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Penile implant surgery is commonly performed by General Urologists in the community. However, when revision surgery is required, or there is scarring of the penis from priapism (a condition of an abnormally prolonged erection leading to fibrosis of the penis) or prior implant placement and subsequent removal due to infection, we are a referral resource for other Urologists. Most of our patients who requires very complex surgery are referred to the Center for Reconstructive Urology by their local Urologists.
The appropriate placement for the cylinders is within the corporal tissue inside the tunica albuginea. In some cases, when there is a bulging along the penis, one possible explanation is that a portion of one of the cylinders is outside of the tunica and not properly positioned at the time of surgery. The following 2 pictures are of a patient who was referred by his Urologist with this complication. Our approach is to widely expose the corpora and then expose the interior of the corpora deep to the tunica, creating a new and proper channel and space for replacement of the cylinders. In most cases, when a penile implant requires revision, it is best to replace the entire device rather than a single component.
|Cylinders not within the corpora of the penis.||Bulging of penile implant just below the skin.|
A late complication of an inflatable implant that can occur is the development of an abnormal dilation of a portion of a cylinder. This is called an aneurism. When this is diagnosed based on history and physical exam, the the bulging is associated with compromised function, the treatment is replacement with a new implant. This can be more complex than a simple revision as the bulging can distort the anatomy. However, replacement with a new device generally restores the ability of the patient to have satisfactory intercourse.
|Penile implant aneurism. This aneurism is small. However, these defects can be larger.|
When a patient sustains an abnormal erection for a very prolonged period of time, this is called Priapism. This condition is best treated less than 4-6 hours after the onset of the erection. However, some patients do not seek treatment until 24-48 or more hours after onset. This delay can be associated with scarring and fibrosis of the inside of the penis. In addition, when a penile implant is placed and then removed for infection or other reasons, this also is association with the development of scarring within the penis. This is a very challenging problem as there is shrinkage of the penis and the normal soft sponge like tissue within the tunica albuginea is replaced by dense scar. Many Urologists perform penile implant surgery, but very few perform surgery when there is penile scarring. Given that the majority of our patients are referred by Urologists, we are a referral center for the treatment of these challenging and complex conditions.
We first achieve wide exposure along the length of the penis, and then use special dilation instruments that safely core out the scar tissue. In some cases we have to use a scalpel to excise scar to create space for the cylinders. When even small dilators will not advance, we then make a second circumcising incision and a second corporotomy (a cut into the corpora) to achieve safe through-and-through access for dilation. On occasion, a graft of Gore-tex has been required to achieve closure after cylinder placement. However, recent technical modification have made the use of grafts unnecessary during the past 9 years. Some of our patients, prior to referral, reported that they were previously told by multiple Urologists that an implant could not be performed due to the scarring. However, it is our experience that if a patient is a candidate for surgery from a medical standpoint, it is extremely unusual for penile implant placement to be impossible.
|Cylinder erosion is seen. When this complication is diagnosed, removal of the implant is required.|
Mr. K. R. developed priapism and required an emergency shunt procedure. He then developed erectile dysfunction managed with a malleable implant that eroded (the obove picture is not Mr. K.R.) and this was removed. As a consequence of his priapism and implant removal, he had severe scarring. After seeing 10 Urologists through his HMO who were unable to perform placement of a new implant because of the severe penile scarring, he was referred to Dr. Gelman. This video is Mr. K.R.'s account of his experience.
|Video of a patient with erectile dysfunction who received treatment at the Center for Reconstructive Urology.|