Worldwide Trends in Penile Implantation Surgery

Data From Over 63,000 Implants

Wesley Baas; Blake O'Connor; Charles Welliver; Peter J. Stahl; Doron S. Stember; Steven K. Wilson; Tobias S. Köhler

Disclosures

Transl Androl Urol. 2020;9(1):31-37. 

In This Article

Discussion

Notably, from this large data collection, a global snapshot of the international trends in penile implantation over the last decade is illuminated. Over the 7-year period of 2005–2012, we have data points for 63,013 penile implantations that occurred. Remarkably, the vast majority (85.9%) of penile implants were done in the United States. From the AMS data, Germany and the United Kingdom were the next two highest implanting countries, but with drastically smaller numbers than the United States. Germany accounts for 2.3% and UK for 2.1% of worldwide implants. In general, only moderate increases were noted in most countries. Australia had a surprising adoption of implantation, and subsequently experienced an increase of over 3,000% during the study period. Within the United States, nine states (New York, Florida, California, Louisiana, Alabama, Pennsylvania, Texas, North Carolina, and Illinois) accounted for 60.8% of the Coloplast implants done nationally.

Interesting geographic variation is noted in the data with reported surgical approaches often varying impressively between countries. Figure 5 demonstrates the predominance of the PS approach, accounting for 60–78% percent of the approaches done over the study period. There does not appear to be a predictive pattern of surgical approach. It appears fluid in nature over the course of the study period. However, Belgium/Netherlands performed 65% of implants via the INF approach, while all other countries had a penoscotal preponderance (Figure 4). The reason for this INF predominance in the Netherlands is unknown; however, it certainly seems feasible that in countries with a relatively low number of implants, the practice patterns of a higher volume implanter may be quite likely to influence the overall results. Additionally, the reliability of the company representatives in a region, as well as their accuracy and completeness of the PIF may influence how the data is interpreted from that region.

The percent change over a 7-year period in the number of annual Coloplast implants done by surgeons in the United States compared to those outside the US can be seen in Table 2. It is notable for the fact that outside of the US, there was either no data or no change in the number of implanters for all categories greater than 16 implants per year. This suggests that there were only a few high-volume implanters outside the US in 2005, and a subsequent rise in high volume implanters was not captured by this analysis. Another explanation is simply that the number of high-volume implanters outside the United States has remained unchanged.

While there has apparently been little growth in high volume implanters outside of the United States, the implant business domestically has blossomed. In terms of implanters within the United States, a rather large increase was seen in the 16–30, 31–50, and >100 implant per year categories. The highest volume category might be deceiving; the 300% increase in the >100 category likely indicates an increase from one physician to three who are extremely high volume, although that cannot be proven from the data. The 46.7% and 66.7% increases seen in the 16–30 and 31–50 categories, respectively, likely correlate with a corresponding 6.5% and 8.3% decreases seen in the 1–5 and 6–15 categories. This would represent low volume implanters increasing the number of implants they perform yearly by additional focus on this subspecialty of prosthetic urology. This could also be secondary to the steady increase in the overall number of implants done yearly over our study period.

Perhaps the increase in the 16–30 and 31–50 categories reflects the growing number of graduating residents who have had more experience with IPPs than their predecessors, and are likely performing more implants once in practice than previous graduates. Past studies have looked into implant practice patterns with varying methodologies. Oberlin et al. recently found that 75% of IPPs in the United States were done by urologist who perform 4 or fewer implant operations yearly, whereas "high volume surgeons" (>50 per year) performed 16% of implants despite accounting for <1% of the urologists studied.[10]

Etiology of erectile function was found to vary across regions as well (Figure 3). In the United States, "organic" causes, prostatectomy, and diabetes accounted for the large majority of reported etiologies of ED. A large predominance of "organic" causes was found in South Korea (52%) compared to other countries that report a larger percent of post-prostatectomy patients such as Australia with 27% and France with 29%. Interpreting this data is quite difficult because of the vague descriptor of "organic" ED. Organic erectile dysfunction could represent a wide spectrum of ED including diabetes, vascular disease, hypogonadism, or a combination of a variety of factors. With that being said, the etiologies of ED in our study correlate to those found in the recent PROPPER study. Using an implant database, the PROPPER study found the most common etiologies of ED resulting in IPP placement were radical prostatectomy (28%), diabetes (21.6%), cardiovascular disease (19.6%), and Peyronie's disease (8.9%).[11] It is unclear how patient age played into the etiology of erectile function seen in this study.

Limitations of this study primarily relate to issues surrounding the PIF. As we used information from PIFs completed by company representatives and others to generate these databases, data from surgeries where no PIF was attained could not be included. Additionally, forms that were incompletely or erroneously filled out may influence captured data.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....