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Complications and troubleshooting in primary penile prosthetic surgery—a review

International Journal of Impotence Research volume 35, pages 679–685 (2023)Cite this article

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Abstract

Penile implant surgery is the gold standard to treat erectile dysfunction with success rates of over 90%. The first penile implants were developed in the early 1900s. Since then, several types of implants have been developed including malleable implants, two-piece inflatable implants, and three-piece inflatable implants. The three-piece inflatable penile prosthesis, which was introduced in 1973, is the most widely used type of penile implant in the United States. Penile implant surgery has undergone numerous advancements over the years, improving outcomes and patient satisfaction. However, as with any surgical procedure, there are risks and complications associated with penile implant surgery. It is important for surgeons to understand these potential complications and to have strategies in place to manage and prevent them to achieve the best possible outcomes for their patients.

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Fig. 1: Glans hypermobility, also referred to as Supersonic transporter deformity (SST).
Fig. 2: Here the normal lateral deviation of the proximal corporal body is shown with a proximal perforation corrected with a suture sling.
Fig. 3: Distal urethral injury identification.
Fig. 4: Glans ischemia.
Fig. 5: Correction of penoscrotal webbing.

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References

  1. Burnett AL, Nehra A, Breau RH, Culkin DJ, Faraday MM, Hakim LS, et al. Erectile dysfunction: AUA guideline. J Urol. 2018;200:633–41.

    Article  PubMed  Google Scholar 

  2. Salonia A, Bettocchi C, Capogrosso P, Carvalho J, Corona G, Hatzichristodoulou G, et al. EAU Guidelines on Sexual and Reproductive Heatlh. 2023. Available from: https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/management-of-erectile-dysfunction.

  3. Gee WF. A history of surgical treatment of impotence. Urology. 1975;5:401–5.

    Article  CAS  Google Scholar 

  4. Henry GD. Historical review of penile prosthesis design and surgical techniques: part 1 of a three-part review series on penile prosthetic surgery. J Sex Med. 2009;6:675–81.

    Article  PubMed  Google Scholar 

  5. Scott FB, Bradley WE, Timm GW. Management of erectile impotence. Use of implantable inflatable prosthesis. Urology. 1973;2:80–2.

    Article  CAS  PubMed  Google Scholar 

  6. Wilson SK, Delk JR. Historical advances in penile prostheses. Int J Impot Res. 2000;12:S101–7.

    Article  PubMed  Google Scholar 

  7. Rodriguez KM, Pastuszak AW. A history of penile implants. Transl Androl Urol. 2017;6:S851–7.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Barnard JT, Cakir OO, Ralph D, Yafi FA. Technological advances in penile implant surgery. J Sex Med. 2021;18:1158–66.

    Article  PubMed  Google Scholar 

  9. Sokolakis I, Pyrgidis N, Ziegelmann MJ, Mykoniatis I, Köhler TS, Hatzichristodoulou G. Penile prosthesis implantation combined with grafting techniques in patients with Peyronie’s disease and erectile dysfunction: a systematic review. Sex Med Rev. 2022;10:451–9.

    Article  PubMed  Google Scholar 

  10. Ziegelmann MJ, Farrell MR, Levine LA. Modern treatment strategies for penile prosthetics in Peyronie’s disease: a contemporary clinical review. Asian J Androl. 2020;22:51–9.

    Article  PubMed  Google Scholar 

  11. Polchert M, Dick B, Raheem O. Narrative review of penile prosthetic implant technology and surgical results, including transgender patients. Transl Androl Urol. 2021;10:2629–47.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Chung E. Penile prosthesis implant in the special populations: diabetics, neurogenic conditions, fibrotic cases, concurrent urinary continence surgery, and salvage implants. Asian J Androl. 2020;22:39–44.

    Article  PubMed  Google Scholar 

  13. Purohit RS, Kent M, Djordjevic ML. Penile prosthesis in transgender men after phalloplasty. Indian J Plast Surg. 2022;55:168–73.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Ziegelmann M, Köhler TS, Bailey GC, Miest T, Alom M, Trost L. Surgical patient selection and counseling. Transl Androl Urol. 2017;6:609–19.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Trost LW, Baum N, Hellstrom WJ. Managing the difficult penile prosthesis patient. J Sex Med. 2013;10:893–906.

    Article  PubMed  Google Scholar 

  16. Köhler TS, Wen L, Wilson SK. Penile implant infection prevention part 1: what is fact and what is fiction? Wilson’s Workshop #9. Int J Impot Res. 2020;33:785–92.

    Article  PubMed  Google Scholar 

  17. Habous M, Tal R, Tealab A, Soliman T, Nassar M, Mekawi Z, et al. Defining a glycated haemoglobin (HbA1c) level that predicts increased risk of penile implant infection. BJU Int. 2018;121:293–300.

    Article  CAS  PubMed  Google Scholar 

  18. Hebert KJ, Kohler TS. Penile prosthesis infection: myths and realities. World J Mens Health. 2019;37:276–87.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Pang KH, Muneer A, Alnajjar HM. A systematic review of penile prosthesis insertion in patients with spinal cord injury. Sex Med Rev. 2022;10:468–77.

    Article  PubMed  Google Scholar 

  20. Masterson TA, Palmer J, Dubin J, Ramasamy R. Medical pre-operative considerations for patients undergoing penile implantation. Transl Androl Urol. 2017;6:S824–9.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Krakhotkin DV, Ralph DJ, Blecher GA, Chernylovskyi VA, Greco F, Bakurov EE, et al. Management of residual penile curvature after penile prosthesis placement. Asian J Androl. 2021;23:129–34.

    Article  CAS  PubMed  Google Scholar 

  22. Levine LA, Dimitriou RJ. A surgical algorithm for penile prosthesis placement in men with erectile failure and Peyronie’s disease. Int J Impot Res. 2000;12:147–51.

    Article  CAS  PubMed  Google Scholar 

  23. Van Dyke M, Baumgarten AS, Ortiz N, Hudak SJ, Morey AF. State of the reservoir: current concepts of penile implant reservoir placement and potential complications. Curr Urol Rep. 2021;22:20.

    Article  PubMed  Google Scholar 

  24. Wen L, Köhler TS, Helo S. A narrative review of the management of benign prostatic hyperplasia in patients undergoing penile prosthesis surgery. Transl Androl Urol. 2021;10:2695–704.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Valenzuela RJ, Ziegelmann MJ, Hillelsohn JH, Farrell MR, Kent MA, Levine LA. Preliminary outcomes of the male urethral “mini-sling”: a modified approach to the Andrianne Mini-Jupette procedure with penile prosthesis placement for climacturia and mild stress urinary incontinence. J Sex Med. 2019;16:1310–7.

    Article  PubMed  Google Scholar 

  26. McAbee KE, Pearlman AM, Terlecki RP. Infection following penile prosthesis placement at an academic training center remains low despite involvement of surgeons-in-training. Investig Clin Urol. 2018;59:342–7.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Hinds PR, Wilson SK, Sadeghi-Nejad H. Dilemmas of inflatable penile prosthesis revision surgery: what practices achieve the best outcomes and the lowest infection rates? (CME). J Sex Med. 2012;9:2483–91.

    Article  PubMed  Google Scholar 

  28. Eid JF. Penile implant: review of a “no-touch” technique. Sex Med Rev. 2016;4:294–300.

    Article  PubMed  Google Scholar 

  29. Bole Md R, Habashy Md E, Yang Md D, Ahmed MBBCh M, Trost Md L, Ziegelmann Md M, et al. Timing and causative organisms associated with modern inflatable penile prosthesis infection: an institutional retrospective. J Sex Med. 2023;20:107–12.

    Article  Google Scholar 

  30. Huynh LM, Huang E, El-Khatib FM, Gross MS, Yafi FA. A systematic review of literature regarding whether immediate preoperative hemoglobin A1c or serum glucose are risk factors for infection following penile prosthesis implantation. Urology. 2021;152:15–24.

    Article  PubMed  Google Scholar 

  31. Talib R, Alnadhari I, Canguven O, Yassin A, Shamsodini A, Alrumaihi K, et al. HbA1c over 8.5% is not predictive of increased infection rate following penile prosthesis implant surgery in diabetic patients with erectile dysfunction. Andrologia. 2021;53:e14132.

    Article  CAS  PubMed  Google Scholar 

  32. Carvajal A, Benavides J, García-Perdomo HA, Henry GD. Risk factors associated with penile prosthesis infection: systematic review and meta-analysis. Int J Impot Res. 2020;32:587–97.

    Article  PubMed  Google Scholar 

  33. Miller JA, Bennett NE. Comparing risk factors for adverse outcomes in virgin inflatable penile prosthesis implantations and revisions: a retrospective cohort study. Sex Med. 2020;8:388–95.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Mulcahy JJ. Current approach to the treatment of penile implant infections. Ther Adv Urol. 2010;2:69–75.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Mulcahy JJ. Long-term experience with salvage of infected penile implants. J Urol. 2000;163:481–2.

    Article  CAS  PubMed  Google Scholar 

  36. Brant MD, Ludlow JK, Mulcahy JJ. The prosthesis salvage operation: immediate replacement of the infected penile prosthesis. J Urol. 1996;155:155–7.

    Article  CAS  PubMed  Google Scholar 

  37. Jiang D, Barnard J, Barham DW, Furr J, Lentz A, van Renterghem K, et al. Immediate salvage with inflatable penile prosthesis in an infected field is associated with a high success rate. Int J Impot Res. 2022. https://doi.org/10.1038/s41443-022-00576-2.

    Article  PubMed  Google Scholar 

  38. Swanton AR, Gross MS, Munarriz RM, Mulcahy JJ. Penile prosthesis salvage: a historical look at the Mulcahy technique and a review of the latest literature. Int J Impot Res. 2023;35:90–94.

  39. Wilson SK, Parker J, Carrion R, Simhan J. Distortion of the implanted penis: SST and cylinder crossover. Int J Impot Res. 2021;33:278–85.

    Article  PubMed  Google Scholar 

  40. Bickell M, Manimala N, Parker J, Steixner B, Wiegand L, Carrion R. Floppy glans syndrome: pathogenesis and treatment. Sex Med Rev. 2016;4:149–56.

    Article  PubMed  Google Scholar 

  41. Ziegelmann MJ, Alom M, Bole R, Kohler T, Trost L. Modified glanulopexy technique for supersonic transporter deformity and glanular hypermobility in men with penile prostheses. J Sex Med. 2018;15:914–9.

    Article  PubMed  Google Scholar 

  42. Karpman E. Management of distal & proximal penile prosthesis crossover. J Sex Med. 2016;13:1008–12.

    Article  PubMed  Google Scholar 

  43. Kohler T, Gupta N, Wilson S. Wilson’s pearls perils and pitfalls of penile prosthesis surgery. Fort Smith, AK: Calvert McBride Publishing; 2018.

  44. Pearlman AM, Terlecki RP. Proximal corporal perforation during penile prosthesis surgery: prevention, recognition, and review of historical and novel management strategies. J Sex Med. 2018;15:1055–60.

    Article  PubMed  Google Scholar 

  45. Krzastek SC, Smith R. An update on the best approaches to prevent complications in penile prosthesis recipients. Ther Adv Urol. 2019;11:1756287218818076.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Stember DS, Kohler TS, Morey AF. Management of perforation injuries during and following penile prosthesis surgery. J Sex Med. 2015;12:456–61.

    Article  PubMed  Google Scholar 

  47. Mulcahy JJ. The prevention and management of noninfectious complications of penile implants. Sex Med Rev. 2015;3:203–13.

    Article  PubMed  Google Scholar 

  48. Sharma D, Smith RP. Troubleshooting intraoperative complications of penile prosthesis placement. Transl Androl Urol. 2017;6:S892–7.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Gupta NK, Ring J, Trost L, Wilson SK, Köhler TS. The penoscrotal surgical approach for inflatable penile prosthesis placement. Transl Androl Urol. 2017;6:628–38.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Ziegelmann MJ, Habashy E. Clinical challenges with penile prosthesis placement and Peyronie’s disease. J Sex Med. 2021;18:1822–5.

    Article  PubMed  Google Scholar 

  51. Clavijo RI, Sávio LF, Prakash NS, Masterson T, Eid JF, Ramasamy R. Three-piece penile prosthesis implantation in refractory ischemic priapism-tips and tricks. Urology. 2017;106:233–5.

    Article  PubMed  Google Scholar 

  52. Henry G, Hsiao W, Karpman E, Bella AJ, Carrion R, Jones L, et al. A guide for inflatable penile prosthesis reservoir placement: pertinent anatomical measurements of the retropubic space. J Sex Med. 2014;11:273–8.

    Article  PubMed  Google Scholar 

  53. Yang DY, Kohler TS. Damage control considerations during IPP surgery. Curr Urol Rep. 2019;20:10.

    Article  PubMed  Google Scholar 

  54. Roth JD, Monn MF, Shelton TM, Mellon MJ. A novel technique for direct visualization of reservoir placement for penoscrotal inflatable penile prostheses using a single incision. Indian J Urol. 2018;34:283–6.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Capoccia EM, Phelps JN, Levine LA. Modified inflatable penile prosthesis reservoir placement into space of retzius: comparing outcomes in men with or without prior pelvic surgery. J Sex Med. 2017;14:968–73.

    Article  PubMed  Google Scholar 

  56. Scherzer ND, Dick B, Gabrielson AT, Alzweri LM, Hellstrom WJG. Penile prosthesis complications: planning, prevention, and decision making. Sex Med Rev. 2019;7:349–59.

    Article  PubMed  Google Scholar 

  57. Grimberg D, Wang S, Carlos E, Nosé B, Harper S, Lentz AC. Counter incision is a safe and effective method for alternative reservoir placement during inflatable penile prosthesis surgery. Transl Androl Urol. 2020;9:2688–96.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Morey AF, Cefalu CA, Hudak SJ. High submuscular placement of urologic prosthetic balloons and reservoirs via transscrotal approach. J Sex Med. 2013;10:603–10.

    Article  PubMed  Google Scholar 

  59. Gross MS, Stember DS, Garber BB, Perito PE. A retrospective analysis of risk factors for IPP reservoir entry into the peritoneum after abdominal wall placement. Int J Impot Res. 2017;29:215–8.

    Article  CAS  PubMed  Google Scholar 

  60. Ziegelmann MJ, Viers BR, Lomas DJ, Westerman ME, Trost LW. Ectopic penile prosthesis reservoir placement: an anatomic cadaver model of the high submuscular technique. J Sex Med. 2016;13:1425–31.

    Article  PubMed  Google Scholar 

  61. Mykoniatis I, Osmonov D, van Renterghem K. A modified surgical technique for reservoir placement during inflatable penile prosthesis implantation. Sex Med. 2020;8:378–82.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Yang D, Heslop D, Houlihan M, Helo S, Ziegelmann M, Köhler TS. The Tubing, Hitch and Lasso, Intussusception Anchor (THALIA) technique: a novel approach to fixate the penile implant reservoir. J Sex Med. 2021;18:224–9.

    Article  CAS  PubMed  Google Scholar 

  63. Kava BR, Lopategui DM, Levine A, Ramasamy R. Trans-fascial placement of a high, sub muscular reservoir in patients following radical cystectomy: safety, efficacy, and predictability of final reservoir location verified with abdominal imaging. J Sex Med. 2019;16:338–45.

    Article  PubMed  Google Scholar 

  64. Baumgarten AS, Kavoussi M, VanDyke ME, Ortiz NM, Khouri RK, Ward EE, et al. Avoiding deep pelvic complications using a ‘Five-Step’ technique for high submuscular placement of inflatable penile prosthesis reservoirs. BJU Int. 2020;126:457–63.

    Article  PubMed  Google Scholar 

  65. Wilson SK, Mora-Estaves C, Egydio P, Ralph D, Habous M, Love C, et al. Glans necrosis following penile prosthesis implantation: prevention and treatment suggestions. Urology. 2017;107:144–8.

    Article  PubMed  Google Scholar 

  66. Xie D, Nicholas M, Gheiler V, Perito D, Siano L, Kislinger I, et al. A prospective evaluation of penile measures and glans penis sensory changes after penile prosthetic surgery. Transl Androl Urol. 2017;6:529–33.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Palmisano F, Boeri L, Cristini C, Antonini G, Spinelli MG, Franco G, et al. Comparison of infrapubic vs penoscrotal approaches for 3-piece inflatable penile prosthesis placement: do we have a winner? Sex Med Rev. 2018;6:631–9.

    Article  PubMed  Google Scholar 

  68. Chao TC, Shei-Dei Yang S, Chang SJ, Lin CD. Webbed penis: etiology, symptoms, surgical treatments, and outcomes. Urol Sci. 2020;31:200–5.

  69. Li Y, Zhu X, Feng D, Gong J, Sun G, Zhang X, et al. A modified scrotoplasty for treating severe penoscrotal webbing in children. Front Pediatr. 2020;8:551.

    Article  PubMed  PubMed Central  Google Scholar 

  70. Carrion R. Ventral phalloplasty. J Sex Med. 2010;7:2914–7.

    Article  PubMed  Google Scholar 

  71. Bonitz RP, Hanna MK. Correction of congenital penoscrotal webbing in children: a retrospective review of three surgical techniques. J Pediatr Urol. 2016;12:161.e1–5.

    Article  CAS  PubMed  Google Scholar 

  72. Hellstrom WJ, Montague DK, Moncada I, Carson C, Minhas S, Faria G, et al. Implants, mechanical devices, and vascular surgery for erectile dysfunction. J Sex Med. 2010;7:501–23.

    Article  PubMed  Google Scholar 

  73. Montague DK. Penile prosthesis corporotomy closure: a new technique. J Urol. 1993;150:924–5.

    Article  CAS  PubMed  Google Scholar 

  74. Hakim LS, Kulaksizoglu H, Hamill BK, Udelson D, Goldstein I. A guide to safe corporotomy incisions in the presence of underlying inflatable penile cylinders: results of in vitro and in vivo studies. J Urol. 1996;155:918–23.

    Article  CAS  PubMed  Google Scholar 

  75. Pestana IA, Greenfield JM, Walsh M, Donatucci CF, Erdmann D. Management of “buried” penis in adulthood: an overview. Plast Reconstr Surg. 2009;124:1186–95.

    Article  CAS  PubMed  Google Scholar 

  76. Hughes DB, Perez E, Garcia RM, Aragón OR, Erdmann D. Sexual and overall quality of life improvements after surgical correction of “buried penis”. Ann Plast Surg. 2016;76:532–5.

    Article  CAS  PubMed  Google Scholar 

  77. Voznesensky MA, Lawrence WT, Keith JN, Erickson BA. Patient-reported social, psychological, and urologic outcomes after adult buried penis repair. Urology. 2017;103:240–4.

    Article  PubMed  Google Scholar 

  78. Tang SH, Kamat D, Santucci RA. Modern management of adult-acquired buried penis. Urology. 2008;72:124–7.

    Article  PubMed  Google Scholar 

  79. Salgado CJ, Navas G, Lalama M, Tanner LM, Gheiler E. Penile prosthesis placement with immediate buried penis correction: a retrospective chart review. Surg Case Rep. 2021;1–3.

  80. Baumgarten AS, Beilan JA, Shah BB, Loeb A, Bickell M, Parker J, et al. Suprapubic fat pad excision with simultaneous placement of inflatable penile prosthesis. J Sex Med. 2019;16:333–7.

    Article  PubMed  Google Scholar 

  81. Shaeer O, Shaeer K, AbdelRahman IF. Simultaneous suprapubic lipectomy and penile prosthesis implantation. J Sex Med. 2018;15:1818–23.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Urology, Mayo Clinic, Rochester, MN, USA

    Eileen R. Byrne, Garrett N. Ungerer, Matthew J. Ziegelmann & Tobias S. Kohler

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  2. Garrett N. Ungerer
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ERB and GNU drafted the manuscript; ERB, GNU, MJZ, and TSK were involved in revisions and final approval of the manuscript.

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Byrne, E.R., Ungerer, G.N., Ziegelmann, M.J. et al. Complications and troubleshooting in primary penile prosthetic surgery—a review. Int J Impot Res 35, 679–685 (2023). https://doi.org/10.1038/s41443-023-00699-0

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