Penile Implant Surgery in Germany — Effective, Established, Yet Underused

Germany implants far fewer penile prostheses than evidence warrants — and the authors say structural barriers, not lack of efficacy, are to blame

Journal: Urologie (Heidelberg, Germany) | Published: 2026-02-25 | Type: Narrative review | PMID: 41739182 Authors: Daniel Schlager (Ortenau-Klinikum Offenburg, Andrology), Christian Leiber-Caspers (Maria-Hilf-Krankenhaus Alexianer Krefeld, Andrology) Funding/COI: No study funding listed. Both authors disclose financial relationships — consulting fees and/or speaking honoraria — from Boston Scientific and Coloplast, the two dominant penile prosthesis manufacturers. Leiber-Caspers additionally holds a board position in the German Society of Andrology (DGA). These conflicts are directly material to the paper's central argument.

Summary

This is a narrative review summarizing the 50-year history of penile prosthesis technology and arguing that Germany's implantation rates are inexplicably low given the procedure's documented efficacy. The authors report ~80% functional device survival at 10 years and "excellent" patient and partner satisfaction without providing precise satisfaction percentages. The core argument: underuse isn't explained by poor outcomes or patient reluctance, but by fragmented care, low institutional volume, and inadequate resource allocation. The proposed fix — centralization — would concentrate procedures at high-volume specialist centers like those where the authors practice.

Claims

• Modern inflatable and semi-rigid penile prostheses show functional survival of approximately 80% at 10 years
• Patient and partner satisfaction is described as "excellent," but no satisfaction percentage or validated scale score is cited in the abstract
• Infection rates characterized as "low" — no specific rate given
• A "substantial gap" exists between evidence-based guidelines and real-world implantation rates in Germany — but no absolute implant-per-capita figure is provided
• Particularly affected populations: men post-radical prostatectomy, men with diabetes-associated ED, and vasculogenic ED patients
• A volume-outcome relationship exists for penile prosthesis surgery (surgeons and centers doing more produce better results)
• Authors trace implant history to 16th century structural supports; the modern prosthetic era began ~50 years ago with Scott et al.'s inflatable design and the Small-Carrion malleable device

Study Quality

This is a narrative review, not a systematic review or meta-analysis. The authors do not report a search protocol, inclusion/exclusion criteria, or risk-of-bias assessment for the studies they cite. The 80% 10-year functional survival figure is attributed to "long-term studies" without specifying which studies, sample sizes, or whether those figures come from registry data, manufacturer-sponsored trials, or independent research. Utilization data is attributed to "national and international registry data" — again unspecified.

The paper presents an advocacy argument dressed as a literature review. It identifies a problem (underuse), attributes causation (structural barriers), and proposes a solution (centralization) — but without a systematic evidence base, these remain the authors' clinical opinions, not findings derived from primary analysis.

Red Flags

• Severe COI: Both authors receive financial compensation from Boston Scientific and Coloplast — the companies that manufacture and sell penile prostheses. A review concluding "more penile prostheses should be implanted" authored by paid consultants to prosthesis makers is a textbook conflict.
• No quantitative utilization data in abstract: "Consistently low" implantation rates are asserted without a single absolute number — no implants per 100,000 eligible men, no year-over-year trend data
• Satisfaction claims without scales: "Excellent satisfaction" with no validated instrument (EDITS, IIEF, etc.) cited
• No systematic search reported: Narrative review methodology allows cherry-picking; no PRISMA flowchart or equivalent
• Self-serving centralization argument: Centralizing care benefits high-volume specialist centers — which is where both authors are employed
• Infection rate listed as "low" without definition: Absolute infection rates matter clinically and vary significantly by surgical approach; vague qualitative language obscures this
• Full-text conclusions diverge from abstract: The full-text conclusion reads more like a historical editorial than a structured clinical analysis

Strengths

• Raises a legitimate clinical question: if outcomes are good, why is utilization low?
• Correctly identifies volume-outcome relationships as a relevant structural concern
• COI is disclosed, which is more than many industry-adjacent reviews manage
• Historical context on device evolution is potentially useful for clinicians unfamiliar with the field

Verdict

Two prosthesis manufacturer consultants wrote a review arguing Germany needs more penile prosthesis implantations, then declined to include the specific utilization numbers that would anchor the argument. The 80% 10-year survival figure is the paper's lone concrete data point, and it lacks a citation in the abstract. The COI here isn't incidental — it's the lens through which every conclusion should be read. This review might serve as a readable introduction to penile prosthesis history for a trainee, but its utilization and advocacy claims carry no independent evidentiary weight. File under: interested-party literature.