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

Unexpected nuances of the penoscrotal inflatable penile prosthesis

The inflatable penile prosthesis was first implanted with a large vertical suprapubic incision. Nowadays, three surgical approaches are utilized: penoscrotal, infrapubic, and subcoronal. Globally the penoscrotal approach is used most often. Our first author describes nuances of the high transverse scrotal incision technique gained over 48 years of experience. Many of these methods will interest the reader because they are divergent from the common practice of implanters across the world. These distinctions are designed to diminish the risk of infection, speed up the surgery, and improve outcomes for both the patient and his surgeon.

A review of surgical techniques for impending distal erosion and intraoperative penile implant complications: part 2 of a three-part review series on penile prosthetic surgery

INTRODUCTION

More than half of intraoperative complications occur during dilatation of the corpora cavernosa, a critical step in the placement of any type of penile prosthesis, which can be especially difficult in a patient with corporal fibrosis. A late manifestation of cylinder placement can be impending erosion with lateral extrusion or medial deviation (into the urethra) of the distal tips. There are many different approaches to try and fix these surgical issues.

AIM

The review article evaluates the many different surgical techniques prosthetic surgeons use in the management of intraoperative complications and lateral extrusion.

METHODS

A review of the literature was preformed with published results being evaluated to try to help guide the management of intraoperative complications and impending distal erosion. There is a special focus on dilation of the corpora cavernosa.

MAIN OUTCOMES MEASURES

The article reviews and evaluates the outcomes of the landmark papers in the management of intraoperative complications and impending distal erosion.

RESULTS

Intraoperative complications of penile implant placement can be distressing for the prosthetic surgeon, but with proper recognition, most of these complications can be navigated with excellent postoperative results.

CONCLUSIONS

This review article summarizes many of the techniques, outcomes, and new developments in the complicated field of penile prosthetic surgery to help guide the implanting surgeon.

Increasing size with penile implants

Penile prosthesis implantation is suitable treatment for men with erectile dysfunction when nonsurgical treatment options fail or are otherwise unsatisfactory. Three-piece inflatable penile prostheses closely approach the ideal of producing normal penile flaccidity and erection. Nevertheless, even in men with normal corpora cavernosa, many report their prosthetic erection is shorter than their former natural erection. This is due to the lack of glans tumescence and the use of penile cylinders, which only expand in girth. Using girth- and length-expanding cylinders can decrease the loss of penile length frequently seen with prosthesis implantation. Some penile prosthesis recipients have abnormal corpora following radical prostatectomy or after removal of an infected penile prosthesis, or as the result of Peyronie's disease, obesity, or ischemic priapism. In these men with abnormal corpora, associated penile-lengthening procedures can be combined with penile prosthesis implantation. However, experience is limited with these combined procedures.

ORIGINAL RESEARCH—SURGERY: Penile Prosthesis Implantation in Cases of Fibrosis: Ultrasound-Guided Cavernotomy and Sheathed Trochar Excavation

INTRODUCTION

Implantation of a penile prosthesis into fibrosed corpora cavernosa is a difficult and risky procedure. Specialized instruments that assist safer and more efficient excavation include Otis Urethrotome and various cavernotomes, all of which operate underneath the tunica albuginea, out of sight. The blind use of such instruments can result in perforation of the tunica albuginea or injury to the urethra.

AIM

This work describes the utility of ultrasonography for adding visual monitoring to any of the above-mentioned instruments, maintaining them in the mid-corpus cavernosum position to avoid perforation, and describes the application of alternative sheathed, sharp instruments that allow fast, efficient, and visually monitored drilling into fibrous tissue.

MAIN OUTCOME MEASURES

Clinical outcome data were examined.

METHODS

Surgery was performed on five cases with extensive fibrosis of the penis. Initial blunt dilatation by Hegar dilators faced considerable resistance. An ultrasound probe was applied to the ventral aspect of the penis. A laparoscopy sheath was advanced under ultrasound guidance up to the fibrous tissue. A sharp laparoscopy trochar was inserted through the sheath. Its tip was oriented in the mid-corpus cavernosum by longitudinal and transverse sonography sections, as it drilled into the fibrous tissue. Laparoscopy scissors were used in the same fashion to cut fibrous tissue lumps. After full excavation, penile prosthesis was implanted.

RESULTS

All implants survived adequately. No complications occurred following implantation. Operative time ranged from 50 to 60 minutes. No difficulty was encountered at excavation.

CONCLUSION

Ultrasound guidance can be a handy adjunct to any of the available techniques developed for excavating the fibrosed corpora cavernosa, with a possible decrease in difficulty and complication rate of the procedure. Utility of sheathed, sharp instruments guided by sonography is an alternative to the cavernotomes, allowing fast and efficient drilling into fibrous tissue.

Corporeal excavation: New technique for penile prosthesis implantation in men with severe corporeal fibrosis

INTRODUCTION

Penile prosthesis implantation in men who have fibrotic corpora as the result of ischemic priapism or previous removal of an infected penile prosthesis poses a significant challenge to the implanting surgeon. We describe a new technique, corporeal excavation, to meet this challenge.

TECHNICAL CONSIDERATIONS

The operative approach is through an inverted T penoscrotal incision that affords exposure of nearly the entire corpus cavernosum on each side. Extended corporotomies are made on the ventral aspect of each corpus cavernosum, and a plane of dissection between the fibrotic corporeal tissue and the inner surface of the tunica albuginea is established, resulting in core removal of nearly all fibrotic intracorporeal tissue. Cylinders are laid into the empty corporeal bed, and the tunica albuginea is closed primarily. Nine patients were identified who had undergone this procedure. The operative notes and medical records were reviewed, and telephone interviews were done for follow-up when patients had not been recently seen in the clinic.

CONCLUSIONS

Successful outcomes were achieved in all 9 patients. Corporeal excavation permits penile prosthesis implantation in men with severe intracorporeal fibrosis usually resulting from priapism or previous removal of infected penile prostheses.

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.

Mechanical reliability of the AMS 700CXM inflatable penile prosthesis for the treatment of male erectile dysfunction

PURPOSE

The AMS 700CXM inflatable penile prosthesis with medium controlled expansion cylinders was introduced in 1990 to provide a device with controlled expansion in girth and fitness for Asian men. We reviewed our experience with the AMS 700CXM prosthesis with particular regard to postoperative complications and reliability.

MATERIALS AND METHODS

From January 1991 to April 1999, 273 men with erectile dysfunction underwent primary penile prosthesis implantation with the AMS 700CXM. Functional status of the prosthesis was assessed retrospectively by reviewing the medical records and a telephone interview.

RESULTS

Patient age was 24 to 78 years and mean followup was 49 months. Of the 28 complications (10.3%) 8 (3%) were nonmechanical and 20 (7.3%) were mechanical. Nonmechanical complications included infection in 2 cases, erosion in 3, surgical complications in 2 and tube kinking in 1. Mechanical complications involved a cylinder tear in 11 cases (4%), pump failure in 4 (1.5%) and a reservoir tear in 2 (0.7%). Mechanical reliability of the device was 98.2% after 2, 95.7% after 3 and 90.4% after 5 years.

CONCLUSIONS

The AMS 700CXM is suitable for Asian men and its mechanical reliability is excellent. However, more device modifications are needed to guarantee good reliability during long-term followup.

Current status of penile prosthesis implantation

Today most men with erectile dysfunction (ED) can be effectively treated with less invasive means than penile prosthesis implantation. Nevertheless, there remain men who do not respond to simple treatments such as systemic medication and who either do not respond to or reject intermediate treatment such as penile injection therapy. For these men, penile prosthesis implantation remains a reasonable option. This review discusses types of penile prostheses, how to choose among prosthesis types, key features of implant techniques, infection management, penile reconstruction related to prosthesis implantation, and patient and partner satisfaction.

Reconstructive surgery using urological prostheses

Urological prostheses have been available and widely used for the past two decades. The use of penile prostheses, artificial urinary sphincters, and testicular implants for genitourinary reconstruction for erectile dysfunction, incontinence, and orchiectomy have been successful, widely used and of low morbidity. More recently designed devices, innovations in implantation techniques, and improved intraoperative and postoperative care have resulted in the successful worldwide use of these prosthetic devices.