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Campbell’s Review – Chapter 23. 788 – 801 PROSTHETIC SURGERY FOR ERECTILE DYSFUNCTION. BackgrounD. 3 major events in ED Tx 1973 - Inflatable Penile Prosthesis 1982 – Intracavernous Injection Therapy 1998 – Effective systemic therapy - sildenafil. Prosthesis Types. Malleable prosthesis

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campbell s review chapter 23

Campbell’s Review – Chapter 23

788 – 801

PROSTHETIC SURGERY FOR ERECTILE DYSFUNCTION

background
BackgrounD
  • 3 major events in ED Tx
    • 1973 - Inflatable Penile Prosthesis
    • 1982 – Intracavernous Injection Therapy
    • 1998 – Effective systemic therapy - sildenafil
prosthesis types
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
prosthesis type
Prosthesis Type
  • 3 – piece inflatable penis
  • Most closely resembles natural flaccidity and erection
  • Provide penile girth expansion and rigidity
  • AMS 700 or Mentor Titan
pre op counseling
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
pre op counseling7
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
surgical approaches
Surgical Approaches
  • Subcoronal – malleable or positional
  • Infrapubic - reservoir placement under direct

vision

  • Penoscrotal – better corporeal exposure, no dorsal nerve injury, pump fixation possible
post op care
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
complications
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
complications14
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

complications15
Complications 
  • EARLY INFECTIONS
    • Swelling, erythema, tenderness, drainage
      • Occasional fever
  • LATE INFECTIONS
    • PAIN
    • Skin may be adherent to pump
complications16
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
complications17
COMPLICATIONS 
  • Rifampin/Minocycline coated prosthesis showed less infection rate than hydrophilic coated devices.
  • IF mechanical failure, usually after 5 years
complications18
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
poor glans support oversized rod
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
special cases
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
special cases21
Special Cases
  • Cavernosal Fibrosis
    • Usually from infected implant removal or ischemic priapism
      • May need to use metz to carve out fibrotic tissue
results outcomes
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