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Experience with the Small-carrion Penile Prosthesis in the Treatment of Organic Impotence
Vol. 115, March Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
EXPERIENCE WITH THE SMALL-CARRION PENILE PROSTHESIS IN THE TREATMENT OF ORGANIC IMPOTENCE ROGER E. NELLANS, WILLIAM NAFTEL, JAY STEIN, LARRY TANSEY, JULES PERLEY AND JOHN RAVERA From the Department of Surgery (Urology), University of California, Irvine and Long Beach Veterans Administration Hospital, Long Beach, California
ABSTRACT
Since certain animals are endowed with an os penis the concept of using penile implants was a natural development. Herein we report on our experience with the Small-Carrion penile prosthesis in 23 patients. The surgical technique is described as well as several examples of postoperative results. The major complication encountered was infection. All patients were able to accomplish coitus without significant difficulty. Proper patient selection and the attitude of the sexual partner constitute the major factors in the ultimate success or failure of the procedure. Erectile impotence, or the inability of the male patient to achieve vaginal penetration, presents a problem to the urologist. Most penile cripples are classified as having psychogenic impotence. 1 The remainder are organic, or pathologic, in nature and may result from trauma, a pelvic operation, neurological diseases (that is multiple sclerosis or degenerative diseases), vascular insufficiency diseases affecting the aorta, iliac and hypogastric vessels, hormonal deficiencies, drugs (parasympathetic and sympathetic blocking agents), priapism, Peyronie's disease or diabetes mellitus. It is well known that certain animals are endowed with an os penis.2 Therefore, the concept of using an os penis in the treatment of impotence was a natural development. Substances first used included bone and cartilage but these proved unsatisfactory because of their absorption by the body. 2 In 1952 Goodwin and Scott described the unsuccessful use of an acrylic rod in reconstructing a penis after amputation for malignancy, although the 2 patients treated for impotence tolerated the procedure well. 3 In 1960 Loeffler and Sayegh described the successful use of a perforated acrylic implant in 2 cases of organic impotence. 4 In 1964 these same authors obtained excellent results in 5 additional cases. 5 Beheri was the first to describe the use of polyethylene rods inserted inside of the corpora cavernosa, producing a penis that better resembled a physiologic erection than the previous methods. He reported on 700 patients during a 7 ½-year period, 95 per cent having psychogenic impotence. 6 In 1967 Pearman described a silicone prosthesis that was inserted in a pocket between Buck's fascia and the tunica albuginea of the corpora cavernosa on the dorsum of the penis. 1 He later modified the prosthesis as well as the site of placement within the phallus and noted improvement in his results. 7 In 1968 Lash implanted silicone prostheses in 13 psychologically impotent patients with gratifying results. 8 In 1973 Morales and associates reported on 15 patients with erectile impotence who underwent polyethylene implants that were trimmed to size at the time of operation. They reported an 80 per cent success rate and made note of the danger of infection, especially in diabetics. 9 Scott and associates developed an implantable prosthesis of dacron-reinforced silicone rubber that is inflatable. It consists of a reservoir and a pumping mechanism located in the scrotum, which inflates and deflates the prosthesis. Early reports have been encouraging despite various technical problems but long-term followup Accepted for publication August 1, 1975. Read at annual meeting of Western Section, American Urological Association, Portland, Oregon, April 13-17, 1975.
280
is lacking. 10 Recently a penile implant developed by Small and Carrion and similar to those by Beheri and Morales has been used. The Small-Carrion prosthesis is silicone sponge-filled with a silicone exterior and inserted perineally instead of dorsally (fig. 1). 11 Herein we report on our experience with this prosthesis in 23 patients. METHODS
The patient is placed in the dorsal lithotomy position. The perineum is shaved and the area is scrubbed with betadine for 10 minutes. A 16F Foley catheter is inserted into the urethra and is used for identification purposes. A 6 cm. vertical perinea! incision is made from the base of the scrotum and is carried down to the bulbocavernosus, which is retracted, and the ischiocavernosus is identified. The fat overlying these muscles can generally be retracted laterally. Care should be taken not to injure the superficial branches of the pudenda! nerve, which run longitudinally along the ischiocavernosus. A 1-inch vertical incision is made in the ischiocavernous muscle and crus penis and 2 stay sutures are used to separate the edges of these structures. This incision should be well away from the ischial tuberosity (fig. 2). Hegar dilators are used with surgical lubricant to dilate the corpus cavernosum distally to a size 9 or 10 so that the dilator can be palpated under the glans penis. The dilatation is then done proximally to the ischial tuberosity with great care usually to a size 6 or 7. The dilatation usually proceeds easily but considerable force must be applied distally in some cases in order to achieve the desired dilatation (fig. 3, A). The correct size Small-Carrion penile prosthesis is then taken from a basin of neosporin solution in which all sizes are being soaked and then placed within the corpus cavernosum so that it rests against the ischial tuberosity proximally and under the glans distally (fig. 3, B). Judgment of the correct size can only be made during the surgical procedure. It is important that the curved proximal portion of the prosthesis conforms to the normal curvature of the crus and directed posterolaterally. Also one should ascertain by palpation that the narrow proximal portion of the prosthesis is not bent upon itself. The stay sutures are removed and the incision in the corpus and ischiocavernosus is closed with a running 3-zero suture of chromic catgut. The same procedure is done on the opposite side. The lengths of the prostheses at the glans penis must be identical. If they are not, either a mismatched pair has been used, a bending of the proximal portion of the prosthesis has occurred or the corpus has not been dilated adequately. The wound is then irrigated with the neosporin irrigant and the
EXPERIENCE WITH SMALL-CARRION PENILE PROSTHESIS
Postoperatively, sitz baths and heat lamp therapy may be beneficial. Some patients may need jockey shorts or athletic supporters to conceal the penis and to keep the penis from rubbing on the garments. Coitus is not recommended until 1 month postoperatively. The prosthesis is made in 4 different lengths (15.8, 14.5, 13.3 and 12 cm.) and 2 diameters (0.9 and 1.1 cm.). Longer sizes have been introduced recently. RESULTS
FIG. 1. Small-Carrion penile prostheses are 2 foam-filled silicone tubes that are soft and pliable yet sufficiently firm to maintain shape.
Skin Incision
Pubic S:1mPlwsis
Incision in Rt. Crus
1schiocavernosus m. Bulbocavernosus m. FIG. 2. Vertical midline perinea! incision
subcutaneous tissue is closed with interrupted sutures of 4-zero chromic catgut. The skin is then closed with a subcuticular suture of 4-zero dexon. The Foley catheter is then removed. The patient is started on gentamicin the evening prior to the operation and this is continued for 3 postoperatively. He is instructed to scrub the and genitalia for 10 T.inutes on the
Our patients ranged in age from 31 to 68 years and the longest followup has been 1 year. The causes of impotence in our series are shown in table 1. Most patients were highly motivated and a thorough history and physical examination were performed prior to the surgical procedure. Psychiatric consultation was not obtained routinely. Pain and ,,w,"""'"" Approximately two-thirds of our nonparaplegic patients experienced minimal or no penile or perinea! Approximately one-third had moderate to severe penile or perinea! pain (especially when , lasting 1 week to 1 month postoperatively (table 2). Only 2 had persisting longer than 1 month and in each case the pain totally subsided within 6 months. Two patients experienced mild pain with coitus in the early postoperative period. During the first postoperative week most patients had a mild amount of penile swelling but this subsided without difficulty. In 2 patients prostheses were inserted at the time of cystectomy and urethrectomy. These patients complained of severe penile pain and had moderate penile swelling during the first week postoperatively but this soon subsided and both patients were able to have coitus free of pain. Size of prosthesis. A variety of sizes were used with the appropriate size determined during the operation. Approximately half of the patients required the largest prosthesis available (15.8 by 1.1 cm.) and several would have benefited from the larger prosthesis that has been developed recently. Coitus. Successful coitus was achieved in all but 2 patients. Most experience orgasm and are quite satisfied with the prosthesis. 2 patients complain that the prosthesis is too short and experience some difficulty with vaginal penetration. Both of these patients are obese and it is thought that this factor is responsible for their difficulties. An example of this type patient is shown in figure 4, j. Nearly all patients have coitus weekly starting 4 to 6 weeks postoperatively. Two patients have had coitus only once (7 and 10 months postoperatively). A few patients had satisfactory coitus within 2 weeks of the operation and had no ill effects. Infection. Because of infection the prosthesis was removed surgically in 1 instance. This patient, a juvenile diabetic, continued to experience severe perinea! and penile pain from the immediate postoperative period until the prosthesis was removed 8 days later. A small amount of purulence was found in the corpora cavernosa but the wound healed without incident and the patient has received subsequently a SmallCarrion prosthesis through the dorsal approach. Two paraplegics in our series have spontaneously extruded their prosthesis through the urethral meatus. Neither was free of the catheter at the time of implantation. Concealment. Three of our patients experienced concealment difficulties and in 1 patient it posed a major problem since it was obviously noticeable in street clothes (fig. 4, d). Voiding difficulties. Only 2 patients complained of any postoperative obstructive symptoms. One patient, discussed previously, was a juvenile diabetic whose prosthesis was removed because of pressure necrosis. We postulate that the larger diameter and/or increased length was responsible for this problem. The other was the oldest of the group and was known to have mild enlargement. We that a small amount of urethral compression could cacse syrnptoms in a ""'''~·--~~. bladder,
282
NELLANS AND ASSOCIATES
Penile Prosthesis
Hegar dilator FIG.
TABLE
Rt. Crus
3. A, Hegar dilator inserted in corpus cavernosum. B, Small-Carrion prosthesis being inserted
1. Etiology of impotence in our series of 23 patients No. Pts.
Diabetes mellitus Paraplegia Cystectomy Radical prostatectomy Status post-C-spine fusion Status post-radiation therapy Peyronie's disease Spinal cord tumor
6 6
5 2 1
1 1 1 23
Total
TABLE
Penile Perinea!
2. Postoperative pain*
None No.(%)
Mild No.(%)
13 (55)
7 (30) 9 (39)
8 (35)
Moderate No.(%) 0 3 (13)
Severe No.(%) 3 (13) 3 (13)
* Includes 6 paraplegics.
Hemorrhage and hematoma. Bleeding was not a problem, with blood loss averaging approximately 100 cc per procedure. A perineal hematoma developed in 1 patient but resolved subsequently. Penile hematoma was only encountered in the 2 patients undergoing simultaneous urethrectomy and this resolved in each case in approximately 10 days. Sexual partner. An incomplete sampling of sexual partners indicates that the prosthesis provides an experience that closely approximates normal coitus. Indeed, some women have not been able to detect any difference. DISCUSSION
Many patients with impotence, either functional or organic, have normal libido but find coitus impossible. In these patients a penile prosthesis provides a means by which they and their partners can experience satisfactory coitus. Previous investigators have indicated that prostheses may be inserted for either organic or psychogenic impotence.•. 8 All patients in our series were organically impotent but we believe that with proper preoperative psychiatric evaluation and counseling, many patients with functional impotence may be good surgical candidates.
As recommended by Small and Carrion we have chosen the perineal approach for insertion of the prosthesis, although insertion through the dorsal aspect of the penis is being evaluated. We believe the paired penile prostheses are far superior to the previously described implants. Their stability, owing to their insertion in the crura, which attach to the ischial tuberosities, is excellent. Selection of the proper size is a critical factor and must be determined at the time of the operation and, therefore, a full range of sizes must be available. To ensure proper diameter following dilatation the prosthesis should insert easily into each corpus. The more snugly the prosthesis fits within the corpus the more erect the penis will be (fig. 4). Concealment has not been a major problem. If necessary patients are advised to use athletic supporters or tight-fitting underwear. A minimal amount of pain is usually encountered postoperatively. In a few patients pain was a significant factor but resolved with time. Surprisingly, some patients have had no pain. The amount of pain experienced did not correlate with the size of the prosthesis, size of the penis or tightness of the prosthesis in the corpus. The danger of infection, especially in diabetics and paraplegics, must be kept in mind and constituted the major complications in our series (table 3). Any prolonged or undo amount of pain should make one suspicious. A diameter and/or length too large may result in voiding difficulties or pressure necrosis with secondary inflammation. It was necessary to surgically remove the prosthesis in only 1 patient and he subsequently received another prosthesis that has been successful. Two paraplegics with catheters at the time of the operation spontaneously extruded their prostheses through the urethra. Four other paraplegics who did not have catheters successfully retained their prostheses and are quite satisfied. Therefore, it is stressed that patients should be free of the catheter prior to implantation. Reference has been made in the literature to the immediate insertion of prostheses following radical cystectomy but the fear of infection has deterred most. 12 Two of our patients had simultaneous cystectomy and urethrectomy for carcinoma of the bladder with insertion of the prosthesis without any evidence of infection. All of our patients were given prophylactic antibiotic coverage.
EXPERIENCE WITH SMALL-CARRION PENILE PROSTHESIS
283
F1G. 4. Ten representative postoperative results
TABLE
3. Major and minor complications in our series No. Pts. (%)
Major: Infection resulting in Surgical removal Extrusion* Total Minor: Voiding difficulty, not requiring catheter Hematoma Total
owing to poor patient selection in 2 cases, inadequate length in 1 and extrusion in 2. ADDENDUM
1 2 3
(13)
2 3
Since this manuscript was submitted for publication we have performed the operation on 25 additional patients. The prosthesis had to be removed in 1 patient because of persistent pain and in another because of infection. The remaining 23 patients have had an uneventful postoperative course and are quite satisfied with the results.
(13)
REFERENCES
* The extrusions occurred in paraplegics who had catheters.
One added benefit was noted in the paraplegics in our series. It is well known that a paraplegic with a short phallus has difficulty keeping a condom catheter in place and sometimes requires indwelling catheter drainage for this reason. After insertion of the penile prosthesis application of the condom catheter is quite easy and inadvertent removal, leakage and so forth are lessened. Because of the relative simplicity of the procedure one might consider performing this procedure on any person requiring a condom catheter who has difficulty keeping the condom in place. All patients are able to accomplish coitus without significant difficulty. Two patients possibly would have benefited from longer prostheses had they been available. They complain of difficulty maintaining vaginal penetration. Proper patient selection is essential. Candidates for the procedure should have a strong sexual desire. This desire coupled with the attitude of the sexual partner constitutes a major factor in the ultimate success or failure of the procedure. We recommend that this procedure be discussed fully with each partner, together and individually. Of 23 18 are satisfied. Dissatisfaction was
1. Pearman, R. 0.: Treatment of organic impotence by implantation of a penile prosthesis. J. Urol., 97: 716, 1967. 2. Bett, W.R.: Os penis in man and beast. Ann. Roy. Coll. Surg., 10: 405, 1952. 3. Goodwin, W. E. and Scott, W.W.: Phalloplasty. J. Urol., 68: 903, 1952. 4. Loeffler, R. A. and Sayegh, E. S.: Perforated acrylic implants in management of organic impotence. J. Urol., 84: 559, 1960. 5. Loeffler, R. A., Sayegh, E. S. and Lash, H.: The artificial os penis. Plast. Reconstr. Surg., 34: 71, 1964. 6. Beheri, G. E.: Surgical treatment of impotence. Plast. Reconstr. Surg., 38: 92, 1966. 7. Pearman, R. 0.: Insertion of a silastic penile prosthesis for the treatment of organic sexual impotence. J. Urol., 107: 802, 1972. 8. Lash, H.: Silicone implant for impotence. ,J. Urol., 100: 709, 1968. 9. Morales, P. A., Suarez, ,J. B., Delgado, J. and Whitehead, E. D.: Penile implant for erectile impotence. J. Urol., 109: 641, 1973. 10. Scott, F. B., Bradley, W. E. and Timm, G. W.: Management of erectile impotence: use of implantable inflatable prosthesis. Urology, 2: 80, 1973. 11. Small, M. P. and Carrion, H.: The Small-Carrion penile prosthesis for the management of impotence. Read at annual meeting of American Urological Association, St. Louis, Missouri, May 19-23, 1974. 12. Grabstald, H.: Postradical cystecto!lly impotence treated by penile silicone implant. N. Y State J. Med., 70; 2344, 1970.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
EXPERIENCE WITH THE SMALL-CARRION PENILE PROSTHESIS IN THE TREATMENT OF ORGANIC IMPOTENCE ROGER E. NELLANS, WILLIAM NAFTEL, JAY STEIN, LARRY TANSEY, JULES PERLEY AND JOHN RAVERA From the Department of Surgery (Urology), University of California, Irvine and Long Beach Veterans Administration Hospital, Long Beach, California
ABSTRACT
Since certain animals are endowed with an os penis the concept of using penile implants was a natural development. Herein we report on our experience with the Small-Carrion penile prosthesis in 23 patients. The surgical technique is described as well as several examples of postoperative results. The major complication encountered was infection. All patients were able to accomplish coitus without significant difficulty. Proper patient selection and the attitude of the sexual partner constitute the major factors in the ultimate success or failure of the procedure. Erectile impotence, or the inability of the male patient to achieve vaginal penetration, presents a problem to the urologist. Most penile cripples are classified as having psychogenic impotence. 1 The remainder are organic, or pathologic, in nature and may result from trauma, a pelvic operation, neurological diseases (that is multiple sclerosis or degenerative diseases), vascular insufficiency diseases affecting the aorta, iliac and hypogastric vessels, hormonal deficiencies, drugs (parasympathetic and sympathetic blocking agents), priapism, Peyronie's disease or diabetes mellitus. It is well known that certain animals are endowed with an os penis.2 Therefore, the concept of using an os penis in the treatment of impotence was a natural development. Substances first used included bone and cartilage but these proved unsatisfactory because of their absorption by the body. 2 In 1952 Goodwin and Scott described the unsuccessful use of an acrylic rod in reconstructing a penis after amputation for malignancy, although the 2 patients treated for impotence tolerated the procedure well. 3 In 1960 Loeffler and Sayegh described the successful use of a perforated acrylic implant in 2 cases of organic impotence. 4 In 1964 these same authors obtained excellent results in 5 additional cases. 5 Beheri was the first to describe the use of polyethylene rods inserted inside of the corpora cavernosa, producing a penis that better resembled a physiologic erection than the previous methods. He reported on 700 patients during a 7 ½-year period, 95 per cent having psychogenic impotence. 6 In 1967 Pearman described a silicone prosthesis that was inserted in a pocket between Buck's fascia and the tunica albuginea of the corpora cavernosa on the dorsum of the penis. 1 He later modified the prosthesis as well as the site of placement within the phallus and noted improvement in his results. 7 In 1968 Lash implanted silicone prostheses in 13 psychologically impotent patients with gratifying results. 8 In 1973 Morales and associates reported on 15 patients with erectile impotence who underwent polyethylene implants that were trimmed to size at the time of operation. They reported an 80 per cent success rate and made note of the danger of infection, especially in diabetics. 9 Scott and associates developed an implantable prosthesis of dacron-reinforced silicone rubber that is inflatable. It consists of a reservoir and a pumping mechanism located in the scrotum, which inflates and deflates the prosthesis. Early reports have been encouraging despite various technical problems but long-term followup Accepted for publication August 1, 1975. Read at annual meeting of Western Section, American Urological Association, Portland, Oregon, April 13-17, 1975.
280
is lacking. 10 Recently a penile implant developed by Small and Carrion and similar to those by Beheri and Morales has been used. The Small-Carrion prosthesis is silicone sponge-filled with a silicone exterior and inserted perineally instead of dorsally (fig. 1). 11 Herein we report on our experience with this prosthesis in 23 patients. METHODS
The patient is placed in the dorsal lithotomy position. The perineum is shaved and the area is scrubbed with betadine for 10 minutes. A 16F Foley catheter is inserted into the urethra and is used for identification purposes. A 6 cm. vertical perinea! incision is made from the base of the scrotum and is carried down to the bulbocavernosus, which is retracted, and the ischiocavernosus is identified. The fat overlying these muscles can generally be retracted laterally. Care should be taken not to injure the superficial branches of the pudenda! nerve, which run longitudinally along the ischiocavernosus. A 1-inch vertical incision is made in the ischiocavernous muscle and crus penis and 2 stay sutures are used to separate the edges of these structures. This incision should be well away from the ischial tuberosity (fig. 2). Hegar dilators are used with surgical lubricant to dilate the corpus cavernosum distally to a size 9 or 10 so that the dilator can be palpated under the glans penis. The dilatation is then done proximally to the ischial tuberosity with great care usually to a size 6 or 7. The dilatation usually proceeds easily but considerable force must be applied distally in some cases in order to achieve the desired dilatation (fig. 3, A). The correct size Small-Carrion penile prosthesis is then taken from a basin of neosporin solution in which all sizes are being soaked and then placed within the corpus cavernosum so that it rests against the ischial tuberosity proximally and under the glans distally (fig. 3, B). Judgment of the correct size can only be made during the surgical procedure. It is important that the curved proximal portion of the prosthesis conforms to the normal curvature of the crus and directed posterolaterally. Also one should ascertain by palpation that the narrow proximal portion of the prosthesis is not bent upon itself. The stay sutures are removed and the incision in the corpus and ischiocavernosus is closed with a running 3-zero suture of chromic catgut. The same procedure is done on the opposite side. The lengths of the prostheses at the glans penis must be identical. If they are not, either a mismatched pair has been used, a bending of the proximal portion of the prosthesis has occurred or the corpus has not been dilated adequately. The wound is then irrigated with the neosporin irrigant and the
EXPERIENCE WITH SMALL-CARRION PENILE PROSTHESIS
Postoperatively, sitz baths and heat lamp therapy may be beneficial. Some patients may need jockey shorts or athletic supporters to conceal the penis and to keep the penis from rubbing on the garments. Coitus is not recommended until 1 month postoperatively. The prosthesis is made in 4 different lengths (15.8, 14.5, 13.3 and 12 cm.) and 2 diameters (0.9 and 1.1 cm.). Longer sizes have been introduced recently. RESULTS
FIG. 1. Small-Carrion penile prostheses are 2 foam-filled silicone tubes that are soft and pliable yet sufficiently firm to maintain shape.
Skin Incision
Pubic S:1mPlwsis
Incision in Rt. Crus
1schiocavernosus m. Bulbocavernosus m. FIG. 2. Vertical midline perinea! incision
subcutaneous tissue is closed with interrupted sutures of 4-zero chromic catgut. The skin is then closed with a subcuticular suture of 4-zero dexon. The Foley catheter is then removed. The patient is started on gentamicin the evening prior to the operation and this is continued for 3 postoperatively. He is instructed to scrub the and genitalia for 10 T.inutes on the
Our patients ranged in age from 31 to 68 years and the longest followup has been 1 year. The causes of impotence in our series are shown in table 1. Most patients were highly motivated and a thorough history and physical examination were performed prior to the surgical procedure. Psychiatric consultation was not obtained routinely. Pain and ,,w,"""'"" Approximately two-thirds of our nonparaplegic patients experienced minimal or no penile or perinea! Approximately one-third had moderate to severe penile or perinea! pain (especially when , lasting 1 week to 1 month postoperatively (table 2). Only 2 had persisting longer than 1 month and in each case the pain totally subsided within 6 months. Two patients experienced mild pain with coitus in the early postoperative period. During the first postoperative week most patients had a mild amount of penile swelling but this subsided without difficulty. In 2 patients prostheses were inserted at the time of cystectomy and urethrectomy. These patients complained of severe penile pain and had moderate penile swelling during the first week postoperatively but this soon subsided and both patients were able to have coitus free of pain. Size of prosthesis. A variety of sizes were used with the appropriate size determined during the operation. Approximately half of the patients required the largest prosthesis available (15.8 by 1.1 cm.) and several would have benefited from the larger prosthesis that has been developed recently. Coitus. Successful coitus was achieved in all but 2 patients. Most experience orgasm and are quite satisfied with the prosthesis. 2 patients complain that the prosthesis is too short and experience some difficulty with vaginal penetration. Both of these patients are obese and it is thought that this factor is responsible for their difficulties. An example of this type patient is shown in figure 4, j. Nearly all patients have coitus weekly starting 4 to 6 weeks postoperatively. Two patients have had coitus only once (7 and 10 months postoperatively). A few patients had satisfactory coitus within 2 weeks of the operation and had no ill effects. Infection. Because of infection the prosthesis was removed surgically in 1 instance. This patient, a juvenile diabetic, continued to experience severe perinea! and penile pain from the immediate postoperative period until the prosthesis was removed 8 days later. A small amount of purulence was found in the corpora cavernosa but the wound healed without incident and the patient has received subsequently a SmallCarrion prosthesis through the dorsal approach. Two paraplegics in our series have spontaneously extruded their prosthesis through the urethral meatus. Neither was free of the catheter at the time of implantation. Concealment. Three of our patients experienced concealment difficulties and in 1 patient it posed a major problem since it was obviously noticeable in street clothes (fig. 4, d). Voiding difficulties. Only 2 patients complained of any postoperative obstructive symptoms. One patient, discussed previously, was a juvenile diabetic whose prosthesis was removed because of pressure necrosis. We postulate that the larger diameter and/or increased length was responsible for this problem. The other was the oldest of the group and was known to have mild enlargement. We that a small amount of urethral compression could cacse syrnptoms in a ""'''~·--~~. bladder,
282
NELLANS AND ASSOCIATES
Penile Prosthesis
Hegar dilator FIG.
TABLE
Rt. Crus
3. A, Hegar dilator inserted in corpus cavernosum. B, Small-Carrion prosthesis being inserted
1. Etiology of impotence in our series of 23 patients No. Pts.
Diabetes mellitus Paraplegia Cystectomy Radical prostatectomy Status post-C-spine fusion Status post-radiation therapy Peyronie's disease Spinal cord tumor
6 6
5 2 1
1 1 1 23
Total
TABLE
Penile Perinea!
2. Postoperative pain*
None No.(%)
Mild No.(%)
13 (55)
7 (30) 9 (39)
8 (35)
Moderate No.(%) 0 3 (13)
Severe No.(%) 3 (13) 3 (13)
* Includes 6 paraplegics.
Hemorrhage and hematoma. Bleeding was not a problem, with blood loss averaging approximately 100 cc per procedure. A perineal hematoma developed in 1 patient but resolved subsequently. Penile hematoma was only encountered in the 2 patients undergoing simultaneous urethrectomy and this resolved in each case in approximately 10 days. Sexual partner. An incomplete sampling of sexual partners indicates that the prosthesis provides an experience that closely approximates normal coitus. Indeed, some women have not been able to detect any difference. DISCUSSION
Many patients with impotence, either functional or organic, have normal libido but find coitus impossible. In these patients a penile prosthesis provides a means by which they and their partners can experience satisfactory coitus. Previous investigators have indicated that prostheses may be inserted for either organic or psychogenic impotence.•. 8 All patients in our series were organically impotent but we believe that with proper preoperative psychiatric evaluation and counseling, many patients with functional impotence may be good surgical candidates.
As recommended by Small and Carrion we have chosen the perineal approach for insertion of the prosthesis, although insertion through the dorsal aspect of the penis is being evaluated. We believe the paired penile prostheses are far superior to the previously described implants. Their stability, owing to their insertion in the crura, which attach to the ischial tuberosities, is excellent. Selection of the proper size is a critical factor and must be determined at the time of the operation and, therefore, a full range of sizes must be available. To ensure proper diameter following dilatation the prosthesis should insert easily into each corpus. The more snugly the prosthesis fits within the corpus the more erect the penis will be (fig. 4). Concealment has not been a major problem. If necessary patients are advised to use athletic supporters or tight-fitting underwear. A minimal amount of pain is usually encountered postoperatively. In a few patients pain was a significant factor but resolved with time. Surprisingly, some patients have had no pain. The amount of pain experienced did not correlate with the size of the prosthesis, size of the penis or tightness of the prosthesis in the corpus. The danger of infection, especially in diabetics and paraplegics, must be kept in mind and constituted the major complications in our series (table 3). Any prolonged or undo amount of pain should make one suspicious. A diameter and/or length too large may result in voiding difficulties or pressure necrosis with secondary inflammation. It was necessary to surgically remove the prosthesis in only 1 patient and he subsequently received another prosthesis that has been successful. Two paraplegics with catheters at the time of the operation spontaneously extruded their prostheses through the urethra. Four other paraplegics who did not have catheters successfully retained their prostheses and are quite satisfied. Therefore, it is stressed that patients should be free of the catheter prior to implantation. Reference has been made in the literature to the immediate insertion of prostheses following radical cystectomy but the fear of infection has deterred most. 12 Two of our patients had simultaneous cystectomy and urethrectomy for carcinoma of the bladder with insertion of the prosthesis without any evidence of infection. All of our patients were given prophylactic antibiotic coverage.
EXPERIENCE WITH SMALL-CARRION PENILE PROSTHESIS
283
F1G. 4. Ten representative postoperative results
TABLE
3. Major and minor complications in our series No. Pts. (%)
Major: Infection resulting in Surgical removal Extrusion* Total Minor: Voiding difficulty, not requiring catheter Hematoma Total
owing to poor patient selection in 2 cases, inadequate length in 1 and extrusion in 2. ADDENDUM
1 2 3
(13)
2 3
Since this manuscript was submitted for publication we have performed the operation on 25 additional patients. The prosthesis had to be removed in 1 patient because of persistent pain and in another because of infection. The remaining 23 patients have had an uneventful postoperative course and are quite satisfied with the results.
(13)
REFERENCES
* The extrusions occurred in paraplegics who had catheters.
One added benefit was noted in the paraplegics in our series. It is well known that a paraplegic with a short phallus has difficulty keeping a condom catheter in place and sometimes requires indwelling catheter drainage for this reason. After insertion of the penile prosthesis application of the condom catheter is quite easy and inadvertent removal, leakage and so forth are lessened. Because of the relative simplicity of the procedure one might consider performing this procedure on any person requiring a condom catheter who has difficulty keeping the condom in place. All patients are able to accomplish coitus without significant difficulty. Two patients possibly would have benefited from longer prostheses had they been available. They complain of difficulty maintaining vaginal penetration. Proper patient selection is essential. Candidates for the procedure should have a strong sexual desire. This desire coupled with the attitude of the sexual partner constitutes a major factor in the ultimate success or failure of the procedure. We recommend that this procedure be discussed fully with each partner, together and individually. Of 23 18 are satisfied. Dissatisfaction was
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