To reduce risk of infection, our patients are given an antibiotics such as vancomycin and gentamicin 1 hour prior to beginning the surgical procedure to guard against bacteria. After the pubic hair is shaved, a 5-minute Chlorhexidine wash is performed, followed by a skin prep with Chlorhexidine/Alcohol 70% (Chloraprep) surgical prep.
The patient is positioned on the operating table with the pubic symphysis at the point of flexion, so that flexing of the table elevates the pelvic rami up, rotating the crus of the penis upwards toward the operator, and flattening the lower abdomen. This maneuver allows for more proximal exposure of the crura (important for precise placement of cylinders, optimal concealment of cylinder input tubing) and stretches the muscles of the lower abdomen (to provide counter-traction for easier reservoir placement).
After the patient is draped in sterile fashion, a large thoracic Vi-drape is placed on top of the sterile drapes, and the penis and scrotum are delivered through a small opening. This isolates the penis, protects the prosthesis from acquiring lint from adjoining drapes (which could act as a nidus for infection) and also prevents the irrigation from soaking through the drapes. Another advantage of the Vi-drape is that it secures all the surgical drapes without the use of additional sharp towel clips.
A Foley catheter is inserted to identify the urethra, capped, and a Scott retractor is secured with tubing across the base of the penis.
Large blunt yellow hooks are utilized instead of the small sharp blue ones. These provide better exposure and are less likely to injure the device or gloves.
Incision, Initial Dissection and Exposure of the Crura
For the incision, we use a high longitudinal scrotal approach, on the median raphe about 1 inch inferior to the junction with the penis, rather than a classic peno-scrotal incision. We favor the scrotal incision, rather than a transverse scrotal or 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 and heals without scarring, thus giving a better cosmetic result than a transverse scrotal or infrapubic incision, as the scar will be concealed by the scrotal raphe. 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 tendency of migrating to a high scrotal position next to the base of the shaft of the penis, 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. In this situation the pump could be felt by the partner during sexual activity and penetration.
Using the Foley catheter and urethra for traction, dissection is minimized, by pushing surrounding tissues laterally prior to making an incision. An incision is made on to the peno-scrotal raphe and the dissection is carried down through the subcutaneous tissues to the level of Bucks fascia. Five yellow hooks are then utilized to secure the edges of the incision to the Scott retractor in order to obtain and maintain exposure.
Making the incision straight down unto the urethra reduces postoperative swelling and edema and also fashions a thick layer of subcutaneous tissue. This will provide for deeper placement of pump tubing in the scrotum, better closure of the incision and complete separation and concealment of tubing from the skin suture line.
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 that touched the patient's skin are changed. A 3M #1012 drape is used to loosely drape the operative field. A small fenestration is made in the drape and 4 blunt yellow hooks are used to secure and retract the cut edges of the drape to the edges of the skin incision.
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 cylinders; and placement of the pump in the scrotum and the reservoir in the retropubic space, all through the small fenestration in the #1012 drape. All are placed without direct contact with the skin.
With the scrotal skin completely covered and proceeding within the small fenestration of the drape, 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, Buck's fascia is incised 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 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 with RB-1 needle (Ethicon) 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.
After the right crus is tagged, instead of making another incision in Buck’s fascia on the left, the urethra is mobilized to the right, and exposure of the tunica albuginea of the left crus is obtained by reflecting the edges of Buck's fascia towards the left and securing it with the yellow hooks on the left. This effectively preserves Buck's fascia and enables the use of a second layer of tissue that will further conceal input tubing to the cylinders when closing. The crus on 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. This also reduces infection risk.
Dilation of the corpora
It is during this process that a 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 right underneath the tunica albuginea is preferable and easier than centrally through cavernosal muscle tissue. This also will preserve cavernosal smooth muscle and partial erectile function much is described by patients even after penile implantation.
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 then 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:
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.
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 (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 similarly 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.
Sizing of the corpora
There is a tendency for inexperience implanters 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 the distal apex of the corporotomy) 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 distal portion of the corpus cavernosum.
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 saline irrigation (another good reason for keeping the corporotomy small 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.
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. However using rear tip extenders will negatively impact the quality of the erection as the non-inflatable portion of the cylinders will dilate the pseudo-capsule over time and the base of the cylinders will not be held firmly to the patients's body. The erection will wobble and we recommend judicious use of rear tip extenders.
If dilation to #13 French distally and #14 French proximally has not been possible, we use a narrow device such as the Coloplast Alpha Narrow or AMS-CXR cylinders. For a large and capacious penis, a Coloplast Titan 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 AMS 700 LGX or CX cylinders for these large penises, especially if rear tip extenders are needed. These cylinders do not provide adequate rigidity when inflated especially in patients with long and wide penises.
The reason for this is that in general long penises tend to also have larger diameters that are not filled by the 21cm LGX cylinders (girth expansion limited to 18 mm). This may cause the cylinders to curve inside the corpora as they lengthen with inflation. For penises longer than 18cm, as previously mentioned, a Coloplast Titan 20 or 22cm cylinder, will provide the patient with a better erection.
Finally, when using pre-connected 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 and reduce the length of tubing in the scrotum. 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 shaft of the penis, providing longer tubing length and lower scrotal placement of the pump.
Only after the choice of device is made and it is ready to be implanted, the device is opened on the surgical field. Air must be purged prior to cylinder insertion and the device is primed with injectable saline. With the Furlow introducer and Keith needle, the cylinder traction suture is passed through the glans penis, through the "No-Touch" drape and we secure the traction suture with clamps. Prior to the passing of the traction suture, the right and left cylinders are oriented so that input tubing from the two cylinders do not cross over each each other.
After both traction sutures have been passed through the glans penis, the proximal portion of each cylinder is inserted first, then the distal tip placed in the corporal orifice and the traction suture pulled to insert the distal portion of the cylinder. The cylinder must lay flat in the corpora when traction is applied with 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 with saline is performed, using a filled 60-cc syringe. If adjustment in cylinder length needs to be performed, saline is completely removed from the cylinders prior to adding or removing rear tip extenders and repositioning of the cylinders. This facilitates the maneuver and prevents injury to the cylinder.
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, it provides for a watertight closure. Prior to ligation of the suture, 3cc of Surgiflo hemostatic Matrix (Ethicon) is injected in each corpora. If hemostasis cannot be accomplished, drains should be used to prevent formation of a scrotal hematoma. Any bleeding could result in a large scrotal hematoma, which if not evacuated with drains, will liquefy and possibly provide a wonderful milieu for bacterial growth, and subsequently infect the penile implant. 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.
Once the corporotomy is closed, attention turns to fashioning a scrotal pouch, into which the pump will be placed. Our aim here is to have the pump readily accessible to the patient yet unobtrusive and concealed to the naked eye, providing a good cosmetic outcome.
A flap of scrotal fascia is developed beneath the urethra for a distance of 2 to 3 cm. Approximately 1 to 2 cm from the urethra, a small 1-cm transverse opening is made in the scrotal fascia with the Bowie electrocautery. A closed, long nasal speculum is pushed gently into the opening, behind both testicles, towards the bottom of the scrotum. The speculum must be kept closed, as we do not want to over-dilate the pouch but, rather, have it fit snugly around the pump. Tubing from the pump to the reservoir is then tunneled along the inguinal cord, using a tubing passer, towards the region of the external inguinal ring on the side where the reservoir will be placed. the pump is gently positioned into the scrotal pouch.
It is important to not pull too hard on the pump as that will place it too superficially underneath the skin. The opening in the scrotal fascia is then closed with a running 3-0 Vicryl suture after meticulous hemostasis is obtained.
The reservoir is to be placed in the space of Retzius or in a pre-peritoneal space, next to or above the bladder. To avoid perforating the bladder, the Foley catheter is uncapped and the urine drained. Using a blunt curved Mayo scissors, a small defect is made in the floor of the inguinal canal between the base of the penis and the medial aspect of the inguinal cord. Blunt use of the finger to perform this maneuver will create a very large defect in the floor of the canal thus predisposing for reservoir herniation. The hole in the floor of the canal is best made by tilting the scissors at a 90 degree angle with the plane of the abdominal wall and by positioning the tip of the scissors just over the pubic ramus. A common mistake here is not going deep enough with the scissors for fear of bladder puncture. Incomplete perforation of the floor of the inguinal canal prior to substituting the scissors with the operator’s index finger will result in separation of the transversalis fascia from the undersurface of the internal oblique muscle, rather then dilation of the space of Retzius. This also causes loss of counter-traction of the transversalis fascia, making puncture of the fascia and access to the space of Retzius very difficult. Finally, positioning of the reservoir above the transversalis fascia leads to auto-inflation, palpable reservoir and also predisposes to reservoir herniation.
The excursion of the Mayo scissors ounce the fascia must be limited to a few millimeters and once the space of Retzius is entered, the tip of the scissors is replaced a closed, long nasal speculum. The operator’s finger is used to help in this dilation and confirm the location of the reservoir. Again, there is no need to over dilate this space, and care must be taken not to split the floor of the inguinal canal during dilation of the space of Retzius as this may cause reservoir herniation. The empty reservoir is then placed through the blades of the open nasal speculum.
After it is correctly placed, the reservoir is filled with an appropriate amount of saline and connected to the pump. Especially when an AMS reservoir is used, a surrogate test is performed with a 60cc syringe to check for auto-inflation and further confirm reservoir placement. The Coloplast reservoirs have a Lock-out valve preventing autoinflattion and therfore this maneuver is not as important when using Coloplast devices. Presence of bloody urine may indicate that a bladder perforation has occurred. It is better to identify this problem at this point of the procedure because it will necessitate removal and replacement of the reservoir on the contralateral side of the bladder.
The operating table is now unflexed, to a neutral position, and the point at which the tubing from the reservoir crosses the tubing from the pump is identified. Both tubes are clamped 2 finger breadths below the point of crossing. Tubing is then appropriately trimmed and a connected to each other.
The surgical site is irrigated and re-examined for hemostasis. Once hemostasis is obtained, the wound is closed in 3 layers: Buck’s fascia and the scrotal pouch are closed with 3-0 Vicryl in a running fashion and the skin with a nonabsorbable vertical mattress stitch with 4-O proline. Injectable saline is used for irrigation in all cases. Once the corporotomies are closed and all of the tubing has been covered with a layer of Buck’s fascia, the drape is removed and the subcutaneous tissues and skin are closed. We use non absorbable sutures because we feel the patient will benefit from warm baths, starting on the 3rd postoperative day. This helps reabsorb any swelling and edema and also keep the scrotum clean. The foley catheter is kept indwelling until the next morning. The stitches are removed after 14 days.
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 two days to avoid pushing the pump up. We further instruct the patient to keep the penis straight and up, 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 in the shaft of the penis. We suggest a minimum of 1 postoperative instructional visit, but some patients come back as many as 3 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