New Findings Regarding the Influence of Assistants on Surgical Outcomes in Inflatable Penile Prosthesis Implantation - Beyond the Abstract

Erectile dysfunction (ED) is widely prevalent in the United States, affecting as many as 52% of men between 40 and 70.1  Inflatable penile prostheses (IPP) implantation is the definitive treatment for refractory ED. IPP surgery has high rates of efficacy2,3  and satisfaction 4,5  among patients. Despite this, overall utilization of IPP surgery among eligible patients remains low, and may even be declining. 6  One potential cause of this issue may be inadequate exposure to IPP surgery during residency.

The reasons for inconsistent resident exposure to IPP surgery are multifactorial. Residents often lack exposure to IPP implantation during their training, and only 15% of residency programs have a dedicated implant surgeon.7  There may also be hesitancy among attending urologists to include trainees in these challenging procedures. Although IPP complications can be infrequent with contemporary techniques and implants, these complications can still be devastating. Implant surgeons are understandably reluctant to incorporate teaching if they perceive it may influence outcomes.

This retrospective study compares a single-surgeon’s experience over the course of 253 primary and revision IPP surgeries with assistance from either a resident or a dedicated registered nurse first assistant (RNFA). Assistant selection was determined purely by schedule availability. Resident training level varied from postgraduate year (PGY) 2 to 5. Pertinent patient characteristics and surgical complications (including device complications, surgical site infection, post-operative bleeding, iatrogenic injury, cardiovascular events, pulmonary events, and urinary retention) were evaluated. Measured outcomes included operative time, emergency room (ER) visits, unplanned post-operative visits, pain medication refills, and the Clavien-Dindo grade of surgical complications.

The only significant differences among outcomes in resident cases were a modest 16.5 minute increase in operative time (71.4 min vs 87.9 min, p < 0.01) and an increase in post-operative ER visits (3.0% vs 10.6%, p = 0.03). Subgroup analysis by PGY level indicated that more senior resident involvement was associated with longer operative time, which indicates the increased participation of trainees in these cases. Residents were involved in more revision cases and in those with medically complex patients due to scheduling at the main hospital (a tertiary referral center) versus smaller regional hospitals. We thus speculate that resident involvement did not increase complications despite being disproportionately involved in more complex cases. This also may have played a role in the increase in postoperative ER visits, which was not associated with any difference in postoperative complications as graded on the Clavien-Dindo scale.

Our findings largely agree with previous research in urology11-13 and other surgical fields 8,9  that supports the notion that resident involvement increases operative time but not surgical complications or long-term outcomes. Our study is limited by lack of randomization, the retrospective nature, and the single-center/single-surgeon dataset. Despite these limitations, it represents a critical first step in addressing the need to establish more comprehensive IPP surgical training for residents. Given that the experience at our center is in-line with related surgical education research regarding trainee involvement, the results may be more generally applicable. We suggest expert implant surgeons nationwide may incorporate trainees with confidence. Increasing resident exposure during training could help improve access to life-changing treatment for millions of men suffering from ED.

Written by: James M. Jones III, Geisel School of Medicine at Dartmouth, Hanover, NH, USA

  1. Laumann, E. O., Paik, A. & Rosen, R. C. Sexual dysfunction in the United States: Prevalence and predictors. J. Am. Med. Assoc. 281, 537–544 (1999).
  2. Mulhall, J. P., Ahmed, A., Branch, J. & Parker, M. Serial assessment of efficacy and satisfaction profiles following penile prosthesis surgery. J. Urol. 169, 1429–1433 (2003).
  3. Lee, D. J. et al. Trends in the Utilization of Penile Prostheses in the Treatment of Erectile Dysfunction in the United States. J. Sex. Med. 12, 1638–1645 (2015).
  4. Rajpurkar, A. & Dhabuwala, C. B. Comparison of satisfaction rates and erectile function in patients treated with sildenafil, intracavernous prostaglandin E1 and penile implant surgery for erectile dysfunction in urology practice. J. Urol. 170, 159–163 (2003).
  5. Saavedra-Belaunde, J. A., Clavell-Hernandez, J. & Wang, R. Epidemiology regarding penile prosthetic surgery. Asian J. Androl. 22, 2–7 (2020).
  6. Rezaee, M. E., Goddard, B., Munarriz, R. M. & Gross, M. S. Regional Variation in Penile Prosthesis Utilization among Medicare Patients with Erectile Dysfunction. Urology 141, 64–70 (2020).
  7. Kovac, J. R. Centers of excellence for penile prosthetics are a novel concept that will likely prove difficult to implement. Transl. Androl. Urol. 6, S898–S899 (2017).
  8. Archie, J. P. Influence of the first assistant on abdominal aortic aneurysm surgery. Texas Hear. Inst. J. 19, 4–8 (1992).
  9. Mahan, M. E. et al. First assistant impact on early morbidity and mortality in bariatric surgery. Surg. Obes. Relat. Dis. 15, 1541–1547 (2019).
Read the Abstract
email news signup