Penile implant surgery is a well-established treatment for erectile dysfunction. While patient and partner satisfaction rates are high, any non-infectious complication can significantly affect functional outcomes, revision rates and long-term device survival. This narrative review synthesises contemporary evidence on the prevention, recognition and management of non-infectious complications across the pre-operative, intra-operative and post-operative phases of penile implant surgery. A structured search of PubMed from 1980 to 2024 identified 38 relevant articles. Infectious complications were excluded as they represent a distinct clinical entity with separate diagnostic and therapeutic pathways and have been extensively reviewed elsewhere. This narrative review aims to provide a consolidated, practical resource for penile prosthetic surgeons by integrating anatomical considerations, technical pitfalls and evidence-based versus expert-based recommendations with prevention strategies and early recognition of non-infectious complications, the key component in optimizing long-term outcomes.
Penile prosthesis (PP) surgery represents a cornerstone intervention for erectile dysfunction (ED). Despite extensive literature, the most-cited primary studies across the full history of the field have not been comprehensively characterized. We aimed to identify and evaluate the 50 most-cited primary studies in PP surgery, describing citation trends, research themes, and academic contributions using bibliometric methods. The Web of Science Core Collection was searched from database inception through 21 April 2025 using predefined PP-related terms. Study design and level of evidence were independently assessed by two reviewers using the Oxford Centre for Evidence-Based Medicine (OCEBM) framework, with disagreements resolved by consensus. The 50 studies (1977-2017) accrued 5652 citations (median, 105; range, 75-215). Most were retrospective observational studies (82.0%) and were assigned Level 4 evidence (56.0%). The Journal of Urology published 28 studies (56.0%). Steven K. Wilson was the most prolific contributor, authoring or co-authoring 10 studies. Non-mutually exclusive themes included surgical outcomes (n = 38), infection (n = 12), and special populations (n = 6). The findings describe the historical development of PP research and highlight the continued need for geographically diverse, prospective, and higher-quality studies.
Partial plaque excision and grafting (PEG) is the gold standard treatment for patients with severe Peyronie's Disease (PD) with preserved erectile function and deformity refractory to conservative management. Post-PEG satisfaction rates are highly variable, with many patients attributing dissatisfaction to penile shortening. We aim to explore patient-reported penile shortening in the pre- and postoperative period. A retrospective chart review and telephone survey was conducted for 137 patients who underwent PEG at a single institution from February 2007 - November 2022. Overall, 75.2% of patients had measured increased or stable stretched penile length (SPL) following PEG, with a mean gain of 1.5 ± 0.9 cm in those who objectively gained length. 75.9% of patients reported preoperative perceived shortening; 46.0% reported postoperative perceived shortening. Perceived preoperative shortening was associated with perceived postoperative shortening (84.1% vs 68.9%, p = 0.03). There was no significant association between perceived postoperative shortening and objective change in SPL (p = 0.38). Subjective postoperative shortening was associated with lower satisfaction rates (38.1% vs 58.1%, p = 0.002) and shorter median follow-up (21 vs 53 months, p = 0.007). Although PEG generally results in SPL gain, managing expectations is critical, with emphasis that the goal of PEG is to achieve functional straightness and rigidity, not necessarily restore penile length lost to PD.
Inflatable penile prosthesis configuration remains highly variable among surgeons, with decisions often guided by individual experience rather than standardized criteria. We evaluated agreement between the Canguven Penile Prosthesis Calculator (an anatomy-based decision-support tool) and experienced penile prosthesis surgeons to characterize inter-surgeon variability using a standardized virtual-case model. A total of 60 cases were constructed incorporating total corporal length, proximal corporal length, scrotal size, and predefined prosthesis model (AMS 700 CX™, Boston Scientific Corporation, Marlborough, MA, USA; Titan™, Coloplast Corporation, Minneapolis MN, USA; and Infla10™, Rigicon Inc., Ronkonkoma, NY, USA). A total of 7 experienced penile prosthesis surgeons from 6 institutions independently evaluated the cases, blinded to calculator recommendations, and selected cylinder length, rear-tip extender, and reservoir volume, generating 340 surgeon-case decisions. Agreement was assessed using exact agreement, clinically acceptable agreement (±1 cylinder size), and kappa statistics. Exact agreement between calculator recommendations and surgeon-selected cylinder length was observed in 198 of 340 decisions (58.2%), increasing to 302 of 340 decisions (88.8%) within a clinically acceptable range. The mean absolute difference was 0.95 ± 1.18 cm, with discrepancies greater than 2 cm observed in 38 of 340 decisions (11.2%). Inter-rater agreement was moderate (Fleiss' κ = 0.46, 95% CI 0.41-0.51), and pairwise agreement between the calculator and individual surgeons ranged from κ = 0.43 to 0.55. Reservoir selection demonstrated excellent agreement (329/340 decisions, 96.8%). Variability in prosthesis configuration decisions was primarily driven by differences in rear-tip extender utilization, reflecting consistent but distinct surgeon-specific strategies. Inflatable penile prosthesis configuration demonstrates substantial variability among experienced surgeons, although most differences fall within clinically acceptable limits. The anatomy-based algorithm demonstrated moderate agreement with expert surgeon selections and may provide a structured, anatomy-based framework for prosthesis configuration planning while preserving individualized surgical decision-making.
Metoidioplasty is a genital gender-affirming surgery that preserves native sensation and erectile capability but remains technically demanding, particularly regarding urethral lengthening. We evaluated perioperative and functional outcomes of a single-stage modified metoidioplasty using dorsal labia minora graft augmentation, ventral anterior vaginal advancement flap reconstruction, and bilateral rotational scrotoplasty incorporating bilateral Martius fat pads. 23 transgender men underwent surgery at a tertiary referral center between 2017 and 2025. Median age was 38 (33-46) years and median follow-up was 36 (24-48) months. Median operative time was 165 (147.5-175) min and hospital stay was 2 (1.5-2.5) days. Early and late complications were observed in 13.0% of patients each. Cumulatively, urethral fistula and urethral stenosis occurred in 17.4 and 8.7% of patients, respectively. 2 (8.7%) fistulas resolved spontaneously, while 17.4% of patients required surgical revision. Patient-reported satisfaction was high, with 95.7% of patients satisfied with surgery and 91.3% reporting satisfaction with micturition and quality-of-life improvement using a non-validated binary questionnaire. This buccal mucosa graft-sparing, tissue-preserving approach appears feasible and safe, with urethral complication rates within the spectrum of outcomes reported in the literature, while potentially simplifying specific reconstructive steps and avoiding donor-site morbidity. Larger prospective comparative studies are warranted.
This retrospective single-arm pilot study evaluated a novel minimally invasive approach combining Botulinum Toxin A injection with penile traction therapy for the treatment of penile retraction. This study was conducted in 168 men with retractile penis treated between October 2023 and June 2025. Flaccid penile length was measured in the standing position with the penis in a naturally dependent state after a resting period in a room-temperature environment, using a rigid ruler from the pubic symphysis to the tip of the glans with compression of the suprapubic fat pad. Psychological outcomes were assessed using the Self-Esteem and Relationship questionnaire and the Index of Male Genital Image, while erectile function was evaluated using the five-item International Index of Erectile Function. Mean baseline flaccid penile length was 4.4 ± 0.66 cm, increasing significantly to 6.9 ± 0.81 cm at 6 months (P < 0.001). Improvements were also observed under thermal stimulation and in the penile retraction reduction ratio, which decreased from 27.3-11.6% at 6 months (P < 0.001). Erectile penile length and five-item International Index of Erectile Function scores showed no significant changes. Psychological outcomes improved significantly, with Self-Esteem and Relationship and Index of Male Genital Image scores increasing from 28.8 ± 4.3 and 39.3 ± 5.7-54.4 ± 5.6 and 59.0 ± 7.3, respectively (P < 0.001). Mild transient injection-site pain occurred in 11.3% of patients without other complications. This combined therapy may represent a feasible minimally invasive option for selected patients with penile retraction and reduced visible flaccid penile exposure. However, it does not confer true anatomical penile elongation, and given the exploratory single-arm design, the findings should be interpreted with caution. Further prospective randomized controlled studies using standardized penile measurements and longer follow-up are needed to clarify the durability of treatment effects and the independent contribution of each treatment component.
Artificial intelligence (AI)-based language models are increasingly explored as tools for interpreting and applying clinical guideline recommendations. In urology, the European Association of Urology (EAU) recently introduced a guideline-specific chatbot; however, its comparative performance relative to contemporary general-purpose large language models (LLMs) remains unclear. In this structured comparative study, five AI systems-the EAU Guidelines Bot, ChatGPT-5, Gemini 2.5 Pro, Copilot - Smart GPT-5, and Perplexity Pro-were evaluated using 13 clinical questions derived directly from strongly recommended statements in the EAU erectile dysfunction (ED) guidelines. Responses were independently assessed by three senior reviewers across five predefined domains: relevance, clarity, structure, clinical utility, and factual accuracy, using a 5-point Likert scale. The primary outcome of the study was the composite performance score, which was calculated as the mean of the five domain scores. Inter-rater reliability was calculated using ICC(2,k), and differences among models were analyzed with the Friedman test followed by Holm-adjusted Wilcoxon post-hoc comparisons. Significant performance differences were observed across all domains (all p < 0.001). The highest composite scores were observed for Gemini 2.5 Pro [4.60 (4.40-4.73)] and the EAU Guidelines Bot [4.53 (4.47-4.80)], followed by ChatGPT-5 [4.27 (4.07-4.47)]. Lower composite scores were observed for Copilot - Smart GPT-5 [3.73 (3.40-3.87)] and Perplexity Pro [3.60 (3.47-3.80)]. Domain-level analysis showed consistently high median scores (≥ 4) for factual accuracy among top-performing models, whereas variability was more pronounced in clarity, structure, and clinical utility. These findings suggest that both guideline-specific systems and advanced general-purpose LLMs may generate responses broadly consistent with guideline-based recommendations in structured ED scenarios. However, variability across domains-particularly in structure and clinical utility-and modest differences in composite performance suggest that these models should be interpreted as supportive tools rather than definitive clinical decision-making systems, requiring further validation in real-world settings.
Despite the recognized emotional importance of post-coital intimate behaviors such as hugging, cuddling, talking, kissing, massaging, listening to sensual music, showering, and reading erotic literature (collectively termed afterplay), their impact on female sexual satisfaction has not been systematically studied. This prospective randomized study evaluated the effect of afterplay on sexual satisfaction among sexually active women in heterosexual relationships. Couples with medical comorbidities, psychiatric disorders, or diagnosed sexual dysfunction were excluded. Participants were randomized into two groups using computer-generated random numbers. Both groups received weekly educational sessions on desire, arousal, lubrication, orgasm, satisfaction, pain, and foreplay, with Group B receiving an additional 15-minute session focused on afterplay. Sexual satisfaction was assessed at baseline and after 8 weeks using the Sexual Satisfaction Scale for Women (SSS-W), supplemented by diary-based records of sexual experiences. A total of 431 women completed the study (Group A: 211; Group B: 220), with comparable baseline characteristics. After 8 weeks, Group B showed significantly greater improvement across all SSS-W domains compared with Group A (p ≤ 0.05). These findings identify afterplay as an important factor influencing female sexual satisfaction. Partner education regarding afterplay may represent a simple and effective intervention for improving sexual well-being and addressing female sexual dissatisfaction.
Gender-affirming care aims to reduce gender-related distress. Informational needs regarding masculinizing genital gender-affirming surgery (GGAS) remain poorly understood. We conducted a cross-sectional survey, inviting transmasculine individuals who had undergone phalloplasty or metoidioplasty. Participants rated the importance of specific topics on a 1-5 Likert scale before, during, and after surgery, reported the information they received and identified sources and preferred delivery formats. Forty-four patients were included (response rate 48.4%). Before surgery, the topics deemed of high importance (4 or 5) were possible complications, preparation of the donor site, long-term follow-up and complications and differences between surgical techniques (all 100%); written materials were the preferred format (87.5%). Participants reported important informative gaps (% importance high - %coverage), particularly regarding the management of ischemic complications (62.0%), urethral fistula (33.0%) or stenosis (32.0%), financial costs (35.0%), and the need for a structured support plan after surgery (22.0%). During hospitalization, respectful communication (95.4%), nursing experience with GGAS (100%), and clear instructions for self-care at discharge (97.7%) were deemed to be of high importance (4 or 5). In follow-up, patients emphasized guidance on prevention of injury to the neophallus (97.7%) and criteria for unscheduled visits (93.2%). These findings highlight the need for comprehensive, written, team-based counselling, and structured continuity of care to align surgical services with patient priorities.
