The secret of success. Interview with the major Urologist implanter in Italy
Antonini what is a penile prosthesis?It is an endocavernous device made up of two cylinders that are inserted into the two natural cylinders of the penis: the “corpora cavernosa”. It can be non-hydraulic (malleable) and hydraulic (three-component). The first is the simplest, consisting of two cylinders of constant consistency which produce an erection of sufficient rigidity for penetration, but such as to allow the penis to be flexed to be placed in the briefs. It represents the model of first choice in cases where there are limitations in the patient’s manual ability. The hydraulic models instead consist of two inflatable cylinders, a control device inside the scrotum and a liquid tank positioned near the bladder. A closed circuit system is created, where the liquid is transferred to the two cylinders to obtain erection and, again manually controlled, is transferred back to the tank to obtain flaccidity. The hydraulic prosthesis allows you to obtain an erection with a consistency and appearance that is indistinguishable from a natural erection. The hydraulic models therefore allow, on command, erections of excellent rigidity, with the same sensitivity as before the operation, and with the same capacity for ejaculation and orgasm, all without noticing anything from the outside, in fact all the elements of the prosthesis are inside the body. The great advantage of hydraulic prostheses is that they have penile rigidity only during sexual activity, allowing the erection to be hidden in other moments of relationship life.
What is the indication for implanting a penile prosthesis?
The implantation of a penile prosthesis is indicated in all forms of erectile dysfunction that do not respond to other therapeutic measures or in cases in which pharmacological treatments are contraindicated or have led to the appearance of important side effects. A penile prosthesis is the best surgical option for treating men with erectile dysfunction. Some consider it a “last resort” for men suffering from impotence. I don’t agree. A penile implant can be performed in any patient suffering from organic Erectile Dysfunction (ED). Most of these problems fail to resolve spontaneously with non-surgical treatments. Postponing an implant means having a significant and irreversible shortening of the penis caused by poor oxygenation of the corpora cavernosa. This is even more serious in patients suffering from induratio penis plastica, a pathological condition which causes deformity and severe curvature of the penis.
Howis it possible to know the centers that carry out this surgery in Italy?
Finally in Italy thanks to the SIA Società Italiana di Andrologia the Italian register of penile prosthetic implantology began in January 2015. The aim is to disseminate correct information to the public by offering a list of facilities and implant surgeons who can be contacted for a specialist consultation. It is a fundamental tool for understanding how many penile prosthesis implants are carried out in Italy, interacting with institutions to communicate what the real needs are in the area and above all which surgeons are most qualified to carry out this surgery.
Is it true that he is one of the surgeons who implants the most penile prostheses in Italy?
Yes, it’s true. I have dedicated myself completely to this surgery and over time I have tried to ultra-specialize in this sector trying to achieve very high quality standards in terms of results.
Is it true that you perform minimally invasive surgery for this procedure?
The technique I used, defined as the Minimally invasive penile prosthesis implant, has the characteristic of being minimally invasive and therefore revolutionary: I learned and developed it after a long period of training in the United States, where I collaborated with the most important American urological surgeon in the sector, Professor Paul Peritoof Coral Gables Hospital in Florida. I use it especially in patients operated on for prostate cancer and in those suffering from diabetes and induratio penisplasta. The innovation lies entirely in the technique used to position the implant: an infrapubic incision of just 2 cm is made at the base of the penis for the implantation of the hydraulic penile prosthesis. The operation lasts about twenty minutes, compared to 50 minutes for the traditional one, for the benefit of post-operative pain, which is almost non-existent, and the risk of infections which decreases considerably and is close to zero percent. Previously, the surgical incision was made between the penis and the scrotum, resulting in far greater post-operative discomfort and the patient’s ability to activate the system only after a month. Now with this new approach the times have been significantly shortened and the system can be activated just 7 days after the operation, and the resumption of sexual activity begins a month later.
https://antoniniurology.com/procedure/mini-invasive-plant/
What is the difference between a surgical approach and a minimally invasive technique?
The minimally invasive technique should not be confused with the surgical approach. It’s one thing to make a more or less large cut, it’s another thing to have codified “technical” maneuvers that few people in the world know and which make implanting the prosthesis extremely easy without the risk of creating bleeding and therefore hematomas, a true source of infection of the device.
In this type of operation you work in a small space and only a perfect knowledge of the anatomy and the maneuvers to be carried out allows for an excellent result.
What are the real objectives of this technique?
This surgery has two final objectives: the aesthetic one and the functional one. If one of the two is missing it means that a good job has not been done. Furthermore, the possible infection of the prosthesis makes everything much more complex. I would like to list the real advantages of this technique. The intervention must be rapid. The less time you take, the less chance you have of the denture becoming infected. If you are not, the risks increase significantly. At that point you are forced to remove the prosthesis and plan a reimplantation every few months. The incisions in the cavernous bodies of the penis must be minimal to avoid blood leaking from them after having closed them, which can cause hematomas, a real source of infection. The dilation of the cavernous bodies, if possible, must be minimal to preserve as much erectile tissue as possible and not give the patient the sensation of a “cold penis”. Cutting the skin in the infrapubic region avoids cutting the scrotum. The scrotal tissue, in fact, with its muscular bands, is easily bleeding due to the presence of numerous vessels and therefore develops hematomas more easily. Furthermore, it is much more subject to infections than the pubic region and cutting it means creating pain for the patient who can only manage it after 20/30 days. As evidence of this, my work was recently published in the prestigious journal International Journal of Impotence Research with the results, in terms of effectiveness of the procedure and satisfaction of the patients. Today, thanks to technological development, there are prostheses that provide an increase in expansion in width and length over time. The quicker their activation, the more likely they are to work better and to counteract the formation of the pseudo-capsule or internal scar of the corpora cavernosa which shortens their length. Incising in the infrapubic region allows for better implantation of the prosthesis balloon in the para-vesical region. About a year ago, the ectopic implantation of the reservoir that feeds the prosthesis in patients who have had previous abdominal and pelvic surgery (removal of the prostate for cancer) was approved by the FDA (Food and Drug Administration) in the United States. With the cut on the scrotum it is really complicated, if not impossible, to implant it in this way. The infrapubic approach is therefore essential if you want to implant it above the transversalis fascia in an ectopic position.
In summary, the minimally invasive technique can be summarized in six key points:
- absence of hematomas
- infections close to 0%
- possibility of better implanting the reservoir
- little post-operative pain
- rapid activation of the prosthesis
- reduction of penile shortening
After having carried out and codified many hydraulic implants perfectly with the peno-scrotal surgical technique, it was truly complex to radically change the surgical approach but I am firmly convinced that I did well and that the future of penile prosthetic implantology is the mini-invasive infrapubic access. We are in the era of robotic surgery. Fortunately, medicine is making giant strides. I believe that continuous professional development and seeing where the medical world is going is essential to have the best result in the interests of patients. In addition to this, together with a targeted staff, we have created a reception service completely dedicated to the patient which includes not only the simple logistical organization in the preparation phases for the operation and the entire post-operative period, but also real emotional support (https://antoniniurology.com/informazioni-contatti-antonini/ welcomed/). These are men who every day have to live with the dominant imbalance between an apparently unsolvable deficit in such an important function of their body, and being animated by an unchanged thirst to still want to experience that extraordinary pleasure of life that is sex. A devastating imbalance, which in most cases becomes the viaticum that slowly leads, almost without realizing it, to falling ill with that dark evil that is depression. And it is precisely these men “without pleasure in today and without passion for tomorrow” that we turn to. Any type of surgical intervention is characterized by great psychological stress. We know this well and this is why we intervene by emotionally preparing the patient, giving him the courage to face a surgical procedure in such a delicate and private anatomical part. In addition to a psychotherapist who more scientifically evaluates the patient’s motivations, we provide real support with the contribution of other former patients who have already experienced the same situation and are available to talk about their experience and show the result of the prosthetic implant. This gives great courage and strengthens their conviction. We do this for each of them, taking care of them, welcoming and understanding their needs. I believe this is precisely the secret of success. Put the patient at ease, make him feel understood in his “drama” of an incomplete man and make him reborn. Yes, for us the day of the prosthetic implant is the day of the patient’s rebirth.
MedicItalia interviews Dr. Antonini
© Antoniniurology
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Sexual Function/Infertility
(*.pdf) Impact of Surgeon Case Volume on Reoperation Rates
after Inflatable Penile Prosthesis Surgery
