1. Campbell’s Review – Chapter 23 788 – 801 PROSTHETIC SURGERY FOR ERECTILE DYSFUNCTION

2. BackgrounD 3 major events in ED Tx –1973 - Inflatable Penile Prosthesis –1982 – Intracavernous Injection Therapy –1998 – Effective systemic therapy - sildenafil

3. 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

4. Prosthesis Type 3 – piece inflatable penis Most closely resembles natural flaccidity and erection Provide penile girth expansion and rigidity AMS 700 or Mentor Titan

6. 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

7. 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

8. Surgical Approaches Subcoronal – malleable or positional Infrapubic - reservoir placement under direct vision Penoscrotal – better corporeal exposure, no dorsal nerve injury, pump fixation possible

9. AMS 700 by PenoScrotal approach

11. Safe reservoir insertion in retropubic space possible if bladder is empty

12. 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

13. 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

14. 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

15. Complications  EARLY INFECTIONS –Swelling, erythema, tenderness, drainage Occasional fever LATE INFECTIONS –PAIN –Skin may be adherent to pump

16. 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

17. COMPLICATIONS  Rifampin/Minocycline coated prosthesis showed less infection rate than hydrophilic coated devices. IF mechanical failure, usually after 5 years

18. 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

19. 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

20. 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

21. Special Cases Cavernosal Fibrosis –Usually from infected implant removal or ischemic priapism May need to use metz to carve out fibrotic tissue

22. 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