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Surgical tips in difficult penile prosthetic surgery: a narrative review

International Journal of Impotence Research volume 35, pages 690–698 (2023)Cite this article

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Abstract

Penile prosthesis implantation continues to represent a reliable solution to address erectile dysfunction when oral medications fail, are not tolerated or are contraindicated, and most typically is associated with excellent satisfaction rates and durable results. Despite the dramatic improvements in the prostheses’ design, in the surgical instruments and techniques over the years, certain categories of patients still pose a significant surgical challenge. The aim of the current review is to provide a quick and useful practical guidance based on our expertise in the identification and management of the difficult penile prosthesis implantation cases. A narrative review design was here preferred to fulfil our purpose. The search strategy included a range of terms, e.g. penile prosthesis, corporal fibrosis, infection, ischaemic priapism, Peyronie’s disease, radical prostatectomy, pelvic surgery. Extensive corporal fibrosis after explantation of an infected device or after prolonged ischaemic priapism may represent the most difficult situations to deal with in penile prosthesis implantation surgery. Penile prosthesis implantation in patients with Peyronie’s disease and in those who previously underwent radical prostatectomy also presents with an increased risk of complications. Experienced surgeons need to be able to recognise promptly and manage urethral perforation, cylinder crossover, tunical perforation and erosion, as these complications are more common when dealing with difficult penile prosthesis implantation cases. Applying penile lengthening techniques and principles can be useful in selected cases to ensure better postoperative satisfaction rates, especially in those patients who have experienced a more significant degree of loss of length preoperatively. High-volume-implanting surgeons should always be involved in complex cases to minimise the risk of complications. A thorough preoperative counselling can set realistic patients’ expectations in this context, further contributing to postoperative satisfaction.

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Fig. 1: Extensive penile fibrosis with evident shrinkage after the explantation of an infected device.
Fig. 2: Additional small corporotomies can be useful to allow Metzenbaum scissors to be pushed safely through the distal fibrotic tracts under direct vision.
Fig. 3: Corporeal reconstruction using grafts.
Fig. 4: Necrotic tissue noted at the site of the corporotomy in a case of early PPI after ischaemic priapism, the corporeal dilatation usually does not pose significant challenge.
Fig. 5: Tunical string-vest incisions for girth and length restoration after PPI.
Fig. 6: Ventral phalloplasty.

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Authors and Affiliations

  1. Department of Urology, King’s College Hospital NHS Foundation Trust, London, UK

    Nicolò Schifano & Onur Omer Cakir

  2. Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy

    Nicolò Schifano

  3. ASST Sette Laghi—Circolo e Fondazione Macchi Hospital, Varese, Italy

    Paolo Capogrosso & Federico Dehò

  4. International Andrology, Rome, Italy

    Giulio Garaffa

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Conception of the work: NS and GG; Data collection: NS, PC and OOC; Data analysis and interpretation: NS, PC and OOC; Drafting the article: NS and OOC; Critical revision of the article: PC, FD and GG; Final approval of the version to be published: NS, PC, OOC, FD and GG.

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Correspondence to Nicolò Schifano.

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Schifano, N., Capogrosso, P., Cakir, O.O. et al. Surgical tips in difficult penile prosthetic surgery: a narrative review. Int J Impot Res 35, 690–698 (2023). https://doi.org/10.1038/s41443-022-00629-6

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