Urol. int. 30: 211-217 (1975)
Treatment of Organic Impotence by Implantation of Silicone Penile Prosthesis S. S h ish ito , M. S hirai and S. M atsuda Department of Urology, Tohoku University School of Medicine, Sendai
Abstract. To help bolster penile tension me- Key Words chanically, we have tried implantation of silicone Organic impotence penile prostheses varying in type. Our simple and Silicone penile prosthesis apparently successful procedures for organic im potence with the implantation of intrapenile silicone prostheses may well deserve recommendation in view of spinal impairment therapeutically categorized irreparable.
Organic impotence may roughly be traced in origin to (1) genital or ganic abnormalities, (2) nervous system impairment causing genital organ ic inactivity, (3) endocrine disorders, and (4) organic derangements impeding ejaculation. Among these, the nervous system impairment organically causing im potence has long been left out of medical treatment as a irremediable dis order. However, in view of ever increasing labor casualties and traffic ac cidents in recent years multiplying the number of victims with nervous in jury and eventual organic impotence, it appears necessary to establish some treatment formula for the relief of depression in such victims. To help bolster penile tension mechanically, we have tried implanta tion of silicone prostheses varying in type, and now, with an improved de vice, believe to have established an apparently satisfactory course of treatment. This paper briefly describes our surgical procedures of im planting such prostheses for organic impotence cases.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
Surgical Procedures Silicone Prosthesis Four varieties of silicone prostheses were tried in our surgical procedures for treatment of organic impotence (fig. 1): ‘types A and B\ both 10 cm long, 10 mm
212
Shishito /S hirai/M atsuda
Fig. 1. Various types of silicone penile prostheses.
Preoperative Arrangements In preparing a silicone prosthesis, the silicone bar is cut to adjust to the length of an individual penis (standard 10 cm) with both ends made smooth by sandpaper ing. Sterilization of the silicone prosthesis may be done by means of either gassing, boiling, or dry-heating. Starting a few days prior to operation, antiedemic agents will be administered to each patient. The day before operation, the patient is led to have his hair shaved thoroughly all over the lower abdomen, including pubic, pen ile, scrotal, and perineal areas, and take a bath the night before operation.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
wide, semicircle in section, with both ends streamlined, only different in hardness, 45 shore for ‘A’ and 60 shore for ‘B’; ‘types C and D’, basically similar in construction to ‘A and B’, both 10 cm long, 12 mm wide, with a hardness of 70 shore, only different in distal structure, smoothly concaved for ‘C’, and attached by a silicone sponge for ‘D \ These types, developed in sequence yet leaving some faults, have given place to the present improved type, ‘type E’ (Japan Medical Plastics Center, Tokyo) which is further equipped internally with a polycarbonate tube to strengthen the structural tension and a new device of silicone bag filled with silicone fluid set at the tip to resist impact.
Treatment of Organic Impotence
213
Operative Techniques With the patient under general or epidural anesthesia, the area for operation is sterilized by application of isodine draped all over only exposing the penis. A No. 20F ballon catheter is inserted through the urethra into the bladder, and the balloon is distended with 5 cm3 water. A No. 3 silk suture, stitching through the glans penis at the dorsal median line, is fixed to the bandage to keep the penis stretched. This thread can prevent the penis from twisting and the operation from missing the penile dorsal median line. A 3 cm longitudinal dorsal incision is made in the midline. The subcutaneous tissue is carefully separated right and left, with spe cial attention paid not to damage blood vessels. The incision is carried through Colles’ fascia, Buck’s fascia and the tunica albu ginea into the corpora cavernosa. By using curved scissors, an excavation is made between the undersurface of the tunica albuginea and the corpora cavernosa to make a tunnel-like space extending from the corona glandis distally to the suspenso ry ligament proximally. In the process, deliberate attention must be kept not to im pair the blood vessels and nerves running over the tunica albuginea. Stripping the tunica albuginea off the back, pushing down the corpora cavernosa, can help the space-making go relatively easy. After expanding the space, when necessary with the help of a metal bougie like the urethro-dilator, the prepared silicone prosthesis is in serted in the space (fig. 2, 3). The above-described method represents our improved technique for implanting the silicone prosthesis, overcoming the fault in the earlier practice with the implant
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
Fin. 2. The insertion of a silicone penile prosthesis.
214
Shishito /S hirai/M atsuda Silicone prosthesis Colles' fascia Buck's fascia
Tunica albuginea
Corpus spongiosum
Fig. 3. Schematic drawing of cross-section of phallus with prothesis in place.
not always stable in place between Buck’s fascia and the tunica albuginea [Shirai and C hiba, 1971]. The incised parts are then closed in turn by interrupted sutures at an interval of about 2 mm: the tunica albuginea with 3-0 chromic catgut; Buck’s fascia and then Colles’ fascia with 4-0 chromic catgut or nylon, and finally the skin with 4-0 nylon. Postoperative Care The penis thus having the silicone prosthesis implanted is held upright, gently pressed by an elastic bandage or press-net. When the patient, relieved of anesthesia, is able to walk, the indwelling catheter may be removed except for specific cases with spinal impairment. In such cases, the catheter may preferably be left in posi tion until the operative scar completely heals. Postoperative routine administrations of antibiotics, antiinflammatory and antiedemic drugs should never be neglected. Even with the operative scar completely healed, the patient is advised not to attempt sexual relations for at least 4 weeks af ter the operation.
Our surgical procedures for organic impotence performed in 13 cases by implanting a silicone penile prosthesis proved generally encouraging though one case needed reoperation because of the implant pushed out by aseptic necrosis. As already described, our earlier practice of implanting the prosthesis between Buck’s fascia and the tunica albuginea disclosed occasional instability of the implant, causing some difficulty for the bol stered penis to make its way through the vagina. The difficulty has been
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
Operative Results
Treatment of Organic Impotence
215
removed in the present routine with the place of the prosthesis altered un der the tunica albuginea. The hardness of the silicone prosthesis around 60 shore is favored in our practice; too harder levels seem unfavorable. Also recommendable is implantation of the prosthesis as deep under the pubis as possible.
To help bolster erection, splint-like genital tools are known to have been devised with various designs. Intrapenile implantation of cartilage has also been tried to extend help to men complaining of coitus failure be cause of organic genital defects [H eller , 1944; M orales et al., 1956]. The recent developments of intrapenile implantation of silicone prosthesis reported by L oeffler et al. [1964], P earman [1967, 1972] and L ash [1968] have been observed going a long way toward providing substantial relief to men of organic impotence. Intravital use of silicone in liquid form involves various problems [Arthaud , 1973], but in solid form it causes only a minimal or negligible tis sue reaction. With its advantages of available choice of hardness, elastic property, and insignificant physical troubles on the body, silicone is now widely used in medical practice. P earman [1967], in his effort to determine the size and configuration of a silicone penile bolster, experimentally provided a tunnel between Buck's fascia and the tunica albuginea, extending from the corona glandis distally to the suspensory ligament proximally. Infusing paraffin in this tunnel, he obtained a cast, semicircle in section, 10-13 mm in width, and 6-10 cm in length. Adjusting to this size, P earman [1967] developed a silicone prosthesis, finally not semicircle but three fifths of a circle in sec tion with a Teflon coil spring or bar inset to increase strength of the prosthesis. In our practice, the silicone prosthesis has been used with a design, semicircle in section, 10-12 mm in width, 10 cm in length, with a hard ness ranging between 40, 60 and 70 shore. Special devices have been provided for the latest type with an inner polycarbonate tube to increase strength and a bag of silicone fluid at the tip to resist impact. In implanting the silicone prosthesis, P earman [1972] adopted the place under the tunica albuginea, from the corona glandis distally to the suspensory ligament proximally. In our cases, the earlier practice of in
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
Discussion
Shishito /S hirai/M atsuda
serting the prosthesis between Buck’s fascia and the tunica albuginea tended to cause occasional instability in the implanted prosthesis. Remov ing the fault, we now follow a routine to implant the silicone prosthesis just under the tunica albuginea, extending from the corona glandis at the tip, to the suspensory ligament at the base. Implant stability has become fairly satisfactory, but there still remains room to implement our proce dure such as for giving solidity to the glans penis, inciting further efforts for improvements in both surgical technique and material adaptation. As regards the indications for the operation, Pearman [1967, 1972] qualifies the cases with a sexual desire matched by a normal perception on the penis and a potential sense similar to orgasm. On the other hand, L ash [1968] reported his experience of the opera tion performed in cases of either organic or functional impotence, particu larly noting favorable results in cases of premature ejaculation without organic defect in erection. The advantage, he explains, is the possible maintenance of intravaginal masculine tension for the benefit of the part ner even after ejaculation. In our routine, the operation is limited usually in cases of organic im potence, with the indications, wider than P earman ' s [1967, 1972] sugges tion, embracing even such a case of spinal impairment that has no percep tion on the penis nor potential orgasm but eagerly desires sexual inter course with his young wife. In some paraplegics, the benefit of the opera tion has been appreciated with profound satisfactions in the mental as pects for the operated and in both mental and physical aspects on the part of the spouse. Such instances may well support the significance of this op eration. Complications by the operation were reported by L ash [1968] in one among his 28 cases with the implant lost into the urethra, and among P earman ' s [1972] 114 cases, there was aseptic necrosis in 2, prominent lymphatic edema in 2, postoperative hematoma in 1, 'rocker motion’ of the glans in 7, and in 3 cases the tip of the silicone prosthesis was asso ciated with herniation of the tunica albuginea. In the earlier practice, we also encountered one case in which aseptic necrosis caused the silicone prosthesis to protrude out of the corona glan dis over the penile skin. Later improvements of the prosthesis with a spe cial design at its tip and exact adjustment of its length apparently have had effects in overcoming such an unfavorable outcome. With the number of subjects still insufficient statistically, we wish to accumulate experience with increased numbers of cases to determine
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
216
Treatment of Organic Impotence
217
whether our techniques can be free of any unfavorable side effects in long-term results. References Arthaud , J. B.: Silicone-induced penile sclerosing lipogranuloma. J. Urol. 110: 210
(1973). H eller , E.: Knorpelverpflanzung bei Verletzung des Corpus cavernosum penis zur
Wiederherstellung der Kohabitationsfahigkeit. Zbl. Chir. 71: 65-68 (1944). Lash, H.: Silicone implant for impotence. J. Urol. 100: 709-710 (1968). Loeffler , R. A.; Sayegh, E. S., and L ash, H.: The artificial os penis. Plast. re-
constr. Surg. 34: 71-74 (1964). M orales, P. A.; O’C onnor , J. J., jr., and H otchkiss. R. S.: Plastic reconstructive
surgery after total loss of the penis. Amer. J. Surg. 92: 403-408 (1956). P earman, R. O.: Treatment of organic impotence by implantation of a penile
prosthesis. J. Urol. 97: 716-719 (1967). P earman, R. O.: Insertion of a silastic penile prosthesis for the treatment of organic
sexual impotence. J. Urol. 107: 802-806 (1972). Shirai, M. and C hiba, R.: A study on the male sexual impotence. II. Treatment of
Request reprints from: Prof. S. Shishito , Department of Urology, Tohoku Univer sity School of Medicine, Sendai 980 (Japan)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
organic impotence by implantation of a penile prosthesis. Jap. J. Urol. 62: 156-161 (1971).
Treatment of Organic Impotence by Implantation of Silicone Penile Prosthesis S. S h ish ito , M. S hirai and S. M atsuda Department of Urology, Tohoku University School of Medicine, Sendai
Abstract. To help bolster penile tension me- Key Words chanically, we have tried implantation of silicone Organic impotence penile prostheses varying in type. Our simple and Silicone penile prosthesis apparently successful procedures for organic im potence with the implantation of intrapenile silicone prostheses may well deserve recommendation in view of spinal impairment therapeutically categorized irreparable.
Organic impotence may roughly be traced in origin to (1) genital or ganic abnormalities, (2) nervous system impairment causing genital organ ic inactivity, (3) endocrine disorders, and (4) organic derangements impeding ejaculation. Among these, the nervous system impairment organically causing im potence has long been left out of medical treatment as a irremediable dis order. However, in view of ever increasing labor casualties and traffic ac cidents in recent years multiplying the number of victims with nervous in jury and eventual organic impotence, it appears necessary to establish some treatment formula for the relief of depression in such victims. To help bolster penile tension mechanically, we have tried implanta tion of silicone prostheses varying in type, and now, with an improved de vice, believe to have established an apparently satisfactory course of treatment. This paper briefly describes our surgical procedures of im planting such prostheses for organic impotence cases.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
Surgical Procedures Silicone Prosthesis Four varieties of silicone prostheses were tried in our surgical procedures for treatment of organic impotence (fig. 1): ‘types A and B\ both 10 cm long, 10 mm
212
Shishito /S hirai/M atsuda
Fig. 1. Various types of silicone penile prostheses.
Preoperative Arrangements In preparing a silicone prosthesis, the silicone bar is cut to adjust to the length of an individual penis (standard 10 cm) with both ends made smooth by sandpaper ing. Sterilization of the silicone prosthesis may be done by means of either gassing, boiling, or dry-heating. Starting a few days prior to operation, antiedemic agents will be administered to each patient. The day before operation, the patient is led to have his hair shaved thoroughly all over the lower abdomen, including pubic, pen ile, scrotal, and perineal areas, and take a bath the night before operation.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
wide, semicircle in section, with both ends streamlined, only different in hardness, 45 shore for ‘A’ and 60 shore for ‘B’; ‘types C and D’, basically similar in construction to ‘A and B’, both 10 cm long, 12 mm wide, with a hardness of 70 shore, only different in distal structure, smoothly concaved for ‘C’, and attached by a silicone sponge for ‘D \ These types, developed in sequence yet leaving some faults, have given place to the present improved type, ‘type E’ (Japan Medical Plastics Center, Tokyo) which is further equipped internally with a polycarbonate tube to strengthen the structural tension and a new device of silicone bag filled with silicone fluid set at the tip to resist impact.
Treatment of Organic Impotence
213
Operative Techniques With the patient under general or epidural anesthesia, the area for operation is sterilized by application of isodine draped all over only exposing the penis. A No. 20F ballon catheter is inserted through the urethra into the bladder, and the balloon is distended with 5 cm3 water. A No. 3 silk suture, stitching through the glans penis at the dorsal median line, is fixed to the bandage to keep the penis stretched. This thread can prevent the penis from twisting and the operation from missing the penile dorsal median line. A 3 cm longitudinal dorsal incision is made in the midline. The subcutaneous tissue is carefully separated right and left, with spe cial attention paid not to damage blood vessels. The incision is carried through Colles’ fascia, Buck’s fascia and the tunica albu ginea into the corpora cavernosa. By using curved scissors, an excavation is made between the undersurface of the tunica albuginea and the corpora cavernosa to make a tunnel-like space extending from the corona glandis distally to the suspenso ry ligament proximally. In the process, deliberate attention must be kept not to im pair the blood vessels and nerves running over the tunica albuginea. Stripping the tunica albuginea off the back, pushing down the corpora cavernosa, can help the space-making go relatively easy. After expanding the space, when necessary with the help of a metal bougie like the urethro-dilator, the prepared silicone prosthesis is in serted in the space (fig. 2, 3). The above-described method represents our improved technique for implanting the silicone prosthesis, overcoming the fault in the earlier practice with the implant
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
Fin. 2. The insertion of a silicone penile prosthesis.
214
Shishito /S hirai/M atsuda Silicone prosthesis Colles' fascia Buck's fascia
Tunica albuginea
Corpus spongiosum
Fig. 3. Schematic drawing of cross-section of phallus with prothesis in place.
not always stable in place between Buck’s fascia and the tunica albuginea [Shirai and C hiba, 1971]. The incised parts are then closed in turn by interrupted sutures at an interval of about 2 mm: the tunica albuginea with 3-0 chromic catgut; Buck’s fascia and then Colles’ fascia with 4-0 chromic catgut or nylon, and finally the skin with 4-0 nylon. Postoperative Care The penis thus having the silicone prosthesis implanted is held upright, gently pressed by an elastic bandage or press-net. When the patient, relieved of anesthesia, is able to walk, the indwelling catheter may be removed except for specific cases with spinal impairment. In such cases, the catheter may preferably be left in posi tion until the operative scar completely heals. Postoperative routine administrations of antibiotics, antiinflammatory and antiedemic drugs should never be neglected. Even with the operative scar completely healed, the patient is advised not to attempt sexual relations for at least 4 weeks af ter the operation.
Our surgical procedures for organic impotence performed in 13 cases by implanting a silicone penile prosthesis proved generally encouraging though one case needed reoperation because of the implant pushed out by aseptic necrosis. As already described, our earlier practice of implanting the prosthesis between Buck’s fascia and the tunica albuginea disclosed occasional instability of the implant, causing some difficulty for the bol stered penis to make its way through the vagina. The difficulty has been
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
Operative Results
Treatment of Organic Impotence
215
removed in the present routine with the place of the prosthesis altered un der the tunica albuginea. The hardness of the silicone prosthesis around 60 shore is favored in our practice; too harder levels seem unfavorable. Also recommendable is implantation of the prosthesis as deep under the pubis as possible.
To help bolster erection, splint-like genital tools are known to have been devised with various designs. Intrapenile implantation of cartilage has also been tried to extend help to men complaining of coitus failure be cause of organic genital defects [H eller , 1944; M orales et al., 1956]. The recent developments of intrapenile implantation of silicone prosthesis reported by L oeffler et al. [1964], P earman [1967, 1972] and L ash [1968] have been observed going a long way toward providing substantial relief to men of organic impotence. Intravital use of silicone in liquid form involves various problems [Arthaud , 1973], but in solid form it causes only a minimal or negligible tis sue reaction. With its advantages of available choice of hardness, elastic property, and insignificant physical troubles on the body, silicone is now widely used in medical practice. P earman [1967], in his effort to determine the size and configuration of a silicone penile bolster, experimentally provided a tunnel between Buck's fascia and the tunica albuginea, extending from the corona glandis distally to the suspensory ligament proximally. Infusing paraffin in this tunnel, he obtained a cast, semicircle in section, 10-13 mm in width, and 6-10 cm in length. Adjusting to this size, P earman [1967] developed a silicone prosthesis, finally not semicircle but three fifths of a circle in sec tion with a Teflon coil spring or bar inset to increase strength of the prosthesis. In our practice, the silicone prosthesis has been used with a design, semicircle in section, 10-12 mm in width, 10 cm in length, with a hard ness ranging between 40, 60 and 70 shore. Special devices have been provided for the latest type with an inner polycarbonate tube to increase strength and a bag of silicone fluid at the tip to resist impact. In implanting the silicone prosthesis, P earman [1972] adopted the place under the tunica albuginea, from the corona glandis distally to the suspensory ligament proximally. In our cases, the earlier practice of in
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
Discussion
Shishito /S hirai/M atsuda
serting the prosthesis between Buck’s fascia and the tunica albuginea tended to cause occasional instability in the implanted prosthesis. Remov ing the fault, we now follow a routine to implant the silicone prosthesis just under the tunica albuginea, extending from the corona glandis at the tip, to the suspensory ligament at the base. Implant stability has become fairly satisfactory, but there still remains room to implement our proce dure such as for giving solidity to the glans penis, inciting further efforts for improvements in both surgical technique and material adaptation. As regards the indications for the operation, Pearman [1967, 1972] qualifies the cases with a sexual desire matched by a normal perception on the penis and a potential sense similar to orgasm. On the other hand, L ash [1968] reported his experience of the opera tion performed in cases of either organic or functional impotence, particu larly noting favorable results in cases of premature ejaculation without organic defect in erection. The advantage, he explains, is the possible maintenance of intravaginal masculine tension for the benefit of the part ner even after ejaculation. In our routine, the operation is limited usually in cases of organic im potence, with the indications, wider than P earman ' s [1967, 1972] sugges tion, embracing even such a case of spinal impairment that has no percep tion on the penis nor potential orgasm but eagerly desires sexual inter course with his young wife. In some paraplegics, the benefit of the opera tion has been appreciated with profound satisfactions in the mental as pects for the operated and in both mental and physical aspects on the part of the spouse. Such instances may well support the significance of this op eration. Complications by the operation were reported by L ash [1968] in one among his 28 cases with the implant lost into the urethra, and among P earman ' s [1972] 114 cases, there was aseptic necrosis in 2, prominent lymphatic edema in 2, postoperative hematoma in 1, 'rocker motion’ of the glans in 7, and in 3 cases the tip of the silicone prosthesis was asso ciated with herniation of the tunica albuginea. In the earlier practice, we also encountered one case in which aseptic necrosis caused the silicone prosthesis to protrude out of the corona glan dis over the penile skin. Later improvements of the prosthesis with a spe cial design at its tip and exact adjustment of its length apparently have had effects in overcoming such an unfavorable outcome. With the number of subjects still insufficient statistically, we wish to accumulate experience with increased numbers of cases to determine
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
216
Treatment of Organic Impotence
217
whether our techniques can be free of any unfavorable side effects in long-term results. References Arthaud , J. B.: Silicone-induced penile sclerosing lipogranuloma. J. Urol. 110: 210
(1973). H eller , E.: Knorpelverpflanzung bei Verletzung des Corpus cavernosum penis zur
Wiederherstellung der Kohabitationsfahigkeit. Zbl. Chir. 71: 65-68 (1944). Lash, H.: Silicone implant for impotence. J. Urol. 100: 709-710 (1968). Loeffler , R. A.; Sayegh, E. S., and L ash, H.: The artificial os penis. Plast. re-
constr. Surg. 34: 71-74 (1964). M orales, P. A.; O’C onnor , J. J., jr., and H otchkiss. R. S.: Plastic reconstructive
surgery after total loss of the penis. Amer. J. Surg. 92: 403-408 (1956). P earman, R. O.: Treatment of organic impotence by implantation of a penile
prosthesis. J. Urol. 97: 716-719 (1967). P earman, R. O.: Insertion of a silastic penile prosthesis for the treatment of organic
sexual impotence. J. Urol. 107: 802-806 (1972). Shirai, M. and C hiba, R.: A study on the male sexual impotence. II. Treatment of
Request reprints from: Prof. S. Shishito , Department of Urology, Tohoku Univer sity School of Medicine, Sendai 980 (Japan)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 5:43:25 AM
organic impotence by implantation of a penile prosthesis. Jap. J. Urol. 62: 156-161 (1971).
