Campbell’s Review – Chapter – 801 PROSTHETIC SURGERY FOR ERECTILE DYSFUNCTION

BackgrounD 3 major events in ED Tx – 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 – 1 st 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