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Inflatable Penile Prosthesis

Counseling

• Irreversible treatment (destroys native corpora)
• Can use with VED, does not work with other ED treatments
• Satisfaction: 86-98% (inflatable), 66-89% (malleable)
• Expectations: will not replicate normal appearing erections, lengthen penis, engorge glans, affect libido, dissatisfaction reported due to perceived length, chronic pain/coolness, difficulty operating, decreased sensation
• Malleable implant: can be used to keep condom catheter in place (spinal cord injury), but increased risk for erosion if poor/no sensation
• Predictors of postop dissatisfaction (CURSED Penis): Compulsive, Unrealistic, Revision, Surgeon shopping, Entitled, Denial, and Psychiatric
• Preoperative optimization: ensure no UTI or systemic infection, HbA1c < 7.5-8.5%

Penoscrotal approach

1. Position in supine position, shave with razor if available (preferred over clippers)
2. Prep and drape, use iodine sticky drape to decrease infectious risk - large half over superior portion of drape, smaller half as X shape to close hole between legs posterior to scrotum
3. Give vancomycin + gentamicin (5mg/kg ideal body weight)
4. Place 14Fr catheter into urethra, minimize lubrication
5. Place Lone Star retractor with small loop inferiorly and white connector across behind infrapubic region, place hook into urethra to retract superiorly
6. Perform ~2-3cm penoscrotal transverse incision, dissect through dartos, place 6 hooks for retraction
7. Identify urethra and bluntly dissect laterally to identify corpora
8. Protecting urethra, place 2-0 PDS stitch ~5mm lateral to urethra in corpora in proximal-to-distal fashion, snap/cut, then repeat ~1cm further lateral (repeat more proximally to create 4 stitches total)
9. With #15 scalpel on finger, incise between stitches longitudinally, going 5mm proximal to stitch all the way to distal point of stitch
10. Use #11 dilator distally and #13 proximally, aim laterally to avoid urethral injury, measure corpora and perform goal-post test (dilators in proximal corpora should not cross), irrigate to confirm no urethral injury
11. Prepare appropriate size device
12. Thread Keith needle and load urethrotome, pass distally and pass needle through glans (grab w/ hemostat), feed distal portion of prosthesis into corpus and secure stitch to retractor
13. Place proximal end into corpus and use placement tool to secure and seat device
14. Once device seated, tie proximal ends of stitch over a finger x8, then tie distal ends securely under tension to avoid prosthesis herniation or incisional bleeding
15. Once prosthesis secured bilaterally, test inflate to ensure adequate placement and length
16. Identify external inguinal ring, place plastic retractor, pop through with finger to enter retropubic space of Retzius, place retractor further interior, then place reservoir and inflate (waist should fill inguinal ring without herniating
17. Grasping lateral and inferior incisional edges, create subdartos pouch and dilate with nasal speculum, then place pump into pouch
18. Cut excess tubing length, fill ends with water, and secure connector
19. Close inferior dartos hole vertically then close incisional dartos hole horizontally (both with 3-0 vicryl)
20. Close skin with 4-0 monocryl interrupted fashion
21. Place bacitracin ointment then provide mummy wrap

5-step high submuscular technique for reservoir placement

1. Place patient in trendelenberg position
2. Palpate external inguinal ring and place pediatric Deaver retractor
3. Create submuscular tunnel above transversalis using finger blunt dissection, avoid widening neck (will prevent balloon prolapse)
4. Place sponge stick, aim medial (towards ipsilateral nipple, keeps pocket deep to rectus)
5. Ensure pocket is ≥ 10cm
6. Insert reservoir via clamp, overfill to 120mL, then compress
7. Palpate to ensure device is not too deep or too lateral

Risks + Side Effects

• Post-surgical side effects: penile edema/hematoma (3%), urinary retention (2%)
• Urethral injury: 1-3% risk, abort procedure, repair urethra, place catheter, consider placement in 4-6 weeks, can leave cylinder in uninjured side (if already dilated) to avoid shortening
• Crural injury: 1-3% risk, do not need to abort procedure but does require repair to prevent proximal sliding
• Crossover: ensure correct location during dilation, can fix intraop without aborting procedure, may present postoperatively and require repair to resituate
• Infection: 2-5% risk, usually within 3mo implantation, requires immediate explant of all implanted parts, can occasionally attempt salvage replacement,
• Erosion: 2% risk, more common in SCI (unable to feel erosion occurring), surgery to remove and repair overlying tissue with placement of spacer cylinder, can replace after 5-6mo
• Extrusion: surgery to resituate cylinder in correct position vs repair + explant
• Failure: 5-40% risk at 10-15yrs
• Reservoir erosion into bowel/bladder: rare, requires device removal and repair
• Penile necrosis: rare, can be caused by compromising distal blood flow in high-risk patients, remove device to optimize blood flow
• Aneurysm: cylinder herniation through corporotomy defect (early) or weakness of device wall due to frequent/aggressive long-term use, identify with physical exam or MRI, replace cylinders
• Penile shortening: no objective difference noted, some subjective differences reported
• Cold glans: due to lack of engorgement, can use PDE5i or MUSE to help engorge glans tissue
• Glans bowing (concorde deformity): cylinders too short, replace with longer cylinders or anchor glans to distal corpora tunica albuginea through dorsal subcoronal incision
• Glans buckling (S-shaped deformity): cylinders too long, requires replacing with adequate length cylinders
• Autoinflation: occurs with increased abdominal pressure on reservoir, more common if no lockout valve, prevent with low pressure cavity for reservoir, can replace reservoir