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Preoperative counseling and expectation management for inflatable penile prosthesis implantation
Gopal L. Narang1, Bradley D. Figler1, Robert M. Coward1,2
1Department of Urology, UNC School of Medicine, Chapel Hill, NC, USA; eigh, NC, USA



Post-operative satisfaction
……Contemporary series have cited IPP satisfaction rates from 78–96% . …… among a cohort of 47 men who underwent IPP placement and reported 79% satisfaction. When analyzing the reasons for satisfaction, they noted psychological factors, relational factors, improvements of sexual function, and improvement in voiding (63). …..Although the vast majority of patients are satisfied with IPP placement, minor dissatisfaction can occur. Poor surgical outcomes such as infection, erosion, device failure, or intraoperative complications clearly may affect satisfaction. Other than recognized complications,….patient dissatisfaction was attributed to decreased penile length, unrealistic expectations, unnatural feel, infrequent intercourse, delayed ejaculation, and partner dissatisfaction . Inappropriate assumptions regarding the penile prosthesis, its implantation, the resulting erection, or its effect on preexisting relationships may be causes for post-operative dissatisfaction …… Focused communication regarding changes in penile length and sensation as well as the dynamics of partner satisfaction are the next key steps in expectation management.

Penile length and sensation
One of the most common reasons for post-operative dissatisfaction after penile prosthesis implantation is perceived loss of penile length (66). Over 70% of patients endorse a loss in length, even in the absence of measurable evidence (48). Preoperative stretched length provides a realistic expectation for post-operative results (67). Patients should be counseled on post-operative length and understand that IPP placement will help restore rigidity but not augment length, even when the lengthening cylinder of the AMS 700 LGX is chosen. Strategies to maintain length, such as preoperative vacuum erection device use, have been proposed and may benefit overly concerned patients. While the authors of this review do not routinely recommend it, a suggestion of a short period of preoperative vacuum therapy or penile traction for certain patients prior to penile implant surgery may facilitate active participation on the patient’s part to help them achieve what they perceive to be the maximum possible length. Patients with a history of radical prostatectomy, corporal fibrosis from such conditions as priapism or intracavernosal injections, and Peyronie’s disease are at increased risk of penile shortening and may require additional focused counseling (43).
Changes in penile sensation should also be addressed preoperatively. Poor glandular engorgement after prosthesis implantation can affect patient and partner satisfaction (66). The use of intra-urethral alprostadil may be an effective therapeutic option for some patients lacking glandular engorgement (68). Some may experience an unnatural feeling with intercourse which can also influence satisfaction (69). This can improve with time, and additionally may improve with appropriate sex or couple’s therapy. Ultimately, setting appropriate preoperative expectations regarding penile length and sensation is the best way to limit post-operative dissatisfaction for these common complaints.


Partner satisfaction
Researchers have shown that satisfaction after surgery is influenced by both the patient and the partner. Gittens and colleagues evaluated patient and partner satisfaction after IPP placement using patient surveys and demonstrated 77.8% and 78.1% satisfaction, respectively (59). When further examining the relationship, they found that patients who were more satisfied with their implant had statistically significant higher partner satisfaction scores, compared with men reporting dissatisfaction with their device. Interestingly, patients who were dissatisfied with their implant were more likely to have partners with low female sexual functional scores (70). This observation highlights the importance of counseling the female partner prior to placement of the IPP in order to assess female partner sexual dysfunction and libido.
Such a study speaks to the multifaceted and interconnected nature of patient and partner satisfaction. Partners are often overlooked during preoperative counseling and unaware of changes that may occur with implantation. These changes, such as decreased penile length, girth, and glandular rigidity can affect a partner’s sexual experience. Furthermore, IPP implantation alters the dynamics of intercourse, as prosthesis inflation and deflation need to be incorporated seamlessly and may prove difficult for some patients.
Involving partners early in preoperative counseling may help optimize the post-operative experience. Counseling may facilitate communication and help set appropriate expectation. Patients and partners may also benefit from pre-surgical sex therapy, focusing on increasing sexual communication and offering strategies to apply postoperatively (8).

Conclusions
Preoperative counseling is a dynamic process that begins at the first visit and continues until the patient enters the operating room,,,,,,,,. Lastly, expectation management with a detailed discussion of penile length, sensation, and patient and partner satisfaction is paramount to having a satisfied patient after placement of an IPP. Providing accurate, realistic expectations ultimately prepares patients for the best possible outcomes.

robertm wrote:It's interesting that they imply that pre-operative VED therapy could have psychological benefits but not real physical benefits. That's disappointing.