Three-component Hydraulic Penile Prosthesis Implant

grafica_Tecnica-mini-invasiva-antoniniurology-2021

Minimally invasive surgical technique, with infrapubic access

Using the minimally invasive technique, we are able to implant all components of the three-piece hydraulic prosthesis through a 2 cm incision at the base of the penis.

The procedure can be safely performed under general, spinal, or local anesthesia in less than 15 minutes.

Patients can usually resume sexual activity within 4 to 6 weeks.

Description of the Technique

After performing trichotomy strictly in the operating room, the skin is cleansed and disinfected for 10 minutes with a povidone-iodine solution, and cefazolin is administered intravenously. The first step is the induction of an artificial hydraulic erection by injecting 0.9% saline solution into the corpora cavernosa.

This maneuver allows identification of any conditions requiring correction (e.g., penile curvature or “hourglass” deformities); in addition, it promotes dilation of the corpora cavernosa and facilitates both the identification of the dorsal nerve and the lateral placement of the sutures alongside it.

1) Three-component hydraulic penile prosthesis implantation

2) Access is gained through a 2.5 cm incision in the skin above the pubic bone.

3) Using a blunt finger, the Colles band is opened and the corpora cavernosa are isolated bilaterally.

4) Four suspension points are placed on the corpora cavernosa, two on each side, using 2/0 polyglycolic acid, which will later be used to close the corporotomies.

5) Four suspension points are placed on the corpora cavernosa, two on each side, using 2/0 polyglycolic acid, which will later be used to close the corporotomies.

6) Four suspension points are placed on the corpora cavernosa, two on each side, using 2/0 polyglycolic acid, which will later be used to close the corporotomies.

7) Four suspension points are placed on the corpora cavernosa, two on each side, using 2/0 polyglycolic acid sutures, which will later be used to close the corporotomies.

8) At this point, two minimal bilateral corporotomies of 1.5 centimetres each are performed to allow the prosthetic cylinders to pass through.

9) At this point, two minimal bilateral corporotomies of 1.5 centimetres each are performed to allow the prosthetic cylinders to pass through.

10) Using only the Furlow introducer to maintain the residual erectile tissue, the corpora cavernosa

11) Using only the Furlow introducer to maintain the residual erectile tissue, the corpora cavernosa

12) They are dilated and measured proximally and distally.

13) They are dilated and measured proximally and distally.

14) Using an 8 cm nasal speculum, create paravesical space for the flat reservoir (Conceal filled with 100 ml of saline solution), posterior to the transversalis fascia, proceeding from top to bottom through the external inguinal ring, which is perforated.

15) Using an 8 cm nasal speculum, create paravesical space for the flat reservoir (Conceal filled with 100 ml of saline solution), posterior to the transversalis fascia, proceeding from top to bottom through the external inguinal ring, which is perforated.

16) Using an 8 cm nasal speculum, we create the paravesical space for the flat reservoir (Conceal filled with 100 ml of physiological solution), posterior to the transversalis fascia, proceeding from top to bottom through the external inguinal ring, which is perforated.

17) Using an 8 cm nasal speculum, create paravesical space for the flat reservoir (Conceal filled with 100 ml of saline solution), posterior to the transversalis fascia, proceeding from top to bottom through the external inguinal ring, which is perforated.

18) The prosthetic cylinders are then implanted and a hydraulic test is carried out to verify their correct functioning and positioning.

19) The prosthetic cylinders are then implanted and a hydraulic test is carried out to verify their correct functioning and positioning.

20) The prosthetic cylinders are then implanted and a hydraulic test is carried out to verify their correct functioning and positioning.

21) The prosthetic cylinders are then implanted and a hydraulic test is carried out to verify their correct functioning and positioning.

22) The prosthetic cylinders are then implanted and a hydraulic test is carried out to verify their correct functioning and positioning.

23) The prosthetic cylinders are then implanted and a hydraulic test is carried out to verify their correct functioning and positioning.

24) Close the corporotomies bilaterally with the previously placed suspension sutures.

25) Close the corporotomies bilaterally with the previously placed suspension sutures.

26) Once again, the nasal speculum is used to develop a ‘subdartocidal pouch’ in a portion of the scrotum to house the hydraulic system's activating pump.

27) Once again, the nasal speculum is used to develop a ‘subdartocidal pouch’ in a portion of the scrotum to house the hydraulic system's activation pump.

28) Once again, the nasal speculum is used to develop a ‘subdartocidal pouch’ in a portion of the scrotum to house the hydraulic system's activating pump.

29) Once again, the nasal speculum is used to develop a ‘subdartocidal pouch’ in a portion of the scrotum to house the hydraulic system's activating pump.

30) Connect the prosthetic system tubes and leave a Jackson-Pratt drain in place for approximately 24–48 hours, then close the skin with sutures.

31) Connect the prosthetic system tubes and leave a Jackson-Pratt drain in place for approximately 24–48 hours, then close the skin with sutures.

32) Connect the prosthetic system tubes and leave a Jackson-Pratt drain in place for approximately 24–48 hours, then close the skin with sutures.

The average time to complete the implant was 15 minutes, compared with 50 minutes for the penoscrotal approach, resulting in significant benefits in terms of postoperative pain — which is almost nonexistent — and a markedly reduced risk of infection. The risk is nearly zero because no bladder catheter is used, and there is no contamination from the scrotal skin, which is far more prone to bacterial colonization than the infrapubic region.

The access is so minimally invasive, both in the corporotomies and in the implantation of the activation pump, that the occurrence of hematomas and serous fluid collections is drastically reduced. Even when they occur, they are eliminated thanks to the drainage left in the scrotal pouch for about 24–48 hours postoperatively.

Finally, the infrapubic approach also allows easier and more convenient access to the external inguinal ring for placement of the reservoir, whether in a paravesical position or ectopic, above the transversalis fascia.

The reduction of discomfort during the postoperative period and the ability to handle the scrotum almost immediately allow the patient to activate the hydraulic system as early as 7 days after surgery and to resume sexual activity one month later. This latter aspect is crucial to fully exploit the potential of the new AMS LGX model. In fact, this device enables the penis to gain, over time, at least 2 cm in length and 2 cm in girth.
The earlier the activation, the lower the risk of immediate formation of a pseudocapsule in the corpora cavernosa, which could otherwise hinder this expansion.
After surgery, a single dose of gentamicin and a ten-day course of cefazolin therapy are administered.
We can conclude that this surgical technique is very fast, safe, and ensures an excellent aesthetic result, achieved with a skin incision of only 2.5 cm.

Contains descriptive photos of the surgical procedure.

Minimally invasive infrapubic – Original article

Minimally invasive infrapubic inflatable penile prosthesis implant for erectile dysfunction: evaluation of efficacy, satisfaction profile and complications.

(read more)

The Journal of Sexual Medicine – Surgical Technique

Minimally Invasive Infrapubic Inflatable Penile Implant