University of North Carolina, Chapel Hill, North Carolina, USA

Correspondence to: C C Carson, University of North Carolina, Division of Urology, 427 Burnett-Womack, CB 7235, Chapel Hill, NC 27599-7235, USA. E-mail: carson@med.unc.edu

Subcutaneous extrusion of penile prosthesis cylinders beneath the glans penis is an unusual but difficult complication of penile prosthesis. Without surgical repair, extrusion, infection, and corporeal fibrosis may ensue. Twenty-eight patients with distal corporeal extrusion were reviewed to identify the optimum treatment outcome for these penile prosthesis complications. Records of 28 men with subcutaneous distal penile prosthesis cylinder extrusion were reviewed. Mean age was 56.2 y. Etiology of erectile dysfunction was diabetes mellitus in 11, vasculogenic in 10, Peyronie's disease in five, radical pelvic surgery in five. Duration of penile prosthesis was 8-72 months (mean 42.6). No patient had penile prosthesis infection or device exposure through the skin. Distal corporoplasty was treated on 18/28 men using cylinder repositioning and direct tunica albuginea repair. Ten men underwent repair using a Gortex windsock. 8/18 corporoplasty and 6/10 windsock patients required glans fixation for treatment of hypermobile glans following cylinder relocation. In two patients with windsock repair, extrusion recurrence occurred 6 and 18 months following surgery and 1/6 had post operative infection requiring prosthesis removal. Mean surgical time for corporoplasty was 52.8 minutes while windsock reconstruction was 89.6 minutes. Distal subcutaneous penile prosthesis cylinder extrusion produces coital pain and predisposes to cylinder exposure and infection. Early repair with or without additional prosthetic materials will return penile prostheses to a normal functioning state. Distal corporoplasty with cylinder repositioning appears to be a simple, low morbidity solution to this difficult dilemma. Outcomes with distal corporoplasty result in better function, less pain, and fewer recurrences than Gortex windsock repair.

International Journal of Impotence Research (2002) 14, 81-84. DOI:10.1038/sj/ijir/3900829

penile prosthesis; extrusion; erectile dysfunction; infection; penile pain

Introduction

Penile prosthesis implantation continues to be appropriate therapy for men with organic erectile dysfunction who have failed less invasive therapy and are motivated to pursue continued erectile function and sexual activity. While penile prosthesis implantation is widely successful and infection rates low, surgical and mechanical morbidity continues in a small number of patients.¹ Urologists implanting penile prostheses must be familiar with morbidity associated with penile prostheses, and methods for revision, reconstruction, and salvage. One complication of penile prosthesis implantation involves distal extrusion of the penile prosthesis cylinder through the corpus cavernosum during or after the implantation procedure. These erosions may occur from overly vigorous distal dilation, but are most common in patients with decreased distal penile sensation such as paraplegics, diabetics, and patients with previous irradiation or corporal fibrosis.² Another etiology may be use of standard cylinder diameters in men with a narrow or scarred penis when narrow, down-sized cylinders such as AMS 700CXM or Mentor Alpha Narrow might be more appropriate. Various methods have been suggested for repair of these distal penile erosions.^2,3,4 They include direct closure of the distal corpus cavernosum with replacement of the penile prosthesis in its original position, corpus closure with prosthesis downsizing, patching of the corpus cavernosum with synthetic or autologous material, and prosthetic cylinder rerouting.

This study compares surgical time, outcome and morbidity from two standard techniques for treatment of distal penile prosthesis extrusion.

Patients and methods

Between August 1993 and June 2001, 28 men with penile prosthesis were evaluated for distal penile prosthesis cylinder extrusion. All patients had inflatable penile prostheses. Mean age was 56.2 y (range 39-74). Twenty-three men had AMS 700, three Mentor Alpha1, and two Surgitek Uniflate 1000 prostheses. Etiology of erectile dysfunction (ED) was diabetes mellitus in 11, severe vascular disease in 10, Peyronies disease in 5, radical pelvic surgery in 5. Nine patients had had previous penile prosthesis revisions for corporal fibrosis or penile prosthesis infection. No patient had penile prosthesis infection at the time of revision for distal extrusion. All patients underwent surgical revision by the same urological surgeon (CC). All surgical procedures were carried out under general or spinal anesthetic and all patients were premedicated with broad spectrum prophylactic antibiotics before induction of anesthesia. Patient records were reviewed for subsequent morbidity, recurrence, and outcome.

Patients underwent two types of surgical procedures. Distal corporoplasty with rerouting of the penile prosthetic cylinder or Gortex graft reinforcement of the area of extrusion. Eight of 10 men who underwent Gortex windsock reinforcement were operated on prior to the use of the rerouting procedure.

Eighteen men underwent distal extrusion repair using a Gortex windsock reinforcement. Gortex windsock placement procedures were carried out by proximal exposure of the corpus cavernosum and penile prosthesis cylinder infrapubically in 14 men and penoscrotally in four. A Gortex 'windsock' patch was created from Gortex polytetrafluoroethylene (PTFE) polypropylene mesh (Marlex). A windsock was created by tailoring a piece of flat 0.6 mm Gortex to match the shape of the distal portion of the penile prosthetic device. The windsock shape is created by suturing two sides of the tailored patch together with soft nonabsorbable suture, usually 3-0 Gortex suture. The long ends of the suture may be kept to secure the windsock in place to the tunica albugineas once positioning is complete. The Gortex windsock patch is placed on the distal portion of the prosthetic cylinder, the prosthetic cylinder is reinserted using a Furlow insertion tool with a Keith needle. Once positioned, the Gortex patch is pulled into position with the cylinder stitch. To reduce the possibility of future extrusion, the windsock is secured to the corpus cavernosum with interrupted sutures of 2-0 or 3-0 PDS. The tunica albuginea is then closed over the windsock and prosthetic cylinder. When the closure is compromised by the girth of the Gortex patch, additional patching material may be used to reinforce the distal portion of the corpus cavernosum. Post operatively, patients are asked to maintain prosthesis flaccidity for 4-6 weeks and perioperative antibiotics are carried out in a standard post-operative fashion.

Rerouting procedures are carried out in a fashion previously described by Mulcahy and Carson.^2,3 This procedure begins with a circumcoronal incision over the extruded prosthetic cylinder. Peri-operative antibiotics and anesthesia were similar to that described earlier. A circumcoronal incision is used, and is extended half-way around the penis in a 180° are whose center point is over the extruded cylinder tip. Skin is retracted to an area approximately 2 cm proximal to the corona penis and Buck's fascia is dissected free from the tunica albuginea. Using electrocautery, a longitudinal corporotomy incision is completed on the lateral aspect of the penile shaft to avoid the penile nerve supply. The penile prosthesis is then fully deflated and the cylinder retracted into the wound. Using electrocautery, a transverse incision is carried out in the medial portion of the surgical capsule. Care must be taken not to expose the contralateral prosthetic cylinder. Using blunt dissection, a channel is created in this proximal area in the normal corpus cavernosum tissue, dilating to an area in the distal corpus cavernosum beneath the glans penis. The tunica albuginea is usually preserved despite cylinder extrusion and is easily visualized and dissected free for subsequent closure. After creating a distal channel using Metzenbaum scissor dissection, Hegar or Brooks dilators are used to complete dilation of the distal portion of the corpus cavernosum, taking care not to injure the distal end of the corpus cavernosum. The prosthetic cylinder is then replaced in the new, more medial location using a Furlow inserter and Keith needle. Thorough irrigation of the operative site is performed using antibiotic solution and the corpus cavernosum closed carefully using 3-0 PDS sutures. Buck's fascia is then secured with 4-0 chromic catgut and a subcuticular distal penile closure carried out using additional 4-0 chromic catgut. A dry sterile dressing is applied without compression. Following extrusion repair, six of 18 corporoplasty and five of 10 Goretex windsock patients required glanuloplasty as previously described.

Patient records were reviewed for subsequent morbidity, outcome, and recurrence.

Results

Twenty-eight men with subcutaneous distal penile prosthesis cylinder extrusion underwent revision procedures. Pre-procedure complaints included patient pain 26/28, partner discomfort 14/28, concern for extrusion 14/28, penile curvature 10/28, difficulty voiding 2/28. Prosthetic devices had been in place from 8 to 82 months (mean 46.8). Comparative patient profile is reviewed in Table 1.

Mean surgical time was 52.8 minutes for rerouting (range 36-81), for windsock 89.6 minutes (range 64-142). Morbidity for the two procedures is outlined in Table 2. Major morbidity was more frequently seen with windsock procedures, however, post operative prolonged pain and discomfort were equally distributed between the two groups. One patient with the windsock technique sustained a post-operative penile prosthesis associated infection requiring prosthesis explantation and two patients had recurrence of extrusion 6 and 18 months after repair.

Functional results were similar with the two groups. While one patient with rerouting sustained glans hypesthesia, 26 of 28 patents reported return to normal function and coital activity using their penile prosthetic device at an average follow-up of 34.2 months (range 6-85). Four patients with continued post-operative pain, resolved their pain 6-11 months after revision surgery.

Discussion

Distal penile prosthesis cylinder extrusion without associated penile prosthesis infection is an uncommon, but repairable complication of penile prosthetic implantation. Because of distal penile pain and discomfort, penile curvature, and partner discomfort, revision and modification of a prosthetic device to relieve this complication and to prevent erosion of the prosthetic cylinders through the skin, surgical revision is frequently required. The presence of a suspected infection, periprosthetic fluid, purulent exudate or erosion through the penile skin or urethra contraindicate immediate repair and revision procedures. Earlier use of synthetic or autologous materials to repair these extruded cylinders required exposure of the prosthetic device at the proximal corporotomy incision, significant manipulation of the prosthesis, and subsequent longer operating time and more difficult recovery. Mulcahy described a rerouting procedure in 14 patients with follow-up as long as 2 y.² His report documents rerouting was successful and all 14 patients returned to normal prosthetic and sexual function following their revision. Alter et al, have used a tunica vaginalis fascial flap to reconstruct the tunica albuginea following the extrusion with satisfactory success.⁸ Hellstrom and Reddy reported cadaveric allograft material for reinforcement procedures and plaque incision with similar success.⁹ Jarow and Carson have reported increased infection rates in penile prostheses with construction using artificial material with higher morbidity.^7,10 Difficult penile prosthesis implantation requiring reinforcement materials, whether natural or artificial, result in increased infection rates. Jarow reports the risk of penile prosthesis at 21.7% in patients requiring reconstruction and artificial materials compared with an overall penile prosthesis infection rate of 1.8%.¹⁰ Similarly, Carson reports an increase in infection risks in patients requiring Gortex graft for reconstruction in patients with severe corporal fibrosis.⁷ These complex reconstructions not only require additional artificial material but also longer operative times, more incisions, and additional foreign bodies.¹¹

Hsu and Brock have reported that the distal corporal tunica albuginea is thinner and layers less reinforced than penile shaft tunica.⁵

While implantation of penile prosthetic devices continues to increase as patients requiring more invasive treatment of their erectile dysfunction continue to emerge, unique morbidity associated with penile prostheses requires creative approaches by urologic surgeons. Distal subcutaneous penile prosthesis cylinder erosion produces coital pain and predisposes the cylinder to exposure, erosion and infection. Early repair is important and minimal morbidity can be maintained with rerouting procedures compared with more aggressive, more significant reinforcement procedures using Gortex, cadaveric materials, or tunical vaginalis. Distal corporoplasty rerouting results in shorter operative time, better function, less pain, and fewer recurrences than Gortex windsock repair.

1 Carson CC, Mulchy JJ, Govier FE. Efficacy, safety, and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis: results of a long term multicenter study. J Urol 2000; 164: 376-380. MEDLINE

2 Mulcahy JJ. Distal corporoplasty for lateral extrusion of penile prosthesis cylinders. J Urol 1999; 161: 193-195. MEDLINE

3 Carson CC. Repair of distal extrusion of a penile prosthesis. Contemp Urol 1998; 10: 13-17.

4 Fishman IJ. Corporal reconstruction for penile prosthesis implantation. Prob Urol 1993; 7: 350-367.

5 Hsu GL et al. Anatomy and strength of a tunica albuginea: its relevance to penile prosthesis extrusion. J Urol 1994; 151: 1205-1208. MEDLINE

6 Ball TP. Surgical repair of penile SST deformity. Urology 1980; 15: 603-605. MEDLINE

7 Carson CC. Increased infection risks with corpus cavernosum reconstruction and penile prosthesis implantation with corporal fibrosis. Int J Impot Res 1996; 8: (Suppl) S155.

8 Alter GJ et al. Use of prefabricated tunica vaginalis fascia flap to reconstruct the tunica albuginea after recurrent penile prosthesis extrusion. J Urol 1998; 159: 128-132. MEDLINE

9 Hellstrom WJ, Reddy S. Application of pericardial grafts in the surgical treatment of Peyronies disease. J Urol 2000; 163: 1445-1448. MEDLINE

10 Jarow JP. Risk factors for penile prosthesis infection. J Urol 1996; 156: 402-404. MEDLINE

11 Hershorn S, Ordorica RC. Penile prosthesis insertion with corporal reconstruction with synthetic vascular graft material. J Urol 1995; 154: 80-84. MEDLINE

12 Lewis RW, McLauren R. Reoperation for penile prosthesis implantation. Prob Urol 1993; 3: 381-401.

Table 1 Patient profile in 28 men

Table 2 Results in 28 men