Elsevier

Sexual Medicine Reviews

Volume 7, Issue 2, April 2019, Pages 349-359
Sexual Medicine Reviews

Review
Penile Prosthesis Complications: Planning, Prevention, and Decision Making

https://doi.org/10.1016/j.sxmr.2018.04.002Get rights and content

Abstract

Introduction

Inflatable penile prosthesis (IPP) is an established treatment option for men with erectile dysfunction (ED) refractory to medical therapy. Standardization of surgical technique and improvements in device construction have reduced all-cause complication rates to less than 5% in recent reports. Nonetheless, complications do exist, and can strongly impact morbidity and the quality of life of patients. Prosthetic urologists must be aware of the constellation of complications that can arise during or after IPP placement.

Aim

To provide a comprehensive review of penile prosthesis complications and discuss preventative strategies, as well as proper preoperative, intraoperative, and postoperative decision making.

Methods

A review of the available literature from 1973 to 2018 was performed using PubMed with regard to IPP complications.

Main Outcome Measures

We reviewed publications that outlined preoperative planning strategies and the following IPP complications: hematoma, floppy glans, corporal fibrosis, corporal perforation and crossover, urethral injury, infection, impending erosion, and glandular ischemia.

Results

Careful patient and device selection, setting realistic expectations of postsurgical outcomes, and adherence to a perioperative checklist is essential in the preoperative period. Intraoperatively, anticipate corporal fibrosis situations and always dilate laterally during corporal passage to reduce the risk of crossover and urethral injury. Limit perioperative antiplatelet therapy, apply compressive dressing, use a closed suction drain if indicated, and leave the device partially inflated postoperatively to reduce risk of hematoma. After surgery, monitor patients for potential complications that may warrant device explantation or salvage: IPP infection, glans ischemia, and impending erosion.

Conclusions

By using evidence and expert opinion-based decision-making strategies in the preoperative, intraoperative, and postoperative period of IPP placement, surgeons can reduce the risk of complications and dissatisfaction, even in ED patients with multiple comorbid conditions.

Scherzer ND, Dick B, Gabrielson AT, et al. Penile Prosthesis Complications: Planning, Prevention, and Decision Making. Sex Med Rev 2019;7:349–359.

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

  1. (a)

    Conception and Design

    • Nickolas D. Scherzer; Brian Dick; Andrew T. Gabrielson; Laith M. Alzweri; Wayne J.G. Hellstrom

  2. (b)

    Acquisition of Data

    • Nickolas D. Scherzer; Andrew T. Gabrielson; Brian Dick

  3. (c)

    Analysis and Interpretation of Data

    • Nickolas D. Scherzer; Andrew T. Gabrielson; Brian Dick; Laith M. Alzweri

Category 2
  1. (a)

    Drafting the Article

    • Nickolas D. Scherzer; Andrew T. Gabrielson; Brian Dick

  2. (b)

    Revising It for Intellectual Content

    • Laith M. Alzweri; Wayne J.G. Hellstrom

Category 3
  1. (a)

    Final Approval of the Completed Article

    • Nickolas D.

References (73)

  • O. Shaeer

    Implantation of penile prosthesis in cases of corporeal fibrosis: modified Shaeer's excavation technique

    J Sex Med

    (2008)
  • M. Mooreville et al.

    Implantation of inflatable penile prosthesis in patients with severe corporeal fibrosis: introduction of a new penile cavernotome

    J Urol

    (1999)
  • J. Mulhall et al.

    Penile Prosthetic Surgery for Peyronie's Disease: Defining the Need for Intraoperative Adjuvant Maneuvers

    J Sex Med

    (2004)
  • A. Rajpurkar et al.

    Penile implant success in patients with corporal fibrosis using multiple incisions and minimal scar tissue excision

    Urology

    (1999)
  • A.F. Morey et al.

    High Submuscular Placement of Urologic Prosthetic Balloons and Reservoirs Via Transscrotal Approach

    J Sex Med

    (2013)
  • S.K. Wilson et al.

    A new treatment for Peyronie's Disease: modeling the penis over an inflatable penile prosthesis

    J Urol

    (1994)
  • L. Trost et al.

    Critical Appraisal and Review of Management of Strategies for Severe Fibrosis During Penile Implant Surgery

    J Sex Med

    (2015)
  • U.A. Anele et al.

    Suprapubic cystostomy for the management of urethral injuries during penile prosthesis implantation

    J Sex Med

    (2014)
  • S.K. Wilson et al.

    Infection reduction using antibiotic-coated inflatable penile prosthesis

    Urology

    (2007)
  • B.R. Kava et al.

    Contemporary revision penile prosthesis surgery is not associated with a high risk of implant colonization or infection: A single-surgeon Series

    J Sex Med

    (2011)
  • K.P. Collins et al.

    Complications of penile prostheses in the spinal cord injury population

    J Urol

    (1988)
  • D.H. Zermann et al.

    Penile Prosthetic Surgery in Neurologically Impaired Patients: Long-Term Followup

    J Urol

    (2006)
  • J.P. Jarow

    Risk Factors for Penile Prosthesis Infection

    J Urol

    (1996)
  • C.C. Carson

    Infections in Genitourinary Prostheses

    Urol Clin North Am

    (1989)
  • M.R. Licht et al.

    Cultures from genitourinary prostheses at reoperation: questioning the role of Staphylococcus epidermidis in periprosthetic infection

    J Urol

    (1995)
  • J.J. Mulcahy

    Long term experience with salvage of infected penile implants

    J Urol

    (2000)
  • M.S. Gross et al.

    Multicenter investigation of the micro-organisms involved in penile prosthesis infection: An analysis of the efficacy of the AUA and EAU guidelines for penile prosthesis prophylaxis

    J Sex Med

    (2017)
  • T.C. Siegrist et al.

    No touch technique: a novel technique for reducing postoperative infections in patients receiving multicomponent inflatable penile prostheses

    J Urol

    (2008)
  • C.E. Wolter et al.

    The hydrophilic coated inflatable penile prosthesis: one year experience

    J Sex Med

    (2004)
  • M.D. Brant et al.

    The prosthesis salvage operation: immediate replacement of the infected penile prosthesis

    J Urol

    (1996)
  • J.J. Mulcahy

    Distal corporoplasty for lateral extrusion of penile prosthesis cylinders

    J Urol

    (1999)
  • L.A. Levine et al.

    Penile Prosthesis Surgery: Current Recommendations From the International Consultation on Sexual Medicine

    J Sex Med

    (2016)
  • S.K. Wilson et al.

    Glans Necrosis Following Penile Implantation: Prevention and Treatment Suggestions

    J Urol

    (2017)
  • F. Jhaveri et al.

    Penile prosthesis implantation surgery: a statewide population based analysis of 2354 patients

    Int J Impot Res

    (1998)
  • H.G. Villarreal et al.

    Outcomes of and Satisfaction with the Inflatable Penile Prosthesis in the Elderly Male

    Advances in Urology

    (2012)
  • T.S. Hakky et al.

    The evolution of the inflatable penile prosthetic device and surgical innovations with anatomical considerations

    Curr Urol Rep

    (2014)
  • Cited by (0)

    Conflict of Interest: Dr. Hellstrom is a consultant/advisor for Coloplast and Boston Scientific

    Funding: None.

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