Penile prosthetic surgery for the management of Peyronie's disease

Current devices, outcomes, and pain management considerations in penile implant surgery: an updated review of the literature

ABSTRACT

Penile prosthesis surgery is a definitive treatment for erectile dysfunction (ED). The two categories of penile prosthesis are endorsed by professional guidelines, inflatable penile prosthesis (IPP) and malleable penile prosthesis (MPP). Each modality of penile prosthesis offers distinct advantages and incorporates specific design features, allowing for personalized device selection that aligns with individual needs and preferences. While the overall complication rate of penile implant surgery remains low, surgeons should maintain a high index of suspicion for complications in the perioperative time period. Multimodal analgesic regimens including nerve blocks and narcotic-free pathways should be administered to manage perioperative pain. Finally, the high patient satisfaction after penile prosthesis surgery underscores the success of this ED treatment option.

A narrative review on malleable and inflatable penile implants: choosing the right implant for the right patient

A penile prosthesis/implant is an excellent option for men with erectile dysfunction refractory to medical treatment or with contraindications to medical management. In this narrative review, we discuss the different types of penile prostheses and the considerations for patient and device selection to maximize satisfaction. There are three main prosthesis types to choose from: three-piece inflatable devices, two-piece inflatable devices, and malleable/semirigid devices. The three-piece devices are the gold standard in advanced economy countries but require reservoir placement and manual dexterity, which can be limiting to some patients. The two-piece inflatable devices are a good option for patients who have standard-sized penises, lack significant penile pathology, have limited dexterity issues, or should avoid reservoir placement due to potential complications. The malleable devices are popular in countries where insurance coverage is limited but are increasingly used in advanced economy countries for length conservation in specific patient populations. Finally, not every patient needs an implant, and assessing partner sexual function is an important consideration for patient-partner satisfaction. Surgeons need to be familiar with the strengths and limitations of each device and the patient characteristics that will yield the best outcome from penile prosthesis surgery.

Penile implant surgery-managing complications

Penile prosthesis surgery represents the end-stage treatment for erectile dysfunction. It is conventionally used only in cases of erectile dysfunction refractory to pharmacological treatments or vacuum constriction devices. Contemporary literature suggests that penile prothesis surgery is associated with a high satisfaction rate and a low complication profile. However, it must be appreciated that the complications of surgery can have devastating consequences on a patient’s quality of life and satisfaction and include infection, prosthesis malfunction, penile corporal perforation and penile length loss. Several factors – such as appropriate patient selection, methodical preoperative assessment and patient optimization, specific intraoperative protocols and postoperative recommendations – can reduce the risk of surgical complications. This narrative review discusses the diagnosis and management of both intraoperative and postoperative complications of penile prosthesis surgery.

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.

Long-term patient-reported outcomes in men with Peyronie's disease undergoing nonsurgical and nonintralesional injection management

Peyronie's disease (PD) has a negative impact on overall quality of life for many patients and their partners. There is a significant portion of patients who elect noninvasive therapy and in this scenario we have little data with which to counsel patients. We aim to evaluate long-term patient-reported outcomes in a cohort of men with PD who elected conservative treatment. We identified all males with a diagnosis of PD evaluated at our institution by a single provider between May 2012 and January 2018. We excluded men who were <18 years old or had undergone surgical or intralesional injection (ILI) treatments. A PD-specific questionnaire was sent to those who met our inclusion criteria. 88/514 patients completed the survey and met the inclusion criteria. Penile curvature subjectively improved in 49%, remained stable in 34%, and worsened in 17%. Penile shortening was reported in 89% of patients. Penile shortening subjectively improved in 27%, remained stable in 59%, and worsened in 14%. Roughly 60% reported worsened intercourse satisfaction and erectile function. 60% reported that PD had negatively impacted their self-esteem and 69% felt that PD negatively impacted their sexual partner. Patients who utilized penile traction therapy (PTT) were significantly more likely to report improvements in penile curvature, shortening, and ability to engage in penetrative intercourse. Our survey provides important data on patient-reported outcomes in men with PD electing nonsurgical and non-ILI interventions. Although 49% of men noted at least a mild subjective improvement in their curvature over time, a majority had declining erectile function, decreased intercourse satisfaction, and psychosocial distress. These data can be used when counseling patients with a new diagnosis of PD who are considering treatment options.