Intraoperative complications

The typical complication that may occur during dilation of the corpora cavernosa is perforation of the tunica albuginea. Typically the perforation occurs during the initial step of dilatation; if this is the case, interrupting the dilatation on that side and completing the same procedure contralaterally will show the real length of the crus. With a size nine Hegar dilator in place in the corpus cavernosum contralateral to the perforation, the surgeon should go back to the crus affected by the perforation and use only large dilators to complete the dilation. After completing the dilatation and placing the cylinders, a polydiox- ane suture may be passed through the rear tip of the cylinder and then through the tunica albuginea at the most proximal end of the corporotomy to anchor the cylinder in proper place. Alternatively a Dacron sock can be sutured to the rear tip of the prosthesis and fixed to the wall of the tunica with one or two sutures.

Proximal corporal perforations do not mean that surgery must be terminated. If there is a distal perforation, most experienced surgeons agree that surgery should be interrupted to prevent prosthesis infection. Although termination of surgery is the most prudent course in most distal perforations, in special cases such as extremely fibrotic corpora, primary suture of the albuginea with or without grafting may render good results. In such cases, after suturing the urethral perforation and inserting the cylinders, use of a suprapubic cystostomy tube or Foley catheter for one month has produced a successful outcome in a few reports [14].

Surgical Treatment of Erectile Dysfunction 143

thema of the incision or genitalia, and/or cutaneous fixation of prosthesis components, such as the pump to the scrotal skin [25]. This is the most feared complication after penile implant surgery. The use of antibiotics alone has not been successful in eradicat- ing postoperative infections. It is difficult, if not impossible, for antibiotics to penetrate the area of a postoperative infection because the pseudo-capsule, which forms around the device, the relatively poor blood supply in the area, and the biofilm or slime produced by Staphylococci and other bacteria that provide a protected cavity in which bacteria can pro- liferate. When an infection develops around a portion of the implant, it may easily migrate to all other parts along the connecting tubes, as well as any

foreign body, such as polytetrafluoro-ethylene or Penile buckling due to overized left cylinder in

Fig. 12.3

MRI imaging. permanent sutures in the immediate area. In the face of infection the surgeon has two options. The first is to remove the prosthesis and reinsert it at least three months or more later. If this

Postoperative complications

option is chosen, the penis will be noticeably shorter The most significant postoperative complication

and the reinsertion procedure more difficult because associated with implant surgery is prosthetic infec-

of the scar tissue that forms during that interval. The tion, which occurs in 1 to 3% of cases [25]. Other

second option is to use a salvage procedure, which important complications include distal and proximal

entails removing the prosthesis and all foreign mate- perforation of the tunica albuginea, SST deformity,

rials, cleaning the wound with a series of antiseptic “S-shaped” deformity of the penis, erosion of a com-

solutions and reinserting a new prosthesis at the ponent, and mechanical malfunction of the device

same operation. Mulcahy [32] reported a success [30]. The best way to manage complications is to

rate of 85% with the salvage procedure. There are prevent them from happening by adequate sterile

several circumstances in which salvage should not handling and correct sizing of the cylinders.

be considered. These include prosthesis infections in Diagnosis of complications is based on clinical

patients with diabetic ketoacidosis, life-threatening history and physical examination, but imaging tech-

sepsis, and frank tissue necrosis or urethral erosion niques may be useful to plan a surgical approach.

of the cylinders in the fossa navicularis. If one MRI is the most valuable imaging technique for diag-

excludes these conditions, a salvage approach is a nosis of penile prosthesis complications [31]. MRI is

reasonable procedure. According to a technique first radiation-free, demonstrates penile anatomy in

described by Mulcahy [32,33], all prosthetic parts three orthogonal planes, and is superior to any other

and foreign materials are removed; the wound is irri- imaging method in demonstrating soft tissue con-

gated with a series of seven antibiotic solutions; the trast [30,31,56] (see Figure 12.3). All penile implants

drapes, instruments, gloves and gowns are then except the now-discontinued Omniphase and

changed, and a new prosthesis system placed in the Duraphase models, are compatible and safe with

wound.

MRI field strength Tesla 1.5 and 3.0. The Omniphase Also a delayed form of salvage therapy using or Duraphase prostheses are unsafe during MRI

primary removal of the prosthesis, continuous scanning due to their metallic components [60,61].

antibiotic irrigation for several days, and secondary Prosthetic infection should be suspected when

prosthesis reimplantation, ideally after 72 hours, has there is increasing postoperative pain, fever, ery-

been published [25]. If salvage procedures are

144 Chapter 12 planned, it seems wise to treat the patient with

systemic antibiotics for up to 48 hours prior to the salvage surgery, especially if fluid is available for culture and antibiotic testing [30].

If mechanical problems in an inflatable device develop after surgery, a trend to remove and replace the entire device has emerged recently. Common mechanical failures are tubing fracture, cylinder or reservoir leak, cylinder aneurysm, or connector dis- ruption. Most urologists consider that replacing the entire device will give the patient added longevity in all parts [14,30]. Certainly after two or three years, it is prudent to replace all the prosthesis components because there can be significant wear of the device within that period. In addition, repeated penile inci- sions to change cylinders may shorten the penile length [34]. Furthermore, bacteria-positive cultures of clinically uninfected penile prostheses have been found in 70% of tested implants. In some patients, more than one organism grew, and in some patients the pump culture was negative but the biofilm was positive [35]. This may explain the higher infection rate that occurs with revision surgery [36,37,38]. Combining complete implant removal with a modi- fied salvage protocol leads to a markedly decreased incidence of infection in patients with a penile prosthesis who are undergoing revision for non- infectious reasons [39].

A correct procedure in a properly selected patient does not necessarily result in a satisfactory outcome for the patient. A common reason for patient dis- satisfaction is the lack of adequate engorgement of the glans during sexual activity. Typically, the patient reports that the corpora cavernosa are perfectly rigid after activating the implant but the glans remains soft, interfering with the patient’s sexual satisfaction. Mulhall et al. [40] recently reported a beneficial effect of oral sildenafil on glans engorgement in patients with penile implants complaining of lack of glans engorgement. By using the IIEF, the authors also showed that sildenafil caused a statistically significant improvement in implant assisted inter- course. Similar results with the use of 500 µg of intra-urethral alprostadil were reported by Chew and Stuckey [41] in a patient who had been treated with a Dynaflex prosthesis.

In case of impending distal protrusion of cylinders,

a new pocket for the tip of the cylinder within the distal corpus cavernosum should be created after hemicircumcision. Also windsock techniques with synthetic materials have been described for this condition. In some patients, an SST deformity develops, also termed “floppy glans”. This condition is best treated by a circumcising incision, dissection of the glans from underlying tissue, and non-absorbable suture fixation of the glans to the tips of the corpora [56].

Intraoperative complications