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Penile Implant Surgery in Patients with Chronic Priapism
Quynh-Chi Dang • Jan 5, 2022 • 302 hits
Patients with chronic priapism require special considerations when undergoing penile implant surgery. Dr. Jonathan Clavell shares advice about assessing the extent of fibrosis present, special preoperative therapies, and additional surgical techniques in order to place a penile implant successfully.
We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable Urology Brief
• Managing patient expectations is important in penile implant cases. For patients with chronic priapism, a smaller penile implant may have to be placed and cycled before a larger implant can be placed successfully.
• With priapism patients, Dr. Clavell emphasizes the importance of severity and timing; waiting a longer time period to place the penile implant since the patient’s last priapism episode means that there will be more scar tissue in the corpora.
• Dr. Clavell encourages surgeons to place penile implants in priapism patients as soon as possible and to encourage them to use a vacuum erection device to keep corporal space open and maximize the size of implant.
• It is important to come into the operation with adequate tools that are able to drill through the fibrosis caused by chronic priapism. Additionally, surgeons must be ready to use a counter incision or to extend the incision distally.
Table of Contents
(1) Evaluating Fibrosis in Penile Implant Surgery
(2) Managing Penile Implant Expectations in the Chronic Priapism Patient
(3) Penile Implant Surgery Techniques in the Chronic Priapism Patient
Evaluating Fibrosis in Penile Implant Surgery
Patients with priapism experience recurrent episodes of prolonged erections without sexual stimulation. Patients who successfully manage their priapism episodes with medication can be treated as normal penile implant patients. For patients who have chronic priapism, Dr. Clavell advises urologists to be flexible in the operating room due to the extensive fibrosis that may be present in the corporal tissue.
[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.
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Managing Penile Implant Expectations in the Chronic Priapism Patient
Dr. Clavell encourages urologists to set different expectations between normal penile implant patients and penile implant patients with chronic priapism. For patients with chronic priapism, his goal is to fit any prosthesis, even if it is not the patient’s desired size. Once the patient starts cycling the implant post-operatively, the corporal tissue will expand and allow the urologist to insert a bigger prosthesis. Once again, Dr. Clavell emphasizes the importance of timing and recommends that penile implants be placed as soon as the incisions from priapism surgery heal.
[Dr. Jonathan Clavell]
When you ask for pearls, I have five different pearls. For example, pearl number one is education–set proper expectations. It is unlikely that the patient will have the same erection he had prior to his priapism episode. Explain that the goal is to get any prosthesis in there. You can not guarantee that you will be able to get a fully sized implant. Sometimes the only thing you will be able to get in will be a narrow base or a CXR. In those cases, I tell them that there might be a possibility that I might only be able to get a narrow base implant. Once you place that narrow base, they're going to start cycling the implant. If they're not happy with that, they can start cycling that implant regularly to expand the tissues inside. Then you can come back several months later and you will be able to get a bigger implant in.
Pearl number two: if you were the one who took care of the priapism, or if the patient was referred to you early on after his priapism episode, try to get him on your schedule as soon as possible. Remember, timing is everything. Getting an implant in sooner will be easier than waiting several months to a year later. If he had a distal shunt and he has incisions in his glans, I would wait for those incisions to heal before I get an implant in. Usually those incisions will heal within six to eight weeks.
And at that time, I bring the patient back for the penile prosthesis. I've had several patients who've been referred to me from local urologists who did a T-shunt for example, or they did a Burnett snake procedure in which they've just placed a Hagar all the way down to the bone.
We know that those guys are very unlikely to have, you know, natural erections again. And I tell them like, as soon as that heals, I see them. Let's say after two or three weeks since their episode, they still have scar tissue. They still have their, you know, stitches and the glans. And I tell them, ‘Hey man, we're gonna wait for this to heal. And we're getting you on the schedule today and that way as soon as those incisions heal, we're on the schedule to get that implant in.’
[Dr. Jose Silva]
Is there more risk of extrusion in those cases?
[Dr. Jonathan Clavell]
I mean, in theory, yes. I've done it twice already, and you know, both patients have done very well, of course. For those types of patients, you are not going to oversize their implant. I will not place a malleable implant on those patients because again, there is a higher risk of extrusion and erosion on guys who have malleable implants. So I would be very conservative, but if you can get an implant there and they should be okay.
Penile Implant Surgery Techniques in the Chronic Priapism Patient
In the case that a priapism patient cannot immediately undergo penile implant surgery, Dr. Clavell recommends using vacuum erection device (VED) therapy in order to keep the corporal space open and fit a maximum-sized implant. Furthermore, if he cannot dilate the penile implant through the proximal incision, he makes a counter incision or extends his incision distally in order to dilate the penile implant. If a counter incision or an incision extension is not made, forceful dilation can cause urethral injuries and penile perforations. He emphasizes that complex penile implant patients should be referred to penile implant specialists in the event that a urologist cannot perform the penile implant surgery successfully.
[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.
Dr. Jonathan Clavell
Dr. Jonathan Clavell is a high-volume prosthetic urology surgeon and assistant professor of urology at UT Health Science Center Houston.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2021, November 24). Ep. 23 – Complex Penile Implants [Audio podcast]. Retrieved from https://www.backtable.com
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