Stesura Seveso 237Archivio Italiano di Urologia e Andrologia 2021; 93, 2 ORIGINAL PAPER No conflict of interest declared. highest patient and partner satisfaction among all treat- ment options (3). In the literature, the rate of patient and partner satisfaction varies between 70 and 87% (4).The high satisfaction of the couples also increases the quali- ty of their sexual lives (5). Short form (SF) 36 scale is used to measure patient’s qual- ity of life (QoL). It has both easy and short applicability. Since it is not specific to any disease group, it is recom- mended to be used in all physical disease groups to determine QoL, to reveal the psychosocial aspect of the disease and to determine the change in treatment. (6). Ure et al. evaluated patients’ QoL with SF 36 scale and observed that it was significantly increased after PPI compared to the preoperative period (7). However, in studies about patient QoL who underwent PPI, partner QoL was not mentioned much (8). In the current study, patients that did not respond to first-line and second-line treatments, and therefore underwent two-piece PPI were evaluated. The changes in QoL with satisfaction levels of patients' and partners' were retrospectively examined. MATERIALS AND METHODS The data of 61 patients that underwent PPI due to organ- ic ED between March 2016 and March 2020 were retro- spectively reviewed. In total 45 patients and 45 partners agreed to voluntarily participate in the study. Inclusion criteria: male patients with placement of two-piece PPI and their female partners, having not received a psychi- atric diagnosis and treatment before PPI in their anamne- sis, postoperative follow-up period of at least one year. Depending on the medical history and socioeconomic sta- tus of the patients, the type of prosthesis to be applied was decided. The patients were informed about possible intra- operative and postoperative complications. Two-piece prosthesis implantation was performed under spinal anes- thesia. In the perioperative period, the penoscrotal region was mechanically cleaned using chlorhexidine alcohol for 10 min. All operations were performed with a penoscro- tal incision. Dual antibiotics (ciprofloxacin and amoxi- cillin-clavulanic acid) were continued for two weeks after hospital discharge. The patients were trained to use the prosthesis after one month and were allowed to use the prosthesis after six weeks. Objective: The aim of this study is to retro- spectively examine patient-partner satisfac- tion and changes in quality of life due to two-piece penile pros- thesis implantation (PPI). There is no data about partner Quality of Life (QoL) related to two-piece PPI in the literature. Material and Methods: SF 36 scale and modified Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS), which were filled before two-piece PPI and at the sixth postoperative month follow-up by male patients (n = 45) and female partners (n = 45), were evaluated. Results: We found patient-partner satisfaction rates as 80% and 86% respectively. The changes in all mean scores of SF 36 (mean total score, mean physical health score and mean mental health score) were statistically significant (p < 0.01). Again, the differences between all mean scores of SF 36 accord- ing to the level of patient-partner satisfaction were statistically significant (p < 0.01). Conclusions: Two-piece PPI is an important option for ED treat- ment. It provides significant improvement in patient-partner QoL with high treatment satisfaction. KEY WORDS: Two-piece penile prosthesis implantation; Patient- partner satisfaction; Quality of life. Submitted 13 December 2020; Accepted 2 January 2021 INTRODUCTION Erectile dysfunciton (ED) is a benign disease and it affects physical and psychosocial health condition. It has an important effect on patient’s and partner’s quality of life. ED treatment consists of three steps. Lifestyle modifica- tion and risk factor modification should be performed either before or together with ED treatment. Oral phos- phodiesterase 5 inhibitors (PDE5I), vacuum erection device, topical/intraurethralal prostadil, and shock wave therapy are used in the first-line treatment. In the second-line treatment, intracavernosal injection of alprostadil or combination therapy is applied. For the third-line treatment, penile prosthesis implantation (PPI) is available (1). Treatment failure is seen in approximately 80% of patients due to their discontinuation with first- line and second-line treatment (2). PPI is therefore an important option for patients that do not comply with or respond to these therapies. In the treatment of ED, PPI is a method that provides Does two-piece PPI provide improvement in patient-partner quality of life? Engin Özbay 1, Remzi Salar 2, Halil Ferat Öncel 2 1 SBU Istanbul Kanuni Sultan Süleyman Research and Training Hospital, Department of Urology, Turkey; 2 SBU Sanlıurfa Mehmet Akif İnan Research and Training Hospital, Department of Urology, Turkey. DOI: 10.4081/aiua.2021.2.237 Summary Archivio Italiano di Urologia e Andrologia 2021; 93, 2 E. Özbay, R. Salar, H.F. Öncel 238 SF-36 scale was respectively administered before PPI and at the postoperative sixth month follow-up by face-to- face interviews. Modified Erectile Dysfunction Inventory of Treatment Satisfaction (mEDITS) was filled at the postop- erative sixth month, too. Statistical analysis IBM SPSS Statistics 22.0 program was used for statistical analysis while evaluating the findings obtained in the study. While evaluating the study data, in addition to descriptive statistical methods (Mean, Standard devia- tion), Paired Samples t test was used for the pre-post comparisons of the parameters showing normal distribu- tion. Student t test was used for comparisons between the two groups. Significance was evaluated at the p < 0.05 level. RESULTS The mean age of 45 male patients was 49.7 (± 12) years, and the mean age of their female partners was 42.3 (± 10) years. The mean follow-up period was 40 (± 23) months. Diabetes mellitus (%42), radical prostatectomy (%14), penile vascular disease (%38) and Peyronie dis- ease (%6) were the etiology of ED. Since there was no patient that presented to the hospital with priapism, we did not include it in the table. The American Medical Service (AMS®) two-piece penile prosthesis was implant- ed in 45 patients. The mean length of hospital stay was three days. In the early postoperative period, one patient developed scrotal hematoma and one developed soft tis- sue infection due to negligent antibiotic use. In two patients, penoscrotal pain lasted for two months postop- eratively. At the fourth postoperative month, mechanical damage was observed in the two-piece penile prosthesis of one patient. The patient-partner satisfaction rates were evaluated using mEDITS at the sixth month. According to the results, 80% of the patients (n = 36) and 86.7% of the partners (n = 39) expressed satisfaction with PPI while 20% of the patients (n = 9) and 13.4% of the part- ners (n = 6) were dissatisfied with the procedure. SF 36 scale can also be evaluated under two main subscales as “Physical Health” and “Mental Health”. Table 1 shows the evaluation of SF-36 scores before and after PPI. According to mean total score before PPI, the increase seen in mean total score after PPI was statistically signifi- cant (p < 0.01) in patients. And also the increases seen in mean physical health score and mean mental health score after PPI were statistically significant (p < 0.01). According to Table 1, the statistical results of the part- ners were similar to the statistical results of the patients (p < 0.01). Table 2 shows the evaluation of SF-36 scores according to satisfaction status. The mean total score of the satisfied group after PPI was significantly higher than the dissatisfied group (p < 0.01). Again mean mental health score and mean physical health score of the satis- fied group after PPI were significantly higher than the dissatisfied group (p < 0.01). According to Table 2, the statistical results of partners showed to be similar to the statistical results of the patients (p < 0.01). DISCUSSION Two-piece prostheses are preferred in patients who have undergone or are scheduled to undergo organ transplan- tation in the pelvic region, those with a history of radical pelvic surgery or pelvic radiotherapy, and cases that pose difficulty in terms of reservoir placement in the Retzius region (9). Other reasons for the preference of two-piece prostheses include their simple application, which makes it easier for the physician to guide the patients in terms of their use and also the full cost coverage of a two- piece penile prosthesis by Turkish Social Security Institution (10). Lastly, in socioeconomically and socio- culturally developed countries, three-piece prostheses are the most preferred type since they can mimic erec- tion as close to nature as possible and have a more cos- metic appearance (11). The disadvantages of three-piece prostheses are that mechanical damage complicates cases and they are more expensive than other types of pros- thesis (12). In this study, we used two-piece prostheses for their ease of use and socioeconomic reasons, as well as due to the presence of radical pelvic surgery history in the study population. The most common cause of dissatisfaction after PPI is shortening of the penile length, which is generally 1 to 2 cm (13). In a previous study, the satisfaction rate of patients that underwent prosthesis implantation due to priapism was observed to be 60% due to the complaint of penile shortening (14). Patients with Peyronie’s disease that undergo PPI may require additional surgical proce- dures to maintain penile length (15). Other reasons for patient dissatisfactions include the development of post- operative infections, mechanical damage, erosion, penile pain, short prosthesis, and soft glans syndrome (13). Presence of DM, spinal cord injury, revision surgery, steroid-dependent patients and complicated PPI proce- dure increase the risk of postop infection. When prosthe- Table 1. Evaluation of SF-36 scores before and after PPI. Before PPI After PPI p Mean ± SD Mean ± SD Male patients Physical health 63.25 ± 9.35 82.11 ± 16.63 0.001** Mental health 58.35 ± 13.65 81.89 ± 18.55 0.001** Total scores 60.80 ± 10.69 82.01 ± 17.45 0.001** Female partners Physical health 62.06 ± 10.43 84.52 ± 15.21 0.001** Mental health 55.34 ± 13.92 80.09 ± 19.52 0.001** Total scores 58.69 ± 11.69 82.31 ± 17.35 0.001** Paired Samples t test. **p < 0.01. Table 2. Evaluation of SF-36 scores according to satisfaction status. Unsatisfied Satisfied p Mean ± SD Mean ± SD Male patients Physical health 52.33 ± 13.47 89.56 ± 4.61 0.001** Mental health 46.42 ± 8.23 90.77 ± 3.55 0.001** Total scores 49.37 ± 10.67 90.16 ± 3.83 0.001** Female partner Physical health 49.10 ± 10.63 89.97 ± 4.96 0.001** Mental health 35.38 ± 10.17 86.96 ± 7.96 0.001** Total scores 42.24 ± 10.39 88.47 ± 6.46 0.001** Paired Samples t test. **p < 0.01. sis infection develops, all elements of the prosthesis are removed (16). Infection treatment is applied. If the new prosthesis is implanted 3-6 months later, the procedure becomes very difficult and the penis becomes shorter. To prevent this complication, salvage procedure can be performed. While removing the prosthesis, mechanical cleaning is applied to the infected tissues with antibiotic solutions in the same session. New PPI is applied in the same session or postponed after 6-8 weeks (17). In our study three patients were dissatisfied with the shortening of their penis length, two patients used oral ciprofloxacin for two months to relieve penile pain. The penile prosthesis of one patient was replaced due to mechanical damage. Soft tissue infection was observed in one patient and was suppressed with intravenous antibiotherapy. The unnatural appearance of the prosthesis and the unnatural sensation may also be the cause of dissatisfac- tion for patient and partner (18). Sexual desire disorder, sexual arousal disorders, orgasm and ejeculation prob- lems can also be the cause of dissatisfaction with the patient and partner related to penile prosthesis implan- tation (19). In the current study three patients were dis- satisfied due to ejaculation disorder, two patients and four partners complained of not being fully satisfied with orgasm and one couple was dissatisfied due to the unnat- ural appearance of the penis. In a study conducted with two-piece prostheses, the patient-partner satisfaction rates were observed to be over 80% (20). Çayan et al. conducted a PPI study with 883 patients and reported no statistically significant dif- ference in patient-partner satisfaction rates related to two- and three-piece prostheses, while their satisfaction rates were higher than one-piece prostheses (21). In our study, we calculated the patient and partner satisfaction rates as 80% and 86%, respectively, which is consistent with the literature. Ozbay et al. in a study observed that patients with erec- tile dysfunction due to organic origin disease had sexual dysfunction together with their female partners and the sexual dysfunction of couples improved together after PPI (19). Studies have repeatedly shown that PPI positively affects patients’ QoL, perceived quality of the couple relation- ship, partner satisfaction, body image, the relationship with the outside world, and the satisfaction with the implant function (22, 23). In addition, in a study where the patient follow-up period was at least 15 years, it was found that 60% of the patients still used penile prosthe- ses, satisfaction was high, and the QoL results were suf- ficient (8). In this study, patient QoL was not at a healthy level before PPI. The significant increase in patients' mean total score, mean physical health score and mean mental health score after PPI indicated an improvement in patient QoL. QoL of satisfied patients was also at a high level. Sexual dysfunction of the female patient negatively affects QoL (24). A high rate of sexual dysfunction was observed with the decrease in QoL of female patients with organic origin diseases, and it was observed that the same findings were also observed in the male partners of the patients (25-28). Successful treatment of female patients' diseases such as hypertension, diabetes, pitu- itary insufficiency, hypothyroidism and breast cancer improves their sexual dysfunction and QoL (29, 30). There are many studies in the literature that evaluate QoL of male patients with penile prostheses, but findings evaluating QoL of female partners could not be observed in these studies (8, 22, 23). In this study, partners’ QoL was not at a healthy level before PPI. The significant increase in partners' mean total score, mean physical health score and mean mental health score after PPI indi- cated an improvement in partner QoL. Satisfied partner QoL was also at a high level. 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