A Technique of Maintaining Penile Prosthesis Position to Prevent Proximal Migration

0022-534 7/87 /1372-0294$02.00/0 Vol. 137, February Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright© 1987 by The Williams & Wilkins Co.

A TECHNIQUE OF MAINTAINING PENILE PROSTHESIS POSITION TO PREVENT PROXIMAL MIGRATION JOHN J. MULCAHY From the Department of Urology, Indiana University Medical Center, Wishard Memorial Hospital, Indianapolis, Indiana

ABSTRACT

A technique for proximal reconstruction of the corpora cavernosa using a synthetic vascular graft fashioned into a cup is described. In 6 cases this procedure was critical and successful in the repair of the corpora cavernosa associated with the placement of a penile prosthesis. Surgery for the placement of penile prostheses is becoming more and more commonplace. Advances in technology have now resulted in prostheses that are totally contained within the corporeal bodies and yet they become alternately rigid and flaccid. Complications of prosthetic implantation have been seen more commonly than with most other surgical procedures. Many of these complications are hydraulic in nature, owing to a kink in the tubing or leakage of fluid from an inflatable prosthesis.' Others are a result of damage to the corpora cavernosa by the presence of the prosthesis or by weakness in the tunica albuginea covering these structures. 2 Recently, 4 cases were encountered in which proximal migration of a rod prosthesis occurred. The tunica albuginea had been damaged at the original implantation or had been weakened by pressure of the foreign body in place within the erectile tissue. In 2 other cases it was necessary to reconstruct artificially the proximal corpus cavernosum to accommodate placement of a penile prosthesis. A technique is devised in which a cylindrical polytetrafluorethylene (Teflon) vascular graft is used. A cup is fashioned with a segment of this graft by closing 1 end with a double row of running 3-zero braided polyester suture. A corporotomy is made via a penoscrotal or prepubic incision. The distance from the incision to the desired proximal extent of the prosthesis is determined, which represents the length of cylindrical graft used for the cup. A size 12 or 14 graft is chosen, depending on the width of the prosthesis to be used. The cup is placed on the proximal end of the prosthesis (fig. 1), and the device in its rigid state is inserted into the corporeal body and pushed firmly behind the glans penis. At this location the cup is secured firmly to the tunica albuginea of the corpus cavernosum at the corporotomy site with approximately 4 to 6, 3-zero braided polyester sutures. The edge of the cup may be spatulated to facilitate suture placement and the graft is incorporated into the closure of the corporotomy as well.

first noticed this condition about 8 months after the original surgical implantation. With the patient under general anesthesia the right rod was repositioned more distally with the support of a polytetrafluoroethylene cup placed through a penoscrotal incision. The procedure was performed in the outpatient clinic. The patient reported satisfactory function of the device with no further problems 1 year postoperatively. Case 3. A 59-year-old man with hypertensive vascular disease underwent uneventful placement of a hydroflex penile prosthesis, 19 cm. long X 11 mm. wide. About 2 months after implan-

CASE REPORTS

Case 1. A 30-year-old paraplegic with sacral decubitus ulcers had had a malleable penile prosthesis inserted 2 years previously. At presentation the tip of the right rod was palpable at the penoscrotal junction and the proximal end of the prosthesis could be palpated easily in the area of the buttocks, close to the sacral decubitus ulcers. The position of the rods was confirmed by x-ray (fig. 2). According to the technique described, a prepubic incision was made and the right rod was anchored with a polytetrafluoroethylene cup so that the tip of each rod lay behind the glans penis. The device was functioning well when the patient was seen at followup 1½ years postoperatively. Case 2. A 56-year-old hypertensive man presented 1 year after implantation of a malleable prosthesis with the tip of the right rod 4 cm. more proximal than that of its mate. The patient FIG. 1.

Accepted for publication August 29, 1986.

cup. 294

Malleable prosthesis inserted into polytetrafluoroethylene

FIG. 2. Case 1. X-ray shows proximal migration of right malleable rod.

tation he noticed proximal migration of the left cylinder, and was able to move the cylinder up and down in the shaft of the penis while the prosthesis was erect. A penoscrotal incision was made and a polytetrafluoroethylene cup was inserted, which stabilized the left rod and fixed it permanently in a distal location. The patient had a superficial bladder tumor resected 9 months after this repair and the device was working well at that time. Case 4. A 54-year-old man had undergone multiple coronary bypass procedures and a hydroflex prosthesis with 19 cm. x 11 mm. bilateral cylinders was inserted to restore erectile capability. He and his wife were not happy with the turgor of the erection, and proximal migration of the left cylinder of about 3 cm. was noticed 3 months postoperatively. Both cylinders were removed via a penoscrotal incision and a 19 cm. X 13 mm. cylinder was inserted into the right corporeal body. With a size 14 polytetrafluoroethylene cup it was impossible to place the cup far enough proximally to accommodate a 19 cm, x 13 mm. cylinder in the left corporeal bodyo Instead a 16 cm, X 13 mm, cylinder 'Nas placed in the proximal polytetrafluoroethylene cup and the edges of the cup were sutured to the tunica albuginea of the corpus cavernosurn so that the tip of the prosthesis rested in the subglandular area. A gratifying result to the patient and his wife was achieved with regard to turgor and appearance of the erection. They were still with the results when last contacted 14 months after Comment: Two additional ;.mv,~.C,V~ of the nr,IV1fPt,•,atluvc>uv,cHJ for f.H<HC•.U

became infected and was artificial urinary sphincter was placed removed, An around both corpora cavernosa and the corpus spongiosum at the urethral bulb, since was impossible to dissect spongiosum from cavernosa. The patient was partially dry and, subsequently, ~ m ri a penile prosthesis. A second AMS800 artificial urinary sphincter was placed around the distal bulbous urethra just proximal to the penoscrotal junction. Malleable rods were placed within the corpora cavernosa. To prevent the proximal end of each rod from lying within the proximal artificial sphincter cuff polytetrafluoroethylene cups were used to limit the functional extent of each corpus cavernosum to the area distal to the sphincter cuff, which encompassed the entire penis (fig. 3). The patient has remained almost totally dry and is potent 2 years postoperatively. Case 6. A 52-year-old man with diabetes mellitus and severe 0 -0

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FIG. 3. Case 5. Corpora cavernosa functionally shortened to prevent malleable rods from resting within proximal sphincter cuff.

FIG. 4. Case 6. Penile reconstruction with polytetrafluoroethylene cups sutured to ischiopubic rami.

vascular disease suffered an infection in the penis following uu1c,:,1m;ut of a Small Carrion prosthesis. The process became so severe that penile necrosis occurred with loss of 75 per cent of the distal penile shaft. The ,....,"..,'"~'" l year after for reconstruction accu.mc111,mt,u with an inflatable penile surrounded ··a left thickness skin grafts. Owing to severe scarring of the remnant crural bodies, the proximal corpora cavernosa were recreated with polytetrafluoroethylene cups secured to the ischiopubic rami with 3-zero braided polyester suture (fig. At 1 year followup a satisfactory functional result was achieved. The patient voids through a urethral meatus near the penoscrotal junction. DISCUSSION

Proximal perforation of the corpus cavernosum may be owing either to aggressive or misdirected dilation of the erectile tissue at the time of implantation, or a weakening of the tunica albuginea with time under the pressure of the prosthesis. The natural inclination when faced with a situation of proximal perforation is to expose the affected areas perineally and to suture the defect closed. This may suffice temporarily but eventually a perforation and proximal migration of the prosthesis will recur. Another possible solution would be to staple

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MULCAHY

or sew the prosthesis directly to the ischium or its periosteum. When this has been tried extreme pain was experienced by the patient or the suture eventually tore out of the prosthesis. When faced with a perforation of significant girth at the time of implantation it would be prudent to use a synthetic cup as described rather than return another day to attempt reinsertion if the cylinder is left out or to repair the defect when proximal migration of the inserted cylinder occurs. This problem seems to be unique to the semirigid rod and new generation of selfcontained inflatable prostheses. The input tubing coming off of the old inflatable cylinders almost at a right angle anchors the cylinder in place and prevents back and forth migration. There have been no complications related to the cup place-

ment specifically, no infection or recurrence of proximal migration and the cup placement did not seem to affect prosthesis performance in any adverse manner. This technique of using a synthetic cup provides an easy and reliable method of reconstructing the proximal crural bodies and preventing proximal migration of rod-like prostheses. REFERENCES 1. Kessler, R.: Complications of inflatable penile prostheses. Urology,

18: 470, 1981. 2. Kaufman, J. J., Lindner, A. and Raz, S.: Complications of penile prosthesis surgery for impotence. J. Urol., 128: 1192, 1982.