What are the risks ofa penile prosthesis

As with any surgical procedure, there are complications associated with the placement of a penile prosthesis. These risks may be subdivided into intraoperative complications (those occurring during surgery) and postoperative complications (those occurring after surgery).

Intraoperative Complications

Perforation

During dilation of the corpora cavernosa, the dilating instrument can perforate the urethra. If this occurs, the procedure must be terminated, the catheter must be left in place, and the urethra must be allowed to heal. If one cylinder has already been placed on the other side, it may be left in place and connected to the pump and reservoir before the surgery is completed. If the patient desires, the surgeon can go back in a few months and try to replace the cylinder. Some men find that they are able to achieve adequate rigidity with only one cylinder in place and do not wish to undergo another surgical procedure.

Similarly, during dilation of the corpora, a hole may be made from one corpus cavernosum into the other. The surgery can continue in this case, but the cylinders must be properly placed in each corpus cavernosum. If a hole is made, a cylinder may cross over, meaning that it starts in one corpus cavernosum but passes through the hole and ends in the other corpus cavernosum. If this situation goes unrecognized, it may cause asymmetry and pain with use of the prosthesis.

Existing Scarring

In individuals with significant penile fibrosis, such severe scarring may be present that narrower cylinders will be required. Rarely, it will be difficult to close the corpora over the cylinders. A patch of synthetic material or tissue must be removed from another area of your body in this case and used to cover the corporal defect.

Excessive Bleeding and Anesthesia Complications

As with all surgical procedures, there are bleeding and anesthetic risks with the implantation of a penile prosthesis.

Postoperative Complications

Decreased Penile Length

Decreased penile length is actually not a complication of penile implantation, but rather is intrinsic to the surgery. The cylinders are of a fixed length. To obtain penile rigidity, the cylinders increase in width (girth). Very observant patients will note a 1- to 2-cm decrease in penile length after the procedure.

Infection

One of the most devastating complications of penile prosthesis surgery is infection. Infection rates range from 2-16% in first-time procedures but increase to 8-18% in reoperations. Patients with diabetes and spinal cord injury, in particular, are at increased risk for infection.

Signs of infection include persistent pain, erosion of a part of the prosthesis, purulent drainage, fever, swelling and redness of the scrotum, and fixation of the tubing to the scrotal skin. In most cases, but particularly when infection occurs early after implantation, the entire prosthesis must be removed emergently. The area must then be irrigated with antibiotics, and intravenous antibiotics followed by oral antibiotics must be given. Implantation of a second prosthesis can be attempted 6 months later, after the area has completely healed.

When an infection occurs later and is caused by less aggressive bacteria, the surgeon may try to salvage the prosthesis. In such a case, the patient is taken to the operating room, the infected prosthesis is removed, the area is irrigated copiously with antibiotic solutions, and a new prosthesis is placed. The risk of infection associated with the new prosthesis in this situation is about 15%.

In an attempt to help decrease the risk of infection, some of the penile prostheses come impregnated with antibiotics and others have a coating which allows an antibiotic to be adhered to it.

Erosion and Migration

Erosion (destruction of a tissue surface) and migration (spontaneous change of place) of the prosthesis occur more commonly with placement of rigid prostheses and in men with indwelling catheters or on clean intermittent catheterization. These complications may also occur when the prosthesis is too long or the patient has an unsuspected urethral injury.

In the case of urethral erosion, there may be some splaying of the urine stream and the tip of the prosthesis may protrude into the urethra. In such cases, the affected cylinder is removed, and the corpora are irrigated with an antibiotic solution and closed. A catheter is placed into the bladder for about 1 week to promote urethral healing. A new cylinder can be placed 6 months later.

The tubing may also erode through the skin. Such tubing erosion is often a sign of a smoldering infection, in which case the best thing to do is to remove the prosthesis. The surgeon can also attempt the salvage technique described earlier.

Lastly, the cylinders may migrate proximally toward the base of the penis, a condition that shows up as a new droop in the glans. When this happens, the cylinder must be removed, the defect in the corpus cavernosum corrected, and the cylinder replaced.

Glans Droop

If the cylinders to be implanted are too short, they will not provide adequate support to the tip of the penis, causing the glans to droop. This drooping of the glans may make it difficult for the man to achieve vaginal penetration. A glans droop can be corrected by a simple surgical procedure and often does not require replacement of the prosthesis.

Penile Ischemia and Necrosis

These complications, which are extremely rare, occur when there is an injury to the blood supply to the corpora cavernosa or to the glans. Men with severe diabetes, those with extensive vascular disease, and those who require an extensive dissection for placement of the prosthesis are at increased risk of developing penile ischemia or necrosis. If the postoperative dressing is too tight, it may also cause ischemia.

Perineal Pain

Patients often experience some discomfort during the first 2 months or so after placement of a penile prosthesis. If the pain persists for a longer period, your physician may evaluate whether you have an infection or whether the prosthesis is too large. Some men may experience penile discomfort with the initial inflation of the prosthesis that is related to stretching of the tunica (the thick white membrane wrapped around the corpora cavernosa), but this usually resolves with time as the tunica stretches.

Residual Penile Curvature

In patients with Peyronie's disease, placement of the prosthesis and maneuvering of the prosthesis when it is erect in the operating room are usually all that is needed to correct the penile curvature that can occur with this condition. In rare cases, residual curvature may persist after placement of the prosthesis. If this condition does not improve with use of the prosthesis, then another procedure may be performed to excise the plaque.

Mechanical Problems

The incidence of mechanical problems with prostheses is approximately 5%—quite a low rate. Such problems may potentially include leaks, aneurysms, and rupture of the cylinders.

Leaks typically occur at connection sites and where the cylinder tubing enters the cylinder. Leaking prostheses either will not work or will not provide adequate rigidity. Connection site leaks may be easily repaired. A leaking cylinder can be replaced, but it is recommended that the entire prosthesis be replaced if the prosthesis has been implanted for a few years.

Aneurysms (i.e., dilations of a part of the cylinder) are very uncommon with the current prosthesis models. If they occur, the affected cylinder must be removed and replaced with a new device.

The cylinders can also rupture, usually as a result of unrecognized damage during the closure of the corpora. This problem is often detected when the device is inflated 4 to 6 weeks after surgery.

Autoinflation

Autoinflation is the phenomenon whereby the device inflates on its own without you manipulating the pump. It is the result of increased pressure around the reservoir. The newer penile prostheses have "lockout valves" which prevent autoinflation.

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