Agreement between an anatomy-based inflatable penile prosthesis configuration algorithm and expert surgeon decision-making: a virtual case study.

Inflatable penile prosthesis configuration remains highly variable among surgeons, with decisions often guided by individual experience rather than standardized criteria. We evaluated agreement between the Canguven Penile Prosthesis Calculator (an anatomy-based decision-support tool) and experienced penile prosthesis surgeons to characterize inter-surgeon variability using a standardized virtual-case model. A total of 60 cases were constructed incorporating total corporal length, proximal corporal length, scrotal size, and predefined prosthesis model (AMS 700 CX™, Boston Scientific Corporation, Marlborough, MA, USA; Titan™, Coloplast Corporation, Minneapolis MN, USA; and Infla10™, Rigicon Inc., Ronkonkoma, NY, USA). A total of 7 experienced penile prosthesis surgeons from 6 institutions independently evaluated the cases, blinded to calculator recommendations, and selected cylinder length, rear-tip extender, and reservoir volume, generating 340 surgeon-case decisions. Agreement was assessed using exact agreement, clinically acceptable agreement (±1 cylinder size), and kappa statistics. Exact agreement between calculator recommendations and surgeon-selected cylinder length was observed in 198 of 340 decisions (58.2%), increasing to 302 of 340 decisions (88.8%) within a clinically acceptable range. The mean absolute difference was 0.95 ± 1.18 cm, with discrepancies greater than 2 cm observed in 38 of 340 decisions (11.2%). Inter-rater agreement was moderate (Fleiss' κ = 0.46, 95% CI 0.41-0.51), and pairwise agreement between the calculator and individual surgeons ranged from κ = 0.43 to 0.55. Reservoir selection demonstrated excellent agreement (329/340 decisions, 96.8%). Variability in prosthesis configuration decisions was primarily driven by differences in rear-tip extender utilization, reflecting consistent but distinct surgeon-specific strategies. Inflatable penile prosthesis configuration demonstrates substantial variability among experienced surgeons, although most differences fall within clinically acceptable limits. The anatomy-based algorithm demonstrated moderate agreement with expert surgeon selections and may provide a structured, anatomy-based framework for prosthesis configuration planning while preserving individualized surgical decision-making.