235

PROBLEMS AND VARIATIONS

IN THE PLACEMENT OF THE

THREE-COMPONENT

INFLATABLE PENILE

PROSTHESIS

Troubleshooting for theMalfunctioning Prosthesis

24

Although there are ongoingchanges in the design of penileprostheses, we believe there re-main basic surgical considerationsthat are universal and applicableto all penile prosthesis surgery.We have chosen to discuss themore complex three-componentprosthesis to illustrate all possibleproblems.

IDENTIFICATION OF PROXIMALURETHRA AND CORPORACAVERNOSA

FIG. 24-1. After the bladder isemptied by catheterization, an in-cision at the penile scrotal junctionis made over the median rapheextending 4 to 5 cm.

A 22 Fr Van Buren sound ispassed into the urethra to facili-tate identification of the urethraand the corpora on both sides ofthe urethra. The surgeon shoulddissect down to the corpus spon-giosum surrounding the urethraand then laterally on either sideof the corpus spongiosum to

Penis

Scrotum

Incision

Anus

24-1

236 Critical Operative Maneuvers in Urologic Surgery

identify the corpora cavernosa.This dissection defines a clearborder between the urethra andcorpora cavernosa, thus prevent-ing injury to the urethra duringthe operation.

An artificial erection can be in-duced by injecting saline solutionwith prostaglandin E1 (20 µg) intoa corpus cavernosum for full va-sodilation while a tourniquet isapplied around the base of the pe-nis. This maneuver will allow thesurgeon to estimate erect penilesize, diameter, curvatures, and fi-brotic plaques and will thus facil-itate subsequent corporeal dissec-tion and dilatation.

CORPOREAL INCISION ANDDILATATION

FIGS. 24-2, 24-3, AND 24-4. A verticalcorporeal incision of 4 cm is madebetween two traction sutures (0Prolene) at the 6-o’clock position.The incision should be as proxi-mal as possible and parallel to theurethra.

FIG. 24-5. If the incision is too dis-tal, the surgeon will have diffi-culty inserting the proximal pros-thesis, especially with rear-tipextenders, and the tubing may bepressed against the cylinder wall.Even with the protective sheathover the tubing, the constant pres-

sure over time may cause thecylinder walls to erode.

If the incision is too proximal,the surgeon will have difficultywith distal cylinder insertion andwith closure of the corporotomy.

FIG. 24-6. The surgeon first estab-lishes a dissection plane betweenthe most lateral corporeal tunicaand sinus bodies using long scis-sors in a forward-and-backwardspreading motion. This dissectiontechnique not only avoids the ure-thra and the median septum butalso preserves as much as possiblethe sinus endothelium and thecavernosal artery. Preservation ofthe vascular architecture, evenwhen diseased, enhances thequality of later erections.

FIG. 24-7. After the initial scissorsdissection, the space between thecorporeal tunica and sinuses is di-lated with Hegar size 7 to 13 dila-tors in preparation for cylinderplacement. We prefer to dilate thecorpus cavernosum to the size ofa size 13 dilator because it makesthe cylinder placement easier.

FIGS. 24-8 AND 24-9. The dilatationshould extend to the most distalend and reach the most proximalend at the crus. When distal di-latation is incomplete, the surgeonmay find a glandular droop “SSTsyndrome” after placement of thecylinders.

24-2

Corpuscaver-nosum

Distalbulbousurethra

Incision

Urethra

Corpuscavernosum

Skin

Skinincision

Corporealincision

Cross-sectional View

Ventral penis

Dorsal penis

Skinincision

UrethraCorporealincision awayfrom urethra

Tractionsutures

24-4

24-3

Glans penis

Corpuscavernosum

Dilatation todistal end

Chapter 24 Problems and Variations in the Placement of the Three-Component Inflatable Penile Prosthesis 237

24-5

24-6

24-7

24-8 24-9

Incision too distal

A B

Optimal incision

Corpuscavernosum

Optimal imaginary planeof dissection

Urethra

Vascular sinusbodies

Cavernosalartery

Penis

Cross-sectional ViewPenis

Result aftercorporeal dilatation

Urethra

Preservation ofcavernosal arteryand sinus bodies

SST GlandularDroop Syndrome

Insufficientdistal dilatation

Optimal dilatationand cylinder placement

A

B

238 Critical Operative Maneuvers in Urologic Surgery

CYLINDER SELECTION ANDINSERTION

We use the American Medi-cal Systems (AMS, Minneapolis,Minn.) inflatable penile prosthe-sis, which is representative of thegeneric type of three-componentprosthesis.

FIG. 24-10. After the measure-ments of both cylinder lengths aremade, the surgeon has the choiceof using three different cylindersizes (12, 15, or 18 cm) with threedifferent-sized rear-tip extenders(RTE) and two different-sizedreservoirs. The shortest rear-tipextenders are placed against thecylinder first. For example:

1. 15 cm cylinder � 1 cm RTE �2 cm RTE � 18 cm (65 ml reservoir)

2. 18 cm cylinder � additional RTE ifneeded � >18 cm (100 ml reservoir)

The 12 and 15 cm cylinders al-ways require the 65 ml reservoir,whereas the 18 cm cylinder re-quires the 100 ml reservoir.

The most common corporeallengths range from 18 to 20 cm;the 15 cm cylinder is most com-monly selected.

The ideal situation is for the in-flatable portion of the cylinders tolie within the corpora cavernosaof the penis and the rear-tip ex-tenders to fill the spaces of thetwo crura.

SPECIFIC DIFFICULTIES INCYLINDER PLACEMENT

Fibrosis of the corporeal bodiessecondary to treatment for pri-apism from Peyronie’s disease,injections, and diabetes can com-plicate dilatation and cylinderplacement.

Distal Corpora CavernosaFIG. 24-11. Even with complete di-

latation of the distal corpora cav-ernosa and proper placement ofthe prosthesis, natural anatomicvariation may still result in adrooping glans penis.

In this case a horizontal inci-sion around the base of the glanspenis is made, exposing the dorsalnerves, glandular tissues, and dis-tal corporeal bodies. The surgeonshould place two stitches approx-imating the glandular tissues tothe corpus cavernosum just lateralto the dorsal nerves to correct thedrooping glandular configuration.

FIG. 24-12. When dilating the dis-tal corpora cavernosa, the surgeonmay encounter a common prob-lem of mild fibrotic webbing in di-abetic patients (A). Usually this fi-brotic web can be broken up bysimply dilating the corporealtract.

In cases of more severe scar-ring, such as with Peyronie’s dis-ease, an incision or excision with

24-10

AMS Inflatable Penile Prosthesiswith Rear-Tip Extenders

Cylinder

Tubing andprotective sheath

Rear-tip extendersplaced in above order

1 cm 2 cm 3 cm

Chapter 24 Problems and Variations in the Placement of the Three-Component Inflatable Penile Prosthesis 239

a replacement graft may be neces-sary (B). We prefer to use a non-expandable model (CX model;American Medical Systems) forthe prosthesis of choice in thissituation.

In the dilatation of the fibroticdistal corpus cavernosum, thesurgeon may perforate the corpo-real tissue and enter the urethra at

the fossa navicularis (C). The sur-geon may still place the cylinderin the intact contralateral corpuscavernosum but should postponefurther manipulation of the af-fected side until a later date.

Aggressive dilatation may alsolead to perforation of the distalcorporeal body at the glans penis(D).

24-11

24-12

Dorsalnerves

Glanspenis

Glans penis

Skin incision

Selected points forstitch placement

Lateral View

Top View

CorpuscavernosumA

B

Correction for Natural Glans Penis Droop

Distalcorporacavernosa Severe

fibrosiswith excisionandreplacementgraft

Distalcorporealperforation

Perforationinto urethra

Fibroticweb offibrosis

Glans penis

A B

DC

240 Critical Operative Maneuvers in Urologic Surgery

FIG. 24-13. The primary closure ofa perforation is neither effectivenor satisfactory. A Dacron “wind-sock” graft anchored to the corpuscavernosum walls is the only ac-ceptable alternative for primaryrepair after a distal perforation.1The windsock graft should bestitched to the corporeal wallssuch that the prosthetic cylindertip matches the contralateral tip.

Another alternative is to post-pone any further manipulation for3 to 6 months and then redilatethe corporeal body.

Proximal Corpora Cavernosa andthe Crura

For fibrosis of the proximal cor-pora cavernosa and atrophy of thecrura, corrective surgical maneu-vers are easier.

FIG. 24-14. If there is a fibrotic nar-rowing of the crus such that therear-tip extenders cannot be placedwithin, the easiest solution is toplace a running plication stitchproximally to obliterate the nar-rowed space (A). This stitch en-sures that proximal migration ofthe cylinder will not occur.2

Perforation of the proximalcrus from aggressive dilatation (B)or atrophy of the crus (C) requiresadditional maneuvers. A Dacronwindsock graft or a Dacron orGore-Tex sleeve (2 mm thickness)with a closed blunt end can be an-chored to the corpus cavernosummore distally (D) and even an-chored to the periosteum of thepubic ramus (E).1,3

24-13

From Fishman IJ: Contemp Urol 51, 1991.

Dacron "Windsock" Graft for Repair ofDistal Corpus Cavernosum Perforation

A

B

CD

Chapter 24 Problems and Variations in the Placement of the Three-Component Inflatable Penile Prosthesis 241

24-14

E from Mulcahy JJ: Prob Urol 5(4):608, 1991.

Patencywith

severefibrosis

Perforation

Plication stitch

Prosthesis

Corpuscavernosum

Syntheticsleeve or"cup"

Atrophy

A

B C D

Syntheticcups

Pubicramus

Proximalcorpora cavernosa

Glans penis

E

242 Critical Operative Maneuvers in Urologic Surgery

FIG. 24-15. When there is a dis-ruption of the median septum, thesurgeon may have difficulty withdilatation and subsequent cylin-der placement in the proper cor-poreal body. By first establishingthe correct space for one side andinserting a Hegar size 8 dilatorwithin, the surgeon can dissectand then dilate the opposite side

and establish a proper compart-ment for cylinder placement. Thecylinder should be placed whilethe Hegar dilator is still within theopposite corporeal body. Once onecylinder is in place, the other cylin-der replaces the Hegar dilator.

FIG. 24-16. An aneurysm of thecorpus cavernosum may be re-sected, and nonexpandable cylin-ders (e.g., CX model; AMS) maybe inserted.

FIG. 24-17. Once the cylindershave been placed, the surgeonshould check for any filling diffi-culties or any “buckling” effect ofthe cylinders. Buckling suggeststhat either the cylinder is too longor the diameter of the corpus is toonarrow for the selected cylinder.

The 12 cm cylinders have anoninflated diameter of 8.5 mmand the 15 and 18 cm cylindershave a noninflated diameter of10.5 mm, which can be expandedto 18 mm or greater.

24-15

24-16

24-17

Glans penis

Corporacavernosa

Medianseptum

Dilatation leading toperforation of septum

Glanspenis

Aneurysm ofcorpus cavernosum

Resection ofredundancy

Closure

Buckling of Prosthesis

Glanspenis

Corporacavernosa

Chapter 24 Problems and Variations in the Placement of the Three-Component Inflatable Penile Prosthesis 243

RESERVOIR PLACEMENTInguinal Approach

FIGS. 24-18 AND 24-19. If the patientis right-handed, the surgeon shouldapproach the retropubic spacethrough the right inguinal ring,applying traction on the right scro-tum, testis, and spermatic cord lat-erally with the left hand. The sur-geon inserts the right index fingeradjacent to the spermatic cordthrough the external inguinal ringand to just lateral to the junction ofthe rectus abdominis muscle andthe pubic bone.

FIGS. 24-20 AND 24-21. Once the sur-geon has palpated the space, an 8cm–long nasal speculum (Killian),with the handles facing up, ispassed adjacent to the surgeon’sindex finger by the assistant.

24-18

24-19

24-20 24-21

Penis

Scrotum

Skinincision

Rectus abdominismuscle

Pubic bone

Externalinguinal ring

Spermatic cord

Path of dissection

Reservoir Placement

Lateral marginof rectusabdominis muscle

Pubictubercle

Index finger lateral torectus abdominis muscleand above pubic bone

Testis

Spermatic cord

Externalinguinal ring

Invertedplacement of

nasal speculum

Lateral marginof rectusabdominis muscle

Pubic tubercle

Surgeon's index fingerpositioned before speculum

Long Nasal Speculum

8 cm

1 cm

244 Critical Operative Maneuvers in Urologic Surgery

FIG. 24-22. After the speculum isspread by the assistant, the sur-geon passes long Mayo scissorsbetween the spread speculumwings and spreads these densefascial layers to enter the retropu-bic space. The bladder should bedrained before this maneuver.

Once the dense tissues are open,the surgeon reinserts the right-hand fingers and slides them intothe retropubic space for reservoirplacement.

After bluntly dissecting a spaceadjacent to the bladder with thefingers, the surgeon places the

reservoir in the space (65 ml for 12and 15 cm cylinders or 100 ml for18 cm cylinders). If there is spon-taneous efflux of saline solutioninto the syringe after initial infla-tion of the reservoir, then thespace is too small and requiresfurther blunt dissection.

Suprapubic ApproachFIG. 24-23. In patients who have

had previous inguinal herniasurgery or who have a weaknessof this area due to previous sur-gery, a suprapubic approach forreservoir placement, with the tub-ing coming over the pubis into thescrotum, is the safest method.

Previous radical retropubic pros-tatectomy or open prostatectomywith severe fibrosis may requirethat the reservoir be placed in theperitoneal cavity.

PUMP PLACEMENTFIG. 24-24. The pump is placed in

the scrotum with the reservoirtubing in a lateral position and thetwo cylinder tubings in a medialposition. When the patient is stand-ing, the pump should be in a ver-tical position. Excessive scrotaldissection sometimes leads to ahorizontal and posterior place-ment of the pump. This horizon-tal pump placement makes it dif-ficult for the patient to deflate theprosthesis.

Lateral marginof rectusabdominis muscle

Pubic symphysis

Mayo scissorsspreading fascia

Nasal speculumspread open

24-22

Dissection for Reservoir Placement

Inguinalapproach

Suprapubicapproach

24-23

Chapter 24 Problems and Variations in the Placement of the Three-Component Inflatable Penile Prosthesis 245

If the tubes are not alreadyconnected, the “quick-connect”system is used for the three com-ponents.

ANTIBIOTIC ADMINISTRATION ANDDRAIN PLACEMENT

Bacterial infection is the worstcomplication with any kind ofprosthetic surgery whether a pe-nile prosthesis or an artificialknee. Aside from strict steriletechnique and preferably an earlymorning case-scheduling, the sur-geon should be generous with theuse of antibiotic solutions for irri-gation during the operation. Atypical irrigating solution is 50,000U bacitracin and 1 g neomycin orkanamycin in 1 L solution.

Preoperative and postoperativeantibiotic administration is im-portant for the assurance of a suc-cessful outcome. Antibiotic ad-ministration should be continueduntil after the drain and Foleycatheter are removed.

A Jackson-Pratt or Blake suc-tion drain can be left adjacent to

the tubings for 24 hours postoper-atively if the dissection has beenextensive. A Foley catheter (16 Fr)is left in place for 24 to 48 hourspostoperatively.

TROUBLESHOOTING ANDREVISION OF THE MALFUNCTIONALPROSTHESISIncision

A superficial penile-scrotal inci-sion is made over the tubing ofthe prosthesis.

By using electrocautery to di-vide the scar tissues over the pros-thesis, the surgeon will not injurethe prosthetic material even whendividing tissues directly over theprosthesis.

A Van Buren sound (22 Fr)placed in the urethra gives thesurgeon a palpable landmark toavoid while searching for theprosthetic tubing, thus preventinginjury to the urethra.

The two tubings medial to theurethra are from the cylinders,and the single lateral tubing isfrom the reservoir.

Penis

Optimal verticalplacement of pump

Scrotum

Poor horizontal and lateralpump positioning caused

by excessive scrotaldissection

24-24

246 Critical Operative Maneuvers in Urologic Surgery

Sequential Testing

FIG. 24-25. The surgeon first iden-tifies the cylinder tubings becausethey are the most common site ofleakage. When the scar tissue overthe tubing is divided, a sudden re-lease of prosthesis fluid shouldmake the surgeon suspect a re-gional leak. The leaking can occuron either side of the tubing con-nection (1) or where there is ex-cessive tubing redundancy.

If no leakage is identified, thesurgeon should trace both tubingsto the cylinders. By making asmall corporotomy, the surgeoncan examine another site of poten-tial leakage. The sleeve around thetube protects it; however, if theplacement of the tubing is in con-tact with the cylinders within thecorporeal body, there is a potentialfor damage to the cylinder as wellas to the tubing (2). Althoughcylinders now have extra rein-forcement, the long-term com-pression of the tubing against thecylinder may lead to erosion andlaceration of the cylinder.

If the corporotomy does not re-veal an obvious leak, the next stepis to divide the reservoir tubing(3) and place a 60 ml syringe filledwith saline solution to the pumpend of the tubing.

By inflating the cylinders usingthe scrotal pump, the surgeonshould be able to identify anymalfunctions of either the cylin-ders or the pump. When the cylin-ders are deflated, the syringeshould receive an equal volume ofsaline solution as used in the in-flation.

If there is a malfunction de-tected by performing the abovemaneuver, the surgeon shoulddivide the tubing to the cylin-ders (4) and connect two sy-ringes filled with saline solutionto each of the two tubes and in-

flate the cylinders. Malfunctionsare more commonly found in thecylinders and are rarely found inthe pump.

Depending on the findings, ei-ther the cylinders or the pumpmust be replaced (5).

Reservoir

If the pump and cylinders plustubings are all intact, the surgeonconnects an empty large syringeto the reservoir.

The reservoir should return ap-proximately 65 or 100 ml. Depend-ing on the previous operativenotes indicating the cylinder size,the surgeon should know whetherit is a 65 or 100 ml reservoir.

By instilling either 65 or 100 ml,the surgeon should be able todraw back the exact same amountof fluid.

If the surgeon can instill thesaline solution but there is a spon-taneous efflux into the syringe, thefibrous capsule needs to be “re-cracked” and established bysaline solution reinfusion.

FIG. 24-26. If there is a question-able malfunction, our preferencehas been to leave the reservoirand place another one from asuprapubic approach.

The removal of a reservoir notonly is difficult but also requiresexcessive tissue dissection and isnot worth the time spent. The in-ert empty reservoir will not causeany problems.

After the reservoir is emptied,the reservoir tubing is cut at themost distal end.

The new reservoir is placed inthe perivesical or retropubic spacevia a separate suprapubic inci-sion, and the tubing is placed overthe pubic bone and tunneledthrough the subcutaneous tissuesdown into the scrotum.

Chapter 24 Problems and Variations in the Placement of the Three-Component Inflatable Penile Prosthesis 247

3

2

1

54

Pump

Cylindertubing

Cylinder

Reservoir

Troubleshooting for Malfunctional Prosthesis

Rectus abdominismuscle

Pubic bone

Tubing to pump over pubis andthrough subcutaneous tunnel

Penis

Reservoir

Suprapubic Placement of Reservoir(Lateral View)

24-25

24-26

K E YP O I N T S

� Erection is induced to estimateerect penile size and evaluate forpossible fibrosis.

� The urethra and corpora caver-nosa are identified before the cor-poreal incisions are made. Trac-tion stitches are placed and a6-o’clock proximal incision be-tween these stitches is ideal forcylinder placement.

� Lateral dissection between thecorporeal tunica and sinuses isperformed with Hegar size 7 to13 dilators; the corporeal sinusesand the cavernosal artery arepreserved.

� Cylinder size and correspondingreservoir are selected (12 and 15cm cylinder, 65 ml reservoir; 18cm cylinder, 100 ml reservoir).The shortest rear-tip extendersare placed first, next to the prox-imal cylinder.

� Fibrosis, if present, is corrected.� An inguinal approach is used for

the reservoir placement. In pa-tients who have had previoushernia or organ surgery, a supra-pubic approach is appropriate.The reservoir can be placed inthe peritoneal cavity if scarringin the retropubic space is severe.

� The pump should be placed inthe vertical position.

� The cylinders are inflated to 50%.The drain and Foley catheter areleft in place for 24 hours postop-eratively.

P O T E N T I A LP R O B L E M S

� Injury to urethra: Place cylinderin unaffected side only → post-pone cylinder placement in af-fected side

� Atrophied crus: Ligate crus anduse cylinder without rear-tip ex-tenders or select a shorter cylin-der → alternatively, use a Gore-Tex or Dacron sleeve graft

� Septal disruption: Continue dilata-tion of corpora cavernosa

� Improper cylinder inflation or buck-ling: Check for improper cylinderlength or diameter → check forfibrosis with a narrow corporealdiameter

� Aneurysm of corpus cavernosum:Correct the aneurysm and selecta nonexpandable prosthesis

� Bladder is punctured while creatingreservoir: Place reservoir in theperitoneal cavity

REFERENCES1 Fishman IJ: Complicated implanta-

tion of inflatable penile prosthesis,Urol Clin North Am 14(1):217, 1987.

2 Palma PCR, Netto NR Jr: Ligation ofcrura penis for corporeal length ad-justment in cases of short rod-like pe-nile prosthesis, J Urol 143:764, 1990.

3 Mulcahy JJ: The management ofcomplications of penile implants,Prob Urol 5(4):608-627, 1991.

248 Critical Operative Maneuvers in Urologic Surgery