Surgical Aspects

Preparation
Surgery always requires an adequately informed patient, both as to risks and benefits. In this case, the sexual partner should also be involved in the discussion.

Preoperative counselling about a penile prosthesis

Counsel patient, with partner, that
• The glans will not be filled
• The result will be adequate for vaginal penetration
• There is a small (2-5%) incidence of infection
• The penis will be colder
• Ejaculation will still be possible
• The only solution to a failed operation is a replacement prosthesis
• A prosthesis is not as good as the original

Prior to surgery, antibacterial cleansing occurs and the surrounding areas are shaved.

The operation is done under regional or general anaesthesia. Circumcision is often necessary with many semi-rigid prostheses, so this should be done initially.

With the patient asleep under general anesthesia, the device is inserted into the erectile tissue of the penis through an incision in the fibrous wall.

After an incision has been made on the underside of the penis, the tissues on both sides of the urethra are expanded to allow placement of the implants.

In order to implant the pump for the inflatable implant, incisions are made in the abdomen and the perineum (area between the anus and the genitals). A fluid reservoir is inserted into the groin and the pump is placed in the scrotum. The cylinders, reservoir, and pump are connected by tubes and tested before the incisions are closed.

Implants in place, surgical incision closed with absorbable sutures.

Postoperative management
Pain relief must be provided as the operation is painful. To minimize swelling, ice packs are applied to the penis for the first 24 hours following surgery.

The incision sites are cleansed daily to prevent infection.

A broad spectrum antibiotic should be taken orally for a week after the operation.

If there are difficulties with voiding, use clean intermittent catheterisation.

Semi-rigid prostheses may be used after four weeks. Patients can be taught how to pump up an inflatable prosthesis after four to six weeks.

Postoperative problems
Infection occurs in 1-10% of cases, depending on the difficulty of the procedure. Repeat operations are more prone to infection. It is usually necessary to remove the infected part or complete prosthesis, and, although difficult, it is possible to replace it six months later.

It shows the placement of the reservoir behind the abdominal wall.

The cylinders are in the penis.
The pump is in the scrotal sac. At the top of the pump is the inflation site which is squeezed to push fluid into the cylinders. At the bottom of the pump is the deflation site which is squeezed to allow the fluid to return to the reservoir

Here is another angle to give a better idea where the parts are located

This illustrates the direction of the flow of the fluid into the cylinders, to produce the erection, when the inflation pump is squeezed repeatedly.

Note the reservoir at the top is now deflated.

By holding the deflation site and squeezing the penis, the fluid returns to the reservoir and the penis is flaccid again.

Postoperative Photograph of the Efficacy of an Inflatable Pump.

Appearance of a penis after insertion of an inflatable prosthesis, with the device deflated (top) and inflated (left)

Late Complications
In spite of concern about silicone implants in women, there have been no reports of immunologic disorders in the 20 years these implants have been used for men.

Problems do exist with these procedures, however. Though many patients benefit from implant surgery, it is an irreversible procedure. Erectile tissue is permanently damaged when these devices are implanted.

Mechanical breakdown can occur, and a less than optimal quality of erection may result. Infection may be the major cause of penile implant failure. Some experts believe that almost any intermittent pain that continues to occur after an implant is due to an infection, usually low-grade. Redness and fever often accompany a full-blown infection. If the infection can be caught early enough, implant failure can be prevented. Most infections are caused by Staphylococcus, which is treated with antibiotic therapy for at least 10 to 12 weeks. If antibiotics fail, a surgical exchange, in which the infected implant is simultaneously replaced with a new one, should be considered.

Finally,
In spite of being the most invasive of the procedures for the treatment of erectile dysfunction, the major advantages of the penile prostheses are: the relative spontaneity associated with their use, their applicability to and effectiveness in patients with all types of organic dysfunction and importantly, high patient and partner satisfaction (90% to 95%).

In recent times, improvement of both prosthesis and surgical techniques have enabled this procedure to be performed with local anesthesia, in outpatient clinics, with preservation of the intracavernosal vascularization, which eventually led to maintenance of a residual erection in practically all patients.

Additionally, the confirmation that this is the only effective surgical option for male impotence treatment has made penile prosthesis implants a quite attractive procedure for patients, with high rates of satisfaction.