Mechanical failure of the American Medical Systems Ultrex inflatable penile prosthesis: before and after 1993 structural modification

PURPOSE

The 700 Ultrex (American Medical Systems, Minnetonka, Minnesota) is the only penile prosthesis capable of length and girth expansion. Early experience with the 700 Ultrex showed an increased mechanical failure rate compared with the 700CX, mostly secondary to cylinder failure. In 1993 the Ultrex cylinders were modified. We examined the performance of the Ultrex device before and after modification.

MATERIALS AND METHODS

We compared our results with the Ultrex prosthesis before (group 1) and after (group 2) the 1993 modification. We implanted 239 devices from October 1989 to December 1999. A total of 26 patients have died. Followup was obtained on the results of 137 of the remaining 213 implants (64%), including 85 pre-modification devices in 85 patients and 52 post-modification devices in 51, via a mailed questionnaire, telephone survey or chart review. The questionnaire and survey included a 5-point satisfaction scale. Groups 1 and 2 were compared in regard to 3 end points, namely cylinder, mechanical and overall failure.

RESULTS

Followup was less than 1 to 136 months (median 92, 25th to 75th percentiles 43 to 108) in group 1 and less than 1 to 92 months (median 46, 25th to 75th percentiles 21 to 75) in group 2. The 5-year Kaplan-Meier estimates of overall, mechanical and cylinder survival in groups 1 and 2 were 64.7%, 70.7% and 80.2%, and 77.7% (p = 0.23), 93.7% (p = 0.017) and 96.2% (p = 0.008), respectively. Overall satisfaction was similarly high in groups 1 and 2 (mean 3.9 and 4 points).

CONCLUSIONS

On long-term followup the 1993 modification of the Ultrex cylinders appears to have significantly decreased the propensity of cylinder failure of the pre-modification device.

[When and why to use penile prostheses: seven years of experience]

During the last years important changes in the management of the patients with erectile dysfunction have been verified. Psychologist, neuro-physiologist and bioengineers have given a valuable help in this field. Implant surgery represents, to our notice, the curative more acceptable choice for patient and the partner, since the results are excellent and the materials used extremely manageable. In each case the degree of satisfaction of the patient remains the only legitimate indicator currently for establish the effectiveness of the therapy.

Comparison of in-patient and out-patient penile prosthesis surgery

Between December 1996 and December 1998, 79 inflatable penile implant insertions have been performed at our institution by a single surgeon. The objective of this analysis was to compare our in-patient and out-patient experience with penile prosthesis insertion with respect to ease of performance and complication profiles. Data was collected in a prospective manner for both groups (in-patient, n = 33 and out-patient, n = 46). The two groups were compared with respect to intra-operative blood loss, operative time, time lost from work, narcotic use and complication rates. Both groups of patients experienced similar operative blood loss, essentially identical operative times, time lost from work and narcotic use. Most importantly, overall complication rates were 6% for the in-patient group and 4% for the out-patient group. Inflatable penile implant surgery is feasible in an ambulatory surgical setting. There is no difference in complication rates, loss of time from work, or intra-operative and post-operative course. Furthermore, there is a significant saving at our institution by performing the procedure in an out-patient fashion. In-patient prosthetic surgery is reserved for secondary procedures following a prior implant infection or primary implants in men with significant co-morbidities that require in-patient postoperative monitoring.

Penile prosthesis implantation

The development of effective systemic therapy for the treatment of erectile dysfunction has resulted in a significant increase in the number of men presenting for treatment. Not all men with erectile dysfunction will respond to systemic therapy; those who fail may be candidates for penile prosthesis implantation if second and third lines of treatment also fail or are rejected by the patient and his partner. Penile prosthesis implantation continues to play a role in the treatment of erectile dysfunction. There is a potential for the number of penile prosthesis implantation procedures to actually increase. The ideal penile prosthesis is a three-piece inflatable device that permits good penile flaccidity and increases in size and becomes rigid with inflation.

Peyronie's disease in men under age 40: characteristics and outcome

Peyronie's disease is most commonly seen in the fifth decade of life. However, a wide range of age (20-83 y) is reported. During a 6-year period, men with Peyronie's disease presenting under the age of 40 were reviewed retrospectively and followed-up. The prevalence of Peyronie's patients presenting under age 40 was 8.2%. Their mean age was 32.47 +/- 5.37 (range: 23-39) y and 78.9% of them presented during the acute phase of the disease. Pain on erection was a part of presenting symptom complex in 52.6% and the majority (84%) had a degree of penile curvature < 60 degrees. Erectile dysfunction (ED) was present in 21% of patients, who responded well to intracavernous injection test. After a minimal 2-year follow-up, improvement in penile deformity was observed in 36.8%, and 42.1% had stable disease while 21% experienced deterioration of the penile curvature. The onset of Peyronie's disease is clinically more noisy and acute in patients presenting under age 40 and this forces the physicians to treat them more vigorously.

Penile prosthesis implantation in a transsexual neophallus

Reconstruction surgery for a female to male transsexual usually involves mastectomy, hysterectomy and creating an aesthetically appealing neophallus. We have successfully inserted an inflatable prosthesis using the AMS CX prosthesis in a 45 year old transsexual, who had a large bulky neophallus constructed from the anterior abdominal subcutaneous fat, about 9 years ago. The single cylinder CX prosthesis was well anchored to the symphysis pubis using a dacron windsock tubing, the activation pump was placed in the dependent pouch of the right labium and the reservior in the usual perivesical space. The patient subsequently had debulking procedure using liposuction to create a more aesthetic and functional phallus. To date, the inflatable neophallus prosthesis is functioning well.

The role of intraoperative antibiotic irrigation and postoperative antibiotic therapy for contaminated implantable prosthesis: in a rat model in vivo

The aim of this study was to determine the usefulness of intraoperative antibiotic irrigation solution and long-term effective antibiotic therapy for the infected prostheses. Forty-five male Wistar albino rats were divided into three equal groups and a small piece of silicone prosthesis contaminated with Staphylococcus epidermidis was implanted into the scrotum. In the first group, the silicone pieces were irrigated with an antibiotic solution intraoperatively and antibiotic therapy was applied for 20 days postoperatively. The second group underwent only antibiotic therapy. In the third group (control) neither intraoperative irrigation nor postoperative antibiotic therapy was applied. Postoperative clinical infection was determined as follow-up. All implants were extracted 20 days after the implantation and cultured to observe the bacterial growth. In the first group, in 13 rats the cultures were negative and in two rats, the cultures revealed positive bacterial growth. In the second group, in four rats the cultures were negative, in five rats the cultures were positive and six rats revealed infectious findings. In the third group, 13 rats revealed infectious findings, and in the remaining two rats the cultures were positive. The differences between three groups are statistically significant (P < 0.05). We conclude that intraoperative antibiotic irrigation and postoperative antibiotic therapy are highly beneficial in the infected prosthesis surgery.

Future considerations: advances in the surgical management of erectile dysfunction

As treatment options for erectile dysfunction (ED) continue to expand, and with more attractive alternatives such as effective systemic treatment becoming available, the number of men presenting for treatment of ED is increasing exponentially. Since a subset of these men continue to require surgical therapy, there is a potential for the number of operations for the treatment of ED and related disorders to actually increase. Areas in the surgical treatment of ED where improvements are needed are identified, including: measures to prevent penile prosthesis infections, better penile implants, improved penile augmentation procedures, better surgical procedures for the treatment of Peyronie's disease, improved penile revascularization procedures, and new motor and sensory penile nerve grafting procedures. International Journal of Impotence Research (2000) 12, Suppl 4, S140-S143.

Penile prosthesis implantation in the treatment of Peyronie's disease and erectile dysfunction

Although men afflicted with Peyronie's disease (PD) usually have a number of treatment options, those who also present with erectile dysfunction (ED) arising from unknown or iatrogenic causes are not easily treated. Surgical straightening procedures that have been used to treat PD may not restore erectile function and failure to straighten the penis with surgery may be the result of erectile inadequacy during the post-operative period. This paper discusses penile prosthesis implantation as a surgical option for patients with PD, placing emphasis on the choice of devices and surgical techniques. Several new techniques which hold the promise of high success rates and low morbidity are mentioned. International Journal of Impotence Research (2000) 12, Suppl 4, S122-S126.

[Penile prosthesis for erectile dysfunction--long-term follow-up]

Our armamentarium for the treatment of erectile dysfunction has recently been expanded by addition of Viagra and the MUSE. However, their long-term results are still unknown. The insertion of a penile prosthesis is invasive, expensive, and irreversible, but under optimal condition provides an acceptable, definitive solution for erectile dysfunction. We evaluated our long-term results with penile prosthesis insertion (PPI). From 1987-1998, 57 patients underwent PPI in our department. Mean age was 55 years and the common causes of erectile dysfunction were atherosclerotic disease (23), radical pelvic surgery (15), and diabetes mellitus (14). Semirigid prostheses were inserted in 12 and inflatable prostheses in 45, including 42 single-component and 3 multi-component prostheses. Recently we interviewed these patients by telephone, using a standard questionnaire. Those not satisfied with the surgical results (83% of the living patients) were examined in our clinic. Mean follow-up was 53 months. In 37 (84%) the prosthesis was mechanically functional (rates after 1, 5 and 10 years were 87.8%, 80%, and 75%, respectively). In only 2 (2.5%) had serious complications led to prosthesis removal. All mechanical failures had occurred in those with inflatable prostheses after a mean of 48.5 months (range 4-113). At the time of the survey 68% were sexually active and 64% were satisfied with the surgical result. We conclude that PPI is safe treatment for erectile dysfunction. Although the rate of mechanically functioning prostheses decreases with time, modern multi-component prostheses may lead to better mechanical results.

Efficacy, safety and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis: results of a long-term multicenter study. AMS 700CX Study Group

PURPOSE

We performed a long-term multicenter study of the AMS 700CX 3-piece inflatable penile prosthesis, focusing on longevity, morbidity and patient satisfaction in men implanted up to 134 months with a median followup of 47.7 months.

MATERIALS AND METHODS

We performed a large scale retrospective multicenter study in 2 phases. Phase 1 was a medical record review of 372 men who underwent implantation with the AMS 700CX penile prosthesis from 1987 to 1996 by 7 frequent penile prosthesis implanters. Phase 2 included a structured telephone interview of 207 patients by a neutral observer.

RESULTS

For the 372 men in phase 1 mean device mechanical reliability plus or minus standard deviation was 92.1% + or - 3.3% after 3 and 86.2% + or - 4.6% after 5 years. Patient age was 21 to 79 years (mean 57.6 + or - 11.0) at implantation. The etiology of erectile dysfunction was vascular in 27.7% of the cases, Peyronie's disease in 16.9%, diabetes mellitus in 12.9% and radical surgery in 11.6%. Of the men 55.6% received previous treatment for erectile dysfunction. Postoperative infection and device malfunction developed in 3.2% and 17.5% of the cases, respectively. Of the 207 men interviewed in phase 2, 86% still had an AMS 700CX penile prosthesis implanted, including 87.1% with erection suitable for coitus. Currently 79% of those with a device use it at least twice monthly and 88.2% would recommend an implant to a relative or friend.

CONCLUSIONS

The AMS 700CX penile implant produced suitable erection and excellent patient satisfaction at long-term followup in the majority of men. Implant reliability is excellent and postoperative morbidity is low.

Current concepts in erectile dysfunction

As the population ages, the prevalence of sexual dysfunction has steadily increased. Erectile dysfunction (ED) is defined as the consistent inability to obtain and/or maintain an erection sufficient for satisfactory sexual relations. Complete ED is defined as the absolute inability to participate in penetrative relations at any stage. Results from the Massachusetts Male Aging Study of 1300 men between the ages of 40 and 70 years show 52% of men--1 in 2--have some degree of ED; 5% of 40-year-olds and 25% of 75-year-olds have complete ED. Taking a detailed medical history and performing a thorough physical examination are essential for the safe and effective treatment of men with ED. This article reviews the physiology and pharmacology of ED. Although effective therapies are available, including surgery, external devices, and subcutaneous penile injections, many find those modalities unacceptable. The oral agent sildenafil is now widely used but not without concern about specific health risks as well as lifestyle issues. This article also reports clinical trial results for new oral agents that will soon offer new options for men who cannot use or are dissatisfied with other therapies.

[Treatment of erectile dysfunction in cases of venous and corporovenous insufficiency of phallus]

A total of 230 patients of different age with impaired venous drainage of penis cavernous bodies were examined. Test with intracavernous injection of papaverin, dopplerography of the vessels and cavernosometry were employed. To treat venous and corporovenous insufficiency, it is suggested to make a resection of the deep dorsal vein, ligation of the superficial and circular veins with suturing tunica albuginea. In negative result of the surgery viagra in a done 50 (100) mg is recommended or penile implants.

The plug and patch: a new technique for repair of corporal perforation during placement of penile prostheses

PURPOSE

Proximal corporal perforation is an uncommon intraoperative complication during placement of a penile prosthetic device. Unrecognized corporal perforation can result in migration or malfunction of the prosthesis. A windsock repair using a nonabsorbable mesh plug has been described. We describe a new technique called the plug and patch to treat this complication.

MATERIALS AND METHODS

From July 1994 to May 1999, 175 patients underwent placement of a penile prosthesis at our institution. Of the patients 8 (4.5%) had proximal corporal perforation. Each perforation was repaired using our plug and patch technique. A 5x7 cm. polyglycolic acid patch was folded on itself and passed into the area of the corporal perforation to act as a plug. A solitary absorbable suture was placed affixing the tail of the patch to the corpora. The corpus was subsequently re-dilated and remeasured, and the prosthesis was placed as usual.

RESULTS

All 8 patients were satisfied with the penile prosthesis. There were no infectious complications or proximal migration of the prosthetic cylinders. The plug repair added an average of 6 minutes to the operating time. Only 1 patient had discomfort in the area of the repair, which resolved spontaneously approximately 6 weeks postoperatingly.

CONCLUSIONS

The plug and patch is a rapid and effective technique to repair intraoperating proximal corporal perforations. Potential advantages include shorter operating time, technical simplicity and the use of only absorbable materials. This technique may result in lower infection rates compared to the standard windsock repair.

Erectile function after radical prostatectomy

The early detection of prostate cancer through the use of prostate-specific antigen screening has resulted in the performance of many more radical prostatectomy procedures as a curative treatment for this disease. Many patients who are candidates for this procedure already suffer from erectile dysfunction, and the incidence of inadequate erections following radical prostatectomy is certainly high. Nerve-sparing procedures during performance of this operation are encouraged as the incidence of erectile dysfunction is lower if one or both nerves are spared. If the patient is already impotent before the procedure, medical treatments with oral agents, intraurethral compounds, or intracorporally injected medications may be more effective with the nerves intact. Early institution of medical therapy, specifically intracorporal injections, after 2 months postoperatively has resulted in a higher incidence of spontaneous return of erections at 1 year. Vacuum erection devices may be successful in restoring erections but extensive practice in their use is necessary, and they may be unappealing to many patients. A penile prosthesis will restore erections if the patient is so motivated for implantation of such a device. These are expensive and require invasive surgery, but satisfaction rates among patients and partners who have used them have been in the range of 85%, the highest satisfaction rate among all of the treatments of erectile dysfunction.

Treatment of male sexual dysfunction

Male sexual dysfunction is a prevalent condition in the population, is a major health problem and has previously been both under diagnosed and under treated. There are now a number of treatments available that are safe and easy to use which provide an effective solution for most presenting patients. Oral drugs have recently become the first-line option for many men with about 60-70% of new presentations achieving success. Those who fail a trial of oral treatments have a number of other options available, which are able to provide erections sufficient for intercourse in many of the oral drug failures. All these options, their indications, side-effects and complications are outlined in this chapter.

Economic cost of male erectile dysfunction using a decision analytic model: for a hypothetical managed-care plan of 100,000 members

OBJECTIVE

This paper examined the economic cost of male erectile dysfunction (ED) for a hypothetical managed-care (MC) model.

DESIGN AND SETTING

A prevalence-based cost-of-illness approach was used to estimate the direct medical cost for ED treatment. A treatment plan algorithm was developed from a MC perspective to model the initial treatment selection of various patient groups [vacuum erection device, intracavernosal injection (ICI) therapy, transurethral alprostadil suppository, sildenafil, testosterone replacement therapy, penile prosthesis] and their therapy outcomes during a 3-year period. Overall cost was based on 1998 US dollars. Total direct medical cost of ED considered in this model included the cost of initial physician consultation and evaluation, the cost incurred by patients from various treatment groups (pharmacological and surgical options), as well as the cost related to patients' follow-up for treatment within the 3-year period. Consideration for therapy switches made by patients who failed initial therapy was included as part of the clinical assumptions for this model. Treatment response and expected outcomes (dropouts) were considered for the various treatment options.

PARTICIPANTS

A total of 100,000 enrolled members were included in the study.

MAIN OUTCOME MEASURES AND RESULTS

The total cost of ED was $US3,204,792 for the 3-year period in the hypothetical MC plan. The treatment portion accounted for approximately 80% of the total cost while the cost of medical services and diagnostic tests were minimal in comparison. The 3 year total cost of nonsurgical treatment was $US2,473,045. Costs associated with each treatment alternative were $US81,866 (testosterone transdermal patch), $US51,930 (vacuum erection device), $US384,624 (ICI therapy), $US226,483 (transurethral alprostadil suppository) and $US1,728,142 (sildenafil citrate). Results from the model showed a noticeable trend of decreasing cost patterns over time and reflected the attrition observed for many of the standard medical therapies for ED.

CONCLUSIONS

Sildenafil and the vacuum erection device should be considered as first-line management strategies for ED whereas ICI therapy, transurethral alprostadil suppository and penile prosthesis implant should be reserved for second- or third-line therapy. Because costs associated with switches related to successive treatment failures can be high, treatment considerations should, therefore, focus on achieving long term patient satisfaction. The patient's preferred treatment choice, using goal-directed therapy during the initial consultation and evaluation visit, should be used.

Implantation of inflatable penile prosthesis in patients with severe corporeal fibrosis: introduction of a new penile cavernotome

PURPOSE

Implantation of penile prosthetic cylinders into scarred corpora remains a challenge in the field of prosthetic urology. We describe a new penile cavernotome, which allows for easier dilation of fibrotic corpora cavernosa and facilitates inflatable penile prosthesis cylinder insertion.

MATERIALS AND METHODS

A set of 5 cavernotomes between 6 and 13 mm. in diameter are used to drill a space in fibrotic corpora with controlled 1 mm. cuts. The cavernotomes are advanced in an oscillating fashion and also allow shaving of severely stenotic areas for easier cavity development. They were used in 16 patients with fibrotic corpora secondary to different etiologies. A high transverse scrotal incision was used in all cases. Of the 16 patients 14 received downsized cylinders.

RESULTS

Implantation of both cylinders of an inflatable 3-piece device was successful in all cases. Proximal crural perforation occurred intraoperatively in 5 patients and was corrected by attaching the rear tip extender to the tunica with nonabsorbable suture. Postoperatively, distal tunical perforation of the corpora in 4 patients was repaired with natural tissue. Operative time was reduced compared to our previous experience with implantation in cases of corporeal fibrosis using extensive corporotomies or the Carrion-Rossello cavernotomes. In no case was the procedure terminated for urethral laceration or inadequate dilation for cylinder insertion. No grafting materials were necessary to close the corporotomy.

CONCLUSIONS

The new cavernotomes along with the high transverse scrotal incision and downsized prostheses resulted in successful implantation in all of our cases. Dilation of fibrotic corpora was easier and quicker with the new cavernotomes because extensive corporeal resection was not necessary. Complications were acceptable for these difficult cases and prosthesis survival is 100% to date.

Prosthesis implantation after radial free flap phalloplasty in patients with bladder exstrophy

METHODS

Inflatable penile prosthesis were implanted into sensate radial free-flap phalloplasties in two adult patients with bladder exstrophy.

RESULTS

Neither patient reported loss of sensation, and both were able to inflate the prosthesis and engage in sexual intercourse three months later.

CONCLUSION

The construction of a functional neophallus is well described however has not previously been reported in exstrophy patients who are suited to this procedure due to the presence of crura, and the absence of a neourethra. Scarring from previous reconstructive procedures however may make implantation difficult, and long-term follow up is required to evaluate this procedure in patients with bladder exstrophy.

Phallic construction in a 65-year-old male pseudohermaphrodite

The authors constructed a functional, sensate phallus for a 65-year-old male pseudohermaphrodite. Although their technique is employed frequently for gender reassignment and posttraumatic reconstruction, the opportunity to perform this procedure to aid an adult patient with ambiguous genitalia is unusual. Of course, having such a patient present for treatment in his seventh decade of life is also unique. After careful consideration of his history, previous failure of medical therapy, and overall excellent medical condition the authors determined that age alone should not be an impediment to phallic construction for this patient. Their decision not to construct a penile urethra, and therefore avoid potential urethral complications, helped to ensure an uneventful postoperative course. Their success in this case has clearly broadened the range of patients that can benefit from phallic construction.

[New treatments for impotence]

The development of new oral drugs and the poor results of the reconstructive vascular surgery has modified the therapeutical approach of the impotent patient. The doctor has to be aware of these changes in the management of impotence.

Erectile dysfunction caused by sacral gun-shot injury

A 22-year-old man suffering from isolated erectile dysfunction associated with damage to the right spinal nerve S2 caused by sacral gun-shot injury. He has no loss of bladder innervation. Treatment has been implantation of a penile prosthesis.

[Erectile dysfunction. Its diagnosis and treatment]

Erectile dysfunction is a health problem affecting more than 50% of men between 40 and 70 years old. Although several therapeutic options have become available in the last 20 years, only a small percentage of the patients, perhaps no more than 10%, seek treatment. The recent introduction of oral and intra-urethral medication has been highly publicised, therefore more patients will be involved in this new wave of enthusiasm for non-invasive options. We are challenged to develop new options as to how to present these treatments to our patients. Traditionally the diagnosis of erectile dysfunction is based on a comprehensive evaluation regarding aetiology, including family and sexual history, physical examination, blood tests, pharmacological testing with vasoactive drugs and Doppler study of the penile arteries. Other studies, such as Rigiscan, corpus cavernosum electromyography, cavernosometry, cavernosography and penile angiography should be performed when indicated. With regard to treatment, penile intracavernosal injection remains the best nonsurgical treatment. Application of a vacuum device and penile prosthesis implantation are also reliable therapeutic options. Only a limited number of patients are suitable for arterial revascularization or penile venous surgery. However, in the near future, we will have to face the requests of our patients for an oral or topical prescription without concern for the cause of erectile dysfunction. The results of these new therapies on organic impotence are not as exciting, but warrant further studies.

Spontaneous breakage of malleable penile prosthesis

The reported complications of malleable penile prosthesis include infection, erosion and chronic pain. We report the first two cases of bilateral breakage of malleable penile prosthesis.

[Reconstructive phalloplasty]

We examine some surgical techniques proposed for phallic reconstruction. Together with cutaneous flaps, muscle-cutaneous flaps, who present the advantage of more constant results, are progressively listed. We also present a personal technique of phallic reconstruction with double prosthesis: one external, vascular and one internal, for the erection.

Malleable penile implants without plaque surgery in the treatment of Peyronie's disease

The objective of this retrospective study is to evaluate the surgical outcome with malleable penile implants without plaque surgery in the treatment of impotence associated with Peyronie's disease. This study included 20 men with Peyronie's disease who underwent placement of a malleable penile prosthesis. The surgeries were performed in three day surgery units in Cairo and Jeddah. The implantation of the prosthesis straightened the penile shaft in all cases but a variable degree of deviation of the glans penis persisted in seven cases (35%), and led to dissatisfaction in 2 out of 16 patients followed for one year (12.5%). No operative or postoperative complications occurred and no reoperations were needed. We conclude that malleable penile implants are safe and effective in the treatment of Peyronie's disease associated with impotence.

Electron microscopic findings of penile tissues in veno-occlusive dysfunction: is penile biopsy necessary?

In this study, we examined the biopsy patterns of penile tissues taken during operation from patients subjected to surgical treatment for veno-occlusive dysfunction, and evaluated the importance of penile biopsy. We evaluated the findings from 17 patients with venous impotence. Fourteen of them underwent total vein ligation and the rest penile prosthesis implantation. Tissue specimens taken from superficial and deep dorsal veins, tunica albuginea and corpus cavernosum during operation were examined under electron microscope. Tissue specimens taken from 3 cadavers were used as the control group. Although the deep and superficial vein specimens of all patients did not show significant differences, oedema and increase of fibroblasts in collagen fibres of the corpus cavernosum and tunica albuginea were demonstrated. We concluded that penile biopsy as an invasive method does not give enough information about the choice of treatment for erectile dysfunction.

Long-term results of total penile reconstruction with a prefabricated lateral arm free flap

PURPOSE

We present 5-year followup results of patients who underwent total penile reconstruction with a prefabricated lateral arm free flap technique.

MATERIALS AND METHODS

We treated 3 female-to-male transsexuals and a man with penile amputation with a 2-stage technique of total penile reconstruction. In the first stage the neourethra is constructed as a tubed skin graft incorporated in the territory of the lateral arm flap. Three to 6 months later the lateral arm flap with its well epithelialized conduit is fashioned into a penis, an inflatable prosthesis is incorporated and the construction is transferred to the pubis with vascular, urethral and nerve repairs.

RESULTS

In addition to the 2 surgical procedures required to construct the penis, the patients have required an average of 3 revisions. There were no complications beyond the first year postoperatively. All 4 patients are able to void in the standing position and are free of fistulas or strictures. The inflatable prosthesis allows them to achieve penetration during sexual intercourse. All reconstructed penises have recovered erogenous and tactile sensibility. Patient satisfaction with the reconstructed penis is high. All transsexuals are married and fully integrated as men.

CONCLUSIONS

With the prefabricated lateral arm free flap technique it is possible to achieve a fully functional penis with stable long-term results and excellent patient satisfaction. To our knowledge our series represents the first report of a technique for functional penile reconstruction with at least 5 years of followup.

[Diagnosis and treatment of erectile dysfunction]

Pathogenesis of erectile dysfunction is well studied now. So another problem arises: how to choose individual methods of diagnosis and treatment as well as sequence of diagnostic and therapeutic measures. Our method of purposeful approach to diagnosis and treatment of erectile dysfunction is based on the choice of the patient who decides himself the scope and invasiveness of the diagnosis and treatment. The patient makes his choice after he is informed about all available diagnostic techniques and treatment methods.

Comparison of long-term outcomes of penile prostheses and intracavernosal injection therapy

PURPOSE

Intracavernosal injection therapy is one of the most popular therapies for erectile dysfunction today. Yet, most clinicians consider intracavernosal injection a palliative treatment for erectile dysfunction because of the high patient initiated dropout rate. In contrast, penile prostheses appear to offer a more permanent cure for erectile dysfunction. We compare the long-term outcomes of both therapies in contemporaneously treated patients and determine the reasons for failure of each.

MATERIALS AND METHODS

Telephone survey and chart review was conducted on the first 115 patients treated with intracavernosal injection and 65 patients undergoing insertion of a penile prosthesis during the same period at our institution. Mean patient age was 57 and 60 years, respectively, and mean followup of all patients was 5.4 years (range of 3.3 to 16).

RESULTS

An equal percentage of patients were lost to followup in both groups, including 19% of the intracavernosal injection group and 18% of the penile prosthesis group. Of the intracavernosal injection patients 6 (6%) died during followup and 10 (19%) of the prosthetic patients died (p < 0.05). At the time of contact only 41% of the patients were still using intracavernosal injection. In contrast, 70% of the patients were still sexually active with the prosthesis (p < 0.01). Mean duration of use of the penile prosthetics was 63 months compared to 37 months for intracavernosal injection (p < 0.001). The most common reasons for discontinuing intracavernosal injection were inadequate erections (16 cases), lack of spontaneity (14), side effects (12), lack of partner (10), loss of sexual interest (6) and spontaneous return of normal erections (4). More than half of the patients (61%) who discontinued intracavernosal injection remain sexually active with other therapies, including penile prosthesis in 11, vacuum devices in 4, vascular surgery in 1 and oral medication in 1, and 14 without any therapy. We could not identify any significant clinical parameters that would accurately predict which patients most benefited by the long-term use of intracavernosal injection therapy. In contrast, only 6 patients discontinued use of the implant because of complications (infection, erosion and malfunction) and 7 for reasons independent of the implant (that is lack of partner, loss of sexual interest and co-morbidity).

CONCLUSIONS

Intracavernosal injection serves as only a palliative therapy for the majority of patients with erectile dysfunction but there exists a core group who derives long-term satisfaction with its use. The majority of patients who discontinue intracavernosal injection remain sexually active yet do not progress to more invasive or effective therapies. The reason for discontinuing therapies for erectile dysfunction is often unrelated to the actual therapeutic modality. Our findings suggest that further improvements in intracavernosal injection therapy and the development of alternative methods of delivery of vasoactive agents will have only a limited impact on the overall outcome of therapy for erectile dysfunction and that increased attention to issues separate from the erection is warranted.

Erectile dysfunction: a practical approach for primary care

Erectile dysfunction has been poorly recognized and managed in the past, due to its taboo aspects and erroneous perceptions of its medical significance. With research, improved understanding has guided a practical approach to its diagnosis and treatment. In most presentations, erectile dysfunction has an organic etiology. Likely causes are often discerned from the clinical history and physical examination. Management may be a simple matter of addressing correctable risk factors, or a direct intervention may need to be pursued. For an individual patient, selection of the "ideal" treatment is based on an understanding of the extent of the problem and consideration of the patient's preferences.

Use of a prefabricated tunica vaginalis fascia flap to reconstruct the tunica albuginea after recurrent penile prosthesis extrusion

PURPOSE

Although a penile prosthesis usually perforates into the urethra, it can extrude through the glans or corporeal shaft. Various materials have been used to reconstruct tunica albuginea but no method of repair has been satisfactory in such difficult cases. Repair of the weakened tunica albuginea should ideally be performed with autogenous tissues. Inasmuch as the scarred tissue bed is inadequate to ensure graft survival and no local flaps are available for this purpose, prefabrication of a local flap has been designed.

MATERIALS AND METHODS

We present 2 cases in which the distal corpus was reconstructed with a prefabricated tunica vaginalis fascia flap. The first stage involves grafting rectus fascia onto the external tunica vaginalis of the testicle. At the second stage the prefabricated tunica vaginalis fascia flap is transposed to the distal corpus, placing it as a buttress between the cylinder and urethra medially or between the cylinder and thin lateral and distal tunica albuginea. The flap also replaces part of the tunica albuginea.

RESULTS

In both patients repair of the tunica albuginea was successful and each has a functioning inflatable penile prosthesis at 2 1/2 1 1/2 years postoperatively, respectively.

CONCLUSIONS

Reconstruction of the weak tunica albuginea with a prefabricated tunica vaginalis fascia flap is an excellent procedure in these difficult cases.

Management of severe corporeal fibrosis with implantation of prosthesis via a transverse scrotal approach

PURPOSE

We reviewed our experience in the management of severe corporeal fibrosis with placement of the AMS 700 CXM* prosthesis to determine the efficacy of this approach.

MATERIALS AND METHODS

The records of 26 men with severe corporeal fibrosis who underwent placement of the AMS 700 CXM prosthesis via a transverse scrotal approach between August 1991 and July 1996 were reviewed.

RESULTS

In all cases the AMS 700 CXM prosthesis was successfully implanted with primary closure of the tunica albuginea, although 2 patients required extended corporotomies. Followup data were available on all 26 men. At a mean followup of 22.5 months (range 3 to 63) 24 of the 26 men had a functional device (92%). One patient required explantation for infection and 1 underwent explantation for cylinder cross-over.

CONCLUSIONS

Implantation of the AMS 700 CXM prosthesis in patients with severe corporeal fibrosis produced good results at approximately 2 years of followup.