Introduction: Penile prosthetic implants have been used for almost 50 years for refractory erectile dysfunction, with approximately 20,000 annual implants in the United States alone. Historically, some urologists have advocated for routine pre-operative cystoscopy to evaluate for the presence of lower urinary tract obstruction prior to prosthesis placement. The rationale being that the treatment of lower urinary obstruction should supersede prosthetic placement and management of these conditions may be complicated with a prosthetic in place. Anecdotally, the risk of such significant asymptomatic urethral pathology is quite low. Cystoscopy, in addition to carrying the risk of peri-procedural infection, does have a substantial associated cost. Thus, our objective was to retrospectively evaluate the prevalence and cost of incidentally discovered urethral pathology during inflatable penile prosthesis (IPP) placement.
Methods: We retrospectively identified all inflatable IPP insertions (CPT 54405 or 54410) performed or aborted by a single surgeon (ACL) from 1/1/14 to 9/15/21. Of those, we then identified and reviewed patients who underwent intraoperative urethral dilation (CPT 52281), direct vision internal urethrotomy (CPT 55276), or cystoscopy (CPT 52000). Costs were calculated based on our institution’s cost data. Total and average cost of routine office cystoscopy for each IPP was compared to total cost of aborted IPPs.
Results: A total of 726 inflatable IPP placement cases were identified. An intraoperative cystoscopy was performed in 13 (1.8%) cases. Of those, 5 (0.7%) cystoscopies were planned and 8 (1.1%) were unplanned. Of the IPP cases with unplanned cystoscopies, 4 cases were aborted (0.5%); 3 cases were aborted due to a urethral stricture and 1 case was aborted due to a urethral perforation following corporal dilation. Unplanned intraoperative cystoscopies and interventions had an average supply cost of $216, totaling $1,732. The total supply cost of aborted IPPs due to urethral stricture was $4,182, an average of $1,394 per case. If every IPP case underwent a pre-operative cystoscopy, the estimated total cost would have been $234,498 ($323 per case).
Conclusions: Given the rarity of incidental urethral strictures requiring aborted IPP and intervention, the cost of routine pre-operative cystoscopy far exceeded the cost of aborted IPP procedures.