For referring physicians
Erectile dysfunction and the penile prosthesis: the operations
The erectile dysfunction I treat sits next to something else: a urethra or bladder neck that has been rebuilt, a pelvis that has been operated on or radiated, a neophallus, a priapism that will not stop, or a device that has failed. This page is what I do and the papers behind it. The selection rules are still being written down.
Who comes to me
Most of my prosthesis patients are men who have also lost continence or a working urethra to prostate cancer treatment, men whose pelvis has been operated on more than once, transgender men after phalloplasty, and men with a device that has eroded, infected or failed. Peyronie's disease is part of the same practice. When a stricture or a sphincter is also in the plan, the urethra is settled first, and the timing of the sphincter is on the incontinence page.
Where the reservoir goes
The space of Retzius is the traditional home of the reservoir and the pelvis I operate in has often been through it already. High submuscular placement, beneath the abdominal wall muscles, keeps the reservoir out of that space; in the survey we ran of surgeons trained in both techniques, high submuscular placement was rated safer for the viscera and the vessels and easier to learn and teach. The laparoscopic video shows a reservoir being removed from the abdomen, which is the problem the placement decision is meant to avoid. The corporal anatomy matters too: the intracavernosal pillars we described in the anatomy lab are what a dilator meets, and the paper draws the implications for placement.
Refractory priapism
Ischemic priapism that has outlasted shunts and irrigation is a prosthesis indication, not a contraindication. In our public hospital series, acute placement of a malleable prosthesis resolved the priapism immediately and sent every man home within a day; the episodes before it had averaged four emergency visits, two admissions and an estimated cost above 80,000 dollars per man. The delayed prosthesis in a fibrosed penis is a harder operation and a shorter penis, which is the argument for deciding early.
Reoperation
At revision, a reservoir or balloon that is not infected can be drained and left in place: in 551 prosthetic operations the drain and retain group had the same infection rate as first-time implants, which spares the dissection of an old reservoir out of a scarred pelvis.
The prosthesis in a neophallus
A neophallus has no corpora, so the prosthesis has to be anchored and covered in ways the review below describes, and the urethra inside the flap is settled before it goes in. The urethral side of that decision is on the phalloplasty urethra page.
Videos by operation
Most operative videos are age-restricted on YouTube, so you need to be signed in to watch them.
Penile prosthesis and reservoir
Prosthesis placement, revision and the neophallus
Videos are being edited for the library.
The pelvis the reservoir has to share
Papers
- Malleable penile prosthesis is a cost-effective treatment for refractory ischemic priapism. J Sex Med. 2014. PubMed 25536880
- Penile prosthesis insertion for acute priapism. Urol Clin North Am. 2013. PubMed 23905940
- Nationwide emergency department visits for priapism in the United States. J Sex Med. 2013. PubMed 23841493
- High submuscular versus space of Retzius placement of inflatable penile prosthesis reservoirs: results of a surgeon survey. Can J Urol. 2014. PubMed 25347372
- Penile intracavernosal pillars: lessons from anatomy and potential implications for penile prosthesis placement. Int J Impot Res. 2016. PubMed 27053154
- Safety of the "drain and retain" option for defunctionalized urologic prosthetic balloons and reservoirs during artificial urinary sphincter and inflatable penile prosthesis revision surgery: 5-year experience. Urology. 2013. PubMed 24125688
- Prosthetic considerations in neophallic reconstruction. Curr Sex Health Rep. 2017. DOI 10.1007/s11930-017-0126-1
- Clinical outcomes of a combined robotic, transabdominal, and open transperineal approach for anastomotic posterior urethroplasty. J Endourol. 2021. PubMed 33820448