tool of utmost importance in our training program. The study clearly highlights the need for standardization in this particular care program, underlines the lack of evidence-based strategies and also emphasizes to the importance of experience in high volume centers. The next level in this academy is the availability of a standard theoretical handbook explaining in detail all topics that have been touched in the webinars. The final tool in this first level is the access to a virtual platform where one can see interactive high definition video’s demonstrating the surgical techniques. These videos are recorded by using different high resolution cameras simultaneously that shoot from different angles demonstrating the procedures in detail. This enables the spectator to see the skin to skin surgical procedures in detail. Once the first level is completed the candidates are evaluated and a selected group is allowed to enter the second level. In this level the candidates will be exposed for several months to penile implant surgery in European Centers of Excellence, where they can actively participate in the operating room. Before permitted to scrub in and learn the surgery step by step, the candidates are trained on 3-D models. These 3-D models have been developed in collaboration with the University of Rochester (NY) with Ahmed Ghazi. These models are based on MRI derived molds and consist of a biodegradable hydrogel. The models mimic real life much better than cadavers, moreover they are cheaper, more ethical, more user friendly [3, 4]. Once a surgeon is well trained in this field, it is a condition sine qua non to establish a state of the art penile implant center. This penile implant center should be well structured, a fact in which the present study also emphasize to as the authors abundantly prove that there is a lack in homogeneous organizational steps in order such a center to be offered to erectile dysfunction patients. The key to success is a well-trained and organized team. The medical team involved should be multi-disciplinary, involving besides the urologist also cardiologists, endocrinologists, gynecologists, sexologists. Even more important is to collaborate with specialized nurses, on the ward, in the OR and on the outpatient clinic. If you can rely on those nurse practitioners they make life easier and more importantly they will significantly improve the care delivered to your patients and their surgical outcome. It is crystal clear that a specialized nurse assembling and preparing the device during surgery will be beneficial to the outcome, the same goes for the dedicated nurses assisting at the outpatient clinic seeing your patients prior to surgery to counsel your patients and even more important coordinating the postoperative care. It should be stressed that the partner should be involved from the preoperative stage and should be continuously involved after surgery. Needless to say that during preoperative counseling of