Saturday, 29 October 2016

Implantation of three pieces inflatable penile prosthesis in patients with refractory erectile dysfunction

At present, patients with erectile dysfunction non responsive to oral medications and intracavernosal injection therapy are best served with penile prosthesis implantation.  
Among the various types of penile prosthesis available, the best results are achieved after the implantation of three pieces inflatable penile prosthesis as they guarantee a more natural erection and better girth and rigidity than their semirigid counterpart. 
Three pieces inflatable penile prosthesis are formed by 2 cylinders, which will be placed inside the corpora cavernosa of the penis, a pump, usually located in the scrotum between the testicles, and an intra-abdominal reservoir.  The components of the implant are connected by small tubing and all the system is filled with sterile water.
In most cases the device can be inserted though a 3 cm long incision at the root of the scrotum. This approach guarantees enough exposure to allow the surgeon to place the cylinders, the pump and the reservoir.
Classically the reservoir is positioned in proximity to the urinary bladder in the pelvis, but more recently an ectopic placement under the external oblique muscle of the abdomen has been described in patients who have previously undergone pelvic surgery.
Ectopic placement of the reservoir now represents the solution of choice in patients who have undergone previous extensive pelvic surgery as the classical placement in the pelvis would be associated with a significant risk of injury of the intra-abdominal organs. In the past these patients were managed with insertion of the reservoir under direct vision though a second abdominal incision. Ectopic placement of the reservoir is safe, as the device is positioned above the fascia transversalis, well away from the intra-abdominal organs, and avoids the inconvenience of performing a second abdominal incision.
Penile prosthesis implantation is usually performed under general anaesthetic and the procedure takes less than one hour. Patients are discharged the day after and usually are able to engage in penetrative sexual intercourse after six weeks.
In the hands of experienced high volume surgeons, this procedure is very safe with patients' and partners' satisfaction rates well above 95%.
Mechanical reliability of the device is also extremely high and in most patients the implant is still perfectly working after 10 years. Furthermore, if the device stops working, it can be easily replaced.

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