Practical Considerations in Inflatable Penile Implant Surgery

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madman

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ABSTRACT

Background:
Penile prosthesis implantation remains an effective solution for men with medical-refractory erectile dysfunction (ED) following radical pelvic surgery. Despite the distortion of pelvic anatomy, a penile implant can be performed with excellent clinical outcomes provided strict patient selection, proper preoperative workup, and safe surgical principles are adhered to.

Aim: To provide practical recommendations on inflatable penile prosthesis (IPP) implantation in patients with medical-refractory ED, with an emphasis on patient selection and counseling, preoperative workup as well as surgical considerations to minimize intraoperative complications.

Methods: A Medline search on relevant English-only articles on penile prostheses and pelvic surgery was undertaken and the following terms were included in the search for articles of interest: “bladder cancer”, “prostate cancer”, “rectal cancer”, “pelvic surgery” and “inflatable penile implant”.

Outcomes: Clinical key recommendations on patient selection, preoperative workup, and surgical principles.

Results: Patients should be made aware of the mechanics of IPP and the informed consent process should outline the benefits and disadvantages of IPP surgery, alternative treatment options, cost, potential prosthetic complications, and patient’s expectations on clinical outcomes. Specialized diagnostic test for workup for ED is often not necessary although preoperative workup should include screening for active infection and optimizing pre-existing medical comorbidities. Precautionary measures should be carried out to minimize infective complications. Corporal dilation and reservoir placement can be challenging in this group, and surgeons may require knowledge of advanced reconstructive surgical techniques when dealing with specific cases such as coexisting Peyronie's disease and continence issues.

Clinical translation: Strict patient selection and counseling process coupled with safe surgical principles are important to achieving excellent clinical outcomes and patient satisfaction rates.

Strengths and limitations: This masterclass paper provides an overview of the practical considerations for men who are undergoing IPP surgery following radical pelvic surgery. Limitations include the lack of high-quality data and detailed surgical descriptions of each surgical troubleshooting step for various prosthetic-related complications.

Conclusion: The IPP implantation can be performed efficiently and safely in patients following radical pelvic surgery.




INTRODUCTION

Presently, most data relating to erectile dysfunction (ED) and penile rehabilitation is derived from prostate cancer patients. Our recent understandings of the pathophysiology of ED in men following radical pelvic surgery especially in radical prostatectomy (RP) men highlights that corporal oxygenation is critical to the earlier return of erectile function and preservation of penile size.1−3 For men who do not regain spontaneous erection or develop medical-refractory ED especially in the setting of corporal fibrosis, penile prosthesis implant continues to play an important role.1,3 Despite the introduction of various pro-erectile pharmacological agents in penile rehabilitation programs, penile prosthesis surgery offers sexual spontaneity and remains an effective, safe, and reliable definitive treatment for men with ED.4−7

The inflatable penile prosthesis (IPP) implantation is a more natural device than a malleable prosthesis since it closely replicates a normal penile erectile function in terms of penile rigidity and flaccidity.5,8
Over the last 4 decades, significant scientific advances in terms of device technology and surgical techniques have improved the mechanical reliability and durability of IPP.5,9 Nonetheless, IPP surgery is not without risks and can carry additional cosmetic and psychosocial consequences in poorly selected and consented individuals. In the current climate of digital health information and consumer-driven access to better healthcare service, strict patient selection and counseling coupled with judicious adherence to safe surgical principles are paramount to ensure excellent clinical outcomes and patient satisfaction rates.10−13 The following article provides a practical overview of patient selection and preparation for IPP surgery and offers strategic recommendations to address the technical challenges encountered in patients following radical pelvic surgery.




PATIENT SELECTION AND COUNSELLING

PREOPRATIVE PREPARATION

INTRAOPERATIVE CONSIDERATIONS

Incision
Corporal Fibrosis
Reservoir Considerations


SPECIAL CASES
Patients Exposed to Adjuvant Therapies

PEYRONIES DISEASE

Concurrent or Sequential Continence Surgery




CONCLUSIONS

For motivated individuals, IPP remains one of the most effective treatments to restore sexual function in men especially following radical pelvic surgery. Penile prosthesis implantation should be discussed as part of the treatment algorithm for penile rehabilitation and the patient needs to understand that this is an irreversible surgical solution. Despite the scientific advances in penile prosthetic design and technology, it remains critical that strict patient selection and counseling processes coupled with safe surgical principles are adhered to, to ensure excellent clinical outcomes and patient satisfaction rates. There is a need to establish a standardized surgical approach with key recommendations to minimize surgical complications and streamline penile prosthesis implantation care for men,
 

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