The management of residual curvature after penile prosthesis implantation in men with Peyronie's disease

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

? To report our experience in the management of residual curvature after implantation of a penile prosthesis in men with Peyronie’s disease (PD).

PATIENTS AND METHODS

? From January 1985 to June 2009, 62 (29%) of the 209 patients with PD that have undergone the insertion of a penile prosthesis have required an additional straightening procedure to correct the residual curvature after the insertion of the cylinders of the implant. ? The types of additional manoeuvres, their success in correcting the residual curvature and eventual complications have been reported.

RESULTS

? Among the additional straightening procedures, modelling was more successful in achieving straightening when performed on an inflatable device (84%) than on a malleable implant (54%). ? If the curvature persisted after modelling or if the curvature was ventral, straightening was achieved with tunical plications or incision with or without grafting.

CONCLUSION

? Although it is common for the simple implantation of cylinders alone to straighten the penis, some patients will present a residual curvature that must be successfully corrected with additional straightening procedures.     

可充胀阴茎假体治疗勃起功能障碍的体会

目的：探讨三件套可充胀阴茎假体治疗勃起功能障碍（ED）的疗效。方法：选择5例ED患者，其中50岁以上4例，并发糖尿病3例，高血压动脉粥样硬化1例，另1例为骨盆骨折、尿道断裂伤引起神经性ED。5例均采用三件套可充胀阴茎假体植入术。结果：4例术后伤口如期愈合，能够达到满意的性生活，另1例因阴茎过短，假体植入后，伤口长期不愈合，出现组织排异现象，导致尿道海绵体坏死、穿孔。漏尿而最后不得不取出假体。结论：ED患者植入三件套可充胀阴茎假体，手术切口小，愈合后不易察觉，治疗效果好，患者乐于接受。     

AMS 3-Piece Inflatable Penile Prosthesis Implantation in Men with Peyronie's Disease: Comparison of CX and Ultrex Cylinders

Purpose

We compared the ability of the CX and Ultrex cylinders to straighten the penis in men who received a 3-piece AMS 700^* series inflatable penile prosthesis for erectile dysfunction and erectile deformity due to Peyronie's disease.

Materials and Methods

The records of 34 and 38 patients receiving devices with CX and Ultrex cylinders, respectively, were reviewed.

Results

All 34 patients receiving the CX cylinders achieved complete penile straightening with cylinder inflation and bending alone. In 10 of 38 patients receiving the Ultrex cylinders complete straightening with cylinder inflation and bending could not be achieved, and simultaneous corporoplasty was necessary.

Conclusions

Girth expanding CX cylinders have better penile straightening properties than girth and length expanding Ultrex cylinders. We recommended use of CX cylinders for 3-piece AMS 700 series inflatable penile prosthesis implantation in men with Peyronie's disease.     

A surgical algorithm for penile prosthesis placement in men with erectile failure and Peyronie's disease

We developed an algorithm for surgical management and placement of penile prostheses in patients with erectile failure (ED) and Peyronie's disease (PD). We identified 46 men ages 40 to 77 y with PD who could not attain an adequate erection with sexual stimulation and pharmacotherapy. All men were candidates for penile straightening and inflatable prosthesis placement using the following algorithm. Manual molding was attempted initially, followed by tunica incision for insufficient straightening. For tunical defects greater than 2 cm, polytetrafluoroethylene (PTFE) patch grafting was performed to prevent prosthesis cylinder herniation and recurrent deformity from cicatrix contraction. Mean preoperative penile curvature was 53 degrees (0-90). Prosthesis implantation with manual molding, implant with plaque incision, and implant with plaque incision and PTFE grafting were successfully accomplished in 25 (54%), 12 (26%), and nine (20)% respectively. Mean follow-up was 39 months (range 1-74). Full erectile capacity with a straight phallus was achieved in all patients. Complications included temporary (< 8 months) decreased penile sensation in four (9%), mild (< 2 cm) penile shortening in three (7%), delayed ejaculation in one (2%), and infection requiring explanation in one diabetic male (2%). All of the implanted prostheses provided satisfactory rigidity with no mechanical failures or recurrent curvature. We conclude that inflatable penile prosthesis implantation is a safe and effective therapy with a high satisfaction rate in men with ED and PD. The developed algorithm helps define prosthesis placement and straightening techniques to obtain optimal results with minimal complications.     

Outcomes and satisfaction rates for the redesigned 2-piece penile prosthesis

PURPOSE: We evaluated long-term viability, quality of life and satisfaction with the redesigned 2 piece Ambicor inflatable penile prosthesis. This device underwent revision of the rear tip extender and reinforcement of the pump tubing connection to decrease fluid leak failure in 1998. MATERIALS AND METHODS: In this retrospective analysis we evaluated 146 men with erectile dysfunction at 2 centers who underwent device implantation between June 1999 and October 2004 with the redesigned prosthesis. Patient information forms were completed, including patient history, surgical information and revision data. Patients were mailed a modified Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire, a modified Erectile Dysfunction Inventory of Treatment Satisfaction Partner survey and a questionnaire regarding pertinent inflatable penile prosthesis questions. RESULTS: A total of 146 men with a mean age of 58.7 years (range 25 to 78) were evaluated after inflatable penile prosthesis placement. Time from implant to followup was 3 to 73 months (mean 38). Only 1 device (0.7%) was removed due to infection. One implant (0.7%) was replaced due to fluid loss and 1 (0.7%) was revised due to improper sizing. Kaplan-Meier life table analysis indicated that the percent of patients free from reoperation was 99.2% at 12 months, 99.2% at 36 months and 91% at 48 months or greater. Of the 101 subjects completing the survey the average patient used the prosthesis 5 times monthly and 88.9% reported continued use. Of the patients 91% said that it was easy to use and 95% had little to no trouble learning to use it, while 84% stated that the inflatable penile prosthesis provided good to excellent rigidity for coitus. Overall patient and partner satisfaction was 85% and 76%, respectively. Of the patients 86% said that they would recommend the prosthesis to friends or if need be undergo the procedure again. CONCLUSIONS: The redesigned Ambicor 2-piece penile prosthesis appears to be safe and effective. It is associated with a low rate of revision as well as high patient and partner satisfaction.     

Long-term Followup of and Patient Satisfaction With the Dynaflex Self-Contained Inflatable Penile Prosthesis

Purpose

We analyzed our experience with the Dynaflex^* self-contained inflatable penile prosthesis to define specific complication rates and patient satisfaction in the long term.

Materials and Methods

From October 1990 through October 1994, 62 men underwent implantation of a Dynaflex prosthesis. Mean and median time since implantation was 50 and 53 months, respectively (minimum 24). In addition to standard followup and tabulation of complications, patients were contacted and interviewed regarding satisfaction with the prosthesis.

Results

Mechanical device failures occurred in 9.7% of cases with a mean time to failure of 40 months in 6 prostheses. An additional 16.1% of patients had an unsuccessful outcome due to dissatisfaction with the Dynaflex. Of the patients with a functional Dynaflex prosthesis contacted at the time of this review 88.1% expressed satisfaction.

Conclusions

Mechanical failure rates for the Dynaflex prosthesis are comparable to those previously reported for multicomponent inflatable penile prostheses. Patient dissatisfaction, mainly due to difficulty in operating the Dynaflex inflation and deflation mechanisms, is much higher than for multicomponent inflatable penile prostheses. However, in patients who are successful in mastering operation of the Dynaflex satisfaction rates are high. Careful patient selection, and extended training and education efforts are the keys to maximizing successful outcomes with the Dynaflex prosthesis.     

10 years of experience with penile prosthesis implantation in Taiwanese patients

PURPOSE: We evaluated the long-term results of penile prosthesis implantation during the last 10 years. Special considerations were examined concerning Asian corporeal diameter, device survival and sociocultural factors influencing patient-partner satisfaction. MATERIALS AND METHODS: We followed 331 patients who underwent penile prosthesis implantation from December 1985 to May 1996. Surgical data, postoperative complications and information from a survey on satisfaction are reported. RESULTS: The most prevalent corporeal diameter in our patients was 11.0 to 11.5 cm. Postoperatively wound infection was the most serious surgical complication. The 5-year device survival was similar in the malleable and inflatable types except for a poorer outcome with the self-contained inflatable Hydroflex penile prosthesis. Overall patient satisfaction with surgery was 86.6%. CONCLUSIONS: Penile prosthesis implantation still has its place as definitive therapy in some patients with uncorrectable erectile dysfunction. In Taiwanese society more consideration of prosthesis selection, surgical preparation and patient-partner counseling is the basis for further success in the future.     

Peyronie’s disease: Contemporary evaluation and management

Peyronie’s disease is a common yet poorly understood condition characterized by penile pain, curvature, sexual dysfunction and psychological bother. Peyronie’s disease represents a penile wound healing disorder, and is thought to arise from exuberant scarring in response to penile trauma in genetically predisposed men. In the absence of active treatment, the majority of men experience stable or worsening symptoms, with few reporting spontaneous resolution in penile curvature or other deformity. In contrast, penile pain improves or resolves in the majority of men. Treatment options vary based on symptom severity and stability. Several oral therapies are commonly prescribed, although to date there are no strong data to support any oral agents as monotherapy for Peyronie’s disease. Other options including penile traction therapy and intralesional injections result in modest improvements for many patients, particularly when used early after symptom onset. Penile straightening through approaches, such as penile plication and plaque incision or partial excision and grafting, represent the most rapid and reliable approach to correct penile curvature once the symptoms have stabilized. Side-effects vary based on the type of surgery carried out, and include penile shortening, sensation changes and erectile dysfunction in the minority of men. In patients with drug refractory erectile dysfunction and Peyronie’s disease, placement of a penile prosthesis will address both issues, and is associated with high levels of patient satisfaction. The current review provides a practical approach to the modern evaluation and management of patients presenting with Peyronie’s disease.     

IMMEDIATE SALVAGE PROCEDURE FOR INFECTED PENILE PROSTHESIS

Purpose

The most devastating complication after the insertion of a penile prosthesis is the development of infection. The standard approach involves removing the entire device, treating intensively with antibiotics and attempting to reinsert a prosthesis at a later date, often with a suboptimal result. Based on the encouraging results of others, during the last 24 months we have used in 2 separate private urological practices a salvage procedure for treatment of infected inflatable penile prostheses.

Materials and Methods

The protocol used in 7 men with an infected inflatable penile prosthesis included removal of all device components, a 7-step vigorous intraoperative irrigation with 4 different solutions, including vancomycin, immediate reimplantation of a new inflatable penile prosthesis and postoperative outpatient antibiotics with oral ciprofloxacin or intravenous vancomycin or cefazolin.

Results

Of the 7 men 6 have experienced excellent results with no infection, minimal morbidity and preservation of penile length. The only failure occurred in a poorly controlled diabetic who required multiple revisions and may have had latent infection for months before it became apparent.

Conclusions

We believe that an immediate salvage procedure for an infected inflatable penile prosthesis is an effective treatment for this difficult complication.     

Implantation of penile prostheses in patients impotent after priapism

Review of recent implantations of penile prostheses done at Duke University Medical Center reveals 6 patients implanted for impotence secondary to priapism. Of these 6 patients, 5 had sickle cell anemia-induced priapism and 1 had idiopathic priapism. One patient had implantation of an inflatable prosthesis later followed by a semirigid prosthesis, 3 had implantation of a semirigid prosthesis, and 1 had an unsuccessful attempt at implantation of a semirigid prosthesis. The 5 patients with successful implantation have obtained satisfactory postoperative coital function. We believe that penile prostheses are beneficial in patients with impotence secondary to priapism. The degree of fibrosis encountered suggests that a semirigid prosthesis is more favorable, since the inflatable prosthesis may not overcome corporeal rigidity.     

Long-term followup of treatment for Peyronie's disease: modeling the penis over an inflatable penile prosthesis

PURPOSE: We originally reported inflatable penile implants used to treat impotence in patients with Peyronie's disease in 1993. We now present a historical prospective study of 104 patients in whom the modeling procedure was used to correct Peyronie's curvature after implantation with the Mentor Alpha 1dagger and AMS 700CXdouble dagger penile prostheses. We compared revision-free survival experience of these implants with 905 similar implants in men with nonPeyronie's disease. MATERIALS AND METHODS: The reasons for revision were classified as mechanical failure, patient dissatisfaction, infection and medical causes, including reoperation for straightening. Overall and cause specific revision-free survival in the 2 study cohorts was compared. Maximum followup was more than 12 years and average followup was more than 5. RESULTS: No significant difference in device survival was observed in the 2 study cohorts in 5 years. Similarly each prosthesis provided the same permanent straightening without the need for revision. In Peyronie's disease cases mechanical survival of the Mentor Alpha 1 was superior to that of the AMS 700CX (p = 0.0270). There was no significant difference in mechanical reliability of the devices in nonPeyronie's disease cases. CONCLUSIONS: Implantation and modeling appear to provide permanent straightening without an increase in revisions. In the nonmodeled group there was no significant difference in mechanical reliability of the AMS 700CX or Mentor Alpha 1. In modeled cases the Mentor Alpha 1 appeared less likely to fail mechanically than the AMS 700CX when followed more than 5 years. Based on this single series modeling may predispose the AMS 700CX to earlier mechanical failure.     

Treatment of Penile Fibrosis with Prosthetic Implantation and Flap Advancement with Tissue Debulking

Purpose

Even after successful penile prosthesis implantation in patients with extensive penile fibrosis, a subset will have insufficient penile length for satisfactory sexual intercourse. We report a combined surgical approach to gain additional functional length in these patients.

Materials and Methods

During the last 18 months 11 patients with extensive cavernous fibrosis underwent penile prosthesis implantation with a modified suprapubic V-Y advancement flap and lower abdominal tissue debulking.

Results

After prosthesis implantation the accompanying procedures allowed these patients to gain an additional 3.5 to 6.5 cm. in functional length. All patients had a functional device after a mean followup of 12 months. No prosthesis became infected and no patient required an additional flap procedure.

Conclusions

This surgical approach allows patients to gain additional functional length for satisfactory intercourse after treatment of extensive penile fibrosis.     

Clinical experience implanting aninflatable penile prosthesis with controlled-expansion cylinder

Ninety-four patients with erectile dysfunction underwent implantation of controlled-expansion inflatable penile prosthetic cylinders. Most of these patients had aneurysmal dilatation of the corpora cavernosa after prior implantation of inflatable devices. Follow-up of forty-six months has shown their efficacy to be excellent for management of primary impotence, penile straightening procedures, and revision after cylinder leaks. None of the patients has had recurrence of the primary condition that required revision.     

三件套可控性阴茎假体植入术治疗器质性勃起障碍

目的观察三件套可控性阴茎假体植入术治疗器质性阴茎勃起障碍(ED)的疗效、安全性及可靠性。方法我科自1999年3月~2003年10月起使用国产/进口可控性阴茎假体对7例器质性ED患者进行假体植入治疗,并对其进行随访观察。结果7例器质性ED假体植入患者术后1周内均有不同程度的阴茎疼痛,其中1例因长期焦虑症状和阴茎勃起疼痛取出假体;其余假体目前使用情况良好。结论可控性阴茎假体植入术治疗器质性ED有效、安全、疗效可靠。良好的医患沟通,严格掌握手术适应证,正确仔细术中操作,正确及时假体使用指导是手术成功有效的保证。     

Inflatable penile prostheses in patients undergoing cystoprostatectomy with urethrectomy

When urethrectomy is indicated in the male patient in combination with cystoprostatectomy for diffuse transitional cell carcinoma, an additional challenge to reconstruction and sexual rehabilitation will be encountered. Inflatable penile prostheses were implanted in 19 patients who had undergone cystoprostatectomy with prophylactic urethrectomy. Of the patients 13 underwent cystoprostatectomy with en bloc urethrectomy and delayed placement of an inflatable penile prosthesis. The remaining 6 patients required urethrectomy and simultaneous implantation of an inflatable penile prosthesis 6 to 12 weeks after radical cystectomy. All 19 patients healed appropriately and had an adequate functioning prosthesis. However, results in patients in whom the glandular urethra could be preserved safely were far superior to those in patients requiring total urethrectomy. This was so because of easier and improved cylinder placement with better support to the glans, increased glandular sensation and a more acceptable penile appearance. The inflatable penile prosthesis can be used successfully in the cystourethrectomy patient with gratifying results, especially when the glandular urethra remains intact.     

Increasing size with penile implants

Penile prosthesis implantation is suitable treatment for men with erectile dysfunction when nonsurgical treatment options fail or are otherwise unsatisfactory. Three-piece inflatable penile prostheses closely approach the ideal of producing normal penile flaccidity and erection. Nevertheless, even in men with normal corpora cavernosa, many report their prosthetic erection is shorter than their former natural erection. This is due to the lack of glans tumescence and the use of penile cylinders, which only expand in girth. Using girth-and length-expanding cylinders can decrease the loss of penile length frequently seen with prosthesis implantation. Some penile prosthesis recipients have abnormal corpora following radical prostatectomy or after removal of an infected penile prosthesis, or as the result of Peyronie’s disease, obesity, or ischemic priapism. In these men with abnormal corpora, associated penile-lengthening procedures can be combined with penile prosthesis implantation. However, experience is limited with these combined procedures.     

Inflatable penile prosthesis: new device for cylinder insertion

A new device for insertion of the inflatable penile cylinders into the corpus cavcrnosum significantly simplifies the implantation of the inflatable penile prosthesis. Use of this device assures accurate positioning within the corpora, with a minimum of device manipulation and tissue trauma, thereby minimizing postoperative complications.     

三件套可膨胀型阴茎支撑体植入术治疗阴茎勃起功能障碍

目的 :介绍三件套可膨胀型支撑体植入术治疗阴茎勃起功能障碍 (ED)的方法和经验。　方法 :4 8例ED病人采用AMS70 0CX CXM和MENTORALPHAⅠ三件套可膨胀型支撑体植入术治疗。　结果 :全组病人均无排异反应 ,无假体故障 ,无尿道损伤 ,无阴茎皮肤坏死 ,术后性生活满意。仅 1例术中损伤白膜 (2 .0 8% )终止手术。 2例术后感染 (4 .17% ) ,10例包皮水肿 (2 0 .8% ) ,8例阴茎疼痛 (16 .6 7% )。有效率达 (97.9% ) ,满意率几乎达 10 0 %。　结论 :三件套可膨胀型支撑体植入术更接近人体生理 ,自然 ,隐蔽性好 ,使用方便 ,手术创伤小 ,成功率高 ,病人满意率高。对各种原因引起的ED切实可行 ,尤其适用于各种难治性、药物治疗无效的病人     

国产三件套可膨胀型阴茎假体植入术治疗截瘫病人勃起功能障碍

目的 :评价国产三件套可膨胀型阴茎假体 (IPP)对截瘫勃起功能障碍 (ED)病人康复治疗的临床应用效果。方法 :阴茎阴囊交界处切口植入国产三件套IPP ,治疗非手术疗法无效的截瘫ED病人 1 8例 ,以咨询或信访方式取得维持性交率及女方性交满意率。　结果 :1 8例截瘫ED病人手术均获成功 ,术后随访 3～ 36个月 ,平均 1 8个月。其中 1例出现假体内液体渗出并局部感染 ,2例出现机械性并发症 ,术后维持性交率 1 7/ 1 8。 3例出现射精反射。　结论 :国产三件套IPP治疗非手术疗法无效的截瘫ED病人 ,隐匿性好 ,康复效果确切 ,且价格低、机械故障率不高于国外产品 ,易被国内病人所接受     

Five-year followup of the Scott inflatable penile prosthesis and comparison with semirigid penile prosthesis

The Scott inflatable penile prosthesis remains one of the most popular devices available for the surgical treatment of impotence despite high complication and reoperation rates. We present our 5-year followup of 116 inflatable prostheses placed before 1981 in 85 patients, with a 61 per cent overall 5-year complication rate. The incidence of complications by year after operation showed that most (22 per cent) devices failed within 1 year after implantation, with failure rates gradually decreasing to 6 and 7 per cent during years 4 and 5, respectively. Of 85 patients receiving an inflatable prosthesis 61 per cent underwent reoperation during the 5-year followup. A 5-year overall complication rate of only 14 per cent was seen in 29 Small-Carrion semirigid prostheses implanted during the same time. The results of numerous recent improvements in the design and structure of the Scott inflatable penile prosthesis to prevent mechanical device failure remain to be tested over the long term.