Indications

• Erectile dysfunction that cannot be managed medically

Types of implants

• Non-inflatable = malleable = semi-rigid - flexible cylinder in each corpora
• Requires less dexterity to operate
• 2-piece inflatable - 2 cylinders + pump in scrotum
• "break/bend" the penis to deflate the cylinders
• 3-piece inflatable - 2 cylinders + pump in scrotum + reservoir in retropubic space
• Permits more fluid transfer, better rigidity for larger phallus
• Difficult to place reservoir if fibrotic e.g. cystectomy, pelvic radiation
• Different brands Coloplast vs. AMS - usually provider/institute preference? should check to see if there is a difference in outcomes

Approaches to implantation

• Infrapubic approach
• Risks damage to dorsal penile nerves (which provide tactile sensation) during corporotomy
• Pudendal n. → dorsal penile nerves → inferior margin of inferior pubis ramus → dorsal-medial corpora → dorsal penis to glans
• Penoscrotal approach
• Avoids dorsal nerves, but reservoir is "blindly" placed trans-inguinally

• Complications
• corporal crossover during corporal dilation (but can still continue)
• Distal corporal perf into urethra - if contralateral corpora already dilated then place a malleable to prevent fibrosis until redo after urethral repair/diversion, or abandon
• Proximal corporal perf at crus - can continue and repair perf
• Post-op complications
• Penile shortening, Infection (2-3%; staph), device malfunction (5% at 5 years), autoinflation (rare with reservoir lockout valve), glans bowing (Concorde deformity - cylinders are too short and glans droops), buckling (cylinders too long), cold glans (ED still has poor blood flow to glans), erosion (requires explant)

Pre-op abx: Ancef + gentamicin (for prosthesis)

Eisenberg

• Supine and frog legged, pillow under knees/feet and taped down
• Shave with special razor
• Pudendal block before prepping (also injects lido/marcaine into the corpora during the surgery)
• Chloraprep
• Penoscrotal incision
• Kefzol irrigation for instruments and rifampin/gent soak for prosthesis

Surgical steps

1. Make transverse incision at penoscrotal junction
2. Place Foley to identify urethra
3. Identify corporal bodies lateral to urethra
4. Place two stay stitches in corpora on each side; these are used to close the corporotomy later
5. Make corporotomy vertically (~ 1.5 cm)
6. Insert dilators proximally (to the crus/pubic ramus) and distally (to the glans). Dilate up to 14 mm.
1. Avoid proximal perforation by not forcing dilator against pubic ramus
7. Measure appropriate length (two sides should be within 1 cm of each other)
8. Prepare prosthesis
1. Cycle sterile saline through reservoir/rods/pump to expel air, then remove air and clamp tubing with rubber shod mosquitoes
2. Keep tubing clamped at all times to avoid introducing air
9. Orient prosthesis appropriately. Load strings at end of rod into Keith needle and load into Furlow inserter
10. Insert Furlow distally towards glans, then advance Keith needle and pull out the strings
1. Aim laterally to prevent urethral perforation
11. Insert proximal end of rod into corpora, using "shoehorn" or Debakey
12. Repeat on other side
13. Place reservoir
1. Deflate bladder
2. Find retropubic space for reservoir- finger dissect plane above pubic ramus just lateral to symphysis to identify external inguinal ring. Then puncture through floor (transversalis fascia) to reach retropubic space.
1. If space not easily identifiable or is dangerous, stay above the transversalis and place reservoir under abdominal muscles
1. Place deflated reservoir, then fill (~60 cc)
1. Coloplast 'one size fits all' reservoir is 110cc
14. Place pump
1. Eisenberg makes space in scrotum and places balled up Raytec to develop space. Place pump and then tunnel tubing through some Dartos
15. Connect rods and reservoir using connectors and crimping tool