Advanced Urological Care

Placement of the Cylinders

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This crucial part of the procedure involves several phases:

1.  Incision and Setting Up the No-Touch Technique
2.  Initial Dissection and Exposure of the Crura
3.  Dilation and Sizing of the Corpora
4.  Prosthesis Selection
5.  Cylinder Insertion and Testing
6.  Closure of theCorporotomy
1. The No-touch technique:
Studies have identified that most infections of implanted devices are associated with organisms that colonize the patient’s skin: Staphylococcus epidermidis, aureus, and Candida albicans. Efforts at reducing infection rates have primarily focused on killing the offending organisms at the time of surgery (e.g., peri-operative antibiotics, Povidone scrub, antibiotic irrigation etc.). Recently, an antibiotic-coated prosthesis has been introduced that targets the production of biofilm on the prosthesis material.

However, Dr. Eid believes that preventing direct contact with the source of bacteria is the most effective way of eliminating infections.  Therefore, a novel technique for prosthesis insertion entitled the “no-touch” technique to reduce the incidence of peri-prosthtetic infection was invented. The technique was developed on the belief that eliminating any contact between the prosthesis and the skin, either directly or indirectly via surgical instruments or gloves, should reduce the incidence of contamination of the device with skin flora responsible for infection. 

+ read more about the Non-Touch Technique

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2. Initial Dissection and Exposure of the Crura
For the incision, we use a high scrotal approach, on the median raphe about 1 inch inferior to the junction with the penis, rather than a classic penoscrotal incision. We favor the scrotal incision, rather than an infrapubic approach, for several reasons: it only needs to be 1 inch in length, it provides easy access to the penis in both obese and thin patients, thus allowing excellent placement of cylinders as well as pump and reservoir; and it closes without scarring, thus giving a better cosmetic result than a penoscrotal incision, as the skin of the penis does not heal well. We find with an infrapubic approach that accurate pump placement and concealment of tubing are more difficult and unpredictable. With that approach, the pump has a higher tendency to migrate to a high scrotal position, leaving the tubing readily palpable at the base of the penile shaft and the pump more visible in an antero-lateral position in the scrotum.   

Using the Foley catheter and urethra for traction, dissection is minimized, pushing surrounding tissues laterally prior to making an incision. Making the incision straight down unto the penis reduces postoperative swelling and edema and also fashions a thick layer of tissue. This will provide for deeper placement of pump tubing in the scrotum, better closure of the incision and complete separation of tubing from the skin suture line.

Surgical drapes are placed, followed by a Vi drape over the genitalia; a capped Foley catheter is inserted. An incision is made in the penoscrotal raphe and the dissection is carried down through the through the subcutaneous tissues to the level of Bucks fascia. A Scott retractor is employed with blunt hooks to maintain exposure.

At this point, the “no touch” principles are employed. The procedure is halted and all of the surgical instruments used thus far, including the Bovie, are discarded and considered contaminated. All surgical gloves are changed. The 3M #1012 drape is used to loosely drape the operative field.  A small fenestration is made in the drape and blunt hooks are used to retract the cut edges of the drape. (See pictures # 48,50,51,52,53 of the Inflatable Penile Prosthesis Procedure)

Implantation of the device proceeds with the usual steps associated with a multi-component prosthesis, including the incision and dilation of the corpora; sizing and placement of the penile components; and placement of the pump in the scrotum and the reservoir in the retropubic space, all through the small fenestration in the #1012 drape.

With the scrotal skin mobilized towards the glans penis over the urethra, we follow a downward course directly on the urethra to the level of Buck’s fascia. At that point the urethra is mobilized to the left and the tunica albuginea of the right proximal crus exposed. Downward traction applied with a short right-angle retractor (small Rich) exposes the proximal crus and at the same time retracts the urethra and catheter towards the left. Utilizing a marking pen, a 2-cm mark is made on the tunica of the crus parallel to and 1 cm lateral from the junction of the tunica albuginea and the urethra. Two 3-0 PDS suture tags are placed deep and wide on either side of this mark and tagged with straight mosquito clamps. (Curved mosquito clamps may be used for the left side for identification purposes). Making the corporotomy close to the urethra allows direct downward orientation of cylinder input tubing to the pump and makes it less likely that the tubing will be palpable by the patient at the base of the penis.  (See pictures # 55, 56, 57, 58, 59, 60 of the Inflatable Penile Prosthesis Procedure)

After the right crus is tagged, instead of another incision being made in Buck’s fascia, the urethra is mobilized to the right, and exposure of the tunica albuginea of the left crus is obtained through the right. This effectively fashions a second layer of tissue that will further conceal input tubing to the cylinders. The crus of the patient’s left side is similarly marked and tagged with two 3 O PDS sutures and curved mosquito clamps. A #15 blade is used to make a small 1.5-cm corporotomy between the traction sutures. The incision is limited to the tunica albuginea, thus avoiding cutting of cavernosal muscle tissue. Keeping the corporotomy small is advantageous as it enables us to close it quickly and with less postoperative bleeding, swelling and pain. (See pictures # 61, 62, 63, 65, 68, 69 of the Inflatable Penile Prosthesis Procedure)

3. Dilation and sizing of the corpora
Dilation of the corpora
It is during this process that perforation can occur. To prevent perforation of the tunica albuginea, the operator must avoid the use of force during dilation. The length of the corporotomy should be just large enough to accommodate a #14 French Hegar dilator. Dilating at the level of the venous plexus at the periphery of cavernosal muscle tissue is preferable and easier than centrally through cavernosal muscle tissue.

Proximal dilation of the corpus cavernosum, using the blunt tip of a large Yankauer suction catheter, is performed first. The blunt tips of a long curved Mayo scissors are positioned at the junction of the tunica albuginea and the cavernosal muscle tissue, and the distal portion of the corpus is dilated to the mid glans in the following fashion:
(See picture # 68 of the Inflatable Penile Prosthesis Procedure)

Dilation is done slowly and gradually, advancing until resistance is met, spreading the scissors, and then pulling back with the scissors open, closing the scissors, advancing further, then spreading the scissors again and pulling back. There is no need to use force. Crossover into the contralateral corpus during distal dilation is avoided by applying constant traction on the glans penis as well as by maintaining the curvature of the Mayo scissors away from the midline of the penis, with the tips next to the tunica albuginea.
(See picture # 69 of the Inflatable Penile Prosthesis Procedure)

When the tip of the scissors reach the glans, the meatus is squeezed between the thumb and index finger and the glans penis tilted away from the dissecting instrument. This maneuver prevents perforation of the tunica of the distal tip of the corpus cavernosum into the meatus. The scissor tip is rotated medially, the blades gently spread to complete the dilation and ensure that the distal tip of the cylinder is positioned under the glans penis. That care must be taken not to apply force or unnecessary pressure during this maneuver cannot be overemphasized. Next, using a blunt-tip Dilamezinsert (See pictures # 69, 70, 71, 72, 77 of the Inflatable Penile Prosthesis Procedure) and blue disposable insert, the distal portion of the penile corpus is dilated to number 12 French diameter. The instrument is flipped into the crus and the crus dilated before the instrument is returned to the scrub nurse. A #13/14 Hegar is used to complete the dilation, first for the proximal aspect of the penis to #14 French diameter, and subsequently to #13 French diameter distally.  (See pictures # 78, 79 of the Inflatable Penile Prosthesis Procedure)
Sizing of the corpora
There is a tendency to oversize the length of the penis. To properly size it, a blunt instrument such as the Dilamezinsert is preferable to a narrower one. It is important when measuring to have a fixed point of reference (we use a traction suture) and to measure distally and proximally without repositioning this point of reference. The penis must not be overstretched over the measuring instrument, especially during measurement of the proximal portion of the corpus cavernosum. (See pictures #80, 76 of the Inflatable Penile Prosthesis Procedure)

4. Prosthesis selection
It is at this point that the choice of cylinders is made. The best method for determining the correct size, we find, is to create an artifical erection by irrigating the corpora with neomycin (another good reason for keeping the corporotomy small - it facilitates this maneuver). This erection helps determine if the penis is straight or curved. Hydraulic expansion of the penis is also useful for detecting or ruling out urethral injury by documenting the presence or absence of irrigant leakage from the meatus around the foley catheter. (See pictures # 93 of the Inflatable Penile Prosthesis Procedure)

Several points need to be considered when selecting a device. Always pick a cylinder size that will permit length adjustment. If possible, a smaller cylinder is preferable to a longer one as it will provide for better axial rigidity (ratio of girth to length is larger) and will require fewer pumps to reach maximal inflation. This enables the patient to achieve an erection faster and also possibly extends the life expectancy of the pump.

If dilation to #13 French distally and #14 French proximally has not been possible, we use a narrow device such as the Alpha Narrow, which is preconnected, or the AMS-CXM cylinders. For a large and capacious penis, a Mentor Alpha 1 will give a better fit, provided the glans penis is also large. With a narrow glans penis, the tip of this cylinder can migrate laterally as it is fully inflated to 21-mm diameter and can become palpable at the lateral aspect of the penile shaft. We avoid using the 21-cm 700 Ultrex AMS cylinders for these large penises, especially if rear tip extenders are needed. 

The reason for this is that in general long penises tend to also have larger diameters that are not filled by the Ultrex cylinders (girth expansion limited to 18 mm). If the device is not undersized, this will cause the cylinders to curve inside the corpora as they lengthen with inflation. If use of an Ultrex device (which lengthens with inflation) is contemplated, the length of the cylinders needs to be reduced by 1 cm, to allow for lengthening. For these long penises, an AMS-CX cylinder or, as previously mentioned a Mentor Alpha 1, will provide a better erection. 

If the penis is curved, a length-expanding cylinder such as the Ultrex is to be avoided as this feature will accentuate the curvature during inflation. An Alpha-1, Alpha-narrow, AMS-700CX or CXM is a better option. These cylinders will straighten the penile shaft straight, making further adjustments of modeling or relaxing incisions of the tunica unnecessary. 

Finally, when using preconnected cylinders it is also important to determine the distance from the rear of the cylinder to the point where the input tubing will exit the corpora. If the patient has a small tight scrotum, we would use a larger cylinder in order to bury input tubing in the corpora. In a larger, longer scrotum adding rear-tip extenders to a shorter cylinder will advance the connection of the input tubing to the cylinder forward in the penis, providing longer tubing length and lower placement of the pump.
5. Cylinder insertion
Only after the choice of device is made and it is ready to be implanted, the device is opened on the surgical field. Except when using the preconnected Ultrex-Plus device, air must be purged prior to cylinder insertion.  With the Furlow introducer and Keith needle, a traction suture from the cylinder is passed through the glans penis, lining up the right and left cylinders so that input tubing from the two cylinders does not cross each other. For the AMS devices, this generally means input tubing in the front of the pump and tubing to the reservoir in the back. For the Mentor devices, the input tubing and tubing to reservoir being lined up on the same plane, this most often means that the tubing to the reservoir will be on the patient’s right side. (See pictures # 100, 101, 103, 107, 109-111, 113-116, 121 of the Inflatable Penile Prosthesis Procedure)

After both traction sutures have been passed through the glans penis, the proximal portion of each cylinder is inserted first, the distal tip placed in the corporal orifice and the traction suture pulled to insert the rest of the cylinder. The cylinder must lay flat in the corpora when traction is applied on the cylinder traction suture. Any folds noted in the cylinder indicate that it may be oversized or that the rear tip is not in its proper position. After both cylinders have been inserted, a surrogate test (see pictures # 123-125 of the Inflatable Penile Prosthesis Procedure) with saline is performed, using a filled 65-cc syringe. If adjustment in cylinder length needs to be performed, saline is completely removed from the cylinders prior to changing rear tip extender size. This facilitates the maneuver and prevents injury to the cylinder.
6. Closure of the corporotomy
The corporotomy is closed with a running 3-0 PDS suture, using a hemostatic stitch. While this takes more time than approximating the previously placed tagging 3-0 PDS sutures and has the potential of causing needle injury to the prosthesis, we find it preferable to pre-placed sutures because it provides for a watertight closure. If this cannot be accomplished, drains should be used to prevent formation of scrotal hematoma. Any bleeding could result in a large scrotal hematoma, which if not evacuated with drains, will surely liquefy and possibly provide a wonderful milieu for bacterial growth. After completion of corporotomy closure the pump is activated and deactivated several times. Each time, the penis is examined, cylinder size and erection assessed and the integrity of the cylinders confirmed. (See pictures # 128, 136, 137, 138, 141, 150 of the Inflatable Penile Prosthesis Procedure)
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