campbell’s review – chapter 23
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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– 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
• 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
• 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 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• Subcoronal – malleable or positional
• Infrapubic - reservoir placement under direct vision
• Penoscrotal – better corporeal exposure, no dorsal nerve injury, pump fixation possible
AMS 700 by PenoScrotal approach
• Safe reservoir insertion in retropubic space possible if bladder is empty
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
• 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
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
Complications
• EARLY INFECTIONS– Swelling, erythema, tenderness, drainage
• Occasional fever
• LATE INFECTIONS– PAIN– Skin may be adherent to pump
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
COMPLICATIONS
• Rifampin/Minocycline coated prosthesis showed less infection rate than hydrophilic coated devices.
• IF mechanical failure, usually after 5 years
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
• “Concorde” type glans after placement b/c of undersized, or inadequate dilation
• SST DEFORMITY
• Oversized cylinders cause pain and can erode
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 Cases
• Cavernosal Fibrosis– Usually from infected implant removal or ischemic
priapism • May need to use metz to carve out fibrotic tissue
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