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 penile 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.