| Procedure Description
Detailed description of the insertion of a multi-component inflatable penile prosthesis utilizing the “No-Touch” procedure:
The multi-component inflatable prosthesis, available from 2 manufacturers (American Medical Systems [AMS], Minnetonka, Minn. and Coloplast Corp. (formerly Mentor), Mineapolis, Minn. consists of 3 components: The first component, a pair of cylinders that are inserted into the corpora cavernosa, the second a pump placed in the scrotum that is used to inflate and deflate the cylinders, and the third a reservoir implanted in the lower abdomen that is filled with sterile saline.
Our overall aim is to work as quickly as possible, but without rushing, to reduce the time the patient is at risk of infection
. As with any surgery, having the proper instruments, sutures and equipment ready at hand expedites the process. We try to use as few instruments as possible and choreograph our movements so that there is a minimum of passing them back and forth with the scrub nurse. A dedicated surgical instrument set for penile prosthesis implantation is recommended and is always available for our cases. These instruments (see pictures #19
of of the Inflatable Penile Prosthesis Procedure) must be scrubbed thoroughly of all potential debris before undergoing final sterilization. Table 1
lists the instruments we find essential.
Having the right number of the correct sutures, along with appropriate needle sizes, avoids unnecessary delay once the procedure is started. We use 3 types of sutures: 4 3-0 PDS RB-1 taper 27”(Ethicon), 3 3-0 Polysorb CV-23 taper 30”(USS) and 2 4-0 Surgipro SC-2 cutting 30”(USS). While it may seem trivial to mention that correct needle sizes must be at hand, these are selected to facilitate working in a narrow deep space, and therefore expedite the procedure.
It is preferable to have on hand a full inventory of cylinders of various sizes. A patient with severe ED
is likely to have a fibrotic penis that is narrow, deformed or atrophied. Trying to dilate it to fit a standard-size cylinder will increase operative time as well as chances of perforation. Very often this problem cannot be determined in advance. For example, for a narrow, fibrotic crura that cannot be dilated to #14 French diameter we would choose a 700 CXM (AMS) or Alpha 1 Narrow (Mentor) cylinder.
The procedure is broken down into 5 phases:
1. Preoperative preparation
2. Placement of the cylinders
3. Placement of the pump
4. Placement of the reservoir
5. Assembly of the components and closure
Careful and specific postoperative care
is important to obtain a good outcome. The patient is instructed to stay flat on his back as much as possible for the first 3 postoperative days. He is warned against sitting on the scrotum for the first week to avoid pushing the pump up. We further instruct the patient to keep the penis straight, towards the umbilicus until inflation of the device is started. This is started only when it becomes possible for the patient to easily deflate the prosthesis, typically between the fourth and eighth week postoperatively. For some patients, this can be as soon as 2 weeks, if dissection was kept to a minimum and good hemostasis was obtained.
Once the patient is able to inflate and deflate the device, he is asked to do it every day or every other day during the warm baths, until he feels completely comfortable with the process and no discomfort is felt. We suggest a minimum of 2 postoperative instructional visits, but some patients come back as many as 6 times before they feel entirely comfortable with their prosthesis.
Successful implantation of a penile prosthesis followed by good patient outcome depends on:
- A knowledgeable surgical staff and optimal patient preparation
- Correct instruments and full menu of prostheses
- Advance planning with ability to make changes as dictated by the circumstances
- Choosing the best-fitting prosthesis
- Keeping the corporotomy small and dissection minimal to obtain good hemostasis
- Placing the pump and tubing to optimize cosmesis and make the patient look normal
- Meticulous postoperative care
1. Goldstein I, Lue TF, Padma-Nathan H et al (the Sildenafil Study Group). Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med. 1998;338:1397-1404.
2. Padma-Nathan H, Steers WD, Wicker PA for the Sildenafil Study Group. Efficacy and safety of oral sildenafil in the treatment of erectile dysfunction: A double-blind, placebo controlled study of 329 patients. Int J Clin Pract. 1998;52:375-380.
3. Dinsmore WW, Hodges M, Hargreaves C et al. Sildenafil citrate in erectile dysfunction: Near normalization in men with broad-spectrum erectile dysfunction compared with age-matched healthy control subjects. Urology. 1999;53:800-805.
4. Montorsi F, McDermott TE, Morgan R et al. Efficacy and safety of fixed-dose oral sildenafil in the treatment of erectile dysfunction of various etiologies. Urology. 1999;53:1011-1018.
5. Dutta TC, Eid JF. Vacuum constriction devices for erectile dysfunction: A long-term prospective sudy of patients with mild, moderate and severe dysfunction. Urology. 1999;54:891-893.
6. Gupta R. Kirschen J, Barrow RC, Eid JF. Predictors of success and risk factors for attrition in the use of intracavernous injection. J Urol. 1997;157:1681-1686.
7. Wilson SK. Penile prostheses at the millennium. Contemporary Urology. 2001;:35