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Small-Carrion penile prosthesis
SMALL-CARRION
PENILE PROSTHESIS
New Implant for Management
MICHAEL
P. SMALL,
M.D.
HERNAN M. CARRION, JULIAN A. GORDON,
of Impotence
M.D
M.D.
From the Department of Urology, University of Miami School of Medicine, and Veterans Administration Hospital, Miami, Florida
ABSTRACT - The etiology of impotence and a review of various techniques in treatment are discussed. A perineal surgical approach with a new type of paired sponge-filled silicone prostheses is described. The prostheses are inserted into previously dilated corpora cavernosa. Of the initial 31 patients, excellent results were obtained in 27, and a good result in 1. Of the 3 patients with initial serious complications, adequate functional results were attained in 2. The distinct advantages and potential complications using the Small-Carrion penile prosthesis and surgical technique are discussed.
The treatment of impotence by using prosthetic devices is not new. Finding the most efficient prosthesis and the most efficacious technique of placement have been the goals of many physicians for the past two decades. Our search for a more physiologic prosthesis with greater ease of insertion and a lower complication rate has led to this study and to the presentation of our results using the Small-Carrion penile prosthesis. Etiology of Impotence and Need for Prosthetic Device There are many causes of impotence. A complete review of this subject and the physiology of erection has been made by others.1-4 Organic impotence is the loss ofthe ability to obtain and/or maintain a functional erection due to the interruption of certain physiologic processes. The complex reflexes entailed in the mediation of the mechanism of erection are also affected by physiologic factors. The most common causes of organic impotence are: 1. Trauma A. Spinal cord injury B. Pelvic fracture
UROLOGY
/ APRIL 1975 / VOLUME
V, NUMBER 4
2. Postoperative A. Prostatectomy B. Cystectomy C. External sphincterotomy D. Abdominal perineal resection 3. Vascular disease A. Arteriosclerosis B. Priapism 4. Neurologic disease A. Peripheral neuropathy B. Multiple sclerosis 5. Endocrinologic and metabolic disease A. Diabetes B. Hypogonadism C. Renal failure 6. Medications A. Estrogen B. Parasympatholytics C. Morphine D. Heroin Stafford-Clark3 has estimated, and most authorities agree, that psychogenic factors are the cause of impotence in approximately 90 per cent of patients. Even after adequate attempts at sex counseling and a trial of androgen therapy, many
479
FIGURE 1.
Various mostheses:
and (C) Morales.
/A) Pearman and Lash, (B) Small-Carrion, I
I
’
of these patients will be candidates for surgical management of their impotence. History of Surgical Management of Impotence The first materials used for internal penile splinting were cartilage and bone grafts which were found to be disappointing.5-7 The use of synthetic materials was first described by Goodwin and Scott’ who used acrylic implants. The surgical procedure of placing an acrylic prosthesis between the corpora cavernosa for the management of impotence was described by Loeffler and Sayegh.6 They commented, however, that some degree of erection was necessary. As the field of implantablesyntheticsmatured, asearchforbetter material and design continued. Lash, Zimmerman, and Loeffler’ suggested silicone rubber as an excellent material for implantation. Lash in 1968g and Pearman in 1967lO and in 1972l described the use of a silicone prosthesis which was placed on the undersurface of the tunica albuginea through a dorsal penile incision (Fig. 1). Pearman believed that the silicone prosthesis would conform to fit the architecture of the penis; could be inserted easily without damage to the nerves, blood supply, or erectile tissue; would give satisfactory penetration; and not prove awkward in carrying out daily activities. With this type of prosthesis, a variety of complications have occurred: extrusion through the urethra or skin of the dorsal penile shaft; lymphatic edema; irritation of the glans at the corona; and slippage of the glans over the prosthesis making penetration painful, difficult, and even impossible at times.
480
Beheri in 19664 described the use of paired polyethylene rods placed in the corpora cavernosa in 706 patients. He used a midline dorsal penile incision and then opened and dilated the corpora. The rods were placed in this bed extendinq from the crus of the penis upward under the glans. In a short phallus the suspensory ligament was cut to allow elongation of the penile shaft. The prostheses were available in three lengths which were angled to fit back into the crus of the penis. Morales et al. in 19732 described a similar technique and prosthesis (Fig. 1). Complications using the Morales-type prosthesis have been bilateral infection of the corpora cavernosa (in diabetic patients), crural perforation, midshaft septal perforation after misplacement of the prosthesis, and penile pain due to rigidity of the prosthesis. Recently a new prosthesis has been developed by Kothariet al. I1 and Scott, Bradley, and Timm12 involving an implantable hydraulic fluid transfer system where the corpora are inflated and deflated at will, in an attempt to more closely approximate the natural physiologic state. This prosthesis appears to have excellent potential; however, extensive surgery is required and both hydraulic and mechanical failures have been experienced. Small-Carrion Penile Prosthesis Because of the narrow size and rigidity of the Morales prosthesis, a search was begun for a more flexible and more normal-feeling material which at the same time would give more width to the
UROLOGY
/ APRIL 1975
! VOLUME V, NUMBER 4
_ FIGURE
2.
Various sizes of Small-Carrion prosthesis.
phallus in addition to length and firmness. Following the lead of the plastic surgeons and their desire for an ideal implantable breast prosthesis, we believed that a silicone-gel-filled penile prosthesis placed in the corpora cavernosa would meet these criteria. Several prototypes were tried. The first had a firm medical-grade silicone exterior filled with aviscous silicone gel. This type of prosthesis was placed in a number of patients with excellent results. However, this prosthesis proved to have limited shelf life because of diffusion of air through the silicone shell which formed bubbles in the prosthesis and tended to soften it over a period of time. In those patients who had this type of prosthesis inserted, there have been no changes in consistency, and these were found to give excellent structural support. The prosthesis which we are now using consists of a medical-grade silicone exterior with a silicone sponge interior. * This model appears to have the ideal qualities of a penile prosthesis giving adequate width, length, and a consistency similar to the erect penis. The prosthesis is now available in four lengths: 12 cm., 13.3 cm., 14.5 cm., and 15.8 cm., and in two diameters: 0.9 cm. and 1.1 cm. The proper size prosthesis is selected at the time of surgery. *Heyer
UROLOGY
Schulte,
/
Galota,
APRIL 1975
California.
/
VOLUME V, NUMBER 4
The narrower diameter is usually needed in patients in whom it is extremely difficult to dilate the corpora cavernosa, as in those who have had priapism, inflammatory disease of the corpora, or extensive penile trauma. The proximal portion of the prosthesis is curved to fit the crus of the penis and is made of solid medical-grade silicone. The rigidity of the prosthesis in this area allows for adequate support at the crus and ischial tuberosities. The prosthesis can be sterilized in any hospital autoclave (Fig. 2). Operative Technique To prevent further trauma or scarring of the phallus, a perineal surgical approach is used. The patient is placed in the dorsal lithotomy position, and a catheter is placed in the urethra for identification purposes. A vertical midline incision is made from the base of the scrotum toward the anus, and the incision is carried down to the bulbocavernosus muscle (Fig. 3A). The bulbocavernosus muscle and urethra are retracted to one side, and the ischial cavernosus muscle and the crus of the penis are identified (Fig. 3B). If difficulty is encountered in finding these structures, firm compression of the penis will give an impulse in the area of the crus. Once the crus has been identified, it is opened for a length of approximately 2 cm. Hegar dilators are then used to dilate the crus of the penis proximally to the
481
FIGURE 3. technique.
482
UROLOGY
{A)
to
(E)
Small-Carrion
/ APRIL 1975 / VOLUME
operative
V. NUMBER4
ischial tuberosity and distally for the complete extent of the corpora cavernosa (Fig. 3C and D). It is imperative that dilatation be carried completely under the glans penis so that the prosthesis will sit firmly in this area and not allow the glans to flex over the prosthesis. Dilatation is usually started with a no. 5 Hegar dilator; ifthere is no scarring in the corpora, then it is easy to dilate
UROLOGY
/ APRIL1975 / VOLUMEV.
NUMBER4
to a no. 10 or 11. When dilating proximally, care must be taken not to perforate the crus. All four lengths and both diameters ofprosthesis should be available at the time of surgery. The proper size is selected for each individual patient. We have found that the 13.3 cm. (medium) or 14.5 cm. (long) prosthesis will usually be required. The prosthesis should fit firmly against
483
TABLE I. Diagnosis
Classijkation and results of 31 patients having Small-Carrion prosthesis Number of Patients
Postprostatectomy Postpriapism Psychogenic Pelvic fracture
4 2 2 3
Arteriosclerosis Spinal cord injury
2 15
Diabetes mellitus Epispadias and extrophy
2 1
the wall of the corpora cavernosa, and therefore we usually use the wide diameter. The distal end of the prosthesis should extend to the tip of the corpus cavernosum so that the glans penis sits firmly over the prosthesis. After one prosthesis has been inserted, the same procedure is carried out on the contralateral side (Fig. 3E). The incisions in each corpora are then closed with a running suture of 3-O chromic catgut. The remainder of the wound is closed in a routine manner. Drains are not used, and the urethral catheter is removed immediately after surgery. During the procedure the implants are soaked in an antibiotic solution (polymyxin-neomycin, 1 ampule to 1 L. of normal saline), and after insertion the wound is irrigated with the same solution. All patients are also given a broadspectrum antibiotic during surgery which is continued postoperatively. The patient may be discharged from the hospital in four or five days, and intercourse is allowed in three or four weeks. In patients who are impotent after pelvic fracture or who have had proximal urethroplasty, incisions may be made laterally directly over the crura or ventrally in the midline at the penoscrotal junction to avoid a previously scarred area. The remainder of the procedure is identical to that which has been described. Results From February, 1973, to October, 1974, 31 patients had insertion of the Small-Carrion penile prosthesis (Table I). Patients ranged in age from nineteen to seventy-two years. Four patients were impotent after prostatectomy, 2 after priapism, 2 had psychogenic impotence, 2 because of generalized arteriosclerosis, 3 after pel-
484
Results Excellent Excellent Excellent Excellent 2; partial failure (1 lost prosthesis secondary to infection) Excellent Excellent 13; partial failure (1 prosthesis lost secondary to infection); failure (1 incorrect placement of prosthesis) Excellent 2 Good (small phallus)
vie fracture, 15 had spinal cord injuries, 2 were impotent secondary to diabetes mellitus, and 1 was born with extrophy and epispadias. Several patients previously had Pear-man prostheses which proved unsatisfactory because of irritation at the glans penis and, in retrospect, were also not satisfactory to the female partner. Complications have been minimal (Table II). Urinary retention which was temporary and required Foley catheter drainage for twenty-four hours developed in 2 patients; a prosthesis extruded transurethrally in 2 patients, one of whom had been on Foley catheter drainage for a long time and had also undergone transurethral prostatectomy and sphincterotomy, and the other required surgery at the penoscrotal junction ventrally and subsequently a wound infection developed in one corpus cavernosum. After extrusion ofthe prosthesis, the wounds and urethras healed satisfactorily, and both patients are having adequate although probably not optimal intercourse with the one remaining intracorporal penile prosthesis. One patient had incorrect placement of the prostheses requiring subsequent removal because of extensive scar tissue TABLE II. Complications resulting fi-om Small-Carrion prosthesis in 31 patients Complications Urinary retention (temporary) Severe wound infection with extrusion of prosthesis Incorrect placement of prosthesis Superficial wound infection (without sequelae) Serious
Number of Patients 2 2 1 3 3
UROLOGY / APRIL1975 / VOLUMEV, NUMBER4
FIGURE 4. (A)and(B) Postoperatiue results demonstrating prosthesis gives normal appearance of erect penis.
in the perineum secondary to periurethral abscess formation and proximal urethroplasty. Superficial wound infections which healed without sequelae developed in 3 patients. Figure 4 shows typical postoperative results, demonstrating that the prosthesis gives the phallus the normal appearance of an erect penis. Comment The adequate management of impotence has always been an enigma to urologists as well as other physicians dealing with this disease entity. After the patient has undergone urologic and endocrinologic evaluation, sex counseling, possible psychiatric therapy, and even an empiric course of androgen therapy without response, penile prosthesis is indicated. Bilateral intracorporeal placement of a penile prothesis is physiologic because it closely mimics the normal state of erection. In this location, the prosthesis gives excellent support because of the firmness of the corpora, gives added length, and, more importantly, added width to the penis. The SmallCarrion prosthesis accomplishes all of these. By using a medical-grade silicone shell with a silicone sponge interior, the shape and consistency of a normal erection is obtained. While this prosthesis is firm, there is enough flexibility to keep the phallus inconspicuous under jockey shorts either in the normal position or against the abdominal wall. To obviate scar formation on the penile shaft, a perineal approach was developed. How-
UROLOGY
! APRIL1975 / VOLUMEV,
NUMBER4
ever, in patients who have marked periurethral induration or scar formation, lateral incisions or a more distally placed midline incision may be utilized rather than dissect through a scarred perineum. Patients with the perineal incision may resume sexual activities sooner than those with a penile incision. Insertion of this prosthesis in impotent patients with spinal cord injuries and neurogenic bladders has one additional advantage: added length and girth obtained with this prosthesis permits patients with a short phallus who have difficulty keeping an external collection device in place, to do so easily. Caution must be exercised, however, in patients with neurogenic bladder who have borderline decompensation of their bladder. Elongating and possibly compressing the shaft of the urethramayincreaseurethralresistanceenough to cause further decompensation. This may necessitate external sphincterotomy with the prosthesis in place. One would do well to fully evaluate these patients prior to inserting the prosthesis and performing any transurethral surgery first. If a prosthesis already has been inserted and transurethral surgery is found to be necessary, then it might be best performed through a perineal urethrostomy. Simultaneous insertion of penile prosthesis at the time of radical prostatectomy or cystectomy, as suggested by Grabstald, l2 has not been attempted. We believe that infection would be more
485
likely to occur when the urinary tract is opened and urine is bathing the wound and the prosin selected cases where thesis. However, adequate antibiotic coverage has been obtained, this might be a consideration. Addendum In addition to the 31 patients reported, 10 additional cases have been added to our series. These were older men with organic impotence secondary to arteriosclerosis and peripheral neuropathy. There have been no further complications. 7413 Miami Lakes Drive Miami, Florida 33014 (DR. SMALL) References Insertion of a Silastic penile pros1. PEARMAN, R. 0.: thesis for the treatment of organic sexual impotence, J. Urol. 107: 802 (1972). 2. MORALES, P. A., SUAREZ,J. B.,DELGADO, J., and WHITEHEAD, E. D.: Penile implant for erectile impotence, ibid. 109: 641 (1973).
A%
3. STAFFORD-CLARK, D. : The etiology and treatment of impotence, Practitioner 172: 397 (1954). 4. BEHERI, G. E.: Surgical treatment of impotence, Plast. Reconst. Surg. 38: 92 (1966). Uber die volle plastiche 5. BOGORAS, N. A.: wiederherstellung einer zum koitus fahigen penis (penilplastica totalis), Zentralbl Chir. 63: 1271 (1936). 6. LOEFFLER, R. A., and SAYEGH, E. S.: Perforated acrylic implants in the management of organic impotence, J. Urol. 84: 559 (1960). 7. GOODWIN, W. E., and SCOTT, W. S.: Phalloplasty,
ibid. 68: 903 (1952). 8. LASH, H., ZIMMERMAN, D. C., and LOEFFLER, R. A.: Silicone implantation: inlay method, Plast. Reconstr. Surg. 34: 75 (1964). 9. LASH, H.: Silicone implants for impotence, J. Urol. 100:709 (1968). 10. PEARMAN, R. 0.: Treatment of organic impotence by implantation of penile prosthesis, ibid. 97: 716 (1967). 11. KOTHARI, D. R., TIMM, G. W., FROHIB, D. A., and BRADLEY, W. E.: An implantable fluid transfer system for treatment of impotence, J. Biomech. 5: 567 (1972). 12. SCOTT, E. B., BRADLEY, W. E., and TIMM, G. w.: Management of erectile impotence, Urology 2: 80 (1973). 13. GRABSTALD, H. : Postradical cystectomy impotence treated by penile silicone implant, N. Y. State J. Med. 70: 2344 (1970).
UROLOGY
/
APRIL1975 I VOLUMEV,
NUMBER4
PENILE PROSTHESIS
New Implant for Management
MICHAEL
P. SMALL,
M.D.
HERNAN M. CARRION, JULIAN A. GORDON,
of Impotence
M.D
M.D.
From the Department of Urology, University of Miami School of Medicine, and Veterans Administration Hospital, Miami, Florida
ABSTRACT - The etiology of impotence and a review of various techniques in treatment are discussed. A perineal surgical approach with a new type of paired sponge-filled silicone prostheses is described. The prostheses are inserted into previously dilated corpora cavernosa. Of the initial 31 patients, excellent results were obtained in 27, and a good result in 1. Of the 3 patients with initial serious complications, adequate functional results were attained in 2. The distinct advantages and potential complications using the Small-Carrion penile prosthesis and surgical technique are discussed.
The treatment of impotence by using prosthetic devices is not new. Finding the most efficient prosthesis and the most efficacious technique of placement have been the goals of many physicians for the past two decades. Our search for a more physiologic prosthesis with greater ease of insertion and a lower complication rate has led to this study and to the presentation of our results using the Small-Carrion penile prosthesis. Etiology of Impotence and Need for Prosthetic Device There are many causes of impotence. A complete review of this subject and the physiology of erection has been made by others.1-4 Organic impotence is the loss ofthe ability to obtain and/or maintain a functional erection due to the interruption of certain physiologic processes. The complex reflexes entailed in the mediation of the mechanism of erection are also affected by physiologic factors. The most common causes of organic impotence are: 1. Trauma A. Spinal cord injury B. Pelvic fracture
UROLOGY
/ APRIL 1975 / VOLUME
V, NUMBER 4
2. Postoperative A. Prostatectomy B. Cystectomy C. External sphincterotomy D. Abdominal perineal resection 3. Vascular disease A. Arteriosclerosis B. Priapism 4. Neurologic disease A. Peripheral neuropathy B. Multiple sclerosis 5. Endocrinologic and metabolic disease A. Diabetes B. Hypogonadism C. Renal failure 6. Medications A. Estrogen B. Parasympatholytics C. Morphine D. Heroin Stafford-Clark3 has estimated, and most authorities agree, that psychogenic factors are the cause of impotence in approximately 90 per cent of patients. Even after adequate attempts at sex counseling and a trial of androgen therapy, many
479
FIGURE 1.
Various mostheses:
and (C) Morales.
/A) Pearman and Lash, (B) Small-Carrion, I
I
’
of these patients will be candidates for surgical management of their impotence. History of Surgical Management of Impotence The first materials used for internal penile splinting were cartilage and bone grafts which were found to be disappointing.5-7 The use of synthetic materials was first described by Goodwin and Scott’ who used acrylic implants. The surgical procedure of placing an acrylic prosthesis between the corpora cavernosa for the management of impotence was described by Loeffler and Sayegh.6 They commented, however, that some degree of erection was necessary. As the field of implantablesyntheticsmatured, asearchforbetter material and design continued. Lash, Zimmerman, and Loeffler’ suggested silicone rubber as an excellent material for implantation. Lash in 1968g and Pearman in 1967lO and in 1972l described the use of a silicone prosthesis which was placed on the undersurface of the tunica albuginea through a dorsal penile incision (Fig. 1). Pearman believed that the silicone prosthesis would conform to fit the architecture of the penis; could be inserted easily without damage to the nerves, blood supply, or erectile tissue; would give satisfactory penetration; and not prove awkward in carrying out daily activities. With this type of prosthesis, a variety of complications have occurred: extrusion through the urethra or skin of the dorsal penile shaft; lymphatic edema; irritation of the glans at the corona; and slippage of the glans over the prosthesis making penetration painful, difficult, and even impossible at times.
480
Beheri in 19664 described the use of paired polyethylene rods placed in the corpora cavernosa in 706 patients. He used a midline dorsal penile incision and then opened and dilated the corpora. The rods were placed in this bed extendinq from the crus of the penis upward under the glans. In a short phallus the suspensory ligament was cut to allow elongation of the penile shaft. The prostheses were available in three lengths which were angled to fit back into the crus of the penis. Morales et al. in 19732 described a similar technique and prosthesis (Fig. 1). Complications using the Morales-type prosthesis have been bilateral infection of the corpora cavernosa (in diabetic patients), crural perforation, midshaft septal perforation after misplacement of the prosthesis, and penile pain due to rigidity of the prosthesis. Recently a new prosthesis has been developed by Kothariet al. I1 and Scott, Bradley, and Timm12 involving an implantable hydraulic fluid transfer system where the corpora are inflated and deflated at will, in an attempt to more closely approximate the natural physiologic state. This prosthesis appears to have excellent potential; however, extensive surgery is required and both hydraulic and mechanical failures have been experienced. Small-Carrion Penile Prosthesis Because of the narrow size and rigidity of the Morales prosthesis, a search was begun for a more flexible and more normal-feeling material which at the same time would give more width to the
UROLOGY
/ APRIL 1975
! VOLUME V, NUMBER 4
_ FIGURE
2.
Various sizes of Small-Carrion prosthesis.
phallus in addition to length and firmness. Following the lead of the plastic surgeons and their desire for an ideal implantable breast prosthesis, we believed that a silicone-gel-filled penile prosthesis placed in the corpora cavernosa would meet these criteria. Several prototypes were tried. The first had a firm medical-grade silicone exterior filled with aviscous silicone gel. This type of prosthesis was placed in a number of patients with excellent results. However, this prosthesis proved to have limited shelf life because of diffusion of air through the silicone shell which formed bubbles in the prosthesis and tended to soften it over a period of time. In those patients who had this type of prosthesis inserted, there have been no changes in consistency, and these were found to give excellent structural support. The prosthesis which we are now using consists of a medical-grade silicone exterior with a silicone sponge interior. * This model appears to have the ideal qualities of a penile prosthesis giving adequate width, length, and a consistency similar to the erect penis. The prosthesis is now available in four lengths: 12 cm., 13.3 cm., 14.5 cm., and 15.8 cm., and in two diameters: 0.9 cm. and 1.1 cm. The proper size prosthesis is selected at the time of surgery. *Heyer
UROLOGY
Schulte,
/
Galota,
APRIL 1975
California.
/
VOLUME V, NUMBER 4
The narrower diameter is usually needed in patients in whom it is extremely difficult to dilate the corpora cavernosa, as in those who have had priapism, inflammatory disease of the corpora, or extensive penile trauma. The proximal portion of the prosthesis is curved to fit the crus of the penis and is made of solid medical-grade silicone. The rigidity of the prosthesis in this area allows for adequate support at the crus and ischial tuberosities. The prosthesis can be sterilized in any hospital autoclave (Fig. 2). Operative Technique To prevent further trauma or scarring of the phallus, a perineal surgical approach is used. The patient is placed in the dorsal lithotomy position, and a catheter is placed in the urethra for identification purposes. A vertical midline incision is made from the base of the scrotum toward the anus, and the incision is carried down to the bulbocavernosus muscle (Fig. 3A). The bulbocavernosus muscle and urethra are retracted to one side, and the ischial cavernosus muscle and the crus of the penis are identified (Fig. 3B). If difficulty is encountered in finding these structures, firm compression of the penis will give an impulse in the area of the crus. Once the crus has been identified, it is opened for a length of approximately 2 cm. Hegar dilators are then used to dilate the crus of the penis proximally to the
481
FIGURE 3. technique.
482
UROLOGY
{A)
to
(E)
Small-Carrion
/ APRIL 1975 / VOLUME
operative
V. NUMBER4
ischial tuberosity and distally for the complete extent of the corpora cavernosa (Fig. 3C and D). It is imperative that dilatation be carried completely under the glans penis so that the prosthesis will sit firmly in this area and not allow the glans to flex over the prosthesis. Dilatation is usually started with a no. 5 Hegar dilator; ifthere is no scarring in the corpora, then it is easy to dilate
UROLOGY
/ APRIL1975 / VOLUMEV.
NUMBER4
to a no. 10 or 11. When dilating proximally, care must be taken not to perforate the crus. All four lengths and both diameters ofprosthesis should be available at the time of surgery. The proper size is selected for each individual patient. We have found that the 13.3 cm. (medium) or 14.5 cm. (long) prosthesis will usually be required. The prosthesis should fit firmly against
483
TABLE I. Diagnosis
Classijkation and results of 31 patients having Small-Carrion prosthesis Number of Patients
Postprostatectomy Postpriapism Psychogenic Pelvic fracture
4 2 2 3
Arteriosclerosis Spinal cord injury
2 15
Diabetes mellitus Epispadias and extrophy
2 1
the wall of the corpora cavernosa, and therefore we usually use the wide diameter. The distal end of the prosthesis should extend to the tip of the corpus cavernosum so that the glans penis sits firmly over the prosthesis. After one prosthesis has been inserted, the same procedure is carried out on the contralateral side (Fig. 3E). The incisions in each corpora are then closed with a running suture of 3-O chromic catgut. The remainder of the wound is closed in a routine manner. Drains are not used, and the urethral catheter is removed immediately after surgery. During the procedure the implants are soaked in an antibiotic solution (polymyxin-neomycin, 1 ampule to 1 L. of normal saline), and after insertion the wound is irrigated with the same solution. All patients are also given a broadspectrum antibiotic during surgery which is continued postoperatively. The patient may be discharged from the hospital in four or five days, and intercourse is allowed in three or four weeks. In patients who are impotent after pelvic fracture or who have had proximal urethroplasty, incisions may be made laterally directly over the crura or ventrally in the midline at the penoscrotal junction to avoid a previously scarred area. The remainder of the procedure is identical to that which has been described. Results From February, 1973, to October, 1974, 31 patients had insertion of the Small-Carrion penile prosthesis (Table I). Patients ranged in age from nineteen to seventy-two years. Four patients were impotent after prostatectomy, 2 after priapism, 2 had psychogenic impotence, 2 because of generalized arteriosclerosis, 3 after pel-
484
Results Excellent Excellent Excellent Excellent 2; partial failure (1 lost prosthesis secondary to infection) Excellent Excellent 13; partial failure (1 prosthesis lost secondary to infection); failure (1 incorrect placement of prosthesis) Excellent 2 Good (small phallus)
vie fracture, 15 had spinal cord injuries, 2 were impotent secondary to diabetes mellitus, and 1 was born with extrophy and epispadias. Several patients previously had Pear-man prostheses which proved unsatisfactory because of irritation at the glans penis and, in retrospect, were also not satisfactory to the female partner. Complications have been minimal (Table II). Urinary retention which was temporary and required Foley catheter drainage for twenty-four hours developed in 2 patients; a prosthesis extruded transurethrally in 2 patients, one of whom had been on Foley catheter drainage for a long time and had also undergone transurethral prostatectomy and sphincterotomy, and the other required surgery at the penoscrotal junction ventrally and subsequently a wound infection developed in one corpus cavernosum. After extrusion ofthe prosthesis, the wounds and urethras healed satisfactorily, and both patients are having adequate although probably not optimal intercourse with the one remaining intracorporal penile prosthesis. One patient had incorrect placement of the prostheses requiring subsequent removal because of extensive scar tissue TABLE II. Complications resulting fi-om Small-Carrion prosthesis in 31 patients Complications Urinary retention (temporary) Severe wound infection with extrusion of prosthesis Incorrect placement of prosthesis Superficial wound infection (without sequelae) Serious
Number of Patients 2 2 1 3 3
UROLOGY / APRIL1975 / VOLUMEV, NUMBER4
FIGURE 4. (A)and(B) Postoperatiue results demonstrating prosthesis gives normal appearance of erect penis.
in the perineum secondary to periurethral abscess formation and proximal urethroplasty. Superficial wound infections which healed without sequelae developed in 3 patients. Figure 4 shows typical postoperative results, demonstrating that the prosthesis gives the phallus the normal appearance of an erect penis. Comment The adequate management of impotence has always been an enigma to urologists as well as other physicians dealing with this disease entity. After the patient has undergone urologic and endocrinologic evaluation, sex counseling, possible psychiatric therapy, and even an empiric course of androgen therapy without response, penile prosthesis is indicated. Bilateral intracorporeal placement of a penile prothesis is physiologic because it closely mimics the normal state of erection. In this location, the prosthesis gives excellent support because of the firmness of the corpora, gives added length, and, more importantly, added width to the penis. The SmallCarrion prosthesis accomplishes all of these. By using a medical-grade silicone shell with a silicone sponge interior, the shape and consistency of a normal erection is obtained. While this prosthesis is firm, there is enough flexibility to keep the phallus inconspicuous under jockey shorts either in the normal position or against the abdominal wall. To obviate scar formation on the penile shaft, a perineal approach was developed. How-
UROLOGY
! APRIL1975 / VOLUMEV,
NUMBER4
ever, in patients who have marked periurethral induration or scar formation, lateral incisions or a more distally placed midline incision may be utilized rather than dissect through a scarred perineum. Patients with the perineal incision may resume sexual activities sooner than those with a penile incision. Insertion of this prosthesis in impotent patients with spinal cord injuries and neurogenic bladders has one additional advantage: added length and girth obtained with this prosthesis permits patients with a short phallus who have difficulty keeping an external collection device in place, to do so easily. Caution must be exercised, however, in patients with neurogenic bladder who have borderline decompensation of their bladder. Elongating and possibly compressing the shaft of the urethramayincreaseurethralresistanceenough to cause further decompensation. This may necessitate external sphincterotomy with the prosthesis in place. One would do well to fully evaluate these patients prior to inserting the prosthesis and performing any transurethral surgery first. If a prosthesis already has been inserted and transurethral surgery is found to be necessary, then it might be best performed through a perineal urethrostomy. Simultaneous insertion of penile prosthesis at the time of radical prostatectomy or cystectomy, as suggested by Grabstald, l2 has not been attempted. We believe that infection would be more
485
likely to occur when the urinary tract is opened and urine is bathing the wound and the prosin selected cases where thesis. However, adequate antibiotic coverage has been obtained, this might be a consideration. Addendum In addition to the 31 patients reported, 10 additional cases have been added to our series. These were older men with organic impotence secondary to arteriosclerosis and peripheral neuropathy. There have been no further complications. 7413 Miami Lakes Drive Miami, Florida 33014 (DR. SMALL) References Insertion of a Silastic penile pros1. PEARMAN, R. 0.: thesis for the treatment of organic sexual impotence, J. Urol. 107: 802 (1972). 2. MORALES, P. A., SUAREZ,J. B.,DELGADO, J., and WHITEHEAD, E. D.: Penile implant for erectile impotence, ibid. 109: 641 (1973).
A%
3. STAFFORD-CLARK, D. : The etiology and treatment of impotence, Practitioner 172: 397 (1954). 4. BEHERI, G. E.: Surgical treatment of impotence, Plast. Reconst. Surg. 38: 92 (1966). Uber die volle plastiche 5. BOGORAS, N. A.: wiederherstellung einer zum koitus fahigen penis (penilplastica totalis), Zentralbl Chir. 63: 1271 (1936). 6. LOEFFLER, R. A., and SAYEGH, E. S.: Perforated acrylic implants in the management of organic impotence, J. Urol. 84: 559 (1960). 7. GOODWIN, W. E., and SCOTT, W. S.: Phalloplasty,
ibid. 68: 903 (1952). 8. LASH, H., ZIMMERMAN, D. C., and LOEFFLER, R. A.: Silicone implantation: inlay method, Plast. Reconstr. Surg. 34: 75 (1964). 9. LASH, H.: Silicone implants for impotence, J. Urol. 100:709 (1968). 10. PEARMAN, R. 0.: Treatment of organic impotence by implantation of penile prosthesis, ibid. 97: 716 (1967). 11. KOTHARI, D. R., TIMM, G. W., FROHIB, D. A., and BRADLEY, W. E.: An implantable fluid transfer system for treatment of impotence, J. Biomech. 5: 567 (1972). 12. SCOTT, E. B., BRADLEY, W. E., and TIMM, G. w.: Management of erectile impotence, Urology 2: 80 (1973). 13. GRABSTALD, H. : Postradical cystectomy impotence treated by penile silicone implant, N. Y. State J. Med. 70: 2344 (1970).
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