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Surgical Techniques: Penile Prosthesis for Cylinder Tip Malposition
© 2009 International Society for Sexual Medicine
Surgical Techniques Penile Prosthesis for Cylinder Tip Malposition
jsm_1443
2372..2375
Culley C. Carson, MD University of North Carolina—Surgery, Chapel Hill, NC, USA
Correct placement of implant
Correct placement of implant cylinders
Incorrect placement of implant
Fibrous capsule formed around cylinders
Incorrect placement of implant cylinder
FIGURE 1 Step 1: To facilitate penile prosthesis function, cylinder tips should be maintained evenly and equally distal beneath the glans penis providing good glans support. In the upper left photo, the blue circle denotes the tip of the left cylinder placed correctly within the penile shaft. In the upper right photo, the tip of the right cylinder is more proximal and absent from beneath the glans penis during inflation. The cylinder tip is denoted by the blue circle and is palpable approximately 2 cm below the glans penis. This patient had pain at the right cylinder tip during intercourse. Some fibrosis of erectile tissue distally in the right corpus cavernosum prevented full distal dilation. The right illustration denotes that the tip of the right cylinder does not terminate in the erectile tissue under the glans penis.
2372
J Sex Med 2009;6:2372–2375
Surgical Techniques Incision through dorsal surface of fibrous capsule Tunica albuginea Erectile tissue
Fibrous capsule in correct position
Fibrous capsule in incorrect position
Fibrous capsule Cylinder
Incision
Erectile tissue under capsule
Ventral surface of fibrous capsule
Fibrous capsules around implant cylinders
Implant cylinder
Implant cylinder
Tunica albuginea Erectile tissue
FIGURE 2 Step 2: The incision is transverse scrotal and 2 cm below the penoscrotal junction (upper left inset). The left lower inset depicts that deep to the tunica is erectile tissue and deep to the erectile tissue surrounding each cylinder is the fibrous capsule. On the right corpus cavernosum, the distal end of the fibrous capsule does not terminate at the glans penis. Efforts to dilate this with a blunt dilator will be futile and may penetrate the tunica distally. The three layers above the device from outside to inside (upper right photo) are tunica albuginea, erectile tissue, and dorsal surface of the fibrous capsule. The illustration shows the distal cylinder pulled from the distal fibrous capsule. Under the cylinder is the ventral surface of the fibrous capsule and under this layer is erectile tissue.
J Sex Med 2009;6:2372–2375
2373
Surgical Techniques Dissection of capsule
Dilator creating new corporatomy channel
Collapsed capsule
Dilation of erectile tissue
Collapsed capsule
Dilator
Implant cylinder
FIGURE 3 Step 3: Repeat dilation can be carried out. In order to avoid distal corpus cavernosum damage and extrusion, it is important to find and dissect a new path within the corpus cavernosum tissue. Initial dissection using Metzenbaum scissors or a Kelly clamp can identify the spongy tissue beside the capsule where the cylinder was removed. New dilation can then be carried out using Hagar, Brooks dilators, or the dilamezinsert. It is often helpful to use a large Kelly clamp to facilitate initial dilation. Care should be taken that the dilators have completely dilated to the distal portion of the corpus cavernosum below the glans penis to correct the cylinder discrepancies. This new dilation will not be affected by the preexisting capsule, since the dilation is occurring outside the previous capsule. The illustration and the lower left inset shows the newly placed cylinder and its relation to the previous fibrous capsule.
2374
J Sex Med 2009;6:2372–2375
Surgical Techniques Preop
Postop
Implant cylinders correctly placed in corpus cavernosa Cylinder newly placed behind the old fibrous capsule Collapsed capsule
FIGURE 4 Step 4: Once dilation is carried out, the cylinder is replaced in the newly dilated corpus cavernosum channel. Care is taken to be sure that the two cylinder tips are at the same level beneath the glans penis and are providing adequate glans penis support. The cylinder is newly placed within the newly dilated tract using a Furlow insertion tool. Other than irrigating the previous tract with antibiotics, hydrogen peroxide, and betadine, there is no need to excise the old fibrous capsule. The illustration now depicts the tips of the cylinders in the normal local and position within the glans penis. The prosthesis should be cycled to be sure that position is adequate before returning the patient to the recovery room. Conflict of Interest: Speaker for AMS and Coloplast.
J Sex Med 2009;6:2372–2375
2375
Surgical Techniques Penile Prosthesis for Cylinder Tip Malposition
jsm_1443
2372..2375
Culley C. Carson, MD University of North Carolina—Surgery, Chapel Hill, NC, USA
Correct placement of implant
Correct placement of implant cylinders
Incorrect placement of implant
Fibrous capsule formed around cylinders
Incorrect placement of implant cylinder
FIGURE 1 Step 1: To facilitate penile prosthesis function, cylinder tips should be maintained evenly and equally distal beneath the glans penis providing good glans support. In the upper left photo, the blue circle denotes the tip of the left cylinder placed correctly within the penile shaft. In the upper right photo, the tip of the right cylinder is more proximal and absent from beneath the glans penis during inflation. The cylinder tip is denoted by the blue circle and is palpable approximately 2 cm below the glans penis. This patient had pain at the right cylinder tip during intercourse. Some fibrosis of erectile tissue distally in the right corpus cavernosum prevented full distal dilation. The right illustration denotes that the tip of the right cylinder does not terminate in the erectile tissue under the glans penis.
2372
J Sex Med 2009;6:2372–2375
Surgical Techniques Incision through dorsal surface of fibrous capsule Tunica albuginea Erectile tissue
Fibrous capsule in correct position
Fibrous capsule in incorrect position
Fibrous capsule Cylinder
Incision
Erectile tissue under capsule
Ventral surface of fibrous capsule
Fibrous capsules around implant cylinders
Implant cylinder
Implant cylinder
Tunica albuginea Erectile tissue
FIGURE 2 Step 2: The incision is transverse scrotal and 2 cm below the penoscrotal junction (upper left inset). The left lower inset depicts that deep to the tunica is erectile tissue and deep to the erectile tissue surrounding each cylinder is the fibrous capsule. On the right corpus cavernosum, the distal end of the fibrous capsule does not terminate at the glans penis. Efforts to dilate this with a blunt dilator will be futile and may penetrate the tunica distally. The three layers above the device from outside to inside (upper right photo) are tunica albuginea, erectile tissue, and dorsal surface of the fibrous capsule. The illustration shows the distal cylinder pulled from the distal fibrous capsule. Under the cylinder is the ventral surface of the fibrous capsule and under this layer is erectile tissue.
J Sex Med 2009;6:2372–2375
2373
Surgical Techniques Dissection of capsule
Dilator creating new corporatomy channel
Collapsed capsule
Dilation of erectile tissue
Collapsed capsule
Dilator
Implant cylinder
FIGURE 3 Step 3: Repeat dilation can be carried out. In order to avoid distal corpus cavernosum damage and extrusion, it is important to find and dissect a new path within the corpus cavernosum tissue. Initial dissection using Metzenbaum scissors or a Kelly clamp can identify the spongy tissue beside the capsule where the cylinder was removed. New dilation can then be carried out using Hagar, Brooks dilators, or the dilamezinsert. It is often helpful to use a large Kelly clamp to facilitate initial dilation. Care should be taken that the dilators have completely dilated to the distal portion of the corpus cavernosum below the glans penis to correct the cylinder discrepancies. This new dilation will not be affected by the preexisting capsule, since the dilation is occurring outside the previous capsule. The illustration and the lower left inset shows the newly placed cylinder and its relation to the previous fibrous capsule.
2374
J Sex Med 2009;6:2372–2375
Surgical Techniques Preop
Postop
Implant cylinders correctly placed in corpus cavernosa Cylinder newly placed behind the old fibrous capsule Collapsed capsule
FIGURE 4 Step 4: Once dilation is carried out, the cylinder is replaced in the newly dilated corpus cavernosum channel. Care is taken to be sure that the two cylinder tips are at the same level beneath the glans penis and are providing adequate glans penis support. The cylinder is newly placed within the newly dilated tract using a Furlow insertion tool. Other than irrigating the previous tract with antibiotics, hydrogen peroxide, and betadine, there is no need to excise the old fibrous capsule. The illustration now depicts the tips of the cylinders in the normal local and position within the glans penis. The prosthesis should be cycled to be sure that position is adequate before returning the patient to the recovery room. Conflict of Interest: Speaker for AMS and Coloplast.
J Sex Med 2009;6:2372–2375
2375