Treatment of Organic Impotence by Implantation of a Penile Prosthesis

Treatment of Organic Impotence by Implantation of a Penile Prosthesis

Vol. 97. Apr. Printed in U.S.A. THE JOURNAL OF UROLOGY Copyright © 1967 by The Williams & Wilkins Co. TREATMENT OF ORGANIC IMPOTENCE BY IMPLANTATIO...

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Vol. 97. Apr. Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright © 1967 by The Williams & Wilkins Co.

TREATMENT OF ORGANIC IMPOTENCE BY IMPLANTATION OF A PENILE PROSTHESIS ROBERT 0. PEARMAN From the Department of Surgery, Division of Urology, University of California Medical Center and the Department of Urology, Veterans Administration Center, Los Angeles, California

Effective therapy of the impotent male patient presents a challenge in urological practice. The mechanism of copulation requires a complex co-ordination of the nervous, vascular and muscular systems. An erection is the result of a highly conditioned reflex which can be initiated or terminated by many psychic stimuli. Although psychic factors are responsible for most cases of impotence, a small percentage of cases will be found which are of organic origin. As yet, external appliances are crude in design and construction, difficult to apply and usually unsatisfactory to the wearer. Sex drive and function and the importance assigned to them by each individual are as varied as his occupation. The "penile cripple" deserves as much thought and consideration as that which is given to his other deranged physiologic and pathologic functions. Organic impotence is the loss of ability to produce and maintain a functional erection due to pathology of the nervous or vascular system, or to deformation or loss of the penis. It may result from: 1) injury to nerves or blood vessels (trauma, pelvic operations, radical perineal prostatectomy and sympathectomy); 2) neurological diseases (tabes dorsalis, multiple sclerosis and various degenerative diseases of the nervous system); 3) vascular disease affecting the aorta, iliac and hypogastric arteries; 4) hormone deficiency or imbalance (bilateral testicular abnormalities, Cushing's syndrome, Addison's disease, acromegaly and diabetes); 5) drugs (parasympathetic and sympathetic blocking agents and antihistamines, excessive use of alcohol, tobacco or narcotics); 6) Peyronie's disease with marked curvature of phallus. It is obvious that an operation is not indicated for many of these cases. In some, the primary disease is of such paramount concern to both patient and physician that any thought of sexual function is completely Accepted for publication August 2, 1966. Read at the annual meeting of the American Urological Association, Inc., Chicago, Illinois, May 30-June 2, 1966.

obliterated. The reader is referred to the excellent review of the various methods which have been used for reconstruction of the penis by Huffman and associates.1 Except for the publications of Lowsley and Kirwin,2 O'Conor,3 Loeffler and associates, 4 • 5 and Lash and associates 6 I am unable to find any references in the literature relating to the treatment of organic impotence per se. The purpose of this study was to design a prosthesis which conformed to the anatomical architecture of the penis, which could be inserted easily by operative procedures without interfering with the nerve, blood supply or erectile tissue of the organ, that would give the support necessary for satisfactory penetration and yet not prove awkward in carrying on everyday activities. Careful anatomical dissections of the phallus were carried out on 20 postmortem specimens. It was discovered that Buck's fascia could be dissected free from the tunica albuginea of the corpora cavernosa on the dorsum of the penis. Attempts to dissect one corpus cavernosum from the other or to make a pocket between the two were futile due to the thinness and toughness of 1 Huffman, W. C., Culp, D. A. and Flocks, R. H.: Injuries of the external male genitalia. In: Reconstructive Plastic Surgery; Principles and Procedures in Correction, Reconstruction, and Transplantation. Edited by J. M. Converse. Philadelphia: W. B. Saunders Co., chapt. 70, pp.

2057-2074, 1964. 2 Lowsley, 0. S. and Kirwin, T. J.: Clinical Urology, 3rd edition, vol. 1. Baltimore: The Williams & Wilkins Co., 1956, p. 147. 3 O'Conor, V. J., Jr.: Impotence and the Leriche syndrome: An early diagnostic sign; consideration of the mechanism; relief by endarterectomy. J. Urol., 80: 195-197, 1958. 4 Loeffier, R. A. and Sayegh, E. S.: Perforatf:d acrylic implants in the management of orgamc impotence. J. Urol., 84: 559, 1960. 5 Loeffier, R. A., Sayegh, E. S. and Lash, H.: The artificial os penis. Plast. & Reconstruct. Surg., 34: 71-74, 1964. 6 Lash, H., Zimmerman, D. C. and Loeffier, R. A.: Silicone implantation: Inlay method. Plast. & Reconstruct. Surg., 34: 75-80, 1964.

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Frf\. L Cavernosogram demonstrn,tes communication of corpora cavernosa with each other and with corpus spongiosum.

the septum. These attempts invariably resulted in the opening into one or the other of the cavernous bodies. Cavcrnosograms of cadavers and of patients were performed and the results ,vere correlated with the findings on aspiration and irrigation of the corpora cavernosa in cases \Yith priapism (fig. 1). These studies revealed that the corpora cavernosa communicate ,vith each other through defects in the septum and also communicate with the corpus spongiosum in a fair percentage of cases. It was demonstrated that a pocket could be developed through a small incision on the dorsum of the penis between Buck's fascia and the tunica albuginea of the corpora cavernosa and extended proximally to the suspensory ligament and distally to just under the eorona of the glans penis. Hot paraffin ,ms injected using the tunnel as a mold. The resulting model was a half circle rod, flat on the bottom and curved on top, 10 to 13 mm. in diameter and 6 to 10 cm. in length, with some flattening of the end near the corona. This model

appears to fit the contour of the penis without producing pressure points (fig. Many reports attest to the fact that some plastic materials are well tolerated when implanted in the phallus for yarious .reasons. 1 , ' ~ Our experience confirms this_lO Silieone was selected because it is unbreakable, can be bent double for ease of insertion, has the necessary body and rigidity, produces a n1inirnurn of tissue reaction and has the proper resiliency and lack of fatigue. Furthermore, if necessary 1t can be reinforced with an embodied coiled or flat spring or a rod of teflon (fig. Of the 3 grades of silicone produced, the firmest proved to be the one of choice. After much experimentation it was found that a% circle rod of silicone fulfilled the requirements better Hrnn a ;,-z circle rod because it gave more support and better resisted bending. The prosthesis serves only as a stint or crutch which enables the patient to insert his penis into the vagina. In the selection of cases the patient should be screened to rule out psychological impotence even cases of organic impotence have a strong logical overlay. The patient should have a sexual desire, normal sensation of the and be able to have some semblance of an orgasm. The patient also must feel that this aspect of his life is important enough for him to assume the calculated risk of an operation and its complications. TECHNIQUE

The pubic, penile and scrotal areas are carefully shaved the night before the operation and the patient is instructed to showerusingpHisoHex. With the patient under general or spinal anes-· thesia, the area is prepared with a pHisoHcx scrub. The area is draped with only the penis 7 Berry, J. L.: Evaluation of a new procedure for correction of post-prostatectomy incontinence. Bull. New York Acad. Med.,

790-794, 1964.

8 Stewart, B. L., Belt, E., Belt, B. G., Goodwin, D. A. and Letorneau, N. H.: Experience with the Berry operation for the treatment of incontinence in the male patient ..J. Urol.,

267-272, 1964. 9 Watkins, J. K., Straffon, R. A. and

E. F.: A medical silastic prosthesis for urinary incontinence in the male: Prelirninnry report. Cleveland Clin. (;Juart., 157-162, 19(i4. 10 Pearman, R. 0., Brosman, S., W. L. and Goodwin, W. E.: Genesis of plastic urethral catheter. Exhibit, Western Section American Urological Association meeting, San Francisco, California, April 26-29, 1965.

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PEARMAN

FIG. 2. A, partial sagittal section of penis with urethral catheter in place. Silicone prosthesis in pocket between Buck's fascia and the tunica albuginea of the corpora cavernosa. Prosthesis extends from just under corona of glans penis to suspensory ligament of penis. B, cross sections of penis with urethral catheter and silicone prosthesis in place. Section on right shows glans penis turned revealing its proximal surface. Section through base of penis is shown at extreme left.

Fm. 3. Experimental models of prosthesis. A, anteroposterior view, top to bottom: silicone rod, 3'1! circle rod reinforced with teflon, coiled spring and flat spring. B, lateral view, top to bottom: silicone rod, 3,1! circle rod reinforced with teflon, coiled spring and flat spring.

A No. 20F. balloon catheter is inserted through the urethra into the bladder and the balloon is distended with 5 cc water. The catheter is connected to table side drainage. A No. 3 silk suture on a straight needle is passed through the glans penis and used for traction. The silk suture is tied

Fm. 4. A, silicone prosthesis in place at operation extending from just under corona of glans penis to suspensory ligament. On right, silk sutures identify edges of Buck's and Calles' fascia. Traction suture through glans penis. Urethral catheter and tourniquet not shown. B, post-surgical case with prosthesis in place. Arrow points to where mole was removed.

TREATMENT OF ORGANIC IMPOTE~JCE

to 6 rubbcT bands wliich arc Jllaced over the handle of a towel clip and the towel clip is fastened to the drape This serves to keep the penis in nonnal alignment during the operation. A I-inch drain is applied to tlie base of the penis a.s close to the pubis as possible; to serve as a tourniquet i'L 3 cm. longitudinal dorsal incision made in the midline and about mid-shaft of the penis extending through the skin and subcutaneous tissue taking care to disturb the 1·eins as little as possihk, retracting them Calles' fascia is identified and incised. Below this Buck's fascia is identified and incised. A plane of cleavage Buck's fascia and the tunica albuginea of the corpora cavernosa is established by sharp and the use of meniscus scissors which is ideally suited for this purpose. Several fine silk sutures on the edge of Buck's fascia held by small serve to incrc-,ase exposure. vVith the aid of a vein retractor and the use of meniscus

l. (',}

Kling dre;;sing is applied snugly to the penis and the tourniquet is refoa,,ecl. Th
A pro~tlwsis of silicone .ba.s been which conforms to the anatomy of the when inserted in a pocket between fascia and the tunica albuginea of the corpora cavcrnosa on the clorsmn of the penis. This operatrnu i.s recommended for the trnatmc:nt of organic im potC'nce in .selected cases.

u is developed between Buck's fascia and the tunica of the corpora cavernosa prnximally as far as tlrn suspensory ligament of ihe penis and to just under the corona of the glans J)l:nis. A Hcgar cervical dilator ideal for further dcnlopment of the pockets. The length of a % circle silastic rod necessary is determined aucl the proximal end is cut and trimmed. The rnr! fa bent double for inBuck's fascia is closed witb sertion (fig. 4, interrupted 4-0 chromic sutures. fascia is closed in a like manner. The skin is closed with

I thank Drs. R. A. Loeffler, H. Lash and W. Gooclivin for encouragement and help; Air Rudolph Schulte for constrnctiou of the experimental models; and the Dow Aid to Medical Research for silicone rods.

intenu11ted sutures of 5-0 chromic catgut. A

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