0022-5347 /79/1223-0325$02.00/0 Vol. 122, September Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1979 by The Williams & Wilkins Co.
PENOSCROTAL APPROACH FOR PLACEMENT OF PAIRED PENILE IMPLANTS FOR IMPOTENCE JOHN M. BARRY*
AND
AVERY SEIFERT
From the Division of Urology, University of Oregon Health Sciences Center and Urology Section, Veterans Administration Hospital, Portland, Oregon ABSTRACT
A new penoscrotal approach to implant paired penile prostheses was developed and applied satisfactorily to 24 of 26 impotent men.
A
A, saline distension of corpora cavernosa and penoscrotal incision. B, left corpus cavernosum incision. Urethra easily avoided because it is directly visible. C, dilatation of distal left corpus cavernosum with penile prosthesis. Proximity of incision to distal penis allows control of distal prosthesis placement. D, final position of paired penile prostheses and relationship to skin and corpora cavernosa incisions.
Erectile impotence can be treated satisfactorily with paired silicone penile prostheses. 1 The 2 basic surgical approaches for Accepted for publication December 8, 1978. Read at annual meeting of Western Section, American Urological Association, Seattle, Washington, July 16-20, 1978. * Requests for reprints: Division of Urology, University of Oregon Health Sciences Center, Portland, Oregon 97201.
implanting these prostheses are perineal 1 and dorsal penile. 2 The perineal approach requires the technical inconveniences of perineal fat incision and incision of the paired ischiocavemous muscles, which embrace the corpora cavernosa. Damage to the dorsal neurovascular bundle of the penis is a potential complication of the dorsal approach. Because of these considerations a previously undescribed penoscrotal approach for implanting 325
326
BARRY AND SEIFERT
paired penile prostheses was developed and evaluated in 26 impotent men during a 1-year period. SURGICAL PROCEDURE
The patients were given an aminoglycoside or a cephalosporin antibiotic with their preoperative medications and this was continued for 24 hours. With the patient supine 5 ml. of an antiseptic soap solution was injected into the urethra and the genitalia were scrubbed with the solution for 10 minutes. After the patient was draped a 16F Foley urethral catheter was inserted and a tourniquet was placed at the base of the penis (part A of figure). A 23 gauge needle was thrust through the tunica albuginea into 1 of the corpora cavernosa and 60 to 100 ml. normal saline were injected to produce an erection and to dilate the corporeal bodies. The corpora cavernosa were palpated distally through the glans penis to determine where the prosthesis would seat distally and the prosthesis rigid shaft length was estimated by measuring from the symphysis to mid glans. Subtraction of 2 cm. from this measurement provided the proper rigid shaft length for the Flexirod penile prosthesis.* The addition of 2 cm. provided an estimate of the shaft length for the Small-Carrion prosthesis.t A 5 cm. vertical, midline incision was made on the ventral shaft of the penis, ending at the scrotum. The laterally placed corpora cavernosa were identified by their white tunicae albuginea and the purple corpus cavernosum was avoided by visualization and palpation of the catheter. The skin, subcutaneous tissue and Buck's fascia at the base of the penis were retracted laterally and stay sutures were placed on either side of the proposed incisions in the corpora cavernosa. The tourniquet was then removed, allowing the proximal corpora cavernosa to be dilated, and 5 cm. incisions were made in both corporeal bodies between the stay sutures (part B of figure). Without further dilatation the penile prosthesis was inserted distally, hugging the inside of the lateral wall of the tunica albuginea (part C of figure). After the prosthesis had been pushed to its maximum length under the glans the proximal limb was inserted into the same corpus cavernosum. When difficulty was experienced dilating a corpus cavernosum with the blunt end of the Small-Carrion prosthesis it was reversed and the sharper end was used. It was then removed and the blunt end was reinserted distally. The other prosthesis was inserted into the opposite corpus cavernosum, again without using a Hegar dilator. (Hegar dilators were used only if saline dilatation failed.) The tunica albuginea incisions were . * Medical Engineering Corp., 3037 Mt. Pleasant St., Racine, Wisconsm 53403. t Heyer-Schulte Corp., 600 Pine Ave., Goleta, California 93017.
each closed with running 3-zero polyglycolic acid suture, the stay sutures were removed, and the skin and subcutaneous tissue were approximated with 4-zero chromic catgut or polyglycolic acid sutures (part D of figure). During the surgical procedure 1 gm. per cent neomycin sulfate was used liberally as a wound irrigant. A dry, sterile, gentle compression dressing was applied and was removed along with the urethral catheter 24 hours after the procedure. The procedure was modified for implanting a Flexirod shaft by inserting a No. 6 Hegar dilator proximally into each corpus cavernosum and trimming the proximal end of the Flexirod shaft to its proper length as measured against the dilator. The flexible hinge of the prosthesis corresponded to the sites of the corporeal incisions. POSTOPERATIVE CARE
The patients usually were discharged from the hospital the day after the operation and were instructed to wash the operative site gently with soap and water once a day. They were seen in followup 1 and 4 weeks postoperatively. Intercourse with lubrication was encouraged 1 month postoperatively. The patient and his wife were instructed to telephone the surgeon with the results of the procedure 2 months later. RESULTS
During the 12-month period ending July 1, 1978, 26 patients had undergone this procedure. One diabetic required removal of the prosthesis because of infection and 1 patient has residual distal dorsal chordee from Peyronie's disease after the procedure recommended by Raz and associates. 3 There have been no urethral or neurovascular bundle injuries. DISCUSSION
Our experience with infections in insulin-dependent diabetics and a review of Small's experience4 have prompted us to treat insulin-dependent diabetics with a cephalosporin or a tetracycline for the week preceding and the week after implantation. REFERENCES
1. Small, M. P., Carrion, H. M. and Gordon, J. A.: Small-Carrion
penile prosthesis. Urology, 5: 479, 1975. 2. Melman, A.: Experience with implantation of Small-Carrion penile implant for organic impotence. J. Urol., 116: 49, 1976. 3. Raz, S., deKernion, J.B. and Kaufman, J. J.: Surgical treatment of Peyronie's disease: a new approach. J. Urol., 117: 598, 1977. 4. Small, M. P.: Small-Carrion penile prosthesis: a report on 160 cases and review of the literature. J. Urol., 119: 365, 1978.
THE JOURNAL OF UROLOGY
Copyright© 1979 by The Williams & Wilkins Co.
PENOSCROTAL APPROACH FOR PLACEMENT OF PAIRED PENILE IMPLANTS FOR IMPOTENCE JOHN M. BARRY*
AND
AVERY SEIFERT
From the Division of Urology, University of Oregon Health Sciences Center and Urology Section, Veterans Administration Hospital, Portland, Oregon ABSTRACT
A new penoscrotal approach to implant paired penile prostheses was developed and applied satisfactorily to 24 of 26 impotent men.
A
A, saline distension of corpora cavernosa and penoscrotal incision. B, left corpus cavernosum incision. Urethra easily avoided because it is directly visible. C, dilatation of distal left corpus cavernosum with penile prosthesis. Proximity of incision to distal penis allows control of distal prosthesis placement. D, final position of paired penile prostheses and relationship to skin and corpora cavernosa incisions.
Erectile impotence can be treated satisfactorily with paired silicone penile prostheses. 1 The 2 basic surgical approaches for Accepted for publication December 8, 1978. Read at annual meeting of Western Section, American Urological Association, Seattle, Washington, July 16-20, 1978. * Requests for reprints: Division of Urology, University of Oregon Health Sciences Center, Portland, Oregon 97201.
implanting these prostheses are perineal 1 and dorsal penile. 2 The perineal approach requires the technical inconveniences of perineal fat incision and incision of the paired ischiocavemous muscles, which embrace the corpora cavernosa. Damage to the dorsal neurovascular bundle of the penis is a potential complication of the dorsal approach. Because of these considerations a previously undescribed penoscrotal approach for implanting 325
326
BARRY AND SEIFERT
paired penile prostheses was developed and evaluated in 26 impotent men during a 1-year period. SURGICAL PROCEDURE
The patients were given an aminoglycoside or a cephalosporin antibiotic with their preoperative medications and this was continued for 24 hours. With the patient supine 5 ml. of an antiseptic soap solution was injected into the urethra and the genitalia were scrubbed with the solution for 10 minutes. After the patient was draped a 16F Foley urethral catheter was inserted and a tourniquet was placed at the base of the penis (part A of figure). A 23 gauge needle was thrust through the tunica albuginea into 1 of the corpora cavernosa and 60 to 100 ml. normal saline were injected to produce an erection and to dilate the corporeal bodies. The corpora cavernosa were palpated distally through the glans penis to determine where the prosthesis would seat distally and the prosthesis rigid shaft length was estimated by measuring from the symphysis to mid glans. Subtraction of 2 cm. from this measurement provided the proper rigid shaft length for the Flexirod penile prosthesis.* The addition of 2 cm. provided an estimate of the shaft length for the Small-Carrion prosthesis.t A 5 cm. vertical, midline incision was made on the ventral shaft of the penis, ending at the scrotum. The laterally placed corpora cavernosa were identified by their white tunicae albuginea and the purple corpus cavernosum was avoided by visualization and palpation of the catheter. The skin, subcutaneous tissue and Buck's fascia at the base of the penis were retracted laterally and stay sutures were placed on either side of the proposed incisions in the corpora cavernosa. The tourniquet was then removed, allowing the proximal corpora cavernosa to be dilated, and 5 cm. incisions were made in both corporeal bodies between the stay sutures (part B of figure). Without further dilatation the penile prosthesis was inserted distally, hugging the inside of the lateral wall of the tunica albuginea (part C of figure). After the prosthesis had been pushed to its maximum length under the glans the proximal limb was inserted into the same corpus cavernosum. When difficulty was experienced dilating a corpus cavernosum with the blunt end of the Small-Carrion prosthesis it was reversed and the sharper end was used. It was then removed and the blunt end was reinserted distally. The other prosthesis was inserted into the opposite corpus cavernosum, again without using a Hegar dilator. (Hegar dilators were used only if saline dilatation failed.) The tunica albuginea incisions were . * Medical Engineering Corp., 3037 Mt. Pleasant St., Racine, Wisconsm 53403. t Heyer-Schulte Corp., 600 Pine Ave., Goleta, California 93017.
each closed with running 3-zero polyglycolic acid suture, the stay sutures were removed, and the skin and subcutaneous tissue were approximated with 4-zero chromic catgut or polyglycolic acid sutures (part D of figure). During the surgical procedure 1 gm. per cent neomycin sulfate was used liberally as a wound irrigant. A dry, sterile, gentle compression dressing was applied and was removed along with the urethral catheter 24 hours after the procedure. The procedure was modified for implanting a Flexirod shaft by inserting a No. 6 Hegar dilator proximally into each corpus cavernosum and trimming the proximal end of the Flexirod shaft to its proper length as measured against the dilator. The flexible hinge of the prosthesis corresponded to the sites of the corporeal incisions. POSTOPERATIVE CARE
The patients usually were discharged from the hospital the day after the operation and were instructed to wash the operative site gently with soap and water once a day. They were seen in followup 1 and 4 weeks postoperatively. Intercourse with lubrication was encouraged 1 month postoperatively. The patient and his wife were instructed to telephone the surgeon with the results of the procedure 2 months later. RESULTS
During the 12-month period ending July 1, 1978, 26 patients had undergone this procedure. One diabetic required removal of the prosthesis because of infection and 1 patient has residual distal dorsal chordee from Peyronie's disease after the procedure recommended by Raz and associates. 3 There have been no urethral or neurovascular bundle injuries. DISCUSSION
Our experience with infections in insulin-dependent diabetics and a review of Small's experience4 have prompted us to treat insulin-dependent diabetics with a cephalosporin or a tetracycline for the week preceding and the week after implantation. REFERENCES
1. Small, M. P., Carrion, H. M. and Gordon, J. A.: Small-Carrion
penile prosthesis. Urology, 5: 479, 1975. 2. Melman, A.: Experience with implantation of Small-Carrion penile implant for organic impotence. J. Urol., 116: 49, 1976. 3. Raz, S., deKernion, J.B. and Kaufman, J. J.: Surgical treatment of Peyronie's disease: a new approach. J. Urol., 117: 598, 1977. 4. Small, M. P.: Small-Carrion penile prosthesis: a report on 160 cases and review of the literature. J. Urol., 119: 365, 1978.
