British Journal of UroIoRy (1978). 50. 114-117
Surgical Management of Impotence using the Inflatable Penile Prosthesis: Experience with 1 03 Patients WILLIAM L. FURLOW Ma yo Clinic and Ma yo Foundation, Rochester, Minnesota, USA
Summary-The inflatable hydraulic penile prosthesis has been implanted in 103 patients with both organic and psychogenic impotence. The 4 failures in this series resulted from infection. Mechanical problems occurred in 2 7 patients, but with additional implant experience, these have been significantly reduced. All mechanical complications are correctable through secondary and tertiary surgical procedures. Ninety-eight of 99 patients with a normally functioning prosthetic device had satisfactory intercourse without significant difficulty. The inflatable penile prosthesis has proved to be a highly satisfactory method of treating male impotence.
The surgical management of organic impotence received little attention until 1964, when Lash et al. (1964) described the use of a silicone inlay for plastic reconstruction of the penis after surgical treatment for Peyronie’s disease. Pearman (1967) then applied the concepts as described by Lash et al., devising a silicone rod that could be implanted between Buck’s fascia and the tunica albuginea and that was effective enough to permit vaginal penetration without buckling of the penile shaft. The use of this device has been satisfactory in the treatment of the organically impotent male. The size and shape of the silastic rod have been improved to conform to the variability in penile size and to permit ease of insertion. Pain with intercourse generally has not been a problem; however, migration of the rod has occurred, and this occasionally has led to painful intercourse and buckling of the glans penis. Recently, the availability of this device has been restricted as the result of reports indicating that, in at least 1 patient, breakage occurred, resulting in buckling of the shaft as well as pain and requiring removal (Mandler, personal communication). In 1973, Scott et al., reported their initial experience with the inflatable penile prosthesis, a totally implantable device using inflatable silastic cylinders placed inside each corpus cavernosum Received 16 May 1977. Accepted for publication 28 June 1977.
and connected by silastic tubing to a pumping mechanism implanted in the scrota1 pouch; the fluid for inflation is provided by a reservoir implanted behind the rectus muscle. Small and Carrion (1975) reported the development and use of a silastic prosthesis which consisted of 2 semirigid moulded silicone rods implanted side by side in the matrix of each corpus cavernosum. The technique, results, advantages, and disadvantages of the device have been previously reported (Furlow, 1976). Until about 2 years ago, urologists at the Mayo Clinic managed the organically impotent male by implanting the Pearman prosthesis. At that time, however, our favourable experience with the inflatable genitourinary sphincter in treating male incontinence led us to consider using the Scott prosthesis for the treatment of organic impotence. This report summarises our experience with the inflatable penile prosthesis in 103 patients with impotence who were seen during the period October 1974 to December 1976. Patients and Procedure Patient Selection. In our series, impotence was presumed to follow as a recognised complication of certain disease states in 103 patients (Table 1). To establish the organic basis for the impotence in a clinical setting, we relied on the history, the MMPI (Minnesota Multiphasic Personality Inventory) 114
SURGICAL MANAGEMENT OF IMPOTENCE USING THE INFLATABLE PENILE PROSTHESIS
Table 1 Causes of Impotence in 103 Patients with Inflatable Penile Prosthesis Come
Number of patients
Postperineal trauma Postprostatectomy Postcystectomy Neurologic disorders Diabetes Psychogenic Physiological Peyronie’s disease Proctocolectomy Postradiation Estrogen therapy Peripheral vascular disease Coronary artery disease
13 17 5 11 25 10 8
5 2 1 1
2 3 103
Total
psychological consultation, and lengthy discussion with the patient, his spouse, or in some instances with the patient’s fiancte-in the last instance, with the permission of the patient and in his presence. Early in our experience, we excluded as surgical candidates those patients with functional or psychogenic impotence; however, we now recognise that some patients with psychogenic impotence should be seriously considered as suitablecandidates for implantation. Of the 103 patients, lOwith functional or psychogenic impotence have undergone implantation of the inflatable penile prosthesis. In addition. the clinician must be certain of the patient’s motivation to undergo implantation. To this end, an important feature of the interview has been the description and demonstration of the prosthetic device, including its advantages and the potential complications and risk involved. To aid in this discussion, we use a model with the prosthesis in place.
Age Distribution. The youngest patient in our series was a 22-year-old man with an imperforate anus, neurogenic dysfunction of the bladder, and lifelong impotence. The oldest man in our series was 77 years of age (Table 2). In the absence of chronic or debilitating disease state, age alone should not be a factor in patient selection. Table 2 Age Distribution Inflatable Penile Prosthesis
of
103 Patients with
Age (years)
Number of potients
20-29 30-39 40-49 50-59 60-69 10-19
12 10 22 27 28 4
Total
I03
115
Surgical Considerations. As with any relatively new surgicaltechnique, the principles of successful implantation evolve as the result of experience with the procedure. The basic technique of implantation of the inflatable penile prosthesis has been described by Scott et al. (1973). As our experience has increased, we continue to modify the basic technique in an effort to minimise the potential complications (Furlow, 1976). Some of the specific surgical guidelines are summarised in Table 3. Table 3 Surgical Recommendations for Implantation of Inflatable Penile Prosthesis Incise tunica, incisions 1 to 1.5 cm dorsolaterally Close tunica with 2-0 proline interrupted sutures Dilate corpus with No. 10 Hegar dilator (avoid overdilatation) Use cylinder size of approximately 0.5 cm less than measured Place distal end of cylinder in glans Place proximal end in deep subpubic portion of corpora Avoid stretching penis when estimating size Insert cylinder by instrument or freezing Avoid overdistention of cylinder before and after insertion Keep tubing in tissue planes with gentle curves Make all connections distal to external ring in subcutaneous tissue Place pump low in scrotum-outside the tunica vaginalis Place reservoir posterior to rectus and anterior to posterior sheath Test mechanism to ensure function after each layer of closure Use small-calibre urethral catheter (12 F) Modified from Furlow, W. L. (1976). Surgical management of impotence using the inflatable penile prosthesis: experience with 36 patients. Mayo Clinic Proceedings, 51, 325-328.
Results Complications occurred in 33 patients. The complications with this surgical procedure can be divided into 2 types: pathological and mechanical. Pathological complications include infection of the prosthesis (4 patients), scrotal haematoma (3 patients), scrotal erosion (1 patient), and pump malposition (1 patient). The 2 problems with postoperative phimosis occurred early in the series. The most serious complication has been infection of the prosthesis, because it always necessitates total removal of the prosthesis in order to permit clearing of the infection. Fortunately, the incidence of infection in our series was low (4 of 103 patients). Mechanical problems with the device occurred in 27 patients (Table 4). A number of these problems can be avoided through strict adherence to specific surgical guidelines as outlined in Table 3. In a recent survey of our results after 1 year, and again after 2 years of experiencewith implantation,
116
BRITISH JOURNAL OF UROLOGY
Table 4 Mechanical Complications in 27 Patients with Inflatable Penile Prosthesis Complication
Number of patients
Replaced Replaced Replaced Replaced Replaced Corrected New prosthesis Replaced
Cylinder buckling Cylinder ballooning Cylinder rupture Cylinder leak Inadequate cylinder length Tubing kink Fluid loss Pump defect Total
Disposition
30.
* 3 patients had 2 mechanical complications each. we found a reduction of 17% in mechanical complications-from 25% during the first 14 months to 8% during the past 12 months (5 of 60 patients). Fortunately, these mechanical problems were all correctable, though requiring secondary and tertiary surgical procedures. The results of implantation with the inflatable penile prosthesis have been satisfactory. Of the 103 patients, 99 have normally functioning prostheses. The 4 failures resulted from infection involving some portion of the prosthetic device. In each instance, the entire device was removed in order to clear up the infection. Of the 99 patients with a normally functioning prosthesis, 98 have reported that satisfactory intercourse has been achieved without significant difficulty. One patient continues to find it difficult to insert the penis when the device is inflated, and he plans to return shortly for evaluation. Buckling of the glans penis may occur as the result of malpositioning of the prosthesis within the corpora at the distal end beneath the glans. Discussion The inflatable penile prosthesis, thus far, has proved to be a highly satisfactory method of treating organic impotence. Our experience was originally limited to patients considered to have organic impotence. During the past 6 months, we have enlarged our guidelines for patient selection to include those with functional or psychogenic impotence who are considered to be emotionally unstable for implantation of the penile prosthesis. Through careful patient screening and the cooperative efforts of a clinical psychologist or a psychiatrist interested in the problems of human sexual behaviour , we have avoided implanting the
device in patients who, because of deep-seated emotional problems, would not benefit from implantation. This is often a difficult decision when such emotional problems exist in an organically impotent male, because implantation may improve the patient’s emotional state. We believe that use of the MMPI, as well as psychiatric consultation, is essential for valid patient care in achieving the goals implied in the use of penile prosthetic devices. The use of this device in the psychologically impotent male requires these stringent guidelines in patient selection. From the urologists’ viewpoint, we must be prepared to handle the possible consequences resulting from the strong dependence on the physician that occurs as the result of surgical implantation of a mechanical device in an emotionally unstable patient. Transfer of this dependence from psychiatrist to urologist, if it occurs, can be premature, which is unsettling for both physician and patient. The patient-partner acceptance has been excellent. Orgasmic sensation is preserved, and when present before the onset of impotence, ejaculation isunaffected. Pain has not been a problem after the first 6 weeks unless associated with 1 of the complications mentioned. Long-standing low-grade pain that moves from 1 portion of the prosthesis to another should cause the physician to suspect an infection within the spaces surrounding the silastic material. Experience with the genitourinary sphincter indicates that infection of this kind may be present for months, causing only low-grade pain until it becomes evident clinically by reaching the skin surface in a dependent portion of the prosthesis-either in the scrota1 pouch or in the distal end of the corpus cavernosum. The mechanical problems initially encountered have been significantly minimised as further experience is gained with the surgical technique. The mechanical problems associated with this device are easily recognised if the physician understands how the device functions. The 25% Hypaque solution that is used to fill the system permits good roentgenographic visualisation of the device. It is important to take films with the device both inflated and deflated. In our experience, mechanical problems have been correctable but only by surgical intervention. The reasons for some of these complications remain unclear. Material defects occasionally have been recognised, and new production methods are under investigation by the manufacturer. However, most of the major mechanical problems in our series probably can
SURGICAL MANAGEMENT OF IMPOTENCE USING THE INFLATABLE PENILE PROSTHESIS
117
Table 5 Post-operative Considerationsafter Implantation of Inflatable Penile Prosthesis
References
Partially inflate prosthesis for 7 to 10 days Avoid asymmetric dilatatioh of cylinders Inflate and deflate mechanism daily Position pump daily to avoid kinking Remove catheter early-third or fourth day post-operatively Instruct patient in use of pump-use sample prosthesis to demonstrate Instruct patient to avoid early active usage for 4 to 6 weeks Instruct patient in initial usage
using the inflatable penile prosthesis: experience with 36 patients. Mayo Clinic Proceedings, 51, 325-328. Lash, H., Zimmerman, D. C. and Loeffler, R. A. (1964). Silicone implantation: inlay method. Plastic und Reconsfmcfive Surgery, 34,75-80. Maadler, J. (Personal communication.) Pearman, R. 0. (1967). Treatment of organic impotence by implantation of a penile prosthesis. Journal of Urology, 97,
Modified from Furlow, W. L. (1976). Surgical management of impotence using the inflatable penile prosthesis: experience with 36 patients. Mayo Clinic Proceedings, 51,325-328.
ment of erectile impotence: use of implantable inflatable prosthesis. Urology, 2,8042. Small, M. P. and Carrion, H. M. (1975). A new penile prosthesis for treating impotence. Confemporury Surgery, 7 ,
be prevented by strict adherence to the surgical principles listed in Table 3. In addition, the postoperative care should follow certain specific guidelines (Table 5 ) to ensure further the functional success of the procedure. Our experienceindicatesthat implantation of the inflatable penile prosthesis is a highly acceptable method of treating organic impotence.
Furlow, W. L. (1976). Surgical management of impotence
716-719. Scott, F. B., Bradley, W. E. and Timm, G. W. (1973). Manage-
29-33.
The Author William L. Furlow, MD, FACS, Consultant, Department of Urology, Mayo Clinic and Mayo Foundation; Associate Professor of Urology, Mayo Medical School. Requests for reprints to: Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA.
Surgical Management of Impotence using the Inflatable Penile Prosthesis: Experience with 1 03 Patients WILLIAM L. FURLOW Ma yo Clinic and Ma yo Foundation, Rochester, Minnesota, USA
Summary-The inflatable hydraulic penile prosthesis has been implanted in 103 patients with both organic and psychogenic impotence. The 4 failures in this series resulted from infection. Mechanical problems occurred in 2 7 patients, but with additional implant experience, these have been significantly reduced. All mechanical complications are correctable through secondary and tertiary surgical procedures. Ninety-eight of 99 patients with a normally functioning prosthetic device had satisfactory intercourse without significant difficulty. The inflatable penile prosthesis has proved to be a highly satisfactory method of treating male impotence.
The surgical management of organic impotence received little attention until 1964, when Lash et al. (1964) described the use of a silicone inlay for plastic reconstruction of the penis after surgical treatment for Peyronie’s disease. Pearman (1967) then applied the concepts as described by Lash et al., devising a silicone rod that could be implanted between Buck’s fascia and the tunica albuginea and that was effective enough to permit vaginal penetration without buckling of the penile shaft. The use of this device has been satisfactory in the treatment of the organically impotent male. The size and shape of the silastic rod have been improved to conform to the variability in penile size and to permit ease of insertion. Pain with intercourse generally has not been a problem; however, migration of the rod has occurred, and this occasionally has led to painful intercourse and buckling of the glans penis. Recently, the availability of this device has been restricted as the result of reports indicating that, in at least 1 patient, breakage occurred, resulting in buckling of the shaft as well as pain and requiring removal (Mandler, personal communication). In 1973, Scott et al., reported their initial experience with the inflatable penile prosthesis, a totally implantable device using inflatable silastic cylinders placed inside each corpus cavernosum Received 16 May 1977. Accepted for publication 28 June 1977.
and connected by silastic tubing to a pumping mechanism implanted in the scrota1 pouch; the fluid for inflation is provided by a reservoir implanted behind the rectus muscle. Small and Carrion (1975) reported the development and use of a silastic prosthesis which consisted of 2 semirigid moulded silicone rods implanted side by side in the matrix of each corpus cavernosum. The technique, results, advantages, and disadvantages of the device have been previously reported (Furlow, 1976). Until about 2 years ago, urologists at the Mayo Clinic managed the organically impotent male by implanting the Pearman prosthesis. At that time, however, our favourable experience with the inflatable genitourinary sphincter in treating male incontinence led us to consider using the Scott prosthesis for the treatment of organic impotence. This report summarises our experience with the inflatable penile prosthesis in 103 patients with impotence who were seen during the period October 1974 to December 1976. Patients and Procedure Patient Selection. In our series, impotence was presumed to follow as a recognised complication of certain disease states in 103 patients (Table 1). To establish the organic basis for the impotence in a clinical setting, we relied on the history, the MMPI (Minnesota Multiphasic Personality Inventory) 114
SURGICAL MANAGEMENT OF IMPOTENCE USING THE INFLATABLE PENILE PROSTHESIS
Table 1 Causes of Impotence in 103 Patients with Inflatable Penile Prosthesis Come
Number of patients
Postperineal trauma Postprostatectomy Postcystectomy Neurologic disorders Diabetes Psychogenic Physiological Peyronie’s disease Proctocolectomy Postradiation Estrogen therapy Peripheral vascular disease Coronary artery disease
13 17 5 11 25 10 8
5 2 1 1
2 3 103
Total
psychological consultation, and lengthy discussion with the patient, his spouse, or in some instances with the patient’s fiancte-in the last instance, with the permission of the patient and in his presence. Early in our experience, we excluded as surgical candidates those patients with functional or psychogenic impotence; however, we now recognise that some patients with psychogenic impotence should be seriously considered as suitablecandidates for implantation. Of the 103 patients, lOwith functional or psychogenic impotence have undergone implantation of the inflatable penile prosthesis. In addition. the clinician must be certain of the patient’s motivation to undergo implantation. To this end, an important feature of the interview has been the description and demonstration of the prosthetic device, including its advantages and the potential complications and risk involved. To aid in this discussion, we use a model with the prosthesis in place.
Age Distribution. The youngest patient in our series was a 22-year-old man with an imperforate anus, neurogenic dysfunction of the bladder, and lifelong impotence. The oldest man in our series was 77 years of age (Table 2). In the absence of chronic or debilitating disease state, age alone should not be a factor in patient selection. Table 2 Age Distribution Inflatable Penile Prosthesis
of
103 Patients with
Age (years)
Number of potients
20-29 30-39 40-49 50-59 60-69 10-19
12 10 22 27 28 4
Total
I03
115
Surgical Considerations. As with any relatively new surgicaltechnique, the principles of successful implantation evolve as the result of experience with the procedure. The basic technique of implantation of the inflatable penile prosthesis has been described by Scott et al. (1973). As our experience has increased, we continue to modify the basic technique in an effort to minimise the potential complications (Furlow, 1976). Some of the specific surgical guidelines are summarised in Table 3. Table 3 Surgical Recommendations for Implantation of Inflatable Penile Prosthesis Incise tunica, incisions 1 to 1.5 cm dorsolaterally Close tunica with 2-0 proline interrupted sutures Dilate corpus with No. 10 Hegar dilator (avoid overdilatation) Use cylinder size of approximately 0.5 cm less than measured Place distal end of cylinder in glans Place proximal end in deep subpubic portion of corpora Avoid stretching penis when estimating size Insert cylinder by instrument or freezing Avoid overdistention of cylinder before and after insertion Keep tubing in tissue planes with gentle curves Make all connections distal to external ring in subcutaneous tissue Place pump low in scrotum-outside the tunica vaginalis Place reservoir posterior to rectus and anterior to posterior sheath Test mechanism to ensure function after each layer of closure Use small-calibre urethral catheter (12 F) Modified from Furlow, W. L. (1976). Surgical management of impotence using the inflatable penile prosthesis: experience with 36 patients. Mayo Clinic Proceedings, 51, 325-328.
Results Complications occurred in 33 patients. The complications with this surgical procedure can be divided into 2 types: pathological and mechanical. Pathological complications include infection of the prosthesis (4 patients), scrotal haematoma (3 patients), scrotal erosion (1 patient), and pump malposition (1 patient). The 2 problems with postoperative phimosis occurred early in the series. The most serious complication has been infection of the prosthesis, because it always necessitates total removal of the prosthesis in order to permit clearing of the infection. Fortunately, the incidence of infection in our series was low (4 of 103 patients). Mechanical problems with the device occurred in 27 patients (Table 4). A number of these problems can be avoided through strict adherence to specific surgical guidelines as outlined in Table 3. In a recent survey of our results after 1 year, and again after 2 years of experiencewith implantation,
116
BRITISH JOURNAL OF UROLOGY
Table 4 Mechanical Complications in 27 Patients with Inflatable Penile Prosthesis Complication
Number of patients
Replaced Replaced Replaced Replaced Replaced Corrected New prosthesis Replaced
Cylinder buckling Cylinder ballooning Cylinder rupture Cylinder leak Inadequate cylinder length Tubing kink Fluid loss Pump defect Total
Disposition
30.
* 3 patients had 2 mechanical complications each. we found a reduction of 17% in mechanical complications-from 25% during the first 14 months to 8% during the past 12 months (5 of 60 patients). Fortunately, these mechanical problems were all correctable, though requiring secondary and tertiary surgical procedures. The results of implantation with the inflatable penile prosthesis have been satisfactory. Of the 103 patients, 99 have normally functioning prostheses. The 4 failures resulted from infection involving some portion of the prosthetic device. In each instance, the entire device was removed in order to clear up the infection. Of the 99 patients with a normally functioning prosthesis, 98 have reported that satisfactory intercourse has been achieved without significant difficulty. One patient continues to find it difficult to insert the penis when the device is inflated, and he plans to return shortly for evaluation. Buckling of the glans penis may occur as the result of malpositioning of the prosthesis within the corpora at the distal end beneath the glans. Discussion The inflatable penile prosthesis, thus far, has proved to be a highly satisfactory method of treating organic impotence. Our experience was originally limited to patients considered to have organic impotence. During the past 6 months, we have enlarged our guidelines for patient selection to include those with functional or psychogenic impotence who are considered to be emotionally unstable for implantation of the penile prosthesis. Through careful patient screening and the cooperative efforts of a clinical psychologist or a psychiatrist interested in the problems of human sexual behaviour , we have avoided implanting the
device in patients who, because of deep-seated emotional problems, would not benefit from implantation. This is often a difficult decision when such emotional problems exist in an organically impotent male, because implantation may improve the patient’s emotional state. We believe that use of the MMPI, as well as psychiatric consultation, is essential for valid patient care in achieving the goals implied in the use of penile prosthetic devices. The use of this device in the psychologically impotent male requires these stringent guidelines in patient selection. From the urologists’ viewpoint, we must be prepared to handle the possible consequences resulting from the strong dependence on the physician that occurs as the result of surgical implantation of a mechanical device in an emotionally unstable patient. Transfer of this dependence from psychiatrist to urologist, if it occurs, can be premature, which is unsettling for both physician and patient. The patient-partner acceptance has been excellent. Orgasmic sensation is preserved, and when present before the onset of impotence, ejaculation isunaffected. Pain has not been a problem after the first 6 weeks unless associated with 1 of the complications mentioned. Long-standing low-grade pain that moves from 1 portion of the prosthesis to another should cause the physician to suspect an infection within the spaces surrounding the silastic material. Experience with the genitourinary sphincter indicates that infection of this kind may be present for months, causing only low-grade pain until it becomes evident clinically by reaching the skin surface in a dependent portion of the prosthesis-either in the scrota1 pouch or in the distal end of the corpus cavernosum. The mechanical problems initially encountered have been significantly minimised as further experience is gained with the surgical technique. The mechanical problems associated with this device are easily recognised if the physician understands how the device functions. The 25% Hypaque solution that is used to fill the system permits good roentgenographic visualisation of the device. It is important to take films with the device both inflated and deflated. In our experience, mechanical problems have been correctable but only by surgical intervention. The reasons for some of these complications remain unclear. Material defects occasionally have been recognised, and new production methods are under investigation by the manufacturer. However, most of the major mechanical problems in our series probably can
SURGICAL MANAGEMENT OF IMPOTENCE USING THE INFLATABLE PENILE PROSTHESIS
117
Table 5 Post-operative Considerationsafter Implantation of Inflatable Penile Prosthesis
References
Partially inflate prosthesis for 7 to 10 days Avoid asymmetric dilatatioh of cylinders Inflate and deflate mechanism daily Position pump daily to avoid kinking Remove catheter early-third or fourth day post-operatively Instruct patient in use of pump-use sample prosthesis to demonstrate Instruct patient to avoid early active usage for 4 to 6 weeks Instruct patient in initial usage
using the inflatable penile prosthesis: experience with 36 patients. Mayo Clinic Proceedings, 51, 325-328. Lash, H., Zimmerman, D. C. and Loeffler, R. A. (1964). Silicone implantation: inlay method. Plastic und Reconsfmcfive Surgery, 34,75-80. Maadler, J. (Personal communication.) Pearman, R. 0. (1967). Treatment of organic impotence by implantation of a penile prosthesis. Journal of Urology, 97,
Modified from Furlow, W. L. (1976). Surgical management of impotence using the inflatable penile prosthesis: experience with 36 patients. Mayo Clinic Proceedings, 51,325-328.
ment of erectile impotence: use of implantable inflatable prosthesis. Urology, 2,8042. Small, M. P. and Carrion, H. M. (1975). A new penile prosthesis for treating impotence. Confemporury Surgery, 7 ,
be prevented by strict adherence to the surgical principles listed in Table 3. In addition, the postoperative care should follow certain specific guidelines (Table 5 ) to ensure further the functional success of the procedure. Our experienceindicatesthat implantation of the inflatable penile prosthesis is a highly acceptable method of treating organic impotence.
Furlow, W. L. (1976). Surgical management of impotence
716-719. Scott, F. B., Bradley, W. E. and Timm, G. W. (1973). Manage-
29-33.
The Author William L. Furlow, MD, FACS, Consultant, Department of Urology, Mayo Clinic and Mayo Foundation; Associate Professor of Urology, Mayo Medical School. Requests for reprints to: Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA.
