madman
Super Moderator
ABSTRACT
Rationale: Penile Prosthesis Implantation (PPI) is the definitive treatment for Erectile Dysfunction not responsive to conservative management strategies. Furthermore, it is a staple of surgical treatment of severe Peyronie’s Disease (PD) and phallic reconstruction. Expert implantologists occasionally face disastrous complications of penile implant surgery which can prove to be very challenging. In this article, we present a selected number of case reports which exemplify this kind of situation and discuss management strategies while also commenting on plausible aetiologies.
Patients’ concerns: The first case describes a PPI performed in end-stage fibrotic corpora after multiple instances of implantation/explant. The second and third cases show two diametrically opposed approaches to the management of glans necrosis after PPI in post-radical cystectomy patients. The fourth case describes the history of a diabetic patient suffering from glandular, corporal, and urethral necrosis after a complicated PPI procedure. The fifth case reports the surgical treatment of a case of recurring PD due to severe scarring and shrinking of a vascular Dacron patch applied in a previous operation.
Diagnosis: Complication diagnosis in all patients was mainly clinical, intra-, and postoperative, with Penile Color Doppler Ultrasonography performed when needed in order to demonstrate penile blood flow.
Interventions: The patients underwent complex surgical procedures that addressed each specific complication. Complex penile implants with fibrosis-related complications, penile prosthesis explant with and without surgical debridement of necrotic areas, penile prosthesis explant with necrotic penile shaft, and urethral amputation with perineostomy, and complex corporoplasty with scar tissue excision and patch application with PPI were performed in the five patients.
Outcomes: Penile anatomy and erectile function with PPI was achieved in 4 out of 5 patients. 1 of 5 patient is scheduled to undergo a total phallic reconstruction procedure at the time of this writing.
Lessons: Management of disastrous complications of penile implant surgery can be very challenging even in expert hands. In-and-out knowledge of possible PPI and PD complications is required to achieve an acceptable outcome.
INTRODUCTION
Penile Prosthesis Implantation (PPI) is known to be the preferred treatment strategy for patients suffering from Erectile Dysfunction (ED) and unsuccessfully managed with conservative strategies.1 Moreover, PPI is a staple of treatment for severe Peyronie’s Disease (PD) and complex phallic reconstructive surgery,2 allowing the surgeon to perform extensive modifications of existing anatomy while remaining certain of being able to restore a functional erection. In fact, satisfaction and utilization rates for penile prosthesis are fairly high.3
*Recent advances in penile prosthesis manufacturing, materials, and implantation techniques have definitely lowered the impact of complications in most cases,4 but high-volume reference centers for PPI may happen to face peculiar clinical situations
In this article, we present a selected number of extreme complications in penile implant surgery which show that management of such cases can be challenging, even in expert hands. A case of end-stage implant surgery in severely fibrotic corpora after multiple PPI surgeries are presented, followed by two cases of glans necrosis in post-radical cystectomy patients with completely different management choices; then we describe a case of glandular, corporal, and urethral necrosis in a diabetic patient after a complicated PPI procedure, and a case of recurring PD after severe scarring due to the shrinkage of a previously applied patch in a corporoplasty procedure. We also discuss the possible etiology of these disastrous complications on a case-by-case basis and the rationale behind the treatment choices made.
Case report 1: End-stage implant surgery using a malleable penile prosthesis after multiple implants- and explant surgeries due to functional problems and prosthesis infections
Case report 2-3: Glans necrosis. A severe complication following penile prosthesis implantation in two patients with Ileal neobladder
Case report 4: Glans, corpora cavernosa, and urethral necrosis after penile implantation and grafting for Peyronie's Disease after intraoperative corpus spongiosum injury
Case report 5: Severe vascular Dacron graft retraction and scarring after surgery for Peyronie’s Disease
DISCUSSION
Extreme complications of penile prosthetics surgery are not always manageable by following a standardized approach. Caseby-case examination of risk factors and highlighting of critical events can prove essential in order to make the correct choices for achieving the best possible outcome.
CONCLUSIONS
In conclusion, we can say that management of extreme complications following PPI surgery does not always follow standardized procedures. Deep knowledge and critical analysis of pre-operative, intra-operative and post-operative factors involved in the genesis of every single complication is required to make the best out of the worst situations. It is also very important to know when to make certain decisions, as even a few hours delay, can make a difference. Complex PPI surgery remains, to this day, a field in which careful consideration of a large number of little details is the key to success in even the most challenging of procedures.
Rationale: Penile Prosthesis Implantation (PPI) is the definitive treatment for Erectile Dysfunction not responsive to conservative management strategies. Furthermore, it is a staple of surgical treatment of severe Peyronie’s Disease (PD) and phallic reconstruction. Expert implantologists occasionally face disastrous complications of penile implant surgery which can prove to be very challenging. In this article, we present a selected number of case reports which exemplify this kind of situation and discuss management strategies while also commenting on plausible aetiologies.
Patients’ concerns: The first case describes a PPI performed in end-stage fibrotic corpora after multiple instances of implantation/explant. The second and third cases show two diametrically opposed approaches to the management of glans necrosis after PPI in post-radical cystectomy patients. The fourth case describes the history of a diabetic patient suffering from glandular, corporal, and urethral necrosis after a complicated PPI procedure. The fifth case reports the surgical treatment of a case of recurring PD due to severe scarring and shrinking of a vascular Dacron patch applied in a previous operation.
Diagnosis: Complication diagnosis in all patients was mainly clinical, intra-, and postoperative, with Penile Color Doppler Ultrasonography performed when needed in order to demonstrate penile blood flow.
Interventions: The patients underwent complex surgical procedures that addressed each specific complication. Complex penile implants with fibrosis-related complications, penile prosthesis explant with and without surgical debridement of necrotic areas, penile prosthesis explant with necrotic penile shaft, and urethral amputation with perineostomy, and complex corporoplasty with scar tissue excision and patch application with PPI were performed in the five patients.
Outcomes: Penile anatomy and erectile function with PPI was achieved in 4 out of 5 patients. 1 of 5 patient is scheduled to undergo a total phallic reconstruction procedure at the time of this writing.
Lessons: Management of disastrous complications of penile implant surgery can be very challenging even in expert hands. In-and-out knowledge of possible PPI and PD complications is required to achieve an acceptable outcome.
INTRODUCTION
Penile Prosthesis Implantation (PPI) is known to be the preferred treatment strategy for patients suffering from Erectile Dysfunction (ED) and unsuccessfully managed with conservative strategies.1 Moreover, PPI is a staple of treatment for severe Peyronie’s Disease (PD) and complex phallic reconstructive surgery,2 allowing the surgeon to perform extensive modifications of existing anatomy while remaining certain of being able to restore a functional erection. In fact, satisfaction and utilization rates for penile prosthesis are fairly high.3
*Recent advances in penile prosthesis manufacturing, materials, and implantation techniques have definitely lowered the impact of complications in most cases,4 but high-volume reference centers for PPI may happen to face peculiar clinical situations
In this article, we present a selected number of extreme complications in penile implant surgery which show that management of such cases can be challenging, even in expert hands. A case of end-stage implant surgery in severely fibrotic corpora after multiple PPI surgeries are presented, followed by two cases of glans necrosis in post-radical cystectomy patients with completely different management choices; then we describe a case of glandular, corporal, and urethral necrosis in a diabetic patient after a complicated PPI procedure, and a case of recurring PD after severe scarring due to the shrinkage of a previously applied patch in a corporoplasty procedure. We also discuss the possible etiology of these disastrous complications on a case-by-case basis and the rationale behind the treatment choices made.
Case report 1: End-stage implant surgery using a malleable penile prosthesis after multiple implants- and explant surgeries due to functional problems and prosthesis infections
Case report 2-3: Glans necrosis. A severe complication following penile prosthesis implantation in two patients with Ileal neobladder
Case report 4: Glans, corpora cavernosa, and urethral necrosis after penile implantation and grafting for Peyronie's Disease after intraoperative corpus spongiosum injury
Case report 5: Severe vascular Dacron graft retraction and scarring after surgery for Peyronie’s Disease
DISCUSSION
Extreme complications of penile prosthetics surgery are not always manageable by following a standardized approach. Caseby-case examination of risk factors and highlighting of critical events can prove essential in order to make the correct choices for achieving the best possible outcome.
CONCLUSIONS
In conclusion, we can say that management of extreme complications following PPI surgery does not always follow standardized procedures. Deep knowledge and critical analysis of pre-operative, intra-operative and post-operative factors involved in the genesis of every single complication is required to make the best out of the worst situations. It is also very important to know when to make certain decisions, as even a few hours delay, can make a difference. Complex PPI surgery remains, to this day, a field in which careful consideration of a large number of little details is the key to success in even the most challenging of procedures.
