Abstract Introduction Urologic prosthetic reservoirs (UPR) can become firmly adherent to surrounding structures, and their removal during revision surgeries carries significant risks. Over the last decade, the “drain and retain” maneuver has been increasingly implemented to safely leave decommissioned UPRs in place. The utility and safety of this technique have not been further explored in the literature following the original descriptive publications. Objective We sought to update the efficacy and safety of the “drain and retain” maneuver by analyzing a contemporary multi-institutional cohort. Methods Patients who underwent inflatable penile prosthesis (IPP) surgery at seven busy penile implant centers in the United States between July 2016 and June 2024 were reviewed. We compared patients who underwent revision IPP surgery and subtotal device removal with “drain and retain” to those who had complete component removal and exchange. Explant cases for infection and revision cases using the original UPR were excluded. Postoperative complications and infection rates were evaluated and compared to patients receiving primary IPP surgery as a control group. Results 1201 primary IPP cases and 231 revision cases were included. Among the revision cases, 112 (48.5%) utilized the "drain and retain" technique, while 119 (51.5%) involved complete reservoir removal. Patient demographics are listed in Table 1. There were no statistically significant differences in postoperative infection rates (p = 0.897) among the groups (Table 2). Similarly, there were no statistically significant differences in postoperative infections when stratified by different prosthesis types (p = 0.987). Regarding non-infections complications, there were no significant differences between the “drain and retain” group compared to revision cases where all components were removed. (p = 0.393) (Table 3). Conclusions To our knowledge, this is the most extensive study assessing the safety of leaving UPR in place during IPP revision surgery. The "drain and retain" strategy is a safe approach for IPP revision surgery. It avoids the potential morbidity of dissection into the retropubic space while maintaining infection and complication rates comparable to primary IPP cases. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific; Coloplast; BK Ultrasound.

Physician review websites offer patients insight into their potential care teams when seeking a new provider. A firm understanding of the factors which patients deem important when assigning these ratings may allow sexual medicine providers an opportunity to improve patient satisfaction. Online ratings and reviews through Healthgrades.com and Vitals.com were collected for all physicians listed in the SMSNA healthcare provider directory. Physicians were included if they had received more than 10 ratings and 5 written reviews. The frequency for which specific positive and negative descriptors were included in written reviews compared to a provider's average online rating using Wilcoxon-Mann-Whitney tests and non parametric correlation. Factors which were significantly associated with changes on average ratings were then tested using multiple regression. Of 331 SMSNA providers, 145 (43.8%) met the inclusion criteria, including 129 male and 16 female providers, receiving an average of 57.0 ratings and 22.6 written reviews each. The average rating was 3.96/5. Factors signficantly associated with worsened online ratings included physicians appearing rude or uncaring (-47.0%, p = 0.013), poor clinic staff or nurse quality (-39.2%, p = 0.000), lack of email or phone availability (-37.2%, p = 0.001), poor facilities appearance (-29.5%, p = 0.045), and complications following procedures (-22.7%, p = 0.028). No factors were significantly associated with improved ratings. Physicians can gain insight into the patient's perspective through a careful review of common trends in online physician reviews. On an analysis of reviews for SMSNA providers, multiple factors which remain in the provider's control, including availability, quality of explanations, appearing rushed, ability to answer questions, listening skills, medical knowledge, friendliness, trustworthiness, and patience. By focusing on these factors, sexual medicine providers may be able to maintain positive online reviews while offsetting the impact of factors that may remain outside their control, including the quality of clinic or hospital facilities and complications following procedures.

Abstract Introduction Collagenase clostridium histolyticum (CCH) was first approved by the FDA in December 2013 for the nonsurgical management of Peyronie’s disease (PD) in men who are otherwise healthy. Penile fracture (PF) is a rare but concerning adverse event with known association with CCH administration. Objective To determine the risk of PF in men with PD who are receiving CCH and correlations between the risk of PF and comorbidities previously excluded in studies investigating the safety of CCH, namely the IMPRESS trial. Methods The TriNetX database was used to measure the rate of hospital visits for penile fracture using the ICD-10 code S39.840A. Results were limited to patients who were diagnosed with PD (ICD-10 N48.9) and were seen between July 2013 to July 2023. Patients were excluded if they had a history of surgical intervention for PD, including plaque excision and grafting, penile plication, and insertion of inflatable penile prosthesis. An odds ratio (OR) was calculated to compare the rates of PF between patients who had and had not received CCH. For those who received CCH, OR’s were calculated to determine if the presence of certain comorbidities increased the risk of PF. Results Within the examined time period, 44,542 patients with PD experienced 280 PF’s. The rate of PF in those who had and had not received CCH were 1.25% (N = 37) and 0.59% (N = 243) respectively, OR 2.122 (95% CI: 1.499-3.001, p<0.0001). Tobacco use, diabetes mellitus, peripheral vascular disease, hypertension, hyperlipidemia, erectile dysfunction, and hypogonadism were not associated with an increased risk of PF in men receiving CCH (p>0.05) (Table 1). Conclusions While the rate of PF following CCH use for PD was low at 1.25%, this was significantly higher than in those who did not receive CCH. Despite this, men who were previously excluded from studies examining the safety of CCH use for PD due to comorbidity burden were without an increased rate of PF, suggesting that these men may be able to receive CCH without additional risk of PF. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Antares Pharma, Clarus Therapeutics, Coloplast.

Abstract Introduction Inflatable penile prosthesis (IPP) surgery is a common procedure for treating erectile dysfunction, and skin preparation with antiseptic solutions is a standard practice to reduce infection risk. However, some antiseptic solutions, such as chlorhexidine-based Irrisept, have been associated with severe skin reactions. Several studies have reported cases of contact dermatitis, blistering, and chemical burns following the use of chlorhexidine-based antiseptic solutions before surgery. Objective This case report aims to highlight the potential risk of severe skin reactions when using Irrisept and other chlorhexidine antiseptic solutions during penile prosthesis surgery. It also explores the novel technique of pinch skin autografting used to salvage the implant and achieve successful wound healing after delayed skin necrosis. Methods 61-year-old male with a history of prostate cancer and erectile dysfunction who underwent insertion of an IPP. Results The patient's penile shaft developed blisters 3 weeks post-implantation, which progressed to full-thickness necrosis despite conservative treatment. The distribution and location of the reaction led to the hypothesis that it was caused by the chlorhexidine-based Irrisept antiseptic. The antiseptic solution used copiously throughout the case and 10CC was injected under pressure into the drain which also may explain the reaction observed. The patient underwent wound debridement and was treated with pinch skin autografts from the bilateral thighs. The autografts resulted in 95% epithelialization with excellent cosmetic outcomes with no other complications. To the best of our knowledge, this is the first reported case of Irrisept-induced delayed skin necrosis and the use of pinch skin grafting to salvage the implant after penile prosthesis surgery. Conclusions Skin reactions to Irrisept antiseptic solution during penile prosthesis surgery are rare but can be severe. Surgeons should be cautious and consider alternative skin preparation methods in patients with a history of skin allergies or sensitivities. This case also highlights the potential of pinch skin autografting as a salvage technique for post-IPP skin reactions. A multidisciplinary approach involving reconstructive burn surgeons and specialty wound care teams may be beneficial in optimizing outcomes in such cases. Disclosure No.

Abstract Introduction The utilization of rear tip extenders (RTE) is often imperative during Inflatable Penile Prosthesis (IPP) placement. The impact of RTE on perioperative morbidity of IPP surgery is underexplored. Objective In this study, we assess intraoperative and postoperative outcomes among patients undergoing primary IPP implantation with or without RTE. Methods We performed a multicenter, retrospective analysis of men undergoing primary IPP placement between July 2016 and July 2021. A total of 4308 patients were identified, of which 2963 had no RTE and 1345 had RTE. After 1:1 propensity score matching for all confounding variables, 840 patients without RTE were compared to patients with RTE for intraoperative and postoperative outcomes. Chi-square and Mann–Whitney tests were used for statistical analysis for categorial and continuous variables respectively. For multivariable analysis, we used a forward stepwise model and included significant variables found on preoperative characteristics of patients. Kaplan–Meier time to event analysis were compared with Mantel-Cox log-rank test. Results Patients with RTE use had more postoperative complications (9.6% vs 5.2%, p < 0.001). More specifically, RTE patients had more episodes of postoperative hematoma and bleeding (2.0% vs 0.7%, p = 0.033), device malfunction (2.7% vs 1.8%, p = 0.006), and glans-related complications (0.8% vs 0, p = 0.015). On multivariable analysis, use of RTE (OR 1.58, 95% CI 1.07-2.34, p = 0.021), AMS 700 series device (OR 1.93, 95% CI 1.27-2.94, p = 0.002), penoscrotal approach (OR 2.60, 95% CI 1.61-4.18, p < 0.001), and older age (OR 1.02, 95% CI 1.00-1.04, p = 0.035) were associated with increased risk of postoperative complications. Patients with RTE use had increased rate of postoperative IPP revision (5.0% vs 2.1%, p = 0.002). The use of RTE (OR 1.71, 95% CI 1.00-2.90, p = 0.046), AMS 700 series device (OR 1.73, 95% CI 1.01-2.97, p = 0.048), penoscrotal approach (OR 3.16, 95% CI 1.63-6.17, p < 0.001), and history of Peyronie’s disease (OR 2.24, 95% CI 1.31-3.82, p = 0.003) were associated with increased risk of postoperative IPP revision or explantation. On Kaplan–Meier analysis, use of RTE was associated with increased risk of postoperative complications and IPP revision or explantation within 48 months (log rank p = 0.001 and p = 0.002 respectively). Conclusions In this large multi-institutional cohort, patients with RTE experienced more hematoma, device malfunctioning, and glans related post operative complications. The use of RTE is an independent predictor of post-operative complications and IPP revision or explanation. Disclosure No.

Abstract Introduction Testosterone replacement therapy (TRT) has garnered substantial attention in recent years as a potential solution to various health concerns associated with low testosterone levels. TRT addresses symptoms ranging from low energy and libido to muscle loss and mood disturbances. Interest in TRT varies across different geographical regions, and comprehending these distinctions may assist healthcare providers in tailoring the appropriate use of TRT. Objective This study aims to assess global interest in testosterone replacement therapy and explore its correlation with available health-related and socioeconomic data. Methods Google Trends was employed to gauge online-based public interest in TRT. The data from various countries were ranked and compared using correlation statistics with health-related and socioeconomic data from the World Health Organization and the World Bank. Results Interest in TRT, as indicated by Google Trends, has experienced a consistent increase over the past five years. The top five countries with the highest levels of interest were the United States, Australia, Canada, New Zealand, and the United Kingdom, respectively. Positive correlations were identified between the rank of TRT interest for each country and government healthcare expenditure (R = 0.517, 95%CI; 0.211, 0.731) as well as gross domestic product per capita (R = 0.581, 95%CI; 0.286, 0.776). However, there was no significant correlation between TRT interest and population life expectancy (R = 0.229, 95%CI −0.130, 0.535), the percentage of the population with internet accessibility (R = 0.225, 95%CI; −0.102, 0.555), density of medical doctors per population (R = 0.096, 95%CI; −0.261, 0.430), or the WHO universal health coverage index (R = 0.314, 95%CI; −0.039, 0.598). Conclusions The analysis reveals a rising trend of interest in TRT, particularly in countries with higher GDP and greater government healthcare expenditure. This heightened interest may be attributed to improved economic status and increased healthcare spending. These findings can inform healthcare policy implementation based on each country’s income level and facilitate the monitoring of inappropriate TRT usage within individual countries. Disclosure No.

Abstract Introduction Erectile Dysfunction (ED), a prevalent and distressing condition affecting men globally, has a multifactorial etiology. Objective To investigate the potential role of diet and fluid intake on development and severity of ED. Methods Retrospective chart review of a prospectively collected database was performed for patients presenting to our Men’s Health clinic at a single academic institution between July 2018 and March 2020. Demographics, SHIM (Sexual Health Inventory for Men) and ADAM (Androgen Deficiency in Aging Males) questionnaire scores, dietary patterns, fluid consumption habits. Were documented. Patients were categorized into two groups based on their ED status determined by questionnaire scores, and comparisons were made regarding demographics, dietary preferences, and fluid intake. Results The study included 618 males, of which 513 (83%) had ED, and 105 (17%) had a normal erectile function. As expected, patients with ED were older, diabetic and hypertensive, p < 0.05. Paleo diet (p 0.030) and organic food consumption (p 0.011) were associated with a lower risk of ED, while consumption of artificial sugary drinks was linked to a higher risk of ED (p 0.036). Other diets such as vegan, vegetarian, gluten-free, keto, low-fat and Mediterranean, as well as quantity of water fluid intake were not associated with ED risks. When accounting for diabetes and hypertension on multivariate analysis, none of the dietary patterns and fluid choices maintained statistical significance. Conclusions This study highlights the complex relationship between different factors that contribute to ED. While certain dietary and fluid preferences seemed promising based on initial analysis, their significance diminished when considering the presence of diabetes and hypertension. It is evident that diet plays a role in the development of ED, but further investigation through extensive and prospective studies is needed to gain a deeper understanding. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: sprout.

Abstract Introduction Hypogonadism has been reported with substantial frequency in patients with various types of malignancies. Multiple myeloma (MM) is a cancer that affects plasma cells, a type of white blood cell responsible for producing antibodies. It is the second most common blood cancer, accounting for approximately 10% of hematologic malignancies. However, the prevalence, pathophysiology, and significance of hypogonadism as a sequela of MM or its standardized treatment regimens has not been extensively studied. Objective To characterize the existing literature on hypogonadism in patients with MM, including the prevalence, underlying mechanisms, and link to overall disease prognosis. Furthermore, we will examine the effects of testosterone therapy on MM and its hypogonadal symptomatology. Methods Relevant studies published up to November 2022 were retrieved through a search of PubMed using the keywords ‘hypogonadism’, ‘multiple myeloma’, and ‘testosterone’. Studies that reported on the presentation, management, or outcomes of patients with MM and how they were affected by a hypogonadal state were included. The search yielded 72 studies, of which 11 met the inclusion criteria. Results The most comprehensive assessment of the frequency of hypogonadism in a MM cohort found that 74% of 561 MM patients were classified as hypogonadal compared to 33% of patients in a control population. Further evaluation found that male patients with MM were found to have significantly lower levels of testosterone than control (p<0.0001). Another assessment of hormone level differences between MM patients and controls found that male patients had higher: FSH, LH, estrogen, and E/T ratios than healthy controls. Testosterone supplementation was found to lower interleukin-6 (IL-6) levels, which could potentially contribute to the adverse effects of MM. This effect could arise from the finding that IL-6 concentration was independently associated with severe symptomatology in MM patients on multivariate analysis in a study by Wang et al. (p=0.004). Hypogonadism can occur as an adverse effect of MM treatment with immunotherapy/chemotherapy initiation. A small study by Greenfield et al. found that 65% of patients intensively treated for MM were subsequently hypogonadal. This was further supported by a study by Anderson et al. examining sexual function after autologous hematopoietic stem cell transplant (AHSCT), which saw a significant increase in erectile dysfunction at 1-month follow-up from 68.4% to 100% of all patients. Conclusions There appears to be a relationship between MM and hypogonadism, potentially due to the inflammatory state caused by the disease itself. This may have some association with the inflammatory cytokine IL-6. However, there is a paucity of data fully exploring this relationship, the underlying mechanisms, and the effects of testosterone therapy on MM. The true relationship is likely multifactorial, given the mixture of studies that found hypogonadism in MM at baseline as well as after systemic treatment. Future prospective and randomized studies are necessary to elucidate the true link between MM and/or its treatment and hypogonadism. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Hims & Hers Inc, Coloplast, Clarus Therapeutics, Antares Pharma, Acerus.

Abstract Introduction The recent international outbreak of Monkeypox virus (Mpox), has raised concerns regarding the recognition and management of this disease among healthcare professionals. The genitourinary presentation of Mpox as variable cutaneous lesions poses a unique challenge for Urologists in its prevention, diagnosis, and management. Objective To assess the understanding and recognition of Mpox among international urologists and urology trainees. Methods A survey relating to the presentation, transmission, and management of Mpox was distributed to urologists and urology trainees during the joint 23rd Sexual Medicine Society of North America (SMSNA)/ 23rd International Society for Sexual Medicine (ISSM) conference. Results Out of 960 attendees, 97 (10.1%) responded to the survey. The rate of respondents who correctly identified a Mpox lesion from a series of cutaneous lesions was 25.8%. A similarly low number of respondents were able to identify the likelihood of having anogenital lesions and oral bleeding on presentation with Mpox at 15.5% and 19.6% respectively. A higher number of respondents accurately noted that diagnosis of Mpox may be made with PCR (79.4%) and that men with multiple male sexual partners are at the highest risk of transmission (72.2%) (Table 1). Conclusions When surveyed regarding the presentation, transmission, and management of Mpox, urologists and urology trainees were generally unable to accurately identify Mpox from a series of cutaneous lesions or the rate at which Mpox may present with anogenital lesions. The limited recognition of its presentation, appropriate diagnostic methods, and distinguishing features from sexually transmitted lesions raises concerns about potential missed diagnoses and delayed treatment. Continued education within the urology community may be necessary for the appropriate detection of and intervention against Mpox. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Antares Pharma, Clarus Therapeutics.

Abstract Introduction The VERTICA® is a hand-held, home use device, designed to treat “mild to moderate” and moderate erectile dysfunction (ED) using radiofrequency (RF) electrodes. These electrodes deliver sequential RF energy to the penile area, with additional electrodes on a pad applied to the perineal area to also cover the penile crus. We hypothesize that 1) RF energy raises penile temperature, enhancing erectile response, and 2) RF energy posits a direct structural and biochemical impact on tunical and corporal tissue, improving the tunical veno-occlusive mechanism. Objective The purpose of the current study is to evaluate the safety and efficacy of the VERTICA® investigational device for treatment of ED. Methods This study is a pivotal, prospective, randomized, controlled, double-blind clinical trial. Around 100, in our center 33 adult, heterosexual, and sexually active males (≥22 years) with mild to moderate and mild organic ED (IIEF EF score 11-21) will be enrolled and randomized 1:1 for Active or Sham VERTICA® treatment. Patients are instructed to use the device 3 times a week for 4 weeks (12 treatments), twice a week for an additional 4 weeks (8 treatments) and then 1-2 times a week for another 4 months. Every treatment comprises a 15-minute session involving ring electrodes, followed by an additional 15-minute session incorporating both ring and pad electrodes. Compliance and treatment data is monitored using a smartphone app. Subjects are instructed to attempt sexual activity weekly or 6 times a month, logging events in the Sexual Encounter Profile (SEP) form. Monthly follow-up assessments at months 1, 2, 3, and 6 include evaluating the efficacy of the treatment using the IIEF-EF, SEP, EHS, EDITS, and SHIM questionnaires. Enhancements in ED will be measured by comparing the scores of these questionnaires within both groups and, for every individual, before and after completing the study. Results A pilot study with 28 subjects demonstrated the device’s safety and efficacy, with no serious adverse events reported in 144 treatment sessions. Conclusions In conclusion, the VERTICA® investigational device shows promise in the treatment of mild to moderate erectile dysfunction (ED) based on the pilot study and the ongoing pivotal clinical trial. If the results of this trial are promising, the VERTICA® device could offer a novel and effective treatment option for men with mild to moderate ED, potentially improving their quality of life and sexual health. Disclosure Yes, this is sponsored by industry/sponsor: OhhMed. Clarification: Industry funding only - investigator initiated and executed study. Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout.

Abstract Introduction Management of malfunctioning inflatable penile prostheses (IPPs) is varied, with some patients undergoing complete exchange of the entire device and others undergoing exchange of non-functioning components only. The impact of partial component exchange versus complete device exchange on infectious and non-infectious complications is unknown. Objective To describe the infectious and non-infectious complications in men undergoing IPP revision with partial and complete component exchange for device malfunction. Methods We performed a multicenter retrospective cohort study of patients who underwent IPP revision. Men undergoing procedures for implant infection were excluded. Patients were divided into two groups based on whether they had complete exchange of the entire device or partial exchange of only one or two components (i.e. pump revision only, or pump and/or reservoir exchanged but cylinders left in situ). Differences between baseline demographics were assessed with two tailed student t-tests and Fisher’s exact tests. Time to revision was log transformed to reduce deviation from normality. Multivariate analysis was performed controlling for significant covariates and clinically relevant variables. A descriptive analysis was performed of non-infectious complications. Results 466 men underwent IPP revision. Of these, 377 had complete exchange of the entire device and 89 had partial component exchange. Men undergoing partial exchange had a significantly higher infection rate (6.7% vs 2.1%, p=0.034). Although the partial exchange group was more likely to receive antifungals (52.8 vs 17.8%, p<0.001) and have a modified salvage washout (78.4 vs 61.2%, p=0.003), this cohort was less likely to receive vancomycin and gentamicin for antimicrobial prophylaxis (60.7 vs 81.7%, p<0.001). Time to revision from original implantation was significantly shorter in the partial exchange group (46 vs 168 months, p<0.001). In multivariate analysis, partial exchange surgery (OR 2.6, 95%CI 0.7-9.5, p=0.15), vancomycin and gentamicin antimicrobial prophylaxis (OR 0.4, 95%CI 0.1-1.5, p=0.20), modified salvage washout (OR 1.6, 95%CI 0.3-8.4, p=0.54), and antifungal prophylaxis (OR 2.7, 95%CI 0.7-10.3, p=0.13) were no longer associated with postoperative infections. The partial exchange group had greater rates of mechanical complications (20.2% vs 10.6%, p=0.019) such as pump malfunction and tubing breakage. Conclusions While patients undergoing partial component revision were more likely to receive non-standard antibiotics, antifungal prophylaxis, and undergo a modified salvage washout, they had more infectious and mechanical/non-infectious complications. These findings suggest that partial component exchange increases the risks in men undergoing IPP revision for non-infectious indications. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific, Antares Pharma, Clarus Therapeutics, Cynosure, Promescent, Sprout, Viome

Abstract Introduction Inflatable penile prosthesis (IPP) can be used in both acute and delayed management of priapism-induced erectile dysfunction. Prolonged priapism may result in corporal fibrosis that makes IPP placement more difficult. The current literature on IPP placement in men with a history of priapism is limited to small series and often single-center experiences. Objective We sought to evaluate a multicenter experience of IPP placement in men with a history of priapism. Methods We performed a multicenter, retrospective cohort study of patients with a history of priapism undergoing IPP placement by 7 highly experienced implant surgeons. Malleable prosthesis placement patients were excluded. Demographic, intraoperative, and postoperative variables were collected. Descriptive statistics were performed using mean and standard deviation for continuous variables, whereas frequencies and percentages were used for categorical variables. We evaluated differences in complication rates in those undergoing early or delayed IPP placement. We defined early placement as ≤4 months from priapism to IPP. Results 31 patients underwent IPP placement at a mean of 97.4 ± 26.7 months following ischemic priapism. The mean duration of priapism was 52.3 ± 21.2 hours. The mean age of the cohort was 52.4 ± 4.2 years with a mean follow-up of 11.6 ± 1.3 mo. Overall, 25 patients (48.3%) had a prior shunt for priapism and 6 (19.4%) had penoscrotal decompression. Four patients (12.9%) underwent early placement and 27 (87.1%) delayed placement. Intraoperative urethral injury occurred in 1 (3.2%) patient. Infection occurred in 1 (3.2%) patient at 4 months postoperatively and was explanted without salvage. Seven (22.5%) implants were revised or removed for infectious or non-infectious complications at a mean 8.8 ± 1.0 months after implantation, of which 5 (71.4%) were cylinder-related (2 displacements of a cylinder through the corporotomy, 1 lateral displacement of the distal cylinders requiring revision, 1 proximal cylinder migration, 1 cylinder leak). No complications occurred in those undergoing early IPP placement. Full-sized cylinders (Boston Scientific CX or Coloplast Titan) were used in all cases that resulted in cylinder extrusion or migration. Narrow cylinders (Coloplast Titan NB or Boston Scientific CXR) were used in only 9 (29.1%) cases. Conclusions IPP placement in men with a history of priapism carries a notable incidence of non-infectious complications, especially in men undergoing delayed placement or when full-sized cylinders are used. Few IPPs in this series were placed early after the priapism episode, as our surgeons are predominantly at tertiary referral centers. Priapism patients should be referred to prosthetic experts early to decrease future morbidity. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Antares Pharma: SpeakBoston Scientific, Clarus Therapeutics, Coloplast, Cynosure, Promescent, Sprout, Viome

Abstract Introduction The American Urological Association (AUA) recommendations on antibiotic prophylaxis in penile implant surgery are based on low quality evidence and expert opinion. Recent evidence suggests the recommended regimens may be suboptimal. Objective To determine if the AUA recommended antibiotic regimen (vancomycin + gentamicin) for primary penile implant surgery is associated with a higher infection risk than non-standard regimens. Methods We performed a multicenter, retrospective cohort study of patients undergoing primary IPP surgery. Patients undergoing revision surgery or with a history of IPP placement were excluded. Additionally, patients who underwent concomitant procedures for Peyronie’s disease or stress urinary incontinence were excluded. Patients were divided into those receiving standard AUA antibiotic prophylaxis (vancomycin + gentamicin) and those receiving any other (non-standard) antibiotic prophylaxis. The time to postoperative device explanation due to infection via a Cox regression model, the microorganisms involved, and the management of patients with device infection were evaluated. A subgroup analysis to identify the appropriate dosage of gentamicin was also performed. Results 4,161 patients underwent primary IPP placement (2,411 received vancomycin + gentamicin and 1,750 received other regimens). The infection rate was similar between groups, 1.0 vs 1.2% for standard vs non-standard prophylaxis. In the multivariate Cox regression analysis, the use of vancomycin + gentamicin (HR: 2.74, 95%CI: 1.38-5.41, p=0.004) and diabetes (HR: 1.87, 95%CI: 1.03-3.39, p=0.04) were significantly associated with higher risk of device explantation due to infection. Concomitant infusion of antifungals (HR: 0.08, 95%CI: 0.03-0.19, p<0.001) was associated with lower risk of infection. Staphylococcus aureus and Escherichia coli were the most frequently cultured microorganisms. Device infection was most commonly managed with salvage using a malleable prosthesis (40.4%). In patients of both groups receiving gentamicin as part of perioperative antibiotic prophylaxis, the use of weight-based gentamicin compared to 80 mg gentamicin was associated with similar risk of device explantation due to infection (HR: 2.88, 95% CI: 0.83 to 10, p = 0.1). Conclusions Vancomycin + gentamicin for antibiotic prophylaxis in primary penile implant surgery is independently associated with a higher infection risk than non-standard antibiotic regimens while antifungal use is associated with lower infection risk. There does not appear to be a difference in weight-based vs low dose (80mg) gentamicin on infection risk. Our results further demonstrate the importance of antifungal use in prophylaxis regimens. Additionally, a critical review of the recommended prophylactic regimens is needed. Tailoring individual regimens to local antibiograms may provide the best infection prevention. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific, Antares Pharma, Clarus Therapeutics, Cynosure, Promescent, Sprout, Viome.

Abstract Introduction Inflatable penile prosthesis (IPP) placement is associated with high postoperative patient satisfaction. Patients often express concerns about postoperative penile length. There is scant evidence in the literature of clinical and surgical factors that predict IPP length. Objective To evaluate predictors of cylinder length for men undergoing primary IPP placement in a large multicenter cohort. Methods Patients undergoing primary IPP placement for treatment of erectile dysfunction at 16 high-volume implant centers were included. All patients had preoperative demographics, surgical characteristics, and device length retrospectively collected at their respective institutions and combined for analysis. Descriptive statistics were reported for the full group. Univariate analysis was utilized to isolate variables significantly associated with device length and all variables reaching p<0.1 were included in linear regression modeling. Results 3,953 men underwent primary IPP placement. The mean age was 61.8±10.4 years and BMI was 29.8±4.2 kg/m2. The mean total device length was 20.6±2.1cm. 1291 (32.7%) had diabetes mellitus, 641 (16.2%) were smokers, 705 (17.8%) had a prior radical prostatectomy, 195 (4.9%) had prior radiation, 549 (13.9%) had Peyronie’s disease, and 884 (22.4%) had a history of intracavernosal injections. In univariate analysis, BMI (B=0.05, 95%CI 0.04 to 0.07, p<0.001), a history of Peyronie’s disease (20.4 vs 20.6cm, p=0.02), and use of intracavernosal injection (20.7 v 20.9cm, p=0.02) were predictors of shorter total device length. Use of rear tip extenders (20.7 v 20.0cm, p<0.001), penoscrotal approach (21.0 v 20.3, p<0.001), and single corporal dilation (20.8 v 20.4cm, p<0.001) were associated with longer length. In multivariable analysis, a history of Peyronie’s disease (B=-0.29, 95%CI -0.47 to -0.11, p=0.002) and greater BMI (B=0.05, 95%CI 0.03 to 0.07, p<0.001) were predictors of shorter total device length. Independent predictors of longer device length were penoscrotal approach (B=-0.85, 95%CI -1.03 to -0.65, p<0.001), rear tip extender use (B=1.00, 95%CI 0.84 to 1.17, p<0.001), and single corporal dilation (B=-0.5, 95%CI -0.67 to -0.34, p<0.001). Conclusions In this series, Peyronie’s disease and greater BMI are independent predictors of shorter IPP device length, while use of rear tip extenders, single corporal dilation, and penoscrotal approach are independent predictors of longer device length. These results are important in counseling patients regarding expectations of postoperative length. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Intuitive Surgical, Fidelis, Urofill, Boston Scientific, Endo Pharma, Coloplast, Cynosure, Antares Pharma, Clarus Pharmaceuticals, Acerus Pharma