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

IntroductionImplantation of penile prosthesis in case of corporeal fibrosis poses a greater risk of complications because of the blinded aggression involved. Penoscopic excavation and ultrasonography‐guided excavation can decrease these complications but still have limitations.AimThis work described the combination of penoscopy‐guided and ultrasound‐guided excavation in a trial to eliminate the limitations inherent to both.MethodsTwelve patients with penile fibrosis were operated upon. A guide wire was inserted under ultrasound monitoring, along which penoscopic corporotomy and resection was performed. Ultrasound was also used to monitor penoscopic excavation toward the tip of the corpus cavernosum and crus.Main Outcome MeasuresEase of the procedure, safety, extent of dilatation, and girth of prosthesis implanted.ResultsThe procedure was relatively easy. Ten cases were dilated up to size 13.5 Hegar, and two up to size 14. Size 13 prosthesis was implanted in all cases.ConclusionThe relative safety of the procedure, the low incidence of complications, the possibility of restoring length and girth to an extent, and the resultant generous dilatation of the corpora for accommodating a sizable unhindered inflatable penile prosthesis all make ultrasound‐guided penoscopic corporotomy and resection a valid option for prosthesis implantation in cases of penile fibrosis. Shaeer O. Implantation of penile prosthesis in cases of corporeal fibrosis: Modified Shaeer's excavation technique. J Sex Med 2008;5:2470–2476.     

Corporoscopic excavation of the fibrosed corpora cavernosa for penile prosethesis implantation: optical corporotomy and trans-corporeal resection, Shaeer's technique

IntroductionImplantation of a penile prosthesis in cases of neglected or resistant ischemic priapism, or delayed re-implantation following prosthesis infection and extraction, is usually a difficult and risky procedure due to fibrosis of the corpora cavernosa. Among the common complications are perforation of the urethra, tunica albuginea, and infection. The complications are usually due to the use of blind force against resistance.AimWe propose the techniques of Trans-Corporeal Resection and Optical Corporotomy as adjuvant measures for excavating the fibrosed corpora cavernosa under vision, without the use of force against resistance.MethodsSix patients with diffuse fibrosis of the corpora cavernosa were operated on. The instruments and technique are the same as for optical urethrotomy and transurethral resection. Optical Corporotomy was started with, where the corpora are incised from within. After establishment of a satisfactory passage, Trans-Corporeal Resection followed to scrape the fibrous tissue. Implantation of penile prosthesis was completed as usual. The procedure was performed through 1.5 cm incision in the tunica albuginea.Main Outcome MeasuresLength, girth, and straightness in the erect position, as well as the incidence of complications.ResultsOperative time was an average of 90 minutes. No difficulty was encountered during the procedure. No complications were noted through 1 year of follow-up.ConclusionOptical Corporotomy and Trans-Corporeal Resection allow for force-free, visually monitored excavation of the fibrosed corpora cavernosa, aiming at safer penile prosthesis implantation. Shaeer O, and Shaeer A. Corporoscopic excavation of the fibrosed corpora cavernosa for penile prosethesis implantation: Optical Corporotomy and Trans-Corporeal Resection, Shaeer’s Technique. J Sex Med 2007;4:218–225.     

Trans-corporal incision of Peyronie's plaques

IntroductionPatients presenting with Peyronie's disease (PD) curvature and erectile dysfunction (ED) can achieve straightening and rigidity through penile prosthesis implantation and manual modeling and, if necessary, a relaxing tunical incision with or without grafting. Unfortunately, this maneuver will not correct PD‐induced shortening. In addition, incision and grafting after the prosthesis has already been implanted adds to operative time and risk, and may indicate mobilization of the neurovascular bundle and, possibly, a secondary skin incision.AimThis work describes trans‐corporal incision (TCI), a minimally invasive endoscopic approach for plaque incision from within the corpora cavernosa, restoring straightness and length to the penis, before calibration of the corpora cavernosa, allowing implantation of a longer prosthesis in a straight penis, with neither mobilizing the neurovascular bundle nor a secondary incision.MethodsSixteen patients with PD deformity and refractory ED were operated upon. Intra‐operative artificial erection demonstrated the deformity. Through a penoscrotal incision, the corpora were dilated. TCI was performed to incise Peyronie's plaques at the point of maximum deformity. Artificial erection was re‐induced and correction of curvature evaluated. Length was measured before and after TCI. Implantation proceeded as usual.Main Outcome MeasuresPenile straightness and length.ResultsFollowing implantation, the penis was straight in all cases. Pre‐TCI length of the corpora was unequal on either side. Post‐TCI, both corpora were of equal length with an average increase of 2.5 cm (11.9%) on the right side and 1.9 (9.1%) on the left.ConclusionTCI; corporoscopic incision of Peyronie's plaques upon implantation of penile prosthesis is a minimally invasive approach that restores both straightness and length to patients with PD and ED, with neither mobilization of the neurovascular bundle nor plaque incision and grafting. Shaeer O. Trans‐corporal incision of Peyronie's Plaques. J Sex Med 2011;8:589–593.     

Distal Penile Shaft Reconstruction and Reinforcement: The “Double‐Windsocks” Technique

IntroductionThe management of penile prosthesis protrusion and the implantation of a prosthesis in fibrotic penile corporal bodies represents a challenging task even for experienced surgeons.AimTo demonstrate the long‐term efficacy and safety of a new technique for distal shaft reconstruction and reinforcement in cases of penile prosthesis protrusion or cases of penile prosthesis implantation in corporal fibrosis.MethodsBetween August 2007 and August 2012, 69 patients underwent surgery for penile prosthesis protrusion (45 patients) or severe distal corporal fibrosis (24 patients). The mean age at the time of surgery was 56 years (range 38–69). All patients underwent distal shaft reconstruction using our technique, involving the creation of two neocorpora (“double windsocks”).Main Outcome MeasuresFunctional outcome and patient satisfaction were evaluated with item numbers 1 and 7 of the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire. Furthermore, clinical data concerning the early postoperative outcome were analyzed retrospectively.ResultsMean follow‐up time was 22.5 months (range 6–48). Based on answers to EDITS questionnaire item 1, 42 patients (60.9%) were very satisfied and 19 patients (27.5%) were somewhat satisfied with the outcome of the procedure. Furthermore, answers to the self‐confidence domain question (EDITS item 7) revealed that 63 patients (91.3%) felt that the treatment had a positive effect with respect to their ability to engage in sexual activity.No patient exhibited device extrusion, postoperative infection, or skin dehiscence, and glans sensation as well as orgasmic ability were also preserved in all cases. Neuropraxia was reported in five cases (3.4%) immediately after the operation. The recovery of orgasmic ability was delayed in 17 (24.6%) patients. All patients were able to perform sexual intercourse postoperatively.ConclusionThe “double‐windsocks” technique is an effective option for difficult cases of distal penile shaft reconstruction and reinforcement. Egydio PH and Kuehhas FE. Distal penile shaft reconstruction and reinforcement: The “double‐windsocks” technique. J Sex Med 2013;10:2571–2578.     

Extracorporeal Transseptal Penile Prosthesis Implantation for Extreme Cases of Corporeal Fibrosis: Shaeer Implantation Technique

Background

Penile prosthesis implantation into scarred corporeal bodies is one of the most challenging procedures in prosthetic urologic surgery, especially following infection and extrusion of a penile implant. Several instruments and techniques have been used for making dilatation of scarred corporeal bodies easier and safer in expert hands. Nevertheless, in some cases, implantation is not possible.

Penile prosthesis surgery in patients with corporal fibrosis: a state of the art review

IntroductionPenile prosthesis has become one of the most accepted treatment options in patients who do not respond to conservative medical therapies (oral or intracavernous injections). When penile fibrosis is present, this surgery becomes a real surgical challenge even for a skillful surgeon.AimThe aim of this study was to review latest techniques to implant a penile prosthesis in patients with corporal fibrosis.MethodsWe performed a systematic search in the following databases: PubMed, EMBASE, Cochrane, SCOPUS, and Science Citation Index without any date limits for the terms: “penile prosthesis,”“penile fibrosis,”“impotence,”“fibrosis,”“cavernotomes,”“downsized prosthesis cylinders,”“patient satisfaction,”“penile graft,” and “vascular graft.”Main Outcome MeasureWe reported in each technique and series data regarding penile size, complication rate, infection rate, technical pitfalls and details, use of additional surgical tools or implanted material (grafts, etc.), patients' satisfaction, and overall success rate.ResultsWhen penile corporal fibrosis is present, this surgery becomes a real surgical challenge even for a skillful surgeon. Over the years, multiple surgical approaches have been suggested to facilitate implantation in this difficult situation. Traditional approaches include the resection of scar tissue, performing extensive corporotomies and the eventually use of grafts to cover the corporal gap. Outcomes can be improved combining the use of techniques for scar incision (extensive wide excision, multiple incisions minimizing excision, corporal counter incisions, corporal excavation technique or Shaeer's technique) and cavernotomes and downsized prosthesis. Surgical strategies like upsizing prosthesis, suspensory ligament release or scrotoplasty must be kept in mind to utilize in this special scenario.ConclusionsPenile prosthesis in a patient with severe corporal fibrosis remains a surgical challenge. There are several techniques and surgical strategies that an implant surgeon should know and manage to minimize complications and improve outcomes. Martínez‐Salamanca JI, Mueller A, Moncada I, Carballido J, and Mulhall JP. Penile prosthesis surgery in patients with corporal fibrosis: A state of the art review. J Sex Med 2011;8:1880–1889.     

A Preliminary Report on the Usage of an Intracorporal Antibiotic Cast with Synthetic High Purity CaSO4 for the Treatment of Infected Penile Implant

IntroductionCurrently, the surgical treatment of infected penile prostheses is complete removal and either immediate salvage procedure, which carries a significant infection risk, or delayed implantation. With delayed implantation the risk of infection is lower, but the patient loses penile length and width due to corporal fibrosis.AimWe present our experience with the use of a novel temporary synthetic high purity calcium sulfate (SHPCaSO4) component that acts as a “spacer” at the time of removal of an infected prosthesis while providing constant delivery of local antibiotic elution to the infected area.Main Outcome MeasuresDemonstrate that the use of a novel material, SHPCaSO4, can be an innovative way to bridge the gap between removal of an infected penile implant and delayed reimplantation.MethodsTwo patients (Patient A and B) presented with pain and erythema and were found to have infected malleable penile prosthesis. Both underwent removal of all infected components, and sent for tissue culture. The SHPCaSO4 was mixed with vancomycin and tobramycin, allowed to set up for 5 minutes, and then injected into the corporal space followed by closure with 2‐0 Vicryl sutures. The injected SHPCaSO4 was palpable in the penile shaft both proximally and distally, as an “intracorporal casts.”ResultsPatients denied pain postoperatively. Delayed implantation occurred at 6 weeks for patient A. This went uneventful and a new three‐piece inflatable implant was inserted. Patient B underwent salvage placement of right malleable implant at 15 weeks, and here significant corporal fibrosis was encountered. Patients have had no infection since their delayed implantation (mean follow‐up 4 months).ConclusionsData in reference to SHPCaSO4 shows that this product dissolves in approximately 4–6 weeks. This may account for the difference in the ease of delayed implantation between the two patients. Further investigation is warranted.     

Removal of a Detached Head of the Brooks Dilator from the Corpora Cavernosa During Penile Prosthesis Implantation

IntroductionSeveral complications during and after penile implantation have been reported. The most difficult part of the procedure seems to be the dilatation of the corpora, especially in fibrotic cases.AimTo report a rare intraoperative complication during dilatation of the corpora and its management.MethodsDuring dilation of the corpora cavernosa with Brooks dilators for the implantation of penile prosthesis, its head was detached and stuck at the tip of the corpus cavernosum. Several trials to remove the head of the dilator using different kinds of clamps were unsuccessful. Finally, an incision was performed to the distal lateral part of the corpora cavernosa and the head of the dilator was removed. Implantation was completed uneventfully.ResultsThe patient instructed to inflate the prosthesis and use it for sexual intercourse after 6 weeks. Follow-up was 14 months and the patient is using properly the prosthesis.ConclusionsAlthough this is a very rare complication not previously described, we recommend examination of the dilators before use. Hatzimouratidis K, Koliakos N, Koutsogiannis I, Moisidis K, Giakoumelos A, and Hatzichristou D. Removal of a detached head of the Brooks dilator from the corpora cavernosa during penile prosthesis implantation.     

Erectile Function Significant Enough for Penetration During Sexual Intercourse after Removal of Inflatable Penile Prosthesis

IntroductionFifty‐two‐year‐old male with history of multiple insults to his erectile tissue, including insertion and removal of penile implant, presents with significant partial erectile function, substantial enough for anal penetration during sexual intercourse.AimErectile function rigid enough for anal penetration, let alone any erectile function after removal of an inflatable penile prosthesis (IPP), is rare. This article, to our knowledge, is the first case of a patient who has undergone multiple insults to his erectile tissue, including an episode of ischemic priapism followed by implantation and removal of an IPP, who presents with erectile function sufficient enough for coitus.Main Outcome MeasuresOutcome measured via standardized patient questionnaires and penile Doppler following injection of Trimix.MethodAn objective measure of the patient's erectile function was performed via penile Doppler.ResultsPenile Doppler after 10‐mcg injection of Trimix revealed numerous perforating vessels from the corpora spongiosum providing blood flow to the corpora cavernosa. The patient obtained approximately 60–70% rigid erection.ConclusionsTo our knowledge, and after thorough review of the literature, we could not find any reports of erectile function significant enough to take part in sexual intercourse and penetration after removal of a three‐piece IPP. The implant usually disrupts the normal anatomy which allows for cavernosal arterial vasodilation and increased blood flow into the corpora. Following dilation of the corpora the cylinders are inserted and inflated, and the smooth muscle that makes up the corpora cavernosum is compressed against the wall of the tunica albuginea. Theoretically, the remaining smooth muscle tissue may retain some of its physiologic function, adding some additional girth to the penis with an already activated IPP during sexual intercourse. Martinez DR, Mennie PA, and Carrion R. Erectile function significant enough for penetration during sexual intercourse after removal of inflatable penile prosthesis. J Sex Med 2012;9:2938–2942.     

Simultaneous penile lengthening and penile prosthesis implantation in patients with Peyronie's disease, refractory erectile dysfunction, and severe penile shortening

IntroductionDue to loss of length, patients who had penile prosthesis implantation for Peyronie's disease (PD) show a statistically significant reduction in their levels of satisfaction when compared with the general implant population.AimThe aim of this study is to report our experience of penile lengthening with circumferential graft during penile prosthesis implantation in patients with PD and severe penile shortening.MethodsBetween March 2006 and February 2008, 23 patients with PD, refractory erectile dysfunction, and severe penile shortening underwent penile lengthening with circumferential graft and concomitant implantation of an inflatable penile prosthesis.Main Outcome MeasuresSurgical outcome and complications have been recorded during postoperative follow‐up. Patients' satisfaction has been assessed 6 months postoperatively with the administration of the modified Erectile Dysfunction Index of Treatment Satisfaction (EDITS) questionnaire.ResultsAfter an average follow‐up of 22 months (range 6–36), 20 patients attended all the postoperative follow‐up visits and returned the EDITS questionnaire. An average length gain of 2.8 cm (range 2.2–4.5) was recorded, and all patients were able to cycle the device and engage in penetrative sexual intercourse. Patient recorded complications included diminished glans sensitivity in four (20%) and persistent dorsal curvature of less than 15° in three (15%). Overall, 18 patients (90%) were satisfied with the cosmetic and functional result of surgery.ConclusionPenile lengthening with circumferential graft during penile prosthesis implantation in patients with PD represents a safe and reproducible technique that yields higher satisfaction rates than penile prosthesis implantation alone in patients with severe penile shortening. Sansalone S, Garaffa G, Djinovic R, Egydio P, Vespasiani G, Miano R, Loreto C, and Ralph DJ. Simultaneous penile lengthening and penile prosthesis implantation in patients with Peyronie's disease, refractory erectile dysfunction, and severe penile shortening. J Sex Med 2012;9:316–321.     

A Review of Surgical Techniques for Impending Distal Erosion and Intraoperative Penile Implant Complications: Part 2 of a Three‐part Review Series on Penile Prosthetic Surgery

IntroductionMore than half of intraoperative complications occur during dilatation of the corpora cavernosa, a critical step in the placement of any type of penile prosthesis, which can be especially difficult in a patient with corporal fibrosis. A late manifestation of cylinder placement can be impending erosion with lateral extrusion or medial deviation (into the urethra) of the distal tips. There are many different approaches to try and fix these surgical issues.AimThe review article evaluates the many different surgical techniques prosthetic surgeons use in the management of intraoperative complications and lateral extrusion.MethodsA review of the literature was preformed with published results being evaluated to try to help guide the management of intraoperative complications and impending distal erosion. There is a special focus on dilation of the corpora cavernosa.Main Outcomes MeasuresThe article reviews and evaluates the outcomes of the landmark papers in the management of intraoperative complications and impending distal erosion.ResultsIntraoperative complications of penile implant placement can be distressing for the prosthetic surgeon, but with proper recognition, most of these complications can be navigated with excellent postoperative results.ConclusionsThis review article summarizes many of the techniques, outcomes, and new developments in the complicated field of penile prosthetic surgery to help guide the implanting surgeon. Henry GD and Laborde E. A review of surgical techniques for impending distal erosion and intraoperative penile implant complications: Part 2 of a three‐part review series on penile prosthetic surgery. J Sex Med 2012;9:927–936.     

The Genetic Inactivation of Inducible Nitric Oxide Synthase (iNOS) Intensifies Fibrosis and Oxidative Stress in the Penile Corpora Cavernosa in Type 1 Diabetes

IntroductionEndogenously elicited inducible nitric oxide synthase (iNOS) induction counteracts fibrosis and oxidative stress in penile tissues in rat models of Peyronie's disease and erectile dysfunction.AimThe current study aimed to determine whether the genetic blockade of iNOS expression in the iNOS knock out (iNOS KO) mouse intensifies fibrosis and oxidative stress in the penile corpora cavernosa, and this is exacerbated by streptozotocin (STZ)-induced diabetes and counteracted by insulin.Main Outcomes MeasuresQuantitative assessment of histological and biochemical markers in mouse corporal tissue.MethodsMale iNOS KO and wild type (WT) mice were left untreated or injected with STZ, with or without insulin treatment. At 8 weeks, glycemia, glucosuria, and proteinuria were determined, and corporal tissue sections were obtained and subjected to Masson trichrome staining for smooth muscle (SM)/collagen ratio, and immunostaining for α-smooth muscle actin (ASMA) for, SM content, proliferating cell nuclear antigen (PCNA) for cell replication, TGFβ1 as profibrotic factor, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay for apoptosis, and xanthine oxidoreductase (XOR) for oxidative stress. Collagen was estimated by the hydroxyproline reaction.ResultsThe corporal SM/collagen ratio and SM content were reduced, and collagen content increased in iNOS KO mice as compared with WT mice, but apoptosis was decreased and cell replication increased, whereas TGFβ1 and XOR did not vary. Severe hyperglycemia caused in the WT a reduction of the corporal SM/collagen ratio and SM content and an increase in apoptosis without changes in PCNA, TGFβ1, or XOR. In the iNOS KO mouse the hyperglycemia-induced alterations were exacerbated, with additional increases in oxidative stress and TGFβ1. Insulin normalized glycemia and partially protected the SM in both the WT and the iNOS KO mice.ConclusionsThe antifibrotic, antioxidative, and SM-protective roles of iNOS in the penile corpora cavernosa were confirmed in the iNOS KO/STZ mouse model. These findings support the importance of endogenously-elicited iNOS induction in protecting the penile corpora cavernosa from the pro-fibrotic effects of hyperglycemia. Ferrini MG, Rivera S, Moon J, Vernet D, Rajfer J, and Gonzalez-Cadavid NF. The genetic inactivation of inducible nitric oxide synthase (iNOS) intensifies fibrosis and oxidative stress in the penile corpora cavernosa in type 1 diabetes.     

Ischemic priapism and implant surgery with sharp corporal fibrosis excision

IntroductionProlonged ischemic priapism is commonly associated with severe erectile dysfunction. Subsequent implant surgery is complicated by fibrosis of corporal tissue.AimIn this article we review clinical practice methods for safe and effective use of intracavernosal injection therapy as well as management of erectile dysfunction that may result from inappropriate priapism treatment.MethodsA case report is presented followed by a review of literature addressing surgical techniques for penile prosthesis implantation in the setting of corporal fibrosis.Main Outcome MeasuresReview of literature and discussion of best-practice management.ResultsErectile dysfunction should be clearly distinguished from premature ejaculation. Careful training and monitoring of patients using penile self-injection therapy is essential for preventing episodes of priapism. Local injection clinics that are primarily motivated by financial considerations threaten the safe management of men with sexual dysfunction. Development of corporal fibrosis occurs during prolonged ischemic priapism and is duration-dependent. Implant surgeons should be familiar with maneuvers to address fibrotic corporal tissue. Stember DS, and Mulhall JP. Ischemic priapism and implant surgery with sharp corporal fibrosis excision.     

Historical Review of Penile Prosthesis Design and Surgical Techniques: Part 1 of a Three-Part Review Series on Penile Prosthetic Surgery

IntroductionThroughout history, many attempts to cure complete impotence have been recorded. Early attempts at a surgical approach involved the placement of rigid devices to support the natural process of erection formation. However, these early attempts placed the devices outside of the corpora cavernosa, with high rates of erosion and infection. Today, most urologists in the United States now place an inflatable penile prosthesis (IPP) with an antibiotic coating inside the tunica albuginea.AimThe article describes the key historical landmarks in penile prosthesis design and surgical techniques.MethodsThe article reviews and evaluates the published literature for important contributions to penile prosthesis design and surgical techniques.Main Outcome MeasuresThe article reviews and evaluates the historical landmarks in penile prosthesis design and surgical techniques that appear to improve outcomes and advance the field of prosthetic urology for the treatment of erectile dysfunction.ResultsThe current review demonstrates the stepwise progression starting with the use of stenting for achieving rigidity in the impotent patient. Modern advances were first used in war-injured patients which led to early implantation with foreign material. The design and techniques of penile prostheses placement have advanced such that now, more complications are linked to medical issues than failure of the implant.ConclusionsToday's IPPs have high patient satisfaction rates with low mechanical failure rates. Gerard D. Henry. Historical review of penile prosthesis design and surgical techniques: Part 1 of a three-part review series on penile prosthetic surgery. J Sex Med 2009;6:675–681.     

Laparascopic capsulotomy to treat autoinflation of inflatable penile prostheses

IntroductionInflatable penile prosthetic implants are a reliable treatment for erectile dysfunction. Mechanical failures now are the most common reason for revision of this type of device, and autoinflation is a common cause for device revision. There are currently no published surgical treatments for this malfunction.AimTo describe a simple outpatient surgical revision for an automatically inflating device using laparascopic dissection.Main Outcome MeasuresComplete deflation of penile prosthesis on follow‐up visit, intraoperative and postsurgical complications, and length of procedure.MethodsWe performed a retrospective review of patients treated for inflatable penile prosthesis autoinflation with laparascopic capsulotomy to release constricting connective tissue rind surrounding the device reservoir at a single institution. We collected information about etiology of impotence, surgical procedures relating to implant and revision of prosthetic devices, and follow‐up evaluations.ResultsFour patients underwent laparascopic capsulotomy to treat autoinflation. Mean operative time was 45 minutes, and no adverse surgical or perioperative outcomes occurred. All four patients had deflated corporal cylinders at the time of follow‐up evaluation.ConclusionsLaparascopic capsulotomy is an easy and reliable method of treating inflatable penile prosthesis autoinflation that can be performed in the outpatient setting. Abbosh PH, Thom MR, and Bullock A. Laparascopic capsulotomy to treat autoinflation of inflatable penile prostheses. J Sex Med 12;9:1212–1215.     

A Pilot Study to Determine Penile Oxygen Saturation Before and After Vacuum Therapy in Patients with Erectile Dysfunction After Radical Prostatectomy

IntroductionProvoked and spontaneous nocturnal erections are thought to play a role in maintenance of male sexual health through oxygenation of the corpus cavernosa. Conversely, hypoxia is thought to be an etiological factor in the pathogenesis of cavernosal fibrosis and long‐term erectile dysfunction. It has been hypothesized that the early penile hypoxia after radical prostatectomy (RP) may lead to fibrosis and consequently a decrease in stretched penile length and long‐term erectile dysfunction.AimThe aim of this study was to assess the changes in penile tissue oxygenation with vacuum erection device (VED) use.MethodsTwenty men between 2 and 24 months following RP were enrolled prospectively. Each man cycled a VED to achieve full erection 10 consecutive times over a period of approximately 2 minutes without constriction ring.Main Outcome MeasuresTissue oximetry was measured at baseline and immediately after VED using a tissue oximeter at five sites: right thigh, right corpora, glans, left corpora, and left thigh. Additional measurements were captured over the course of an hour.ResultsMean age and time from surgery was 58.2 years and 12.6 months, respectively, and the average Sexual Health Inventory for Men score was 7. Use of the VED significantly increased both glanular and corporal oximetry relative to the baseline values for the entire 60 minutes. An initial increase of 55% was seen in corporal oxygenation with VED use.ConclusionsThis is the first study demonstrating that a single, brief application of the VED without a constriction ring results in significant improvement in penile oxygen saturation. The use of a VED has significant benefits for patients both with regard to cost and invasiveness when compared with other penile rehabilitation protocols. Welliver RC Jr, Mechlin C, Goodwin B, Alukal JP, and McCullough AR. A pilot study to determine penile oxygen saturation before and after vacuum therapy in patients with erectile dysfunction after radical prostatectomy. J Sex Med 2014;11:1071–1077.     

Successful Placement of Penile Prostheses in Men With Severe Corporal Fibrosis Following Vacuum Therapy Protocol

IntroductionPenile prosthesis (PP) implantation in men with severe corporal fibrosis presents a significant surgical challenge. For the past 7 years, we have used a novel, preoperative protocol of daily vacuum therapy (VT) using a vacuum erection device for at least 3 months before PP placement for men with severe corporal fibrosis from PP infection or ischemic priapism.AimTo evaluate this standardized preoperative regimen.MethodsWe retrospectively reviewed all patients who underwent three-piece PP placement at our institution from 2008 through 2015. Of these, 13 men had severe corporal fibrosis from prior PP infection (11 of 13) or prolonged ischemic priapism (2 of 13). Our protocol included VT for 10 to 15 minutes at least two times daily in all patients for at least 3 months (mean = 3.5 months).Main Outcome MeasuresWe report on our surgical experience and post-VT stretched flaccid penile length (SFPL) compared with baseline SFPL.ResultsAll 13 men underwent successful three-piece PP placement with standard-size cylinders without additional surgical maneuvers. There was one infection and one erosion requiring revision. Daily average use of VT was 32.5 minutes. SFPL increased 0.92 cm (range = 0–2 cm, SD = 0.76 cm) after VT and three-piece PP placement compared with preoperative SFPL. These men also noted improved quality of life and sexuality as measured by postoperative office interviews.ConclusionThe use of VT before surgery appears to result in softening of corporal fibrosis and facilitates placement of a PP regardless of the period from developing corporal fibrosis to starting VT. We strongly recommend preoperative corporal tissue rehabilitation with VT to improve surgical outcomes and to decrease difficulty during PP implantation in men with severe corporal fibrosis.     

Penile prosthesis implantation in cases of fibrosis: ultrasound-guided cavernotomy and sheathed trochar excavation

IntroductionImplantation of a penile prosthesis into fibrosed corpora cavernosa is a difficult and risky procedure. Specialized instruments that assist safer and more efficient excavation include Otis Urethrotome and various cavernotomes, all of which operate underneath the tunica albuginea, out of sight. The blind use of such instruments can result in perforation of the tunica albuginea or injury to the urethra.AimThis work describes the utility of ultrasonography for adding visual monitoring to any of the above-mentioned instruments, maintaining them in the mid-corpus cavernosum position to avoid perforation, and describes the application of alternative sheathed, sharp instruments that allow fast, efficient, and visually monitored drilling into fibrous tissue.Main Outcome MeasuresClinical outcome data were examined.MethodsSurgery was performed on five cases with extensive fibrosis of the penis. Initial blunt dilatation by Hegar dilators faced considerable resistance. An ultrasound probe was applied to the ventral aspect of the penis. A laparoscopy sheath was advanced under ultrasound guidance up to the fibrous tissue. A sharp laparoscopy trochar was inserted through the sheath. Its tip was oriented in the mid-corpus cavernosum by longitudinal and transverse sonography sections, as it drilled into the fibrous tissue. Laparoscopy scissors were used in the same fashion to cut fibrous tissue lumps. After full excavation, penile prosthesis was implanted.ResultsAll implants survived adequately. No complications occurred following implantation. Operative time ranged from 50 to 60 minutes. No difficulty was encountered at excavation.ConclusionUltrasound guidance can be a handy adjunct to any of the available techniques developed for excavating the fibrosed corpora cavernosa, with a possible decrease in difficulty and complication rate of the procedure. Utility of sheathed, sharp instruments guided by sonography is an alternative to the cavernotomes, allowing fast and efficient drilling into fibrous tissue. Shaeer O. Penile prosthesis implantation in cases of fibrosis: Ultrasound-guided cavernotomy and sheathed trochar excavation.     

AMS 700CX/CXM Inflatable Penile Prosthesis Has High Mechanical Reliability at Long-Term Follow-Up

IntroductionAMS 700CX/CXM inflatable penile prosthesis is increasingly applied for the treatment of erectile dysfunction (ED). However, there are a few long-term survival data of the inflatable penile prosthesis (IPP) over 10 years.AimTo determine the long-term mechanical reliability of AMS 700CX/CXM inflatable penile prosthesis in patients with ED.MethodsA total of 438 consecutive patients with ED received implantation of an AMS 700CX/CXM penile prosthesis at our institution from January 1991 to April 2009. In 397 patients (90.7%), the medical records were available and current status of penile prosthesis could be obtained by a direct telephone interview. The overall and mechanical survival rates of penile prosthesis were evaluated using Kaplan–Meier method.Main Outcome MeasuresAssessing the mechanical and overall survival rates of the AMS 700CX/CXM penile prosthesis using Kaplan–Meier analysis, and looking for clinical factors related to survival of the CX/CXM using log-rank test.ResultsMean age of 397 patients was 63.1 years (range, 24-93) and follow-up duration was 113 months (range 1-219). Eighty-two patients (20.6%) experienced mechanical failure at a median follow-up of 82 months. Mechanical survival rate of the penile prosthesis was 97.6%, 93.2% and 78.2% at 3, 5, and 10 years after implantation, respectively. 12 patients (3.0%) experienced nonmechanical failure including infections, tissue erosion resulting in cylinder protrusion at the meatus and chronic discomfort. Overall survival rate of the penile prosthesis was 95.0%, 91.0% and 75.5% at 3, 5, and 10 years after implantation, respectively. Patients with neurogenic cause for ED showed lower median overall survival of penile prosthesis compared with patients with non-neurogenic cause. Patient age, obesity, and diabetes mellitus had no association with overall survival of penile prosthesis after implantation.ConclusionsThe AMS 700CX/CXM could be accepted and applied in more patients as a reliable treatment alternative of ED. Kim DS, Yang KM, Chung HJ, Choi HM, Choi YD, and Choi HK. AMS 700CX/CXM inflatable penile prosthesis has high mechanical reliability at long-term follow-up.     

Traction therapy for men with shortened penis prior to penile prosthesis implantation: a pilot study

IntroductionLoss of penile length after penile prosthesis implantation is one of the most common complaints. There is no recognized reliable technique to gain length once the device is placed.AimsThis noncontrolled pilot study was designed to evaluate the efficacy and safety of external penile traction therapy in men with a shortened penis used before inflatable prosthesis implantation.MethodsTen men with drug refractory erectile dysfunction and a complaint of a shorter penis as a result of radical prostatectomy in four, prior prosthesis explantation in four, and Peyronie's disease in two were entered into this trial. External penile traction was applied for 2–4 hours daily for 2–4 months prior to prosthesis surgery.Main Outcome MeasuresBaseline stretched penile length (SPL) was compared with post‐traction SPL and postimplant inflated erect length. A non‐validated questionnaire assessed patient satisfaction.ResultsAll men completed the protocol. Daily average device use was 2–4 hours and for up to 4 months. No man had measured or perceived length loss after inflatable penile prosthesis placement. Seventy percent had measured erect length gain compared with baseline pre‐traction SPL up to 1.5 cm. There were no adverse events.ConclusionExternal traction therapy appears to result in a preservation of penile length, as no man had measured or perceived length loss following prosthesis placement, but in fact, a small length gain was noted in 70% of the subjects with no adverse events. The protocol is tedious and requires compliance to be effective. External traction therapy prior to inflatable penile prosthesis placement appears to preserve and possibly result in increased post‐prosthesis implant erect length. Levine LA and Rybak J. Traction therapy for men with shortened penis prior to penile prosthesis implantation: A pilot study. J Sex Med 2011;8:2112–2117.