Corporal Excavation and Grafting for Inflatable Penile Prosthesis Implantation in Severe Corporal Fibrosis

Abstract

ABSTRACT Introduction Inflatable Penile Prosthesis (IPP) insertion becomes substantially more difficult in men with severe corporal fibrosis due to the need for dilation through scar tissue and decreased diameter of the corporal bodies. In this setting, traditional strategies of dilation have increased risk of urethral and glanular perforation given obliteration of normal dilation planes. This is a rare, but significant surgical challenge whose body of evidence contains few studies with small cohorts. Objective To describe and analyze our institution's experience with complex IPP placement in patients with severe corporal fibrosis using corporal excavation and/or grafting. Methods We performed a retrospective review of all patients with severe corporal fibrosis who underwent IPP placement using a technique of corporal excavation and/or grafting between 01/2006—05/2021. Corporal excavation involved a penoscrotal incision extending the full length of penile shaft for complete exposure of the corpus spongiosum and direct excision of the entire central fibrotic core. Corporal grafting involved sewing grafts in areas of the corporal implant bed that remained severely narrowed after excavation to accommodate the IPP cylinder(s). Our two primary outcomes were (1) post-operative complications and (2) surgical success, which was defined as erections sufficient for intercourse in the absence of post-operative complication requiring re-operation. Results Ten cases meeting inclusion criteria were identified with 1 involving corporal excavation only, 4 involving grafting only, and 5 involving corporal excavation and grafting. In all cases, severe fibrosis was due to trauma (n=3), priapism requiring corporal shunting (n=3) or prior IPP infection and explant (n=4). All were implanted with an AMS-700 three-piece IPP and five patients required insertion of a reduced diameter IPP. Five out of 9 (55.6%) cases involving grafting used a Tutoplast pericardium allograft and 4/9 (44.4%) cases used a Gore-Tex synthetic graft. When graft was used, the median area used was 10.0 centimeters (IQR 4.5-11.8). Median operative duration was 315 minutes (IQR 243.75-370.5). Median post-operative hospital stay was 1 day. Post-operative complications included 2 (20%) cases of infection requiring antibiotics and 1 (10%) case of post-operative neuropathic pain/distal glans numbness. Median follow-up duration was 3.8 months (IQR 1.5-65.7) across all groups, with surgical success seen in 3/4 (75%) grafting cases, 1/1 (100%) excavation cases, and 5/5 (100%) simultaneous excavation and grafting cases. Failure was seen in one case due to penile shortening that required a penile lengthening procedure and IPP upsizing 10 months post-operatively. Conclusions IPP insertion in the setting of corporal fibrosis is complex. Downsized cylinders may be required due to contracture of the tunica albuginea. However, patients with corporal fibrosis may safely undergo IPP placement with good intermediate term outcomes using corporal excavation and/or grafting. Disclosure No