Penile Implant Surgery in Patients with Chronic Priapism

[Dr. Jose Silva]
So Jonathan, what about patients that, for example, have a history of priapism, like sickle cell patients? Any pearls on those patients? I mean, even though they're naive, what would you expect with those patients? What can I expect?

[Dr. Jonathan Clavell]
I mean when it comes to these guys who have difficult anatomies, I mean probably the first thing I want to disclose is that saying in Spanish: “No one was born knowing everything.”

Yesterday I saw a quote that I wish to share with everybody here today: “All great surgeons were once new surgeons.” We all learn from others' experiences and research and mentorship. And when it dawned on me and I just asked for advice from new mentors who set me up for success. I mean, if you do not feel comfortable doing a specific procedure or you do not know how to do something, refer that patient to someone else.

You do not need to operate on everyone. I remember when I was in, in fellowship, one of my mentors told me that. So as you gain experience, you will start to feel more comfortable doing these complex procedures. And I mean, that's probably the best way to set yourself up for success early on. And this way we will all be successful.

When it comes to priapism, it's all about two things: the severity and the timing, right? If you have a patient who responds to medical therapy, it should not be that difficult to place a prosthesis. But if you have a patient who has had multiple procedures done to correct his priapism, for example, these chronic sickle cell patients, who've had multiple T-shunts, multiple proximal shunts, and these stuttering priapisms, those cases are going to be a bit more difficult. In those cases, timing is everything. For example, it is not the same thing to treat a patient early on after his priapism episode, let's say weeks versus one who had it six months ago or another one who had a three years ago, the longer it has been since his priapism episode, the more scar tissue I will expect at the time of surgery and specifically with ischemic priapism, it will cause extensive fibrosis inside those corporal tissues. And for these cases, you have to throw the kitchen sink at them. You need to be prepared to try multiple things in order to get a penile prosthesis.

[Dr. Jonathan Clavell]
The third pearl would be, if for any reason you need to wait longer to get the implant–and this is probably the best advice I can give everyone who's listened to this– use a vacuum erection device during their pre-op phase.

Using a vacuum pump twice a day will create negative pressure inside the corporal bodies, bring in venous blood, and it will keep the corporal space open. Aggressive VED therapy is key to setting yourself up for success with these patients. It will help dilate the tissues and allow you to maximize the size of the implant.

Pearl number four: come ready to your surgery; be ready to bring all your drilling tools. You will be drilling inside those corporas to break down that fibrosis. Make sure you have all the instruments you might need. I also use Metzenbaum scissors. There's also a video about this by the way on YouTube.

There's people who use reverse cutting scissors. There's a special dilator called the Dilamezinsert dilator. This one comes with a blunt tip that you can use for straightforward cases. And it also comes in with a pointed tip. I don't use that. I see it and it makes me cringe. I feel like I'm in a medieval movie. But again, it's something that can definitely be handy in some cases.

And the last pearl: If you aren't able to dilate through the proximal incision, be ready to use a counter incision. It's very common for these cases or be ready to just extend your incision. I mean, if you're going peno-scrotal, just extend your incision distally and your corporotomy distally in order to properly dilate to avoid distal injury.The one thing you don’t want to do is be forcefully dilating. Cause you will either injure the urethra, crossover, or just perforate through the side. Again, these are things that I've seen and you want to make sure that you set yourself up for success. So again, these are going to be long, tough cases. Just be ready for it to do a little bit of everything.

[Dr. Jose Silva]
Yeah. And I guess if you make the decision to go in, and you see something, it's okay to close and send it to Jonathan.

[Dr. Jonathan Clavell]
I've actually had those. I remember I will never forget what when I was in fellowship, there was a local surgeon who wasn't able to dilate distally and he put in a very small, like a 15 centimeter implant, when the guy probably needed like 24 cm or something.

Don't do that. I mean, if you can't dilate, just close them up and just refer him to somebody who will be able to take care of this guy. Again, you don't have to operate on everyone. It is not a sign of weakness to ask for help and do the right thing for the patient.