30

Surgery for Erectile Dysfunction

J. Francois Eid

Questions

1.The three treatments that have had the most impact on the history of erectile dysfunction management are:

a.inflatable penile prostheses, penile arterial surgery, and phosphodiesterase-5 (PDE5) inhibitors.

b.inflatable penile prostheses, penile venous ligation, and PDE5 inhibitors.

c.inflatable penile prostheses, intracavernous injections, and PDE5 inhibitors.

d.intracavernous injections, penile venous ligation, and PDE5 inhibitors.

e.intracavernous injections, penile arterial surgery, and PDE5 inhibitors.

2.The most important difference between a prosthetic erection and a normal erection is that the prosthetic erection:

a.is usually shorter.

b.has less girth.

c.has less sensitivity.

d.has greater rigidity.

e.is cooler.

3.The feature that differentiates the AMS 700 LGX prosthesis from others is:

a.penile girth expansion.

b.penile length expansion.

c.that it has two pieces.

d.that it is preconnected.

e.that it is prefilled.

4.The three most commonly used surgical approaches for penile prosthesis implantation are:

a.ventral penile, infrapubic, and inguinoscrotal.

b.subcoronal, inguinoscrotal, and penoscrotal.

c.ventral penile, infrapubic, and penoscrotal.

d.inguinoscrotal, infrapubic, and penoscrotal.

e.subcoronal, infrapubic, and penoscrotal.

5.Compared with the penoscrotal approach, the infrapubic approach has the following advantage:

a.It avoids dorsal nerve injury.

b.It allows scrotal pump anchoring.

c.It provides better corporeal exposure.

d.It allows reservoir placement under direct vision.

e.There is less chance of infection.

6.The traditional method of sizing corpora for cylinders:

a.sizes them correctly.

b.undersizes them by 1 cm.

c.undersizes them by 2 cm.

d.oversizes them by 1 cm.

e.oversizes them by 2 cm.

7.Cylinders that are too long for the corpora result in:

a.an S-shaped deformity and premature failure.

b.an S-shaped deformity and poor rigidity.

c.premature failure and poor rigidity.

d.premature failure and pain.

e.an S-shaped deformity and pain.

8.For most patients, the ideal inflatable penile prosthesis reservoir location is:

a.the inguinal canal.

b.the scrotum.

c.the retropubic space.

d.between the rectus muscle and the peritoneum.

e.extraperitoneal, lateral to the rectus muscle.

9.Wearing the penis up on the lower abdomen (anatomic position) postoperatively helps to:

a.prevent upward penile curvature.

b.prevent downward penile curvature.

c.minimize pain.

d.avoid infection.

e.avoid autoinflation.

.Following penile prosthesis implantation, failure to reach orgasm is best avoided by:

a.supplemental testosterone.

b.using a water-soluble lubricant.

c.not inflating the device to high cylinder pressures.

d.having adequate foreplay.

e.using a rear-entry position.

.Infected penile prostheses are best treated by:

a.removal of the single infected component.

b.removal of all prosthetic components.

c.12 weeks of broad-spectrum antibiotics.

d.hyperbaric oxygen.

e.12 weeks of broad-spectrum antibiotics plus hyperbaric oxygen.

.Five months following three-piece inflatable penile prosthesis implantation, the recipient complains of persistent scrotal pain. Physical examination is normal except for adherence of the scrotal skin to the pump. The most likely cause of this man's symptoms and physical findings is:

a.allergy to silicone.

b.mechanical irritation from too much pumping.

c.overly tight undergarments.

d.infection with gram-positive organisms.

e.infection with gram-negative organisms.

.The following coatings for penile prosthesis are being used in attempts to lower the infection rates:

a.minocycline, rifampin, and polyvinylpyrrolidone.

b.gentamicin, vancomycin, and polyvinylpyrrolidone.

c.gentamicin, vancomycin, and rifampin.

d.gentamicin, rifampin, and povidone-iodine (Betadine Purdue Products L.P., Stamford, CT).

e.minocycline, vancomycin, and povidone-iodine (Betadine).

.Infection rates following penile prosthesis revision surgery have been shown to be equivalent to infection rates following first-time penile prosthesis implantation. This is most likely due to:

a.6 weeks of postrevision, wide-spectrum, intravenous antibiotics.

b.irrigation with hydrogen peroxide, povidone-iodine (Betadine), and multiple antibiotic solutions.

c.hydrophilic-coated devices.

d.antibiotic-coated devices.

e.removal of all prosthetic components.

.During three-piece inflatable penile prosthesis implantation, while the right corpus cavernosum is being dilated, the 8-mm dilator comes out the urethral meatus. Which approach should be used to manage this intraoperative complication?

a.Repair the urethra, continue using the implant, and leave the urethral catheter as a stent for 3 weeks.

b.Repair the urethra, continue using the implant, and insert a suprapubic tube.

c.Abandon the implant and leave the urethral catheter in for 10 days.

d.Abandon the implant, repair the urethra, and leave the urethral catheter as a stent for 3 weeks.

e.Abandon the implant, repair the urethra, and insert a suprapubic tube.

Answers

1.c. Inflatable penile prostheses, intracavernous injections, and PDE5 inhibitors. In the 1970s and 1980s there was considerable enthusiasm regarding penile arterial revascularization and penile venous ligation surgery. However, long-term results with these two treatment modalities have generally been disappointing and consequently these procedures are no longer commonly performed.

2.a. Is usually shorter. In our experience shortness of the prosthetic erection is the most common cause for patient dissatisfaction. The other difference between a prosthetic erection and a normal erection is the absence of glans tumescence.

3.b. Penile length expansion. The middle fabric layer of the AMS 700 LGX cylinder (Endo International, Malvern, PA) provides both controlled girth and length expansion.

4.e. Subcoronal, infrapubic, and penoscrotal. The subcoronal incision should only be used to implant malleable or positionable devices.

5.d. It allows reservoir placement under direct vision. This is the only advantage of the infrapubic surgical approach.

6.e. Oversizes them by 2 cm. The correct cylinder size is one whose length is the same as the length of an imaginary line that runs lengthwise through the center of the corpus cavernosum. Traditional sizing techniques overestimate

this length by approximately 2 cm.

7.a. An S-shaped deformity and premature failure. A malleable prosthesis that is too long may cause pain, but a cylinder that is too long does not. Rigidity is usually not affected.

8.c. The retropubic space. When the reservoir is in the retropubic space, autoinflation of the prosthesis is less likely.

9.b. Prevent downward penile curvature. While healing is taking place, a pseudocapsule forms around the prosthesis. If the cylinders are held down by

an undergarment as this capsule is forming, they may develop downward curvature.

.d. Having adequate foreplay. If a man inflates his prosthesis, he is able to have coitus. However, unless he is sexually aroused, he may be unable to

reach orgasm.

.b. Removal of all prosthetic components. Although only the scrotal pump may appear clinically to be infected, all components of the prosthesis are joined by tubing and the entire device should be considered infected.

.d. Infection with gram-positive organisms. Organisms such as Staphylococcus epidermidis typically cause a low-grade infection manifested by these symptoms and clinical findings. Infections due to gram-negative organisms commonly occur earlier and are associated with erythema and often drainage of pus from the wound.

.a. Minocycline, rifampin, and polyvinylpyrrolidone. Coloplast's three-piece inflatable penile prosthesis is coated with polyvinylpyrrolidone. American Medical Systems' three-piece inflatable penile prostheses are coated with minocycline and rifampin.

.e. Removal of all prosthetic components. Infection rates following repeat penile prosthesis surgery approach the rates seen with first-time penile

prosthesis implantation if the entire device is replaced.

.c. Abandon the implant and leave the urethral catheter in for 10 days. If the implant is not abandoned, the urethra is unlikely to heal and the entire device is at risk of infection.

Chapter review

1.There are three types of penile prostheses in common use: (1) semirigid,

(2)two-piece inflatable, and (3) three-piece inflatable. Normal penile flaccidity and erection is best achieved with a three-piece prosthesis.

2.Device removal is required when there is infection or erosion through the

skin.

3.Safe insertion of the reservoir in the retropubic space requires an empty bladder.

4.Infections occurring within the first few weeks following an implant are more likely to be associated with gram-negative bacteria versus those occurring 6 months or later, which are associated with gram-positive bacteria. In the majority of circumstances, the source of infection is from the skin.

5.Late prosthetic infections can occur due to hematogenous spread.

6.Early penile prosthesis reimplantation after removal of an infection penile prosthesis following eradication of infection minimizes loss of penile length.

7.When one of the cylinders fails, many patients can have successful coitus with only one functional cylinder.

8.Sensation, orgasm, and ejaculatory function are not altered by the placement of a penile prosthesis.

9.The patient should understand preoperatively that implantation of a penile prosthesis causes irreversible changes.

10.Placement of the reservoir in the space of Retzius should be performed only in patients who have not had prior surgery in the area.

11.Peyronie disease compromises inflatable prosthetic device durability and increases malfunction rates.

12.Shortness of the prosthetic erection is the most common cause for patient dissatisfaction.

13.The subcoronal incision should only be used to implant malleable or positionable devices.

14.While healing is taking place, a pseudocapsule forms around the prosthesis. If the cylinders are held down by an undergarment as this capsule is forming, they may develop downward curvature.