Editing Penile Prosthesis (section)

== Adverse Events ==

=== UrologySchool.com Summary ===

* '''<span style="color:#ff0000">Intra-operative'''
*# '''<span style="color:#ff0000">Risks of general anesthesia'''
*# '''<span style="color:#ff0000">Bleeding'''
*# '''<span style="color:#ff0000">Infection'''
*# '''<span style="color:#ff0000">Injury to adjacent structure/organ'''
*#*'''<span style="color:#ff0000">Corpora cavernosa perforation'''
*#*'''<span style="color:#ff0000">Urethral perforation'''
* '''<span style="color:#ff0000">Early post-operative'''
*# '''<span style="color:#ff0000">Infection'''
*# '''<span style="color:#ff0000">Scrotal hematoma'''
* '''<span style="color:#ff0000">Late post-operative'''
*# '''<span style="color:#ff0000">Infection'''
*# '''<span style="color:#ff0000">Device malfunction'''
*# '''<span style="color:#ff0000">Device erosion'''
*# '''<span style="color:#ff0000">Penile shortening'''
*# '''<span style="color:#ff0000">S-shaped penile deformity'''
*# '''<span style="color:#ff0000">Poor glans support'''

=== Intraoperative ===
*'''<span style="color:#ff0000">Organ injury/perforation, cylinder crossover, and damage to the device during implantation'''

==== Corpora cavernosa perforation ====
* To prevent distal or proximal crossover into the contralateral corpus during initial dilation, constant traction should be applied to the shaft of the penis by pulling on the glans, and the curvature of the scissors should be maintained away from the midline of the penis, with the tips next to the tunica albuginea.
*'''If crossover occurs, it is usually preferable to recognize it and correct it when recognized, rather than after further dilation or insertion of the cylinders.'''
* '''Most likely location for perforation is at the septum'''
* '''<span style="color:#ff0000">Distal perforation'''
** '''Evaluated by exposing the damaged corpus apex through a transverse incision of the skin and tunica albuginea near the glans'''
** '''<span style="color:#ff0000">Management'''
*** '''<span style="color:#ff0000">A small hole can usually be</span>''' located distally on the medial aspect of the cavernosal cavity and '''<span style="color:#ff0000">repaired</span>''' using separate PDS stitches. The distal apex of the corpora needs to be closed with a second running suture, and '''a slightly shorter prosthetic cylinder is selected for the perforated side;''' this is necessary to prevent the distal tip of the cylinder from resting on the urethral suture repair.
*** '''A more conservative approach would be to terminate the procedure and bring the patient back for implantation 3 months later.'''
**** The disadvantage of this strategy is that the length of the shaft is foreshortened, and dilation of the scarred corpora is much more difficult.
*** '''If the perforation occurs after both corpora are dilated, a semimalleable cylinder can be placed in the nonperforated side to preserve penile length.'''
* '''<span style="color:#ff0000">Proximal perforation'''
** '''Evaluated by placing a dilator in each crura, and their heights can be compared to confirm that one has penetrated too deeply inside the perineum.'''
** '''<span style="color:#ff0000">Management'''
*** '''<span style="color:#ff0000">Repair</span>''' by anchoring the cylinders to the surrounding corpora tissue by placing stitches above and below the input tubing, which prevents the cylinder from proximal migration and allows the perforation to heal.

==== Urethral perforation ====
* '''<span style="color:#ff0000">Management'''
** '''<span style="color:#ff0000">Abandon the procedure and divert the urine with a urethral catheter''' until deferred repair.
*** '''Urethral repair would be difficult and is unnecessary.'''
*** '''If the contralateral malleable cylinder has already been placed and there is no septal perforation, then it may be left in place.'''
*** '''If this occurs with an inflatable prosthesis, the entire device should be removed and the urethra allowed to heal.'''

=== Postoperative ===

==== Infections ====

===== Epidemiology =====
*'''<span style="color:#ff0000">Incidence: overall infection rates following initial penile prosthesis insertion range from 1-3%</span>'''
**'''Rate is significantly higher (7-18%) for revision surgery'''

===== Risk Factors =====
*'''<span style="color:#ff0000">Most infections are caused by bacteria on the skin at the time of surgery that attach to the device and are then introduced into the patient'''
* '''Patient risk factors (5):'''
*#'''Poor patient hygiene'''
*#'''Spinal cord injury'''
*#'''Urinary tract infection'''
*#'''Distant sites of infection'''
*#'''Revision surgery performed for previous device infection'''
*#*'''Unclear if diabetes or immunosuppression are associated with risk of infection'''
*'''Intraoperative risk factors (6):'''
*#'''Inadequate skin preparation with alcohol/chlorhexidine'''
*#'''Prolonged surgical time (i.e., >2 hours)'''
*#'''Prolonged and repeated exposure of components of the prosthesis to patient’s skin'''
*#'''Frequent repositioning and resizing of the cylinder, pump, or reservoir'''
*#'''Scrotal hematoma (particularly if liquefied)'''
*#'''Not changing gloves before handling the device'''
*'''Post-operative risk factor (1):'''
*#'''Prolonged hospitalization'''
*'''<span style="color:#ff0000">Most important factors to minimize the risk of device infection (2):'''
*#'''<span style="color:#ff0000">Procedures that decrease inoculating bacteria into the surgical wound (4)'''
*##'''<span style="color:#ff0000">Alcohol skin preparation'''
*##'''<span style="color:#ff0000">Reducing surgical time'''
*##'''<span style="color:#ff0000">No touch surgical technique'''
*##'''<span style="color:#ff0000">Perioperative antibiotic use'''
*#'''<span style="color:#ff0000">Use of antibiotic-coated prostheses'''
*#*Specially coated three-piece devices have been developed to inhibit bacterial adhesion and proliferation. These coatings have decreased the incidence of infection by 50-70%

===== Microbiology =====
*'''<span style="color:#ff0000">Typically involves organisms that colonize the skin, such as (3):'''
*#'''<span style="color:#ff0000">Staphylococcus epidermidis'''
*#'''<span style="color:#ff0000">Staphylococcus aureus'''
*#'''<span style="color:#ff0000">Candida albicans'''

===== Diagnosis and Evaluation =====
* '''<span style="color:#ff0000">History and Physical Exam'''
** '''<span style="color:#ff0000">History'''
*** '''<span style="color:#ff0000">Clinical deterioration with persistence of pain and tethering at 3-4 weeks after surgery suggests an infection</span>'''
**** '''<span style="color:#ff0000">Pain that does not seem to improve and is persistent or increased at 2-weeks after surgery should not prompt the use of antibiotics'''
***** '''<span style="color:#ff0000">If the device is not infected, the patient should experience clinical improvement within the next 7-14 days.'''
***** If the device is infected, antibiotics are useless at this point and may delay diagnosis'''.'''
*** '''Fever, erythema, swelling, elevated white blood cell count, and incision drainage are late signs and symptoms of infection and are usually not observed at the initial postoperative visit.'''
*** '''The sooner an infection is diagnosed, the better the chance for successful salvage''' and aggressive early salvage should be considered before systemic symptom such as fever, elevated white blood count, erythema, and abscess formation of scrotum occur
* Imaging
** Studies such as scrotal sonography, computed tomography scan, and magnetic resonance imaging are not helpful in making an early diagnosis.

===== Management =====
* '''<span style="color:#ff0000">Infection necessitates the removal of all device components as well as any permanent sutures or graft material used during corporeal reconstruction</span>'''
** The use of systemic antibiotics to treat symptomatic patients is typically insufficient because of the biofilm and attempts to remove only part of an infected device typically results in persistent infection
* '''<span style="color:#ff0000">A “salvage” procedure involving removal of the infected prosthesis, wound washout, and immediate device replacement can help facilitate reimplantation and preserve penile length.'''
** '''Contraindications to salvage prosthesis:'''
*** '''Patients presenting with''' 
****'''Enterococcus'''
****'''Tissue necrosis'''
****'''Sepsis'''
****'''Diabetic ketoacidosis'''
****'''Cylinder erosion into the urethra'''

==== Device Malfunction ====
* '''Most common types of malfunction in a three-piece prosthetic device include'''
*#'''Cracks in the silicone tubing'''
*#'''Leaks'''
*#'''Pump disruption'''
* '''Management'''
** '''If malfunction occurs'''
*** '''Within a few months after implantation: consider replacing only the defective component, especially if this avoids a repeat corporeal incision'''
*** '''After the device has been in place for >2 years: complete replacement is indicated'''

==== Device Erosion ====
* '''Typically occurs months or years after implantation'''
* '''Can manifest in several different locations.'''
* '''Management'''
** '''Complete removal of all the components of the device, regardless of the location and possible salvage replacement.'''
*** '''If only one of the cylinder tips has eroded through the meatus, the entire device needs to be removed, including the pump and reservoir, and a malleable cylinder is placed in the noneroded side only, to prevent shortening of the penis.'''
*** '''The perforation must be allowed to heal for 8 to 12 weeks before reimplantation is attempted'''

==== Pain only when the device is inflated during intercourse ====
* '''May indicate that the cylinders are too large and are buckling, causing pain.'''
* '''MRI scan with the prosthesis inflated is the best imaging modality to prove the possible size discrepancy and buckling is the next step.'''
* '''If the diagnosis is confirmed, revision of the penile prosthesis with placement of smaller cylinders will usually resolve the problem'''
==== Other complications ====
* '''Postoperative complications occurring less frequently include S-shaped penile deformity, poor glans support (see above), and scrotal hematoma'''.