Campbell’s Review – Chapter 23

788 – 801

PROSTHETIC SURGERY FOR

ERECTILE DYSFUNCTION

BackgrounD

• 3 major events in ED Tx

– 1973 - Inflatable Penile Prosthesis

– 1982 – Intracavernous Injection Therapy

– 1998 – Effective systemic therapy - sildenafil

Prosthesis Types

• Malleable prosthesis– ADV: Low Mechanic Failure / Ease of use– DISADV: Constant rigidity / ▲ Erosion Risk

• Positional prosthesis– SemiRigid – Articulating Segments– Better to maintain up/down positions

• 2 – piece inflatable prosthesis– ADV: Ease of implantation– DISADV: ▲ Mechanical Failure Risk

Prosthesis Type

• 3 – piece inflatable penis

• Most closely resembles natural flaccidity and erection

• Provide penile girth expansion and rigidity

• AMS 700 or Mentor Titan

Pre-Op Counseling

• Pt has failed systemic treatment

• Inform of advantages and disadvantages

• Inform of other options

• DO NOT TREAT FOR ED THAT IS SITUATIONAL – PSYCH COUNSELING OR SEX THERAPY

• Also discuss post-op expectations

Pre-Op Counseling

• B/c the glans is not included in the [prosthetic] erection, it will be shorter

• Normal libido, sensation, orgasm

• Infection possible complication and would require removal and result in scarring

• Failure is possible

Surgical Approaches• Subcoronal – malleable or positional

• Infrapubic - reservoir placement under direct vision

• Penoscrotal – better corporeal exposure, no dorsal nerve injury, pump fixation possible

AMS 700 by PenoScrotal approach

• Safe reservoir insertion in retropubic space possible if bladder is empty

Post – Op care

• Foley removed next day

• Antibiotic for 1 week

• Oral narcotic used for 1 week

• Restrict lifting activities if reservoir present

• Have pts practice pumping 1 month after sx

Complications

• INFECTIONS – No significant illness, but to eradicate infection, removal of prosthesis is required.

• Delay implanation if UTI or cutaneous inf• Shave day of surgery• Prevent by 10 minute skin prep• Gent vancomycin• Paper drapes• Silicone has a sterile charge and should be

irrigated

Complications

• Infections occur either– 1st few weeks - gram negative– After 6 months – gram positive Staph epi

Role of diabetes is controversial as related to infection probability

Complications

• EARLY INFECTIONS– Swelling, erythema, tenderness, drainage

• Occasional fever

• LATE INFECTIONS– PAIN– Skin may be adherent to pump

COMPLICATIONS

• Erosion is evidence of infection

• REMOVE ALL COMPONENTS– ABX alone not sufficient

• Re-Implant?– To minimize scarring of corporeal dilation,

perform as soon as possible to PREVENT SCARRING AND PENILE SHORTENING

COMPLICATIONS

• Rifampin/Minocycline coated prosthesis showed less infection rate than hydrophilic coated devices.

• IF mechanical failure, usually after 5 years

COMPLICATIONS

• Perforation and Erosion– If dilator perforates proximal corpora, use a

larger dilator & allow perforation to heal– If dilator perforates urethra, ABANDON

PROCEDURE; place catheter 7-10 days• Can avoid by keeping tip of dilator under

dorsolateral surface of corpus cavernosum

– If erosion of one cylinder:• REMOVE THAT CYLINDER. OK w/ one

Poor Glans Support / Oversized Rod

• “Concorde” type glans after placement b/c of undersized, or inadequate dilation

• SST DEFORMITY

• Oversized cylinders cause pain and can erode

Special Cases

• Peyronie’s disease– Scarring in tunic albuginea– Corporoplasty likely needed if length and girth

expanders used– If relaxing incision are done and gap is

greater than 1 cm, must cllose to prevent herniation of cylinders

Special Cases

• Cavernosal Fibrosis– Usually from infected implant removal or ischemic

priapism • May need to use metz to carve out fibrotic tissue

RESULTS / OUTCOMES

• AMS and Mentor 5 year device survival equivocal

• Implantation favored over injection and most men had high satisfaction scores from both baseline and after 6 months of continued healing