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Penile implant success in patients with corporal fibrosis using multiple incisions and minimal scar tissue excision
ADULT UROLOGY
PENILE IMPLANT SUCCESS IN PATIENTS WITH CORPORAL FIBROSIS USING MULTIPLE INCISIONS AND MINIMAL SCAR TISSUE EXCISION ATUL RAJPURKAR, HAIKUN LI,
AND
C. B. DHABUWALA
ABSTRACT Objectives. To establish the efficacy of “minimal scar tissue excision” in the treatment of penile fibrosis. Methods. Thirty-four patients with extensive penile fibrosis who underwent placement of penile implant from October 1989 to April 1998 were evaluated by a chart review of the patient’s follow-up data. Function of the implant was evaluated at follow-up visits. The follow-up ranged from 4 to 84 months (mean 23.7, median 22). All patients had undergone minimal scar tissue excision of the fibrous tissue in the penis. Results. All patients underwent successful introduction of the penile implant, and in no patient was the procedure abandoned because of technical difficulty. Intraoperatively, 1 patient developed a tear in the crus. It was not recognized during the initial operation but was repaired at a subsequent date by Gore-Tex grafting. The Uniflate prosthesis of another patient failed 2 years after the initial surgery and was replaced with the Mentor alpha-1 implant. None of the patients developed infection. All the patients had a functioning implant at the time of last review. Conclusions. Minimal scar tissue excision is a safe and effective method in the management of extensive penile fibrosis. UROLOGY 54: 145–147, 1999. © 1999, Elsevier Science Inc.
P
enile fibrosis commonly results from priapism,1 an infected penile implant,2 trauma,3 or intracavernosal injection (ICI).4,5 The fibrosis that occurs after priapism and an infected penile implant is usually extensive and dense; the degree of fibrosis after ICI varies depending on the duration and frequency of use. Regardless of the etiology, penile fibrosis leads to erectile dysfunction and is a difficult clinical problem to treat. Surgery is the only therapeutic modality that is satisfactory. However, because of the dense and unyielding nature of the fibrous tissue and the penile shortening induced by the fibrosis, surgery is difficult and time consuming.6,7 Conventionally, penile fibrosis has been treated surgically by extensive excision of scar tissue before the insertion of a penile prosthesis. The defect in the corpus cavernosum after the excision of the scar tissue is closed with either biologic or synFrom the Department of Urology, Wayne State University, Detroit, Michigan Reprint requests: C. B. Dhabuwala, M.D., Department of Urology, Wayne State University, 4160 John R. Street, Suite 1017, Detroit, MI 48201 Submitted: November 30, 1998, accepted (with revisions): January 25, 1999 © 1999, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
thetic material.8 –10 More recently, a Gore-Tex graft has been used most commonly for this purpose. The disadvantage of this approach is the high incidence of complications, such as infection, implant malfunction, penile angulation, pain, and corporal-cutaneous fistula and the high reoperation rate to correct these complications.11–14 In an earlier study, we had described the procedure of minimal excision of scar tissue for the correction of this difficult and perplexing problem.15 The procedure consisted of the excision of minimal scar tissue followed by dilation of the corpus cavernosum under vision and the insertion of the penile implant. The purpose of the present study is to reaffirm the feasibility and efficacy of this method in the management of penile fibrosis. MATERIAL AND METHODS From October 1989 to April 1998, 34 consecutive patients with penile fibrosis (mean age 59.5 years, median 62) underwent surgery to correct penile fibrosis. Preoperatively, the procedure was discussed with the patients and written consent obtained. The patients were screened for the presence of urinary tract infection, which was treated if present before surgery. The following protocol was strictly implemented to reduce the risk of postoperative infection: 0090-4295/99/$20.00 PII S0090-4295(99)00060-6 145
1. Intravenous antibiotic prophylaxis 1 hour before surgery, continued for 24 to 48 hours in the postoperative period, followed by oral antibiotics for 2 weeks 2. Surgical shaving of the operative part in the preoperative holding area 3. Instillation of an antibiotic (bacitracin and gentamicin) solution into the patient’s bladder, followed by irrigation of the patient’s urethra with a 5% betadine solution to minimize contamination from the urethral flora during surgery 4. Surgical scrub of the patient’s skin with betadine for 15 minutes 5. A 15-minute surgical scrub by the surgeon and all assistants 6. Reduction of traffic in the operating room to a bare minimum 7. Double-gloving, with betadine solution between the glove layers 8. Laminar air flow to reduce the air contamination of the surgical wound The operative procedure is similar to that used in our previous study. In brief, a Foley catheter is placed preoperatively to help identify the urethra during dilation of the fibrotic corpus cavernosum. A midline perineal incision is used in all cases. Both the corpora cavernosa and bulbosum were exposed. A small corporotomy (2 cm) is made on the corpus cavernosum. Minimal scar tissue is excised at the site of corporotomy to facilitate the initiation of corporal dilation. The initial dilation is performed from the corporotomy site to the ischial tuberosity almost under direct vision starting with blunt-tipped Metzenbaum scissors. Once an initial passageway is created, further dilation is achieved by 7 to 11-gauge Hegar dilators and/or Dilamezinsert. Next, distal dilation is attempted in a similar manner. When it is difficult to dilate the distal corpora because of extensive fibrosis, an additional subcoronal incision is made and dilation of the distal fibrotic area is carried out under direct vision through the distal corporotomy. Finally, the dilators are passed from the proximal to the distal corporotomy. The penile length is measured and an adequately sized penile prosthesis is inserted into the penis. These maneuvers avoid proximal crural perforation and distal injury to the urethra because this part of the dilation is performed under direct vision. When it is difficult to close the defect in the tunica albuginea after insertion of the prosthesis, a 0.4-mm polytetrafluoroethylene (PTFE) graft is used. The wound is liberally sprayed with an antibiotic solution (160 mg gentamicin and 50,000 IU bacitracin mixed in 1 L of normal saline) during the procedure.
RESULTS Thirty-four patients with extensive penile fibrosis were included in this study. Four patients had fibrosis secondary to priapism (of these, 3 were secondary to sickle cell anemia, and 1 patient had developed priapism spontaneously); 2 patients had fibrosis secondary to ICI therapy; and 28 patients had developed fibrosis secondary to an infected penile implant. Of the 28, 3 patients each had undergone four previous penile implant procedures, 2 had undergone three, 2 had undergone two, and 21 had undergone one previous implant procedure. A perineal incision was used in all cases. An additional subcoronal incision was required in 30 of the 34 patients. At the time of surgery, 32 pa146
tients were found to have extensive bilateral fibrosis; 2 patients had extensive unilateral fibrosis. All patients underwent successful introduction of a penile implant, and in no patient was surgery abandoned because of extensive penile fibrosis. We did not use Roselli cavernotomes or Otis urethrotomes for dilation of the fibrous tissue in any of our patients, as we were able to achieve successful dilation and implantation by a combination of minimal scar tissue excision and multiple incisions, as described above. Fifteen patients had the Mentor alpha-1 implant, 1 patient a Mark 2 prosthesis, 7 the AMS-600 prosthesis, 7 the AMS-700 prosthesis, and 4 patients had the semirigid implant. Although we used a Gore-Tex graft in 13 of 34 cases, a much smaller length was required to cover the defect in the tunica albuginea after minimal scar tissue excision. Intraoperatively, 1 patient developed a tear in the crus. It was not recognized during the initial operation but was repaired at a later date with a Gore-Tex graft. None of the patients developed any early postoperative complications, including infection. The follow-up was between 3 months and 8 years. Four patients underwent reoperation. The Uniflate prosthesis of 1 patient failed 2 years after the original surgery and was replaced with the Mentor alpha-1 implant. In another patient, crural perforation went unrecognized at the time of the original procedure. This was repaired at a later date by Gore-Tex grafting. Two other patients underwent reoperation to change their semirigid prosthesis to an inflatable one. Thus, in only 1 of these 4 patients was the second procedure directly related to technical difficulty during the initial implantation. All patients had a functioning implant at the time of last review. COMMENT Penile fibrosis can result from multiple causes, such as priapism,1 use of ICI,4,5 after implant removal for infection,7 and penile trauma.3 When extensive, wide excision of the scar tissue is the surgical procedure that has been widely used to treat this condition. This approach compromises the blood supply to the penis, contributing to the poor healing of the surgical wound and an inadequate delivery of antibiotic to the surgical site. This is responsible for the high rate of postoperative infection seen in patients treated by this method.11–14 There is also a high reported rate of intraoperative complications (31%),11,12 and the incidence of later complications was 50% to 65%. In these studies, the incidence of all complications ranged from 65% to 81%. These included infection (18% to 30%), penile angulation (6%), pain (6%), and malfunction of the device (6% to 12%). There UROLOGY 54 (1), 1999
was also a high rate of reoperation in these series (30% to 50%).11,12 In the present study, only one intraoperative complication (2.9%) was encountered. This was a crural perforation that went unrecognized at the initial operation but was repaired with a Gore-Tex graft at a later date. Postoperatively, 1 patient developed implant malfunction 2 years after the initial procedure. No patient developed infection in the postoperative period. Thus, there was only one complication in the postoperative period (2.9%). Intraoperative complications can be minimized by careful dilation of the fibrotic corpus cavernosum. With a perineal incision, dilation of the penile crura can be done under direct vision because of the shorter segment of the crus. This minimizes the chance of crural rupture during dilation. Similarly, distal dilation of the fibrotic corpus cavernosum can be initiated toward the glans penis through the proximal corporotomy under direct vision. This dilation is carried out initially by introducing Metzenbaum scissors distally through the corporotomy and spreading the blades gently to break the dense fibrous tissue. Further dilation is achieved with the help of Hegar dilators or Dilamezinsert. Directing the dilators laterally away from the urethra reduces the chances of urethral injury or septal crossover. In the case of difficulty in performing distal corporal dilation, an additional subcoronal incision can be made. Dilation of the distal fibrotic tissue is achieved in a similar fashion, beginning with Metzenbaum scissors introduced through the distal corporotomy and followed by dilation with the help of Hegar dilators. The use of multiple incisions enables us to perform the entire dilation of the fibrotic tissue for only a short distance and under direct vision. This method of dilation is responsible for the lower incidence of intraoperative complications in our series. Semirigid implants were used in only 4 of the 34 patients. Two of these patients requested a change to an inflatable device. This was performed readily because of the formation of a space lined by a pseudocapsule from the previous implant procedure.
UROLOGY 54 (1), 1999
CONCLUSIONS Minimal excision of scar tissue is a safe and effective method in the surgical management of extensive penile fibrosis. REFERENCES 1. Macaluso JN, and Sullivan JW: Priapism. Review of 34 cases. Urology 25: 233–236, 1985. 2. Montague DK: Periprosthetic infection. J Urol 138: 68 – 69, 1987. 3. Orvis BR, and McAninch JW: Penile rupture. Urol Clin North Am 16: 369 –375, 1989. 4. Chew KK, Stuckey BG, Earle CM, et al: Penile fibrosis in intracavernosal prostaglandin E1 injection therapy for erectile dysfunction. Int J Impot Res 9: 225–230, 1997. 5. Larsen TC, Gasser EH, and Bruskewitz RG: Fibrosis of corpus cavernosum after intracavernous injection of phentolamine/papaverine. J Urol 137: 46 – 47, 1987. 6. Herschorn S, and Ordorica RC: Penile prosthesis insertion with corporal reconstruction with synthetic vascular graft material. J Urol 154: 80 – 84, 1995. 7. Knoll LD: Use of penile prosthetic implants in patients with penile fibrosis. Urol Clin North Am 22: 857– 863, 1995. 8. Das S: Peyronie’s disease: excision and autografting with tunica vaginalis. J Urol 124: 818 – 819, 1980. 9. Fallon B: Cadaveric duramater graft for correction of penile curvature in Peyronie’s disease. J Urol 135: 127–129, 1990. 10. Seftel A, Oates R, and Goldstein I: Use of PTFE tube graft as circumferential neotunica during placement of a penile prosthesis. J Urol 148: 1531–1533, 1992. 11. Boyd S, and Martin F: Simultaneous Ultrex penile prosthesis re-implantation and Gore-Tex grafting corporoplasty— functional outcome of a surgical challenge (abstract). Presented at the American Urological Association Annual Meeting, April 22–27, 1995, Las Vegas, Nevada. 12. Goldstein I, Nehra A, Wener M, et al: Technique and follow-up of sharp corporal tissue excision procedure for prosthesis implantation with bilateral severe diffuse corporal fibrosis (abstract). Presented at the American Urological Association Annual Meeting, April 22–27, 1995, Las Vegas, Nevada. 13. Jarow JP: Risk factors for penile prosthetic infection. J Urol 156: 402– 404, 1996. 14. Knoll LD, and Furlow WL: Corporeal reconstruction and prosthetic implantation for impotence associated with non-dilatable corporeal cavernosal fibrosis. Acta Urol Belg 60: 15–25, 1992. 15. George VK, Shah GS, Mills R, et al: The management of extensive penile fibrosis: a new technique of minimal scartissue excision. Br J Urol 77: 282–284, 1996.
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PENILE IMPLANT SUCCESS IN PATIENTS WITH CORPORAL FIBROSIS USING MULTIPLE INCISIONS AND MINIMAL SCAR TISSUE EXCISION ATUL RAJPURKAR, HAIKUN LI,
AND
C. B. DHABUWALA
ABSTRACT Objectives. To establish the efficacy of “minimal scar tissue excision” in the treatment of penile fibrosis. Methods. Thirty-four patients with extensive penile fibrosis who underwent placement of penile implant from October 1989 to April 1998 were evaluated by a chart review of the patient’s follow-up data. Function of the implant was evaluated at follow-up visits. The follow-up ranged from 4 to 84 months (mean 23.7, median 22). All patients had undergone minimal scar tissue excision of the fibrous tissue in the penis. Results. All patients underwent successful introduction of the penile implant, and in no patient was the procedure abandoned because of technical difficulty. Intraoperatively, 1 patient developed a tear in the crus. It was not recognized during the initial operation but was repaired at a subsequent date by Gore-Tex grafting. The Uniflate prosthesis of another patient failed 2 years after the initial surgery and was replaced with the Mentor alpha-1 implant. None of the patients developed infection. All the patients had a functioning implant at the time of last review. Conclusions. Minimal scar tissue excision is a safe and effective method in the management of extensive penile fibrosis. UROLOGY 54: 145–147, 1999. © 1999, Elsevier Science Inc.
P
enile fibrosis commonly results from priapism,1 an infected penile implant,2 trauma,3 or intracavernosal injection (ICI).4,5 The fibrosis that occurs after priapism and an infected penile implant is usually extensive and dense; the degree of fibrosis after ICI varies depending on the duration and frequency of use. Regardless of the etiology, penile fibrosis leads to erectile dysfunction and is a difficult clinical problem to treat. Surgery is the only therapeutic modality that is satisfactory. However, because of the dense and unyielding nature of the fibrous tissue and the penile shortening induced by the fibrosis, surgery is difficult and time consuming.6,7 Conventionally, penile fibrosis has been treated surgically by extensive excision of scar tissue before the insertion of a penile prosthesis. The defect in the corpus cavernosum after the excision of the scar tissue is closed with either biologic or synFrom the Department of Urology, Wayne State University, Detroit, Michigan Reprint requests: C. B. Dhabuwala, M.D., Department of Urology, Wayne State University, 4160 John R. Street, Suite 1017, Detroit, MI 48201 Submitted: November 30, 1998, accepted (with revisions): January 25, 1999 © 1999, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
thetic material.8 –10 More recently, a Gore-Tex graft has been used most commonly for this purpose. The disadvantage of this approach is the high incidence of complications, such as infection, implant malfunction, penile angulation, pain, and corporal-cutaneous fistula and the high reoperation rate to correct these complications.11–14 In an earlier study, we had described the procedure of minimal excision of scar tissue for the correction of this difficult and perplexing problem.15 The procedure consisted of the excision of minimal scar tissue followed by dilation of the corpus cavernosum under vision and the insertion of the penile implant. The purpose of the present study is to reaffirm the feasibility and efficacy of this method in the management of penile fibrosis. MATERIAL AND METHODS From October 1989 to April 1998, 34 consecutive patients with penile fibrosis (mean age 59.5 years, median 62) underwent surgery to correct penile fibrosis. Preoperatively, the procedure was discussed with the patients and written consent obtained. The patients were screened for the presence of urinary tract infection, which was treated if present before surgery. The following protocol was strictly implemented to reduce the risk of postoperative infection: 0090-4295/99/$20.00 PII S0090-4295(99)00060-6 145
1. Intravenous antibiotic prophylaxis 1 hour before surgery, continued for 24 to 48 hours in the postoperative period, followed by oral antibiotics for 2 weeks 2. Surgical shaving of the operative part in the preoperative holding area 3. Instillation of an antibiotic (bacitracin and gentamicin) solution into the patient’s bladder, followed by irrigation of the patient’s urethra with a 5% betadine solution to minimize contamination from the urethral flora during surgery 4. Surgical scrub of the patient’s skin with betadine for 15 minutes 5. A 15-minute surgical scrub by the surgeon and all assistants 6. Reduction of traffic in the operating room to a bare minimum 7. Double-gloving, with betadine solution between the glove layers 8. Laminar air flow to reduce the air contamination of the surgical wound The operative procedure is similar to that used in our previous study. In brief, a Foley catheter is placed preoperatively to help identify the urethra during dilation of the fibrotic corpus cavernosum. A midline perineal incision is used in all cases. Both the corpora cavernosa and bulbosum were exposed. A small corporotomy (2 cm) is made on the corpus cavernosum. Minimal scar tissue is excised at the site of corporotomy to facilitate the initiation of corporal dilation. The initial dilation is performed from the corporotomy site to the ischial tuberosity almost under direct vision starting with blunt-tipped Metzenbaum scissors. Once an initial passageway is created, further dilation is achieved by 7 to 11-gauge Hegar dilators and/or Dilamezinsert. Next, distal dilation is attempted in a similar manner. When it is difficult to dilate the distal corpora because of extensive fibrosis, an additional subcoronal incision is made and dilation of the distal fibrotic area is carried out under direct vision through the distal corporotomy. Finally, the dilators are passed from the proximal to the distal corporotomy. The penile length is measured and an adequately sized penile prosthesis is inserted into the penis. These maneuvers avoid proximal crural perforation and distal injury to the urethra because this part of the dilation is performed under direct vision. When it is difficult to close the defect in the tunica albuginea after insertion of the prosthesis, a 0.4-mm polytetrafluoroethylene (PTFE) graft is used. The wound is liberally sprayed with an antibiotic solution (160 mg gentamicin and 50,000 IU bacitracin mixed in 1 L of normal saline) during the procedure.
RESULTS Thirty-four patients with extensive penile fibrosis were included in this study. Four patients had fibrosis secondary to priapism (of these, 3 were secondary to sickle cell anemia, and 1 patient had developed priapism spontaneously); 2 patients had fibrosis secondary to ICI therapy; and 28 patients had developed fibrosis secondary to an infected penile implant. Of the 28, 3 patients each had undergone four previous penile implant procedures, 2 had undergone three, 2 had undergone two, and 21 had undergone one previous implant procedure. A perineal incision was used in all cases. An additional subcoronal incision was required in 30 of the 34 patients. At the time of surgery, 32 pa146
tients were found to have extensive bilateral fibrosis; 2 patients had extensive unilateral fibrosis. All patients underwent successful introduction of a penile implant, and in no patient was surgery abandoned because of extensive penile fibrosis. We did not use Roselli cavernotomes or Otis urethrotomes for dilation of the fibrous tissue in any of our patients, as we were able to achieve successful dilation and implantation by a combination of minimal scar tissue excision and multiple incisions, as described above. Fifteen patients had the Mentor alpha-1 implant, 1 patient a Mark 2 prosthesis, 7 the AMS-600 prosthesis, 7 the AMS-700 prosthesis, and 4 patients had the semirigid implant. Although we used a Gore-Tex graft in 13 of 34 cases, a much smaller length was required to cover the defect in the tunica albuginea after minimal scar tissue excision. Intraoperatively, 1 patient developed a tear in the crus. It was not recognized during the initial operation but was repaired at a later date with a Gore-Tex graft. None of the patients developed any early postoperative complications, including infection. The follow-up was between 3 months and 8 years. Four patients underwent reoperation. The Uniflate prosthesis of 1 patient failed 2 years after the original surgery and was replaced with the Mentor alpha-1 implant. In another patient, crural perforation went unrecognized at the time of the original procedure. This was repaired at a later date by Gore-Tex grafting. Two other patients underwent reoperation to change their semirigid prosthesis to an inflatable one. Thus, in only 1 of these 4 patients was the second procedure directly related to technical difficulty during the initial implantation. All patients had a functioning implant at the time of last review. COMMENT Penile fibrosis can result from multiple causes, such as priapism,1 use of ICI,4,5 after implant removal for infection,7 and penile trauma.3 When extensive, wide excision of the scar tissue is the surgical procedure that has been widely used to treat this condition. This approach compromises the blood supply to the penis, contributing to the poor healing of the surgical wound and an inadequate delivery of antibiotic to the surgical site. This is responsible for the high rate of postoperative infection seen in patients treated by this method.11–14 There is also a high reported rate of intraoperative complications (31%),11,12 and the incidence of later complications was 50% to 65%. In these studies, the incidence of all complications ranged from 65% to 81%. These included infection (18% to 30%), penile angulation (6%), pain (6%), and malfunction of the device (6% to 12%). There UROLOGY 54 (1), 1999
was also a high rate of reoperation in these series (30% to 50%).11,12 In the present study, only one intraoperative complication (2.9%) was encountered. This was a crural perforation that went unrecognized at the initial operation but was repaired with a Gore-Tex graft at a later date. Postoperatively, 1 patient developed implant malfunction 2 years after the initial procedure. No patient developed infection in the postoperative period. Thus, there was only one complication in the postoperative period (2.9%). Intraoperative complications can be minimized by careful dilation of the fibrotic corpus cavernosum. With a perineal incision, dilation of the penile crura can be done under direct vision because of the shorter segment of the crus. This minimizes the chance of crural rupture during dilation. Similarly, distal dilation of the fibrotic corpus cavernosum can be initiated toward the glans penis through the proximal corporotomy under direct vision. This dilation is carried out initially by introducing Metzenbaum scissors distally through the corporotomy and spreading the blades gently to break the dense fibrous tissue. Further dilation is achieved with the help of Hegar dilators or Dilamezinsert. Directing the dilators laterally away from the urethra reduces the chances of urethral injury or septal crossover. In the case of difficulty in performing distal corporal dilation, an additional subcoronal incision can be made. Dilation of the distal fibrotic tissue is achieved in a similar fashion, beginning with Metzenbaum scissors introduced through the distal corporotomy and followed by dilation with the help of Hegar dilators. The use of multiple incisions enables us to perform the entire dilation of the fibrotic tissue for only a short distance and under direct vision. This method of dilation is responsible for the lower incidence of intraoperative complications in our series. Semirigid implants were used in only 4 of the 34 patients. Two of these patients requested a change to an inflatable device. This was performed readily because of the formation of a space lined by a pseudocapsule from the previous implant procedure.
UROLOGY 54 (1), 1999
CONCLUSIONS Minimal excision of scar tissue is a safe and effective method in the surgical management of extensive penile fibrosis. REFERENCES 1. Macaluso JN, and Sullivan JW: Priapism. Review of 34 cases. Urology 25: 233–236, 1985. 2. Montague DK: Periprosthetic infection. J Urol 138: 68 – 69, 1987. 3. Orvis BR, and McAninch JW: Penile rupture. Urol Clin North Am 16: 369 –375, 1989. 4. Chew KK, Stuckey BG, Earle CM, et al: Penile fibrosis in intracavernosal prostaglandin E1 injection therapy for erectile dysfunction. Int J Impot Res 9: 225–230, 1997. 5. Larsen TC, Gasser EH, and Bruskewitz RG: Fibrosis of corpus cavernosum after intracavernous injection of phentolamine/papaverine. J Urol 137: 46 – 47, 1987. 6. Herschorn S, and Ordorica RC: Penile prosthesis insertion with corporal reconstruction with synthetic vascular graft material. J Urol 154: 80 – 84, 1995. 7. Knoll LD: Use of penile prosthetic implants in patients with penile fibrosis. Urol Clin North Am 22: 857– 863, 1995. 8. Das S: Peyronie’s disease: excision and autografting with tunica vaginalis. J Urol 124: 818 – 819, 1980. 9. Fallon B: Cadaveric duramater graft for correction of penile curvature in Peyronie’s disease. J Urol 135: 127–129, 1990. 10. Seftel A, Oates R, and Goldstein I: Use of PTFE tube graft as circumferential neotunica during placement of a penile prosthesis. J Urol 148: 1531–1533, 1992. 11. Boyd S, and Martin F: Simultaneous Ultrex penile prosthesis re-implantation and Gore-Tex grafting corporoplasty— functional outcome of a surgical challenge (abstract). Presented at the American Urological Association Annual Meeting, April 22–27, 1995, Las Vegas, Nevada. 12. Goldstein I, Nehra A, Wener M, et al: Technique and follow-up of sharp corporal tissue excision procedure for prosthesis implantation with bilateral severe diffuse corporal fibrosis (abstract). Presented at the American Urological Association Annual Meeting, April 22–27, 1995, Las Vegas, Nevada. 13. Jarow JP: Risk factors for penile prosthetic infection. J Urol 156: 402– 404, 1996. 14. Knoll LD, and Furlow WL: Corporeal reconstruction and prosthetic implantation for impotence associated with non-dilatable corporeal cavernosal fibrosis. Acta Urol Belg 60: 15–25, 1992. 15. George VK, Shah GS, Mills R, et al: The management of extensive penile fibrosis: a new technique of minimal scartissue excision. Br J Urol 77: 282–284, 1996.
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