Wednesday, August 25, 2010

Surgery for Erectile Dysfunction

Surgery usually has one of three goals:

to implant a device that can cause the penis to become erect (Penile Implant surgery)
to reconstruct arteries to increase flow of blood to the penis (Penile revascularization surgery for patient with focal arterial stenosis-post-trauma)
to block off veins that allow blood to leak from the penile tissues (penile venous leak-particularly detected on Doppler showing persistence end-diastolic velocity more than 5 cm/sec)
Implanted devices, known as prostheses, can restore erection in many men with ED. The patient who donot respond to intracavernosal injection of vasodilator agents or Vacuum Erection Device. Neophallus reconstructed patient are also candidates for penile implant surgery. The contra-indications for the penile implant are uncontrolled diabetes,spinal cord injury patients, patients with severe psychiatric imbalance, neurogenic bladder and very short penis. The implant gives erection with causing some decrease in length so this thing has to be emphasized to the patient before the surgery.
Types of penile prosthesis are:
Non-inflatable(Malleable,hinged prosthesis)- less costly but gives constant erection and needs special clothing for concealment of the erection.
Inflatable(2 piece and 3 piece variety):Expensive,surgery is technically demanding but gives near to normal erection.

Choice of three piece implants

700CX: Diameter 12 to 18 mm length constant
700 ultrex: Girth 12 to 18 mm, length increases.So to a patient concerned about the length of the penis post implant this is a good choice.
700 with inhibizone coating

Description of inflatable implant:
Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis. They also leave the penis in a more natural state when not inflated.
Advantages with the penile impants are:
o Good rigidity
o Freedom from medications
o Outpatient/24HR surgery
o Resume sexual activity 4-6 weeks
o No loss of ability to ejaculate or achieve orgasm

Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to perineum or fracture of the pelvis.Surgery to veins that allow blood to leave the penis usually involves an opposite procedure-intentional blockage. Blocking off veins (ligation) can reduce the leakage of blood that diminishes the rigidity of the penis during erection. However the results are not long lasting so the venous ligation surgery have diminished


Infection (5-14%)
Infection in the periprosthetic space usually does not cause significant illness; however, to eradicate the infection, removal of all components of the prosthesis is almost always required.
Infections occurring after penile prosthesis implantation are either early (in the first few weeks following implantation) or late (6 months to 1 or 2 years after implantation). The former are often associated with gram-negative bacteria, whereas the later are usually associated with gram-positive bacteria such as Staphylococcus epidermidis. Early infections are usually acquired during the surgery. 56% of cases occur within 6 months, 36% occu within 7-12 months and 2.3% after 5 months.
Pre-operatively cephalosporins and aminoglycosides should be administered and post-operatively quinolones should be given.
Early infections are likely to be evident by swelling, erythema, tenderness, possible purulent drainage, and occasionally fever. Late infections may be manifested only by persistent or recurrent long-term pain. With long-term infections the scrotal skin may be adherent to the pump.
Treatment of a prosthetic infection with appropriate antibiotics usually results in clinical improvement; however, antibiotic treatment rarely permanently eradicates this type of infection. This is thought to be due to harboring of microorganisms within a biofilm that is adherent to the device. For this reason, when a prosthetic infection is present, all components of the prosthesis should be removed.The corporal spaces should be lavaged with antibiotic solutions. Vancomycin and Gentamycin should be used for lavage.
After the infection has come into control usually in the interim period the Vacuum Erection Device should be encouraged.The advantage being the VED will cause stretching the corpora and to certain extent increase the length and the girth of the penis and cause easier dilatation during the second surgery.
When all incisions have healed and postoperative edema has resolved (usually 2 to 3 months after device removal), reimplantation is advised because early fibrosis is easier to dilate and the scar contraction that leads to shortening has not yet occurred.
New Inhibizone Implants have come with antibiotics-Rifampicin and Minocyclin.
Perforation and Erosion
Perforation is an event that occurs intraoperatively; whereas erosion is an event that occurs or is recognized only postoperatively. When the surgeon is dilating the proximal corpora (crura), a sudden give of the dilator suggests that the crus has been perforated on its medial aspect near its attachment to the pelvic bone. The dilator, almost always a smaller size, travels out into the soft tissues of the perineum. Mulcahy suggested the “wind sock” correction for this, but it is rarely necessary if the perforation is recognized and larger diameter dilators are used to dilate the correct track. When the proximal portion of the cylinder is inserted, it stays within the crus and the small area of perforation heals over it.
With distal dilation, crossover to the opposite side may occur or the urethra may be perforated. If urethral perforation occurs, the implant procedure should be abandoned and a urethral catheter should be left in for 7 to 10 days. Prosthesis reimplantation may be done at a later date. To avoid urethral perforation, the surgeon should keep the tip of the dilator under the dorsolateral surface of the corpus cavernosum. This maneuver also helps to prevent crossover to the opposite side. After the first cylinder is implanted, the surgeon should resound the other side both proximally and distally to see whether crossover in either direction has occurred.
Erosion of the distal end of the prosthesis may occur into the urethra, in which case it is visible through the meatus. This occurs more commonly after semirigid rod implantation, presumably because of constant internal pressure from the rod device. It also occurs more commonly in men with spinal cord injury because of their lack of sensation. In the case of urethral erosion, a urethral catheter is placed for 10 days to allow urethral healing. Many patients are able to have adequate coitus with only one rod in place; hence, a procedure to reimplant the second rod is usually not necessary.
Poor Glans Support
Poor support of the glans penis by cylinder or rod tips leads to a drooping appearance of the glans, which is commonly referred to as the SST deformity after the supersonic transport (Concorde) nose appearance on takeoff and landing. This deformity may result from inadequate distal dilation, too short cylinders, or, in the case of minor deformity, variations in anatomy.
Correction of this deformity can be done in one of two ways. The definitive correction involves removing both cylinders, perforating the distal capsule with Metzenbaum scissors, redilating the distal corpora, resizing, and then inserting longer cylinders or the same cylinders with longer rear tip extenders. Alternatively, dorsal plication of the glans back onto the shaft of the penis can be performed. The latter procedure is preferable when there are minor but otherwise bothersome degrees of SST deformity.

Pump Complications
The technique for pump implantation discussed previously helps to avoid upward pump migration, which tends to take place during healing because of the action of the cremasteric muscles. If upward pump migration occurs, the pump may impinge on the base of the penis, making use of the pump difficult and also interfering with intromission. Revision is sometimes necessary, at which time the pump is relocated to its correct position.
The pump may also be difficult to use if a hematoma or seroma forms around it. These may reabsorb with time; if they do not, pump revision may be necessary.
Autoinflation occurs when the inflatable penile prosthesis partially inflates with physical activity. It can be minimized by placing the reservoir in the prevesical (retropubic) space and by performing the back pressure test as described previously. The cylinders should also be kept deflated during healing after surgery and when the prosthesis is not being used.
Mentor has a reservoir with a lock-out valve available as an option. Initial experience with this device suggests that it reduces the incidence of this complication.


  1. Thanks so much for not only sharing this really helpful information, but for putting it all in one spot for easy reference!


  2. I just want to share this personal story about how my husband survived the problem of NO ERECTION after prostate surgery.
    My husband undertook prostate surgery 3 years ago and before then i always looked forward to great sex with him and after the surgery he was unable to achieve any erections, we were bothered and we tried so many drugs, injections and pumps and rings but none could give him an erection to even penetrate. I searched for a cure and got to know about Dr. Hillary who is renowned for curing problems of this nature and he did encouraged me not to give up and he recommended his herbal medication which my hubby took for 3 weeks and today his sexual performance is optimum. You too can contact him for similar problems on A man who cannot satisfy his wife's sexual need is not a real man!

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