Three-pieces inflatable penile prosthesis implantation with penoscrotal approach and Scrotal Septum Sparing technique: description and early experience

Objective

Penile prosthesis implantation is recognized as a valid option to obtain an artificial erection satisfactory for sexual intercourses in those patients in whom a pharmacological approach is contraindicated or ineffective1-3. Different surgical approaches for three-pieces inflatable penile prosthesis implantation have been described, mainly the penoscrotal and infrapubic approaches. The infrapubic approach doesn’t compromise the integrity of the scrotum and gives a quick recovery and early prosthesis handling. The penoscrotal approach, that entails a scrotal tissue dissection, has the advantage of a better surgical control of the corpora but may expose the patient to a delayed scrotal wound healing, swelling, hematomas and pain. With the penoscrotal approach the scrotal septum is divided. Since the scrotal septum incorporates tiny vascular and nervous branches, the division of such structures involves a greater tissue damage potentially responsible of postoperative prolonged scrotal swelling and pain. We describe our experience with a less invasive transverse penoscrotal approach for three pieces penile implantation, thereby called Scrotal Septum Sparing technique (SSSt).

Methods and results

Patient selection. Inclusion criteria were: patients with end stage erectile dysfunction not responder or not compliant to medical therapy. All patients underwent to psychosexual counselling before surgery.
Devices implanted. AMS CX 700, CXR 700, LGX (AMS Minnetonka, Minnesota).
Procedure. A transverse scrotal skin incision at the penoscrotal junction is made. At first the reservoir is placed and inflated in the retropubic space through the inguinal ring. For patients with previous cystectomy or inguinal surgery (such as bilateral hernia repair with mesh) a separate suprapubic incision is made to insert the reservoir. The scrotal septum is grasped medially with a Babcock forcep and the ventral side of each corporal body is separately exposed. A proximal longitudinal corporotomy is performed bilaterally. The corpora are dilated with Hegar’s dilators. A window between the septum and the ventral aspect of corpus spongiosum is created. Before the insertion into the corporal body the left cylinder is passed through this window. Once both cylinders are appropriately implanted the corporotomies are closed with stay sutures. Finally the pump is placed in the scrotum and the connection of tubings is completed. The skin incision is closed with reabsorbable stay sutures. The cylinders are left 75% inflated to tamponade any corporal bleeding. At the end a compressive dressing is made (Henry mummy wrapTM)4.
Post operative care. Urethral catheter is removed in postoperative day one. Patients are discharged the following day with inflated prosthetic cylinders at 60%. Ten days after the procedure (or as soon as possible) the patients are trained and allowed to self handle the prosthesis pump, in order to stretch the corpora, by maximal inflation for 2 hours a day. Sexual intercourses are allowed after 5 weeks.
From January 2009 to June 2013 we selected 61 patients for penile prosthesis implantation. The age of patients ranged from 40 to 78. The erectile dysfunction was related to radical prostatectomy in 32 patients, induratio penis plastica in 12 patients, diabetes in 5 patients, vascular disease in 7 patients, other oncological surgery in 3 patients, EBRT for prostate cancer in 1 patient and post ischemic priapism in 1 patient. The mean duration of the procedure was 90 minutes (range 65-110). In 10 cases the reservoir was implanted through an abdominal incision. In 18 cases a contextual Wilson modeling procedure5 was performed. We observed an apical perforation of a corpus cavernosum (intraoperatively recognized and repaired) that did not hamper the prosthesis implantation. All patients had a prompt healing of scrotal wound. In 58 patients (95%) scrotal edema was unappreciable since the first post operative day as the scrotal skin appeared wrinkly and the pump was easily perceptible. These patients could easily handle the scrotum learning how to squeeze the pump between 10 and 15 days after the procedure. Three patients (5%) had small hematomas surrounding the pump. In these cases the prosthesis handling was delayed until complete hematoma reabsorption (1-3 months).

Discussion

At our knowledge, no paper until now focused the healing problems of the scrotum after penoscrotal approach for penile prosthesis implantation. We wondered if penile prosthesis implantation could be performed through a minimal scrotal dissection and postulated that the cylinders insertion was feasible by means of a targeted access to the corpora cavernosa saving the midline structure of the scrotum. We performed the SSSt in 61 consecutive patients. The main finding of our study is that our modified approach appears feasible, reproducible and easy to perform.
The penoscrotal approach has several advantages compared to the infrapubic approach6, but the proximity of the surgical wound to the prosthetic pump may delay the device handling7.
It is well recognized that a meticulous bleeding check and careful reconstruction of all scrotal layers are paramount steps to prevent hematomas and ensure a good and fast wound healing.
Scrotal hematoma is an infrequent reason for penile prosthesis revision surgery8,9 but it is a common finding after the implantation by penoscrotal approach, although in our opinion under reported. Moreover patients undergoing penile prosthesis implantation frequently complain about pain in different sites, mainly penis, scrotum and perineum. Pain may be another reason for delaying the activation of penile prosthesis. Although in some patients the scrotal pain seems to depend on foreign body effect of the pump, it is theoretically possible that an extensive scrotal dissection may involve nervous structures causing scrotal bother and pain. Theoretically, the preservation of the septal vascular and neural structures may result in a reduction of post-operative pain and scrotal sensation abnormalities. Moreover a less extensive dissection of scrotal soft tissue may contribute to the reduction of spaces available for edema and hematomas. Although it is not possible to objectively quantify the extent of scrotal edema, we did not observe a perceptible swelling of the scrotum. We observed three cases of hematoma in our series, noticeably limited to the space surrounding the pump and not extended to the whole scrotum. We argue that our technical modification may contribute to an early activation of prosthetic cylinders, needed to prevent corporal fibrosis and penile shaft downsizing, specially for length expanding prosthesis such as AMS LGX.
Anther issue related to scrotal discomfort is the feeling of “palpable” tubes below the skin at the base of the penis. This is a common self-complaint among many implanted patients. This problem occours when corporotomies are not enough proximal or when the scrotal soft tissue covering the tubings is thin. Regarding the latter issue, SSSt ensures a better hiding of tubes since one of them results deeper concealed under the septum.
Our modification to the standard procedure requires simple surgical maneuvers and appears to be effective and reproducible. SSSt seems to reduce the occurence and severity of scrotal complications by means of a less invasive scrotal dissection. Moreover this technique provides a better hiding of connecting tubes into the scrotum. Ultimately, determining whether our technique improves clinical outcomes requires a comparative trial with the standard technicque.

References

1. Montorsi F, Rigatti P, Carmignani G, et al. AMS three-piece inflatable implants for erectile dysfunction: a long-term multiinstitutional study in 200 consecutive patients. Eur Urol. 2000;37: 50-55.

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

3. Hatzimouratidis K, Amar E, Eardley I, et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Eur Urol. 2010;57:804-814.

4. Henry GD. The Henry mummy wrap and the Henry finger sweep surgical techniques. J Sex Med. 2009 Mar;6(3):619-22.

5. Wilson SK, Delk JR 2nd. A new treatment for Peyronie's disease: modeling the penis over an inflatable penile prosthesis. J Urol. 1994 Oct;152(4):1121-3.

6. Kelami A. Operative procedures on male genitalia using a new ‘infrapubic' approach. Eur Urol 1978; 4: 468–70.

7. Montague DK, Angermeir KW. Surgical approaches for penile prosthesis implantation: penoscrotal vs infrapubic. Int J Impot Res. 2003 Oct;15 Suppl 5:S134-5.

8. Henry GD, Donatucci CF, Conners W, Greenfield JM, Carson CC, Wilson SK, Delk J, Lentz AC, Cleves MA, Jennermann CJ, Kramer AC. An Outcomes Analysis of over 200 Revision Surgeries for Penile Prosthesis Implantation: A Multicenter Study. J Sex Med. 2012 Jan;9(1):309-15.

9. Sadeghi-Nejad H. Penile prosthesis surgery: a review of prosthetic devices and associated complications. J Sex Med. 2007 Mar;4(2):296-309.

10. Carrera A, Gil-Vernet A, Forcada P, Morro R, Llusa M, Arango O. Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps. BJU Int. 2009 Mar;103(6):820-4.

11. Katz J. Atlas of Regional Anesthesia. East Norwalk: Appleton-Century-Crofts, 1985: 114–7

12. Elhilali MM, Winfield HN. Genitourinary pain. In Wall PD, Mclazck R eds, Textbook of Pain. Edinburgh: Churchill Livingstone, 1989: 500–1

13. Gee WF, Arnsell JS, Bonica JJ. Pelvic and perineal pain of urologic origin. In Bonica JJ, Malvern N eds, The Management of Pain. Lea & Febiger, 1990: 1368–72.

14. Hamilton WJ. Textbook of Human Anatomy. St Louis: CV Mosby, 1976: 1368–71

15. Yucel S, Baskin LS. The neuroanatomy of the human scrotum: surgical ramifications. BJU Int. 2003 Mar;91(4):393-7.