Complex And Re-Do Penile Implant Surgery

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During the past 21 years, Dr. Gelman has performed hundreds of penile implant surgeries at the Center for Reconstructive Urology at UC, Irvine. Some of our patients have been referred by their Urologist for the initial placement of a penile prosthesis. However, penile implant surgery is commonly performed by General Urologists in the community who do not exclusively specialize in male penile-urethral surgery. Penile prosthesis surgery can be performed by local General Urologists with good results, but the complication rate can be higher when the surgeon does not have a particular expertise with this surgery. We have seen major complications that have never occurred at our facility. Those patients who can have penile implant surgery by their local Urologist, but want the operation to be performed by someone with additional training and expertise, will seek care at the Center for Reconstructive Urology for initial surgery.

However, when complex penile implant revision surgery is required, such as after there are complications from the surgery, or there is scarring of the penis from priapism (a condition of an abnormally prolonged erection leading to fibrosis of the penis) or prior implant placement and subsequent removal due to infection, we are a referral resource for other Urologists.

Re-Do Penile Implant Surgery Slideshow

This slideshow illustrates the various penile implant complications discussed on this page. Please note that the surgery photos are graphical in nature.

A Diagramatic Representationin Color Labeling

Penile Implant Revision Surgery

The following slides in this slideshow depict penile implant revision surgery performed at the Center for Reconstructive Urology.

A Diagramatic Representationin Color Labeling

Penile Implant Cylinder Tear

This is an example of a tear in a penile implant cylinder that caused leakage of fluid out of the system leading to malfunction. The loss of fluid more often is due to a tear in the tubing. The treatment is penile implant revision surgery to replace all components of the inflatable penile prosthesis.

Improperly Placed Penile Implant Cylinders

The proper location of the cylinders should be inside the penis within a structure called the corpora cavernosa. However, when part of the cylinders are not properly placed entirely within this space, there can be bulging in the absence of inflation and malfunction.

Subcutaneous Penile Implant Cylinders

In this slide, part of the cylinders can be seen just under the skin where they should not be visible.

Gore-Tex Patch Graft Used To Repair Damage

In this particular patient, there was damage to the corpora cavernosum on the left which is where the cylinder has to be inserted. This required reconstruction with the use of a graft and the outcome was excellent.

Bulge At Base Of Penis During Penile Implant Inflation

An aneurysm was suspected, and when there is an aneurysm, penile implant revision surgery is indicated.

Inflatable Penile Implant Aneurysm Exposed

This surgery picture of penile implant revision surgery shows the bulging where there is a ballooning of the 1 cylinder, which is called an aneurysm.

Successful Penile Prosthesis Aneurysm Repair

This surgery picture shows the final result after replacement of the penile implant with new cylinders.

Penile Implant Cylinder Crossover

This is a complication of penile implant surgery. There is supposed to be a cylinder on the left and another cylinder on the right. When inexperienced Urologists perform this surgery, they can malposition one of the cylinders where it crosses over to the other side. In this case, the left cylinder crossed over from the left to the right side and did not extend to the tip of the penis.

Penile Implant Surgery Picture Showing Crossover

This man reports that he had penile curvature, mostly to the side, for his entire life. This is called Congenital Penile Curvature. In this picture, the extent of the penile bend is not appreciated because he does not have an erect penis. Given that curvature is best seen during an erection, it is for this reason that we ask our patients to bring pictures of their erect penis to their initial appointment at the Center for Reconstructive Urology.

Repair Of Crossover Penile Implant Complication

This is the result of penile implant revision surgery performed at the Center for Reconstructive Urology. Both cylinders are now properly positions and of equal length.

Complication When Oversized Cylinders Were Used

This man underwent a penile implant surgery by an experienced high-volume Urologist who believed that longer cylinders would lead to a longer penis. In this case, the cylinders buckled during inflation and one at a time extruded to out of the corpora and could be felt under the skin.

Oversized Penile Implant Cylinders: Exploratory Surgery

This man underwent a penile implant surgery by an experienced high-volume Urologist who believed that longer cylinders would lead to a longer penis. In this case, the cylinders buckled during inflation and one at a time extruded to out of the corpora and could be felt under the skin.

Penile Implant Cylinder Considerably Longer Than Penis

With the penis on stretch and one of the cylinders inflated, it can be shown in this intraoperative surgery photograph that the cylinder is much longer than the penis.

Scarring From Penile Implant Cylinders Not In The Proper Space

When the cylinders popped out of the space meant to contain them, the tissues then scarred down, and complex reconstructive surgery was then required.

Scar Tissue Excised For Placement Of New Penile Implant Cylinders

Hard scar tissue within the penis takes up space within the corpora cavernosa, leaving no room for the penile implant cylinders. In these challenging cases, we cut out the internal scar to make space for the cylinders of proper length to fit.

Penile Implant Revision Surgery Using Proper Length Cylinders

After removal of the old device and removal of the obstructing scar tissue within the penis, this is the appearance of the inflated implant when shorter cylinders were used. The patient was highly satisfied with his result.

Penile Implant Cylinder Erosion

In this picture, you can see the penile implant cylinders as they are no longer covered. This is managed with removal and/or replacement.

Penile Gangrene After Penile Implant Surgery

This unfortunate patient underwent a penile implant by a local General Urologist who treated penile curvature at the same time. This involved the cutting of arteries to the head of the penis leading to glans penis gangrene and that doctor was found negligent.

Complication Of Penile Implant Infection

This unfortunate man had a penile implant surgery and developed an infection that was not properly treated leading to a loss of the majority of his penis shaft leaving only the head of his penis remaining. He also developed a urethral stricture. This is a rare complication, and was preventable.

Malfunction Of A Penile Implant

A penile prosthesis is a mechanical device and can malfunction at any time. For example, if there is a tubing leak or cylinder tear, the fluid within the system can escape. This causes no harm. However, the penile implant will then no longer inflate or deflate. When a device malfunctions (in the absence of infection), the options are to do nothing (where the device will no longer be used for sex), remove the device, or replace the penile prosthesis. Most men, especially those wanted to remain sexually active seek penile implant revision surgery to have the device replaced with a new penile implant. This involves the removal and replacement of all components for an inflatable penile implant.

There can be other causes of malfunction that can be addressed without replacement of the device. As a recent example, a patient reported that his device never really inflated properly, and this was confirmed on examination. At the time of surgery, it was noted that the one of the cylinders was partially exposed under the skin. The cylinders are placed inside structures called corporal bodies and the incision into this structure is generally closed after cylinder placement. For whatever reason, the suturing did not lead to proper closure and healing, causing a cylinder to protrude and kink. Once we properly seated this cylinder and closed the open corpora, the device worked properly.

Improper Cylinder Placement Leading To Bulging And Malfunction

The appropriate placement for the cylinders is within the corporal tissue inside the tunica albuginea. The cylinders must be inside the proper space along the length of the penis and sized to the appropriate length. In some cases, when there is a bulging along the penis, one possible explanation is that a portion of one or both of the cylinders is outside of the tunica and not properly positioned at the time of surgery. In other cases, the cylinders may be contained within the penis, but placed where there is a crossover. This is where one cylinder on one side crosses over to the other side somewhere between the 2 ends of the implant. Our approach is to widely expose the corpora and then expose the interior of the corpora deep to the tunica, creating a new and proper channel and space for replacement of the cylinders. This can require extensive dissection to expose a long length of the corpora to insure that the cylinders will truly be in the proper location. In most cases, when a penile implant requires revision, it is best to replace the entire device rather than a single component.

Deformity From Penile Implant Aneurysm

A late complication of an inflatable implant that can occur is the development of an abnormal dilation of a portion of a cylinder. When a portion of a cylinder becomes weakened, this can lead to a bulging as the device is inflated. This is called an aneurysm. When this is diagnosed based on history and physical exam, if the bulging is associated with compromised function, the treatment is replacement with a new implant. This can be more complex than a simple revision as the bulging can distort the anatomy and thin out the tissue that is to cover the cylinder. However, replacement with a new device generally restores the ability of the patient to have satisfactory intercourse without the bulging that was previously problematic.

Scarring After Implant Removal Or Priapism

When a patient sustains an abnormal erection for a very prolonged period of time, this is called Priapism. Most cases of priapism are called “ischemic priapism”. There is blood in the penis, but that blood is trapped and not circulating. This condition is best treated less than 4-6 hours after the onset of the erection. However, some patients do not seek treatment until 24-48 or more hours after onset. This delay can be associated with the development of severe scarring and fibrosis of the inside of the penis. This scarring is exactly where the implant cylinders need to be placed.

In addition, when a penile implant is placed and then removed for infection or other reasons, this also is association with the development of scarring within the penis in the space where the cylinders were once located. This is a very challenging problem as there is shrinkage of the penis and the normal soft sponge-like tissue within the tunica albuginea is replaced by dense scar. Many Urologists perform initial penile implant surgery, but very few perform surgery when there is penile scarring as this requires specific expertise and experience. We are a referral center for the treatment of these challenging and complex conditions.

We first achieve wide exposure along the length of the penis, and then use special dilation instruments that safely core out the scar tissue. These instruments are called cavertomes. In some cases, in addition to using cavertomes, we have to use a scalpel to excise scar within the corporal bodies to create space for the cylinders. When even small dilators will not advance, we then make a second circumcising incision and a second corporotomy (a cut into the corpora) to achieve safe through-and-through access for dilation. On occasion, a graft of Gore-tex has been required to achieve closure after cylinder placement. However, recent technical modification have made the use of grafts unnecessary during the past 15 years. Some of our patients, prior to referral, reported that they were previously told by multiple Urologists that an implant could not be performed due to the scarring. However, it is our experience that if a patient is a candidate for surgery from a medical standpoint, it is extremely unusual for penile implant placement to be impossible. However, that implant may be shorter in length than the prior implant.

Oversized Cylinders

There has been a trend over the past 10 years for Urologists, especially “high volume” implant surgeons with industry sponsorship, to place cylinders in the penis that are longer than the space allows. When deflated, the cylinders can be made to fit. The concept is that when the cylinders are inflated, this will stretch the penis eventually leading to a longer penile length during intercourse. One potential problem with that approach is that it can lead to extrusion of 1 or both cylinders into the tissues just under the skin. In these cases, a very complex revision surgery is required. To date, we have always been able to successfully perform penile implant revision surgery.

Implant Erosion

When there is erosion of a cylinder or tubing, by definition, the implant is infected. Observation is not recommended. The only reasonable options are removal (with placement of a new implant at a later time) or replacement with the generous use antibiotics and a “washout” technique involving the use of irrigation at the time of surgery.

When A Penile Implant Revision May Not Be Practical

Although rare, we have seen men who have had disastrous complications of penile implant surgery by their local General Urologists. One example would be a man how underwent a placement of a penile implant with simultaneous incision of a plaque causing curvature. This incision did not happen after elevation of sensitive blood vessels to the head of the penis (called dorsal arteries) and the patient then developed gangrene to the head of the penis with eventual partial penile amputation. Another patient developed severe infection that was not aggressively managed, and there was loss of the majority of the penile shaft tissue. These are rare events which should not discourage men with erectile dysfunction from pursuing penile implant surgery. It is true with any technically challenging surgery in any area of medicine that expertise is generally associated with a lower complication rate and the prevention of certain complications that are the result of negligence.

Video: Patient Experience

Mr. K. R. developed priapism and required an emergency shunt procedure. He then developed erectile dysfunction managed with a malleable implant that eroded (the above picture is not Mr. K.R.) and this was removed. As a consequence of his priapism and implant removal, he had severe scarring. After seeing 10 Urologists through his HMO who were unable to perform placement of a new implant because of the severe penile scarring, he was referred to Dr. Gelman. This video is Mr. K.R.’s account of his experience.

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Video of a patient with erectile dysfunction who received treatment at the Center for Reconstructive Urology.