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Journal ArticleDOI

Penile prosthesis in the age of the blue pill.

01 Mar 2010-Acta Chirurgica Belgica (Acta Medica Belgica)-Vol. 110, Iss: 2, pp 149-152
TL;DR: The penile implant remains a marginal therapy in Belgium despite being highly effective, having a very low complications rate, a shortage of information in the field, the cost of the implant, perioperative failings or complications in the case of insufficient experience.
Abstract: In the event of proven erectile dysfunction (ED), specif ic treatment strategies are available in the following order : phosphodiesterase type 5 inhibitors (Cialis, Levitra, Viagra), intracavernous injections of vasoactive drugs and implanting a penile prosthesis. According to clinical experience, with all causes taken into considera tion, 25% of patients who suffer from ED do not respond to medical treatment. The penile implant is a highly effective alternative treatment where oral or injected drug therapy has proven unsuccessful or in cases where other medical treatments are contraindicated (1). According to our experience, the number of implant procedures performed increases by 15% each year and 35 prostheses will be implanted in 2009. Unfortunately, the penile implant remains a marginal therapy in Belgium despite being highly effective, having a very low complications rate and a satisfaction rating over 90%. Around 30 to 45,000 implant procedures are performed each year throughout the world with ten times more surgeries in the US than in Europe. In 2008, only 140 penile implants were performed in Belgium. There are an estimated 30 urologists who perform this proce dure and only two among this number perform more than 25 implant procedures per year. Therefore the majority of surgeons performing the procedure have less experience (three implants per year on average). This is not an ideal situation. As is the case in many European countries, it would appear that the low number of penile implants is a result of a lack of training and a shortage of information in the field, the cost of the implant, perioperative failings or complications in the case of insufficient experience. The medical legal risk is probably over-estimated but it does exist. The vast majority of implant models are inflatable. This advance, alongside the highly-informed support of doctors that are sensitive to ED patients and their partners’ quality of life, should make the process of deciding to get an implant more straight-forward. When is it time to consider a penile implant ?

Summary (2 min read)

Introduction

  • In the event of proven erectile dysfunction (ED), specific treatment strategies are available in the following order : phosphodiesterase type 5 inhibitors (Cialis, Levitra, Viagra), intracavernous injections of vasoactive drugs and implanting a penile prosthesis.
  • Unfortunately, the penile implant remains a marginal therapy in Belgium despite being highly effective, having a very low complications rate and a satisfaction rating over 90%.
  • Around 30 to 45,000 implant procedures are performed each year throughout the world with ten times more surgeries in the US than in Europe.
  • This advance, alongside the highly-informed support of doctors that are sensitive to ED patients and their partners’ quality of life, should make the process of deciding to get an implant more straight-forward.
  • The patient must be aware that he will no longer be able to achieve erections naturally, though they will be extremely fulfilling.

The different types of implants

  • There are basically two types of penile implant : semi-rigid implants inflatable implants Inflatable implants are composed of two or three pieces.
  • The three-piece model provides the best flaccidity.
  • New inflatable implant models enable the implant to be lengthened and the diameter to be increased with excellent flaccidity comfort levels.
  • The length of the cylinders and the size of the reservoir will be chosen during the operation after measuring the space available in the cavernous bodies.

Which surgical approach ?

  • The pre-pubic area or the penoscrotal junction are the most commonly used approaches for making a small incision.
  • All the prosthetic components (cylinders, scrotal pump and the abdominal reservoir in the case of a 3-piece implant) can all be implanted through this single incision.
  • If the patient has undergone previous pelvic surgery, a low iliac fossa approach is useful for inserting the balloon containing the saline solution.
  • The operation, which is quick in the hands of highly-trained staff, usually lasts just over one hour.

What is the cost for the patient ?

  • Patients of this surgical procedure are entitled to a very low refund on the procedure itself (K120 = 150 Euros), on the other hand in Belgium, the material has been subject to an 80% refund since 1992 with the condition that the ED has a proven vascular and/or neurological cause.
  • This means that this procedure would cost the patient 1000 Euros for a shared room.
  • Patients stay in hospital for two days following surgery.

Satisfaction with the implant

  • According to their own experience and that of several authors (2-4), a penile implant is the most effective treatment of ED and more than 90% of patients are satisfied on a lasting basis.
  • This in comparison with 50% for Sildenafil, and 40% for intracavernous injections (2).
  • Only five patients who received implants during this period have no implant today.
  • The authors patients’ satisfaction is significant : 86% would recommend the procedure to someone else, 85% would accept an analogous procedure if necessary.

Benefits of penile implants

  • Allows for greater spontaneity when initiating sexual relations .
  • Eliminates the need for costly medication with side effects or contraindications .
  • Does not interfere with ejaculation or orgasm.

Disadvantages of penile implants

  • In the case of the inflatable models, the implant could fail A penile implant may be advisable in cases where oral or intracavernous drug treatments have failed among motivated and well-informed patients.
  • The models available nowadays are very reliable and the satisfaction rate at the medium and long term is very high after a procedure with a low complication rate.

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Introduction
In the event of proven erectile dysfunction (ED), specif-
ic treatment strategies are available in the following
order : phosphodiesterase type 5 inhibitors (Cialis,
Levitra, Viagra), intracavernous injections of vasoactive
drugs and implanting a penile prosthesis. According to
clinical experience, with all causes taken into considera-
tion, 25% of patients who suffer from ED do not respond
to medical treatment. The penile implant is a highly
effective alternative treatment where oral or injected
drug therapy has proven unsuccessful or in cases where
other medical treatments are contraindicated (1).
According to our experience, the number of implant
procedures performed increases by 15% each year and
35 prostheses will be implanted in 2009. Unfortunately,
the penile implant remains a marginal therapy in
Belgium despite being highly effective, having a very
low complications rate and a satisfaction rating over
90%. Around 30 to 45,000 implant procedures are
performed each year throughout the world with ten times
more surgeries in the US than in Europe. In 2008, only
140 penile implants were performed in Belgium. There
are an estimated 30 urologists who perform this proce-
dure and only two among this number perform more than
25 implant procedures per year. Therefore the majority
of surgeons performing the procedure have less
experience (three implants per year on average). This is
not an ideal situation. As is the case in many European
countries, it would appear that the low number of penile
implants is a result of a lack of training and a shortage of
information in the field, the cost of the implant,
perioperative failings or complications in the case of
insufficient experience. The medical legal risk is
probably over-estimated but it does exist. The vast
majority of implant models are inflatable. This advance,
alongside the highly-informed support of doctors that are
sensitive to ED patients and their partners’ quality of life,
should make the process of deciding to get an implant
more straight-forward.
When is it time to consider a penile implant ?
In the beginning the arrival of Sildenafil in 1998 reduced
the number of implant procedures performed. The
number of patients requesting rehabilitation quickly
increased and the number of implant procedures per-
formed rose swiftly in the USA. Organic erectile dys-
function that has not responded to medical treatment in a
motivated patient and partner is the best indication for a
penile implant. Contraindication against other medical
treatments is also a good reason to opt for a penile
implant (treatment with nitroderivatives, etc.). If the
erectile situation is very detrimental, then the rehabilita-
tion request is often significant. Ideally, tests (vascular
and/or neurological) should show an irreversible alter-
ation of the erection processes. The main causes of ED
are vascular, linked to diabetes, following pelvic surgery
(radical prostatectomy) and neurological. Peyronie’s dis-
ease is also a cause of erectile dysfunction which resists
medical treatment. Here surgery can correct the abnor-
mal curvature (tunica albuginea graft or manual shaping
on the implant) and ED at the same time.
In patients suffering ED, physicians regularly observe
a reduction in penis size which is exacerbated in certain
situations, such as Peyronie’s disease, after radical
prostatectomy, after low-flow priapism and in paraplegic
patients. We believe that the indication for surgery
should not be proposed too late as the aesthetic and func-
tional results depend on the size of the implant used.
Certain patients will not be selected to undergo the
implant procedure. These are basically patients who have
not been informed on alternative treatments, patients
with psychological issues who have not received suitable
psychological treatment, patients with general surgical
risks or with severe cavernous fibrosis. Certain badly-
informed patients do not have realistic expectations of
the benefits of a penile implant and in such cases, as is
our usual practice and after providing information, we
endeavour to have them anonymously meet with patients
who have already been operated on. Symptoms of intra -
vesical obstruction or infections in the penis (balanitis,
phimosis) will have to be treated prior to implantation.
The patient is required to sign an informed consent , as
getting a penis implant is a procedure that is influenced
by considerable psycho-emotional expectations and
therefore, has high medical legal risks. The patient must
be aware that he will no longer be able to achieve erec-
tions naturally, though they will be extremely fulfilling.
He should also be informed that the implantation proce-
dure is irreversible and that re-operation may be required
, as is inherent to any prosthetic procedure. Repeat
Acta Chir Belg, 2010, 110, 000-000
Reference number to be mentioned by correspondence : CH/ADRIANNE
Penile Prosthesis in the Age of the Blue Pill
R. Andrianne
Urology Department, Cetism (Centre de Traitement de l’Insuffisance Sexuelle Masculine), Liège University Hospital,
Liège, Belgium.

surgery and replacement of the prosthetic element is
most often linked to a mechanical problem particularly
with hydraulic implants (leaks, cylinder failure, etc.) and
is sometimes required by rare pain phenomena (6%),
infection or erosion (5 to 6%) and sometimes a technical
error in the choice of implant (5 to 6%). The infection
rate, which is the most dangerous complication, drops
with the surgeon and his team’s level of experience.
Infection may appear soon after the operation in the case
of particularly virulent germs or later caused by germs
with low virulence levels. In the event of infection, the
most commonly encountered germ is Staphylococcus
epidermidis. Infection requires a course of treatment
with antibiotics and the material must be totally removed
. In most cases a salvage procedure by replacing the old
implant with a new one after washing in antibiotic solu-
tion is possible. This procedure is effective in 80% of
cases in the absence of significant erosion.
Soaking new products in antibiotics enables us to
reduce infection rates (excluding diabetics) to below 2%.
Mechanical failure rates are currently dropping off due to
improvements in the material being implanted.
Implanting a penile prosthesis is a straight-forward sur-
gical procedure for a surgeon who has received specific
training and has regular practice.
What a patient , interested in a penile implant , needs
to know :
the other options available for treating ED,
what the implant can do for him and the changes to his
body-scheme,
2
R. Andrianne
the functional and cosmetic design,
meet with other patients who have been operated on,
get explanations regarding possible complications :
the worst-case scenario, the major complications and
how often they occur,
the possibility of revision surgery.
The different types of implants
There are basically two types of penile implant :
semi-rigid implants
inflatable implants
Inflatable implants are composed of two or three pieces.
The three-piece model provides the best flaccidity. New
inflatable implant models enable the implant to be
lengthened and the diameter to be increased with excel-
lent flaccidity comfort levels. For several years now
treatments on the surface of the implant (Minocycline
and Rifampicin coating) have reduced the risk of infec-
tion by half.
Two manufacturers share the inflatable implant market :
AMS INC. USA and MENTOR CORP. USA.
Fig. 1
Three piece CX AMS 700 penile prosthesis
Fig. 2
Penoscrotal approch for penile prosthesis implantation
COLOR PRINT ?
COLOR PRINT ?

P
enile Prosthesis in the Age of the Blue Pill 3
Which implant for which patient ?
The implant model that is chosen will depend on the
patient’s background and dexterity, on whether the
patient suffers from Peyronie’s disease or fibrosis in the
cavernous bodies. The length of the cylinders and the
size of the reservoir will be chosen during the operation
after measuring the space available in the cavernous
bodies. If the penis retains good elasticity, then it will
have an optimal cosmetic look when erect.
W
hich surgical approach ?
The pre-pubic area or the penoscrotal junction are the
m
ost commonly used approaches for making a small
incision. All the prosthetic components (cylinders,
scrotal pump and the abdominal reservoir in the case of
a 3-piece implant) can all be implanted through this
single incision. If the patient has undergone previous
pelvic surgery, a low iliac fossa approach is useful for
inserting the balloon containing the saline solution. The
operation, which is quick in the hands of highly-trained
staff, usually lasts just over one hour. Spinal anaesthesia
is the best option and allows to obtain an optimal sizing
of the length of the prosthesis to be implanted.
What is the cost for the patient ?
Patients of this surgical procedure are entitled to a very
low refund on the procedure itself (K120 = 150 Euros),
on the other hand in Belgium, the material has been
subject to an 80% refund since 1992 with the condition
that the ED has a proven vascular and/or neurological
cause. This means that this procedure would cost the
patient 1000 Euros for a shared room. Patients stay in
hospital for two days following surgery.
The importance of well-informed consent
There must be full well-informed consent from the
patient and ideally from his partner also for the surgery.
The patient must be informed of the types of implant
Fig. 3
New scrotal Tactile Pump from AMS-Antibiotic inbibition
Fig. 4
Penile prosthesis in flaccid state (left) and erection state (right)
COLOR PRINT ?COLOR PRINT ?

available, the risk of infection, the risk of mechanical
malfunction and the need for revision surgery. He must
b
e aware that the erection will no longer be fully natural
and that the size which normally doubles in length when
there is no erectile dysfunction will be that of the implant
without tissue tension. When there is no sexual stimula-
tion the glans will not present an erection and phospho-
diesterase type 5 inhibitors are sometimes needed to
improve the erection in the glans during sexual relations.
The patient must be fully aware that the procedure is
irreversible as cavernous tissue is destroyed when the
cylinders are inserted. It is most often the case that penile
sensitivity, libido and ejaculatory orgasm are improved
after penile implant surgery whose sole aim is erectile
restoration. A preoperative urine cytology test is essential
as is a glycated haemoglobin test for diabetic patients in
order to optimise healing and reduce the risk of infection.
Satisfaction with the implant
According to our own experience and that of several
authors (2-4), a penile implant is the most effective treat-
ment of ED and more than 90% of patients are satisfied
on a lasting basis. This in comparison with 50% for
Sildenafil, and 40% for intracavernous injections (2).
Our statistics for 392 procedures from 1983 to 2009
show 109 replacements (89 patients (22.7%) due to wear
or mechanical problems 20 patients (5.1%) due to
problems with infection)
Only five patients who received implants during this
period have no implant today. Our patients’ satisfaction
is significant : 86% would recommend the procedure to
someone else, 85% would accept an analogous proce-
dure if necessary. This can be compared to published
American statistics (5) 93% of partners are happy with
the operation and 89% feel pleasure when using this
device during sexual relations (6).
Conclusion
Benefits of penile implants
Offers a permanent, long-term solution to ED
Provides the ability to have an erection at any time
Allows for greater spontaneity when initiating sexual
relations
Enables the patient to maintain an erection for as
along as he desires
4
R. Andrianne
Eliminates the need for costly medication with side
e
ffects or contraindications
Does not interfere with ejaculation or orgasm
Disadvantages of penile implants
Causes the permanent destruction of cavernous tissue
(which was incapable of achieving an erection)
If an infection occurs, the implant must be removed
Requires surgery and a short healing period
In rare cases may cause a shortening of the penis
when erect
In the case of the inflatable models, the implant could
fail
A penile implant may be advisable in cases where oral or
intracavernous drug treatments have failed among moti-
vated and well-informed patients. Despite the idea of a
last resort treatment, the models available nowadays are
very reliable and the satisfaction rate at the medium and
long term is very high after a procedure with a low com-
plication rate. Ideally, penile implants should be inserted
in a specialised center.
References
1. MONCADA I., JUAN I. Current role of penile implants for erectile
dysfunction. J Impot Res, 2004, 16 : 57-59.
2. RAJPURKAR A., DHABUWALA C. B. Comparison of satisfaction rates
and erectile function in patients treated with sildenafil, intra -
cavernous prostaglandin E1 and penile implant surgery for erectile
dysfunction in urology practice. J Urol, 2003, 170 : 159-163.
3. CARSON C. C., MULCAHY J. J., GOVIER F. E. Efficacy, safety and
patient satisfaction outcomes of the AMS 700CX inflatable penile
prosthesis. J Urol, 2000, 163 : 476-480.
4. AGRAWAL V., RALPH D. An audit of implanted penile prosthesis in the
U.K. BJU International, 2006, 98 : 393-395.
5. KEMPENEERS P., ANDRIANNE R., MORMONT C. Penile prosthesis,
sexual satisfaction and representation of male erotic value. Sexual
and relationship Therapy, 2004, 19 : 379-392.
6. LEVINE L. A., ESTRADA C. R., MORGENTALER A. Mechanical reliabili-
ty and safety of inflatable penile prosthesis : results of a 2 center
study. J Urol, 2001, 166 : 932-937.
R. Andrianne
Urology Department
Cetism (Centre de Traitement de l’Insuffisance Sexuelle Masculine)
Liège University Hospital
Sart Tilman B30
4031 Liège, Belgium
E-mail : robert.andrianne@chu.ulg.ac.be
References
More filters
Journal ArticleDOI
TL;DR: A long-term multicenter study of the AMS 700CX 3-piece inflatable penile prosthesis, focusing on longevity, morbidity and mortality, concluded that the prosthesis has utility in terms of prolonging life and reducing morbidity.

267 citations

Journal ArticleDOI
TL;DR: Patients who underwent penile implant surgery had significantly better erectile function and treatment satisfaction than those receiving sildenafil citrate and intracavernous prostaglandin E1.

159 citations

Journal ArticleDOI
TL;DR: The Ambicor penile prosthesis is associated with a low complication rate and reliable mechanical function, and high satisfaction was reported by patients and partners.

138 citations

Journal ArticleDOI
01 Aug 2006-BJUI
TL;DR: In this paper, the authors conducted a retrospective audit of 413 penile prostheses implanted over a 2-year period in the UK by 76 surgeons and found that about 80% of the surgeons implanted only one or two prostheses per year, usually of the malleable type, and usually on patients in the private sector.
Abstract: OBJECTIVE To assess whether the outcome of implanting penile prostheses is related to the number of prostheses implanted by surgeons, as several reports showed that the outcome of a urological procedure is directly related to the experience of the surgeon. METHODS We conducted a retrospective audit of 413 penile prostheses implanted over a 2-year period in the UK by 76 surgeons. RESULTS About 80% of the surgeons implanted only one or two prostheses per year, usually of the malleable type, and usually on patients in the private sector. Only four surgeons implanted >20 prostheses per year. The overall revision rate for implantation in the UK, at 24%, is far higher than the worldwide average. CONCLUSIONS Guidelines are needed on the number of prostheses a surgeon should implant per year so that revision rates will decline to more acceptable levels and patients will be offered a genuine choice of product.

35 citations

Journal ArticleDOI
TL;DR: Of all the invasive treatments currently available, placement of a penile prosthesis is one of the most successful, giving high levels of satisfaction, so prosthetic surgery may play a major role in the treatment of erectile dysfunction.
Abstract: PURPOSE OF REVIEW The purpose of this review is to appraise new developments and publications in the field of penile prosthetic surgery. Urologists dealing with erectile dysfunction need to recognize the value of penile prosthetic surgery as a very efficacious treatment for this common condition. This type of surgery is needed in a considerable proportion of patients with erectile dysfunction so this review is timely and relevant. RECENT FINDINGS The main themes in the literature covered include risk factors for infection of penile prostheses, its prevention with the use of hydrophilic and antibiotic-coated prostheses, particularly in re-operations, and its management with the new rescue procedures. Surgical tips for prosthetic surgery are also reviewed as well as clinical outcomes and factors influencing them. SUMMARY Of all the invasive treatments currently available, placement of a penile prosthesis is one of the most successful, giving high levels of satisfaction. With the aid of new technical advances, the risk of infection--the most feared complication--can be minimized so prosthetic surgery may play a major role in the treatment of erectile dysfunction.

33 citations

Frequently Asked Questions (1)
Q1. What are the contributions in this paper?

In the event of proven erectile dysfunction ( ED ), specific treatment strategies are available in the following order: phosphodiesterase type 5 inhibitors ( Cialis, Levitra, Viagra ), intracavernous injections of vasoactive drugs and implanting a penile prosthesis.