BACKGROUND:Penile prosthesis surgery (PPS) has advanced significantly over the past decade with a wealth of research published, yet the key studies shaping contemporary clinical practice remain unclear. AIM:To identify and analyze the 50 most-cited primary research articles on PPS, published between 2014 and 2024, examining bibliometric characteristics, authorship networks, and thematic trends. METHODS:A bibliometric analysis using the Web of Science Core Collection identified the most-cited PPS research articles within the study period. Data were extracted, stored, and analyzed using Microsoft Excel. VOSviewer (v1.8) generated authorship networks and keyword co-occurrence maps to visualize collaborations and thematic clusters. OUTCOMES:Bibliometric data on authorship, year, journal, study design, level of evidence, and keywords were extracted, stored, and analyzed. RESULTS:The 50 most-cited articles accrued 2283 citations (median 39). The most-cited study, by MS Gross, received 128 citations. MS Gross also authored the most first author publications (n = 3). Most studies were observational in nature. Over half were published in The Journal of Sexual Medicine (n = 26), followed by The Journal of Urology (n = 7), Urology (n = 5), and BJU International (n = 5). Thematic analysis identified dominant focuses: surgical outcomes (n = 27), complications (n = 26), devices (n = 17), infection (n = 16), special populations such as transgender or post-radical prostatectomy patients (n = 12), surgical techniques (n = 12), and predictors/risk factors (n = 7). CLINICAL IMPLICATIONS:This bibliometric analysis identifies the research domains shaping contemporary PPS, while highlighting a predominance of retrospective, U.S.-centered evidence and the need for future international, coordinated, prospective multicenter research to advance the field. STRENGTHS AND LIMITATIONS:This study benefits from a transparent methodology and validated bibliometric tools. Limitations include the use of a single database, reliance on citation metrics, dominance of high-volume centers, and the absence of altmetric analysis, which may restrict assessment of quality, generalizability, and contemporary research impact. CONCLUSIONS:This bibliometric analysis highlights the most influential PPS publications over the past decade. A concentration of output from U.S.-based authors and high-volume centers, as well as a tendency toward observational designs, underscores the current research landscape. Future work with thematic and geographic diversity as well as prospective and multicenter studies may further advance the field.

BACKGROUND:Urologic prosthetic reservoirs (UPRs) can become firmly adherent to surrounding structures, making their removal during revision surgeries risky. Over the past decade, the "drain and retain" maneuver has been increasingly adopted to safely leave decommissioned UPRs in place. However, outcomes associated with this technique and its safety remains controversial, with ongoing debate in the literature. AIM:To evaluate the efficacy and safety of the "drain and retain" maneuver using a contemporary, retrospective multi-institutional cohort. METHODS:We reviewed records of patients who underwent inflatable penile prosthesis surgery at seven high-volume penile implant centers in the United States between July 2016 and September 2024. We compared revision cases involving subtotal device removal with "drain and retain" to those with complete component removal and exchange. Cases involving explantation for infection or revisions that reused the original reservoir were excluded. Postoperative complications and infection rates were assessed and compared between groups. OUTCOMES:Rates of short-term postoperative infection, non-infectious adverse events, and complications related to retained reservoirs. RESULTS:233 cases were included. Among those, 112 (48.1%) used the "drain and retain" technique, while 121 (51.9%) involved complete reservoir removal. The mean follow-up duration was 12.6 months. No complications were attributed to the retained reservoirs. There were no statistically significant differences between groups in postoperative infection rates (P = .940), device malfunction (P = .674), or symptomatic migration of the new UPR (P = .955). CLINICAL IMPLICATIONS:In this retrospective series with short-term follow-up, decommissioning the reservoir during revision surgery appeared to be a safe approach in the absence of infection; however, these findings may not be reflective of longer-term outcomes. STRENGTHS AND LIMITATIONS:The strengths of this study include its multi-institutional design and the largest original patient cohort reported to date. Limitations include the retrospective, non-randomized design, relatively short follow-up period, and potential attrition bias, as patients experiencing complications may have sought care elsewhere and were not captured in our database. CONCLUSIONS:Based on short-term data from a retrospective series, the "drain and retain" strategy was associated with early safety outcomes comparable to complete removal while avoiding retropubic dissection, though longer-term outcomes remain unknown.

Intraoperative irrigation has become a mainstay in modern penile prosthesis surgery. Though exact origins are unclear, the landmark Mulcahy Salvage Protocol brought specific irrigations to the forefront of prosthesis surgery. Since then, intraoperative irrigation protocols have been modified and adapted for primary and revision cases as well. The prevalence of device biofilm and colonization in revision cases may contribute to the recognized higher risk of infection compared to primary implant surgeries. Evidence demonstrating that washout protocols reduce bacterial load and infectious risk has provided the impetus for guideline statements recommending the use of vigorous mechanical lavage and antimicrobial irrigation for revision cases. Though specific recommendations regarding optimal irrigation selection remain undefined, contemporary evidence suggests that some historic irrigation components, including hydrogen peroxide and high-concentration betadine, should be avoided. Large multi-institutional cohort studies provide a unique avenue for implanters to compare intraoperative irrigation protocols to optimize patient outcomes. PATIENT SUMMARY: We present a literature review summarizing intraoperative irrigation during inflatable penile prosthesis (IPP) surgery in the primary, revision, and salvage settings. While no specific guidelines exist regarding the optimal irrigation cocktail(s) - reflected in the wide variability in irrigant selection across implanters - intraoperative irrigation remains a key aspect of prosthesis surgery and holds meaningful consequences on the patient level to minimize infections. Evidence suggests that hydrogen peroxide and high-concentration betadine should be eliminated from IPP surgery given cytotoxicity and infection risk. Given the infrequent outcome of prosthetic infections, multi-institutional cohort studies provide a practical and unique avenue to accrue the large sample sizes needed to allow for adequately powered investigations regarding intraoperative irrigation.

Abstract Introduction Penile prosthesis (PP) surgery has been an effective and reliable treatment for erectile dysfunction (ED) for over 50 years. It is presumed that there are significant variations in intraoperative techniques and postoperative management strategies among prosthetic urologists. Objective To evaluate the perioperative practice patterns of penile prosthesis surgeon. Methods An anonymous web-based survey was sent to members of the Sexual Medicine Society of North America (SMSNA), the Society for Urologic Prosthetic Surgeons (SUPS), and the Society of Genitourinary Reconstructive Surgeons (GURS). Twenty-seven questions were asked regarding the perioperative practice patterns of the respondents. Descriptive statistics were performed. Results 189 responses were received from surgeons that perform PP. Most respondents (82.6%) were fellowship trained in andrology, reconstruction, or prosthetics. The majority of respondents perform PP placement via the penoscrotal (76.7%) compared to infrapubic approach (23.3%). Corporotomies were most commonly closed with preplaced sutures compared to running closure (89.4% vs 9.5%). PDS (43.9%) and Vicryl (36.5%) sutures (both Ethicon, Raritan, NJ, USA) were the most frequently used for corporotomy closure (Table 1). Slightly over half (55.6%) of respondents routinely use a closed suction drain postoperatively, with 45.2% of those surgeons leaving for 2 or more days. Clinical data influenced 54.3% of respondents’ drain duration, with drain output the most common basis for duration (91.2%). Mummy wrap (73.5%) with scrotal support (78.8%) was the most common postoperative dressing. Of the 56.1% of respondents who leave a Foley catheter postoperatively, the majority remove it on postoperative day one (92.5%). Same day discharge is routinely performed by 61.4% while 23.3% prefer 23-hour observation. Most surgeons (65.6%) leave the device inflated, with 51.6% inflating >50% and 44.4% <50%. There was wide variability in timing of first postoperative visit and initiating device cycling (Table 2). 26.5% of surgeons clear the patient to use the implant for sexual activity at 4 weeks while 55.6% clear at 6 weeks (Table 2). Conclusions Our results demonstrate great variability in practice patterns for PP surgery most notably with drain use, Foley catheter management, and patient disposition. Additionally, postoperative follow-up, device cycling, and implant use varied widely between surgeons. These results on different management strategies will help guide future studies to better understand the implications of these practices on patient outcomes and experiences. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientifice, Cynosure, Antares Pharma, Clarus Pharmaceuticals, Acerus Pharma

BACKGROUND:0.05% Chlorhexidine gluconate (CHG) is now commonly used as an antiseptic irrigation for inflatable penile prosthesis (IPP) surgery. Limited in vitro data suggest compatibility of 0.05% CHG with antibiotic impregnated IPP devices; however, very little clinical research exists to guide use of 0.05% CHG in this population. AIM:Assess the relationship of 0.05% CHG and antibiotic impregnated IPP infection in a large multi-institutional cohort. METHODS:We retrospectively reviewed a multi-institutional cohort of patients who underwent antibiotic impregnated IPP implantation. We identified cases using intraoperative 0.05% CHG and an equal number of consecutive control cases without 0.05% CHG use from each center for comparison. The primary outcome was IPP infection requiring explantation. Patient demographics and surgical variables were analyzed using chi-square tests and multivariable logistic regression to identify variables associated with infection. OUTCOMES:The primary outcome was IPP infection requiring device explanation. RESULTS:Among 14 participating institutions, 761 cases using an antibiotic impregnated IPP were analyzed. Of these, 348 (45.7%) had 0.05% CHG used during the case. Median follow-up was 4 months (interquartile range 1-12) for the 0.05% CHG group and 8 months (interquartile range 2-21) for the control group.Intraoperative 0.05% CHG utilization was not associated with antibiotic impregnated IPP infection rate (1.9% vs. 2.0%, P = .9). On multivariable analysis, prior IPP infection (OR 6.32, 95% CI 1.32-30.2, P = .021) and prior priapism (OR 10.01, 95% CI 1.18-89.7, P = .039) were associated with increased infection risk. CLINICAL IMPLICATIONS:The use of 0.05% CHG irrigation with antibiotic impregnated IPPs was associated with similar infection rates compared to antibiotic irrigation. STRENGTHS AND LIMITATIONS:Limitations include the use of a historical comparator cohort which may introduce unknown confounders, practice variation between multiple sites, shorter follow-up in the 0.05% CHG cohort, and the low incidence of IPP infection which may limit statistical power despite a large sample. The major strengths include the large, multi-institutional cohort, and the use of consecutive patients to minimize selection bias. CONCLUSION:0.05% CHG utilization was not associated with infection rates in antibiotic impregnated IPPs.

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.