Indications
- Bothersome ED refractory to medical management
- Peyronie’s disease with concomitant erectile dysfunction
- Priapism with long ischaemic period
Malleable vs inflatable:
- Inflatable 3 piece is preferred option if available
- Malleable prosthesis useful for upfront late presentation of priapism, buried penis reconstructions, or patients without enough dexterity
- AMS 2-piece with no reservoir available if previous significant pelvic surgery
Work-up:
- Usual ED work-up
- Diabetes – assessment of HbA1c and trends
- History of Peyronie’s, priapism etc.
- Surgical history – radical prostatectomy, cystectomy, inguinal herniae +/- mesh, transplant
- Anticoagulation, immunosuppression, steroids
- Social history – include partner in the discussion
- Exam
- Stretched penile length
- Peyronie’s / artificial erection
- Corporal fibrosis or scarring
- Penoscrotal webbing
- Hydrocele / scrotal exam
- Dexterity / which hand would they prefer
- Inguinal exam – herniae, scars
Pre-operative counselling for IPP:
- Expectation management is key
- Patient satisfaction exceeds 90 %
- Lower satisfaction for Peyronie’s patients, post-prostatectomy (penile shortening)
- IPP will improve erections and spontaneity
- IPP will not change (and may worsen) libido, ejaculation, incontinence, sensation, orgasm, length or girth
- Pain afterwards variable but common
- Length and girth will not be what it used to be
- Length is lost with fibrosis due to ED and disuse over time
- Limited evidence for VED pre-operatively
- Stretched penile length is best estimate
- Ensure partner is on board and part of counselling
Methods to reduce prosthetic infection:
- Pre-operative patient washes
- Optimise diabetes control and consider postponing
- Negative urine culture and no skin infections
- Shaving in theatre immediately prior to surgery
- Alcoholic prep
- Peri-operative antibiotics – +/- antifungal if risk factors for same
- Reduce OT time
- No touch technique during surgery on prosthesis
- Minimise skin exposure and contact with skin
- Antibiotic impregnation (Inhibizone – rifampicin/minocycline for AMS or hydrophilic coating dipped in antibiotics before placement for Coloplast)
- Wound irrigation with antibiotics throughout
- Limit theatre traffic through theatre
- Drains to prevent haematoma (?may contribute to infection)
- Mummy wrap / scrotal compression to prevent haematoma
Penoscrotal vs infrapubic:
- Penoscrotal – avoids neurovascular bundle, greater proximal crural exposure, direct visualisation of pump placement, but blind placement of reservoir
- Infrapubic – may be quicker, direct placement of reservoir placement, but risk of neurovascular bundle injury
Technique for penoscrotal IPP:
- Supine with prosthesis precautions
- Vancomycin and gentamicin
- Razor shave. Thorough scrub. Alcoholic chlorhexidine. 2 x U-shaped drapes to minimise skin exposure
- IDC with spigot. Penile block. Lone star type retractor with penis retracted to umbilicus via hook in dorsal meatus
- Transverse penoscrotal incision
- Blunt dissection down to shiny white of the corpora using hooks and metz
- Expose corpora and retract urethra to contralateral side.
- Stay sutures x 2 and vertical corporotomy
- Use dilators
- Distally – aiming dorsolaterally and feeling for dilator at lateral tip of glans
- Proximally – until ischiopubic shelf
- If Peyronie’s disease or severe fibrosis – can use corporotome to incise plaque during/after dilation
- Use sizer and record size proximally and distally
- Reposition hooks and repeat on contralateral side with urethra retracted to other side
- If more than 15 mm difference each side – is something wrong?
- Appropriate size reservoir based on size of cylinders
- Empty bladder before placing reservoir
- Finger to feel for pubic bone – slightly superolateral to pubic tubercle is superficial ring – use disposable Deaver retractors from set once in plane – scissors should pass easily and open up to dilate space
- Place reservoir in retropubic space – aiming for ipsilateral shoulder – should be able to inflate with saline easily without resistance, palpable mass or reservoir coming back down
- Alternate is submuscular “ectopic” place – for previous surgery – Coloplast ‘Cloverleaf’ standard reservoir or “Conceal” Boston reservoir avoids palpation
- Ensure prosthesis is secured only with shods
- Place cylinders ensuring correct way
- Load suture straight needle on Furlow through corpora – needle comes out glans – take with artery forcep and pull suture through the place cylinder at tip
- Close corporotomies (tie stay sutures +/- further sutures)
- Some may place Surgicel over corporotomies
- Create dartos pouch and open up with nasal speculum – place pump with button out (check which side patient would prefer – same side as reservoir)
- Inflate and check, remodelling as needed
- Close in layers
- Scrotal wrap
Intra-operative problems
Urethral injury
- Identification – meatal bleeding, fluid from urethra during corporal irrigation
- Abandon procedure, leave IDC and come back another day
Severe fibrosis with difficult dilation
- Slow serial dilation
- Cavernotomes
- Use narrower cylinders
- Counter-incisions if really needed
Distal crossover
- Identification – cylinder doesn’t reach the mid glans, or odd angle when inflated
- Management – place dilator in the ‘good’ side, re-dilate the bad side with the dilator in the other side, using Metz aim laterally making the medial border of the new dilation the lateral side of the old the dilation
- Ensure no urethral injury
Proximal perforation
- Identification – lengths different on measurement
- Should feel a clunk on the ischiopubic ramus which is the end of the corpora.
- Place dilators in each side – should be symmetrical
- Management – use good side for correct measurement, and create synthetic ‘windsock’ with Gore-Tex or Dacron, or use an anchoring suture to transfix to corporotomy site
Distal perforation
- Semicircular incision at coronal sulcus ventrally and close tip of corpora with 3-0 PDS
SST deformity (supersonic transporter Jet)
- Floppy glans with inadequate glans support
- Reassess dilation and ensure distally goes to mid glans, use appropriate sized cylinder
- Glansplasty
Post-operative complications
- Infection
- 1 % (may be 2 % in diabetics, also more common in revision surgery)
- Manage with immediate removal of all parts, washout, and delayed reimplantation 3-6 months (will be more difficult)
- Some advocate for immediate reimplantation (even with malleable) to preserve length and prevent scarring, much higher infection rates
- Erosion or impending erosion
- Removal of device +/- replacement (erosion = infected)
- Mechanical failure
- 4 – 10 % need for revision or replacement
- Pain
- Glans ischaemia
- Beware dusky glans on day 1 in diabetics with peripheral vascular disease and smokers, history of radiation
- Immediate removal
Surgical revascularisation for ED
- For reduced arterial inflow – usually younger men with duplex or CTA/angiogram showing reduced inflow, usually with history of trauma.
- Revascularisation with inferior epigastric to deep dorsal artery, or arterialisation by anastomosing inferior epigastric artery to dorsal vein.
- No role for surgery in veno-occlusive disease.