(434) Value of Office Pre-Operative Cystoscopy Prior to Penile Prosthesis Surgery
Authors: Dionise Z , Aksenov L , Yafi F , Lentz A 
Published: May 2023

Abstract

Introduction
Discovery of obstructive urethral pathology, such as urethral stricture, benign prostatic hyperplasia (BPH), or bladder neck contracture (BNC), during inflatable penile prosthesis (IPP) placement may result in aborted prosthetic implantation. Routine pre-operative office cystoscopy to evaluate for obstructive urethral pathology would likely prevent aborted implant cases. However, routine cystoscopy would also represent a substantial cost to the patient and healthcare system, especially since urethral pathology resulting in aborted cases is anecdotally rare.

Objective
Our objective was to evaluate the incidence of unexpected obstructive urethral pathology resulting in aborted IPP cases and then compare the cost of aborted cases to the cost of routine pre-operative office cystoscopy for all planned implants.

Methods
We retrospectively evaluated completed and aborted IPP placements by a high-volume surgeon from 1/1/2014 through 5/23/2022 for both virgin (CPT 54405) and revision (54410) IPPs, with further selected assessment of cases with concomitant cystoscopy (52000), urethral dilation (52281), and direct vision internal urethrotomy (55276). Selected cases were reviewed for additional patient information including prior urologic surgery, pelvic radiation, and clinical information regarding intra-operative cystoscopy. Cost analysis was conducted for office cystoscopy and operative costs associated with IPP cases based on institutional cost data. Outcomes evaluated included incidence of unexpected obstructive urethral pathology requiring aborted IPP placement, break-even points for office cystoscopy compared to cost of aborted IPP cases, and ‘number needed to scope’ to avoid an aborted implant.

Results
From a total of 822 IPP cases performed, 17 (2.1%) had concomitant cystoscopy, of which 11 (1.3%) were unplanned. Nine cystoscopies (1.1%) resulted from inability to place a urethral catheter secondary to urethral stricture (n=5), BNC (n=2), BPH (n=1), and no identifiable pathology (n=1). Three IPPs (0.4%) were aborted due to dense urethral stricture at a total cost of $42,982, with ‘number need to scope’ of 274 to avoid an aborted implant. With total calculated cost for office cystoscopy for all planned IPPs of $164,498 ($200.12 per patient), the rate of aborted IPP due to urethral pathology would need to exceed 1.4% to make routine office cystoscopy cost saving (Figure 1). Alternatively, at the observed incidence of aborted IPP (0.4%), routine office cystoscopy would need to cost $50.50 to break-even with the cost of aborted IPPs.

Conclusions
Unexpected obstructive urethral pathology resulting in aborted IPP is rare. As a result, routine pre-operative office cystoscopy for asymptomatic men prior to IPP does not provide cost savings at our institution.

Disclosure
Any of the authors act as a consultant, employee or shareholder of an industry for: Dr. Aaron Lentz is a speaker, preceptor, and consultant for Boston Scientific and Coloplast. Dr. Faysal Yafi is a speaker, advisor and consultant for Coloplast, Antares Pharma, Clarus Therapeutics, Promescent, Acerus, Sprout and Cynosure.