surgical treatments

The implantation of a penile prosthesis is indicated in all the forms of erectile dysfunction that do not respond to other therapeutic aids, in cases in which drug treatments are contraindicated or might have led to the occurrence of relevant side effects. A penile prosthesis is the best surgical option for the treatment of men with erectile dysfunction. Some regard it as the “last resort” for men suffering from impotence; however, we do not opine that.

A penile implantation can be performed on any patient suffering from organic Erectile Dysfunction (ED), as most of these problems fail to resolve spontaneously with non-surgical treatments. A long hesitation in undergoing this option might cause a significant and irreversible shortening of the penis because of the poor oxygenation of the corpora cavernosa. Which is worse in the patients suffering from Induratio Penis Plastica.

The prostheses can be both non-hydraulic (malleable) and hydraulic (three-component). They consist of two cylinders that are placed in the two natural cylinders of the penis: the “corpora cavernosa”. The non-hydraulic is the simplest: constituted by two cylinders of constant consistency which stimulate erection with the rigidity requested for penetration, also allowing adequate bending of the penis so that it can comfortably get placed immediately after. They represent the model of first choice when patients have limited manual ability or there are cost related issues. It is important to notice that, if on one hand the stiffness conferred to the penis allows the penetration, perennial turgidity of the rod could cause significant lifestyle changes: for example, it is difficult to camouflage under tight-fitting clothing, which could be a problem, for example, while working out or practicing sports. Moreover, the state of high pressure on the cavernous tissue can reduce the tropism and consequently increase the chances of perforation and extrusion of the prosthesis. These prosthesis are, therefore, suggested only in cases where there are limitations of manual ability of the patient or there are issues related to the high costs of implant.

The hydraulic models are instead made up of two cylinders, a control device inside the scrotum and a reservoir of liquid placed near the bladder. It creates a closed loop system, where the liquid gets transferred to the two cylinders to achieve erection, the procedure is manually operated wherein the liquid is again transferred back to the reservoir to obtain flaccidity. The hydraulic prosthesis allows obtaining an erection in solidity with absolutely no distinguishment from a natural erection. The hydraulic models thus allow, on command, erections of optimum rigidity, with the same sensitivity as was present before the surgery, and with the same ability to ejaculate and orgasm, without any significant noticeable feature on the outside; in fact, all the elements of the prosthesis are present within the body.

The great advantage of hydraulic implants is that the penile rigidity is obtained only during the culmination of the sexual activity. This allows the patient to hide the erection during social moments. Thus, in most of the cases, the choice of the prosthesis should rest on a hydraulic device, in order to make the erection and the flaccid states resemble the natural ones. However, in reality, noticeable conditions will make the choice according to National Healthcare system due to the different costs that the public facilities have to endure for the type of prosthesis.

In most of the cases, the selection of the patients eligible for prosthesis implant is based on the exclusion criteria. In other words, patients are considered candidates for prosthetic implant when they are affected by erectile dysfunction on a prevailingly organic cause, cases where the therapeutic path of oral treatment and intracavernous injection of vasoactive drugs with minimal invasiveness prove to be ineffective or the improvement is unacceptable.

In some cases, instead, the prosthesis may be preferable in case of severe curvature secondary to the induratio penis plastica, when the small size of the penis and/or the co-existence of a pre-operative erectile dysfunction does not allow a successful conservative surgery based on the simple straightening or on the excision of the plate and the grafting of an autologous material or heterologous replacement. However, in certain rare cases where, despite the presence of a normal responsiveness to pharmacological treatments, sometimes it may be the Patient himself to request for the prosthetic implant, as the choice of treatment. In this case, like in the rest of the prosthetic surgeries, correct preoperative information is particularly important.

The phases of the surgery include skin incision, exposure of the corpora cavernosa, choice and positioning of the prosthesis components and, in case of hydraulic prosthesis, filling and emptying of the prosthesis.The surgery is usually performed under the loco-regional anesthesia and involves the placement of two expandable cylinders at the corpora cavernosa level of the penis, a reservoir at the paravesical space level and a pump in the scrotum. The three components are connected by the thin connecting tubes that run on the subcutaneous level.

The most significant complication is represented by the infection that generally requires another surgical operation for the removal of the prosthesis. The mechanical reliability and the technical characteristics of the models currently available in the market guarantee excellent results in aesthetic and functional terms; however, some precautions are necessary to avoid cases of postoperative dissatisfaction.

The preoperative interview is very important to understand the expectations of the patient, the surgical results and the aspects of sexuality post-implantation enables one to choose the most appropriate prosthesis. In cases where the preoperative interviews are useful to make the correct treatment choice, the results in terms of sexual rehabilitation of the patient and its favourable effects on the couple become extremely flattering. The patient must be made aware of the irreversibility of the surgical procedure and the specific risks related to it; these, being the mechanical functional problems reduced to a minimum, are mainly represented by the infection of the prosthesis with the highest values, especially in groups at risk with poor immune reactivity, such as diabetes, kidney disease, or immunocompromised.

The correct preoperative information should take into consideration some basic elements: the size of the penis post surgery, in both the erection and flaccid state may differ from the sizes found prior to the operation and this event will be in the long term, this disparity will be found in case of the use of malleable prosthesis as well. Cases of infection of the prosthesis have been described and the consequent need to provide for its removal have been well explained, especially in cases where the need for replanting has been deferred (resulting in at least six months); as with any surgery, infection is an inevitable possibility.

The probability of incurring an infection following our treatment is less than 1%. This percentage may be higher if there is a spinal cord injury or diabetes involved. Men who need surgery to revise or replace an implant are at a higher risk of infection than they were during the first operation. The risk of infection can be significantly reduced if the patient follows the instructions provided in pre and post operative stages. Infections are treated with the immediate removal of the prosthesis. The prosthesis implant does neither directly affect the levels of desire nor the intensity of orgasm.

Difficulty in reaching orgasm may persist only for a short period of time post surgery; in this case, the patient should be encouraged to increase the frequency of intercourse and duration of erotic foreplay. Similarly, the use of the prosthesis does not automatically improve your relational skills, even considering it can play a key role in the recovery of self-esteem, nor will it resolve conflicts between the couple that stem due to erectile dysfunction.

When the penis is erect, the prosthesis makes the penis harder and it appears like a natural erection. A penile prosthesis does not change the sensitivity of the penis or a man’s ability to achieve orgasm. The ejaculation is not affected. Sometimes the patients report “loss of penile length”. The perceived loss of penile length is not due to the positioning of the penile prosthesis: the positioning of the implant stops the process of atrophy and, with proper rehabilitation the patient can recover some of his lost penis length.

“I feel the tubes around my cylinders”.
We do everything that is possible to hide the tubes but some anatomies require installation of the cylinder where the tubes can be felt under the skin.

“The head of the penis is not hard.”
This is a possible situation. The implant does not give adequate bulge to the Glans. Our surgical technique limits the possibility of achieving flaccid penis. Viagra and/or intraurethral creams can be used for the treatment of this problem.

How does one live with inflatable penile prosthesis?
No physical activity or other sports activity will be denied after the implantation of the prosthesis. Our patients, once healed, live a normal active lifestyle.

How effective are the implants?
About 90% – 95% of the implants of inflatable prosthesis produce erections suitable for intercourse. Satisfaction rates with the prosthesis are very high, and typically 80% – 90% of men are satisfied with the results and choose to opt for the surgery again.

It should be emphasized that the operation of penile prosthesis implantation must be performed by specialists dedicated to the medical branch of Andrology and in proper facilities.

Erectile dysfunction and urinary incontinence due to sphincter deficiency are relatively common conditions after radical prostatectomy. They both impact greatly on quality of life domains and have been associated with poor performance outcomes in the past.
When there are not any other options, these conditions are easily fixable with the implantation of prosthetic devices.
Both, the artificial urinary sphincter and the penile prosthesis, are gold standard treatments with proven efficacy, satisfaction and durability. Recently, it was advised to have both operations simultaneously.

Increased feelings of pleasure with improved sexual performance and a drastic reduction in penile curvature in case of deformity. These are the results achieved from the procedure with PRP (Platelet Rich Plasma), used for the treatment of erectile dysfunction and plastic induratio, which was developed in the US and now arrives in Italy.

“The PRP therapy gives strength to all those people who, for various reasons, no longer respond to treatment with inhibitors of phosphodiesterase type 5: the famous love pills. Some patients have also reported an increase in length and circumference of the penis and of the sexual desire“ says Gabriele Antonini, urologist-andrologist of Rome, who collaborated with colleagues Joseph Banno in Chicago and Paul Perito in Miami. The PRP has been successfully used for several years in orthopedics and sports medicine and has quickly became one of the most effective methods of treatment for erectile dysfunction and penis plastic induratio or Peyronie’s disease in the United States.

“The human body has a remarkable ability to heal itself. The regeneration of a fabric is obtained with the natural production of stem cells – recalls Antonini – The PRP provides for the application of concentrated platelets rich in bioactive proteins that release growth factors to stimulate cell regeneration and accelerate tissue repair. “

The treatment starts with a simple blood sample placed in a centrifuge which separates plasma and platelets from the rest of the blood. “The plasma, enriched with highly concentrated platelets, is collected in small syringes and injected into damaged tissue again. The Priapus shot is a procedure performed on an outpatient basis by locally applying a simple anesthetic cream before injection, without any discomfort during the treatment.“ says the urologist.

“In the United States, more than 60,000 PRP procedures were performed with no side effects or complications. In Italy, it was approved by the Ministry of Health,” he continues. “The growth factors stimulate the regeneration of new tissue in the corpora cavernosa, the growth of new blood vessels and, therefore, improving circulation within the penis – said Antonini – The results consist in stronger erections, increased feelings of pleasure. Many of these benefits are immediate after the injection. This treatment is hypoallergenic and free of side effects – he concludes – because it uses and reinfonde the plasma of the same person”.

Peyronie’s disease, also known as Induratio Penis Plastica or chronic inflammation of the tunica albuginea of the corpus cavernosum, it’s a disease involving the formation of calcified fibrous plaques within the penis. It affects 5% of men.

The pathology can cause pain, penile deformity, an hourglass effect and abnormal curvature of the erect penis due to chronic inflammation of the tunica albuginea. A commonly held erroneous belief is that Peyronie’s disease always leads to curvature of the penis.
The scar tissue often leads to deformities or shortening rather than curvature. The condition can also make sexual intercourse painful and difficult until the disease process leads to atrophy. Almost 25% of patients seeking a penile prosthetic implant have a form of Induratio Penis Plastica. The average patient age is 58. 10% have a mild form of the condition, 10% moderate and 80% have a severe form of Peyronie’s disease. It is more common than people think. It is, beyond any reasonable doubt, related to diabetes, which causes endothelial damage and thus fibrosis of the corpus cavernosum, but it is also associated with “vigorous” sexual activity. Early diagnosis is extremely important: a matter of days can make all the difference. The use of integrators as part of the treatment plan for Peyronie’s disease can be of help but does not resolve the problem.

Iontophoresis, low frequency shock waves and laser therapy can help in selected cases. The Vacuum device is very useful both as a preventive measure as well as for the purposes of maintaining the post-operative result. The Vacuum device is a mechanical device using a vacuum created by a pump to stretch penile structures (smooth muscle and tunica albuginea) and to draw blood into the corpus cavernosum, also for the purpose of inducing an erection. The device essentially consists in a large silicone cylinder with an appropriate adaptor, into which the patient’s flaccid penis is inserted and a pump (manual or electric) connected to the cylinder so as to aspirate air, creating negative pressure of up to 450 mmHg. Maintenance time and vacuum management will be suggested in the recovery phase based on the specific pathology. The Vacuum device can be used to treat forms of erectile dysfunction as an alternative to first-line therapies.

There are other pathological conditions which can be treated using the Vacuum device: these include situations in which the penis may undergo retraction or shortening such as, for example, the one of the penis, which may be observed following a radical prostatectomy. In such cases, the penile stretching associated with the oxygenation of the corpus cavernosum can prevent the retraction connected to the loss of erectile function, before the insertion of a prosthetic penile implant. According to the same principle, in cases of shortening due to Induratio Penis Plastica, the use of the Vacuum device can help to slow down the retraction-related shortening of the albuginea characteristic of the disease.

In our practice, men aged over 50 with any degree of erectile dysfunction are candidates for the implantation of a penile prosthesis. Correcting the curvature alone will not guarantee an improvement in erectile function. As a matter of fact, such patients will need to undergo another procedure. However, a long wait can lead to a permanent shortening of the penis: carrying out the surgical procedure as soon as possible will avoid further length loss.
When the penile prosthesis is inserted, we use a new approach to correct the curvature and defects of the tunica albuginea, called “Scratch” technique. Concretely, the fibrosis is broken from within and the shaft is re-modelled prior to implanting the prosthesis.

Benign Prostatic Hyperplasia (BPH) can cause severe trouble in urinating with age. About 50% of men will experience a radical change in urinating during their lives because of this benign growth.
Surgical treatment of benign prostatic hyperplasia (BPH), a treatment method being used for the past 20 years, is based on transurethral resection of the prostate (TURP).
The treatment is undergoing revolution in terms of its nature with the advent of laser technology. In fact, the non-negligible percentage of post-operative complications related to TURP (persistent microhematuria, post-TURP syndrome, anemia), has resulted in the industry’s ever increasing interest in search of the ideal method for resolving the obstruction of prostatic hyperplasia, a system whose main features should be minimal invasiveness, absence in the problems of intraoperative reabsorption of liquids, absence of bleeding, possibility of the total removal of the prostatic adenoma, shorter duration of stay in the hospital and the reproducibility of the results.
The application of the laser technology to prostate surgery is itself a sign of significant improvement in the ideal surgical approach used in the last decade.
The new standard for the surgical treatment of Benign Prostatic Hyperplasia is the photoselective vaporization of the prostate using the GREEN LASER, more commonly called “GreenLight laser prostatectomy”.
It is a minimally invasive procedure that results in significant improvements in the urinary symptoms.
A thin fiber is inserted into the urethra through a cystoscope, an instrument that allows the doctor to examine the bladder and the prostate. The fiber delivers green laser energy that quickly evaporates and removes the prostate tissue. The urologist is able to view and check safely the area of treatment, by adapting to one’s anatomy and needs. Since the prostate tissue is vaporized and removed, it creates a wide channel: as a result, the flow of urine is immediately restored and all the urinary symptoms should be treated.
The green laser light used in the vaporization has a wavelength that gets easily absorbed by the hemoglobin present in the red blood cells. Because of this, the tissue which has blood in it (such as the prostate) gets selectively vaporized. Once the capsule of the prostate is reached, vaporization ceases completing the procedure: by being fibrous, the prostatic capsule has no hemoglobin and is therefore protected from the laser.
The ADVANTAGE of this procedure in comparison to TURP is that, in this procedure, the prostate tissue gets vaporized selectively rather than cut-off. When the prostate tissue gets cut off in the TURP procedure, the prostate bleeds abundantly while, during the photoselective vaporization, this tissue does not bleed at all.
The GreenLight laser exploits the capability of the tissue vaporization by lithium triborate crystals with the consequent advantage of an operation which is mini-invasive, bloodless, without any possibility to cause problems in the resorption of fluid and requires a short stay in the hospital.

The advantages of GREENLIGHT XPS 180 watt manufactured by American Medical Systems, Inc. are numerous.

• With the use of intraoperative saline, the BPH treatment has become more successful (risk of resorption of liquid is minimal or absent).
• Because of the great coagulation capacity of GREENLIGHT XPS that allows the removal of the urinary catheter and the secretion of the discharge to flow in the first or the second day, the number of days required for hospitalization for availing the treatment has reduced significantly.
• Absence of intra and postoperative bleeding complications which can result into re-operations.
• Possibility of treating anticoagulated patients, without suspension of the same (non-insignificant advantage in an era of an ever increasing use of antiplatelet therapies related to cardiovascular events).
• Elimination of problems connected to blood transfusions.
• Possibility of the treatment of the patients with pacemakers, since no electric energy is used.

Quicker functional recovery of the patient.
The results are equivalent to those of TURP with fewer side effects and complications.

• Rapid and significant improvement in urinary flow.
• Treatment given to patients with varying severity in symptoms.
• Further studies support the use of GreenLight on the large sized glands, on anticoagulant and high-risk patients.
• One Day Surgery Procedure (one night of hospitalization). Much lower risk compared to TURP; no significant risk of TURP syndrome.

Much lower risk compared to TURP; no significant risk of TURP syndrome.

• Catheterization of the average duration of 72 hours.
• Mild irritative symptoms that last for short duration only.
• Quick resume of normal activities.

The safety and effectiveness of photoselective vaporization with GREEN LASER has seeped in a revolution in the traditional treatment of Benign Prostatic Hyperplasia (BPH).

Urinary incontinence refers to the involuntary loss of urine at inappropriate times or places causing hygiene or social problems.
In males, this kind of incontinence is rare and generally caused by trauma and/or surgical interventions to the urinary sphincter. Neurological conditions that compromise the innervation of the bladder and urethra might as well be a cause. In other cases, the person experiences a sudden urge to urinate and has to hurry to the toilet, but may “wet himself” before he gets there. The urinary flow ranges from a few drops to full micturition and are both frequent and unpredictable. In this case, we refer to urgency urinary incontinence. In most cases, the disorder is associated with frequent, involuntary and unstoppable contractions of the bladder muscle.
Its causes included neurological disease, urinary tract infections, calculi and bladder tumors. This type of incontinence is frequently seen in the elders, particularly in those with cerebral disease (arteriosclerosis, Parkinson’s disease, etc.) and is aggravated by gait and balance disorders, as well as mental confusion. The AMS 800 device is used to treat urinary incontinence due to resistance to urinary flow in the urethra/bladder (intrinsic sphincteric deficiency) in male, female and pediatric patients. The AMS 800 sphincter is a reliable device for the treatment of incontinence in appropriately selected patients.
The artificial sphincter is currently the best treatment for incontinence due to a sphincteric deficiency subsequent to radical prostatectomy. The positioning of an artificial sphincter for sphincter insufficiency produces satisfactory continence in 80-90% of cases. It simulates a healthy sphincter insofar as it maintains the urethra closed until urination is desired. The artificial urinary sphincter is a small, surgically implanted device which aims to restore the natural micturition control process.
When the natural sphincter (the muscle responsible for controlling the micturition) does not function correctly, as may occur after a prostatectomy, it results in uncontrollable urine loss. In cases of severe incontinence, where rehabilitation techniques and pelvic floor physiotherapy are insufficient to restore continence mechanisms, the use of an artificial sphincter may be a solution to the problem. It is made up of three components: a cuff, which surrounds and closes the urethra, a pump located in the scrotum to deflate the cuff and a reservoir balloon. These components are connected together with flexible tubes.

Where is the device implanted?
Balloon (reservoir): positioned close to the bladder. Tubes: connect the different parts of the device, allowing the movement of liquid within. Cuff: positioned around the urethra. Deactivation valve: a small button on the stiff part of the pump. Pump: positioned within the scrotum such that it can be felt through the skin. The lower part is soft and distensible. The liquid-filled cuff applies gentle pressure to keep the urethra closed and thus hold the urine in the bladder.
In order to urinate, the patient presses the pump several times. The liquid is thus transferred into the reservoir and the cuff remains open. Once emptied, the cuff no longer exerts pressure on the urethra and urine is able to flow out of the bladder. A few minutes after micturition, the liquid automatically returns to the cuff’s balloon, which fills up to close the urethra, restoring continence.
The surgical procedure for the implantation of the artificial urinary sphincter can be carried out as a Day Surgery, involving a single 3 cm incision below the scrotum. It is necessary to wait 30 days after the procedure before starting to use the device.

There are many different surgical techniques available for varicocele. The common approach is that of closing the pathological venous circuit allowing for the subsequent development of collateral circuits through the circuits of the deferential vein and the external gonadal vein.

1. Abdominal techniques
2. Inguinal and subinguinal techniques
3. Radioguided techniques

These techniques involve the ligature of the gonadal vein within the abdomen and thus require opening of the abdomen by either open abdominal or laparoscopic means. They are generally carried out under general or spinal anesthesia. They are somewhat invasive techniques (opening of the abdomen, general or spinal anesthesia) and subject to complications, such as hydrocele (collection of liquid around the testicle) in 8-10% of cases, requiring a second surgical intervention.

These techniques involve the closure of veins upstream of the gonadal vein, the pampiniform plexus veins. Access is via incision of the skin of the inguinal, sub-inguinal (external ring) or high scrotal regions.

These techniques involve closure of the gonadal vein via the insertion of catheters (thin tubes) into a vein in the arm. The advantage of these techniques is that they do not entail any incision. We carry out retrograde sclerosis, preferably via a vein in the fold of the arm. This technical modification offers the advantage of being less invasive than the transfemoral approach and offers easier access to the renal-spermatic region not only on the left, but also on the right, because the catheter advances from the top down. A small quantity of local anesthetic at the puncture site through which the catheter is inserted is enough for the entire procedure. Once the spermatic vein is reached, under radioscopic guidance, the sclerosing substance is injected. During the same session, if the varicocele is bilateral, it is possible to treat both the right and left sides. The patient is allowed to rest for a few hours and is discharged the same day.

Following local anesthesia of the inguinal region, an incision of about 1 cm is made at the root of the scrotum and one of the veins forming the varicocele is isolated and cannulated. After radiological guidance showing the course of the vein, the sclerosing substance is injected. The vein is then tied and the small wound is sutured with absorbable sutures. The patient is discharged as a day case. Again, in this case, we have introduced a few technical modifications, which make this procedure preferable in pre-pubertal or early-pubertal boys.

Local Anesthesia: applied between the external inguinal ring and the root of the scrotum around the spermatic cord using a thin insulin needle. Cutaneous incision: around 2.5cm to the upper part of the scrotum. Exteriorization of spermatic cord: the cord is the structure that allows the passage of the testicular blood vessels and nerves in addition to the vas deferens (the seminal canal). Exposure of the external spermatic fascia: the external spermatic fascia is then incised to reach the veins. The different elements of the spermatic cord are explored: the vas deferens and the 3 venous plexus of the testicle are identified:

1. The pampiniform plexus
2. The deferential plexus
3. The cremasteric plexus

A dilated vein from the pampiniform plexus is isolated. Gonadal phlebography is performed: phlebography allows the continuity with the gonadal vein to be confirmed. The sclerosing liquid is injected: The liquid will cause fibrotic retraction, leading to closure of the lumen of the cannulated vein, the collateral branches of the pampiniform plexus and the gonadal vein downstream. The incised structures are then closed, that is, the spermatic fascia, subcutis and cutis.