Editing Evaluation and Management of Erectile Dysfunction (section)

=== Surgery ===

* '''Indications (4):'''
*# '''Penile injury resulting from genital or pelvic trauma'''
*# '''Penile structural deformity occurring in association with Peyronie disease'''
*# '''Cavernosal fibrosis secondary to prolonged ischemic priapism or infection'''
*# '''Medical therapy for ED is contraindicated, unsuccessful, or undesirable'''
* '''Penile prosthesis'''
** '''See Surgery for Erectile Dysfunction Chapter Notes'''
** '''Effective in men from the general ED population as well as men from a variety of special populations'''
*** Satisfaction rates are high for both implant naïve patients and those undergoing surgical revision of an existing device
** '''Patients should understand that this treatment choice is best conceptualized as irreversible'''
*** Although prostheses can be removed, it is unlikely that a man’s penis will be reliably responsive to other ED therapies after prosthesis explant.
*** While not all nonsurgical options need to be attempted prior to considering placement of a penile prosthesis, all nonsurgical options should at least be discussed with the patient prior to considering surgical intervention.
** '''2019 AUA Best Practice Policy on Antibiotic Prophylaxis recommend an aminoglycoside with either a first- or second-generation cephalosporin or vancomycin 1 hour before surgery and up to 24 hours after surgery for implanted prosthetic devices (AUS, penile prosthesis, sacral neuromodulators)'''
** '''The potential risks of prosthesis surgery include (5):'''
**# '''Risks inherent in the surgical procedure''' (penile edema or hematoma, corpus injury, urethral injury, acute urinary retention, and crura injury)
**# '''Possible changes in the appearance of the penis'''
**#* When objective measures are used, '''small length decreases''' may be documented
**#* Glans will remain flaccid post implant
**# '''Infection'''
**#* '''A serious adverse event that typically occurs within the first 3 months after surgery and usually requires removal of the prosthesis'''
**#** In select cases, an infected prosthesis can be removed, the location of the device washed out using an antibiotic salvage procedure and a new device immediately placed.
**#*** This approach should be restricted to men without evidence of sepsis or severe local infection.
**#** More typically, the infected device is removed, the infection is addressed with antibiotics, and the tissues are allowed to heal (for 6 weeks to 6 months).
**#* '''No evidence that diabetic men are at higher risk of prosthesis infection'''
**# '''Erosions'''
**# '''Device malfunction or failure'''
**#* Almost 50% will still be functional after 20 years of use
* '''Penile arterial reconstruction'''
** '''May be considered for young men with (3):'''
**# '''ED and'''
**# '''Focal pelvic/penile arterial occlusion  and'''
**# '''Without documented generalized vascular disease or veno-occlusive dysfunction'''
** '''Usually used for internal pudendal artery stenosis'''
* '''Penile venous reconstruction'''
** '''Not recommended;''' overall, data indicate that penile venous ligation surgery is unlikely to result in long-term successful management of ED for the overwhelming majority of men and delays treatment with other more reliable options such as penile prosthesis surgery