Penile prosthesis implantation in patient with cavernal fibrosis
The prosthetic implant in patients with fibrosis of the corpora cavernosa is complex even for experienced urologists in this type of surgery given the difficult procedure of demolition or removal of the fibrotic tissue or paque of induratio penis plastica. However, a careful preoperative evaluation of the involvement of the corpus cavernosum allows you to program the possible need for additional operations in more complex cases or also the possibility of not being able to proceed to the prosthesis implant. We reviewed the surgical technique worked in 42 patients scheduled for penile prosthesis implant and preoperative diagnosis of cavernous fibrosis; solutions used and its complications are discussed.
Methods and results
From January 2008 to December 2012 underwent penile prosthesis implantation 93 patients aged between 34 and 73 years; in all preoperative evaluation was performed with routine history, physical examination, blood chemistry, hormonal and penile ultrasound with I.C.I. test. In selected cases, the study was completed with dynamic infusion cavernosometry/graphy. Patients who on the basis of medical history or physical examination resulted predictable or obvious for cavernous fibrosis were stratified into three groups based on ultrasound parameters .
a) Focal or segmental fibrosis ( 21 patients ) : the extension of the process of fibrosis is less than 20 % of the volume of the corpus cavernosum or is localized . The PSV is between 20 and 30 cm / sec . The plot is typical fibrosis patients with monofocal P.I.P., trauma of the corpora cavernosa or subjected to a sustained program of I.C.I.
b ) Extensive fibrosis (15 patients ) : the extension of the process of fibrosis exceeds 60 % of the volume and the cavernous PSV less than 20 cm / sec; it's typical of patients with polifocal P.I.P., major trauma of the corpora cavernosa, severe chronic vascular disease, stuttering priapism or schunt treated priapism.
c) Massive fibrosis – Woody Corpora ( 5 patients): The endothelial tissue is completely replaced by fibrous tissue. It 's almost impossible to assess the PSV and it is clear strong vascular signal around albuginea . It's present in patients with late treated priapism or removal of infected prosthesis.
a) In 15 patients it was enough prosthesis implant alone . In 6 patients with P.I.P. and preoperative recurvatum between 30 ° and 60 ° , it was necessary to perform additional maneuvers ( 5 plaque incision + patch ; 1 Wilson manovre )
b ) The prosthetic implant alone was performed in 5 patients . In 7 patients has become indispensable wide extension of corporotomy with incision / excision of the fibrous tissue and / or use of Rossello cavernotom . In 20 patients have been implanted a AMS CXR prosthesis . There were no infections or extrusions . 4 patients were dissatisfied with the length of the penis and in one it was found persistent curvature of about 30 ° at 12 months but it was well tolerated by the patient.
c) In 3 patients extensive corporotomy up to the crura was required with incision / excision of the cavernous tissue and AMS CRX implant and/or polypropylene mesh . In 2 patients was performed Dhabuwala incision with multiple and progressive dilatation with scissors and cavernotom to realize implantation. 2 patients complain of " short penis " and one implant was removed for infection in the mesh group.
The prosthetic implant in patients with cavernous fibrosis remains a formidable challenge of modern andrologic surgery; in fact have been proposed and implemented a lot of surgical techniques aimed primarily to expand the endocavernos space necessary to the positioning of the cylinders by the use of cavernotom (type Rossello), cold or Collins incision of fibrous tissue or its surgical removal through large corporotomies. In more complex cases, it was possible use of polypropylene mesh in order to pack an half cilinder of albuginea to insert AMS CXR implant. A correct preoperative stratification of severity of fibrosis prepare adequately to this challenge, the surgeon and the patient.Argomenti: andrologia