Campbell’s Review – Chapter 23

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 • 1st 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