Penile Prosthesis
Penile prosthesis implantation is recommended for all forms of erectile dysfunction that do not respond to other therapeutic measures or in cases where drug treatments are contraindicated or have caused significant 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. We disagree. A penile implant can be performed on any patient suffering from organic erectile dysfunction (ED). Most of these problems cannot be resolved spontaneously with non-surgical treatments. Delaying 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 with induratio penis plastica.
Prostheses can be non-hydraulic (malleable) or hydraulic (three-component). They consist of two cylinders that are inserted into the two natural cylinders of the penis: the ‘corpora cavernosa’. The former are the simplest: they consist of two cylinders of constant consistency that produce an erection of sufficient rigidity for penetration, but such as to allow the penis to be bent so that it can be placed in the underwear. They are therefore the model of choice in cases where there are limitations in the patient’s manual dexterity or problems related to the cost of the implant. However, while the rigidity given to the penis allows penetration, the permanent turgidity of the shaft makes the device difficult to conceal under tight-fitting clothing. Patients who are used to playing sports may be forced to make significant lifestyle changes. In addition, the high pressure on the cavernous tissues can reduce their trophism and consequently increase the likelihood of perforation and extrusion of the prosthesis. These prostheses are therefore only indicated in cases where the patient has limited manual dexterity or where cost containment is mandatory.
Hydraulic models, on the other hand, consist of two cylinders, an internal control device in the scrotum and a fluid reservoir located near the bladder. This creates a closed-loop system, where the fluid is transferred to the two cylinders.
to achieve an erection and, again manually, is transferred back to the reservoir to achieve flaccidity. The hydraulic prosthesis allows for an erection that is indistinguishable from a natural erection in terms of consistency and appearance. 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 any external signs, as all the elements of the prosthesis are inside the body. The great advantage of hydraulic prostheses is that they only provide penile rigidity during sexual activity, allowing the erection to be concealed at other times in the patient’s life.
In most cases, therefore, the choice of prosthesis should fall on a hydraulic device, in order to make the erection and flaccid state as similar as possible to natural ones. In the national healthcare system, however, there is a clear bias in the choice due to the different costs that public facilities have to bear depending on the type of prosthesis used. The selection of patients who are candidates for prosthetic implants must, in most cases, be based on exclusion criteria. In other words, patients suffering from predominantly organic erectile dysfunction are eligible for a prosthetic implant if less invasive therapeutic measures, mainly oral therapy and intracavernous injection of vasoactive drugs, are impractical, ineffective or unacceptable.
In some cases, however, surgical prosthetic treatment may be preferable in cases of severe curvature secondary to Induratio Penis Plastica, where the reduced size of the penis and/or the coexistence of pre-operative erectile dysfunction make conservative surgery based on simple straightening or excision of the plaque and grafting of autologous or heterologous replacement material impractical. Less frequent is the case in which, despite normal responsiveness to drug treatments, the patient himself requests a prosthetic implant as the treatment of choice. In this case, as in all prosthetic surgery, correct preoperative information is particularly important.
The stages of the surgical procedure include skin incision, exposure of the corpora cavernosa, selection and positioning of the prosthesis components, and filling and emptying of the prosthesis in the case of a hydraulic prosthesis. The operation is usually performed under local anaesthesia and involves the placement of two expandable cylinders in the corpora cavernosa of the penis, a reservoir in the paravesical space and a pump in the scrotum. The three components are connected by thin connecting tubes that run subcutaneously. The most significant complication is infection, which generally requires re-operation to remove the prosthesis.
The mechanical reliability and technical characteristics of the models currently on the market guarantee excellent results in terms of aesthetics and functionality; however, certain precautions are necessary to avoid cases of dissatisfaction after technically flawless procedures. The pre-operative consultation regarding the patient’s expectations, surgical results and aspects of post-implantation sexuality allows the most appropriate prosthesis to be chosen. In cases where the selection and information are provided correctly, the results in terms of the patient’s sexual rehabilitation and favourable repercussions on the couple are extremely flattering. The patient must be made aware of the irreversibility of the surgical procedure and the risks specifically associated with it. The latter, with mechanical problems having been reduced to a minimum, mainly consist of infection of the prosthesis, with higher values in risk categories due to poor immune reactivity, such as diabetics, nephropathic patients, and immunocompromised patients. Proper preoperative information should take into account some fundamental elements:
The size of the penis, when erect and flaccid, may differ from the preoperative size, and this is more likely to occur in the long term when malleable prostheses are used.
Cases of prosthesis infection have been reported, resulting in the need for removal and delayed reimplantation (at least six months later).
As with any surgical procedure, infection is a possibility. Our infection rate is always less than 1%. This percentage may be higher if there is spinal cord injury or diabetes. Men who require surgery to revise or replace an implant are at higher risk of infection than they were with the first surgery. The risks of infection can be significantly reduced when the patient strictly follows the instructions provided before and after surgery. Infections are treated with immediate removal of the prosthesis.
The prosthetic implant does not directly affect desire levels or orgasm intensity.
Difficulties in reaching orgasm may persist shortly after surgery; in this case, the patient should be encouraged to increase the frequency of intercourse and the duration of foreplay. Similarly, the use of the prosthesis will not automatically improve one’s relationship skills, although it plays a decisive role in restoring self-esteem, nor will it resolve conflicts within the couple that have arisen due to erectile dysfunction. When the penis is erect, the prosthesis makes the penis rigid, similar to a natural erection. A penile prosthesis does not change the sensitivity of the penis or a man’s ability to reach orgasm. Ejaculation is not affected.
Sometimes patients report a loss of penis length. The loss of length is not due to the positioning of the penile prosthesis. In fact, the positioning of the implant stops the process of atrophy and fibrosis; proper rehabilitation with a vacuum device can allow the patient to recover a few centimetres of lost length.
‘I can feel the tubes around my cylinders.’ We do everything possible to hide the tubes, but some anatomies require the cylinders to be implanted where the tubes can be felt under the skin.
‘The head of the penis is not hard.’
This can happen. The implant does not cause swelling of the glans. Our surgical technique limits the possibility of a flaccid penis. Viagra and/or intraurethral creams can be used to treat this problem.
What is life like with an inflatable penile prosthesis?
No physical activity or sport will be precluded after the implant of the prosthesis. Once healed, our patients will have a normal active lifestyle, if they so desire.
How effective are the implants?
Approximately 90%–95% of inflatable prosthesis implants produce erections suitable for intercourse. Satisfaction rates with the prosthesis are very high, and typically 80%–90% of men are satisfied with the results and would choose to have the surgery again.
It should be emphasised that penile prosthesis implantation surgery must be performed by specialists dedicated to the medical field of andrology, and in suitable facilities.
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