Douglas F. Milam M.D.
Urologic Surgery
Penile Implant Placement
Placement of a penile implant is an option for many men with severe erectile dysfunction who do not respond to medical therapy (pills). We have extensive experience with both initial penile implant placement and also revision surgery. Indeed, revision surgery, post-priapism implantation, and implantation following earlier implant loss due to erosion or infection are areas of our special interest.
Most patients in our practice have tried and failed all the medications (pills) and most also either know about or have failed a vacuum device or a self injection program.
We extensively use what are termed validated patient questionnaires in our practice to evaluate baseline pre-operative symptoms and to assess patient outcomes from surgery. When you are seen in the office we will ask you to complete the erectile function questionnaire. The results of the erectile function questionnaire often guide the choice of treatment options.
Like most surgical procedures, a penile implant is not a perfect solution. An implant does not make a man 20 years old again. What it does do, however, is produce a reliable erection that should allow a man to have normal intercourse. Patient and partner satisfaction has been documented in large published surveys to be in the 90 percent range. We will discuss the pros and cons and realistic expectations of penile implant surgery at your consultation. Until then, we would refer you to the Penile Prosthesis Information Form developed by the Sexual Medicine Society of North America. For more information about the mechanism of erection and how a penile implant mimics the natural process click here.
Placement of a penile implant usually involves an overnight surgical stay, though some selected procedures are performed as an outpatient at the Cool Springs Surgical Center. Procedures performed as an overnight stay will be performed in the Main Operating Room Complex at Vanderbilt Hospital. Check-in at admissions is on the first floor at the main entrance. Detailed instructions about where to go and a detailed description of the overnight surgical stay can be obtained here.
In the holding room you will be given an intravenous antibiotic immediately before going back to the operating room. This is one of many steps that we do to minimize the risk of implant infection. When your operation is complete you will be in the recovery room for about 1.5 hours. Dr. Milam will speak to any family member(s) waiting in the surgical waiting room. We leave long acting injectable pain medication under the incision closure. This substantially decreases the amount of post-operative pain our patients experience. You will be watched by the nursing staff overnight. Early in the morning one of our team members will check on you. The overwhelming portion of patients are ready to go home by 7 or 8am on the morning following surgery. Travelling in a car is fine as long as you are not the driver. For those travelling long distances, we recommend stopping the car and briefly walking every 2 hours. After arriving at home it is important to generally be off your feet. Detailed post-op instructions can be reviewed here.
We would be happy to see you for a consultation. Please click here for information on how to schedule an appointment.
Penile Implant Placement Surgery
A large portion of our penile implant procedures are performed through an infrapubic incision. This is a horizontal incision about 1 centimeter above the penis which is slightly wider than the width of the penis. We also utilize the penoscrotal incision for some individuals.
Once the incision is opened, the underlying fascia over the abdominal muscles is exposed. A small vertical incision is then made in the fascia seperating the abdominal wall muscles, The penile prosthesis reservoir is placed in the space underlying the muscle.
Each corporal body is secured between two sutures. This allows us to make a longitudinal incision between the sutures through which the implant cylinders are placed.
The insertion passer is introduced into the open corporal body. In this case the distal corporal measurement is 8.5 cm. We measure and add the distal and proximal measurements of each corporal body to determine the proper length cylinder to implant. Penile implant cylinders come in several standard lengths. We add rear tip extenders (shown in white at the end of this series of photographs) to the back of the implant to custom fit the device to the measured corporal length. It is important not to oversize the device as that can cause deformities.
Inside the corporal bodies is usually a soft spongy trabecular tissue. That is often not the case when operating on patients that have experienced priapism or loss of a prior implant. Those patients often have dense scar within the corporal bodies which can make it difficult to make a space for the implant cylinders. This photo shows the use of cavertomes which have a rasp like surface to cut and dilate scar tissue.
The penile prosthesis has to be carefully filled with normal saline. The process is done in such a way to remove all air from the system.
Modern multicomponent implants usually require only one tubing connection. Ironically, though, when an implant fails it is rarely caused by failure of the connection made in surgery. Note the plastic drape stuck to the skin above the incision. This is to prevent the device from contacting the skin during the implant procedure.
The incision is closed in multiple layers. This is to deeply bury the implant components and to minimize the chance of an implant infection if the patient would develop a superficial skin infection.
Photograph Courtesy of American Medical Systems Corporation
The AMS-700 inflatable penile prosthesis is shown above. There are three versions of this device, LGX, CX, and CXR. From the vantage point of this photo, all three devices look identical. The yellow color of the device is from an antibiotic coating of rifampin and minocycline. Antibiotic coating has reduced the rate of post-implantation infection by about one-half. The white portions of the cylinder are the adjustable rear tip extenders which are snapped on to standard cylinder sizes to custom fit the device to the individual.
Each device, including the AMS-700 shown above, the Coloplast Titan and the AMS-Ambicore shown below, have relative advantages in certain circumstances. We are happy to speak with you about device choice at your appointment.
Photo Courtesy of Coloplast Corporation
Coloplast Titan inflatable penile prosthesis is shown above. This device incorporates a hydrophylic coating which is soaked in antibiotic solution immediately before implantation. Like the AMS-700, the device incorporates a lock out valve to prevent autoinflation and a one touch deflation mechanism.
AMS-Ambicore "Two Piece" inflatable penile prosthesis shown with four different sizes of rear tip extenders. This device does not have a seperate reservoir. There is an internal reservoir located between the white rear tip extender and the tubing take off.
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