Journal of Sexual Medicine
Background. Implantation of inflatable penile prosthesis (IPP) is a well-established treatment for medically refractory erectile dysfunction with proven long-term reliability. However, if an IPP fails, the subsequent surgery to fix the IPP can be more difficult with higher risks of complications than the primary implantation.
Aims. To review and evaluate a case of a difficult IPP replacement surgery for ways to improve surgical techniques and outcomes.
Materials & Methods. Perform a case report of a difficult IPP replacement surgery in which the patient had proximal perforation of the tunica albuginea with a review of the pertinent literature.
Results. The rear tip sling is a successful way to repair proximal perforation of the tunica albuginea. Recent publications show new surgical techniques to lower infection rates in IPP revision surgery.
Discussion. The rear tip sling appears to have better outcomes than a synthetic windsock for repairs of proximal perforation of the tunica albuginea. Recent publications have shown that the revision washout decreases penile prosthesis infection rates in revision surgeries.
Conclusion. While revision surgery for IPPs have higher risks than primary implantation, newer surgical techniques are helping to reduce these risks. Zanoni M, and Henry GD. A case of mechanical failure with proximal perforation at the time of revision surgery. J Sex Med 2009;6:2629–2632.
A Review of Surgical Techniques for Impending Distal Erosion and Intraoperative Penile Implant Complications: Part 2 of a Three-part Review Series on Penile Prosthetic Surgery
Introduction. More than half of intraoperative complications occur during dilatation of the corpora cavernosa, a critical step in the placement of any type of penile prosthesis, which can be especially difficult in a patient with corporal fibrosis. A late manifestation of cylinder placement can be impending erosion with lateral extrusion or medial deviation (into the urethra) of the distal tips. There are many different approaches to try and fix these surgical issues.
Aim. The review article evaluates the many different surgical techniques prosthetic surgeons use in the management of intraoperative complications and lateral extrusion.
Methods. A review of the literature was preformed with published results being evaluated to try to help guide the management of intraoperative complications and impending distal erosion. There is a special focus on dilation of the corpora cavernosa.
Main Outcomes Measures. The article reviews and evaluates the outcomes of the landmark papers in the management of intraoperative complications and impending distal erosion.
Results. Intraoperative complications of penile implant placement can be distressing for the prosthetic surgeon, but with proper recognition, most of these complications can be navigated with excellent postoperative results.
Conclusions. This review article summarizes many of the techniques, outcomes, and new developments in the complicated field of penile prosthetic surgery to help guide the implanting surgeon.
A Survey of Patients with Inflatable Penile Prostheses: Assessment of Timing and Frequency of Intercourse and Analysis of Implant Durability
Introduction. This study was conducted to determine how long after inflatable penile prosthesis (IPP) surgery patients attempt sexual intercourse and the frequency of subsequent relations. We also examined survival-related factors for the AMS 700 CX, Mentor Alpha 1, and Mentor Alpha Narrow Base.
Aims. The aim was to survey men who received IPPs and collect information about their return to sexual function and frequency of use, and to assess the resilience of their devices.
Methods. Phase I involved retrospective chart review of 1,298 virgin IPP surgeries performed by one surgical team from January 1992 to December 1998. Phase II included 330 subjects selected by stratified, systematic, random sampling from phase I patients. Data were collected by computer-assisted telephone interview, using a 27-question survey. All patients had been instructed to wait 4 weeks before using the implant and were taught how to inflate/ deflate their prostheses at the 4-week postsurgical visits.
Main Outcome Measures. The survey examines the length of time after surgery for men to resume sexual function. In the same study, information was garnered about mechanical durability of the device.
Results. Among phase I subjects, the 5-year survival rate was 83% (N = 1,069) for IPP revision for any reason. Of the 330 phase II subjects, 248 (75%) were successfully contacted; 199 (80%) responded to the full survey and 49 (20%) responded to selected parts of the survey. Sexual intercourse was resumed postoperatively at 1–4 weeks for 41% (78/190), at 5–6 weeks for 31% (59/190), at 7–8 weeks for 16% (30/190), and at >8 weeks for 12% (23/190) of the patients. More than 60% of patients reported using their IPP at least once weekly.
Conclusion. The three-piece IPP has excellent 5-year survival rates. Most patients return to sexual activity relatively quickly, with high frequency of usage of their prostheses.
An Outcomes Analysis of over 200 Revision Surgeries for Penile Prosthesis Implantation: A Multicenter Study
Introduction. Inflatable penile prosthesis (IPP) implantation is a well-established treatment for medically refractory erectile dysfunction, with long-term reliability. Overall survival is 96% at 5 years and 60% at 15 years for primary (virgin) implantation.
Aim. The aim of this study was to explore factors associated with success and complications of IPP revision surgery in a multicenter study.
Main Outcome Measures. Reasons for revision including mechanical issues, patient dissatisfaction, corporal deformity, and supersonic transport (SST) deformity were recorded.
Methods. At four institutions, 214 clinically uninfected IPP revisions were performed between November 2000 and November 2007. Data were incomplete for 28 cases (14%). Failure-free survival was estimated using Kaplan–Meier’s Meier product limit method.
Results. The majority of revisions were secondary to mechanical failure (N = 109; 65%) and combined erosion or infection (N = 17 + 15 = 32; 19%). Sixteen percent (N = 26) were carried out on functional uninfected prostheses secondary to patient dissatisfaction (N = 9), SST deformity (N = 10), scrotal hematoma (N = 2), or upsize revision because of corporal fibrosis (N = 5). Average age at revision was 66 years. Mean follow-up time was 55.7 months. In this study, 12 individuals required a secondary revision procedure or suffered a complication. Despite prior reports of high infection rates with revision surgery, only 5.7% of clinically uninfected and noneroded prostheses were complicated by infection or impending extrusion/erosion, following a revision washout protocol. Overall, 93% of cases were successfully revised, providing functioning IPPs.
Conclusions. For this study population, component exchange followed by revision washout showed a low incidence of infection and subsequent mechanical failure.
Comparison of a New Length Measurement Technique for Inflatable Penile Prosthesis Implantation to Standard Techniques: Outcomes and Patient Satisfaction
Introduction. Within a study evaluating the redesigned AMS 700MS inflatable penile prosthesis (IPP) (American Medical Systems, Minnetonka, MN, USA), one site used new length measurement technique (NLMT), a more aggressive dilation and measurement of the corpora cavernosa on a stretched penis, to address penile shortening.
Aim. To compare cylinder size and patient satisfaction, between a NLMT and traditional sizing for IPP implantation.
Methods. Fourteen men received IPPs usingNLMT, and 55 with traditional sizing. Nationwide sales data from 2005 to 2008 for AMS 700 IPPs was obtained from AMS for comparison; additional surveys captured patient satisfaction.
Main Outcome Measure. Demographic data, cylinder sizes, and patient satisfaction were compared between the NLMT and standard techniques.
Results. The Fisher’s exact test (P < 0.001) showed a significant difference between the cylinder sizes with NLMT as compared with standard techniques. Of the 14NLMTpatients, 71.4% (10) received cylinders >21 cm long and 28.6% (4) received cylinders <21 cm long, as compared with 12.7% (7) and 87.3% (48), respectively, for patients implanted by traditional techniques. There were ethnic differences between the samples: 42.9% (6) NLMT patients were of African-American descent, as compared with 10.9% (6) in the standard technique group. However, longer cylinders were utilized more often, with 83.3% (5) of African-Americans treated using the NLMT; as compared with 33.3% (2) of the standard technique group. Nationwide data reveal 12.3% of patients routinely receive 21 cm cylinders. At 6 months postimplantation, patient satisfaction with NLMT was no different than standard techniques. There were no distal erosions, complications, infections, or pain concerns reported through 24 months among the NLMT patients.
Conclusions. The NLMT resulted in a larger number of subjects implanted with larger cylinders. Satisfaction with performance and complication rates for NLMT patients was comparable to those implanted using standard techniques.
Historical Review of Penile Prosthesis Design and Surgical Techniques: Part 1 of a Three-Part Review Series on Penile Prosthetic Surgery
Introduction. Throughout history, many attempts to cure complete impotence have been recorded. Early attempts at a surgical approach involved the placement of rigid devices to support the natural process of erection formation. However, these early attempts placed the devices outside of the corpora cavernosa, with high rates of erosion and infection. Today, most urologists in the United States now place an inflatable penile prosthesis (IPP) with an antibiotic coating inside the tunica albuginea.
Aim. The article describes the key historical landmarks in penile prosthesis design and surgical techniques.
Methods. The article reviews and evaluates the published literature for important contributions to penile prosthesis design and surgical techniques.
Main Outcome Measures. The article reviews and evaluates the historical landmarks in penile prosthesis design and surgical techniques that appear to improve outcomes and advance the field of prosthetic urology for the treatment of erectile dysfunction.
Results. The current review demonstrates the stepwise progression starting with the use of stenting for achieving rigidity in the impotent patient. Modern advances were first used in war-injured patients which led to early implantation with foreign material. The design and techniques of penile prostheses placement have advanced such that now, more complications are linked to medical issues than failure of the implant.
Conclusions. Today’s IPPs have high patient satisfaction rates with low mechanical failure rates.
Physician and Patient Satisfaction with the New AMS 700 Momentary Squeeze Inflatable Penile Prosthesis
Introduction. A single-armed, prospective, multicenter study evaluated the redesigned American Medical Systems (AMS) 700 Momentary Squeeze (MS) pump inflatable penile prosthesis (IPP) with enhanced features for ease of implantation and patient manipulation. The device incorporates design changes to all components: pump, cylinders, rear-tip extenders, and reservoir.
Aim. To assess physician and patient satisfaction with the new AMS 700 MS pump.
Methods. Patients were selected from the existing population experiencing erectile dysfunction (ED) without previous prosthetic implantation.
Main Outcome Measures. Survey questionnaires were used to capture physician feedback on ease of implantation and patient education. Patient satisfaction with the device and existence of autoinflation were assayed.
Results. Sixty-nine patients were implanted at seven U.S. sites. Mean age was 60.1 ± 9.6 years. History of ED was >5 years in 34 (44.7%) patients. Main ED etiology was organic, nonspecific (32%). Eighty-four percent of the physicians felt proximal cylinder insertion was easier because of the smaller angle of cylinder input tubing and narrower base diameter. The new pump was felt easier to implant than the previous model by 57% of the physicians. The patients found the manipulation of the pump simple at device activation, with 96% easily locating the inflation bulb and 94% deflating the device with one push of the deflation button. Reviews were mixed among physicians concerning ease of training compared with the Tactile pump. Patient training was easier in 71%, harder in 21%, and same in 8%. Nevertheless, 67% of the patients were trained in 6 minutes or less. At 6 months, 77% of the patients were very satisfied, 9% somewhat satisfied, and 14% dissatisfied. Autoinflation occurred in two patients (3%).
Conclusion. The new AMS 700 MS IPP seems a distinct improvement over previous devices with most physicians feeling implantation and patient instruction were easier. The device also satisfied 86% of the users and virtually eliminated autoinflation.
We report a case of acute arterial ischemia and deep venous thrombosis due to compression of the external iliac vein and artery by the reservoir of a three-piece inflatable penile prosthesis.