Infection in penile prosthesis implantation is a significant complication, because the entire device often needs to be removed before the infection can be eradicated.
The salvage procedure described by Mulcahy has changed the way that infected prostheses are handled but the procedure cannot always be performed. When penile prosthesis implantation is attempted after previous explantation of an infected device, cylinder implantation is often very difficult due to significant intracorporeal fibrosis. This clinical situation is also often found in erectile dysfunction after priapism.
A new technique of corporeal excavation to deal with this difficult problem has been recently described by Montague and Angermeier from the Cleveland Clinic. The report is published in the May 2006 issue of Urology. The surgical technique which was performed in 9 men is described in detail. The cause of corporal fibrosis was priapism in 4, removal of an infected prosthesis in 4, and diabetes mellitus with renal transplantation in 1. Three piece inflatable prostheses were implanted in all men.
The technique involves a transverse penoscrotal incision that is extended in an inverted T fashion to the frenulum. Long corporotomies are made on each side and horizontal mattress sutures are used for retraction over a ring retractor. The essence of the procedure is the removal of a core of fibrotic tissue that is present in the corpora that inhibits dilation. The core is dissected sharply from the undersurface of the tunica albuginea and removed as a long core of tissue. Once the correct plane of dissection has been established, a penrose drain is used to retract the core and the dissection is extended both proximally and distally. The mean length of the fibrotic core removed was 5.2 cm- the remainder of the corporal length was dilated in the standard fashion. The corpora are then measured and the implant placed in the standard fashion.
Analysis of the results showed that all men had functioning prostheses at their last follow-up visit which was a mean of 44 months post-operatively. One man required cylinder replacement after 46 months due to mechanical failure. Seven of the 9 men had corpora which would not accept the standard 12 mm implant and were given a 10 mm narrow AMS CXM implant. The authors warn that the men should be counseled that the procedure will not lead to an increase in penile length and that the stretched flaccid penile length pre-operatively is what should be expected in the erect state post-operatively.
By Michael J. Metro, MD
Urology. 2006 May; 67(5):1072-75
Montague DK, Angermeier KW
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