ReviewPenile Prosthesis Complications: Planning, Prevention, and Decision Making
Introduction
Inflatable penile prosthesis (IPP) is the established treatment option for erectile dysfunction (ED) refractory to medical therapy, with more than 20,000 implants performed each year in the United States.1 Given that the prevalence of ED correlates with advancing age, increasing life expectancies have expanded the pool of men who can benefit from an IPP.2 The first prototype of a penile prosthesis was constructed by Ambroise Parè in the 16th century (Figure 1). Parè created an artificial penis using a wooden pipe to facilitate micturition from the standing position in a patient with traumatic penile amputation. Although not intended for facilitating sexual intercourse, it is considered the earliest iteration of a penile prosthesis.3 An autologous penile implant specifically designed to simulate an erection was performed by Russian surgeon Nikolaj A. Bogaraz in 1936 using a patient's rib cartilage. The first report of an inflatable penile implant was published in 1973 by Scott et al.4 Since that time, penile prosthesis has evolved from the semi-rigid implant and 1-piece inflatable prosthesis to the modern 2- and 3-piece inflatable device. Today, IPP is currently the gold standard treatment for patients with ED refractory to lifestyle, oral, injectable, and other device-assisted modalities.
In addition to ED that is nonresponsive or contraindicated to medical therapy, IPP is indicated for post-pelvic surgery ED, severe Peyronie's disease (PD) with concomitant ED, and neophallus. Potential complications of IPP include, but are not limited to, infection, hematoma formation, floppy glans, corporal fibrosis causing difficulty with implantation and penile deformity, proximal and distal corporal perforation, device crossover, urethral injury, erosion, and glandular ischemia. Complications have been reported in fewer than 5% of cases, in part due to standardization of surgical technique and improvement in device construction.5 Proper planning, including cost, patient, and prosthesis selection, and surgeon preference are important considerations. Penile implants are extremely effective, with a high level of patient and partner satisfaction, and generally require only a one-time fee for the procedure. However, IPP implantation is still an invasive surgery, and the incidence of complications in the perioperative and postoperative setting are important for the urologist to consider. In addition, patients must be made aware that the implant will not restore spontaneous or natural erections but rather allow for reversible tumescence to allow sexual intercourse.6 Patient and partner satisfaction has been documented to be between 82% and 97%, and the overall survival rate of the IPP at 5, 10, and 15 years is 89.1%, 71.4%, and 60.5%, respectively.7, 8 The aim of this review is to provide an evidence- and expert opinion–based overview of preoperative prevention strategies, intraoperative decision making when recognizing an evolving complication, and postoperative interventions considered in IPP placement.
Section snippets
Preoperative strategies and planning
As stated in the Introduction, IPP is indicated for patients with severe ED refractory to medical therapy (first- and second-line options are vacuum erection devices and intracavernosal injection therapy), but it can also be offered to patients who have failed or have contraindicated phosphodiesterase type 5-inhibitor therapy and do not wish to try the second-line options. It is also recommended to obtain objective evidence of ED using duplex ultrasonography when the diagnosis is in doubt.
Hematoma Formation
Hematoma formation after surgery typically develops in the scrotum, since it is a dependent organ and allows for blood and fluid to collect.17 It is usually evident in the immediate postoperative period when adequate hemostasis has not yet been achieved. The overall incidence ranges from 0.2% to 3.6% of penile prosthesis implantations.17 A combination of postoperative compressive dressing in conjunction with partial device inflation has been used in studies in an attempt to achieve hemostasis
Infection
The risk of infection with a primary implant ranges between 1% and 4%.40 However, spinal cord injuries, IPP revision surgery, penile reconstruction, and patients receiving long-term steroids have an increased risk of infection.43, 44, 45 Patients with a spinal cord injury are at higher risk of infection because they are more prone to development of a urinary tract infection associated with their neurogenic bladder.46 The risk of infection is also positively correlated with length of surgery.47
Discussion
Despite the widespread availability of safe and efficacious oral and injectable therapy, penile prosthesis continues to be the definitive solution for the treatment of organic ED refractory to medical therapy. The advent of advanced surgical techniques (ie, no-touch technique) and infection-resistant materials with enhanced longevity (ie, Parylene) has significantly reduced the likelihood of development of intraoperative and postoperative complications warranting revision surgery. Despite these
Conclusion
IPP is a safe, highly effective, and well-tolerated treatment modality for the management of refractory ED. Despite advances in surgical technique and infection-resistant materials, complications still occur and can lead to significant patient morbidity and, potentially, IPP removal. Thorough preoperative planning and counseling can significantly reduce the risks of intraoperative and postoperative complications and disappointment, even in patients with multiple comorbid conditions.
Statement of authorship
Category 1 Conception and Design Nickolas D. Scherzer; Brian Dick; Andrew T. Gabrielson; Laith M. Alzweri; Wayne J.G. Hellstrom
Acquisition of Data
Nickolas D. Scherzer; Andrew T. Gabrielson; Brian Dick
Analysis and Interpretation of Data
Nickolas D. Scherzer; Andrew T. Gabrielson; Brian Dick; Laith M. Alzweri
- (a)
Drafting the Article
Nickolas D. Scherzer; Andrew T. Gabrielson; Brian Dick
- (b)
Revising It for Intellectual Content
Laith M. Alzweri; Wayne J.G. Hellstrom
- (a)
Final Approval of the Completed Article
Nickolas D.
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Cited by (0)
Conflict of Interest: Dr. Hellstrom is a consultant/advisor for Coloplast and Boston Scientific
Funding: None.