• Our aim is to provide free detailed comprehensive manual for urologic surgical procedures. This site should serve as a valuable reference for urologic residents and medical students in training.

  • Penile Prosthesis

    About The Author

    Dr. Nelson Bennett Dr. Nelson Bennett graduated from Mercer University with a degree Biomedical Engineering in 1995. He went to medical school at The University of Pittsburgh School of Medicine and then went on to complete a residency in Urologic Surgery at the University of Pittsburgh Medical Center. After finishing a 2-year fellowship at Memorial Sloan-Kettering Cancer Center in Sexual Medicine and Surgery, he joined the faculty at the Lahey Clinic Medical Center in Burlington, MA.

    As a board certified urologist and microsurgeon, Dr. Bennett specializes in the management of erectile dysfunction, Peyronie’s disease, disorders of ejaculation and orgasm, low testosterone levels, male infertility, penile implant, and varicocele.

    Dr. Bennett has authored numerous articles and presented research work on a national and international level. He is an active member of the Sexual Medicine Society of North America (SMSNA), the International Research Impotence Society (ISSM), and American Urologic Association (AUA). He routinely is asked to review research manuscripts for the leading urology journals.

    Dr. Nelson Bennett.
    Institute of Urology
    Lahey Clinic Medical Center
    41 Mall Road
    Burlington, MA 01805
    Phone: (781) 744-8334

    SLIDE THE PLAYER BAR TO ADVANCE TO:
    4:00 Incision
    12:45 Placement of reservoir
    1535 Corporotomy
    20:55 Use of Dialamezensert
    27:50 Placement of Corporal Cylinder
    51:30 Closure of the skin

    INTRODUCTION

    HISTORY OF PENILE PROSTHETICS

    The history of implantable devices for erectile dysfunction dates back to the 1930’s(1). In 1936, Borgas inserted costal cartinage into the phallus to provide rigitity(1). By the 1960’s, rubber silicone rods were placed between the tunica albugenia and Buck’s fascia of the penile septum(2). Unfortunately, this technique resulted in numerous complications related to extrusion of the implanted material. Pearman subsequently placed these rods underneath the tunica with better results(3, 4).

    The next significant step in the development of the penile prosthesis was in 1973. Hernan Carrian developed a silicone-based prosthesis that was customizable to the patients corporal length(5, 6). This device filled the corporal space allowing for greater reliability and patient satisfaction with fewer complications. Although material and mechanical improvements in malleable penile prosthetics have taken place regularly over the last 40 years, the use of these devices has diminished as compared to the inflatable (hydraulic) penile prosthesis(7, 8).

    The first inflatable penile prosthesis was developed by Dr. F. B. Scott in 1973(9). It consisted of two cylinders, two pumps and a reservior. The cylinders were made of silicone with Dacron for strength(9). One pump was for cylinder inflation and the other was for deflation. Over the years, improvments in the pump mechanism, reservoir construction and cylinder strength has led to this device being on the used until the mid 1980’s.

    Historically, inflatable devices were of 3 varieties, self-contained (which are now out of production), 2 piece and 3-piece devices. Since its introduction in 1973, the inflatable penile prosthesis has undergone multiple changes in design and manufacturing. AMS now produce both types of inflatable devices. Coloplast (Mentor) produce only 3 piece devices having ceased production of their 2-piece device (Mentor Mark II). Technological advancements over the past 10-15 years have greatly improved post-operative infection rates, device durability, auto-inflation, and overall satisfaction.

    TECHNIQUE OF PROSTHESIS IMPLANTATION

    PREPARATION

    In the week prior to surgery, the patient is asked to wash his pelvis and genitalia with a chlorhexidine wash. Additionally, they begin ciprofloxacin 2 days before surgery. After initiation of and intravenous line, vancomycin and gentamycin are infused. All attempts are made to make sure that the antibiotics have completed infusion one hour before incision.

    After initiation of anesthesia via laryngeal mask or endotracheal tube, blanket-rolls are placed under the knees and the thighs are abducted. With the patient in this modified frog-legged position, the heels are taped to the bed with cloth tape. Next, all pubic hair is removed from the pubis, penis, scrotum and perineum. The skin of the genitalia and abdomen is scrubbed for 5 minutes with an iodine-based soap. Finally, the operative area is painted with and alcohol-based chlorhexidine agent. Next, the patient was draped with paper drapes.

    Incision And Dissection

    After a ‘timeout’, a foley catheter is placed to straight drainage. A #15-blade scalpel is used to make a 4 cm transverse incision at the penoscrotal junction. A “Lone-Star” retractor is postitioned over the operative field and the elastic stays are affixed to the edges of the incision. Blunt dissection is used to dissect down to the proximal corpora cavernosa. Mayo scissors are used to elevate the ischio-cavernosus muscle and it is transected with Bovie cautery. Next, a longitudinal corporotomy of 2 cm in length is used for access to the corpora cavernosa. This is completed bilaterally approximately 1 cm lateral to the urethra. Next, 2-0 PDS suture is placed in the corpora cavernosa for later closure. This, again, is first completed on the right-hand side and the left hand side. Next, corporal dilation is completed with the Dilamezinsert. The wound in copiously irrigated with antibiotic solution.

    Corporal Measurements

    Using the appropriate measuring tool, the internal length of the corpora is measured and recorded.

    Device Placement

    A 3-piece penile prosthesis is removed from packaging, prepped on the side table. If rear-tip-extenders are required they are attached to the proximal end of the prosthesis cylinders. The penile prosthesis is placed in the corpora cavernosa through the corporotomies. The corporotomies are closed by tying the preplaced sutures.

    The penile prosthesis reservoir is placed by using finger dissection in a retrograde fashion through the external ring. The reservoir is placed in the left Space of Retzius. It is then filled with injectable saline and it is checked for backpressure. The reservoir and the penile prosthesis pump are then connected. The device is cycled to ensure no complications or defects are observed.

    A subdartos pouch is made in the scrotum for placement of the penile pump mechanism. The pump mechanism is placed in the subdartos pouch and a 3-0 Vicryl suture is used to fix the pump in place.

    Wound Closure

    After copious irrigation with antibiotic irrigation, the dartos muscle is reapproximated using 3-0 running absorbable suture. Next, the skin is reapproximated with 4-0 chromic gut. The wound is dressed with 4×4 gauze and fluffed rolled gauze. A scrotal support is placed on the patient.

    Post-Operative Care

    We elect to admit the patient overnight. The patient receives IV fluids, peri-operative antibiotics and a regular diet (as tolerated). Pain management is accomplished with patient-controlled analgesia (PCA). The foley catheter is removed on POD #1 and a voiding trial is attempted. Upon discharge, oral pain medication is prescribed, as well as, oral antibiotics.. The patient is seen in the postoperative period at least twice. Approximately, 4-6 weeks after implantation, the is patient is taught how to inflate and deflate the prosthesis.

    COMPLICATIONS

    A summary of the most common and important penile prosthesis complications are presented in Table 1. The most common and important complications will be reviewed in further depth.

    TABLE 1:

    Table 1: Summary of complications of penile prosthesis surgery (Adapted from Sadegi-Nejad J Sex Med 2007;4:296–309)(10)

    Mechanical Malfunction

    The most serious penile prosthetic complication is infection, but mechanical malfunction remains the most frequent reason for reoperation (Table 1). Common reasons for malfunction are cylinder aneurysm, tubing leakage, reservoir leakage, cylinder leakage, and connector fracture. Failure rates have been reported to exceed 10% in some series. Different manufacturers of the prosthetics report varied longevity data, but frequent updates and revisions of the penile implant devices make it difficult to ascertain their true mechanical longevity scientifically(11, 12).

    Erosion/Perforation

    Erosion of a component of the prosthesis is not rare. A component may erode through skin (cylinder or reservoir) or tunica (cylinder). Erosion of the corporal cylinders extracorporally through the distal portions of the corporal bodies may occur iatrogenically from overenthusiastic corporal dilation or oversizing of the cylinders(22). Patients with decreased distal sensation such as those with spinal cord injury or diabetes mellitus may have an increased incidence of distal erosion(23). Our approach to this complication depends on the nature of the erosion. Tunical erosion may be managed with routine device replacement that incorporates closure of the defect. Cutaneous erosion is an urgent matter. The device must be promptly removed and the cavity irrigated. The patient is placed on intravenous antibiotics and admitted to the hospital. The timing of prosthesis replacement is dependent on patient condition and surgeon familiarity with the penile prosthesis infection salvage procedures.

    Infection

    Infection associated with prosthetic surgery is a devastating issue. The monetary and opportunity cost to the healthcare system is huge. Patient discomfort due to the infectious process and the need for additional surgery may be life altering. The reported incidence of initial penile prosthetic surgical infections is between 11.5%), spinal cord injuries, or a history of urinary tract infection(10, 26, 27). Skin-dwelling bacteria are usually responsible for operative wound contamination. The most common bacterium associated with penile implant infection is Staphylococcus epidermidis.

    Highly virulent organisms

    such as methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Enterococcus species, Prevotella species (Bacteroides subspecies), and fungi have been associated with penile implant infections. Men with infected penile implants typically manifest between 1 and 8 weeks postoperatively and complain of fever, pain, and swelling overlying the prosthesis. Purulent wound drainage may also be present. Other signs and symptoms of a developing infection are persistent penile or scrotal pain, , elevated white blood cell count, elevated erythrocyte sedimentation rate, cellulitis, fever, chills, device erosion, or fixation of parts of the prosthesis (tubing or pump) to the scrotal wall.

    CONCLUSIONS

    The penile prosthesis occupies a unique place in the inventory of the urologist. Although, the device is not required for daily living, it has greatly increased the quality of life of countless men. Over the past several years, numerous improvements in the device materials and design have improved reliability and satisfaction. When properly implanted and maintained, the penile prosthesis can make a man with erectile dysfunction experience the joys of sex again.

    REFERENCES

    1. Gee WF. A history of surgical treatment of impotence. Urology. [Historical Article Research Support, U.S. Gov’t, P.H.S.]. 1975 Mar;05(3):401-5.
    2. Loeffler RA, Sayegh ES. Perforated acrylic implants in management of organic impotence. J Urol. 1960 Oct;84:559-61.
    3. Pearman RO. Treatment of organic impotence by implantation of a penile prosthesis. J Urol. 1967 Apr;97(4):716-9.
    4. Pearman RO. Insertion of a silastic penile prosthesis for the treatment of organic sexual impotence. J Urol. 1972 May;107(5):802-6.
    5. Small MP, Carrion HM. Penile prosthesis: new implant for management of impotence. J Fla Med Assoc. 1975 Oct;62(10):21-5.
    6. Small MP, Carrion HM, Gordon JA. Small-Carrion penile prosthesis. New implant for management of impotence. Urology. [Historical Article]. 1975 Apr;5(4):479-86.
    7. Huisman TK, Macintyre RC. Mechanical failure of OmniPhase penile prosthesis. Urology. [Case Reports]. 1988 Jun;31(6):515-6.
    8. Thompson IM, Rodriguez FR, Zeidman EJ. Experience with Duraphase penile prosthesis: its use as replacement device. Urology. [Case Reports]. 1990 Dec;36(6):505-7.
    9. Scott FB, Bradley WE, Timm GW. Management of erectile impotence. Use of implantable inflatable prosthesis. Urology. 1973 Jul;2(1):80-2.
    10. Sadeghi-Nejad H. Penile prosthesis surgery: a review of prosthetic devices and associated complications. J Sex Med. [Review]. 2007 Mar;4(2):296-309.
    11. Dhar NB, Angermeier KW, Montague DK. Long-term mechanical reliability of AMS 700CX/CXM inflatable penile prosthesis. J Urol. 2006 Dec;176(6 Pt 1):2599-601; discussion 601.
    12. Mooreville M, Adrian S, Delk JR, 2nd, Wilson SK. Implantation of inflatable penile prosthesis in patients with severe corporeal fibrosis: introduction of a new penile cavernotome. J Urol. 1999 Dec;162(6):2054-7.
    13. Smith CP, Kraus SR, Boone TB. Management of impending penile prosthesis erosion with a polytetrafluoroethylene distal wind sock graft. J Urol. [Clinical Trial]. 1998 Dec;160(6 Pt 1):2037-40.
    14. Szostak MJ, DelPizzo JJ, Sklar GN. The plug and patch: a new technique for repair of corporal perforation during placement of penile prostheses. J Urol. [Clinical Trial Research Support, Non-U.S. Gov’t]. 2000 Apr;163(4):1203-5.
    15. Carson CC, Mulcahy JJ, Govier FE. Efficacy, safety and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis: results of a long-term multicenter study. AMS 700CX Study Group. J Urol. [Clinical Trial]