Tuesday, January 27, 2009

Complications Of Penile Prosthesis Surgery

The overall satisfaction with penile implants in one study was 83%, compared to 51% for PDE5 inhibitors and about 30% for injection therapy. About a 10% mechanical failure rate can be expected at 10 years, although it may decrease with newer devices. There is good satisfaction by both the patient and partner with penile prosthetic devices. Dissatisfaction usually arises from loss of penile length, although data suggests that this is a patient perception and objective loss is only about 1cm. Having the patient stretch out his flaccid penis in the clinic prior to surgery will provide a realistic expectation of his post-operative erect length.

Dr. Mulcahy presented a case of a man with DM who had a 3-piece penile prosthetic device placed. 8 months later he presented with an infected implant. This scenario occurs in 1-3% of primary procedures and up to 10% of secondary implants. Antibiotic coated devices may decrease this problem. Infections often manifest over the pump or at the fossil navicularis. Antibiotics alone will not work in the presence of the foreign body due to a biofilm that develops over the penile prosthetic device. Options include removal of the implant or a salvage procedure. The latter involves removal of the penile prosthetic device, wound cleansing and placement of a new device. Success rates are about 84%. Vancomycin and gentamicin are given and washing solutions include beta dine and hydrogen peroxide. A water-pick is used to irrigate the wound. Most patients opt for the salvage procedure with the possible 16% failure rate. One benefit is that immediate replacement preserves penile length. Men with sepsis or ketoacidosis, genital necrosis, immunosuppression or bilateral urethral erosion of cylinders should not have a salvage procedure. Copious irrigation is a key to decreasing infections, he concluded.

A 57 year old man with ED and DM presented one year after removal of an infected penile prosthetic. He now has corporal fibrosis. Dr. Montague addressed this case. The tunic albugenia in this patient will have replacement of smooth muscle with fibrosis scar tissue. Corporeal excavation is performed via an extended corporately to develop a plane and mobilize the fibrotic core, which is then excised. A new PP cylinder can then be placed. In the scenario of distal erosion of the cylinder, the corpus cavernous is still present, but does not contain the cylinder. A ventral incision will provide exposure for removal of the cylinder. A transverse incision into the pseudo capsule is followed by dilation and the new cylinder placement. The false passage is then closed.

A man with semi-rigid penile prosthetic later presented with proximal perforation and erosion. Implant perforation can result from dilation of the corpora. There are many factors that contribute to penile prosthetic perforation. With proximal perforation, the cylinder can still be placed but with distal perforation the cylinder placement should be aborted and the contra lateral cylinder removed if already placed. For erosion, all components must be removed. He discussed penile shortening after radical prostate is further compounded by phallic shortening after PP device placement. Lengthening can be achieved using ventral phalloplasty with a wedge of skin mobilized to provide more penile tissue length. The main thing to remember, to avoid health problems need time to see a doctor, who will pick up your good health drugs.

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