The management of extensive penile fibrosis: a new technique of 'minimal scar-tissue excision'

Surgical implant options in patients with penile fibrosis due to infection or previous explants

Penile fibrosis due to previous penile infection and/or prosthesis explants entails situations of high surgical complexity. In these cases, reimplantation should follow an alternative scheme, aimed at minimizing perioperative and postoperative complications, as well as achieving maximum efficiency of the procedure and greater postoperative satisfaction of the patient and his partner. This article reviews the main surgical alternatives for these cases.

Cylinder insertion into scarred corporal bodies: prosthetic urology's most difficult challenge: some suggestions for making the surgery easier

Corporal fibrosis is a process that involves excessive deposition of scar tissue in response to infection, trauma, or ischemia. It does not occur merely as a result of previous IPP surgery. Excessive development of corporal fibrosis is certain after extraneous and disastrous events such as priapism or the removal of a device for infection. The usual surgical planes and spaces are obliterated by proliferation of scar both in the tissues overlying the corpora and the space within the corpora previously occupied by erectile tissue. To maximize success, specialized instruments, downsized cylinders, and lots of experience are necessities. Prosthetic urology produces, for the most part, happy patients. Fibrosis guys, to a man are not happy. Let the expert have the unhappy patient!

Extracorporeal Transseptal Penile Prosthesis Implantation for Extreme Cases of Corporeal Fibrosis: Shaeer Implantation Technique

BACKGROUND

Penile prosthesis implantation into scarred corporeal bodies is one of the most challenging procedures in prosthetic urologic surgery, especially following infection and extrusion of a penile implant. Several instruments and techniques have been used for making dilatation of scarred corporeal bodies easier and safer in expert hands. Nevertheless, in some cases, implantation is not possible.

AIM

This work presents extracorporeal transseptal implantation as a last resort in such cases.

METHODS

In 39 patients with extensive corporeal fibrosis, penile prosthesis implantation is attempted. After failure of alternative techniques, extracorporeal implantation is resorted to in 10 patients. The corpus spongiosum is identified and protected. Diathermy knife is used to cut a longitudinal window into 1 corpus cavernosum, through the septum and into the contralateral corpus cavernosum. A single semirigid implant rod is inserted through the window at the base of the penis, halfway through. The 2 limbs of the rod are bent upward toward the glans, to assume a U shape. The limbs of the U are brought together at midshaft by a gathering suture passed through the corpora cavernosa and septum. The tips of the U are anchored under the glans.

OUTCOMES

Achievement of acceptable coital relationship.

RESULTS

The procedure allowed acceptable coital relationship and concealment in 9/10 cases. In 1 case, infection occurred. Reimplantation with the same method was performed 6 months later, and the implant survived adequately. Perforation, migration, and urethral injury were not encountered.

CLINICAL IMPLICATIONS

This technique may help salvage abandoned cases with corporal fibrosis, particularly when the necessary expertise for alternative techniques is unavailable or when such techniques fail.

STRENGTHS & LIMITATIONS

The technique presented is fairly straightforward and safe. However, the number of cases and duration of follow-up are limited.

CONCLUSION

Extracorporeal transseptal penile prosthesis implantation can salvage cases with severe corporeal fibrosis when all alternatives fail. Shaeer O, Shaeer K. Extracorporeal Transseptal Penile Prosthesis Implantation for Extreme Cases of Corporeal Fibrosis: Shaeer Implantation Technique. J Sex Med 2018;15:1350-1356.

Proximal Corporal Perforation During Penile Prosthesis Surgery: Prevention, Recognition, and Review of Historical and Novel Management Strategies

BACKGROUND

Proximal corporal perforation at time of dilation, although rare, may occur due to factors related to patient anatomy, presence of intra-cavernosal fibrosis, and/or surgical technique.

AIM

To describe tools and techniques designed to prevent and identify proximal corporal perforation, and maneuvers to minimize the risk of subsequent cylinder migration once proximal perforation has been recognized, such that the operation may proceed and result in an acceptable outcome.

METHODS

We discuss tips for prevention, recognition, and management of proximal corporal perforation by presenting a review of the literature as well as our preferences based on a high-volume experience with penile prosthesis surgery.

OUTCOMES

Described techniques aim to minimize risk of cylinder migration in the absence of true proximal repair.

RESULTS

Although proximal perforation may be obvious at times, particularly with a sudden loss of resistance during dilation, discrepant corporal measurements and/or dissimilar proximal deflection of the dilator should also increase the index of suspicion. Numerous techniques have been employed to theoretically reduce the risk of cylinder migration in the setting of proximal corporal perforation. These include formal corporal repair (historical), windsock repairs with non-absorbable grafts, absorbable plugs, and suture fixation of the rear tip extender or shod material covering implant tubing.

CLINICAL TRANSLATION

Intra-operative recognition of proximal corporal perforation, coupled with understanding of surgical strategies to minimize the risk of future device migration, may allow completion of an operation that still results in an optimal outcome.

CONCLUSIONS

Techniques described to prevent proximal migration are not strongly evidence-based, but rooted in logic and supported by high-volume implanters. Intra-operative perforation of the proximal corpora, although rare, can threaten the success of penile implant surgery, though the techniques described herein have been developed to mitigate the potential for subsequent device migration, allowing surgery to proceed and to achieve the desired clinical result. Pearlman AM, Terlecki RP. Proximal Corporal Perforation During Penile Prosthesis Surgery: Prevention, Recognition, and Review of Historical and Novel Management Strategies. J Sex Med 2018;15:1055-1060.

The use of penile prostheses in the management of priapism

Priapism is a relatively uncommon condition that can result in erectile dysfunction (ED) and corporal fibrosis. Cases of prolonged priapism are particularly prone to ED, which arises when priapism is treatment refractory or had a delayed presentation. Due to the emergent nature of priapism, it behooves urologists to be familiar with all potential treatment modalities to minimize adverse outcomes. In this review paper, we aim to summarize the literature regarding the use of penile prosthesis (PP) implantation in the setting of ischemic priapism (IP). In some patients who present later or have prolonged initial treatment, early insertion of PP may be indicated.

Inflatable Penile Prosthesis Insertion in Men with Severe Intracorporal Fibrosis

OBJECTIVES

To retrospectively review a series of men who underwent attempted inflatable penile prosthesis (IPP) insertion into severely scarred corpora, and to analyze the surgical techniques and instruments that contributed to a successful outcome.

PATIENTS AND METHODS

All IPP procedures done by a high-volume prosthetic surgeon during a 5-year period were retrospectively reviewed. Fourteen patients with severe intracorporal fibrosis underwent 15 attempted IPP insertion procedures, and are the subject of this review.

RESULTS

A standardized surgical approach was employed for all patients. Thirteen of the 15 procedures were successful (i.e., an IPP was inserted, with satisfactory cylinder position). One procedure failed due to corporal obliteration. One patient underwent an initial failed attempt, but was successfully implanted 10 months later. Two of the 14 patients (14%) developed peri-prosthetic infection and were explanted.

CONCLUSION

IPP insertion into scarred corpora is difficult and occasionally impossible. We have developed a standardized surgical approach for these cases, using limited corporal excavation, followed by the use of sequential Uramix and then Carrion-Rossello cavernotomes, that we feel has improved our chance of a successful implant. However, due to the rarity of these cases, it is not possible to make definitive statements concerning the optimal surgical technique.

History, Contemporary Outcomes, and Future of Penile Prostheses: A Review of the Literature

INTRODUCTION

Since their introduction, penile prostheses have consistently remained a superior treatment option for men with erectile dysfunction (ED) refractory to conservative measures. Ongoing enhancements to prosthetic design, materials, and surgical techniques have resulted in improved outcomes.

AIM

To review available literature on notable historical advancements and improvements of the penile prosthesis, summarize contemporary outcomes of recent devices, and discuss possible future directions of the penile prosthesis.

METHODS

A PubMed search was performed of all articles published from 1960 to present relating to penile prosthesis. Priority was given to series with 12 months of follow-up or greater, larger series, and studies reporting on outcomes of more recent prosthetic models.

MAIN OUTCOME MEASURES

Main outcomes included historical review of improvements leading to, and contemporary series reporting on rates of mechanical failures, infections, and satisfaction with penile prostheses.

RESULTS

Penile prostheses have undergone numerous enhancements since initial reports of synthetic materials utilized in the 1950s. Among others, recent notable device enhancements include Parylene coating, Bioflex® material, Inhibizone^TM antibacterial impregnation, hydrophilic coating, lockout valves, and easy release pump mechanisms, all of which have improved mechanical reliability, reduced infection rates, and/or improved patient satisfaction with penile prostheses. Contemporary series of 3-piece penile prostheses report mechanical survival of 81-94%, 68-89%, and 57-76% at 5, 10, and 15 years, respectively. Infection rates of current devices are 1-2% in first-time, low-risk populations, and 2-3% for higher risk groups, with patient and partner satisfaction at 92-100% and 91-95%, respectively. Two-piece and malleable devices are associated with slightly higher mechanical reliability and decreased patient satisfaction. Minimal data currently exist on the outcomes of selected patient populations, including Peyronie's disease and corporal fibrosis.

CONCLUSIONS

Penile prostheses are associated with excellent, long-term outcomes and remain the gold-standard treatment for men with refractory ED. Additional research with prospective studies utilizing objective measures and standardized questionnaires is required. Trost L and Hellstrom WJG. History, contemporary outcomes, and future of penile prostheses: A review of the literature. Sex Med Rev 2013;1:150-163.

Distal penile shaft reconstruction and reinforcement: the "double-windsocks" technique

INTRODUCTION

The management of penile prosthesis protrusion and the implantation of a prosthesis in fibrotic penile corporal bodies represents a challenging task even for experienced surgeons.

AIM

To demonstrate the long-term efficacy and safety of a new technique for distal shaft reconstruction and reinforcement in cases of penile prosthesis protrusion or cases of penile prosthesis implantation in corporal fibrosis.

METHODS

Between August 2007 and August 2012, 69 patients underwent surgery for penile prosthesis protrusion (45 patients) or severe distal corporal fibrosis (24 patients). The mean age at the time of surgery was 56 years (range 38-69). All patients underwent distal shaft reconstruction using our technique, involving the creation of two neocorpora ("double windsocks").

MAIN OUTCOME MEASURES

Functional outcome and patient satisfaction were evaluated with item numbers 1 and 7 of the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire. Furthermore, clinical data concerning the early postoperative outcome were analyzed retrospectively.

RESULTS

Mean follow-up time was 22.5 months (range 6-48). Based on answers to EDITS questionnaire item 1, 42 patients (60.9%) were very satisfied and 19 patients (27.5%) were somewhat satisfied with the outcome of the procedure. Furthermore, answers to the self-confidence domain question (EDITS item 7) revealed that 63 patients (91.3%) felt that the treatment had a positive effect with respect to their ability to engage in sexual activity. No patient exhibited device extrusion, postoperative infection, or skin dehiscence, and glans sensation as well as orgasmic ability were also preserved in all cases. Neuropraxia was reported in five cases (3.4%) immediately after the operation. The recovery of orgasmic ability was delayed in 17 (24.6%) patients. All patients were able to perform sexual intercourse postoperatively.

CONCLUSION

The "double-windsocks" technique is an effective option for difficult cases of distal penile shaft reconstruction and reinforcement.

Treatments for fibrosis of the corpora cavernosa

Introduction

Corporal fibrosis usually occurs after explantation of an infected penile prosthesis, severe penile trauma, refractory low-flow priapism, Peyronie’s disease, or the chronic intracavernous injection of vasoactive drugs.

Methods

We analysed current treatmentss for penile fibrosis. We searched PubMed using the keywords ’penile corporal fibrosis’, ’treatment’ and ’penile fibrosis’, resulting in 63 matches, of which 19 articles met the inclusion criteria.

Results and conclusions

This review covers conservative medical therapy for corporal fibrosis and surgical therapeutic methods. The roles of phosphodiesterase- 5 inhibitors and pentoxifylline are analysed. Surgical therapy includes implantation of a penile prosthesis and corporal reconstruction, and these are reviewed. Corporal fibrosis is a major problem for patients, and is associated with severe erectile dysfunction. Conservative treatment options can be applicable in the early phase, but simultaneous corporal reconstruction procedures with concomitant implantation of a penile prosthesis should be attempted in severe cases of corporal fibrosis.

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.

ORIGINAL RESEARCH—SURGERY: Efficacy and Patient Satisfaction Associated with Penile Prosthesis Revision Surgery

INTRODUCTION

Complications that arise after placement of a penile prosthesis may result in the need for revision surgery. Few contemporary penile prosthesis series have focused solely on describing the efficacy and patient satisfaction associated with penile prosthesis revision surgery.

AIM

To determine the overall success of penile prosthesis revision surgery in providing the patient with a functional implant. Device efficacy and patient satisfaction with penile prosthesis revision surgery will be assessed using psychometrically validated instruments.

MAIN OUTCOME MEASURES

The erectile function (EF) and satisfaction domains of the International Index of Erectile Function (IIEF) were used to quantify the overall efficacy and patient satisfaction with revision surgery.

METHODS

Data were derived from a prospective database of consecutive patients undergoing penile prosthesis revision surgery performed by a single surgeon (B.R.K.). Eleven patients filled out the IIEF prior to surgery and 26 completed it following surgery.

RESULTS

Thirty-nine consecutive patients underwent 55 revision procedures related to a prior penile prosthesis. Thirty-four patients (87%) have a functional implant with a median follow-up of 6.5 months (range 1-42 months). Significant improvements in the overall IIEF, EF domain, and satisfaction domain were seen in those patients studied prior to and following revision surgery. The total IIEF, EF domain, and satisfaction domain of the IIEF for the group of 26 responders were 60.7 +/- 19.3, 26.6 +/- 8.7, and 15.7 +/- 5.6, respectively. Patients with fibrotic corporal bodies scored significantly lower on the EF and satisfaction domains than did any other group.

CONCLUSIONS

Penile prosthesis revision surgery is highly successful in providing men with a functional implant. The prostheses function well and patients are satisfied with their devices. Further study of those men with corporal fibrosis is warranted in order to determine the factors needed to improve their overall satisfaction with revision surgery.

Penile prosthesis implantation: surgical implants in the era of oral medication

In patients who are not satisfied with the results of oral agents (phosphodiesterase-5 inhibitors) or in whom oral agents or other medical treatment fails to produce an adequate response, penile prosthesis implantation is an excellent treatment modality for restoring erectile function. Patient/partner acceptance, use, and satisfaction rates of penile pros-theses are better than for many other alternatives including pharmacologic injections. In-flatable penile prostheses are most frequently used and have the highest satisfaction rates. Complications of these multipiece prostheses continue to decline, and patient satisfaction rates, tolerability, and longevity continue to increase.

Penile implant success in patients with corporal fibrosis using multiple incisions and minimal scar tissue excision

OBJECTIVES

To establish the efficacy of "minimal scar tissue excision" in the treatment of penile fibrosis.

METHODS

Thirty-four patients with extensive penile fibrosis who underwent placement of penile implant from October 1989 to April 1998 were evaluated by a chart review of the patient's follow-up data. Function of the implant was evaluated at follow-up visits. The follow-up ranged from 4 to 84 months (mean 23.7, median 22). All patients had undergone minimal scar tissue excision of the fibrous tissue in the penis.

RESULTS

All patients underwent successful introduction of the penile implant, and in no patient was the procedure abandoned because of technical difficulty. Intraoperatively, 1 patient developed a tear in the crus. It was not recognized during the initial operation but was repaired at a subsequent date by Gore-Tex grafting. The Uniflate prosthesis of another patient failed 2 years after the initial surgery and was replaced with the Mentor alpha-1 implant. None of the patients developed infection. All the patients had a functioning implant at the time of last review.

CONCLUSIONS

Minimal scar tissue excision is a safe and effective method in the management of extensive penile fibrosis.

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.

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.