Anesthesia

Question:

I do not want to have spinal anesthesia, because it caused extreme itching in my back and legs after my TURP. I do not want to be given any medications that contain sulfites as preservatives, as they have caused dizziness and fainting on several occasions.

Answer:

This is not a problem. Removal replacements can be performed with any type of anesthesia. I prefer the spinal because they are so safe and non-invasive provided that an experienced anesthesiologist performs it. Your reaction to the spinal is unusual and likely related to a medication, which is no longer used.

Difficulty Inflating and Deflating

Question:

Very many years ago I seen a video about a penile implant where a doc cut to insert behind the sack not behind the penis and not above the penis. Now I just had a penile implant done in Germany but they cut behind the penis and cut in my belly as well placed a catheter too. At lot of things I didn’t wanted this way. I want to show this video to my doc but I cant find it anymore and there are no I don’t know maybe a 1000 videos here this days. Could you please send me your video or let me know where to find this video I seen where you cut behind the sack not before? I know now that it is a lot better this way then what they did to me now. First there is no scar on my belly, second there is no scar where the pump is so I can feel the pump better and the release button. Also is all that hoses etc. of the pump more to the body not in the middle of my penis, which is way more, pain and keep the penis from going deep inside the vagina. Also he did between pump and rods only a very short lines so the pump can not go way to my body either which again keep’s me from entering deeper into the vagina. As you can see my doc was a careless with little or no experience. No I need your much better version of video so I can show them and for complaint reasons and finally I like to ask you would you recommend to have a second surgery or better leave it this way but I have to tell you that I each time I need to turn the pump also around in order to be able to inflate my penis and the release button is underneath not on top. I am not able at squeeze the pump without turning the pump and with two hands only and no light either more harder with more pain possible.

Answer:

Thank you for contacting us. It is unfortunate that you had to go through this experience. Indeed pump placement and surgical technique determines the extent of pain, postoperative swelling, and pump location and ultimately ease of use. It may be possible to fix your problem with relocating and replacing the pump in a better location in the scrotal sac and proper post-operative instructions. In order to have a better cosmetic result as well as concealment of pump tubing to allow for comfortable vaginal penetration the procedure needs to be redone through an incision in the scrotal sac.

Question:

I have been having problems with my penile implant ever since it was placed by my Urologist 4 years ago. I remember right after my implant was placed; I was really swollen (black and blue) for 2 weeks straight. After the swelling and pain went down he tried to show me how to inflate the implant but he struggled with it and I never really learned correctly. Also I think my penis shrank after surgery and I am really unhappy about this. Is this something you see often?

Answer:

Swelling after a penile implant procedure depends on the surgeon’s technique. The more experienced and the more meticulous he surgeon, the less swelling and black and blues will occur. Swelling is caused by bleeding around the pump and can result in scar tissue formation and displacement of the pump after the welling subsides. This will delay the use of the device and can render the pump inaccessible and very difficult to pump. It may be possible to fix your problem with relocating and replacing the pump in a better location in the scrotal sac and proper post-operative instructions. Delaying the use of the device or improper and inadequate sizing of the device may have caused the penis to shrink. With proper technique, small incisions and minimal dissection the problems you mentioned can be avoided.

Question:

I am a 24 years old patient from Greece and I have an implant inserted 3 months ago. The model is the LGX and I have an 18cm implant plus 6 cm extenders. I wanted the Titan model as you recommend since I have a large penis but my doctor insisted to have the LGX. Anyway after the surgery the doctor told me to do some exercise inflating the device 3 time a day in order to gain some length. What happened is that by doing that the pressure at the tips under the glans caused an inflammation on the tissue and I have pain when inflating the device. In fact I cannot inflate it because of the pain. The doctor gave my pills like xefo and mesulid but after 4 weeks the pain is still there when I try to inflate it. There is no infection. I am writing to you because you are the expert and you seem to be a nice person, for your opinion about the issue.

Did you have the same experience with a patient of yours? Do you think that there is a chance that I have an oversized implant? I would be thankful to know your opinion.

Answer:

It is difficult to fully evaluate your situation without a physical exam. I much prefer the Titan Coloplast model for the younger patient as it provides the patient with a normal looking penis when erect with a wider and much firmer erection.

In addition I avoid using rear tip extenders as these further diminish the rigidity of the erection. The AMS rear tip extenders are very thin, diameter of only 9mm, each which is much, much narrower than the base of your penis. This results in an erection that is not well buttressed (attached to the body) to the pelvis, which will swivel as if it is hinged to the pelvic bone instead of being fixed to the pelvis. The back of the 18 cm cylinders measures 4.5 cm and only the front of the cylinders is inflatable which means that you only have 13.5 cm out of a total length of 24cm (18cm plus 6cm of rear tip) which is inflatable. Almost half of your device is non-inflatable! How on earth is this going to possibly give you a firm erection? Coloplast also makes longer cylinders such as 20,22,24,26 and 28cm, which makes the use of rear-tip extenders, unnecessary. If the LGX is oversized, as it expands in girth it will lengthen causing pain and deformity of the glans penis. In addition the mesh inside the LGX cylinder limits the expansion of girth to 18mm and the penis will appear flat when inflated instead of rounder as with Coloplast cylinders. It is also unusual and rare for a penis to measure 24cm and indeed your suspicion may be correct that your doctor oversized your penis. Correct sizing of the penis is difficult especially in younger patients who have a very elastic penile tissue. Inexperienced penile implanters tend to oversize young patients. Oversizing causes pain on inflation and atrophy the glans penis overtime. Unfortunately it is not possible to give you a full evaluation of your situation without the benefit of a physical exam. Whatever you do not, I repeat do not ask the same doctor to revise your implant as the easiest operation is the 1st implant as all subsequent procedures require much, much more experience. If you are not pleased the first time it is very unlikely that he will be able to improve on your result! You need to seek a second opinion with more experienced implanter.

Question:

I had a 2 piece (AMS Ambicor) pump put in about 2 years ago. I have never had luck with it, I press and press sometimes for 25 minutes with no results. When I go back to the surgeon who implanted it he does very well but his hands turn white with all the pressure. He always tells me everything is fine but why?

Answer:

The 2 Piece “pumps”, called Ambicor invented by American Medical Systems, was developed in order to avoid the placement of a reservoir. The reservoir is placed through the scrotal incision and urologist who do not perform many implants are not experienced enough to do this part of the procedure. It was felt that by introducing a simpler implant, more Urologist would be encouraged to perform implants.

The two Piece implants however have many shortcomings including decreased quality and feel of the penis when it is soft, decreased flaccidity of the penis when it is not pumped, decreased strength of the erection when pumped. It is also very, very difficult to inflate, the pump is very small and difficult to grasp. The pump requires an inordinate amount of pressure, which makes it very difficult to inflate for older patients. If after a while 3 to 6 months, you continue to have problems, then your best option is to have the device removed and replaced with an AMS 700 or Coloplast Touch pump. It is always advisable to seek a specialist in implants in order to avoid situations such as yours. For more information on type of devices please check my web site.

Insurance

Question:

I had a 3-piece implant at the hands of a Denver surgeon who left a “cross-over” and a resulting infection. When I found another surgeon here in Denver, he removed the implant, dealt with the infection, and inserted another implant. That, too, became infected and was removed. Six years ago, I had prostate cancer and a radical prostatectomy and my nerves were severed, hence, the implants. My insurance, Anthem BC&BS doesn’t cover anything of this type, so, I’ve paid out-of-pocket for all of this. I now have scar tissue that has taken me from an eight-inch erection to seven and now to four. Although, use of a vacuum pump and injections during the last three months has stretched me back to about 5.5 inches. Might you please give me an idea of what the financial cost might be to have me travel to NY and have Dr. Eid perform one, final 3-piece, implant surgery so that I may finally have this procedure done correctly?

Answer:

I am so sorry to hear about your operative course, sounds like you have really been through tough times. Any time a penile implant becomes infected this must be removed and washed out completely. Even when this is accomplished, sometimes the salvage implant gets infected such as in your case.

The problem with infections after penile implant is that the penis will always shrink and contract in size. All subsequent surgeries are also going to be very difficult and more than one surgery or staged procedures may be necessary. In order to give you a precise estimate of cost I would need to examine the penis and determine the extent of scar tissue present. Only then will I be able to determine what procedure(s) will be indicated. Your case illustrates why preventing infection should always be the foremost objective when performing an implant.

Question:

I need a penile implant; I have Medicare with supplementary insurance, would you be able to do my penile implant?

Answer:

Thanks for your consult, please note that the penile implant procedure is covered by most insurances; however, some insurances have exclusion to the penile implant device or the diagnosis of impotence. Medicare however will pay for your penile implant and your supplementary insurance will cover your copay. You should have no out of pocket expense provided Medicare is your primary insurance.

Question:

Will I need someone to be with me during the procedure? Is it done at a hospital or done as an outpatient?

Answer:

The procedure is indeed performed on an outpatient basis – but like for any outpatient procedures the ambulatory surgery center (and/or any medical facility) requires that an adult escort pick up the patient after the procedure. If a family member or friend is not available to bring you back home or to the hotel, an escort service may be contracted to accompany you. This involves an extra cost of $80.00, and a reservation needs to made in advance for this service.

Question:

I had prostate surgery 3 years ago and am very interested in your procedure. I am 64 years old but was very active prior to the operation. I have Cigna international insurance, which is very good. I am very interested in the fact that your procedure is outpatient? I am coming to the US soon and if it’s affordable and if my insurance will pay for it I would like to schedule it. Please advise.

Answer:

Please contact my staff regarding queries about insurance reimbursement. Because we are a high volume center for penile implants, we are very experienced in predetermination of cost prior to the penile implantation and more importantly experienced in operating on post-prostatectomy patients. Post-prostatectomy patients require more experience because the pelvic anatomy has been altered. Appropriate precautions not to injure bowel or blood vessels during the placement of the reservoir are necessary.

Question:

Regarding insurance I have Medicare and Empire United Health Care as secondary? I was told by physician in Albany that with cardiovascular problems and recent diagnosis of diabetes that this surgery could be paid for by my insurance. How long after surgery would I be able to travel the 90 miles back to Saugerties, New York? (Assuming no complication of implant) Can my own cardiologist at Vassar clear me for surgery?

Answer:

Medicare covers the penile implant procedure and no pre-determination is necessary. Patients are responsible for the 20% copay unless a secondary insurance, such as you have, is available. You can travel back home the same day as the surgery provided you are not the one doing the driving. And yes all pre-operative testing and cardiac clearance are performed near your home and the results sent to us a few days before your procedure. In addition we provide you with all preoperative instructions and prescriptions several days before your procedure.

Question:

I have Tricare as my primary insurance. My understanding is that it picks up all of the copays after Medicare. How much time is required to be in New York before and after the 1-day procedure? What is the process / procedure to schedule surgery with you?

Answer:

The first step in scheduling the procedure is to set up a telephone or online consultation to determine whether or not you are a good candidate for the procedure and to have all of your questions and concerned addressed. After your consultation a preoperative visit and surgery date is scheduled. Usually I will see the patients one day before their surgery.

Surgery is performed on an outpatient setting, thus you would either stay overnight in a Hotel or you can be driven back to your home. Some travel patients stay for at least two to three nights and then fly back home on the third day after the procedure. This is not absolutely necessary and varies from patient to patient.

Question:

I see that you do 300 inflatable penile implants per year. When would be the earliest possibility opening to do a procedure on myself? Are all done in New York City?

I’m a military retiree, age 72, with Medicare and DOD Tricare for life coverage. Would this cover the full cost of an implant procedure?

Answer:

Thank you for contacting me. I only perform this procedure in New York. Medicare covers the procedure 80% and we can assume that Tricare covers the remaining 20% after Medicare. My office staff can verify this for you and confirm it before you schedule the procedure.

Question:

Are penile implants covered by insurance?

Kidney Disease

Question:

Will my Kidney Disease condition allow me to receive your procedure? Have you had patients who underwent the procedure with ESRD (End-stage renal disease); I just needed a medical clearance note from my renal doctor in order to proceed with the surgery. Do I have to consult with you prior to scheduling the implant surgery? As insurance I have MEDICARE.

Answer:

Kidney disease does not preclude you from having a penile implant. I have implanted many men whom have ESRD and are waiting for or have received kidney transplants. If you had previous abdominal surgery to place a kidney transplant, a separate incision may be required to place the reservoir. This will not prolong the recovery period any more than usual. Also having a penile implant does not prevent you from getting a penile implant at a later date. The procedure is also covered by your Medicare insurance.

Penile Implant / Prosthesis Surgery

Question:

I’m considering a Penile implant. I’m 75 years old and don’t feel comfortable traveling to New York for the procedure. Do you have associates in Pittsburgh, PA that you can refer me to?

Answer:

There is no Urologist in the Pittsburgh area that performs the same volume and has the same expertise as we have. I fully understand your reluctance in traveling for a procedure, but you have to realize that surgery is not like buying a car.

The surgeon, the anesthesiologists, the scrub nurse, the penile implant specialized surgical instruments (only available in high penile volume surgery centers) the full inventory of devices available, the pre and post operative management all will make a big difference in the size and function of the penis with the implant, the quality of the erection, the location of the pump in the scrotum, the degree of post-operative swelling, the size of the incision, the ease of locating the pump and manipulating the pump, the degree of post-operative pain and most importantly the risk of infection.

If you get an infection after the implant, the device will need to be removed and the shaft of the penis will shrink and scar down forever making it very difficult to put another implant. You will also permanently lose up to 2 inches of penile length. There is a reason why I invented the “No-Touch” technique and have the lowest infection rate in the world which is 0.39% for the over the last 2600 cases performed with this technique.

Ask yourself would I rather travel and get a successful procedure, or spend weeks on IV antibiotics in a Hospital, in pain with an infection and have permanent loss of penile length?

How can we help and assist you in anyway? Please let us know. Experience makes a huge difference, huge and I appreciate that this is something that is difficult for a patient to recognize, since one assumes that the procedure is the same regardless of the location where it is performed.

Question:

I am a 53 y/o neurologist who sustained a T11-12 SCI 5 years ago. I have light touch sensation over the right scrotum and most of my penis. I experience pain when I jar my right testicle. I have a suprapubic catheter. I have had 2 DVT’s requiring ongoing anticoagulant therapy. I have gradually developed ED refractory to oral agents and shaft/base injections.

Can you please advice regarding your thoughts and opinion as to the best treatment option for me. My thoughts include nerves transplant surgery, penile pump and artificial urinary sphincter. Thank you kindly for your consideration and opinion.

Answer:

Your situation is challenging for the following reasons. Since you are managed with a SP tube, chances are that your urine is colonized with bacteria. Also before considering an artificial urinary sphincter your bladder function needs to be evaluated. Can the bladder store urine? Can the bladder contract and expel urine after you open the sphincter? In general artificial urinary sphincters are not a good option for SCI patients. The sphincter is mostly used for post prostatectomy incontinence.

Since you do have some sensation I assume that your SCI was incomplete which is good. Patients with complete lack of sensation will inadvertently sit on the scrotal pump causing pressure necrosis of scrotal skin and erosion of pump through the skin. A penile prosthesis is an option for you and can be performed without removing your SP tube. The risk of infection is higher, but with careful pre-operative preparation and the “No Touch” technique I believe that it can be performed safely. You will need to contact a very experienced surgeon and the entire procedure must be performed through the scrotum to avoid the skin area above the penis and in a rapid and decisive fashion to limit bacterial inoculation. The prosthesis must not be re-sized once inserted in the penis, so accurate sizing prior to removing the device before it is inserted is a must. In other words out of the sterile container, the device is handled with new sterile gloves, primed, inserted into the penis through the “No-Touch” drape and the penile incision closed. Removal, resizing and repositioning must be avoided. The pump and reservoir must also be inserted through the sane aperture without being repositioned. All of these maneuvers require a very experienced operator!

I believe that nerve transplant is mostly experimental and I do not have any experience with it.

Question:

What are the different ways that a penile implant can be placed?

Answer:

Penile Implant Malfunction

Question:

I am interested in having you replace my IPP, which failed in early June of this year, after 17 years of satisfactory service. My history: age 74, retired engineer, primary insurance is Medicare, very good physical condition, take no medications, became impotent after surgery for rectal cancer in 1974, have permanent colostomy on left side of abdomen, had TURP in 2002 for BHP(no prostate cancer). My initial IPP implant was in 1976, partial replacements in 1977, 1978, 1980, 1981, 1985(July), 1985(Oct) for reservoir(3 times), one or both cylinders(3 times), pump(once). Entire IPP was replaced with AMS Ultrex-700 in 1993 by Dr X, who relocated the pump to the left side of my scrotum. I have 4 specific issues/concerns: 1.Relocation of the pump to the left side has resulted in a significant amount of pain/discomfort, particularly in cold weather. There is more space for the pump on the right, because my right testicle hangs lower than the left. I believe that Dr. X may have stated the relocation was done because of scar tissue, but this is not mentioned in his Operative Report. Would it be feasible to return the pump to the right side?

Answer:

I usually attempt to place the pump on the midline as far away from the penile shaft. Scar issue is rarely a problem unless the scrotum is very small. Indeed adequate pump placement is the most challenging portion of the procedure. The goal is to place it in a comfortable position, well concealed yet readily accessible. Tubing from the pump to the base of the penile cylinders and reservoir should not be visible or palpable by the patient and sexual partner.

Question:

About 7 or 8 years ago, the reservoir began to bulge through the muscle wall, causing some intermittent pain. The bulging and pain has increased over the years. I believe that relocation of the reservoir to the left side was considered by Dr. X, but not done because of possible interference with my colostomy. One Albany, NY urologist told me that repair of this condition would most likely require a Dacron patch, but he was not optimistic about the durability of such a patch. Another Albany urologist said if he did the IPP replacement, he would have a general surgeon assist, and let him decide how to repair the reservoir area. What would be your approach toward the repair of the reservoir bulge?

Answer:

I would have to examine you to determine this. A bulging reservoir is usually caused by mal-position of the reservoir. Ideally the reservoir should be deep in the retroperitoneal area where there is a lot of fat. A reservoir that is palpable indicates that it was placed too superficially between muscle layers rather than below the abdominal muscle. The defect in the superficial muscle fascia is usually very easy to fix after removal of the reservoir and placing the reservoir in a deeper location on the left. Use of mesh and placement of the reservoir near the colostomy should be avoided. One advantage of a bulging reservoir is that it is very easy to remove because I will not have to search for it. Also the AMS reservoirs are easier to remove because they do not have a lock-out valve. When placed appropriately, a reservoir should not be palpable at all by the patient. Most of our patients don’t even know they have a reservoir inside.

Penile length

Question:

I had a 3-piece implant at the hands of a Denver surgeon who left a “cross-over” and a resulting infection. When I found another surgeon here in Denver, he removed the implant, dealt with the infection, and inserted another implant. That, too, became infected and was removed. Six years ago, I had prostate cancer and a radical prostatectomy and my nerves were severed, hence, the implants. My insurance, Anthem BC&BS doesn’t cover anything of this type, so, I’ve paid out-of-pocket for all of this. I now have scar tissue that has taken me from an eight-inch erection to seven and now to four. Although, use of a vacuum pump and injections during the last three months has stretched me back to about 5.5 inches. Might you please give me an idea of what the financial cost might be to have me travel to NY and have Dr. Eid perform one, final 3-piece, implant surgery so that I may finally have this procedure done correctly?

Answer:

I am so sorry to hear about your operative course, sounds like you have really been through tough times. Any time a penile implant becomes infected this must be removed and washed out completely. Even when this is accomplished, sometimes the salvage implant gets infected such as in your case.

The problem with infections after penile implant is that the penis will always shrink and contract in size. All subsequent surgeries are also going to be very difficult and more than one surgery or staged procedures may be necessary. In order to give you a precise estimate of cost I would need to examine the penis and determine the extent of scar tissue present. Only then will I be able to determine what procedure(s) will be indicated. Your case illustrates why preventing infection should always be the foremost objective when performing an implant.

Question:

I had a radical prostatectomy a year ago and have been impotent ever since. By doctor keeps giving me Viagra pills and wants me to start using injection drugs into my penis. I am most worried about the length of my penis, which seems to have become smaller after surgery. Can you give me my length back from before surgery?

Answer:

If performed by an experienced implanter, the size of the penis with the implant fully pumped is the same as the length of the penis after a penile injection without the vacuum pump. With the Coloplast implant only, the girth or diameter of the penile shaft will be bigger than the diameter of the penile shaft with an injection. The AMS implants have narrower cylinders and with this type of implant the diameter of the penis may be smaller than the penis after a penile injection. The vacuum pump will enlarge the (head) glans penis and artificially give the impression of an extra 1/2 inch in erectile length.

Unfortunately fewer than 10% of men recover their normal erections after prostate cancer surgery and many experience permanent penile shrinking. Efforts to prevent this from occurring by offering rehabilitation of erections with penile injections so far have failed to prevent this from occurring. The length of the penis after a penile implant will therefore depend on the length of the stretched penis before the implant and not on the pre-prostatectomy penile length. Therefore I would not be able to restore your original penile length.

Question:

I am 57, in good health other than having E.D. for about 15 years. Currently I used injections and a vacuum pump with satisfactory results, but have thought of having an implant for years. One of my biggest concerns is having a shorter penis afterwards. I have heard you can lose more than an inch in length. I am only 54 and do not want to lose anything. I could like to gain, especially in girth. Is this possible?

Answer:

If performed by an experienced implanter, the size of the penis with the implant fully pumped is the same as the length of the penis after a penile injection without the vacuum pump. With the Coloplast implant only, the girth or diameter of the penile shaft will be bigger than the diameter of the penile shaft with an injection. The AMS implants have narrower cylinders and with this type of implant the diameter of the penis may be smaller than the penis after a penile injection. The vacuum pump will enlarge the (head) glans penis and artificially and give the impression of an extra 1/2 inch in length. In my hands, no loss of length occurs with penile implant surgery.

Question:

Would you be using the Coloplast or the AMS implant on me if I have a 5 in penis in the erect state? I would prefer to have as much length and girth as possible. Is there a difference between companies? Do we make the decision in your office before surgery or during the time of surgery?

Answer:

With the Coloplast implant only, the girth or diameter of the penile shaft will be bigger than the diameter of the penile shaft with an injection. The AMS implants have narrower cylinders and with this type of implant the diameter of the penis may be smaller than the penis after a penile injection.

The final determination of the selection of the implant is best be made on the operating room table since the measurements must include the inner girth of the penis and the proximal length (buried part) of the penile shaft. What is important therefore is to have available for every operation, all of the manufactured devices. This will prevent one from using a device that will result in a sub-optimal erection! Please see website for additional information on this important topic.

Question:

I am a 62 yo professional from Vancouver, HIV positive. Are you aware of any doctors in Vancouver that perform the services you describe (with regard to penile implants)? I had an implant after prostate surgery but the result was not satisfactory. The device is a metallic, articulated shaft that becomes semi-rigid (AMS) when it is manually “straightened”. It’s much smaller than my pre-operative penis and it simply doesn’t work well. It’s also much too small to satisfy my partner. Any thoughts would be appreciated. Thank you for your time.

Answer:

The best implants are the three-piece multicomponent devices. They provide the most natural and most rigid erections. Indeed the semi-rigid implants have an abnormal feel and do not enlarge in girth. In addition overtime they become loose inside the penis and case atrophy of the penile flesh. I am not aware of any Urologist in your area that has the same volume and experienced as we have with penile implants. It is easy and possible to exchange your implant for an inflatable device with a much greater satisfaction however. The inflatable device will also make your penis larger.

Question:

I received the 2 piece AMS inflatable penis implant after suffering from priapism. My penis size before was 8″ in length and after surgery is only 5″. My esteem has been devastated and I am enquiring to see if I could possibly return to my original size (or bigger) I have being doing some research and reduced length is not uncommon, but 3″ is an unacceptable reduction in size. The surgery that I have seen offered that looks most appealing to me is the Penile Triple Augmentation surgery. It consists of Penile Lengthening Surgery, Penile Widening Surgery and Penile Glanular Enhancement Surgery all being performed at the same time. The penile widening procedures that I read about are the one Penile Dermal Fat Grafts (DFG) or Dermal Widening Grafts or Allograft Dermal Matrix AlloDerm (R). Please let me know if there is any new implants or surgery methods (fat implant, cutting internal to allow extra length). Ideally I would like to get to my original 8″ in length and a large increase in thickness. I understand the best three-piece implant is the AMS 700 LGX. What is the maximum implant length available? Is this possible and approximately what are the costs? I would appreciate feedback on this, as I want to feel good about myself again and regain my man-hood.

Answer:

The largest implants available are the 3-piece Coloplast implants, which give the penis the widest diameter and longest length. The AMS LGX only expands girth wise to 18mm wide and the length expansion is limited to 18% of the original length of the cylinder. All of these other procedures, which you describe, are never successful and I recommend that you avoid them. Your best option is to have a physical exam by an experienced implanter to see if you are a candidate for a larger implant. Penile enlargement surgery in my opinion does not work and has many complications including numbness, shrinkage of penile tissue and formation of scar tissue.

Question:

I had a penile fracture when I was 19 and have been on Viagra and Cialis. They both do not help at all. I have lost about 3/4 inch in length and is very thin in girth now. I was also born with a downward curve in my penis, which makes sex very hard, and now because of my ED it is pretty much impossible to have intercourse. It has now lead to indents at the base of my penis on the left and right side which are Peyronie’s disease and makes my penis very unsecured and has cause me to have problems with my suspensory ligament. The head does not fill up anymore cause of the ligament problems. I believe that the injections will just make things worse if I want to hold off from the implant. I have no sex life now cause of my ED, and have lost 2 girlfriends cause of ED. My size before the penile fracture was 6 5/8″ long and girth was 5″. I am now lucky to get 5 7/8″ long and girth of 4 1/2″. I believe that if I don’t get the implant soon my erection length and girth will be much smaller when I get the implant. I’m asking you if you know a good Dr. in the Los Angeles, Ca. area that performs many implants like you do? What implant do you believe would be good for me cause of my age (Coloplast Titan or AMS 700 LGX)?

Answer:

I am not aware of any Urologist in your area that has the same volume and experienced as we have with penile implants. Because you are young, and you have penile scarring and deformity you need to seek the most experienced surgeon possible. This will minimize complications such as infection and penile shrinkage and maximize cosmetic and functional outcome. No one in LA, or anywhere else in the USA, performs the penile prosthesis with the “No-Touch” technique (I invented it), which provides the lowest infection risk in the world. In addition, most penile implanter are urologists who are more concerned with function rather than with size and cosmetic appearance of the penis which provides you with a normal appearance. We place the pump all the way in the back so that your sexual partner will never know that you have an implant. Also on average, and this is documented by the penile implant companies, we place the biggest penile cylinder size of any practice in the US.

Without having the benefit of examining you, but because you are young, I believe that a Coloplast implant with a Touch pump is the best choice for you.

Question

I am a 24 years old patient from Greece and I have an implant inserted 3 months ago. The model is the LGX and I have an 18cm implant plus 6 cm extenders. I wanted the Titan model as you recommend since I have a large penis but my doctor insisted to have the LGX. Anyway after the surgery the doctor told me to do some exercise inflating the device 3 time a day in order to gain some length. What happened is that by doing that the pressure at the tips under the glans caused an inflammation on the tissue and I have pain when inflating the device. In fact I cannot inflate it because of the pain. The doctor gave my pills like xefo and mesulid but after 4 weeks the pain is still there when I try to inflate it. There is no infection. I am writing to you because you are the expert and you seem to be a nice person, for your opinion about the issue.

Did you have the same experience with a patient of yours? Do you think that there is a chance that I have an oversized implant? I would be thankful to know your opinion

Answer:

It is difficult to fully evaluate your situation without a physical exam. I much prefer the Titan Coloplast model for the younger patient as it provides the patient with a normal looking penis when erect with a wider and much firmer erection.

In addition I avoid using rear tip extenders as these further diminish the rigidity of the erection. The AMS rear tip extenders are very thin, diameter of only 9mm, each which is much, much narrower than the base of your penis. This results in an erection that is not well buttressed (attached to the body) to the pelvis, which will swivel as if it is hinged to the pelvic bone instead of being fixed to the pelvis. The back of the 18 cm cylinders measures 4.5 cm and only the front of the cylinders is inflatable which means that you only have 13.5 cm out of a total length of 24cm (18cm plus 6cm of rear tip) which is inflatable. Almost half of your device is non-inflatable! How on earth is this going to possibly give you a firm erection? Coloplast also makes longer cylinders such as 20,22,24,26 and 28cm, which makes the use of rear-tip extenders, unnecessary.

If the LGX is oversized, as it expands in girth it will lengthen causing pain and deformity of the glans penis. In addition the mesh inside the LGX cylinder limits the expansion of girth to 18mm and the penis will appear flat when inflated instead of rounder as with Coloplast cylinders. It is also unusual and rare for a penis to measure 24cm and indeed your suspicion may be correct that your doctor oversized your penis. Correct sizing of the penis is difficult especially in younger patients who have a very elastic penile tissue. Inexperienced penile implanters tend to oversize young patients. Oversizing causes pain on inflation and atrophy the glans penis overtime.

Unfortunately it is not possible to give you a full evaluation of your situation without the benefit of a physical exam. Whatever you do not, I repeat do not ask the same doctor to revise your implant as the easiest operation is the 1st implant as all subsequent procedures require much, much more experience. If you are not pleased the first time it is very unlikely that he will be able to improve on your result! You need to seek a second opinion with more experienced implanter.

Question:

I am 47 years old and had a prostatectomy in April 2009. I started using the first level of Trimix Dec 2009. 15-20 units gave me a good erection for 1 and half to 2 hours. I am currently using 60-70 units of the second level of the Trimix injection to obtain an erection and it is not giving me the satisfactory results. I will start the third level soon. In addition, it appears as if the length of my penis has shortened since the operation. I have been getting mixed answers from several urologists regarding this matter and a solution. What resolution do you suggest for someone in my situation to: maintain a strong erection; gain the girth and length I once had? I am in good health and strength with no medical issues prior to this and take no medication. The penile implant sounds great and I would like more information about the penile prosthesis implant. If I choose this procedure, is it possible to use cylinders, which are the same size as my penis was prior to the prostatectomy?

Answer:

Your e-mail raises several issues regarding the natural history and treatment of ED following prostatectomy. My comments in this e-mail are not to be interpreted as or replace a consultation with a qualified expert in the field of ED. In most cases this may not be the physician near you, a physician in your medical insurance plan or a general urologist. You should seek the help of an expert in ED that is a doctor that only treats ED at the exclusion of all other urological maladies, in order to obtain the best outcome.

Finally my comments represent my medical opinion as to the best way to manage an individual such as yourself based on twenty seven years of experience treating men with ED and experience with over 5000 penile implants. This may not apply to you and you should not expect the same result when cared by another physician.

First I would like to address the issue of ED following prostate cancer surgery. No patient has ever experienced an improvement of erectile function after Nerve Sparring Prostate Cancer Surgery. As a matter of fact most patients experience a decrease in erectile function after the surgery and fewer than 10% regain their normal erections. If one does not experience erections within a few weeks after the surgery it indicates that the nerves were cut, damaged, stretched or bruised during the surgery. Most men who experience recovery of potency recover gradually and do so with in the first 18 to 24 months after the surgery. Very few will recover potency after 24 months.

Nerve injury will also cause the penis to shrink, and atrophy, become deformed causing further deterioration of erectile function. When the cavernosal muscle shrinks, the patient develops an inability to store blood efficiently during erections resulting in a “venous leak.” It is for this reason that fewer than 30% of men who have ED following radical prostatectomy respond to Viagra, Cialis or Levitra. This was independently documented during the clinical trials with these medications. Furthermore no evidence exists that taking these medications on a daily basis will help recover erections or prevent shrinkage.

Penile injection therapy although very effective is not, in my opinion a good long-term option. The only medication, which is approved by the FDA and found, to be safe for long-term use is Prostaglandin E-1 or Alprostadil (Caverject or Edex). When administered to patients who have a venous leak this results in a painful, burning sensation. Because of this many will use Trimix, a mixture of Papaverine, Phentolamine and Prostaglandin E-1. This mixture however was never studied in clinical trials, is not approved by the FDA and many patients using Papaverine develop scarring and fibrosis which further deforms and foreshortens the penis. As a matter of fact the manufacturer of Papaverine has placed a disclaimer on the Papaverine bottle stating that it should not be used for the treatment of ED and is not indicated for penile injection therapy. Men suffering from a venous leak require larger dose of injectable Trimix, which with frequent use, will cause more scarring and exacerbate the venous leak. Finally no convincing data exists that supports the benefits of rehabilitation of erections with injections and or prevention of shrinkage by performing regular self-injections. It is therefore fair to assume that for a young individual who is cured of prostate cancer, and has many more years to live, and for whom erectile function does not return in 24 months following prostatectomy, that this person has permanent irreversible erectile dysfunction. Penile atrophy and shrinkage may also be present. Given the success, reliability and extreme patient satisfaction following penile implant surgery, it is very clear for me, that for an individual in this situation, the best treatment option is a penile implant. It is important to be cognizant that urologists who perform 0 to 3 penile implants per year perform 70% of penile implants in the USA. Only a handful of Urologists perform more than 100 per year. Only 2 Urologists in the USA perform more than 300 per year. There is no substitute for experience and one should not expect the same result and satisfaction if a less experienced doctor performs the implant procedure.

Please consult with your ED specialist before making any further decisions regarding treatment of your ED. My opinion regarding treatment may not apply to your situation and you should not assume that I am recommending that penile implant surgery be performed to you another physician. Results following penile prosthesis surgery vary greatly and depend on the surgeon’s training and experience. My opinion reflects my experience with the penile implant procedure, which may or may not be the same for other physicians. For additional information regarding treatment of ED with penile implants please see my web site. Good luck and hope that this information was helpful.

Question:

My degree of Peyronie’s disease bend is app 30 degrees to the left. My penis length was 6 inches before the onset 20 years ago. How can the penile pump help correct this and how much of a decrease in bend could I expect? In your opinion, how much of my bend could the pump correct?

Answer:

For some patients, the curvature is corrected 100% others are corrected enough to permit sexual activity without difficulty. Patients with Peyronie’s disease in general are best managed conservatively, especially if they are able to have intercourse. If intercourse is not possible (regardless of the rigidity of the erection) a penile prosthesis is the best option for most. It is better to have a longer penis, which is slightly crooked than a very short straight penis. Penile shortening always occurs with correction on angulation (either with plication, Nesbit procedure or plaque excision) without placement of a penile implant.

Question:

How do you maximize the quality of the erection?

Answer:

Penile Trauma/Peyronie’s Disease

Question:

I had a penile fracture when I was 19 and have been on Viagra and Cialis. They both do not help at all. I have lost about 3/4 inch in length and is very thin in girth now. I was also born with a downward curve in my penis, which makes sex very hard, and now because of my ED it is pretty much impossible to have intercourse. It has now lead to indents at the base of my penis on the left and right side which are Peyronie’s disease and makes my penis very unsecured and has cause me to have problems with my suspensory ligament. The head does not fill up anymore cause of the ligament problems. I believe that the injections will just make things worse if I want to hold off from the implant. I have no sex life now cause of my ED, and have lost 2 girlfriends cause of ED. My size before the penile fracture was 6 5/8″ long and girth was 5″. I am now lucky to get 5 7/8″ long and girth of 4 1/2″. I believe that if I don’t get the implant soon my erection length and girth will be much smaller when I get the implant. I’m asking you if you know a good Dr. in the Los Angeles, Ca. area that performs many implants like you do? What implant do you believe would be good for me cause of my age (Coloplast Titan or AMS 700 LGX)?

Answer:

I am not aware of any Urologist in your area that has the same volume and experienced as we have with penile implants. Because you are young, and you have penile scarring and deformity you need to seek the most experienced surgeon possible. This will minimize complications such as infection and penile shrinkage and maximize cosmetic and functional outcome. No one in LA, or anywhere else in the USA, performs the penile prosthesis with the “No-Touch” technique (I invented it), which provides the lowest infection risk in the world. In addition, most penile implanter are urologists who are more concerned with function rather than with size and cosmetic appearance of the penis which provides you with a normal appearance. We place the pump all the way in the back so that your sexual partner will never know that you have an implant. Also on average, and this is documented by the penile implant companies, we place the biggest penile cylinder size of any practice in the US.

Without having the benefit of examining you, but because you are young, I believe that a Coloplast implant with a Touch pump is the best choice for you.

Question:

My degree of Peyronie’s disease bend is app 30 degrees to the left. My penis length was 6 inches before the onset 20 years ago. How can the penile pump help correct this and how much of a decrease in bend could I expect? In your opinion, how much of my bend could the pump correct?

Answer:

For some patients, the curvature is corrected 100% others are corrected enough to permit sexual activity without difficulty. Patients with Peyronie’s disease in general are best managed conservatively, especially if they are able to have intercourse. If intercourse is not possible (regardless of the rigidity of the erection) a penile prosthesis is the best option for most. It is better to have a longer penis, which is slightly crooked than a very short straight penis. Penile shortening always occurs with correction on angulation (either with plication, Nesbit procedure or plaque excision) without placement of a penile implant.

Post-Op Care

Question:

Ever since my rectal cancer surgery in 1974, my urine flow has been slow because my bladder is now tipped backward. In my first IPP replacement, it was 2 full days before I was able to void without a catheter in place. If I was unable to void the day after surgery, would I be discharged with a catheter in place, or would my hospital stay be extended?

Answer:

Difficulty in urination often happens following deep rectal pelvic surgery. I am sure that some nerve fibers to your bladder were removed with your cancer surgery, as were those for your erections. In anticipation of urinary retention, we would automatically place you on medication called an alpha-blocker such as Flomax, Uroxatral or Rapaflo if you are not already on one. Also the catheter would be kept in for two days in order to allow the swelling to dissipate. Admission to the hospital is not necessary. We perform over 90% of penile implants on an ambulatory basis; patients are discharged on the day of the surgery with a catheter, which they can remove on their own. An additional benefit of the catheter is to keep you in bed and avoiding to get out of bed to urinate which further helps in limiting postoperative swelling.

Unsatisfied with Current Implant

Question:

Very many years ago I seen a video about a penile implant where a doc cut to insert behind the sack not behind the penis and not above the penis. Now I just had a penile implant done in Germany but they cut behind the penis and cut in my belly as well placed a catheter too. At lot of things I didn’t wanted this way. I want to show this video to my doc but I cant find it anymore and there are no I don’t know maybe a 1000 videos here this days. Could you please send me your video or let me know where to find this video I seen where you cut behind the sack not before?

I know now that it is a lot better this way then what they did to me now. First there is no scar on my belly, second there is no scar where the pump is so I can feel the pump better and the release button. Also is all that hoses etc. of the pump more to the body not in the middle of my penis, which is way more, pain and keep the penis from going deep inside the vagina. Also he did between pump and rods only a very short lines so the pump can not go way to my body either which again keep’s me from entering deeper into the vagina.

As you can see my doc was a careless with little or no experience. No I need your much better version of video so I can show them and for complaint reasons and finally I like to ask you would you recommend to have a second surgery or better leave it this way but I have to tell you that I each time I need to turn the pump also around in order to be able to inflate my penis and the release button is underneath not on top. I am not able at squeeze the pump without turning the pump and with two hands only and no light either more harder with more pain possible.

Answer:

Thank you for contacting us. It is unfortunate that you had to go through this experience. Indeed pump placement and surgical technique determines the extent of pain, postoperative swelling, and pump location and ultimately ease of use. It may be possible to fix your problem with relocating and replacing the pump in a better location in the scrotal sac and proper post-operative instructions. In order to have a better cosmetic result as well as concealment of pump tubing to allow for comfortable vaginal penetration the procedure needs to be redone through an incision in the scrotal sac.

Question:

I have been having problems with my penile implant ever since it was placed by my Urologist 4 years ago. I remember right after my implant was placed; I was really swollen (black and blue) for 2 weeks straight. After the swelling and pain went down he tried to show me how to inflate the implant but he struggled with it and I never really learned correctly. Also I think my penis shrank after surgery and I am really unhappy about this. Is this something you see often?

Answer:

Swelling after a penile implant procedure depends on the surgeon’s technique. The more experienced and the more meticulous he surgeon, the less swelling and black and blues will occur. Swelling is caused by bleeding around the pump and can result in scar tissue formation and displacement of the pump after the welling subsides. This will delay the use of the device and can render the pump inaccessible and very difficult to pump. It may be possible to fix your problem with relocating and replacing the pump in a better location in the scrotal sac and proper post-operative instructions. Delaying the use of the device or improper and inadequate sizing of the device may have caused the penis to shrink. With proper technique, small incisions and minimal dissection the problems you mentioned can be avoided.

Question:

I had inflatable implant surgery but I am not satisfy because my Glans Penis will not be strong when I want to have sex and this makes me unhappy in sex. I really need your recommendation and if I need any other surgery I am ready and no care about cost just let me have your idea. Hope to receive your soonest reply and kindness.

Answer:

The penile implant cylinders are designed to make the shaft of the penis erect. The Cylinders do not expand the glans penis. If the glans penis engorges with sexual stimulation before the implant is performed, it will engorge with sexual stimulation after the penile implant is inserted. If the penile implant cylinders are oversized, this will apply inner pressure on the glans penis and will present blood from entering the glans and engorging the glans during sexual stimulation. If the glans becomes atrophic or shrunken Collagen injections can restore its size and provided with a fuller appearance and texture.

Question:

I had an AMS 700 penile implant performed 3 years ago and it feels like it deflates during sex. I have to pull out and inflate some more and this is very annoying for my partner. Could my implant be defective or have a leak?

Answer:

The AMS penile implant lasts between 8-15 years depending on how often it is being used. Some implant malfunction before 8 years if the outer silicone layer of the device was damaged during the implantation and the inner mesh exposed to the body. It’s possible that you are not inflating fully initially and that as intercourse occurs the penis becomes loser over the cylinders. Finally a physical exam is the only way of determining if the implant is functioning appropriately.