primary and redo-penile implant surgery: lessons learnt
TRANSCRIPT
Primary and Redo-penile implant surgery: Lessons learnt
by Antoine Faix (MD, Urologist-Andrologist)
www.mhisc.chMen’s Health International Surgical Center - Place des Philosophes 18, 1205 Geneva Switzerland
The«basic»lessonsforRegularimplanters
Consensus2016
ICSM
When?TherightindicaOonAND
TherightpaOent
PrimaryPenileImplant• RestoraOngoferecOlefuncOoninmen
withrefractoryorganicerec2ledysfunc2on(ED)aRerfailure,rejec2onofothertreatmentopOonsinmo2vatedpa2ents
• InformaOonsofalterna2vetreatmentopOons,appropriateexpectaOons,andincreasedrisksassociatedwithdiabetes,acOvesmoking,andothercomorbidiOes
• Preopera2veinforma2onsofspecificpotenOalareasofcomplicaOonand/ordissaOsfacOon,includinginfec2onanditsconsequences,pain,decreasedlengthandgirth,injurytosurroundingOssues,andmechanicalfailure.
• ANDMOTIVATEDANDTRAINEDSURGEONS!Levelofevidence4,strengthofrecommenda2onC
RedoPenileImplant• Anykindofmechanicalfailure,post-PPablaOon
orinfectedPP
• PreoperaOveinformaOonsofhigherriskof
everykindofcomplicaOon
• ANDMOTIVATEDANDEXPERTSURGEONS!
When?TherightindicaOonAND
TherightpaOent
PrimaryPenileImplant• RestoraOngoferecOlefuncOoninmen
withrefractoryorganicerec2ledysfunc2on(ED)aRerfailure,rejec2onofothertreatmentopOonsinmo2vatedpa2ents
• InformaOonsofalterna2vetreatmentopOons,appropriateexpectaOons,andincreasedrisksassociatedwithdiabetes,acOvesmoking,andothercomorbidiOes
• Preopera2veinforma2onsofspecificpotenOalareasofcomplicaOonand/ordissaOsfacOon,includinginfec2onanditsconsequences,pain,decreasedlengthandgirth,injurytosurroundingOssues,andmechanicalfailure.
• ANDMOTIVATEDANDTRAINEDSURGEONS!Levelofevidence4,strengthofrecommenda2onC
RedoPenileImplant• Anykindofmechanicalfailure,post-PPablaOon
orinfectedPP
• PreoperaOveinformaOonsofhigherriskof
everykindofcomplicaOon
• ANDMOTIVATEDANDEXPERTSURGEONS!
How?TrytoavoidsepsisANDTrytodothebest!
PrimaryPenileImplant• Usean2bio2c-impregnatedorhydrophilic
coateddevicesifinflatablePP• PreoperaOveanObioOcswithgram-posiOveand
gram-negaOvecoverageshouldbegivenwiththerapeuOcanObioOclevels
• Avoidtrauma2cskin:ShavingvsclippingtoremovescrotalhairisleRtothesurgeon’sdiscreOon
• Usealcohol-basedskinprepara2onsintheoperaOngroomastheoperaOvesitescrub.
• MinimizeskinanddevicecontactcandecreaseinflatablePP(IPP)infecOonrates.
• PenoscrotalANDInfra-pubicarethemainapproachesforinserOngPPaccordingthesurgeon
RedoPenileImplant• Penileimplantrevisionsurgeryshouldinclude
theuseofcopiousirriga2on,preferablywithanOmicrobials.
• InstablepaOentswithinfectedPPs,reasonableademptsshouldbemadetoremovealldevicecomponents.
• ForpenileimplantinfecOon,surgeonsshoulddeterminewhetherandwhentoaHemptsalvageprocedure.
• ForthepaOentwithpost-explantIPPand
corporalfibrosis,surgeonsshouldbepreparedtoperformspecializedmaneuvers
• Useofspecificcavernotomes,longeror
addiOonalcorporotomyincisions,and/orcorporalexcavaOon
Thechoice!
InflatablePP• PerfectImplantforyoung
paOentwithoutanymanualproblem
• FlacidityandErecOonstates• Needatrainingbeforefirst
manipulaOon(simplestep)
MalleablePP• Malleableimplantsare
recommendedforpaOentswithcompromisedmanualdexterity(rhumatological,neurological…)butmightbeappropriateinotherclinicalscenario(obesity,personalchoice…)
• Besurethatdressingandeverydaylifewillbeeasywithapermanent«semi-rigidpenis»
ARer?TakeOmeAND
Trytodothebest!
PrimaryPenileImplant• Theclinicianshouldprovide
adequatepostsurgicalfollow-uptomaximizepaOentsaOsfacOon,assessforpotenOalcomplicaOons,andassureappropriatedeviceplacementandfuncOon.
RedoPenileImplant• Theclinicianshouldprovide
adequatepostsurgicalfollow-uptomaximizepaOentsaOsfacOon,assessforpotenOalcomplicaOons,andassureappropriatedeviceplacementandfuncOon.
ARer?TakeOmeAND
Trytodothebest!
PrimaryPenileImplant• Theclinicianshouldprovide
adequatepostsurgicalfollow-uptomaximizepaOentsaOsfacOon,assessforpotenOalcomplicaOons,andassureappropriatedeviceplacementandfuncOon.
RedoPenileImplant• Theclinicianshouldprovide
adequatepostsurgicalfollow-uptomaximizepaOentsaOsfacOon,assessforpotenOalcomplicaOons,andassureappropriatedeviceplacementandfuncOon.
The«specific»lessons
forExpertsimplanters
SepsisSalvageornotsalvage…
Differentsitua2ons• Majorsepsis• Uretrallesion• Skinnecrosis• Notstabilizedcomorbidityfactors
• Silentsepsis(inthebeginning)• Erosionpump• Persistentpain• StablepaOent
Differentstrategies• NoSALVAGE
• Removeallthecomponents• Repairifnecessary• ProlongedadaptedanObioOcs• Stretchingtherapybeforenew
implantaOon(Vacuum,TracOon…)
• SALVAGE• Removeallthecomponents• SavetheCCdilataOonwithPP
(MalleableorsoRPP)• Ifpossible3components
(dependsonthescrotalarea)• ProlongedadaptedAnObioOcs
Salvage Protocol
Salvage Protocol
RedoaRerMechanicalFailureHowtomanage…
Differentsitua2ons• UsuallyaRermanyyears
SurgicalStrategies• 3componentschange
• ExceptedifrecentimplantaOon• Reservoir+/-otherside• Repairifnecessary(distal
erosion,graR,etc…)
• HowtoopOmize?• Mini-Salvageprotocol• Longercylinders?
Abouassaly J Urol 2006 Vol 176 2471-2473
RedoaRersepsisHowtobeprepared!…
Differenttools• Specificcavernotomes
(Mooreville,Rossello…)• Differentstrategiesaccordingthe
situaOon
Differentstrategies• Goodexposureof
cavernotomies+/-extensive• +/-doubleapproach• +/-Extensivecavernectomies
RedoaRersepsisHowtobeprepared!…
Differenttools• Specificcavernotomes
(Mooreville,Rossello…)• Differentstrategiesaccordingthe
situaOon
Differentstrategies• Goodexposureof
cavernotomies+/-extensive• +/-doubleapproach• +/-Extensivecavernectomies
Post-PriapismaspecificsituaOon!…
Assoonaspossible….• Iflate,samesituaOon
(oRenworst!)asRedoaRersepsis
• PPtobeconsideredaNer72hourspriapismwithoutresoluOondespiteadequatetreatments(MRI+/-Biopsy)
• IfearlysituaOon(2weekspostacutepriapismnotresolved)
Specificpoints• BecarefulincaseofAl
GhorabprocedureforthedistaldilataOon
• BecarefulincaseofQuackelsprocedureforthemedialdilataOon
• DoublecavernotomiessomeOmesnecessary
• Psychologicalmanagement
