SMALL-CARRION IMPOTENCE:
SHLOMO JOSEPH
RAZ,
OPERATION
IMPROVED
TECHNIQUE*
M.D.
J. KAUFMAN,
M.D.
From the Department of Surgery, Division University of California School of Medicine,
The Small-Carrion prostheses for the treatment of erectile impotence have received wide attention and acclaim. However, several complications during and after the operation have been witnessed and include: infection, urethral erosion and extrusion, malposition and faulty filling of the corpora with the prosthetic rods. The standard method has been to expose the crura of the penis through a midline perineal incision, to open the crura (corpora) a few centimeters from their origin, and to dilate each corpus with graduated Hegar dilators.+ An alternative method is to expose the corpora through an incision of the penile skin (usually a dorsal retrocoronal horizontal incision is employed) and to open the corpora on either side after the skin has been retracted proximally. Hegar dilators are again used to make a space for the prostheses and to aid in the selection of the proper size. Hegar dilators have at times been difficult to insert, and penetration of the capsule of the corpora has occurred in some cases. A modification which obviates the use of Hegar dilators and which gives a more exact idea of the dimensions of the prostheses to be used is described. When there are no contraindications to perineal exposure, this approach is used. The crura are exposed, and following this an 0.5 inch Penrose drain is placed about the base of the penis and applied as a tourniquet (Fig. 1A). A 20gauge scalp vein needle is introduced percutaneously into the anterior portion of one corpus cavernosum on its lateral surface. (The injected
*Supported in part by the Blalock Foundation University Medical Research Foundation.
and the
of Urology, Los Angeles,
California
saline will inflate both corpora via communicating vessels.) The tubing of the needle is connected to a three-way stopcock and is injected by a 50cc. syringe of saline without heparin to simulate erection. Usually 50 to 80 cc. of saline are needed to produce the simulated erection. It is important to aspirate blood after the corpus has been penetrated to ensure proper placement of the needle. When a good erection has been produced by the saline injection (Fig. lB, C), the length of the penis from the corona to the tip of the crus is measured and the appropriate-sized prosthesis selected. It is useful to have at least two sizes available. The tourniquet about the base of the penis should not be applied too snugly so that the fundi of the crura are also filled with saline. Dilation of the corpora and crura with saline provides a soft matrix which the prosthesis penetrates easily. A 2 to 3-cm. incision is then made in each crus on its medial surface. The tip of a Metzenbaum scissors is then passed in both directions to guide proper placement of the prosthesis in the spongy tissue. The previously injected saline will escape from the crus upon incision. The selected prosthesis is introduced, and at the same time the tourniquet is released. We have not encountered difficulty in introducing the prosthesis to the distal tip of the corpora in 22 patients in whom the saline method was employed (Fig. 1D). If the anterior penile approach is used, the tourniquet is placed at the base of the penis after both corpora are exposed by retracting the penile skin proximally. After the induced erection both corpora are opened, and the prostheses are introduced without need for proximal and distal dilation of the corpora with Hegar dilators.
~SMALL, M. P., CARRION, H. M., and GORDON, J. A.: Small-Carrion penile prosthesis: new implant for management of impotence, Urology 5: 479 (1975).
68
FOR
Los
Angeles,
California (DR.
UROLOGY
/ JANUARY 1976 / VOLUME
90024 RAZ)
VII, NUMBER
1
FIGURE 1. (A) Diagram showing application of tour-n:iquet over base of penis before saline injection; and (B) method used to produce artificial erection and dilatory effect on corpora. (C) Unilateral injection of saline into one corpus cavernosum produces artificial erection am d hydraulic dilatation of corpus; filling effect is present in both corpora cavernosa and corpora spongiosa by collateral circulation. (0) After release of tourniquet prostheses are easily introduced into corpora and slide readily to distal extremity of corpora.
UROLOGY
i
JANUARY 1976
/ VOLUME
VII,
NUMBER
1
69
SHLOMO JOSEPH
RAZ,
OPERATION
IMPROVED
TECHNIQUE*
M.D.
J. KAUFMAN,
M.D.
From the Department of Surgery, Division University of California School of Medicine,
The Small-Carrion prostheses for the treatment of erectile impotence have received wide attention and acclaim. However, several complications during and after the operation have been witnessed and include: infection, urethral erosion and extrusion, malposition and faulty filling of the corpora with the prosthetic rods. The standard method has been to expose the crura of the penis through a midline perineal incision, to open the crura (corpora) a few centimeters from their origin, and to dilate each corpus with graduated Hegar dilators.+ An alternative method is to expose the corpora through an incision of the penile skin (usually a dorsal retrocoronal horizontal incision is employed) and to open the corpora on either side after the skin has been retracted proximally. Hegar dilators are again used to make a space for the prostheses and to aid in the selection of the proper size. Hegar dilators have at times been difficult to insert, and penetration of the capsule of the corpora has occurred in some cases. A modification which obviates the use of Hegar dilators and which gives a more exact idea of the dimensions of the prostheses to be used is described. When there are no contraindications to perineal exposure, this approach is used. The crura are exposed, and following this an 0.5 inch Penrose drain is placed about the base of the penis and applied as a tourniquet (Fig. 1A). A 20gauge scalp vein needle is introduced percutaneously into the anterior portion of one corpus cavernosum on its lateral surface. (The injected
*Supported in part by the Blalock Foundation University Medical Research Foundation.
and the
of Urology, Los Angeles,
California
saline will inflate both corpora via communicating vessels.) The tubing of the needle is connected to a three-way stopcock and is injected by a 50cc. syringe of saline without heparin to simulate erection. Usually 50 to 80 cc. of saline are needed to produce the simulated erection. It is important to aspirate blood after the corpus has been penetrated to ensure proper placement of the needle. When a good erection has been produced by the saline injection (Fig. lB, C), the length of the penis from the corona to the tip of the crus is measured and the appropriate-sized prosthesis selected. It is useful to have at least two sizes available. The tourniquet about the base of the penis should not be applied too snugly so that the fundi of the crura are also filled with saline. Dilation of the corpora and crura with saline provides a soft matrix which the prosthesis penetrates easily. A 2 to 3-cm. incision is then made in each crus on its medial surface. The tip of a Metzenbaum scissors is then passed in both directions to guide proper placement of the prosthesis in the spongy tissue. The previously injected saline will escape from the crus upon incision. The selected prosthesis is introduced, and at the same time the tourniquet is released. We have not encountered difficulty in introducing the prosthesis to the distal tip of the corpora in 22 patients in whom the saline method was employed (Fig. 1D). If the anterior penile approach is used, the tourniquet is placed at the base of the penis after both corpora are exposed by retracting the penile skin proximally. After the induced erection both corpora are opened, and the prostheses are introduced without need for proximal and distal dilation of the corpora with Hegar dilators.
~SMALL, M. P., CARRION, H. M., and GORDON, J. A.: Small-Carrion penile prosthesis: new implant for management of impotence, Urology 5: 479 (1975).
68
FOR
Los
Angeles,
California (DR.
UROLOGY
/ JANUARY 1976 / VOLUME
90024 RAZ)
VII, NUMBER
1
FIGURE 1. (A) Diagram showing application of tour-n:iquet over base of penis before saline injection; and (B) method used to produce artificial erection and dilatory effect on corpora. (C) Unilateral injection of saline into one corpus cavernosum produces artificial erection am d hydraulic dilatation of corpus; filling effect is present in both corpora cavernosa and corpora spongiosa by collateral circulation. (0) After release of tourniquet prostheses are easily introduced into corpora and slide readily to distal extremity of corpora.
UROLOGY
i
JANUARY 1976
/ VOLUME
VII,
NUMBER
1
69
