Severe Corporal Fibrosis Research Articles

140 Penile Prosthesis Implantation in Patients with Severe Corporal Fibrosis After Mechanical Therapy

140 Penile Prosthesis Implantation in Patients with Severe Corporal Fibrosis After Mechanical Therapy

Critical Appraisal and Review of Management Strategies for Severe Fibrosis During Penile Implant Surgery.

Penile corporal fibrosis represents a challenging clinical scenario for surgeons placing penile prostheses (PP). Because of its rarity, a small number of series with limited follow-up have reported outcomes in this cohort. The aim of this study was to perform a critical appraisal of the corporal excavation technique, discuss its relevance to contemporary practice, and review alternative surgical methods and outcomes. A critical review was performed of the 2006 article by Montague and Angermeier, "Corporeal excavation: new technique for penile prosthesis implantation in men with severe corporeal fibrosis." Notable inclusions and omissions were described, with emphasis placed on methodology and outcomes. A PubMed search from 1990 to June 2015 was then performed to review and summarize the literature on managing corporal fibrosis during PP surgery. The main outcome measures used were the major contributions and limitations of the 2006 article describing outcomes of the corporal excavation technique. Corporal excavation is a relevant surgical technique for managing severe corporal fibrosis. Compared with alternatives, excavation achieves successful placement of PP without need for grafting and with few complications. The article was limited by several notable omissions including relevant patient demographic and disease characteristics, patient selection, and minimal descriptions of complications and outcomes. Alternative techniques include use of specialized dilators, counter incisions, reconstruction with graft placement, minimal scar tissue excision, and endoscopic resection. Because of limited data, no specific algorithm for managing corporal fibrosis can be prescribed. Corporal fibrosis is a challenging clinical scenario and requires surgical experience and specialized techniques to manage appropriately. Corporal excavation represents one of several viable techniques, which may be chosen based on surgeon's preference and clinical factors.

Use of a microdebrider for corporeal excavation and penile prosthesis implantation in men with severely fibrosed corpora cavernosa: a new minimal invasive surgical technique.

To propose a new minimal invasive surgical technique using a microdebrider (shaver) to excavate the fibrosed corpora cavernosa for penile prosthesis implantation in patients with severe fibrosis. Two patients with severe corporeal fibrosis were implanted with a penile prosthesis using this technique. In the first patient, fibrosis was due to neglected idiopathic ischemic priapism and the second patient had his prosthesis extruded because of erosion in another center. Both patients were counseled about the procedure and the possible complications related to the experimental nature of the technique. A written informed consent was obtained from both patients. Excavation of the corpora was performed using microdebrider in both patients. Both operations were performed successfully without any intraoperative complications, including urethral injury or perforation of the tunica. The mean operation time was 57 min. The postoperative period was uneventful without any infection, migration, erosion, or mechanical failure. The penile length was increased nearly 2 cm in both patients, and the penile girth was increased around 30% in the patient who underwent inflatable penile prosthesis implantation. The microdebrider potentially provides an important advance in patients with severe corporeal fibrosis to excavate the fibrosed corpora cavernosa for penile prosthesis implantation. The main advantages include fast, safe, and effective excavation of fibrous corpora cavernosa adequate for a satisfactory penile prosthesis implantation.

Placement of Inflatable Penile Prosthesis with Severe Corporal Fibrosis from Priapism

Placement of Inflatable Penile Prosthesis with Severe Corporal Fibrosis from Priapism

Editorial Comment

Infection is the bane of penile prosthesis implantation surgery. To eliminate the infection, removal of all of the prosthetic material is necessary. Implantation of a second device at a later date is complicated not so much by placement of the pump or fluid reservoir as it is by cylinder implantation. Infection causes varying degrees of corporeal smooth muscle death, with subsequent fibrosis. This scarring makes the penis smaller and makes cylinder implantation difficult. In some cases, the fibrosis is so pronounced that removal of corporeal fibrotic material (corporeal excavation) is necessary. 1 Montague D.K. Angermeier K.W. Corporeal excavation: new technique for penile prosthesis implantation in men with severe corporeal fibrosis. Urology. 2006; 67: 1072-1075 Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar Coated Implants and “No Touch” Surgical Technique Decreases Risk of Infection in Inflatable Penile Prosthesis Implantation to 0.46%UrologyVol. 79Issue 6PreviewTo explore whether a “no touch” enhancement to the surgical technique of inflatable penile prosthesis (IPPs) implantaion will further decrease infection rates. Full-Text PDF ReplyUrologyVol. 79Issue 6PreviewDiabetes was prevalent in our patient population, with 39% of noncoated implant patients, 37.9% of the standard technique patients, and 43% of the patients implanted with “no touch” having the disease. In our series, we had 28 infections total. Six patients (21%) had diabetes, 4 (14%) had erectile dysfunction (ED) after radical prostatectomy, 7 (25%) had hypertension as an associated condition, and 11 (39%) had other conditions. However, because the total number of infections was small, these figures lack statistical significance. Full-Text PDF

Penile Prosthesis Surgery in Patients with Corporal Fibrosis: A State of the Art Review

Penile prosthesis has become one of the most accepted treatment options in patients who do not respond to conservative medical therapies (oral or intracavernous injections). When penile fibrosis is present, this surgery becomes a real surgical challenge even for a skillful surgeon. The aim of this study was to review latest techniques to implant a penile prosthesis in patients with corporal fibrosis. We performed a systematic search in the following databases: PubMed, EMBASE, Cochrane, SCOPUS, and Science Citation Index without any date limits for the terms: "penile prosthesis,""penile fibrosis,""impotence,""fibrosis,""cavernotomes,""downsized prosthesis cylinders,""patient satisfaction,""penile graft," and "vascular graft." We reported in each technique and series data regarding penile size, complication rate, infection rate, technical pitfalls and details, use of additional surgical tools or implanted material (grafts, etc.), patients' satisfaction, and overall success rate. When penile corporal fibrosis is present, this surgery becomes a real surgical challenge even for a skillful surgeon. Over the years, multiple surgical approaches have been suggested to facilitate implantation in this difficult situation. Traditional approaches include the resection of scar tissue, performing extensive corporotomies and the eventually use of grafts to cover the corporal gap. Outcomes can be improved combining the use of techniques for scar incision (extensive wide excision, multiple incisions minimizing excision, corporal counter incisions, corporal excavation technique or Shaeer's technique) and cavernotomes and downsized prosthesis. Surgical strategies like upsizing prosthesis, suspensory ligament release or scrotoplasty must be kept in mind to utilize in this special scenario. Penile prosthesis in a patient with severe corporal fibrosis remains a surgical challenge. There are several techniques and surgical strategies that an implant surgeon should know and manage to minimize complications and improve outcomes.

Penile Corporeal Reconstruction during Difficult Placement of a Penile Prosthesis

For some patients with impotence and concomitant severe tunical/corporeal tissue fibrosis, insertion of a penile prosthesis is the only option to restore erectile function. Closing the tunica over an inflatable penile prosthesis in these patients can be challenging. We review our previous study which included 15 patients with severe corporeal or tunical fibrosis who underwent corporeal reconstruction with autologous rectus fascia to allow placement of an inflatable penile prosthesis. At a mean follow-up of 18 months (range 12 to 64), all patients had a prosthesis that was functioning properly without evidence of separation, herniation, or erosion of the graft. Sexual activity resumed at a mean time of 9 weeks (range 8 to 10). There were no adverse events related to the graft or its harvest. Use of rectus fascia graft for coverage of a tunical defect during a difficult penile prosthesis placement is surgically feasible, safe, and efficacious.

A Preliminary Report on Combined Penoscrotal and Perineal Approach for Placement of Penile Prosthesis with Corporal Fibrosis

Purpose. This paper aims at describing the combined penoscrotal and perineal approach for placement of penile prosthesis in cases of severe corporal fibrosis and scarring. Materials and methods. Three patients with extensive corporal fibrosis underwent penile prosthesis placement via combined penoscrotal and perineal approach from 1997 to 2006. Follow-up ranged from 15 to 129 months. Results. All patients underwent successful implantation of semirigid penile prosthesis. There were no short- or long-term complications. Conclusions. Results on combined penoscrotal and perineal approach to penile prosthetic surgery in this preliminary series of patients suggest that it is a safe technique and increases the chance of successful outcome in the surgical management of severe corporal fibrosis.

Corporeal excavation: New technique for penile prosthesis implantation in men with severe corporeal fibrosis

Introduction Penile prosthesis implantation in men who have fibrotic corpora as the result of ischemic priapism or previous removal of an infected penile prosthesis poses a significant challenge to the implanting surgeon. We describe a new technique, corporeal excavation, to meet this challenge. Technical Considerations The operative approach is through an inverted T penoscrotal incision that affords exposure of nearly the entire corpus cavernosum on each side. Extended corporotomies are made on the ventral aspect of each corpus cavernosum, and a plane of dissection between the fibrotic corporeal tissue and the inner surface of the tunica albuginea is established, resulting in core removal of nearly all fibrotic intracorporeal tissue. Cylinders are laid into the empty corporeal bed, and the tunica albuginea is closed primarily. Nine patients were identified who had undergone this procedure. The operative notes and medical records were reviewed, and telephone interviews were done for follow-up when patients had not been recently seen in the clinic. Conclusions Successful outcomes were achieved in all 9 patients. Corporeal excavation permits penile prosthesis implantation in men with severe intracorporeal fibrosis usually resulting from priapism or previous removal of infected penile prostheses.

Use of rectus fascia graft for corporeal reconstruction during placement of penile implant

Objectives To report on the technique of using autologous rectus fascia graft for corporeal and tunica reconstruction during placement of an inflatable penile prosthesis. Reconstructing the corpora cavernosa and closing the tunica albuginea over an inflatable penile prosthesis can be challenging when severe fibrosis is encountered. Methods Fifteen patients with severe fibrosis of the corpora or tunica were included in this study. Eight patients had severe corporeal fibrosis secondary to an infected or malfunctioned penile prosthesis that had been previously removed, and seven had severe penile curvature secondary to tunical fibrosis with concomitant erectile dysfunction. All patients underwent corporeal or tunica reconstruction using autologous rectus fascia after placement of an inflatable penile prosthesis. Postoperatively, patients were evaluated at 1, 6, 12, and 24 months. Data on patient satisfaction, graft function, and complications were recorded. Results At a mean follow-up of 18 months (range 12 to 64), augmentation of the tunica or corporeal defect using autologous rectus fascia graft was successful in all patients. The penile prostheses were functioning properly with no evidence of graft infection, erosion, or abdominal wall hematoma. Patients demonstrated good results, with return to sexual intercourse at a mean of 9 weeks postoperatively (range 8 to 10). Conclusions Use of an autologous rectus fascia graft for coverage of a tunical or corporeal defect during penile prosthesis placement in patients with corporeal or tunica fibrosis is surgically feasible, safe, and efficacious. Long-term follow-up of this reconstructive technique has demonstrated excellent clinical results with no morbidity related to the rectus fascia graft harvesting.

Reimplantation of inflatable penile prosthesis into scarred corporeal bodies.

Reimplantation of an inflatable three-piece prosthesis in a patient with severe corporeal fibrosis represents a formidable surgical challenge. In the past, a variety of techniques have been offered to facilitate implantation in these difficult patients including the use of instruments to produce a channel in which cylinders can be placed and choosing multiple surgical sites, including the use of surgical sites that have not previously been used. The author of this communication describes newer tools and techniques to enhance placement of an inflatable device in patients with severe fibrosis. This includes the use of specially designed cavernotomes for dilating fibrotic corpora, the use of downsized prosthetic cylinders, alternative procedures to fix cylinders in the face of perforation as opposed to primary closure of the perforation, and replacing the original cylinders after 1 y after the modified cylinders have served as tissue expanders. Details of these newer techniques are presented by an experienced surgeon.

MANAGEMENT OF SEVERE CORPOREAL FIBROSIS WITH IMPLANTATION OF PROSTHESIS VIA A TRANSVERSE SCROTAL APPROACH

Purpose We reviewed our experience in the management of severe corporeal fibrosis with placement of the AMS 700 CXM * * American Medical Systems, Minnetonka, Minnesota. prosthesis to determine the efficacy of this approach. Materials and Methods The records of 26 men with severe corporeal fibrosis who underwent placement of the AMS 700 CXM prosthesis via a transverse scrotal approach between August 1991 and July 1996 were reviewed. Results In all cases the AMS 700 CXM prosthesis was successfully implanted with primary closure of the tunica albuginea, although 2 patients required extended corporotomies. Followup data were available on all 26 men. At a mean followup of 22.5 months (range 3 to 63) 24 of the 26 men had a functional device (92%). One patient required explantation for infection and 1 underwent explantation for cylinder cross-over. Conclusions Implantation of the AMS 700 CXM prosthesis in patients with severe corporeal fibrosis produced good results at approximately 2 years of followup.

USE OF PENILE PROSTHETIC IMPLANTS IN PATIENTS WITH PENILE FIBROSIS

For a subset group of impotent patients with penile fibrosis, the implantation of a penile prosthesis is their only therapy for restoration of erectile function. In many cases, using a penile prosthesis requires additional corporal reconstructive procedures to rebuild fibrotic corporal bodies. Unfortunately, the surgeon is rarely forewarned that reconstructive surgery will be necessary despite a variety of historic factors that would suggest the possibility of encountering unsuccessful corporal dilatation. To be forewarned is to possibly decide that implant surgery is contraindicated, thereby denying some patients one last opportunity to have potency restored. Corporal reconstruction with or without use of synthetic graft material will not be suitable for all patients in whom severe corporal fibrosis is encountered. There is a relatively high risk of infection in these patients and an indepth, preoperative discussion with those patients in whom corporal reconstruction is considered a possibility is essential in order to be assured of the patient's motivation to "go the extra mile." For some patients, as an elective procedure, there is definitive unwillingness to undergo such a complicated procedure. In those cases, it is usually mutually agreed that if extensive corporal fibrosis is encountered, the procedure will simply be abandoned and no attempt will be made to carry out corporal reconstruction. Many patients with penile fibrosis are young which attests to their greater motivation to not permit their sex life from being terminated at an unacceptably early age. Quite rightly, they maintain that benefits of corporal reconstruction, when successful, far outweigh the risks.

Systemic Sclerosis and Impotence: A Clinicopathological Correlation

A hypothesis of the mechanism of systemic sclerosis associated impotence was developed by making a clinicopathological correlation between the results of preoperative erectile function testing and those of pathological examination of excised erectile tissue in an impotent man with systemic sclerosis. Preoperative examination revealed firm corporeal tissue with diminished penile stretch capability. Pharmacocavernosometry/pharmacocavernosography under conditions consistent with trabecular smooth muscle relaxation revealed severe diffuse corporeal veno-occlusive dysfunction. During penile implantation surgery the compact erectile tissue was unable to be dilated and required sharp corporeal tissue excision under direct vision to achieve cylinder insertion. Histological investigation of the excised corporeal tissue demonstrated severe corporeal fibrosis. Computer assisted color histomorphometry revealed that the mean percentage of trabecular smooth muscle area to total erectile tissue area was 18.2 plus/minus 13.9 percent (normal 40 to 52). Immunohistochemical staining with desmin, a protein found in smooth muscle, verified prolific corporeal fibrosis. In situ hybridization of the corporeal tissue demonstrated messenger ribonucleic acid collagen and fibronectin messenger ribonucleic acid expression. Strong hybridization signals were found in mesenchymal cell types, including trabecular smooth muscle cells. In summary, clinicopathological correlation revealed that veno-occlusive dysfunction and loss of penile length were secondary to the excessive accumulation of extracellular matrix, partially due to trabecular smooth muscle cells undergoing synthetic as opposed to contractile phenotypic activity.

Extensive Corporeal Fibrosis After Penile Irradiation

A potent man with early signs and symptoms of Peyronie's disease 3 months in duration received 1,200 rad of external beam radiation to the penis and presented 5 months later with impotence. Physical examination revealed diffusely woody indurated corporeal tissue. Nocturnal penile tumescence testing was abnormal and pharmaco-cavernosometry demonstrated diffuse corporeal veno-occlusive dysfunction. Treatment by penile injections was unsuccessful. During penile prosthesis implantation bilateral rubbery erectile tissue was encountered, requiring extensive bilateral corporotomy and sharp corporeal tissue excision for prosthesis insertion. Histological analysis of excised corporeal tissue demonstrated extensive corporeal fibrosis and arterial vasculopathy. Computer assisted color histomorphometry revealed that the mean percentage of trabecular smooth muscle area to total erectile tissue area was 26.5 +/- 15.8 (normal 40 to 52%). Immunohistochemical staining with desmin confirmed extensive fibrosis. The most likely explanation for severe corporeal fibrosis is penile irradiation. The hypothesized mechanism of radiation associated fibrosis is ionizing injury to the endothelial cells of the lacunar spaces and cavernous/helicine arteries, which induced irreversible corporeal extracellular matrix structural changes. Penile irradiation, like vascular disease and priapism, is a potential cause of diffuse corporeal fibrosis.