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Complications of Penile Prosthesis Surgery for Impotence
0022-5347/82/1286-1192$02.00/0 Vol. 128, December Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
COMPLICATIONS OF PENILE PROSTHESIS SURGERY FOR IMPOTENCE JOSEPH J. KAUFMAN, ARIE LINDNER
AND
SHLOMO RAZ
From the Department of Surgery, Division of Urology, UCLA School of Medicine, Los Angeles, California
ABSTRACT
Complications and their management in 1,207 cases of semirigid rod prosthesis for erectile failure are presented. Major complications occurred in 7.8 per cent of the cases. Complications and management of 84 cases of impotence treated with inflatable penile prostheses also are discussed. Mechanical problems occurred in 44 per cent of the cases and medical complications occurred in 10 per cent. Previous reports have indicated the variety and frequency of mechanical and medical complications associated with semirigid rod and inflatable prostheses for the treatment of impotence in men. 1- 6 We describe our experience with 1,207 semirigid rod prostheses implanted between 1973 and 1980, and 84 inflatable penile prostheses implanted between 1977 and 1980. SEMIRIGID ROD PROSTHESES
expectantly with diuretics and elevation of the penis, and paraphimosis requiring circumcision in 2. Another complication that relates to individual anatomical variation has to do with difficulty in wearing the prosthesis in a comfortable manner. Most of these patients have a short suspensory ligament. Severing the suspensory ligament in such cases will allow the penis to assume a dependent position when the patient is upright and walking. An irreducible number of infections and painful postoperative complaints will occur despite all precautions. We previously reported our results of psychological inventory among patients treated with semirigid rod prostheses. A satisfaction rate of 78 per cent was obtained in the study. 7
The indications for placement of semirigid rod prostheses are given in table 1. Our experience reflects use of the SmallCarrion rods in 724 patients (61 per cent) and the Finney flexirods in 483 (39 per cent). Our experience with the silver wire prosthesis (Jonas) is limited and is not included in this report. The vast majority of implants was done through a small vertical INFLATABLE PENILE PROSTHESES infrapubic incision. Early cases were implanted by the perinea! Between 1977 and 1980, 84 inflatable penile prostheses were approach and a few cases were done by circumcision or penoimplanted. The approach used was through an incision over the scrotal incisions. None of the complications discussed herein lower part of the pubis to allow access to the corpora, scrotum was attributed to the approach used. and rectus muscles through which the reservoir was placed in The major complications among the 1,207 cases consisted of the pre-vesical space. Complications consisted of fluid leak in pain lasting >4 weeks in 21 cases, too short, producing flexion 19 cases, malposition of the scrotal pump in 5, ballooning of the deformity in 22, too long, producing pain or cosmetic problems cylinders in 4, erosion of the skin by the tubing in 2, capsule in 15, wound infection in 19, urethral erosion in 7, skin erosion formation around the reservoir resulting in spontaneous filling in 6 and urinary retention in 4. In sum, there were 94 major of the cylinders in 2, tubing kink in 1 and unspecified in 4. Of complications (7.8 per cent). The treatment for these complithese 84 patients 37 (44 per cent) had the mechanical problems cations is outlined in table 2. In addition, there were minor treated as indicated in table 3. In addition, 8 patients (10 per complications in 15 patients, consisting of decreased sensation cent) had medical complications, consisting of infection requirin 6, persistent edema in 7 and paraphimosis in 2. ing removal of the prosthesis in 3, pain in 3 requiring removal Pain was the chief complaint in 21 patients, among whom 15 in 2 cases and decreased sensation in 2. were diabetics. The preponderance of pain in this group is The problems of fluid leak and ballooning of the cylinders notable and patients should be forewarned of the possibility. largely have been eliminated as a result of recent changes in Inappropriate size is largely a matter of experience and training the design and placement of the prosthesis. It is now acknowlbut some patients have this problem as a result of an anatomical edged that most fluid leaks occurred as a result of inflow tube condition, wherein the septum between the corpora cavernosa wear. With the introduction ofrear tip extenders and the use of and glans penis is such that the glans will bend despite placeshorter cylinders fluid leaks resulting from inflow tube wear ment of the correct size of prosthesis. These cases must be have been reduced considerably. By the same token ballooning treated by the method of dorsal subcutaneous suturing of the of the cylinders occurred more commonly when long cylinders glans penis to the tunica albuginea of the corpora through a hemicircumcision approach (see figure). TABLE 1. Causes of impotence treated with semirigid rods Wound infection occurred in 19 patients despite the universal No.(%) use of prophylactic antibiotics the night before and the morning of operation, and the irrigation of wounds with topical antibiotic (21) 253 Ca prostate (postop. and after radiation therapy) solutions. Of the 19 wound infections 10 occurred in diabetics 221 (18) Ca bladder (postop.) and 6 occurred in patients who had extensive surgery to release 202 (17) Functional Peyronie's plaques. Urethral erosion occurred in 7 cases, result193 (16) Diabetes ing in the removal of 1 rod in 6 and both rods in 1. Skin erosion 145 (12) Neurogenic and trauma 118 (10) Peyronie's disease resulting in removal of 1 rod occurred in 6 patients. Urinary 35 (3) Benign prostatic hyperplasia retention developed in 4 patients and required subsequent (preop. and postop.) transurethral resection. 29 (2) Arteriosclerosis or vascular surgery Minor complications consisted of decreased sensation in 6 10 (1) Post-priapism Transsexual patients who received no special treatment, edema in 7, treated - -1 - 1,207 (100) Accepted for publication March 19, 1982. 1192
1193
COMPLICATIONS OF PENILE PROSTHESIS SURGERY FOR IMPOTENCE
2. Medical or mechanical complications of semirigid rod prostheses in 1,207 patients treated between 1973 and 1981
TABLE
Complication
No. Cases
Pain lasting up to 4 wks.
21
Treatment
No. Cases
TABLE
3. Complications of inflatable penile prostheses in 84
patients treated between 1977 and 1980 Complication
No. Cases
Major
Inappropriate size: Too short
22
15
Too long Wound infection Urethral erosion
19 7
Skin erosion Urinary retention
6 4
Treatment
No. Cases
Mechanical Removed Expectant therapy
10 11
Fluid leak* Malposition of pump
Changed rods (lengthening) Surgical correction Surgical correction (shortening) Removal Removal of 1 rod Removal of 2 rods Removal of 1 rod Transurethral resection of prostate
10
Ballooning of cylinderst
4
Erosion of skin by tubing
2
Capsule around reservoir Tubing kink Other (not specified)
2 1 4
Infection Pain Decreased sensation
3 3 2
19 5
Replacement Reposition Replacement Monofilament knitted polypropylene cuffing Replacement Removal Local antibiotics and repair Lysis Surgical correction
12 15 17 6 1 6 4
17 4 1 2 2
2 1
Medical Minor Decreased sensation Edema Paraphimosis
6 7 2
None Expectant therapy Circumcision
2
,,
1
2-0 Prolene,,-
2
Removal Removal None
3 2
* Fluid leak: 1977-3/6 (50 per cent), 1978-3/10 (30 per cent), 1979-9/28 (30 per cent), 1980-4/24 (16.6 per cent). t Ballooning: 1978-1/10 (10 per cent), 1979-3/28 (10 per cent).
untimely erection has occurred in a number of patients and this condition was corrected by having patients inflate and deflate the cylinders daily. Compression of the penis during deflation will allow the capsule around the reservoir to stretch. This capsule required lysis in 2 cases. Tubing kinks largely have been eliminated by using right angle tube connectors between the cylinders and the inflow tubes from the pump, and using a straight connector from the pump tube to the reservoir tubing. Malposition of the pump is best avoided by careful placement of the pump in the subdartos pouch and having the patient pull the pump in the most dependent portion of the scrotum, frequently during the postoperative period. However, in patients with a short scrotum it is sometimes difficult to place the pump in a comfortable position. Results are similar to those of other urologists who have reported complication rates varying from 30 to 45 per cent. 5• 6 DISCUSSION
Prosthesis
Method of correcting flexion deformity of glans when this is caused by prostheses that are too short. Polypropylene sutures are placed subcutaneously through hemicircumferential incision. Horizontal mattress sutures are placed into substance of glans penis under skin and sutured to Buck's fascia and tunica albuginea of corpora cavernosa. This procedure has rein-like effect on glans, keeping it pulled back onto shaft of penis.
were used without the rear tip extenders. Currently, with the use of rear tip extenders, the cylinders are shorter and the opportunity for ballooning is less. We corrected ballooning in 2 cases by replacing the cylinders with shorter cylinders and rear tip extenders, and before the advent of this modification by cuffing the proximal third of the cylinders with monofilament knitted polypropylene arterial tube grafts. The problem of spontaneous filling of the cylinders producing
Patients should be selected carefully for this specialized surgery from the standpoint of motivation and to avoid unrealistic expectations. They should be warned that pain usually persists for at least 2 weeks and frequently 4 weeks. Diabetics seem particularly prone to have postoperative pain with the semirigid rod prostheses and this may be related to neuropathic conditions in this group. Assiduous use of prophylactic antibiotics is mandatory but a small number of patients will have infection in any event. The proper selection of rod size will minimize the number of problems associated with prostheses that are too long or too short. It is our opinion that patients should be motivated strongly to have this type of operation and not undertake it lightly. Obviously, with patients who have strong motivation and who are well informed of possible complications improved over-all results can be expected. As a result of technical advances made during the several years of this report complications have declined steadily. REFERENCES 1. Kramer, S. A., Anderson, E. E., Bredael, J. J. and Paulson, D. F.:
Complications of Small-Carrion penile prosthesis. Urology, 13: 49, 1979. 2. Shelling, R. H. and Maxted, W. C.: Major complications of silicone penile prosthesis: predisposing clinical situations. Urology, 15: 131, 1980. 3. Melman, A.: Experience with implantation of the Small-Carrion penile implant for organic impotence. J. Urol., 116: 49, 1976.
1194
KAUFMAN, LINDNER AND RAZ
EDITORIAL COMMENT
In our experience prolonged pain is caused primarily by the implantation of a prosthesis that is too long. Pain lasting more than 6 weeks usually can be corrected by removing the 2 implants through lateral coronal incisions, trimming 0.5 cm. from the proximal end and replacing them. 1 Immediate relief often is obtained. We correct the displaced glans by removing an ellipse of tunica albuginea at the corona on the side opposite the direction of deviation. When this is closed it pulls the glans back in line. Roy P. Finney Department of Surgery, Division of Urology University of South Florida Medical Center Tampa, Florida
This valuable report presents data useful to all urologists engaged in the surgical treatment of impotence. The large number of cases is impressive.
1. Finney, R. P.: Controversies in Neuro-Urology. New York: Churchill Livingston, Inc., chapt. 12, in press.
4. Gerstenberger, D. L., Osborne, D. and Furlow, W. L.: Inflatable penile prosthesis: followup study of patient-partner satisfaction. Urology, 14: 583, 1979. 5. Furlow, W. L.: Use of the inflatable penile prosthesis in erectile dysfunction. Urol. Clin. N. Amer., 8: 181, 1981. 6. Kessler, R.: Complications of inflatable penile prostheses. Urology, 18: 470, 1981. 7. Kaufman, J. J., Boxer, R. J., Boxer, B. and Quinn, M. C.: Physical and psychological results of penile prosthesis: a statistical survey. J. Urol., 126: 173, 1981.
THE JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
COMPLICATIONS OF PENILE PROSTHESIS SURGERY FOR IMPOTENCE JOSEPH J. KAUFMAN, ARIE LINDNER
AND
SHLOMO RAZ
From the Department of Surgery, Division of Urology, UCLA School of Medicine, Los Angeles, California
ABSTRACT
Complications and their management in 1,207 cases of semirigid rod prosthesis for erectile failure are presented. Major complications occurred in 7.8 per cent of the cases. Complications and management of 84 cases of impotence treated with inflatable penile prostheses also are discussed. Mechanical problems occurred in 44 per cent of the cases and medical complications occurred in 10 per cent. Previous reports have indicated the variety and frequency of mechanical and medical complications associated with semirigid rod and inflatable prostheses for the treatment of impotence in men. 1- 6 We describe our experience with 1,207 semirigid rod prostheses implanted between 1973 and 1980, and 84 inflatable penile prostheses implanted between 1977 and 1980. SEMIRIGID ROD PROSTHESES
expectantly with diuretics and elevation of the penis, and paraphimosis requiring circumcision in 2. Another complication that relates to individual anatomical variation has to do with difficulty in wearing the prosthesis in a comfortable manner. Most of these patients have a short suspensory ligament. Severing the suspensory ligament in such cases will allow the penis to assume a dependent position when the patient is upright and walking. An irreducible number of infections and painful postoperative complaints will occur despite all precautions. We previously reported our results of psychological inventory among patients treated with semirigid rod prostheses. A satisfaction rate of 78 per cent was obtained in the study. 7
The indications for placement of semirigid rod prostheses are given in table 1. Our experience reflects use of the SmallCarrion rods in 724 patients (61 per cent) and the Finney flexirods in 483 (39 per cent). Our experience with the silver wire prosthesis (Jonas) is limited and is not included in this report. The vast majority of implants was done through a small vertical INFLATABLE PENILE PROSTHESES infrapubic incision. Early cases were implanted by the perinea! Between 1977 and 1980, 84 inflatable penile prostheses were approach and a few cases were done by circumcision or penoimplanted. The approach used was through an incision over the scrotal incisions. None of the complications discussed herein lower part of the pubis to allow access to the corpora, scrotum was attributed to the approach used. and rectus muscles through which the reservoir was placed in The major complications among the 1,207 cases consisted of the pre-vesical space. Complications consisted of fluid leak in pain lasting >4 weeks in 21 cases, too short, producing flexion 19 cases, malposition of the scrotal pump in 5, ballooning of the deformity in 22, too long, producing pain or cosmetic problems cylinders in 4, erosion of the skin by the tubing in 2, capsule in 15, wound infection in 19, urethral erosion in 7, skin erosion formation around the reservoir resulting in spontaneous filling in 6 and urinary retention in 4. In sum, there were 94 major of the cylinders in 2, tubing kink in 1 and unspecified in 4. Of complications (7.8 per cent). The treatment for these complithese 84 patients 37 (44 per cent) had the mechanical problems cations is outlined in table 2. In addition, there were minor treated as indicated in table 3. In addition, 8 patients (10 per complications in 15 patients, consisting of decreased sensation cent) had medical complications, consisting of infection requirin 6, persistent edema in 7 and paraphimosis in 2. ing removal of the prosthesis in 3, pain in 3 requiring removal Pain was the chief complaint in 21 patients, among whom 15 in 2 cases and decreased sensation in 2. were diabetics. The preponderance of pain in this group is The problems of fluid leak and ballooning of the cylinders notable and patients should be forewarned of the possibility. largely have been eliminated as a result of recent changes in Inappropriate size is largely a matter of experience and training the design and placement of the prosthesis. It is now acknowlbut some patients have this problem as a result of an anatomical edged that most fluid leaks occurred as a result of inflow tube condition, wherein the septum between the corpora cavernosa wear. With the introduction ofrear tip extenders and the use of and glans penis is such that the glans will bend despite placeshorter cylinders fluid leaks resulting from inflow tube wear ment of the correct size of prosthesis. These cases must be have been reduced considerably. By the same token ballooning treated by the method of dorsal subcutaneous suturing of the of the cylinders occurred more commonly when long cylinders glans penis to the tunica albuginea of the corpora through a hemicircumcision approach (see figure). TABLE 1. Causes of impotence treated with semirigid rods Wound infection occurred in 19 patients despite the universal No.(%) use of prophylactic antibiotics the night before and the morning of operation, and the irrigation of wounds with topical antibiotic (21) 253 Ca prostate (postop. and after radiation therapy) solutions. Of the 19 wound infections 10 occurred in diabetics 221 (18) Ca bladder (postop.) and 6 occurred in patients who had extensive surgery to release 202 (17) Functional Peyronie's plaques. Urethral erosion occurred in 7 cases, result193 (16) Diabetes ing in the removal of 1 rod in 6 and both rods in 1. Skin erosion 145 (12) Neurogenic and trauma 118 (10) Peyronie's disease resulting in removal of 1 rod occurred in 6 patients. Urinary 35 (3) Benign prostatic hyperplasia retention developed in 4 patients and required subsequent (preop. and postop.) transurethral resection. 29 (2) Arteriosclerosis or vascular surgery Minor complications consisted of decreased sensation in 6 10 (1) Post-priapism Transsexual patients who received no special treatment, edema in 7, treated - -1 - 1,207 (100) Accepted for publication March 19, 1982. 1192
1193
COMPLICATIONS OF PENILE PROSTHESIS SURGERY FOR IMPOTENCE
2. Medical or mechanical complications of semirigid rod prostheses in 1,207 patients treated between 1973 and 1981
TABLE
Complication
No. Cases
Pain lasting up to 4 wks.
21
Treatment
No. Cases
TABLE
3. Complications of inflatable penile prostheses in 84
patients treated between 1977 and 1980 Complication
No. Cases
Major
Inappropriate size: Too short
22
15
Too long Wound infection Urethral erosion
19 7
Skin erosion Urinary retention
6 4
Treatment
No. Cases
Mechanical Removed Expectant therapy
10 11
Fluid leak* Malposition of pump
Changed rods (lengthening) Surgical correction Surgical correction (shortening) Removal Removal of 1 rod Removal of 2 rods Removal of 1 rod Transurethral resection of prostate
10
Ballooning of cylinderst
4
Erosion of skin by tubing
2
Capsule around reservoir Tubing kink Other (not specified)
2 1 4
Infection Pain Decreased sensation
3 3 2
19 5
Replacement Reposition Replacement Monofilament knitted polypropylene cuffing Replacement Removal Local antibiotics and repair Lysis Surgical correction
12 15 17 6 1 6 4
17 4 1 2 2
2 1
Medical Minor Decreased sensation Edema Paraphimosis
6 7 2
None Expectant therapy Circumcision
2
,,
1
2-0 Prolene,,-
2
Removal Removal None
3 2
* Fluid leak: 1977-3/6 (50 per cent), 1978-3/10 (30 per cent), 1979-9/28 (30 per cent), 1980-4/24 (16.6 per cent). t Ballooning: 1978-1/10 (10 per cent), 1979-3/28 (10 per cent).
untimely erection has occurred in a number of patients and this condition was corrected by having patients inflate and deflate the cylinders daily. Compression of the penis during deflation will allow the capsule around the reservoir to stretch. This capsule required lysis in 2 cases. Tubing kinks largely have been eliminated by using right angle tube connectors between the cylinders and the inflow tubes from the pump, and using a straight connector from the pump tube to the reservoir tubing. Malposition of the pump is best avoided by careful placement of the pump in the subdartos pouch and having the patient pull the pump in the most dependent portion of the scrotum, frequently during the postoperative period. However, in patients with a short scrotum it is sometimes difficult to place the pump in a comfortable position. Results are similar to those of other urologists who have reported complication rates varying from 30 to 45 per cent. 5• 6 DISCUSSION
Prosthesis
Method of correcting flexion deformity of glans when this is caused by prostheses that are too short. Polypropylene sutures are placed subcutaneously through hemicircumferential incision. Horizontal mattress sutures are placed into substance of glans penis under skin and sutured to Buck's fascia and tunica albuginea of corpora cavernosa. This procedure has rein-like effect on glans, keeping it pulled back onto shaft of penis.
were used without the rear tip extenders. Currently, with the use of rear tip extenders, the cylinders are shorter and the opportunity for ballooning is less. We corrected ballooning in 2 cases by replacing the cylinders with shorter cylinders and rear tip extenders, and before the advent of this modification by cuffing the proximal third of the cylinders with monofilament knitted polypropylene arterial tube grafts. The problem of spontaneous filling of the cylinders producing
Patients should be selected carefully for this specialized surgery from the standpoint of motivation and to avoid unrealistic expectations. They should be warned that pain usually persists for at least 2 weeks and frequently 4 weeks. Diabetics seem particularly prone to have postoperative pain with the semirigid rod prostheses and this may be related to neuropathic conditions in this group. Assiduous use of prophylactic antibiotics is mandatory but a small number of patients will have infection in any event. The proper selection of rod size will minimize the number of problems associated with prostheses that are too long or too short. It is our opinion that patients should be motivated strongly to have this type of operation and not undertake it lightly. Obviously, with patients who have strong motivation and who are well informed of possible complications improved over-all results can be expected. As a result of technical advances made during the several years of this report complications have declined steadily. REFERENCES 1. Kramer, S. A., Anderson, E. E., Bredael, J. J. and Paulson, D. F.:
Complications of Small-Carrion penile prosthesis. Urology, 13: 49, 1979. 2. Shelling, R. H. and Maxted, W. C.: Major complications of silicone penile prosthesis: predisposing clinical situations. Urology, 15: 131, 1980. 3. Melman, A.: Experience with implantation of the Small-Carrion penile implant for organic impotence. J. Urol., 116: 49, 1976.
1194
KAUFMAN, LINDNER AND RAZ
EDITORIAL COMMENT
In our experience prolonged pain is caused primarily by the implantation of a prosthesis that is too long. Pain lasting more than 6 weeks usually can be corrected by removing the 2 implants through lateral coronal incisions, trimming 0.5 cm. from the proximal end and replacing them. 1 Immediate relief often is obtained. We correct the displaced glans by removing an ellipse of tunica albuginea at the corona on the side opposite the direction of deviation. When this is closed it pulls the glans back in line. Roy P. Finney Department of Surgery, Division of Urology University of South Florida Medical Center Tampa, Florida
This valuable report presents data useful to all urologists engaged in the surgical treatment of impotence. The large number of cases is impressive.
1. Finney, R. P.: Controversies in Neuro-Urology. New York: Churchill Livingston, Inc., chapt. 12, in press.
4. Gerstenberger, D. L., Osborne, D. and Furlow, W. L.: Inflatable penile prosthesis: followup study of patient-partner satisfaction. Urology, 14: 583, 1979. 5. Furlow, W. L.: Use of the inflatable penile prosthesis in erectile dysfunction. Urol. Clin. N. Amer., 8: 181, 1981. 6. Kessler, R.: Complications of inflatable penile prostheses. Urology, 18: 470, 1981. 7. Kaufman, J. J., Boxer, R. J., Boxer, B. and Quinn, M. C.: Physical and psychological results of penile prosthesis: a statistical survey. J. Urol., 126: 173, 1981.