Surgical Management of Penile Prosthesis Complications

Surgical management of penile prosthesis complications

JJ Mulcahy1*

1Indiana University Medical Center, Department of Urology, Indianapolis, Indiana, USA

Penile implants are mechanical devices used to treat erectile dysfunction. Parts of the implants may wear out with time, and the implants themselves may damage the body cavities in which they have been placed, especially with excessive or aggressive use. Techniques to replace parts, repair body cavities, and deal with infection associated with prosthesis placement have been developed. Satisfaction with the resulting erections is the highest among all the modalities available for treating erectile dysfunction. International Journal of Impotence Research (2000) 12, Suppl 4, S108±S111.

Keywords: surgery; penile implants; infection; Peyronie's disease

Introduction but most have been grati®ed and are happy that the choice has been made. A number of new, effective, non-invasive treatments for erectile dysfunction (ED) have recently become available. The advent of sildena®l has created increased awareness about the problem of waning erections, and a considerable percentage of men are Expectations for implantable devices affected. These newer and simpler forms of treatment are more acceptable than those of the past, and The ®rst modern day implants were introduced over men are now coming forward more frequently for 25 y ago and soon after their introduction mechan- therapy. However, positive response to these new ical problems began to surface. About 50% of the medical treatments is certainly not universal, and a implants required repair or replacement within 5 y.2 sizeable percentage of the male population affected This failure rate encouraged manufacturers to by ED does not respond to these medications. These improve the product, reinforcing or eliminating patients, who fail medical therapy, are left with a areas that tended to wear. With experience, surgeons choice between a vacuum device and a penile have learned techniques of sizing and implantation implant. Although less often chosen today, penile which have reduced the incidence of mechanical implants retain a de®nite role in the treatment of failures and erosion of prosthesis parts against the impotence. tissues of the penis and scrotum. Patients with a scarred penis from a pharmacolo- An important element determining the patient's gic injection program, a previous implant, or trauma satisfaction with his device is the expectation about to the penis may have deformed erections. We ®nd the outcome; proper informed consent outlining the that an implant will both straighten and strengthen features of a penile prosthesis should be given. the penis in such cases when an erection is desired. Unrealistic expectations about penile size, sensitiv- The satisfaction rate among both patients and ity and ejaculation have resulted in disappointment partners who have used a penile implant is highest with the end result. If the patient is prepared 1 among all treatments for erectile dysfunction. Up to beforehand with the knowledge that the implant 85% of these couples are satis®ed with the results will only give a ®rm and bendable or ®rm and soft that an implant provides. Implantation of a penile penis that is suitable for intercourse, he hopefully prosthesis has been a major step for these patients will not expect more from the ultimate outcome. There are a variety of prostheses available, and the mental and manual dexterity of the patient will ultimately determine which one he will be able to operate and provide the best results in a particular *Correspondence: JJ Mulcahy, Indiana University Medical Center, Department of Urology, 535 Barnhill Drive, Suite 420, circumstance. Indeed, a few patients have been Indianapolis, IN 46202, USA. frustrated because they have had dif®culty in E-mail: [email protected] operating some of the more complex devices. Management of penile prosthesis complications JJ Mulcahy S109 Avoiding infectious complications of penile Salvage procedures prosthesis implantation The overall infection rate associated with placement Post-surgical infection can lead to major complica- of the penile prosthesis is reported to be 1 ± 3% in tions and all precautions to prevent it should be most studies.4 Infection was once a dreaded com- taken. Prior to the surgery the urine should be sterile plication necessitating removal of the device, heal- if at all possible, because non-sterile urine may seed ing of tissues, and returning at later date to implant the wound with organisms. This is sometimes another prosthesis if the patient wished. Creating dif®cult in patients who also present with a new cavities within the corpora cavernosa is a more neurogenic bladder. Most urologists prescribe a dif®cult surgery and generally results in the patient prophylactic antibiotic for 48 h post-operatively, having a signi®cantly shorter erection with the new initiated at the time the patient enters the operating prosthesis. Because of this, salvage procedures have room. A strong antiseptic prep of the operative ®eld recently been gaining in popularity. Using salvage is accomplished after the patient is shaved and prior techniques, the infected prosthesis is removed, the to making the incision. During the procedure, great wound thoroughly cleaned with antibacterial solu- care should be taken to control infection. Frequent tions, and a new prosthesis is placed at the same irrigation with antibacterial solution will also help surgical sitting. Long-term positive results between eliminate bacteria which may stray into the operat- 80 and 90% have been achieved using modi®cations ing ®eld. The option of using a catheter during of this technique.5 Using variations of salvage surgery as a guide to identifying the urethra and as a procedures, erosions of prosthetic parts to the method of draining the bladder in the early post- exterior wall of the penis can also be successfully operative period is left to the discretion of the managed in a single procedure. surgeon. Use of a drain post-operatively to minimize swelling in the area of the procedure and eliminate any accumulation of blood which may occur in the immediate post-operative phase is also the surgeon's Special challenges in penile prosthetic surgery choice. Some surgeons view drains as an entrance site for bacteria, but the incidence of implant One of the most challenging procedures in urology infection does not seem to be increased with their is placing the penile prosthesis into scarred corporal use. bodies. Patients who have had infection of the cavernous bodies following an injection program, or those who have experienced priapism, or those who Mechanical device failure have had trauma to the penis (such as the implantation and removal of the penile prosthesis) will have varying degrees of scar tissue present within the If mechanical problems of the device develop spongy tissue of the corpora cavernosa. Gaining following surgery, the tendency has been to replace access to fresh spongy tissue at the corporatomy site the entire device. Although all three vendors of will usually facilitate dilation proximally and dis- penile implants in the United States now have a tally more readily than if access is gained through a lifetime warranty on the parts, failure rates in the scarred area. Mid-corporal incisions tend to provide range of 15% at 5 y and 30% at 10 y are realistic a shorter distance to dilate distally and proximally. for most modern implants.3 Common failures are The surgeon should not hesitate to make a subcor- tubing fracture, cylinder or reservoir leak, cylinder onal incision and dilate backward from the glans if aneurysm, or connector disruption. Most urologists dif®culty is met during distal dilation through a believe that replacing the entire device will give the more proximal incision. A number of instruments patient added longevity of all parts. Certainly, after 2 are available to broaden the caliber of scarred or 3 y, it would be prudent to replace all parts, corporal bodies. These include the Otis urethro- because signi®cant wear of the device can occur tome, the dilamesinsert, the Rossello cavernatome, within that period. Minor problems, such as and the Uramix cavernatome. Each of these instru- connector fracture from excessive angulation may ments will work if access through a narrow cavity develop within a matter of months, and correcting has been gained to the extremities of the corporal that singular problem without removing the entire body. Inexperience with use of these instruments, device would be reasonable. One should appreciate, however, can lead to catastrophic complications, however, that frequent and repeated penile inci- and they are best used by those who have expertise sions to change cylinders tend to shorten the in the replacement of penile implants in complex erections. circumstances.

International Journal of Impotence Research Management of penile prosthesis complications JJ Mulcahy S110 At times, the tunica albuginea of the corpus cedure to remove the angulation from the penis is cavernosum is de®cient and inadequate to cover certainly indicated. portions of the penile prosthesis cylinder. Vascular Placement of the implant in these circumstances graft materials such as Gore-TexTM or dacron have will, in the vast majority of cases, straighten the provided suitable replacement for de®cient tunic erections as well as strengthen them. However, in albuginea in such cases.6 Cadaver pericardium has perhaps 10 ± 15% of cases, a signi®cant curvature also been successfully used for this purpose, and persists after placing an implant. In most of these advances in tissue engineering have made possible cases simply modeling the penis will successfully the use of other non-synthetic materials with the straighten it.9 Using this technique, the cylinders advantage of having less potential for wound should be in¯ated to maximum and the tubing infection. leading to the cylinders clamped. The erection is Lateral, ventral or dorsal extrusion of the distal then forcibly straightened or bent against the angle portion of the cylinder through the tunica into the of curvature. An audible `crack' may be heard as the subcutaneous tissues is a rare problem, but one that scar is fractured, thus allowing the cylinder to is certainly devastating to the patient and his straighten the penis adequately. If modeling is not partner. The cylinder tip may be precariously close satisfactory the concave surface of the curvature may to eroding through the foreskin and may act as a be incised, the cylinders in¯ated, and the newly `spear' causing discomfort for the partner during created defect covered by synthetic materials such intercourse. Cylinders that are relatively large and as Gore-TexTM or dacron. More detailed information tend to ®t tightly in a narrow penis or those that about prosthesis implantation in Peyronie's disease exert excessive pressure against the tunica may is presented by Dr Carson elsewhere in this issue.10 account for this occurrence. The cylinder can A Nesbit procedure can also be performed in these usually be readily reseated in an area of spongy circumstances such that pieces of tunica are re- tissue behind the back wall of the sheath containing moved from the convex surface of the curve and the extruded cylinder.7 This is done by making a tunica closure of the open areas is accomplished to corporatomy over the cylinder laterally, about half balance the constrictions caused by scarring on the the distance towards the peno-scrotal junction, concave surface.11 When tunica incision or graft retracting the cylinder to the side, incising the back procedures are performed, care should be taken not wall of the cylinder sheath and dilating a new cavity to injure the dorsal neurovascular bundle or the behind this back wall up to the subglandular area. corpus spongiosum. The cylinder can then be reseated in this new cavity and the back wall of the cylinder sheath now acts as the outer covering of the cylinder. A second layer Conclusions consisting of the outer wall of the cylinder sheath can also be closed to create a more secure barrier against extrusion of parts. If a hyper-mobile glans With the variety of options available today to restore penis is allowed to slip off the ends of these potency, virtually all patients may be restored to cylinders, problems may occur during vaginal satisfactory erectile function depending on their penetration and cause discomfort to the patient motivation. and his partner. The glans can be ®xed securely against the cylinder heads by dissecting the glans off the end of the cylinder and impaling the substance of the glans with a permanent suture. This is then References tied to the tunica albuginea of the corpus cavernosum adjacent to the cylinder tip in one or more areas 1 Fallon B, Ghanem H. Sexual performance and satisfaction to secure the glans against the tip of the prosthesis with penile prostheses in impotence of various etiologies. Int J cylinder.8 Impot Res 1990; 2: 35 ± 42. Peyronie's disease is commonly associated with 2 Gregory JG, Purcell MH, Standeven J. The in¯atable penile prosthesis: failure of rear tip extender in reducing the soft and curved erections. Prior to the introduction incidence of cylinder leakage. J Urol 1984; 131: 668 ± 669. of sildena®l, a penile prosthesis was used to 3 Carson CC, Mulcahy JJ, Govier FE. Ef®cacy and safety straighten as well as strengthen the erection simul- outcomes of the AMS 700 CX in¯atable penile prostheses: taneously. With the advent of this new effective oral results of a long term multicenter study. J Urol 1999; 161(Vol 4 Suppl): A999, 259. agent, many patients with curvature from Peyronie's 4 Carson CC. Management of prosthesis infections in urologic disease will gain very adequate rigidity using this surgery. Urol Clin N Am 1999; 26: 829 ± 839. medication prior to intercourse. However, a penile 5 Mulcahy JJ. Long term experience with salvage of infected implant is still a very effective treatment in patients penile implants. J Urol 2000; 163: 481 ± 482. who do not respond well to sildena®l and whose 6 Fishman IJ. Corporeal reconstruction for penile prosthesis implantation. Prob Urol 1993; 7: 350 ± 367. erections are soft and curved. If excessive angulation 7 Mulcahy JJ. Distal corporoplasty for lateral extrusion of penile interferes with intercourse, a straightening pro- prosthesis cylinders. J Urol 1999; 161: 193 ± 195.

International Journal of Impotence Research Management of penile prosthesis complications JJ Mulcahy S111 8 Ball TP. Surgical repair of the penile `SST' deformity. Urology 11 Mulcahy JJ, Rowland RG. Tunica wedge excision to correct 1980; 15: 603 ± 604. penile curvature associated with the in¯atable penile pros- 9 Wilson SK, Delk JR II. A new treatment for Peyronie's disease: thesis. J Urol 1987; 138: 63 ± 64. modeling the penis over an in¯atable penile prosthesis. J Urol 1994; 152: 1121 ± 1124. 10 Carson CC. Penile prosthesis implantation in the treatment of Peyronie's disease and erectile dysfunction. Int J Impot Res 2000; 12(Suppl 4): 122 ± 126.

Appendix Dr Nehra: What do you counsel your patients with respect to possible re-operation and re-implantation? Open discussion following Dr Mulcahy's presentation Dr Mulcahy: We give them the numbers Ð 80 ± 90% successful with salvage. They mostly opt for salvage, because they don't want to wait 6 months Dr Carson: The orthopedic literature describes and they don't want a 2 inch shorter erection. using the antibiotics Rifampin in combination with ¯uoroquinolones either around the time of salvage Dr Nehra: Patients who undergo radical prostatec- or in patients with possible infections. Do you have tomies will come back if they have ED, not any experience with the combination? responding to medical therapy, and tell you their penile shaft length has decreased. Dr Mulcahy: I haven't used Rifampin. We've used oral quinolones when the organism has been Dr Mulcahy: Yes, that could be due to TGF-b build sensitive to it. Claudio Toloken published a series up, or, when you remove the prostate and hook the of three salvage patients where he used Rifampin urethra to the bladder neck, you've tethered the successfully as the salvage anti-bacterial, but I'm not penis by that 2 or 3 cm size of prostate that's been sure if Dr Toloken removed the prosthesis or if he removed. just used Rifampin. Dr Wessells: Is skin ®xation always a sign of Dr Wilson: Our infectious disease specialist re- infection? commends that oral Rifampin, 300 mg twice a day, for one week after a salvage because it makes other Dr Mulcahy: Commonly, yes. Prolonged ®xation to antibiotics penetrate much better. We use this in the skin might be a post-op healing element, but a combination with double strength, double dose ®xation that becomes worse after the prosthesis has Bactrim or Septra and continue them for a month. been in, or if it takes a long time for the pump to become loose in the scrotum, this is indicative of Dr Mulcahy: Another modi®cation with the more infection, especially if it's associated with pain. aggressive and resistant organisms is to use intrave- nous Vanc and Gent. When you have an aggressive- Dr Speaker: What do you think of immediate looking infection occurring very soon after the prosthesis placement at the time of non-nerve implant, you must sterilize the interstitial tissues sparing radical prostatectomy? as well as the cavity and the outcome will be much better. Dr Mulcahy: We don't do it. It poses a risk of infection to do those two procedures at once. It's a Dr Carson: When you do the salvage procedures, longer operating time. It isn't that dif®cult to do do you ®nd a new place for the pump and reservoir later; I use a midline incision and put the reservoir or did you put them back in the same cavity? in through the midline; it gives the patient some time for healing. Dr Mulcahy: For the reservoir, I usually use the same cavity, but use another cavity for the pump, because after taking it out, that cavity is pretty much destroyed.

International Journal of Impotence Research