Revision and exchange of prosthesis with insertion of second cylinder in patient with severe corporal fibrosis

VJPU 2016; 2: 088

Giulio Garaffa1, Marco Capece2, Giovanni Chiriaco3, Giovanni Liguori3, Carlo Trombetta3, David J Ralph1

1: The Institute of Urology, UCLH, England
2: University of Napoli, Italy
3: University of Trieste, Italy

Introduction: Surgeons can rely on a variety of tricks to drill a channel in the severely fibrotic corpora cavernosa and to minimize the risk of cross over, tunical and urethral perforation and incomplete distal dilation.

Case presentationThis is the case of a 62 year-old type I diabetic patient who had previously undergone simultaneous implantation of a 3-pieces inflatable penile prosthesis (3p) and plaque incision and grafting to correct a 90 degrees dorsal curvature secondary to Peyronie’s Disease (PD) and end stage erectile dysfunction.

The implant was eventually removed for acute infection and at the subsequent, delayed attempt of reimplantation, only one 1 cylinder was inserted due to the severe corporeal scarring.
The present video shows the revision and exchange of the single cylinder with 2 cylinders to guarantee a better cosmetic and functional outcome.

Protocol: Once adequate exposure of the corpora has been achieved though a penoscrotal and subcoronal incision with reverse degloving of the penile skin, the old cylinder and pump are removed and a mini-salvage washout performed to minimize the risk of infection. Dilation of the contralateral corpus cavernosum is carried out under direct vision with the aid of a distal corporotomy to ensure that an adequate channel is created up to the corporeal tip well away from the midline in order to minimize the risk of urethral injury. Scarred corporeal tissue is excised at the level of the corporotomies to allow for a primary closure of the tunica albuginea over the implant without the need to interpose a graft.

Outcome: Postoperative time has been uneventful. Eight months postoperatively the patient is able to cycle the device correctly and to engage in penetrative sexual intercourse. He is fully satisfied with the outcome of surgery.

Discussion: Penile prosthesis implantation can be extremely challenging in case of severe corporeal fibrosis. However, complications such as incomplete dilation, cross over, tunical perforation and urethral injury can be minimized if the channel is carried out under direct vision and, if necessary, performing multiple small corporotomies to direct the dilators in the right direction. These tricks as well as the availability of cavernotomes and of narrow base cylinders can be extremely useful for the surgeon. When possible, the use of grafts should be avoided in order to reduce the risk of infection. Patients need to be aware that with regular cycling, the device can act as a tissue expander and therefore upsizing of the cylinders at a later stage is simple and almost always possible.