Surgical management of erectile dysfunction

Indication of third-line therapy (penile prostheses) Do not respond to pharmacotherapy Prefer a permanent solution to their problem

Indication of penile prostheses

Potential Contraindications for Penile Prosthetic Surgery Situational ED ED resulting from relationship conflict Potentially reversible ED Inability to follow instructions Hygiene issues and skin cleanliness Noncompliance with concurrent medication (e.g., for hypertension or diabetes) Spinal cord injury Uncontrolled diabetes mellitus

Preoperative patient preparation Patients are often concerned about the size of the incision required to implant the device and should be reassured that only a 1-inch incision is necessary. It is important the patient understands that the procedure is irreversible and that positioning the device permanently results in the loss of any preexisting erectile capability. Patients should know that the preoperative length of the fully stretched flaccid penis is typically the maximal length that can be obtained after prosthetic surgery. Ensuring that the patient (and, ideally, his partner) has realistic expectations is essential to a positive outcome.

Preoperative patient preparation It is best for patients first to see a video and photos of implanted patients to appreciate the look and function of a prosthesis. Next, the patient can be given the opportunity to handle a model of the pump only, without having to handle the reservoir and cylinders.

Preoperative patient preparation A thorough review of the patient’s medical, surgical, and sexual history is critical to evaluating the efficacy of previous nonsurgical treatment, selecting the most appropriate type of prosthesis, identifying contraindications, and mitigating risk factors for potential adverse events.

Preoperative patient preparation The appointment should also include a complete urologic examination, including a penile Doppler ultrasound study after intracorporeal injection of a vasodilating agent to assess severity of ED, vascular flow, tumescence, and penile anatomy. After a penile injection, the penis is more easily stretched, and abnormalities such as shortening, hourglass deformity, and curvature are revealed and can be evaluated. This is also a good time to measure and record the length of the stretched penis and show the patient what size he should expect from the implant.

Non-Inflatable Penile Implant

Non-Inflatable Penile Implant Easy for you and your partner to use - You simply bend it up for an erection. Down when not in use. Good option for men with limited dexterity - Something to consider if you have arthritis or difficulty using your hands. The simplest surgical procedure - Good option for surgeons with limited surgical experience. Of the three types of implants, the non-inflatable device involves the simplest surgical procedure. Least expensive - Non-inflatable implants are the least expensive type of penile implant. This may be a consideration for men not covered by insurance. Totally concealed in body - All parts of the device are implanted inside the body but having a permanent erection is very bothersome for most men. Abnormal feel and appearance. Causes deterioration and thinning of penile flesh over the long-term. Only 20% of implants performed in the USA. Most amount of pain and discomfort post-operatively because the penis needs to adjust to a constant erection. 

Two-piece Inflatable Penile Implant

Two-piece Inflatable Penile Implant Easy for you and your partner to use - You simply pump it up for an erection. Down when not in use. Thought to be a good option for men with limited dexterity - Something to consider if you have arthritis or difficulty using your hands. However the pump is small and difficult to inflate. The simplest inflatable implant surgical procedure - Good option for surgeons with limited surgical experience. Because only a small amount of fluid is transferred into the cylinders to obtain an erection, the penis is not as rigid as with a multi-component inflatable device. Totally concealed in body - All parts of the device are implanted inside the body but having a partial erection is very bothersome for most men. Abnormal feel and appearance. The cylinders have an unnatural shape and make the penis look like a broom with a square head. Causes deterioration and thinning of penile flesh over the long-term. 

Three-piece Inflatable Penile Implant

Three-piece Inflatable Penile Implant Easy for you and your partner to use - You simply pump it up for an erection. Press the release valve above the pump to deflate. Larger softer pump makes is easier to inflate than a two-piece device. Because a larger amount of fluid is transferred into the cylinders to obtain an erection, the penis is the most rigid of all the implants with a multi-component inflatable device. Offers the best flaccidity (softness) of the penile shaft when not in use which is the most comfortable for the patient. The only prosthesis that gives the penis a normal look and feel when erect and when flaccid. Many single patients report that the partner does not realize that the penis has an implant in it. Because it has the least amount of pressure on penile flesh when not in use, pressure atrophy of remaining erectile penile muscle and of the flesh of the glans penis, is less likely to occur. Totally concealed in body - All parts of the device are implanted inside the body. The most involved inflatable implant surgical procedure - Good option for surgeons with large surgical experience. Because the penis is flaccid after the surgery patient have the least amount of pain post-operatively. 

Factors for choosing which implant is the best for a particular individual Age of the patient and partner Overall penile size Ratio between crus (buried) and pendulous penis Ratio between penile length and size of scrotum Overall size of scrotum Size of glans penis History of previous implant Presence of penile shaft or glans penis atrophy or deformity (Peyronie's disease)  Previous abdominal surgery (bladder, prostate and colon) Type of previous abdominal surgery (open vs. laparoscopy or robot) Presence of an colostomy, ileal conduit or neo-bladder Previous peripheral vascular surgery (femoral to femoral artery bypass) History of kidney transplant or other major pelvic surgery Presence or absence of penile curvature or fibrosis Patient’s body type Presence of a very prominent supra-pubic fat pad Whether or not the penis is circumcised Overall health of patient Life expectancy