Testicular Prostheses in Patients With Testicular Cancer

Acceptance Rate and Patient Satisfaction

Klaus-Peter Dieckmann; Petra Anheuser; Stefan Schmidt; Benjamin Soyka-Hundt; Uwe Pichlmeier; Philipp Schriefer; Cord Matthies; Michael Hartmann; Christian G Ruf

Disclosures

BMC Urol. 2015;15(16)

Abstract

Background The loss of a testicle to cancer involves much emotional impact to young males. Little is known about the number of patients with testicular germ cell tumour (GCT) who would accept a testicular prosthesis. Also, knowledge about the satisfaction of implant recipients with the device is limited.

Methods A retrospective chart analysis was performed on 475 consecutive GCT patients. Prior to orchiectomy, all patients were offered prosthesis insertion. Acceptance of implant was noted along with age, clinical stage, histology and year of surgery. 171 implant recipients were interviewed using an 18 item questionnaire to analyze satisfaction with the prosthesis. Statistical analysis involved calculating proportions and 95% confidence intervals. Multivariate analysis was performed to look for interrelations between the various items of satisfaction with the implant.

Results 26.9% of the patients accepted a prosthesis. The acceptance rate was significantly higher in younger men. Over-all satisfaction with the implant was "very high" and "high" in 31.1% and 52.4%, respectively. 86% would decide again to have a prosthesis. Particular items of dis-satisfaction were: implant too firm (52.4%), shape inconvenient (15.4%), implant too small (23.8%), position too high (30.3%). Living with a permanent partner had no influence on patient ratings. Multivariate analysis disclosed numerous inter-relations between the particular items of satisfaction.

Conclusions More than one quarter of GCT patients wish to have a testicular prosthesis. Over-all satisfaction with implants is high in more than 80% of patients. Thus, all patients undergoing surgery for GCT should be offered a testicular prosthesis. However, surgeons should be aware of specific items of dis-satisfaction, particularly shape, size and consistency of the implant and inconvenient high position of the implant within the scrotum. Appropriate preoperative counselling is paramount.

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Table 1. Acceptance rate of testicular prostheses in unselected cohort of GCT patients
	Total n (%)	With prosthesis
	Total n (%)	n (%)	95% CI
Total sample	475 (100)	128 (26.9)	23.0%; 31.2%
Histology*
Seminoma	293 (100)	81 (27.6)	22.6%; 33.1%
Nonseminoma	182 (100)	47 (25.8)	19.6%; 32.8%
Clinical stage**
CS1	313 (100)	91 (29.1)	24.1%; 24.4%
CS 2	138 (100)	32 (23.2)	16.4%; 31.1%
CS 3	24 (100)	5 (20.8)	7.1%; 42.2%
Age at diagnosis ^§
≤20 years	16 (100)	4 (25.0)	7.3%; 52.2%
>20 - ≤ 30 years	103 (100)	34 (33.0)	24.1%; 43.0%
>30 - ≤ 40 years	206 (100)	61 (29.6)	23.5%; 36.4%
>40 - ≤ 50 years	113 (100)	25 (22.1)	14.9%; 30.9%
>50 - ≤ 60 years	37 (100)	4 (10.8)	3.0%; 25.4%
Treatment ^#
1997 - 2003	143 (100)	35 (24.5)	17.7%; 32.4%
2004 – 2009	167 (100)	55 (32.9)	25.9%; 40.6%
2010 – 2014	165 (100)	38 (23.0)	16.8%; 30.2%

*histology: chi-square test p = 0.66.
**clinical stage: Cochran-Armitage Trend Test p = 0.07.
^§age at diagnosis: Cochran-Armitage Trend Test p = 0.006, significant.
^#episode of treatment: Cochran-Armitage Trend Test p = 0.38.
CI 95% confidence intervals.

Table 2. Acceptance of prosthesis – logistic regression model
Parameter	Odds ratio	95% Wald CI		p-value*
Age (years)				0.05
≤20 vs. > 30 - ≤ 40	1.06	0.31	3.62
>20 - ≤ 30 vs. > 30 - ≤ 40	1.28	0.75	2.17
>40 - ≤ 50 vs. > 30 - ≤ 40	0.64	0.37	1.11
>50 - ≤ 60 vs. > 30 - ≤ 40	0.28	0.09	0.82
Histology				0.50
Seminoma yes vs. no	0.84	0.52	1.38
Clinical stage				0.33
CS2 vs. CS1	0.71	0.43	1.15
CS3 vs. CS1	0.70	0.23	1.93
Year of treatment				0.09
2004 - 09 vs. 1997 – 2003	1.65	0.99	2.74
2010–14 vs. 1997 – 2003	1.06	0.61	1.82

*Wald chi square; CS clinical stage; CI confidence intervals.

Table 3. Results of questionnaire regarding patients' satisfaction with testicular implant
Question	Eligible (n)	Answer	(%)	95% CI
Married	167	yes	50.3	41.4%; 59.2%
Living with permanent partner	164	yes	77.4	69.5%; 84.0%
Time living with implant	168	<1 year- 2 years > 2 years	14.9	9.3%; 22.3%
			10.7	5.8%; 17.4%
			74.4	65.7%; 81.8%
Additional surgery after implant insertion	170	yes	4.7	2.1%; 9.6%
Normal appearance with two testicles: important?	168	very important	53.6%	44.1%; 62.6%
		important	31.3	23.2%; 40.6%
Being offered a prosthesis, preoperatively	169	important	98.2	94.2%; 99.6%
Size of the implant	164	too large	9.8	5.0%; 16.3%
		too small	23.8	16.3%; 32.3%
Weight of the implant	166	too heavy	6.6	2.9%; 12.5%
		Just right	91	84.4%; 95.2%
Shape of implant	169	not right	15.4	9.7%; 22.5%
Consistence of implant	164	too firm	52.4	43.4%; 61.1%
Position of implant within scrotum	165	too high	30.3	22.0%; 39.6%
Any particular feeling with the implant	164	convenient	16.5	10.0%; 24.6%
		inconvenient	4.3	1.5%; 9.7%
		strange	9.1	4.6%; 16.0%
Problems with implant during physical exercise	164	no	92.1	85.8%; 96.1%
Concerns about future problems with the implant	164	no	89.0	82.7%; 93.6%
Counseling before implant placement	164	too short	31.1	22.7%; 40.5%
		Insufficient	8.5	4.2%: 14.9%
After all, would you have an implant again?	165	yes	86.1	79.1%; 91.4%
Over-all satisfied with implant	164	very well	31.1	22.2%; 41.0%
		satisfied	52.4	42.1%; 62.4%
		just so	12.2	6.5%; 20.0%
		no	4.3	7.4%; 1.2%

Table 4. Significant associations between various items of satisfaction with prosthesis
	Size of prosthesis
	Too much	Just right	Too small
Weight of prosthesis				p = 0.032*
Too heavy	18.8%	4.6%	7.9%
Right	81.3%	95.4%	81.6%
Too light	-	-	10.5%
Shape of prosthesis			p = 0.002^#
Inconvenient	31.3%	8.3%	28.2%
Just right	68.8%	91.7%	71.8%
	weight of prosthesis
Position within scrotum				p = 0.023^§
Right	81.8%	69.6%	-
Not right	18.2%	30.4%	100%
	shape of prosthesis
Consistency of prosthesis			p = 0.017^#
Too firm	75%	48.6%
Convenient	25%	51.4%
	consistency of prosthesis
Position of prosthesis			p = 0.035*
Right	61.6%	76.9%
Too high	38.4%	23.1%

*Exact Jonckhere Terpstra test.
^#chi square test.
^§Exact Cochran Armitage Trend Test.

Table 5. Significant associations of over-all satisfaction with particular items of patients' satisfaction
	Over-all satisfaction with testicular implant
	Very well	Well	Just so	Not much	Not at all
Size						p < 0.001*
Too large	7.8%	13.3%	-	-	33%
Right	82.4%	65.1%	31.6%	100%	-
Too small	9.8%	21.7%	68.4%	-	66.6%
Shape						p = 0.001**
Inconvenient	5.9%	14.0%	35.0%	-	66.7%
Convenient	94.1%	86.0%	65.0%	100%	33.3%
Consistence						p < 0.001**
Too firm	20.0%	62.8%	75.0%	100%	100%
Convenient	80.0%	37.2%	25.0%	-	-

All numbers represent percentages, *Jonckhere-Terpstra Test, **Cochran-Armitage Trend Test.

Table 6. Survey of the literature – patients' satisfaction with testicular implants
Author	Year	Country	(n)	Method	Over-all satisfaction	Have it again	Shape	Position	Size	Consistency	Other
Petersen [24]	1992	Ger	119	I	93%	93%	-	high 11%	19% too large	10% too firm	-
Petersen [24]	1992	Ger	119	I	93%	93%	-	high 11%	14% too small	10% too firm	-
Lynch [32]	1992	UK	19	Q	79%	95%	-	-	-	-	−
Incrocci [33]	2001	NL	22	Q	95%	95%	-	-	-	29% inconvenient	–
Adshead [22]	2001	UK	71	Q	73%	90%	32% not right	27% not right	37% inconvenient	-	30% weight inconvenient
Boy [28]	2002	Ger	39	Q	97%	-	-	3% too high	36% not right	3% too firm	partners' rating: 55% satisfied
Xylinas [34]	2008	F	63	Q	96%	96%	12% not right	3% not right	5% too small	12% too firm	2% too cold
Yossepowitch [21]	2011	Isr	86	I	88%	86%	-	39% too high	27% not right	73% too firm	after 2005 better results