Agnes J Yost, RN

Inflatable penile prosthesis Although impotence is not a lifethreatening problem, it can create anxiety and frustration, not just for the individual but also for his sexual partner. Impotence can be simply defined as the inability to achieve and maintain a n erection sufficient for intromission. This presentation will be concerned with the surgical treatment of organic impotence and, more specifically, the inflatable penile prosthesis. Candidates for this surgical procedure have a wide range of causes for their impotence, such as diabetes mellitus, spinal cord injury, vascular disease, urethral trauma, and impotence secondary to surgical procedures, such as cystectomy. These patients are usually referred by physicians, but as popular magazines publicize the

Agnes J Yost, R N , is clinical coordinator, urology, Cleveland Clinic Foundation, Cleveland. A graduate o f the Liliane S K a u f m a n n School o f Nursing Montefiore Hospital, Pittsburgh, she has been certified as a urology nurse by the American Board o f Urologic Allied Health Professionals. Yost presented this paper at the 1977 Congress program “Urology-from U to Y .’>

surgery, there may be a greater number of self-referrals. Patient selection is based on the following factors: 1. presumed organic impotence 2. history 3. psychometrics 4. psychiatric consultation 5. motivation 6. discussion of available devices. At present, two types of penile prostheses are used-a noninflatable and semirigid prosthesis, such as the Small-Carrion, and a hydraulically operated prosthesis. The advantages of the SmallCarrion prosthesis are no mechanical failure, simple operative procedure, cheaper device, lower operative fee, shorter hospitalization, and earlier usage. The disadvantages are preoperative correction of prostatism, permanent erection, risk of tissue perforation, and infection. The hydraulic prosthesis has three main parts made of silicone-two cylinders located in the corpora cavernosa, the pump in the scrota1 sac used to inflate and deflate the prosthesis, and the reservoir in the prevesical space that holds the sodium diatrizoate solution used to inflate. By squeezing the pump, fluid is transferred from the reservoir through the

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1. Inflatable penile prosthesis has three

parts-feservoir, cylinders, inflate-deflate bulb. 2. Midline incision extends from the umbilicus to just above the symphysis pubis. 3. The corpora cavernosa are exposed and

an incision is made into the tunica albuginea. 4. Tunnels are dilated and measured in

preparation for the cylinders.

5. Cylinders are inserted using forceps with plastic-covered tips that will not puncture the silicone. 6. Blunt dissection of a pocket in the

scrotum.

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7. Placement of the pump into the scrota1 pocket.

8. Midline incision through the anterior rectus fascia.

9. Passage of the tubings from the cylinders under the fascia.

pump into the cylinders. The cylinders expand and fill the corpora cavernosa. This erects the penis. A pressure release valve on the pump in the scrotum allows the fluid to flow out of the cylinders and back to the reservoir, returning the penis to a flaccid state. Preoperatively these patients receive the usual work-up of laboratory studies, eg, complete blood count, electrolytes, chest x-ray, electrocardiogram, urine culture, studies pertinent to any medical problems, and a Minnesota Multiphasic Personality Inventory. Any positive urine culture is treated with a n appropriate antibiotic, and any medical condition, such as diabetes mellitus, is stabilized. The advantages of the inflatable penile prosthesis are volitional patient control, cosmetically undetectable, and no preoperative correction of pros-

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tatism. The disadvantages are mechanical failure (15%), expensive device, greater surgical fee, graduated usage, and infection. Given the choice of the two prostheses, a n overwhelming majority of patients a t Cleveland Clinic choose the inflatable because of the disadvantage of permanent erection with the Small-Carrion prosthesis. The skin preparation consists of povidone-iodine baths on the nursing division. To minimize colonization of hair follicles and skin nicks, no shave is done until the patient reaches the operating room. The patient is allowed nothing by mouth after midnight the evening before surgery and receives the usual preoperative medication the morning of surgery and a prophylactic antibiotic. In the operating room, the patient is placed in the supine position, prepped,

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12 10. Cylinders are filled with sodium diatrizoate solution.

11. The reservoir is placed behind the rectus muscle and will be connected to the pump tubing, which is marked with a black thread.

12. The entire prosthesis in place and the abdominal incision closed.

and draped. The incision is at lower abdominal midline and extends from the umbilicus to a point just above the symphysis pubis. This is carried down to the anterior rectus fascia. The corpora cavernosa are exposed, and an incision is made into the tunica albuginea. The tunica albuginea is dissected off the underlying spongy tissue. Dissection is carried out distally to the corona and proximally t o the ischial tuberosity. This tunnel is then dilated and measured to determine the length for the cylinders. This procedure of dissection and dilatation is repeated on the opposite side. The cylinders are inserted and the tunica albuginea is closed. The pump is then placed in the scrotum in a pocket formed by blunt dissection. This can be the right or left scrotum. A midline incision is made through the anterior rectus fascia, and

a pocket is made behind the rectus muscle to house the reservoir. This is the deepest resection of the entire procedure. The tubings from the cylinders are passed beneath the fascia into the fascial opening and back down into the area of the external ring where they are connected to the appropriate pump tubings. This extra length of tubing is necessary in case of needed revision. Great care is taken so there are no kinks. The cylinders are filled with a 25% sodium diatrizoate solution, and the pump and cylinder tubings are connected over straight stainless steel connectors. A 50 cc reservoir is placed behind the rectus muscle and secured with a single suture through the tab a t the top. The reservoir tubing is passed down the subcutaneous space t o the area above the external ring and con-

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nected to the pump tubing marked with a black thread. This marking is done by the manufacturer. The fascia is closed over the reservoir, which is tested before the subcutaneous and skin closure is undertaken. A dry sterile dressing is applied. Throughout the procedure, neomycin 1%is used to irrigate. Monofilament, nonabsorbable suture is used. All forceps are covered with plastic so as not to puncture the silicone. Sharps are carefully handled. At the end of the procedure, the penis is left in a deflated position, and a Silastic Foley catheter is inserted and connected to closed gravity drainage. The patient is then sent to the recovery room and monitored. During the postoperative period, the patient is on bed rest and receives a full liquid diet on the operative day. On the first postoperative day, the Foley catheter is removed, intravenous fluids are discontinued, a select diet is begun, and the patient is ambulatory. The abdominal dressing is changed daily using sterile technique and applying polymyxin B-bacitracin-neomycin ointment and a dry dressing. The patient receives a five-day course of antibiotics. Discharge is usually within ten days. The patient is instructed not to use the prosthesis for intercourse until a follow-up examination. Usually there is some degree of tenderness so he is not overly anxious. By the return follow-up in four to six weeks, there is minimal tenderness, and the patient can begin to use the device. The greatest threats to the success of the device are infection and mechanical failure. These require further hospitalization, added expense, and surgical correction or removal. Therefore, the surgical team must be vigilant for breaks in technique and occurrence of prosthesis puncture. a4

Despite the risks, patients are willing to take the chance to achieve sexual function. Careful dissection preserves the pelvic nerves so that sensation and ejaculation are retained. In almost all of our patients, a full erection is possible so that patient and partner are satisfied. The inflatable penile prosthesis has great potential for the surgical treatment of impotence. 0 Rderoncer Altemeier, William A, Burke, John F, Ptuitt, Basil A, Sandusky, William R, eds. Manuel on Control of lnfection in Surgical Patients. Philadelphia: J B Lippincott Co, 1976. Beutler, Larry E, Scott, F Brantley, Karaean, Isrnet. “Psychological screening of impotent men.” Journal of Urology 1 16 (1976) 193. Furlow, William L. “Surgical management of impotence using the inflatable penile prosthesis.” Mayo clinic Proceedings 51 (1976). Masters, William H, Johnson, Virginia E. Human Sexual Inadequacy. Boston: Little, Brown and Co, 1970. Masters, William H, Johnson, Virginia E. Human Sexual Response. Boston: Little, Brown and Co, 1966. Scott, F Brantley, Bradley, William E, Timm, Gerald W. “Management of erectile impotence.” Urology 2 (1973). Stewart, Thomas D, Gerson, Stephen N. ”Penile prosthesis: Psychologic factors.” Urology 7 (1976).

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Inflatable penile prosthesis.

Agnes J Yost, RN Inflatable penile prosthesis Although impotence is not a lifethreatening problem, it can create anxiety and frustration, not just fo...
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