PENILE PROSTHESIS REVISION OR EXCHANGE FOR LENGTH, GIRTH RESTORATION AND IMPROVE AESTHETIC APPEARANCE.
Over 25,000 penile implants are placed annually in the United States. This procedure has demonstrated a satisfaction rate of up to 93%. Despite this high level of satisfaction, a subset of patients remains dissatisfied with surgical outcomes due to multiple factors. These may include loss of penile length and girth, poor esthetic outcome, poor rigidity, hypermobility of the glans (tip of the penis) herniation of reservoir.
Patient and Partner Satisfaction
Satisfaction is largely due to perception and attitude towards the medical encounter and procedure. This is driven by parameters such as patient expectations, comorbidities, surgical complications or premature device failures and partner’s response to the procedure. Therefore, it is very important to consult a specialist doctor for an accurate diagnosis. Only with specific exams, carried out during the consultation, it is possible to evaluate the presence of fibrosis, loss of size, thinning and curvature.
The function of the implant is to restore rigidity to the penis. Often the placement of the prosthesis is performed without concerns of length preservation or restoration. As surgeons we are concerned with the treatment of the medical condition. The surgeon’s focus is the surgical correction of erectile dysfunction. After the surgery, patients may present with complaints that may lead to decreased satisfaction. These conditions may not be apparent until the patient has recovered and is ready to resume sexual activity.
In this article we will review some of the causes of patient dissatisfaction and the treatment options.
PENILE PROSTHESIS REVISION OR EXCHANGE FOR GIRTH AND LENGTH RESTORATION.
LOSS OF LENGTH (SHORTENING OF THE PENIS)
A common complaint after penile prosthesis implantation is loss of penile length. This has been shown to have a negative impact on overall patient satisfaction. Some studies have shown that the subjective feeling of loss of penile length occurred in over 15% patients. In fact, the loss of length has been reported to be 1” to 1.75”.
If you have noticed significant loss of length and girth after the placement of a penile prosthesis, in most cases, it is possible to reconstruct the penis to restore or recover length and girth. Dr. Valenzuela employs a series of techniques that can mediate these conditions. A small midline scrotal incision allows for the removal of the existing implant. He then uses a strategy call Tunica Expansion Procedure or TEP (term developed by Dr. Egydio). TEP allows for stretching of the corpora to recover the largest possible size and diameter of the penis. The length is limited to the maximum stretch of the nerves, vessels, and urethra. This procedure has been shown to restore up to 1.5” in length and girth.
TEP is a series of cuts are made on the capsule of the penis to allow for expansion
TEP for Girth expansion
TEP for length expansion
FLOPPY GLANS (head of the penis)
Another complaint after surgery is hypermobility of the glans or head of the penis when the penis is erect. This can make penetration difficult and even painful. The tips of the cylinders can be palpated and often visible below the glans. This is easily identified by inflating the prosthesis to the maximum and tilting the head of the penis forward and back. Depending on the surgical approach this can result in 5-20% of patients. This condition may result from fibrosis of the cavernosum (tissue inside the penis) These patients tend to low levels of satisfaction with outcome.
CORRECTION OF FLOPPY GLANS
The post implant surgical correction of floppy glans depends on the extent of hypermobility and location of the cylinders. A simple procedure can relocate and fixated the glans directly over the cylinders and eliminate the hypermobility. This procedure can be performed in office under local anesthesia or in the operating room depending on the extent of hypermobility.
1. A circumcision is created
2. Sutures are then placed to “fix” the glans in place
3. These sutures are then tested for strength
4. The circumcision is then closed
In cases where the cylinders may be too short, fixation of the glans decrease the length of the penis. As a result, we recommend a penile prosthesis exchange and re-sizing of the prosthesis. At the time of the procedure the penile prosthesis is removed, the corpora are rechanneled to the level of the mid-glans and placement of a larger penile prosthesis. This will help restore penile length and improve esthetic outcome and function.
VISIBLE TUBING OR HIGH RIDING PUMP
Despite having a functional prosthesis, this condition can be very disturbing to the patients. Patient will often avoid sexual encounters due to feeling insecure and embarrassment. Relocation of tubing or pump to maximize esthetic results, can easily be achieved with an outpatient procedure.
Here are some examples of pump placement:
The pump is high in the scrotum. This makes it more visible due to its location may interfere with sexual activity.
Pump located visible high in the scrotum and at the penoscrotal junction.
Pump low in the scrotum but midline and visible.
In the ideal location the pump should be low in the scrotum, should not interfere with sexual activity and maximize esthetics.
In this case the pump is low in the scrotum, behind the testicles and it is not visible regardless of the angle of the penis
GOALS OF PENILE PROSTHESIS REVISION OR EXCHANGE SURGERY
- Recover axial rigidity and give good penetrative ability.
- Restore girth and length with Tunica Expansion Procedure (TEP).
- Treat the fibrosis that may have appeared after the first surgery.
- Maximize function and esthetics.
- Use national and international protocols to minimize complications
- Rescue a healthy sex life.
Dr. Valenzuela utilizes a series of adjunct procedure to achieve these goals. The choice of prosthesis is made together with the patient, at the time of the consultation, based on a careful evaluation and the needs of the patient. Each case is treated individually, considering the medical condition, lifestyle, personal preference, and cost-effectiveness.