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Ambulatory surgery for a penile prosthesis
Cheryl Parker, R N
Ambulatory surgery for a penile prosthesis
Impotence is rarely due to organic disease. In most cases it is of psychic origin, nearly always the result ofsexual fear.
This statement from the 1952 Yearbook of Urology sounds outdated. Yet, as late as the 1970s, some marriage counseling books and medical articles attributed most impotence to psychological problems. Today, with the development of sophisticated testing methods, an increasing number of patients are found to have an organic cause for their sexual dysfunction. Recent studies have shown that 50% of patients with impotence may have underlying organic problems.' Some physicians believe the proportion may actually be as high as 70% or more. A penile prosthesis may be recommended if the condition cannot be medically corrected or is a result of an unsuccessfully treated psychologicalproblem. Patients often prefer prosthesis insertion as an ambulatory procedure. If there are no medical contraindications, this is the most cost-effective way for treatment. We have established a protocol for these surgical outpatients,
Cheryl Parker, RN, CNOR, is clinic coordinator and private scrub nurse at the McDonald Urology Clinic, Atlanta. She is an associate degree graduate of Georgia State University, Atlanta.
which we will describe. Causes of organic impotence. To understand impotence better, it is important to know how a normal erection occurs. The penis has two cylinders of spongy tissue, one on either side of the urethra, called the corpora cavernosa. During a normal erection, each corpus fills with blood until the penis becomes erect. The anatomy of the vessels and the neurological fibers must all be intact to achieve and maintain an erection. Trauma, surgical or otherwise, is a frequent cause of impotence. Any radical pelvic surgery, such as radical prostatectomy or a n abdominoperineal resection, can result in impotence. Common organic causes are alcoholism, diabetes mellitus, Peyronie's disease, low testosterone levels, drug and chemical therapy, and penile arterial insufficiency secondary to atherosclerosis (Table 1). Anything that interferes with the vascular, neural, or anatomic mechanisms will cause erectile failure. Neurological disorders that affect the descending pathways to the pelvic area can lead to erectile dysfunction. Neurologically induced impotence is often seen in multiple sclerosis or cerebral vascular accident patients. Since blood flow to the penis is necessary for erection, vascular diseases, such as an iliac artery obstruction or generalized atherosclerosis, will affect the ability to have an erection.
AORN Journal, September 1982, V o l 3 6 , No 3
487
Table 1
Organic causes of impotence Inflammatory Prostatitis Urethritis Cystitis Urethral stricture
Vascular Mac artery obstruction Senility Penile artery obstruction from atherosclerosis
Postsurgical or traumatic Prostatectomy Cystectomy Abdominoperineal resection Aortic aneurysm Sympathectomy (lumbar,dorsal, pelvic) Castration Pelvic fracture Spinal cord trauma Pelvic irradiation
Medications Antihypertensives Tranquilizers Diphenylhydantoin (Dilantin) Antihistamines Estrogen Morphine Ethanol
Neurogenic Spina bifida Multiple sclerosis Spinal cord compression
Neoplastic Pituitary tumor Hypothalamic tumor Adrenal tumor Spinal cord tumor Squamous cell cancer of the penis
Endocrine Diabetes mellitus Low serum testosterone Hyperthyroidism Hypothyroidism Addison's disease Cushing's disease At least 60% of males with diabetes mellitus or even an elevated glucose tolerance test are impotent. Many drugs cause erection problems. Among them are tranquilizers, antihypertensive agents, diphenylhydantoin (Dilantin), barbiturates, ethanol, and even antihistamines. Evaluation of impotence. New methods are helpful in differentiating between organic and psychological impotence. A flow sheet is used for each patient having an impotence evaluation. Items on the flow sheet include a sexual function questionnaire, laboratory tests, urodynamics evaluation, intravenous pyelo-
488
Mechanical Peyronie's disease Microphallus Hypospadius Epispadius
gram, penile blood flow (Doppler) test, and the Minnesota Multiphasic Personality Inventory (MMPI). Following a thorough history and physical, a patient may have some or all of the tests on the flow sheet. Included in the laboratory test may be a serum testosterone level and biochemical profile (BCP)20 test. The testosterone test will indicate whether the impotence is related to a low hormone level. The BCP 20 will help the physician evaluate the patient's general well-being. The possibility of diabetes mellitus or even borderline diabetesmellitus will be considered. A glucose toler-
AORN Journal, September 1982, Vo136, N o 3
ance test is often done during the evaluation period, especially if the patient has a family history of diabetes mellitus or is overweight. Urodynamic studies test the nerves and muscles of the bladder. Nerve damage to the part of the spinal cord that causes impotence frequently affects bladder function. Patients with impotence due to diabetes mellitus may have up t o 80% abnormal urodynamic studies. The penile blood flow can be measured in the physician’s office. A penile blood pressure cuff and a Doppler stethoscopedetermine penile blood flow at various pressures. X-ray studies, such as an intravenous pyelogram, are often included in evaluation of patients with primary genitourinary disease. Men normally have erections each night. These are associated with periods of rapid eye movement and are seen on electroencephalographic tracings. Nocturnal penile tumescence (NPT) monitoring requires a patient to spend from Alcoholism
11% Priapism 11% Drug, chemical therapy Peyronie’s disease Psychogenic factors Spinal cord injury Trauma pelvic, genital Vascular disease Other
one to three nights in a “sleep lab.” New methods are becoming available so a patient could be monitored in his own home. If the cause is organic, erections are either absent or decreased during monitoring. If the underlying cause is psychological, the NFT test will usually be normal. In some patients, a psychological screening may be indicated. We administer the MMPI test in the office. Further psychological evaluation is indicated if test results deviate from the normal. Treatment of impotence. Treatment of impotence depends on the cause. Patients who have positive MMPI test results and fail to show clear-cut organic disease are referred to a sex counselor. Patients with urological diseases frequently respond to appropriate treatment of these problems. Sometimes changing antihypertension medications may be all that is necessary to treat the erectile dysfunction. If the Fig 1
Implants by etiology
I2%
Radical pelvic surgery Diabetes mellitus Courtesy of American Medical Systems, Minneapolis
AORN Journal, September 1982, Vol36, No 3
489
Fig 2. (Top) Two types of semirigid prostheses. The device at top is by the Medical Engineering Corporation and the one at the bottom is by American Heyer-Schulte. Fig 3. (Right) The components of the inflatable prosthesis. Illustrations of the inflatable device are courtesy of American Medical Systems.
testosterone level is low, testosterone can be given either intramuscularly or, as preferred, by subcutaneous pellet implantation. After a thorough clinical evaluation, a penile prosthesis may be indicated if a patient has organic impotence that cannot be medically corrected or a psychological problem that
490
cannot be treated. Ambulatory surgery. If the patient and his physician decide a n implant is the best solution, the patient enters preoperative counseling. Figure 1 shows the incidence of penile implant among patients with specific conditions. The various types of prostheses and
AORN Journal, September 1982, Vol36, N o 3
~~
~~
cause erection
Fig 4. The inflatable prosthesis is shown implanted. The penis appears normal in the deflatedposition. The device is inflated with the pump before sexual relations. Fig 5. The penile prosthesis in its inflated and deflated positions. their advantages and disadvantages are discussed with the patient so he can decide which type would be best suited for him. He can examine drawings, diagrams, and actual prostheses before making a choice. In some cases, it may be helpful for patients to talk with other penile implant patients. The patient’s wife may participate in the preoperative discussion on the implant selection if the patient wishes. Basically, there are two types of penile prosthesis-the semirigid and the inflatable (Figs 2 to 5). Both types can be surgically implanted in the ambulatory setting (Table 2). Once the patient has selected a prosthesis, we follow
the protocol for outpatient surgery. Preoperative preparations. Before surgery, the patient is instructed to obtain a pain medication and antibiotic and take povidone-iodine showers for five days prior to surgery. He is also told what he may eat the day of surgery, when to arrive a t the clinic, and t o have a responsible adult drive him home. We review these instructions with the patient before he leaves the clinic to ensure he understands his responsibility for preparations. On the scheduled surgery day, the patient arrives at the clinic one hour before surgery. As a n outpatient facility, we control costs by waiting to prepare
AORN Journal, September 1982, V o l 3 6 , No 3
49 1
Table 2
Types of prostheses The semirigid prosthesis Advantages The patient can begin sexual relations without any delay in achieving an erection. The surgical procedure is simpler than for the inflatable device. The costs of the prosthesis and surgical fee are less. Mechanical problems are less frequent. Disadvantages The semierect penis will be obvious in public bathing. The patient usually needs to take care with clothing to disguise the penis’s semierect state. Subsequent cystoscopicexamination or treatments are more difficult.
The inflatable prosthesis Advantages In the deflated position, the patient’s penis appears normal. The quality of the erection is excellent and may even be better than before the patient developed impotence. No special care with clothing is needed. Subsequent endoscopic examination or operation can be done without
the room or open supplies until the patient arrives. While the patient is in the holding area, the circulating nurse notes any allergies, has the patient sign an operative permit, and checks his preoperative vital signs. He is then given gentamicin (Garamycin)80 mg and methicillin 500 mg. He waits in a holding area while the operating room is prepared. The OR is carefully wiped down with an antiseptic solution. All supplies are assembled and checked according to the type of prosthesis to be inserted. Every size of prosthesis is available sterile in the room, but none is opened until needed to minimize the chance of contamination. Light sources and electrosurgical units are connected and checked. The scrub nurse sets up the Mayo stand and back table in the usual way and prepares a solution of 500 cc of
normal saline and 1 gm of kanamycin (Kantrex). This solution is placed in a spray bottle, and the operative site is sprayed constantly with a fine mist during the procedure. The prosthesis is opened carefully to protect it from lint. It is also sprayed with the antibiotic solution prior to insertion. If an inflatable prosthesis is selected,the solutions to fill the prosthesis are also prepared in advance because the circulator must be free to attend the patient during the procedure. Intraoperatiue care. Once the room is prepared, the patient is brought in and placed in the lithotomy position. The operation is performed under local anesthesia using 2% lidocaine with intravenous (IV) sedation. Throughout the procedure, the circulating nurse monitors and records the patient’s vital signs and condition on the operative
492
difficulty.
Disadvantages 1. The patient has to inflate the prosthesis before beginning sexual relations. 2. The surgical procedure to insert the prosthesis is more complicated as compared with the semirigid prosthesis procedure. 3. The costs of the prosthesis and surgical fee are greater. 4. Mechanical complication is more likely.
AORN Journal, September 1982, Vol36, No 3
record. A povidone-iodine scrub and skin preparation are done. For the semirigid prosthesis, a transverse incision is made just above the penile-scrota1 junction. An indwelling No 20 Foley catheter is used for easy identification of the urethra. Each corpus cavernosum is identified. A longitudinal 3 to 4 cm incision is made in each corpus, and the interior of the corpus is dilated using a modified Turner female metal sound followed by a Kollmann dilator. The size of the prosthesis is reconfirmed before the prosthesis is opened onto the sterile field. Once the corpora have been dilated, the prosthesis can easily be placed. The corpora are then closed using a continuous stitch with 2-0 polyglycolic acid suture. Inserting the inflatable prosthesis is slightly more complicated though similar t o inserting the semirigid prosthesis. All three components of this hydraulic system can be properly placed through the penile-scrota1 incision. Each corpus is opened in a similar manner, and the correct size is determined. The pump is placed in the scrotal sac and the reservoir is placed inside the internal inguinal ring. A ring forceps aids in placing the reservoir, and a Furlow device assists in inserting the expandable cylinders into the corpora. All connections are carefully made. No sharp instruments or needles must come in contact with the prosthesis. When the components are in place, the prosthesis is checked for proper function before the incision is closed. The pump, placed in the scrotal sac, controls the erections. For an erection to occur, several pumping actions are required to move the fluid from the reservoir into the cylinders. A release button on the pump allows the fluid to return to the reservoir, and the penis again becomes flaccid. Necessary adjustments can be made immediately. Precautions are taken to protect the patient’s safety:
1. Patients who are poor medical risks are not selected for outpatient surgery. 2. The patient’s vital signs are monitored throughout the procedure. In addition to taking his blood pressure and manually monitoring his respirations, we use a pulse meter that records his pulse on a monitor and gives a constant sound. 3. Emergency drugs are available in the surgery room. 4. Oxygen, a laryngoscope, and tracheostomy tubes are available in the room. 5. All personnel are certified in cardiopulmonary resuscitation. The procedure to insert the semirigid prosthesis takes approximately -45 minutes to 1 hour. The inflatable prosthesis procedure is usually 1% t o 2 hours. At the completion of the procedure, a compression dressing is applied. The physician may choose to leave a catheter in overnight for patient comfort. Postoperative care. The patient is recovered for 30 minutes to an hour, depending on the amount of sedation he received. He is given gentamicin 80 mg and methicillin 500 mg intramuscularly. Then he is assisted in getting
The prosthesis is
95% SUCCeSSfUI in ending impotence. dressed. Written instructions for home care are reviewed with him and the person who will drive him home. He is encouraged to go home and rest for the remainder of the day, call us if he has any problems, and come to the office on the following day for a dressing change.
AORN Journal, September 1982, Vol36, No 3
493
If h e has a n i n d w e l l i n g Foley catheter, it w i l l be removed at h i s f i r s t postoperat i v e visit. H e w i l l be seen in t h e office for the n e x t t w o days t o have h i s dressing changed and t h e n t h e following week for a postoperative check. U s i n g t h i s protocol, we have done 30 cases w i t h o u t infection. T h e success r a t e for the prosthesis in t r e a t i n g impotence i s over 95%. A s more people become aware t h a t impotence i s often organic, we believe t h i s technique w i l l be more widely used. A m b u l a t o r y surgery t o insert a penile prosthesis is safe, ef0 fective, a n d economical. Note 1. M Bloom, “Impotence in the era of sex
therapy,” Medical World News 18 (March 7, 1977) 37.
Suggested reading Finney, R P. “New hinged silicone penile implant.” Journal of Urology 118 (October 1977) 586. Furlow, W. L. “Inflatable penile prosthesis: Mayo Clinic experience with 175 patients.” Urology 13 (February 1979) 166-171. Malloy, T R; Wein, A J. “The etiology, diagnosis and surgical treatment of erectile impotence.” Journal of Reproductive Medicine (April 1978) 183-193. Scott, F B; Bradley, W E; Tirnm, G. “Management of erectile impotence: Use of implantable inflatable prosthesis.” Urology 2 (July 1973) 80-82. Scott, F B; Byrde, G J; Karacan,I;Olsson, P; Beutler, L E; Attia, S L. “Erectile impotence treated with an implantable, inflatable prosthesis.” Journal of the American Medical Association 241 (June 15, 1979) 2609-2612.
Skin expander helps implant Insertions A new skin-stretchingtechnique permits easier insertion of permanent implants in patients who have had defects due to cancer or trauma. The technique was described at a recent American Society of Plastic and Reconstructive Surgeons science writers seminar. The purpose of the technique, called tissue expansion, is to produce an excess of soft tissue next to a defect so the “new” skin can be stretched easily over the defect and stitched into place, said Erik D Austad, MD. He is instructor of plastic surgery at the University of Michigan Medical School, Ann Arbor. In these defects, overlying skin frequently becomes so tight when it heals that there is almost no room for an implant to fit. In the case of a breast removal, the tight skin often precludes a single-step placement of a standard implant. When this skin is expanded, the final cosmetic and functional result is relatively good, explained Dr Austad. The technique involves the surgical insertion of a temporary implant that is inflated either by periodic injection of a sterile solution or a self-inflating
494
mechanism. The principle is the same as a pregnant woman’s abdominal skin expanding gradually to accommodate her growing fetus. The skin expander is removed before the reconstructive surgery, which may involve the insertion of an implant or Silastic prosthesis. To date, the various expanders have been used on a limited basis when extra skin has been needed in reconstructive surgery involving the arms, legs, scalp, breasts, and face. Dr Austad cited the success of California surgeon Chedomir Radovan, MD, who used a temporary expander device in 68 breast cancer reconstructions. “His results are excellent, and I believe that the tissue expansion technique is the most significant advance in breast reconstructionsince the development of the Cronin-filled breast prosthesis in 1964,” he said. Dr Austad projects this technique could eventually be used for skin repairs in burn victims and for such congenital problems as cleft lip and palate.
AORN Journal, September 1982, V o l 3 6 , No 3
Ambulatory surgery for a penile prosthesis
Impotence is rarely due to organic disease. In most cases it is of psychic origin, nearly always the result ofsexual fear.
This statement from the 1952 Yearbook of Urology sounds outdated. Yet, as late as the 1970s, some marriage counseling books and medical articles attributed most impotence to psychological problems. Today, with the development of sophisticated testing methods, an increasing number of patients are found to have an organic cause for their sexual dysfunction. Recent studies have shown that 50% of patients with impotence may have underlying organic problems.' Some physicians believe the proportion may actually be as high as 70% or more. A penile prosthesis may be recommended if the condition cannot be medically corrected or is a result of an unsuccessfully treated psychologicalproblem. Patients often prefer prosthesis insertion as an ambulatory procedure. If there are no medical contraindications, this is the most cost-effective way for treatment. We have established a protocol for these surgical outpatients,
Cheryl Parker, RN, CNOR, is clinic coordinator and private scrub nurse at the McDonald Urology Clinic, Atlanta. She is an associate degree graduate of Georgia State University, Atlanta.
which we will describe. Causes of organic impotence. To understand impotence better, it is important to know how a normal erection occurs. The penis has two cylinders of spongy tissue, one on either side of the urethra, called the corpora cavernosa. During a normal erection, each corpus fills with blood until the penis becomes erect. The anatomy of the vessels and the neurological fibers must all be intact to achieve and maintain an erection. Trauma, surgical or otherwise, is a frequent cause of impotence. Any radical pelvic surgery, such as radical prostatectomy or a n abdominoperineal resection, can result in impotence. Common organic causes are alcoholism, diabetes mellitus, Peyronie's disease, low testosterone levels, drug and chemical therapy, and penile arterial insufficiency secondary to atherosclerosis (Table 1). Anything that interferes with the vascular, neural, or anatomic mechanisms will cause erectile failure. Neurological disorders that affect the descending pathways to the pelvic area can lead to erectile dysfunction. Neurologically induced impotence is often seen in multiple sclerosis or cerebral vascular accident patients. Since blood flow to the penis is necessary for erection, vascular diseases, such as an iliac artery obstruction or generalized atherosclerosis, will affect the ability to have an erection.
AORN Journal, September 1982, V o l 3 6 , No 3
487
Table 1
Organic causes of impotence Inflammatory Prostatitis Urethritis Cystitis Urethral stricture
Vascular Mac artery obstruction Senility Penile artery obstruction from atherosclerosis
Postsurgical or traumatic Prostatectomy Cystectomy Abdominoperineal resection Aortic aneurysm Sympathectomy (lumbar,dorsal, pelvic) Castration Pelvic fracture Spinal cord trauma Pelvic irradiation
Medications Antihypertensives Tranquilizers Diphenylhydantoin (Dilantin) Antihistamines Estrogen Morphine Ethanol
Neurogenic Spina bifida Multiple sclerosis Spinal cord compression
Neoplastic Pituitary tumor Hypothalamic tumor Adrenal tumor Spinal cord tumor Squamous cell cancer of the penis
Endocrine Diabetes mellitus Low serum testosterone Hyperthyroidism Hypothyroidism Addison's disease Cushing's disease At least 60% of males with diabetes mellitus or even an elevated glucose tolerance test are impotent. Many drugs cause erection problems. Among them are tranquilizers, antihypertensive agents, diphenylhydantoin (Dilantin), barbiturates, ethanol, and even antihistamines. Evaluation of impotence. New methods are helpful in differentiating between organic and psychological impotence. A flow sheet is used for each patient having an impotence evaluation. Items on the flow sheet include a sexual function questionnaire, laboratory tests, urodynamics evaluation, intravenous pyelo-
488
Mechanical Peyronie's disease Microphallus Hypospadius Epispadius
gram, penile blood flow (Doppler) test, and the Minnesota Multiphasic Personality Inventory (MMPI). Following a thorough history and physical, a patient may have some or all of the tests on the flow sheet. Included in the laboratory test may be a serum testosterone level and biochemical profile (BCP)20 test. The testosterone test will indicate whether the impotence is related to a low hormone level. The BCP 20 will help the physician evaluate the patient's general well-being. The possibility of diabetes mellitus or even borderline diabetesmellitus will be considered. A glucose toler-
AORN Journal, September 1982, Vo136, N o 3
ance test is often done during the evaluation period, especially if the patient has a family history of diabetes mellitus or is overweight. Urodynamic studies test the nerves and muscles of the bladder. Nerve damage to the part of the spinal cord that causes impotence frequently affects bladder function. Patients with impotence due to diabetes mellitus may have up t o 80% abnormal urodynamic studies. The penile blood flow can be measured in the physician’s office. A penile blood pressure cuff and a Doppler stethoscopedetermine penile blood flow at various pressures. X-ray studies, such as an intravenous pyelogram, are often included in evaluation of patients with primary genitourinary disease. Men normally have erections each night. These are associated with periods of rapid eye movement and are seen on electroencephalographic tracings. Nocturnal penile tumescence (NPT) monitoring requires a patient to spend from Alcoholism
11% Priapism 11% Drug, chemical therapy Peyronie’s disease Psychogenic factors Spinal cord injury Trauma pelvic, genital Vascular disease Other
one to three nights in a “sleep lab.” New methods are becoming available so a patient could be monitored in his own home. If the cause is organic, erections are either absent or decreased during monitoring. If the underlying cause is psychological, the NFT test will usually be normal. In some patients, a psychological screening may be indicated. We administer the MMPI test in the office. Further psychological evaluation is indicated if test results deviate from the normal. Treatment of impotence. Treatment of impotence depends on the cause. Patients who have positive MMPI test results and fail to show clear-cut organic disease are referred to a sex counselor. Patients with urological diseases frequently respond to appropriate treatment of these problems. Sometimes changing antihypertension medications may be all that is necessary to treat the erectile dysfunction. If the Fig 1
Implants by etiology
I2%
Radical pelvic surgery Diabetes mellitus Courtesy of American Medical Systems, Minneapolis
AORN Journal, September 1982, Vol36, No 3
489
Fig 2. (Top) Two types of semirigid prostheses. The device at top is by the Medical Engineering Corporation and the one at the bottom is by American Heyer-Schulte. Fig 3. (Right) The components of the inflatable prosthesis. Illustrations of the inflatable device are courtesy of American Medical Systems.
testosterone level is low, testosterone can be given either intramuscularly or, as preferred, by subcutaneous pellet implantation. After a thorough clinical evaluation, a penile prosthesis may be indicated if a patient has organic impotence that cannot be medically corrected or a psychological problem that
490
cannot be treated. Ambulatory surgery. If the patient and his physician decide a n implant is the best solution, the patient enters preoperative counseling. Figure 1 shows the incidence of penile implant among patients with specific conditions. The various types of prostheses and
AORN Journal, September 1982, Vol36, N o 3
~~
~~
cause erection
Fig 4. The inflatable prosthesis is shown implanted. The penis appears normal in the deflatedposition. The device is inflated with the pump before sexual relations. Fig 5. The penile prosthesis in its inflated and deflated positions. their advantages and disadvantages are discussed with the patient so he can decide which type would be best suited for him. He can examine drawings, diagrams, and actual prostheses before making a choice. In some cases, it may be helpful for patients to talk with other penile implant patients. The patient’s wife may participate in the preoperative discussion on the implant selection if the patient wishes. Basically, there are two types of penile prosthesis-the semirigid and the inflatable (Figs 2 to 5). Both types can be surgically implanted in the ambulatory setting (Table 2). Once the patient has selected a prosthesis, we follow
the protocol for outpatient surgery. Preoperative preparations. Before surgery, the patient is instructed to obtain a pain medication and antibiotic and take povidone-iodine showers for five days prior to surgery. He is also told what he may eat the day of surgery, when to arrive a t the clinic, and t o have a responsible adult drive him home. We review these instructions with the patient before he leaves the clinic to ensure he understands his responsibility for preparations. On the scheduled surgery day, the patient arrives at the clinic one hour before surgery. As a n outpatient facility, we control costs by waiting to prepare
AORN Journal, September 1982, V o l 3 6 , No 3
49 1
Table 2
Types of prostheses The semirigid prosthesis Advantages The patient can begin sexual relations without any delay in achieving an erection. The surgical procedure is simpler than for the inflatable device. The costs of the prosthesis and surgical fee are less. Mechanical problems are less frequent. Disadvantages The semierect penis will be obvious in public bathing. The patient usually needs to take care with clothing to disguise the penis’s semierect state. Subsequent cystoscopicexamination or treatments are more difficult.
The inflatable prosthesis Advantages In the deflated position, the patient’s penis appears normal. The quality of the erection is excellent and may even be better than before the patient developed impotence. No special care with clothing is needed. Subsequent endoscopic examination or operation can be done without
the room or open supplies until the patient arrives. While the patient is in the holding area, the circulating nurse notes any allergies, has the patient sign an operative permit, and checks his preoperative vital signs. He is then given gentamicin (Garamycin)80 mg and methicillin 500 mg. He waits in a holding area while the operating room is prepared. The OR is carefully wiped down with an antiseptic solution. All supplies are assembled and checked according to the type of prosthesis to be inserted. Every size of prosthesis is available sterile in the room, but none is opened until needed to minimize the chance of contamination. Light sources and electrosurgical units are connected and checked. The scrub nurse sets up the Mayo stand and back table in the usual way and prepares a solution of 500 cc of
normal saline and 1 gm of kanamycin (Kantrex). This solution is placed in a spray bottle, and the operative site is sprayed constantly with a fine mist during the procedure. The prosthesis is opened carefully to protect it from lint. It is also sprayed with the antibiotic solution prior to insertion. If an inflatable prosthesis is selected,the solutions to fill the prosthesis are also prepared in advance because the circulator must be free to attend the patient during the procedure. Intraoperatiue care. Once the room is prepared, the patient is brought in and placed in the lithotomy position. The operation is performed under local anesthesia using 2% lidocaine with intravenous (IV) sedation. Throughout the procedure, the circulating nurse monitors and records the patient’s vital signs and condition on the operative
492
difficulty.
Disadvantages 1. The patient has to inflate the prosthesis before beginning sexual relations. 2. The surgical procedure to insert the prosthesis is more complicated as compared with the semirigid prosthesis procedure. 3. The costs of the prosthesis and surgical fee are greater. 4. Mechanical complication is more likely.
AORN Journal, September 1982, Vol36, No 3
record. A povidone-iodine scrub and skin preparation are done. For the semirigid prosthesis, a transverse incision is made just above the penile-scrota1 junction. An indwelling No 20 Foley catheter is used for easy identification of the urethra. Each corpus cavernosum is identified. A longitudinal 3 to 4 cm incision is made in each corpus, and the interior of the corpus is dilated using a modified Turner female metal sound followed by a Kollmann dilator. The size of the prosthesis is reconfirmed before the prosthesis is opened onto the sterile field. Once the corpora have been dilated, the prosthesis can easily be placed. The corpora are then closed using a continuous stitch with 2-0 polyglycolic acid suture. Inserting the inflatable prosthesis is slightly more complicated though similar t o inserting the semirigid prosthesis. All three components of this hydraulic system can be properly placed through the penile-scrota1 incision. Each corpus is opened in a similar manner, and the correct size is determined. The pump is placed in the scrotal sac and the reservoir is placed inside the internal inguinal ring. A ring forceps aids in placing the reservoir, and a Furlow device assists in inserting the expandable cylinders into the corpora. All connections are carefully made. No sharp instruments or needles must come in contact with the prosthesis. When the components are in place, the prosthesis is checked for proper function before the incision is closed. The pump, placed in the scrotal sac, controls the erections. For an erection to occur, several pumping actions are required to move the fluid from the reservoir into the cylinders. A release button on the pump allows the fluid to return to the reservoir, and the penis again becomes flaccid. Necessary adjustments can be made immediately. Precautions are taken to protect the patient’s safety:
1. Patients who are poor medical risks are not selected for outpatient surgery. 2. The patient’s vital signs are monitored throughout the procedure. In addition to taking his blood pressure and manually monitoring his respirations, we use a pulse meter that records his pulse on a monitor and gives a constant sound. 3. Emergency drugs are available in the surgery room. 4. Oxygen, a laryngoscope, and tracheostomy tubes are available in the room. 5. All personnel are certified in cardiopulmonary resuscitation. The procedure to insert the semirigid prosthesis takes approximately -45 minutes to 1 hour. The inflatable prosthesis procedure is usually 1% t o 2 hours. At the completion of the procedure, a compression dressing is applied. The physician may choose to leave a catheter in overnight for patient comfort. Postoperative care. The patient is recovered for 30 minutes to an hour, depending on the amount of sedation he received. He is given gentamicin 80 mg and methicillin 500 mg intramuscularly. Then he is assisted in getting
The prosthesis is
95% SUCCeSSfUI in ending impotence. dressed. Written instructions for home care are reviewed with him and the person who will drive him home. He is encouraged to go home and rest for the remainder of the day, call us if he has any problems, and come to the office on the following day for a dressing change.
AORN Journal, September 1982, Vol36, No 3
493
If h e has a n i n d w e l l i n g Foley catheter, it w i l l be removed at h i s f i r s t postoperat i v e visit. H e w i l l be seen in t h e office for the n e x t t w o days t o have h i s dressing changed and t h e n t h e following week for a postoperative check. U s i n g t h i s protocol, we have done 30 cases w i t h o u t infection. T h e success r a t e for the prosthesis in t r e a t i n g impotence i s over 95%. A s more people become aware t h a t impotence i s often organic, we believe t h i s technique w i l l be more widely used. A m b u l a t o r y surgery t o insert a penile prosthesis is safe, ef0 fective, a n d economical. Note 1. M Bloom, “Impotence in the era of sex
therapy,” Medical World News 18 (March 7, 1977) 37.
Suggested reading Finney, R P. “New hinged silicone penile implant.” Journal of Urology 118 (October 1977) 586. Furlow, W. L. “Inflatable penile prosthesis: Mayo Clinic experience with 175 patients.” Urology 13 (February 1979) 166-171. Malloy, T R; Wein, A J. “The etiology, diagnosis and surgical treatment of erectile impotence.” Journal of Reproductive Medicine (April 1978) 183-193. Scott, F B; Bradley, W E; Tirnm, G. “Management of erectile impotence: Use of implantable inflatable prosthesis.” Urology 2 (July 1973) 80-82. Scott, F B; Byrde, G J; Karacan,I;Olsson, P; Beutler, L E; Attia, S L. “Erectile impotence treated with an implantable, inflatable prosthesis.” Journal of the American Medical Association 241 (June 15, 1979) 2609-2612.
Skin expander helps implant Insertions A new skin-stretchingtechnique permits easier insertion of permanent implants in patients who have had defects due to cancer or trauma. The technique was described at a recent American Society of Plastic and Reconstructive Surgeons science writers seminar. The purpose of the technique, called tissue expansion, is to produce an excess of soft tissue next to a defect so the “new” skin can be stretched easily over the defect and stitched into place, said Erik D Austad, MD. He is instructor of plastic surgery at the University of Michigan Medical School, Ann Arbor. In these defects, overlying skin frequently becomes so tight when it heals that there is almost no room for an implant to fit. In the case of a breast removal, the tight skin often precludes a single-step placement of a standard implant. When this skin is expanded, the final cosmetic and functional result is relatively good, explained Dr Austad. The technique involves the surgical insertion of a temporary implant that is inflated either by periodic injection of a sterile solution or a self-inflating
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mechanism. The principle is the same as a pregnant woman’s abdominal skin expanding gradually to accommodate her growing fetus. The skin expander is removed before the reconstructive surgery, which may involve the insertion of an implant or Silastic prosthesis. To date, the various expanders have been used on a limited basis when extra skin has been needed in reconstructive surgery involving the arms, legs, scalp, breasts, and face. Dr Austad cited the success of California surgeon Chedomir Radovan, MD, who used a temporary expander device in 68 breast cancer reconstructions. “His results are excellent, and I believe that the tissue expansion technique is the most significant advance in breast reconstructionsince the development of the Cronin-filled breast prosthesis in 1964,” he said. Dr Austad projects this technique could eventually be used for skin repairs in burn victims and for such congenital problems as cleft lip and palate.
AORN Journal, September 1982, V o l 3 6 , No 3