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.     

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.     

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。     

Comparative Study between Corpus Cavernosum-Electromyography Findings and Electron Microscopy of Cavernosal Muscle Biopsies in Erectile Dysfunction Patients

Background: Biopsy and electrical activity recordings of the corpus cavernosum are 2 new diagnostic methods for the evaluation of impotent men. We evaluated the corpus cavernosum ultrastructure and electromyography (EMG) recordings from patients with erectile dysfunction.
Methods: Twenty erectile dysfunction patients with veno-occlusive dysfunction underwent a detailed history, physical examination, biochemical tests, hormonal analysis, injection of an intracavernous vasoactive agent (60 mg papaverine-HCI), color penile Doppler ultrasonography, cavernosometry/ cavernosography and corpus cavernosum electromyography (CC-EMG). Thirteen patients underwent total vein ligation and 7 had penile prosthesis implantations. Tissue samples were obtained during surgery from both corpora cavernosa and examined by transmission electron microscopy. Control corporal tissue samples were taken from 3 cadavers.
Results: In 15 patients, CC-EMG recordings were 15.6 ± 0.65 μV in the flaccid state, which decreased in 13 patients after papaverine (5.61 ± 0.25 μV; P < 0.001). Five patients with diabetes mellitus had low amplitudes in the flaccid state (5.26 ± 0.45 μV), which did not vary significantly after a papaverine injection (4.99 |pL 0.75 μV). The pathology of the corpus cavernosum biopsy specimens revealed a smooth muscle cell thickened basal membrane, dilated rough endoplasmic reticulum, and increased numbers of fibroblasts, but ultrastructurally normal endothelial cells lining the and sinusoids. There was no difference between samples from diabetic or nondiabetic patients, or from either side of the corpora cavernosa. The only pathologic change observed in the controls was mitochondrial swelling.
Conclusion: CC-EMG is less invasive and a valuable method in patients with erectile dysfunction, whereas no specific findings were observed from penile biopsy specimens.     

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.     

HEMODYNAMIC EFFECTS OF TRANSURETHRAL ALPROSTADIL MEASURED BY COLOR DUPLEX ULTRASONOGRAPHY IN MEN WITH ERECTILE DYSFUNCTION

Purpose

We evaluated the hemodynamic effects of transurethral alprostadil in 21 patients with erectile dysfunction using color duplex ultrasonography.

Materials and Methods

Penile arterial diameter, peak flow velocity and end diastolic velocity were compared following intraurethral administration of 500 micro g. alprostadil and intracavernosal injection of 10 micro g. alprostadil.

Results

A dose of 500 micro g. transurethral alprostadil resulted in significant increases in corporeal blood flow comparable to those achieved with intracavernosal injection of 10 micro g. alprostadil as measured by duplex ultrasonography in men with erectile dysfunction. Transurethral alprostadil resulted in statistically significant increases in arterial diameter and peak flow velocity comparable to those achieved with intracavernosal injection. End diastolic velocities were higher after transurethral alprostadil than intracavernosal injections. Color ultrasonography following transurethral alprostadil showed arterial and venous hyperemia of the corpus spongiosum and corpora cavernosa. Furthermore, color ultrasonography revealed communicating vessels between the corpus spongiosum and corpora cavernosa following administration of transurethral alprostadil.

Conclusions

The visualization of communicating vessels between the corpus spongiosum and corpora cavernosa after transurethral alprostadil suggests local mechanisms of drug transfer from one to the other. In addition to potential clinical benefits, transurethral alprostadil may be useful to visualize the vascular anatomy of the penis and to test for patient responsiveness to local vasoactive agents.     

Cavernospongious shunts: anatomical study of intrapenile vascular pathways.

OBJECTIVES: The reality of cavernospongious shunts has never been confirmed and their role in penile erection remains undetermined. We aim to describe the intrapenile vascular anatomy as the precise nature of the connections between the corpus spongiosum, the glans and the corpora cavernosa remains unknown. METHODS: Ten human penises were removed from adult male cadavers 8 days after arterial casting with latex. In four specimens coloured latex was injected into the corpus spongiosum. Ex situ microdissection was performed to analyse the origin and distribution of the penile arteries. The anastomotic arterial pathways were dissected. RESULTS: In all the specimens, 6-10 anastomoses were found between the cavernous arteries (a. profundae penis) and the spongious arterial network. These arteries arose at regular intervals from the cavernous arteries and perforated the tunica albuginea vertically to anastomose with urethral arteries (a. urethralis). No arteriovenous shunts were found between the corpus spongiosum and the corpora cavernosa, nor was there any venous drainage from the corpus spongiosum entering the corpora cavernosa. CONCLUSION: These shunts are arteries connecting the urethral and cavernous arteries. Cavernospongious arterial anastomoses were found in all the cadavers dissected. Further studies are needed to determine their role in penile erection.     

Peyronie's disease: lights and shadows

Peyronie's disease (PD) is characterized by the onset of fibrous plaque inside the tunica albuginea of the penile corpora cavernosa that can cause pain and bending during the erection, making intercourse difficult or impossible. Evidence of the literature supports the autoimmune etiology of PD and suggests genetic and familiar conditions, penile traumatisms, and a history of genital tract diseases as risk factors, but no definitive conclusions arise about the pathogenesis of the disease. Few randomized trials demonstrated that medical therapies, such as vitamin E, colchicine, potassium aminobenzoate, tamoxifen, and injection therapy with verapamil, can stabilize the acute phase of the disease. Extracorporeal shock wave therapy and iontophoresis cannot be considered first-line or gold standard therapies. Satisfactory results have been published with the Nesbit operation in large series with low-stage disease, whereas plication procedures have shown significant relapse rates. A high incidence of long-term penile retractions has been reported in high-stage disease treated with plaque incision and simple graft insertion. Malleable, soft, or inflatable prostheses combined with graft implantation have given the best results in terms of penile straightening and lengthening and patient satisfaction. In conclusion, the etiopathogenesis of PD is not yet clearly understood, no medical therapy is fully effective, and surgery remains the gold standard in patients with severe deformity and/or erectile dysfunction.     

Evaluation of penile hemodynamic status and adjustment of treatment alternatives in Peyronis‘s disease

Aim:Erectile dysfunction may be observed in up to 80%of patients with Peyronis‘s disease.An objective evaluation of the erectile function is attempted to work out in patients with Peyronie‘s disease.Methods:Penile deformity,sexual function and penile vascular status were analyzed in 123patients with Peyronis‘s disease,who had not received any pertinent treatment.Results:Penile edformity,palpable plaque and pain on erection were seen in112(91%),97(78.8%)and27(21.9%)of the123patients,respectively.Of the 76patients evaluated by color Doppler ultrasounography,veno-occlusive dysfunction as the vascular component for erectile dysfunction was found in 17(22.3%),arterial insufficiency in10(13.1%)and a mixed picture in 23(30.2%).Conclusion:The documentation of penile erectile function and the determination of the vascular status using color Doppler ultrasonography can guide the appropriate therapeutic choice.     

Evaluation of penile hemodynamic status and adjustment of treatment alternatives in Peyronie's disease

Aim: Erectile dysfunction may be observed in up to 80% of patients with Peyronie's disease. An objective evaluation of the erectile function is attempted to work out in patients with Peyronie's disease. Methods: Penile deformity, sexual function and penile vascular status were analyzed in 123 patients with Peyronie's disease, who had not received any pertinent treatment. Results: Penile deformity, palpable plaque and pain on erection were seen in 112 (91%), 97(78.8%) and 27 (21.9%) of the 123 patients, respectively. Of the 76 patients evaluated by color Doppler ultrasounography, veno-occlusive dysfunction as the vascular component for erectile dysfunction was found in 17 (22.3%), arterial insufficiency in 10(13.1%) and a mixed picture in 23 (30.2%). Conclusion: The documentation of penile erectile function and the determination of the vascular status using color Doppler ultrasonography can guide the appropriate therapeutic choice.     

Effects of some calcium channel blockers on isolated human penile erectile tissues

The effects of the calcium channel blockers (CCBs) verapamil, nifedipine and diltiazem on contractile activation of isolated human penile erectile tissues were investigated. Specimens of the corpus spongiosum (CS) and corpora cavernosa (CC) were obtained from men with a history of normal penile erection undergoing cystourethrectomy because of bladder malignancy. Preparations were mounted in organ baths and isometric tension was recorded. Deprivation of extracellular calcium abolished electrically induced contractions in both CS and CC preparations within 15 min.; norepinephrine (NE)-induced contractions were reduced by 90% (CS) and 83% (CC) after 30 min. All the CCBs reduced electrically induced contractions concentration-dependently, nifedipine being the most potent agent. Contractions induced by exogenous NE were depressed by about 50%, whereas high K+ (124 mM) induced responses were abolished. It is concluded that contraction in penile erectile tissues is mediated mainly by neuronally released NE stimulating postjunctional alpha-adrenoceptors. The contraction is highly dependent on extracellular calcium and can partly be inhibited by CCBs. It cannot be excluded that some CCBs injected intracavernosally may be useful for diagnosis and even treatment of erectile dysfunction. However, calcium channel blockade may not be as effective as a therapeutic principle as blockade of alpha-adrenoceptors.     

Use of transurethral alprostadil (MUSE) (prostaglandin E1) for glans tumescence in a patient with penile prosthesis

The presence of communication between the emissary veins from the corpora cavernosa and the circumflex veins draining the corpus spongiosum makes it possible for the transfer of alprostadil (prostaglandin E1) in MUSE from the spongiosal compartment to the cavernosal compartment of the penis after its absorption through the urethral mucosa. This leads to engorgement and tumescence of the corpus spongiosum as well as the corpora cavernosa. Lack of tumescence of the glans penis and poor penile girth can be a cause for disappointment and frustration in patients following penile prosthetic surgery. MUSE was used successfully in a patient with a Dynaflex penile prosthesis to enhance the tumescence of the glans penis. It will be a useful adjunct for patients in similar circumstances.     

Pathophysiology of Erectile Dysfunction

Physiology of erection and pathophysiology erectile dysfunction is reviewed. Analysis is obtained from basic and clinical research including animals studies, anatomical studies, and molecular and cellular research on corporal tissue obtained during penile prosthesis implantation. Supraspinal influences and spinal influence on penile erection has been learned from spinal cord injury patient. Corporal smooth muscle relaxation of penile arteries and corpus cavernosum leads to penile erection, results from parasympathetic/nonadrenergic noncholinergic neural pathway activation and simultaneous inhibition of sympathetic outflow. Anatomical studies taught understanding of the mechanism for restriction of blood outflow from the corpora cavernosa. The change of smooth muscle tone has emerged as a key factor in erection and detumescence. Many independent factors converge on the modulation of corporal smooth muscle tone. Neuronal and local neurotransmitter effects via gap junction, potassium channels, and calcium channel. A nitric oxide/cyclic guanosine monophosphate mechanism as well as cyclic aminomonophosphate has an important role in mediating the corporal smooth muscle relaxation necessary for erectile function. Erectile dysfunction can be due to vasculogenic, neurogenic, hormonal, veno-occlusive, psychogenic and/or pharmacogenic factors as well as alterations in the nitric oxide/cyclic guanosine monophosphate (cGMP) or cyclic aminophosphate (cAMP) pathway or other regulatory mechanisms including gap junction or ionic channel resulting in an imbalance in corporal smooth muscle contraction and relaxation. Our present knowledge of the hemodynamics, functional anatomy, neurophysiology, and neuropharmacology of penile erection and dysfunction at the cellular and molecular level has led to better understanding of physiology and pathophysiology of erectile dysfunction.     

国产可膨胀性阴茎假体的研制与临床应用

目的 :探讨国产可膨胀性阴茎假体的研制及治疗勃起功能障碍 (ED)的有效性与安全性。　方法 :根据我国男性生殖系统解剖生理特点 ,研制国产的可膨胀性阴茎假体 ,由改造的液泵阀、储液囊和一对可充液的圆柱体组成 ,用连接导管将其连接为一体。选择 4 5例器质性ED患者进行阴茎假体植入术。均采用阴茎阴囊切口进行手术 ,分别将圆柱体植入阴茎海绵体 ,液泵阀植入阴囊 ,储液囊植入耻骨后膀胱前间隙。　结果 :本组 4 5例未发生术中并发症 ;3例发生术后并发症 ,发生率为 6 .6 %,经术后处理未影响性交质量。 1 0～ 1 2个月后随访均可进行满意性交 ,性生活时间为 (2 0± 6 )min。　结论 :所研制的国产可膨胀性阴茎假体治疗严重器质性ED安全有效 ,机械故障发生率低。     

Efficacy, safety and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis: results of a long-term multicenter study. AMS 700CX Study Group

PURPOSE: We performed a long-term multicenter study of the AMS 700CX 3-piece inflatable penile prosthesis, focusing on longevity, morbidity and patient satisfaction in men implanted up to 134 months with a median followup of 47.7 months. MATERIALS AND METHODS: We performed a large scale retrospective multicenter study in 2 phases. Phase 1 was a medical record review of 372 men who underwent implantation with the AMS 700CX penile prosthesis from 1987 to 1996 by 7 frequent penile prosthesis implanters. Phase 2 included a structured telephone interview of 207 patients by a neutral observer. RESULTS: For the 372 men in phase 1 mean device mechanical reliability plus or minus standard deviation was 92.1% + or - 3.3% after 3 and 86.2% + or - 4.6% after 5 years. Patient age was 21 to 79 years (mean 57.6 + or - 11.0) at implantation. The etiology of erectile dysfunction was vascular in 27.7% of the cases, Peyronie's disease in 16.9%, diabetes mellitus in 12.9% and radical surgery in 11.6%. Of the men 55.6% received previous treatment for erectile dysfunction. Postoperative infection and device malfunction developed in 3.2% and 17.5% of the cases, respectively. Of the 207 men interviewed in phase 2, 86% still had an AMS 700CX penile prosthesis implanted, including 87.1% with erection suitable for coitus. Currently 79% of those with a device use it at least twice monthly and 88.2% would recommend an implant to a relative or friend. CONCLUSIONS: The AMS 700CX penile implant produced suitable erection and excellent patient satisfaction at long-term followup in the majority of men. Implant reliability is excellent and postoperative morbidity is low.     

The Evolution of the Inflatable Penile Prosthetic Device and Surgical Innovations with Anatomical Considerations

Historically, early surgical treatment for erectile dysfunction involved the placement of rigid devices outside of the corpora cavernosa. This practice resulted in high rates of erosion and infection. Today, most urologists in the United States place an inflatable penile prosthesis (IPP) with an infection-retardant coating inside the corpora cavernosa. In addition to changes in the type of implant used, surgical techniques have evolved greatly in recent years, resulting in reduced operating times, lower infection rates, and improved outcomes. However, anatomical considerations have directed the prosthetic surgeon to improve patient outcomes and satisfaction rates by employing both new surgical techniques and postoperative maneuvers.     

Spongiosolysis: a new surgical treatment of impotence caused by distal venous leakage

Until recently ligation of the dorsal veins of the penis had been the only effective surgical treatment in cases of erectile dysfunction caused by venous insufficiency of the corpora cavernosa. Failure of this operation can be owing to persistent distal venous leakage consisting of venous shunts between the distal corpora cavernosa and corpus spongiosum, which can be demonstrated by cavernosography. These shunts can be closed successfully by spongiosolysis, that is by dissecting the distal half of the corpus spongiosum and by isolating the tips of the corpora cavernosa. Of 5 patients who underwent spongiosolysis after previous ligation of the dorsal vein of the penis 4 regained erectile ability with the help of intracavernous injection of a vasoactive drug mixture (15 mg. per ml. papaverine hydrochloride plus 0.5 mg. per ml. phentolamine mesylate, 0.5 to 2 ml. per injection), which was necessary because of concomitant arterial lesions demonstrated by arteriography. The only failure proved to be persistent venous insufficiency of the deep dorsal vein of the penis. Since none of the patients had any serious complication spongiosolysis seems to be a safe procedure in the treatment of distal venous leakage.     

Clinical presentations of Peyronie's disease

Patients with Peyronie's disease usually present soon after the onset of the disease with penile pain and deformity when they develop an erection. They are middle-aged men and a palpable plaque is usually present. A good clinical history and examination are all that are necessary to manage most patients with Peyronie's disease. Further investigation is only required in those men with erectile dysfunction or where surgery is indicated.     

Comparative analysis of the penis corpora cavernosa in controls and patients with erectile dysfunction

OBJECTIVE: To evaluate the presence of structural disorders of the corpora cavernosa in patients with erectile dysfunction (ED), as despite new drugs being effective in many men with ED, some aspects of structural disorders of the corpora cavernosa remain unknown. MATERIALS AND METHODS: Biopsy specimens were taken from the corpora cavernosa of seven patients (mean age 57.8 years, range 51-72) with severe ED who had a penile prosthesis implanted. The controls tissues were fragments of corpora cavernosa obtained from autopsies of six men (mean age 52.3 years, range 40-66) who died from causes unrelated to the urogenital system. For light microscopy, the specimens were processed routinely to paraffin wax, and by immunohistochemistry to evaluate elastic fibres, and by Masson's trichrome to analyse collagen and smooth muscle fibres. Stereological methods were used to quantitatively evaluate the different elements (as a percentage). RESULTS: The percentages of the different elements in the human penis of controls and men with ED, respectively, were: elastic fibres 13.2% and 9.1%; collagen fibres 40.8% and 41.6%; and smooth muscle, 40.4% and 42%. CONCLUSIONS: In patients with ED there was a statistically significant reduction in the percentage of elastic fibres, but no statistically significant difference in collagen and smooth muscle fibres, and no appreciable differences in collagen distribution between the groups.     

Purulent cavernitis as a complication of self injection into the cavernous body

Intracavernous self-injection of vasoactive drugs is commonly prescribed for the treatment of erectile failure. Cavernitis is a serious complication of this treatment. The case of a 63-years-old patient with cavernitis following intracavernous injection of papaverine and subsequent priapism is reported. He had a phlegmonous infection of both corpora cavernosa without infection of the corpus spongiosum. The treatment consisted in surgical debridement of the corpora cavernosa with intracavernous drains inserted for continued irrigation and suction. Complete remission of the infection was ultimately obtained, but fibrosis of the remnants of both corpora cavernosa remained.