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Malleable Penile Prosthesis Is a Cost-Effective Treatment for Refractory Ischemic Priapism Timothy J. Tausch, MD,* Lee C. Zhao, MD,* Allen F. Morey, MD,* Jordan A. Siegel, MD,* Michael J. Belsante, MD,* Casey A. Seideman, MD,* and James R. Flemons, BBA*† *Department of Urology, UT Southwestern Medical Center, Dallas, TX, USA; † Coloplast Corporation, Minneapolis, MD, USA DOI: 10.1111/jsm.12803
ABSTRACT
Introduction. Refractory ischemic priapism (RIP) can be difficult to treat, consuming significant healthcare-related resources. Acute insertion of a malleable penile prosthesis (MPP) has been reported as an effective therapy that treats the priapism and restores sexual function. Aim. We report our 6-year, urban public hospital experience with acute insertion of MPP in patients with RIP. Methods. We retrospectively reviewed the records of patients receiving MPPs for RIP from 2007 to 2013. Data analyzed included duration of erection, number of emergency room (ER) visits, hospital admissions, days of hospitalization, and postoperative course. Costs were estimated using standard Medicare reimbursement rates. Main Outcome Measure. Healthcare-related costs of treatment of RIP episodes in men presenting to our institution. Results. During the study period, 14 men underwent MPP placement acutely for refractory priapism. Thirteen presented with RIP, and one had stuttering priapism over a 14-day hospitalization. Etiologies included sickle cell anemia (4/13, 29%), medication-induced (3/14, 21%), and idiopathic (7/14, 50%). Average preoperative duration of RIP was 82 hours with considerable consumption of health-care resources (average US $83,818 estimated cost, 4 ER visits [range 1–27], 2 hospital admissions [range 1–5], 1.5 shunt procedures [range 1–3], 5 irrigation and drainage procedures using phenylephrine injection [range 2–20], and 5 hospital admission days [range 2–14]). All patients were discharged within 24 hours of MPP surgery. Conclusions. The management of RIP is associated with multiple ER visits, prolonged hospital admissions, and significant resource utilization. MPP insertion is efficacious for the immediate resolution of refractory priapism, with potential cost and resource benefits. Tausch TJ, Zhao LC, Morey AF, Siegel JA, Belsante MJ, Seideman CA, and Flemons JR. Malleable penile prosthesis is a cost-effective treatment for refractory ischemic priapism. J Sex Med **;**:**–**. Key Words. Priapism; Erectile Dysfunction; Penile Prosthesis
Introduction
Methods
R
We queried our institutional review board– approved, institutional database of patients undergoing MPP insertion for RIP at Parkland Memorial Hospital from 2007 to 2013. We reviewed their clinical courses before MPP surgery and recorded the number of hours erect, emergency department visits, hospital admissions, corporal irrigations with phenylephrine injections, and the number/type of shunt procedures. The total costs of treatment prior to implant surgery
ecent literature suggests diminishing efficacy of shunt procedures for priapism as the duration of the priapistic episode is prolonged [1]. In cases of refractory ischemic priapism (RIP), early implantation of penile prostheses has been recommended to alleviate pain, preserve sexual function, and prevent penile shortening and fibrosis [2,3]. We reviewed our series of acute insertion of malleable penile prostheses (MPP) for RIP and analyzed associated costs.
© 2014 International Society for Sexual Medicine
J Sex Med **;**:**–**
2
Tausch et al. A
B
Figure 1 A 2-inch, longitudinal penoscrotal incision was performed to facilitate corporal dilation and malleable penile prostheses (MPP) insertion. Three pairs of traction sutures of 2-0 polydioxanone (PDS®, Ethicon Endo-Surgery, Inc, Blue Ash, OH, USA) were placed along each corporal body. The corpora was incised 3 cm, allowing for escape of ischemic blood, and irrigation of clot (A). Rosello® cavernotomes (Coloplast, Minneapolis, MN, USA) were used to dilate the fibrotic corpora and remove clot (B). During dilation, care is taken to avoid distal perforation, especially in patients who have failed shunt procedures. To minimize the risk of distal erosion, we undersize the MPP by at least 1 cm from the total measured length, so that the cylinder tip resides just proximal to the coronal sulcus. The corporotomies and wound are then closed in multiple layers with absorbable sutures
was estimated using Medicare reimbursement rates obtained from the physician fee schedule for relevant Current Procedural Terminology codes for 2013 [4]. Inpatient hospitalization costs were calculated based upon diagnostic-related group for penile procedures. To improve generalizability of the results, costs were not adjusted for teaching hospital status or geographic location. Our surgical technique is presented in Figure 1. Results
From 2007 to 2013, 14 men underwent MPP placement acutely for RIP. Thirteen (93%) presented with RIP, and one (7%) had stuttering priapism over a 14-day hospitalization. Etiologies included four (29%) with sickle cell anemia, three (21%) medication-induced, and seven (50%) idiopathic. Preoperatively, patients had painful erections for an average of 82 hours before the implant was placed with considerable consumption of healthcare resources (average US $83,818 estimated cost, 4 emergency room visits [range 1–27], 2 hospital admissions [range 1–4], 1.5 shunt procedures [range 1–3], 5 irrigation and drainage procedures using phenylephrine injection [range 2–10], and 6 hospital admission days [range 2–14]). Cost of the prosthesis was only US $3,850. Immediate pain relief was noted upon implantation; all patients were discharged within 24 hours of surgery. There were three complications (21%): one infection requiring explantation, one urethral erosion, and one impending distal extrusion, and all were subsequently reimplanted with inflatable penile prostheses. J Sex Med **;**:**–**
Discussion
Prosthetics in Priapism After 48 hours of priapism, virtually all patients show histologic evidence of necrosis of intracavernosal smooth muscle tissue, rendering shunt procedures useless in maintaining potency [1]. Early implantation of a penile prosthesis in the acute setting offers relief of the compartment syndrome, as well as treatment of erectile dysfunction [2,3,5,6]. We observed that the long corportomies function impressively as an immediate surgical shunt, leading promptly to healthy arterial inflow. In our series, implants were placed acutely during the initial admission to our hospital. All patients were discharged within 24 hours. Risk of distal erosion/extrusion was reduced by undersizing the cylinders so the tips lie just proximal to the coronal sulcus. Our infection rate was 7% (1/14) as were our erosion and extrusion rates, consistent with published reports [2]. Given the technical complexity of these acute implantations, prompt referral to an experienced implanter may prevent patient morbidity and unnecessary cost. Potential Cost Benefits With an incidence of almost 10,000 cases per year in the United States, and an average of US $41,909 per admission, priapism episodes exact a significant annual toll (estimated almost US $124 million) [7]. When analyzing the cost of treating our patients with refractory priapism, we found an average of over US $83,000 spent per patient over multiple encounters. In those with a high risk of erectile dysfunction, acute MPP insertion resulted in relief of pain and discharge within 24 hours—this treat-
3
Malleable Penile Prosthesis for Ischemic Priapism ment strategy could thus substantially decrease the resources consumed during a prolonged admission. Ready access to the implant is essential to prompt surgical intervention, as most cases are emergencies that present at night or over weekends—times when sales representatives are unavailable. Since 2007, the Coloplast Genesis® (Minneapolis, MN, USA) MPP has been available on an off-the-shelf consignment basis at our urban tertiary public hospital. The prosthesis itself represents only 5% of the total cost to treat these patients, but results in a durable cure that provides relief in all cases without need for prolonged treatment of subsequent erectile dysfunction. Conclusions
Insertion of an MPP for patients with RIP results in priapistic pain relief, preservation of sexual function, and can potentially reduce the financial and resource burden of RIP on the health-care system. Corresponding Author: Allen F. Morey, MD, Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9110, USA. Tel: (214) 648-5698; Fax: (214) 648-6310; E-mail: [email protected] Conflict of Interest: Allen F. Morey is a lecturer and meeting participant for both American Medical Systems and Coloplast. James R. Flemons is an employee of Coloplast. Statement of Authorship
Category 1 (a) Conception and Design Allen F. Morey; Lee C. Zhao; James R. Flemons (b) Acquisition of Data Lee C. Zhao; Casey A. Seideman
(c) Analysis and Interpretation of Data Lee C. Zhao; Timothy J. Tausch; Casey A. Seideman; Michael J. Belsante
Category 2 (a) Drafting the Article Timothy J. Tausch; Michael J. Belsante; Lee C. Zhao; Allen F. Morey (b) Revising It for Intellectual Content Timothy J. Tausch; Lee C. Zhao; Allen F. Morey
Category 3 (a) Final Approval of the Completed Article Allen F. Morey; Lee C. Zhao; Timothy J. Tausch References 1 Zacharakis E, Raheem AA, Freeman A, Skolarikos A, Garaffa G, Christopher AN, Muneer A, Ralph DJ. The efficacy of the T-shunt procedure and intracavernous tunneling (snake maneuver) for refractory ischemic priapism. J Urol 2014;191:164–8. 2 Ralph DJ, Garaffa G, Muneer A, Freeman A, Rees R, Christopher AN, Minhas S. The immediate insertion of a penile prosthesis for acute ischaemic priapism. Eur Urol 2009;56:1033–8. 3 Sedigh O, Rolle L, Negro CL, Ceruti C, Timpano M, Galletto E, Soltanzadeh K, Ajamy H, Hosseinee J, Al Ansari A, Shamsodini A, Fontana D. Early insertion of inflatable prosthesis for intractable ischemic priapism: Our experience and review of the literature. Int J Impot Res 2011;23:158–64. 4 Centers for Medicare and Medicaid Services. Physician Fee Schedule. 2013. Available at: http://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/PhysicianFeeSched/ (accessed December 15, 2013). 5 Monga M, Broderick GA, Hellstrom WJ. Priapism in sickle cell disease: The case for early implantation of the penile prosthesis. Eur Urol 1996;30:54–9. 6 Rees RW, Kalsi J, Minhas S, Peters J, Kell P, Ralph DJ. The management of low-flow priapism with the immediate insertion of a penile prosthesis. BJU Int 2002;90:893–7. 7 Stein DM, Flum AS, Cashy J, Zhao LC, McVary KT. Nationwide emergency department visits for priapism in the United States. J Sex Med 2013;10:2418–22.
J Sex Med **;**:**–**
Malleable Penile Prosthesis Is a Cost-Effective Treatment for Refractory Ischemic Priapism Timothy J. Tausch, MD,* Lee C. Zhao, MD,* Allen F. Morey, MD,* Jordan A. Siegel, MD,* Michael J. Belsante, MD,* Casey A. Seideman, MD,* and James R. Flemons, BBA*† *Department of Urology, UT Southwestern Medical Center, Dallas, TX, USA; † Coloplast Corporation, Minneapolis, MD, USA DOI: 10.1111/jsm.12803
ABSTRACT
Introduction. Refractory ischemic priapism (RIP) can be difficult to treat, consuming significant healthcare-related resources. Acute insertion of a malleable penile prosthesis (MPP) has been reported as an effective therapy that treats the priapism and restores sexual function. Aim. We report our 6-year, urban public hospital experience with acute insertion of MPP in patients with RIP. Methods. We retrospectively reviewed the records of patients receiving MPPs for RIP from 2007 to 2013. Data analyzed included duration of erection, number of emergency room (ER) visits, hospital admissions, days of hospitalization, and postoperative course. Costs were estimated using standard Medicare reimbursement rates. Main Outcome Measure. Healthcare-related costs of treatment of RIP episodes in men presenting to our institution. Results. During the study period, 14 men underwent MPP placement acutely for refractory priapism. Thirteen presented with RIP, and one had stuttering priapism over a 14-day hospitalization. Etiologies included sickle cell anemia (4/13, 29%), medication-induced (3/14, 21%), and idiopathic (7/14, 50%). Average preoperative duration of RIP was 82 hours with considerable consumption of health-care resources (average US $83,818 estimated cost, 4 ER visits [range 1–27], 2 hospital admissions [range 1–5], 1.5 shunt procedures [range 1–3], 5 irrigation and drainage procedures using phenylephrine injection [range 2–20], and 5 hospital admission days [range 2–14]). All patients were discharged within 24 hours of MPP surgery. Conclusions. The management of RIP is associated with multiple ER visits, prolonged hospital admissions, and significant resource utilization. MPP insertion is efficacious for the immediate resolution of refractory priapism, with potential cost and resource benefits. Tausch TJ, Zhao LC, Morey AF, Siegel JA, Belsante MJ, Seideman CA, and Flemons JR. Malleable penile prosthesis is a cost-effective treatment for refractory ischemic priapism. J Sex Med **;**:**–**. Key Words. Priapism; Erectile Dysfunction; Penile Prosthesis
Introduction
Methods
R
We queried our institutional review board– approved, institutional database of patients undergoing MPP insertion for RIP at Parkland Memorial Hospital from 2007 to 2013. We reviewed their clinical courses before MPP surgery and recorded the number of hours erect, emergency department visits, hospital admissions, corporal irrigations with phenylephrine injections, and the number/type of shunt procedures. The total costs of treatment prior to implant surgery
ecent literature suggests diminishing efficacy of shunt procedures for priapism as the duration of the priapistic episode is prolonged [1]. In cases of refractory ischemic priapism (RIP), early implantation of penile prostheses has been recommended to alleviate pain, preserve sexual function, and prevent penile shortening and fibrosis [2,3]. We reviewed our series of acute insertion of malleable penile prostheses (MPP) for RIP and analyzed associated costs.
© 2014 International Society for Sexual Medicine
J Sex Med **;**:**–**
2
Tausch et al. A
B
Figure 1 A 2-inch, longitudinal penoscrotal incision was performed to facilitate corporal dilation and malleable penile prostheses (MPP) insertion. Three pairs of traction sutures of 2-0 polydioxanone (PDS®, Ethicon Endo-Surgery, Inc, Blue Ash, OH, USA) were placed along each corporal body. The corpora was incised 3 cm, allowing for escape of ischemic blood, and irrigation of clot (A). Rosello® cavernotomes (Coloplast, Minneapolis, MN, USA) were used to dilate the fibrotic corpora and remove clot (B). During dilation, care is taken to avoid distal perforation, especially in patients who have failed shunt procedures. To minimize the risk of distal erosion, we undersize the MPP by at least 1 cm from the total measured length, so that the cylinder tip resides just proximal to the coronal sulcus. The corporotomies and wound are then closed in multiple layers with absorbable sutures
was estimated using Medicare reimbursement rates obtained from the physician fee schedule for relevant Current Procedural Terminology codes for 2013 [4]. Inpatient hospitalization costs were calculated based upon diagnostic-related group for penile procedures. To improve generalizability of the results, costs were not adjusted for teaching hospital status or geographic location. Our surgical technique is presented in Figure 1. Results
From 2007 to 2013, 14 men underwent MPP placement acutely for RIP. Thirteen (93%) presented with RIP, and one (7%) had stuttering priapism over a 14-day hospitalization. Etiologies included four (29%) with sickle cell anemia, three (21%) medication-induced, and seven (50%) idiopathic. Preoperatively, patients had painful erections for an average of 82 hours before the implant was placed with considerable consumption of healthcare resources (average US $83,818 estimated cost, 4 emergency room visits [range 1–27], 2 hospital admissions [range 1–4], 1.5 shunt procedures [range 1–3], 5 irrigation and drainage procedures using phenylephrine injection [range 2–10], and 6 hospital admission days [range 2–14]). Cost of the prosthesis was only US $3,850. Immediate pain relief was noted upon implantation; all patients were discharged within 24 hours of surgery. There were three complications (21%): one infection requiring explantation, one urethral erosion, and one impending distal extrusion, and all were subsequently reimplanted with inflatable penile prostheses. J Sex Med **;**:**–**
Discussion
Prosthetics in Priapism After 48 hours of priapism, virtually all patients show histologic evidence of necrosis of intracavernosal smooth muscle tissue, rendering shunt procedures useless in maintaining potency [1]. Early implantation of a penile prosthesis in the acute setting offers relief of the compartment syndrome, as well as treatment of erectile dysfunction [2,3,5,6]. We observed that the long corportomies function impressively as an immediate surgical shunt, leading promptly to healthy arterial inflow. In our series, implants were placed acutely during the initial admission to our hospital. All patients were discharged within 24 hours. Risk of distal erosion/extrusion was reduced by undersizing the cylinders so the tips lie just proximal to the coronal sulcus. Our infection rate was 7% (1/14) as were our erosion and extrusion rates, consistent with published reports [2]. Given the technical complexity of these acute implantations, prompt referral to an experienced implanter may prevent patient morbidity and unnecessary cost. Potential Cost Benefits With an incidence of almost 10,000 cases per year in the United States, and an average of US $41,909 per admission, priapism episodes exact a significant annual toll (estimated almost US $124 million) [7]. When analyzing the cost of treating our patients with refractory priapism, we found an average of over US $83,000 spent per patient over multiple encounters. In those with a high risk of erectile dysfunction, acute MPP insertion resulted in relief of pain and discharge within 24 hours—this treat-
3
Malleable Penile Prosthesis for Ischemic Priapism ment strategy could thus substantially decrease the resources consumed during a prolonged admission. Ready access to the implant is essential to prompt surgical intervention, as most cases are emergencies that present at night or over weekends—times when sales representatives are unavailable. Since 2007, the Coloplast Genesis® (Minneapolis, MN, USA) MPP has been available on an off-the-shelf consignment basis at our urban tertiary public hospital. The prosthesis itself represents only 5% of the total cost to treat these patients, but results in a durable cure that provides relief in all cases without need for prolonged treatment of subsequent erectile dysfunction. Conclusions
Insertion of an MPP for patients with RIP results in priapistic pain relief, preservation of sexual function, and can potentially reduce the financial and resource burden of RIP on the health-care system. Corresponding Author: Allen F. Morey, MD, Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9110, USA. Tel: (214) 648-5698; Fax: (214) 648-6310; E-mail: [email protected] Conflict of Interest: Allen F. Morey is a lecturer and meeting participant for both American Medical Systems and Coloplast. James R. Flemons is an employee of Coloplast. Statement of Authorship
Category 1 (a) Conception and Design Allen F. Morey; Lee C. Zhao; James R. Flemons (b) Acquisition of Data Lee C. Zhao; Casey A. Seideman
(c) Analysis and Interpretation of Data Lee C. Zhao; Timothy J. Tausch; Casey A. Seideman; Michael J. Belsante
Category 2 (a) Drafting the Article Timothy J. Tausch; Michael J. Belsante; Lee C. Zhao; Allen F. Morey (b) Revising It for Intellectual Content Timothy J. Tausch; Lee C. Zhao; Allen F. Morey
Category 3 (a) Final Approval of the Completed Article Allen F. Morey; Lee C. Zhao; Timothy J. Tausch References 1 Zacharakis E, Raheem AA, Freeman A, Skolarikos A, Garaffa G, Christopher AN, Muneer A, Ralph DJ. The efficacy of the T-shunt procedure and intracavernous tunneling (snake maneuver) for refractory ischemic priapism. J Urol 2014;191:164–8. 2 Ralph DJ, Garaffa G, Muneer A, Freeman A, Rees R, Christopher AN, Minhas S. The immediate insertion of a penile prosthesis for acute ischaemic priapism. Eur Urol 2009;56:1033–8. 3 Sedigh O, Rolle L, Negro CL, Ceruti C, Timpano M, Galletto E, Soltanzadeh K, Ajamy H, Hosseinee J, Al Ansari A, Shamsodini A, Fontana D. Early insertion of inflatable prosthesis for intractable ischemic priapism: Our experience and review of the literature. Int J Impot Res 2011;23:158–64. 4 Centers for Medicare and Medicaid Services. Physician Fee Schedule. 2013. Available at: http://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/PhysicianFeeSched/ (accessed December 15, 2013). 5 Monga M, Broderick GA, Hellstrom WJ. Priapism in sickle cell disease: The case for early implantation of the penile prosthesis. Eur Urol 1996;30:54–9. 6 Rees RW, Kalsi J, Minhas S, Peters J, Kell P, Ralph DJ. The management of low-flow priapism with the immediate insertion of a penile prosthesis. BJU Int 2002;90:893–7. 7 Stein DM, Flum AS, Cashy J, Zhao LC, McVary KT. Nationwide emergency department visits for priapism in the United States. J Sex Med 2013;10:2418–22.
J Sex Med **;**:**–**
