Gangrene of the distal penis after implantation of malleable penile prosthesis in a diabetic patient

Management of Disastrous Complications of Penile Implant Surgery

RATIONALE

Penile Prosthesis Implantation (PPI) is the definitive treatment for Erectile Dysfunction not responsive to conservative management strategies. Furthermore, it is a staple of surgical treatment of severe Peyronie's Disease (PD) and phallic reconstruction. Expert implantologists occasionally face disastrous complications of penile implant surgery which can prove to be very challenging. In this article we present a selected number of case reports which exemplify this kind of situations and discuss management strategies while also commenting on plausible aetiologies.

PATIENTS' CONCERNS

The first case describes a PPI performed in end-stage fibrotic corpora after multiple instances of implantation/explant. The second and third cases show two diametrically opposed approaches to the management of glans necrosis after PPI in post-radical cystectomy patients. The fourth case describes the history of a diabetic patient suffering from glandular, corporal and urethral necrosis after a complicated PPI procedure. The fifth case reports the surgical treatment of a case of recurring PD due to severe scarring and shrinking of a vascular Dacron patch applied in a previous operation.

DIAGNOSIS

Complication diagnosis in all patient was mainly clinical, intra- and postoperative, with Penile Color Doppler Ultrasonography performed when needed in order to demonstrate penile blood flow.

INTERVENTIONS

The patients underwent complex surgical procedures that addressed each specific complication. Complex penile implants with fibrosis-related complications, penile prosthesis explant with and without surgical debridement of necrotic areas, penile prosthesis explant with necrotic penile shaft and urethral amputation with perineostomy, and complex corporoplasty with scar tissue excision and patch application with PPI were performed in the five patients.

OUTCOMES

Penile anatomy and erectile function with PPI was achieved in 4 out of 5 patients. 1 of 5 patient is scheduled to undergo a total phallic reconstruction procedure at the time of this writing.

LESSONS

Management of disastrous complications of penile implant surgery can be very challenging even in expert hands. In-and-out knowledge of possible PPI and PD complications is required to achieve an acceptable outcome. Bettocchi C, Osmonov D, van Renterghem K, et al. Management of Disastrous Complications of Penile Implant Surgery. J Sex Med 2021;18:1145-1157.

Nondegloving technique for Peyronie's disease with penile prosthesis implantation and double dorsal-ventral patch graft

A circumcising incision to deglove the penis for penile prosthesis (PP) implantation can increase the risk of ischemic injury to the glans penis. In order to avoid vascular complications, we describe a novel technique utilizing a ventral incision to perform the PP implantation and a double-dorsal patch graft, or “sliding technique” (ST), in patients with severe Peyronie's disease (PD). Three patients with severe PD and erectile dysfunction at our institution underwent ST and PP implantation through a ventral incision. This new approach was not only successful in facilitating the ST and PP implantation in these patients but also allowed for adequate exposure of the penile shaft with no reported loss of sensation. We also conducted a review of current literature regarding the approaches for PD. While ischemic complications of PP implantation and ST are rare, there are reports of ischemic injury in patients undergoing a circumcising incision. The combination of a circumcising incision and a patient's underlying peripheral artery disease potentially raises a patient's risk of this rare complication. Our innovative ventral incision provides an alternative method for PP implantation and ST in order to avoid ischemia of the penis, while still allowing for adequate exposure.

Penile Size Restoration With Nondegloving Approach for Peyronie's Disease: Initial Experience

INTRODUCTION

The sliding technique (ST), commonly done with a subcoronal circumcising incision with penile degloving, has been used to restore penile size in patients with severe Peyronie's disease (PD) and erectile dysfunction, but with a potential risk of ischemic injury to the glans penis.

AIM

To provide detailed surgical techniques regarding the nondegloving ventral incision and report our initial experience with this approach to perform the ST and penile prosthesis placement in patients with severe PD.

METHODS

This was a retrospective review of patient outcomes after penile prosthesis placement with penoplasty for severe PD and erectile dysfunction from January 2015 to December 2017.

MAIN OUTCOME MEASURES

Primary outcomes included straightening rates, penile measurement, along with immediate and late complications. Secondary outcomes include operative time and overall patient satisfaction.

RESULTS

12 Patients had significant penile atrophy and/or curvature >60 degrees and underwent inflatable penile prosthesis placement with grafting procedure. Significant penile atrophy was determined by a combination of the patient's subjective report and the surgeon's objective assessment through stretched penile length. 7 (58.3%) of those patients underwent ST, of which the last 5 had the procedure performed through a nondegloving ventral incision. Mean degree of curvature prior to ST was 66 degrees (45-90 degrees). Mean penile length gain was 2.6 cm (2.0-3.0 cm). At a mean follow-up of 15.5 months (3-31 months), only 1 patient had minimal residual curvature of 15 degrees. There were no vascular complications.

CLINICAL IMPLICATIONS

This nondegloving technique theoretically maintains blood flow continuity to the glans penis by preserving the continuity of the skin, dartos fascia, and neurovascular bundle.

STRENGTHS & LIMITATIONS

Strengths of this study include the novel nature of this approach, no incidence of vascular complications, and adaptability to other grafting procedures during penile prosthesis placement. Limitations include the use of 5-item International Index of Erectile Function scores to assess preoperative erectile function on PD, small population, longer incision, and a possible steep learning curve.

CONCLUSION

While ischemic complications of ST and penile prosthesis implantation are rare, there are reports of ischemic injury in patients undergoing a subcoronal circumcising incision with penile degloving. The non-degloving technique with ventral incision provides for an alternative method for ST and penile prosthesis placement to maintain dartos and skin continuity to the glans penis while still allowing for adequate surgical exposure. Clavell-Hernández J, Wang R. Penile Size Restoration With Nondegloving Approach for Peyronie's Disease: Initial Experience. J Sex Med 2018;15:1506-1513.

Penile Prosthesis Complications: Planning, Prevention, and Decision Making

INTRODUCTION

Inflatable penile prosthesis (IPP) is an established treatment option for men with erectile dysfunction (ED) refractory to medical therapy. Standardization of surgical technique and improvements in device construction have reduced all-cause complication rates to less than 5% in recent reports. Nonetheless, complications do exist, and can strongly impact morbidity and the quality of life of patients. Prosthetic urologists must be aware of the constellation of complications that can arise during or after IPP placement.

AIM

To provide a comprehensive review of penile prosthesis complications and discuss preventative strategies, as well as proper preoperative, intraoperative, and postoperative decision making.

METHODS

A review of the available literature from 1973 to 2018 was performed using PubMed with regard to IPP complications.

MAIN OUTCOME MEASURES

We reviewed publications that outlined preoperative planning strategies and the following IPP complications: hematoma, floppy glans, corporal fibrosis, corporal perforation and crossover, urethral injury, infection, impending erosion, and glandular ischemia.

RESULTS

Careful patient and device selection, setting realistic expectations of postsurgical outcomes, and adherence to a perioperative checklist is essential in the preoperative period. Intraoperatively, anticipate corporal fibrosis situations and always dilate laterally during corporal passage to reduce the risk of crossover and urethral injury. Limit perioperative antiplatelet therapy, apply compressive dressing, use a closed suction drain if indicated, and leave the device partially inflated postoperatively to reduce risk of hematoma. After surgery, monitor patients for potential complications that may warrant device explantation or salvage: IPP infection, glans ischemia, and impending erosion.

CONCLUSIONS

By using evidence and expert opinion-based decision-making strategies in the preoperative, intraoperative, and postoperative period of IPP placement, surgeons can reduce the risk of complications and dissatisfaction, even in ED patients with multiple comorbid conditions. Scherzer ND, Dick B, Gabrielson AT, et al. Penile Prosthesis Complications: Planning, Prevention, and Decision Making. Sex Med Rev 2019;7:349-359.

Glans Necrosis Following Penile Prosthesis Implantation: Prevention and Treatment Suggestions

OBJECTIVE

To examine possible etiology and treatment outcomes in 21 patients with glans necrosis following penile prosthesis implantation.

METHODS

Glans necrosis typically presented with a dusky glans on the first postoperative day following prosthesis implantation.

RESULTS

The blood supply to the glans penis consists of the dorsal arteries and the terminal branches of the spongiosal arteries. Using the cohort in our study, we compiled preoperative comorbidities and adjunctive surgical maneuvers that might compromise glans vascularity, leading to glans necrosis. Preoperative risk factors were arteriosclerotic cardiovascular disease (90%), diabetes mellitus (81%), smoking (81%), previous prosthesis explantation (57%), and previous radiation therapy (48%). The most prevalent intraoperative and postoperative factor was subcoronal incision for reasons as simple as coincident circumcision or as complex as for penile degloving (86%). Other factors detected were penile wrapping with an occlusive elastic bandage (62%), use of a sliding technique for penile lengthening (33%), and coincident distal urethral injury repair (29%). Seventeen patients (81%) managed expectantly with preservation of implanted prosthesis sustained significant glandular loss. Four patients managed with immediate prosthesis removal healed without sequelae.

CONCLUSION

Patients with preoperative risk factors undergoing penile prosthesis implantation should avoid high-risk adjunctive surgical maneuvers. Upon development of signs of glans necrosis postoperatively, in the setting of these high-risk factors, immediate implant removal may prevent subsequent glans necrosis.

Urinary incontinence following transurethral prostatectomy presenting as self inflicted penile gangrene

An elderly diabetic man with a 67 g prostate developed a moderate degree of stress urinary incontinence along with urge urinary incontinence after transurethral resection of the prostate. Initially, he did not perform the recommended pelvic floor exercise and wrapped a rubber band around his penis to control the problem. He presented with late development of penile gangrene requiring partial amputation of his penis. The stress urinary incontinence subsided on subsequent follow-up. The patient is now doing well.

Ischemic Gangrene of the Glans following Penile Prosthesis Implantation

The development of ischemic gangrene of the penis following implantation of prosthesis is unusual, and very few cases are available in the literature. As a result, no established treatment protocol is available. We report our experience within a case of gangrene of the glans following implantation of a three-component prosthesis. We present a 53-year-old male, smoker with diabetes and hypercholesterolemia, who underwent surgery for the insertion of a penile prosthesis with 3 components to correct his erectile dysfunction and severe Peyronie's disease. The procedure was carried out without incidents. During the postoperative period, the patient began to complain from penile and perineal pain. He developed avascular necrosis of the glans. The necrosed area was excised. Four weeks later, he developed fever and perineal pain arriving to the emergency room with the prosthesis extruding through the glans. He had emergency surgery to remove the prosthesis plus surgical lavage and was prescribed broad-spectrum antibiotic therapy. Four weeks later, the penis was completely revascularized and reepithelialized. Ischemic gangrene following penile prosthesis implantation takes place in patients with poor peripheral vascularisation. Diabetes mellitus has been the common denominator to all of the reported cases.