BackTable / Urology / Podcast / Transcript #23

Podcast Transcript: Complex Penile Implants

with Dr. Jonathan Clavell

Dr. Jose Silva brings Dr. Jonathan Clavell back onto the show to discuss complex penile implant cases. They cover how to deal with mechanical complications of AMS700 and Coloplast Titan, penile implants in Peyronie's disease, penile implants in priapism, tips for successful revision surgery, and how to manage post-operative infections. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Common Complaints after Penile Implant Surgery

(2) Difficult Anatomy for Penile Implant Surgery

(3) Penile Implant Surgery in Peyronie’s Patients

(4) Infections during Penile Implant Surgery

(5) Glans Hypermobility during Penile Implant Surgery

(6) Impending Erosions in Penile Implant Surgery

(7) Glans Ischemia after Penile Implant Surgery

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Complex Penile Implants with Dr. Jonathan Clavell on the BackTable Urology Podcast)
Ep 23 Complex Penile Implants with Dr. Jonathan Clavell
00:00 / 01:04

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[Dr. Jose Silva]
Hello everyone and welcome back to the Backtable Urology podcast, you source for all things Urology. This is Oche Silva as your host this week. Very excited to have back Dr. Jonathan Clavell. Uh, Dr. Clavell is a men's health specialist and assistant professor of urology at UT Houston. So welcome back Jonathan, how you been?

[Dr. Jonathan Clavell]
I've been doing great, man. And I'm excited to be back at the back table urology podcast.

[Dr. Jose Silva]
Good. So, so last time we talk about a penal implant. You went through your selection process of, say the patient comes to your office and has the, uh, and you talk about all the treatments and then you go from there. Uh, but the implant. So, so this time I wanted to talk, how's your process with more complex cases also, uh, talk about some post-op complaints or common complaints at that patient, say, so, so, so I'm going to start with those.
So, so let's talk about post-procedure common complaints. Uh, I put up a list and I wanted to, to have your take on this. So let's say it's already six week out or eight weeks out. And the patient says that the, the, the pump is difficult to, to find, uh, or have he having difficulty pumping it. Uh, what do you tell the patient?

(1) Common Complaints after Penile Implant Surgery

[Dr. Jonathan Clavell]
It was such a common complaint in my practice that I actually even decided to create a YouTube video on what are the best practices to find the pump, how to locate the pump, how to deflate, how to inflate the pump. And there's multiple, you know, ways to, how to, you know, grab it in your hand or you which fingers to use, which muscles in your forearm to use.
Um, and it took me probably about three weeks to put that video together. and, and again, it's paid off a ton and I've right now, I've been actually too, I've been actually able to decrease the amount of calls that I get, um, or text messages in my case. Cause again, most of these guys even have my cell phone.
So that's one of the ways that I've been able to mitigate those complaints, but yeah, I mean, when the pump is difficult to find, I mean, you just have to sit down with them and you have to explain to them, you know, what is the orientation of the pump by show them the pump, you know, like the key chain that the company provides and I show them how to, you know, how it's oriented within their scrotum.
One of the best tricks that they can use is warm baths because in the warm bath, the, you know, the warm water will create, it will make the scrotum be a little bit softer. Uh, the scrotum will be saggier and they will be able to feel the parts a lot, a lot better. And again, know your audience.
I mean, I tried to avoid placing, for example, the Coloplast Titan implant, tends to be a little bit more difficult to deflate because that button tends to be a little bit flatter, especially when you're using a one touch pump. So for those guys, I try not to use that pump if I'm using a Coloplast, or I would just go with a Boston Scientific, uh, pumps so that they can actually feel for things.
So again, um, and it's just knowing your audience. If you have a really old guy, I try to avoid, you know, placing a difficult pump that they're going to struggle with.

[Dr. Jose Silva]
Yeah, definitely. I mean, you can try, you think where you're doing the procedure is perfect and then it retracts, or, you know, let's say it's six months after the procedure and they are still having issues. What do you do then?

[Dr. Jonathan Clavell]
So it really depends. I mean, if I, if I noticed that the pump is not well-placed or, or if it's too posterior, I mean, we can try placing it more like our interiorly, like me, for example, whenever I place my pumps, I try to place them right on the front of the scrotum. Cause when, when they're very posterior, especially on older guys, it's going to be more difficult for them to find it.
For younger guys, I mean, they, they, they get it. Um, it's not rocket science for them, so they're able to, to make it work. But I mean, sometimes you just have to reposition it. And I mean, if it becomes an issue that they cannot, you know, work it at all. You have two options. You can leave the device kind of like 80% inflated for them. Or you can just switch them out to a malleable. Um, of course that's the last resort. and I, sometimes I have the local reps from the companies they come in and they, you know, they sit down with the patient they're here in my office and they can spend 30 minutes with them trying to explain to them how to make it work.

[Dr. Jose Silva]
Good. It's a good thing that you mentioned the malleable. I mean, don't use it that much, but there's some patients that, that that's the way to go in order to prevent any problems.

[Dr. Jonathan Clavell]
let's put it this way. I just recently, probably about six or seven months ago. I had this patient who everything, you know, he came into the office, he requested the inflatable penile implant. We put it in and then post-op, I find, I find out that he comes in for his post-op appointment. I teach him how to use it.
I my send him the video for him to start, you know, uh, cycling that implant. And then two weeks later the guy comes back for teaching. I teach him again and I'm like, well fine, whatever. Then three weeks later, he comes back again and I'm like, wait, what's going on? and what I find out is the guy's having early Alzheimer's and I didn't even know from prior to the, to the surgery.
And right now the guy has already showed up to my office like five times. So those are the types of things that you have to be aware of. I mean, if you have a guy who still, I mean, I'm not gonna. prohibit him from getting a penile prosthesis, but you have to be very aware, especially if they're single, they don't have somebody who can inflate or cycle the implant for them.
You have, it has to be kept in your radar that you should probably you know place a malleable for these guys.

[Dr. Jose Silva]
Exactly. And I guess at the end of the day, you, you, you find out the hard way.

[Dr. Jonathan Clavell]
Exactly.

[Dr. Jose Silva]
So, and for the patients, I have a few that comes that say, Hey, the, the, the tubing is either visible or, or I feel discomfort right there in the tubing. How long do you wait? What do you tell the patient? Do you have a video for them also of that?

[Dr. Jonathan Clavell]
I do not have a video

[Dr. Jose Silva]
Okay. Okay.

[Dr. Jonathan Clavell]
But one of the things that I, that I try to do is, uh, at the time of surgery, if I feel like the tubing is very long, I try to, you know, adjust it right there. I mean, it will take you, yes, an extra 10 minutes or, you know, five to 10 minutes for you to cut the tubing to the actual length, reconnect it. I mean, it's a hassle, but I would rather have a hassle of 10 minutes in the operating room than having a guy complaining. And then you have to come take him back to the operating room for that. so I try to avoid that at all costs if I can. However, there are some guys that will still complain about it.
It really depends on is a pump sitting well or is the pump actually high riding in the scrotum. And that's why they feel it. Sometimes they can start forming scar tissue, uh, that will cause that tubing to be more palpable. And sometimes you can just readjust that. I mean, if it's something, if it's been more than three months, you know, three to six months, and they're still complaining about that, I just try to re you know, to, to go back in there and try to adjust things for them.

[Dr. Jose Silva]
You will just either cut the tubing. You, you wouldn't change he entire piece if it's not infected

[Dr. Jonathan Clavell]
Usually I usually, I mean, most of the time I would just, uh, you know, cut the pump out and just place a new pump. If it's just from the tubing, from the pump. Sometimes I've had guys who complain about the tubing right at the base of the penis, for, you know, where it connects into the, to the reservoir.
And sometimes for those, I've been able to, uh, go directly there and make a small incision in that area and try to get a deeper and get tissues to cover that. So again, sometimes you don't have to take everything out and replace it. It's just a matter of, of making, you know, doing something. So it feels comfortable for these guys.

[Dr. Jose Silva]
And you mentioned the high riding pump. Sometimes I feel that the, the tubing goes like along the, the, the implant or the corpora, and then it comes down. I don't know if you can do a release of that tubing. I mean, is that something that we can, that can be done?

[Dr. Jonathan Clavell]
I mean, those things can actually be avoided sometimes. Um, again, we have to be very conscious of what is your approximate measurement. if your approximate measurement, for example, is more than 10 centimeters, you want, you know, you, you should consider, you know, placing a rear tip extender, to make, especially for the Coloplast device, because now the, the AMS device, it has a longer tubing. and they, made that longer tubing just to avoid us surgeons from placing and, you know, being obligated to place, uh, those rear tip extenders. So, again, it's just being conscious of what are your approximal measurements? I mean if you have a guy who's 14 centimeters, proximal, and he's a, whatever, let's say eight centimeters distal. Don't put in a 21 plus one, because it's probably, he's probably going to be struggling. Uh, that pump is probably going to be a little bit high riding. So just try to make sure that you dissect lower to make sure that you get that proximal core as approximately as possible, and that will avoid you from, from having that high riding pump.

[Dr. Jose Silva]
So definitely, So, usually like a standard more than 10 centimeters. Think about extenders, right. And then go bigger.

[Dr. Jonathan Clavell]
Yeah. So it really depends on where you're making your incision. Uh, cause me, for example, whenever I measure, I usually measure right in between my corpora, my corpora tend to be a little bit bigger, and I do that on purpose, uh, just to make sure that I don't struggle to place the implant in. But you want to make sure that, that the apex, that proximal apex of that coporotomy is less than 10 centimeters. Um, and if you are able to get that, you're not going to struggle at all and you shouldn't be having, uh, those, you know, those high riding pumps, because again, you don't want the pump to either be too long and then you have to, then you'd have to be cutting tubings and readjusting things for you.

[Dr. Jose Silva]
So I think we, another question. So a patient says that the penis sticks out. You feel it and he's deflated. I mean, th they're they're used to having a more flacid, but now that it's sticking out, they tell you, Hey, I'm using a tape to tape it to, to, to the suprapubic area, uh, infrapubic area sorry. What do you tell them in those cases?

[Dr. Jonathan Clavell]
I mean, those tend to be a little bit, you know, difficult to manage post-op so if you, if I have a guy who, when I do the stretch test before the surgery, and I see, and I noticed that the penis is big. I mean, you know, which guy, I mean, as urologists, we know which guys have bigger penises than others, right?
So if you have a guy who has a, you know, a really big penis, I will tell them, it's like, Hey man, just so you know, the penile implant will keep your penis on stretch at all times. it's going to be a little bit more difficult for you to be, to be able to adjust it, but it's still, you know, you're still going to be able to adjust it.
There are ways that they can avoid it from showing for example, one of my patients what he recommended was using biker shorts. Especially if he's going to be wearing tight pants, because biker shorts, again, it's a strong spandex it will help keep everything nice and concealed. And that way it's not gonna, you know, people are not going to notice that he has, that he, that he has, you know, a big penis, for example.

[Dr. Jose Silva]
maybe that's what he wants.

[Dr. Jonathan Clavell]
Exactly.

[Dr. Jose Silva]
He wants to go around like that.

[Dr. Jonathan Clavell]
Those complaints are actually less common. Uh, yes, you, you can have some guys who will complain about auto inflation, uh, for those patients that complained that the, the, the implant is auto inflating at times. Like, hey man, it is, you know, a 1% risk that it can happen, but it can still happen. For those, especially if you're using the coloplast vice make sure that, you know, when you're, when you're placing the reservoir, that the lockout valve of that reservoir is not hitting against the pubic bone, because it will cause auto inflation. And then for the AMS, I mean that, it's less common for that to happen, but again, it's one of those risks that can happen and they just have to deal with it. I mean, in a sense, unfortunately,

(2) Difficult Anatomy for Penile Implant Surgery

[Dr. Jose Silva]
So Jonathan, what about patients that, for example, they had history of priapism, uh, Sickle cell patients. any pearls on those, on those cases? I mean, even though they're, they're naive, what would you expect on those? Uh, or what somebody like me, uh, doesn't do much of those cases. What, what, what can you, can I expect?

[Dr. Jonathan Clavell]
I mean when it comes to these guys who have difficult anatomies, I mean the, probably the first, the first thing I want to disclose and probably one very important thing is like, you know that in Spanish, we have a saying like “no one was born knowing everything.” I mean, so just yesterday I saw quotes, uh, that I wish to share with everybody here today.
It's like all great surgeons were once new surgeons. Uh, we all learn from others' experiences and research and mentorship. And when it dawned on me and I just asked for help seek advice from new mentors, who set you 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, uh, one of my mentors told me that it's like, Hey, remember, you do not need to operate on everyone. And in most cases you have one time to make it right. 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, you know, to make sure that you set yourself up for success early on. And this way we will all be successful. Regarding priapism specifically. I mean, in my opinion, again, this is my personal opinion. 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. Uh, 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 and multiple, uh, you know, even proximal shunts, and they have these stuttering priapisms, those cases are going to be a bit more difficult. In those cases, timing is everything. In my opinion. Um, 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 I mean, it, we all know it will cause extensive fibrosis inside those corporal tissues. And for these cases, you have to throw the kitchen sink at them. Uh, do you need to be prepared to try multiple things in order to get a penile prostheses?
And, and when you ask for pearls, I have five different pearls. For example, pearl number one, education: set proper expectations. It is unlikely that the patient will have the same erection he had prior to his prior prism episode. Explain that the goal is to get any procedures in there.
You can not guarantee that you will be able to get a fully sized implant. Uh, sometimes the only thing you will be able to get in will be a narrow base or a CXR. and in those cases, I mean, I tell them like, Hey man, 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, when they start cycling that implant regularly, it will expand the tissues inside. And then when you, 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 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. And as soon as those incisions heal, I mean, let's say six to eight weeks since his, you know, usually those incisions will heal within six to eight weeks.
And at that time I bring him back, uh, you know, for, for, you know, for the penile prosthesis, uh, 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, hey man, as soon as that heals, I see them. Let's say, you know, two or three weeks after their, their episode, they still have scar tissue. They still have their, you know, stitches and the glans. And I tell them, say, 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, we're on the schedule to get that implant in.

[Dr. Jose Silva]
Is there more risk of, uh, extrusion in those cases?

[Dr. Jonathan Clavell]
I mean, in theory, yes. Um, I've done it twice already. Um, and you know, both patients have done very well, of course, you know, for, for that, for those type of patients, you are not going to oversize their implant. Uh, make sure, I mean, 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.
Uh, so I would be very conservative, but I will, I mean, you can get an implant there and they should be okay. probably 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: vacuum erection device during their pre-op phase.
Uh, using a vacuum pump every day, twice a day will create negative pressure inside the corporal bodies, bring venous blood, and it will keep the corporal space open. Aggressive VDD therapy is key to set 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 be bringing in all your drilling tools. Um, you will be drilling inside those corporas to break down that fibrosis. Make sure you have all the instruments you might need. For example, while the ones that I use the most is, uh, the Rosa Jacari on, uh, covering your tomes.
There's people who use the Euro mix. Give very no tomes. I also use Metzenbaum scissors. There's also a video about this by the way, YouTube.
Um, so Metzenbaum scissors, uh, there's people who use reverse cutting scissors. Uh, there there's a special dilator called the dilamezinsert. Yeah. dilamezinsert dilator. Um, that one, 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 I, and it makes me cringe. Um, I feel like I'm in a medieval movie. but again, it's something that can definitely be handy, uh, in, in some cases.
And the last pearl would be, if you aren't able to dilate through the proximal incision, be ready to either 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, you 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, you will crossover, or you will 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 away in and, and, and you see something, you're just not back to just, it's okay to close and send it to Jonathan.

[Dr. Jonathan Clavell]
I I've I've actually, I've actually had those. I remember I will never forget what when I was in fellowship, there was a surge, a local surgeon who wasn't able to, you know, to dilate, uh, distally and the guy just, you know, he put in a very small, like a 15 centimeter implant, and the guy probably needed like 24 cm or something.
And I'm like, Don't do that. I mean, if you can't dilate, just close them up and just, and, and just refer him to somebody who, who, you know, 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 just, you know, do the right thing for the patient.

(3) Penile Implant Surgery in Peyronie’s Patients

[Dr. Jose Silva]
And so, um, for patients that have Peyronie's, I mean, after using Trimix or whatever the reason is, how do you prepare for those cases? Uh, are you, do you try to do a modeling? Do you know beforehand that you're already going to do a, a graft?
[Dr. Jonathan Clavell] I mean for, I am for Peyronie's man. We can't, we can have a full two-hour podcast about Peyronie's disease, but yeah, when it comes to Peyroni's again, it's similar to priapism cases, I make sure to set proper expectations on a, you assess the severity of the curvature, make sure that you have at least an idea of how bad that curvature is.
I mean, don't tell them, it's like, oh yeah, we're going to be able to do a modeling, you know, procedure. And this is going to be a real straightforward case. And then all of a sudden you go in there and the guy has a, you know, 120 degree curvature. You want to make sure that you know what you're getting yourself into, make sure that both you and the patient are on the same page when it comes to, what are the goals of the surgery. Is a goal to make the penis straight like an arrow, or is he okay to be what we call functionally straight?
Right. Um, it's not the same thing for a guy to, to be a 20 degree curvature, which, which most of us have some degree of curvature. So again, you want to make sure that you set those proper expectations. Is his goal to get back as much length as possible. You need to make sure he understands what are the risks involved and what are the expectations to set yourself up for success?
So in a scenario, for example, like you mentioned, like if, if the patient has like a 90 degree curvature, like severe curvature and who, and he also has erectile dysfunction, I try to fix everything at the time of the implant surgery. There are different ways we can do this. Um, most of the time, again, with these severe curvatures.
Just placing the implant is not going to be enough. For example, a guy who has a, you know, a mild curvature, like those with a 45 degree, you can probably get away with just placing the implant and do, you know, very mild manual modeling, uh, or probably do, uh, Paul Parado. He uses a scratch technique in which he, uh, from inside the corpora, you can actually get a nasal speculum inside the corporotomy and then he uses either a 12 blade that has like a little hook or the tip of Metzenbaum scissors. You can just scratch the, that plaque from the inside. And sometimes you're able to, you're going to be able to, uh, to model that later and the penis will actually be kind of straight. Um, I've used it before you can actually bill for that, just like. Uh, you can, you can bill for that. Just like if it was an incision of the Peyroni’s plaque. It's just doing it from the inside instead of from the outside.
So again, you know, however, if there is a patient who has severe curvature, if it's 60 degrees or more, I personally prefer to do a plaque incision with, or without grafting. There's two approaches you can use to do this. Most people use a circumcision incision, they deglove the penis in order to access the tunica.
If you need to, uh, elevate the neurovascular bundle for dorsal plaques, you can do so. If you need to, you know, for ventral plaques and you need to, you know, elevate the urethra, you can definitely do it. So. Uh, me personally, I prefer to use a ventral incision. So instead of degloving the penis, I actually just, you know, make an incision, right along that ventral raphae, and I'm able to expose everything. There's also a video on YouTube about that. Um, and, and you can actually, uh, elevate both the skin dartos and to neurovascular. Altogether this way, we can keep the skin attached to the glans at all times. And theoretically we could avoid the risk of glans ischemia.
I mean, there was a study back in 2017, for example, that looked at the risk factors for cases with glans ischemia and they had 17 patients who had glans ischemia with penile prosthesis placement, and out of those 17 patients, 86% had a circumcision with the gloving. So for this reason, when we, when I was in my fellowship, uh, Dr. Wong, who's my mentor. Uh, and I, we published approaching these cases with the use of a ventral non degloving incision. And then another thing that I personally do for these cases, when it's severe curvatures and they do not have, you know, the plaque is not calcified, and there's no hourglass deformity.
I would, instead of doing one incision of the point of maximal curvature, I do multiple incisions. And instead of going at the point of maximal curvature, I should go around it. and that way with multiple incisions, I, the, those incisions are going to be smaller. And most of the time I don't even have to place a graft.
I'm actually, I actually plan to present my findings. Uh, I've done, you know, more than 35 cases, I believe now, using this approach and I'm actually presenting it next month.

[Dr. Jose Silva]
So you're not doing sutures you’re just doing the incisions.

[Dr. Jonathan Clavell]
So I, yeah, that is correct. So whenever, cause again, whenever we're placing a penile prosthesis, whenever we do Peyronie’s cases and we're doing a plaque incision with, with grafting again, the biggest risk with that is erectile dysfunction. The good thing about, uh, about these guys who also need a penile prothesis, you don't have to worry about that.
Uh, so in sometimes if the defect is less than two centimeters, uh, in, you know, in size, you can get away without having to place a graft. So what I do is because again, if you have a guy who has severe curvatures, again, 90 degrees, a hundred degree curvature, even 75 degree curvatures, and you make an incision to the point of maximum curvature.
When you get that penis straight, you will have a very large defect. Now you're probably going to have to graft. and in order for me to avoid that, what I started doing was making multiple smaller incisions and all of those incisions are probably a centimeter, a centimeter and a half. Again, you have to close the neurovascular bundle.
You have to close a box, you have to close dartos and all those will serve, enough there. They will serve as a scaffold to be able to cover those defects. And you don't have to worry about placing a graft. That being said nowadays, we have different types of grafts. There are these hemostatic patches. And the good thing about it is you don't have to worry about sewing a graft. Cause we all know that whenever we do these Peyronie’s cases and used to have to sew a graft that's 30 minutes that you have to add into your surgery in order for you to get that water tight.
Right? So I am one that uses a seal graft. Whenever I need to use it specifically for these, Peyronie's and erectile dysfunction cases that I'm using a penile implant.

[Dr. Jose Silva]
So, so you will then put the implant, see what you have left left after you, you put a, mean, you, you, you put the implant, you inflate it and then you see if there's a big gap, you will close those or,

[Dr. Jonathan Clavell]
Yes. Yes. So again, it really depends on what is your approach. Many surgeons, what they do is they place the implant first and then they do the reconstruction. I don't do it that way. I do my reconstruction first, and then I place the implant at the end, because again, I don't want it to. I don't want the implant to be exposed for a long time because that can increase the risk of infection.
Um, so I would place the implant. I will test it. And if the defect is not that big, I just close them. And again, I haven't had, you know, erosions, I haven't had, uh, any guys who have, uh, herniations or aneurism. And they've done very well.

[Dr. Jose Silva]
And I went to ask you for patients that, that you just also in the post-op period, let's say a patient comes to, I mean, after you, the implant, everything is working fine. What they say that is pointing down? That it doesn't go up. And when you see the anatomy it’s just because the fat pad is all over the penis.

[Dr. Jonathan Clavell]
I, I will never forget it. When I was in training, I was in fellowship. There was one guy who, I mean, he even threatened my mentor to, to sue him, uh, all because the, because this, his penis was just like, you're saying, it's like, it's pointing down. It's not pointing up. Um, and he's upset about that. Um, and we told him like, Hey man, this is on you.
I mean, you are the one who has that big fat pad. That's just creating weight on top of that implant. So now. We had that horrible experience during fellowship. I tell all my patients, whenever they have, you know, a large fat pad, I tell them like, Hey man, this might create weight on your implant and it will, your penis is not going to look like the mannequin.
So, so again, I mean, for those it's, it's just about trying to avoid these types of scenarios. Uh, cause these guys can sometimes be very difficult to manage. every patient with a large patch. I will try to set expectations prior to the surgery. As soon as the patient was properly sized, there are several tricks that we can try.
Uh, there, I mean, I Rafael Carrion. He published an article, uh, several years ago about placing an implant and at the same time, removing that suprapubic fat pad, I mean, you can do that. I don't do that. I usually tell him like, Hey, you can see a plastic surgeon, uh, for, you know, for you to do this just because I don't want to be dealing with it.
You know, post-op, uh, uh, and you can also try a ventral phalloplasty for guys who are complaining or worried about their size. Uh it's like, hey, my penis looks smaller. Uh, and I tell him like, Hey man. And I usually push the fat once the implants and I push the fat pad all against their bone. And like, you can see you have about three inches underneath, underneath your skin.
Um, and again, and I try to tell him like, Hey man, when you're having sex, Your partner will be creating pressure on top of that. So you will be able to penetrate more than why it actually looks like. and there's also another technique that we can use is called a dorsal phalloplasty. Uh, this was a technique developed by, uh, by a surgeon in Egypt, his name's Dr. Shair, and he places sutures from the dermis of the suprapubic fat pad, you know, that skin. And then he tacks it down to the periosteum of the pubic bone. And with, you know, what those stitches it's basically just like pulling the skin around the shaft down. He's able to expose the penis a little bit more. It will still be looking down, but again, at least it looks like they have a bigger penis.

[Dr. Jose Silva]
Hm. Okay. Good to know. Yeah. I wasn't aware of that one, so I need, I need to take a look at that one.

[Dr. Jonathan Clavell]
that just in case that, that one, if, especially if it's a redo case, it is painful.

[Dr. Jose Silva]
Okay. So, so forget it. I'll send it to you.

[Dr. Jonathan Clavell]
I remember I once had a guy like, oh yeah, let's do it. I'm like, oh, what am I doing here?

[Dr. Jose Silva]
So you mentioned re-do so in terms of redo, I mean, at some point, do you want an MRI or any special imaging? Or you just go straight into exchanging the depends on the situation

[Dr. Jonathan Clavell]
It really depends on what you're expecting and how curious you really are. I mean, if there is something that you can not explain with the physical exam, then MRI could definitely help, especially if it's something, uh, within the corporal bodies. And then if the patient had the implant done by someone else and needs a revision, um, I would always recommend to get a CT scan at least to make sure to know exactly where that reservoir is located.

[Dr. Jose Silva]
So let's say, let's say, uh, uh, you, you have a patient, a simple redo. Let's say the, the, the patient did the, it's not working anymore. How's the process, just a simple excision of that and a replacement. do you guys also venture, I mean, uh, penoscrotal approach?

[Dr. Jonathan Clavell]
So it depends. Um, it D just, I mean, one thing that everybody needs to understand, I mean, all surgeons out there listening to this podcast is that you do whatever you feel comfortable with. If the patient had an infrapubic, you know, implant, you can't. take it out and replace it through a penoscrotal incision and vice versa.
They get patient had a penoscrotal implant. You can still take it out through, uh, infrapubic incision. Um, yes, it's going to be, I mean, it's going to be a little bit different, but it's not, it's really not that difficult. That's one thing. The other good thing about going through the other approach is all the tissues will be virgin.
For example, if the patient had the, implant, I mean, I love to have guys who, who had their implants originally placed through the infra pubic approach. And then I go in to do my, my revision and everything, all the planes are virgin, right. Uh, so again, it's going to be a lot easier to do that. And you just do, whatever's comfortable for you.

[Dr. Jose Silva]
And do you tend to remove all the fibrous tissue on the capsule, for example, around the, the pump. Do you tend to remove that or do you actually use it, to put the new pump there?

[Dr. Jonathan Clavell]
So it's so sometimes, I mean, I'm going to be really honest with you. I, if it's something that looks, you know, that's very prominent and very hard and you know, fibrous in texture, I will try to take it out. At least some of it. I don't take all of it out sometimes I just ignore it. the one thing though that I, that I would say is that I try to place a pump in a different spot, you know, in a different, uh, pockets.
So I will create a new pocket and make sure that there is no contact between that capsule and the new pump.

[Dr. Jose Silva]
and in terms of the, of the reservoir, how aggressive are you removing it in this patient? That is not infected.

[Dr. Jonathan Clavell]
So, again, for those, it really depends. One, if I wasn't the one who placed it originally again, I would reiterate get imaging to see if it is actually accessible for you. Are there any surrounding structures? How close is it to the bladder? How close is it to the iliacs? I mean, there's a patient have a hernia repair on the other side that I won't be able to access if so, I would try to take it out in order to place a new reservoir in that same space.
If the implant malfunctioned within two years, I would probably reuse that same reservoir, especially if you're going to be using the same, you know, company, uh, if it's, if it was a previous AMS implant, I would just, you know, try to reuse the same, uh, reservoir if it's been within two or three years.
I am one again, this is just my personal opinion. I try to take it out. Uh, but if it is really deep and I am really, really struggling to take it out, sometimes the best thing is to just drain, you know, take all the fluid out and just retain it and just leave it there again, just be conscious of where it's located, because again, if the only downside to that is if the new implant now gets infected and you need to take everything out, trying to find that you will definitely need to do a counter incision, but I would rather do a counter incision later on without risking injury, to major structures than being too aggressive during your revision case for something that's probably not going to cause any problems down the road, and then you end up regretting it. So again, drain and retain is something that's definitely, uh, feasible is something that we can definitely do safely, again drain if in doubt, just drain the reservoir and leave it in place.

(4) Infections during Penile Implant Surgery

[Dr. Jose Silva]
Okay. And there's always, I mean, talk about infection versus erosion and, and, and, and, and something there's a fine line. I mean, as long as the patient doesn't have any systemic symptoms, uh, but taking, I mean, what do you, when do you say, okay, I'm gonna, I'm not gonna put a new one. Uh, let's say, the pump is eroding through a scrotum versus an infection, or when do you make the decision to just exchange everything at that moment? Or just, take it out and then come back on another occasion.

[Dr. Jonathan Clavell]
I mean, he really depends on how bad, you know, the, that infection is. If there's gross, gross puss, leaking out. I mean, if, if there's pus, uh, I usually try to take everything out, remove it. Then I would have a conversation before the surgery, with the patient, with what are the risks. Any patient who has an infection I tell them like, we have three options. I can take everything out and come back another day. I can, you know, take everything out, place a malleable, right? Wash everything out, place a malleable. But you have about a 15, 20% chance that this is going to fail. And then we, and then I can also take everything out, replace it with a three-piece inflatable implant again, but you have about a 50% chance at best that this can, that this can work or that this is going to eventually work. And usually I let the patients decide as long as they're aware of what they're getting themselves into, uh, we can, we can make, uh, we can make it happen. Uh, you don't always have to. I mean, it is possible on the, I just want to rephrase this.
It is possible to replace it with a three-piece. I've done it before and they've done well, of course, in these patients, I will, I need to make sure what infection we're dealing with, what that culture has shown. And I will keep them on antibiotics probably for a little bit longer, maybe two or three weeks, rather than just one week afterwards.
Also, evaluate what are the risk factors. If this guy's like an uncontrolled diabetic, I mean, don't shoot yourself in the foot. If the guy's healthy and doesn't have any risk factors for infection, then it's something that we can definitely, uh, consider.

[Dr. Jose Silva]
And in those cases you do a wash out, you try to remove the biofilm. Uh, w w what, what techniques do you use to, clean those corpora.

[Dr. Jonathan Clavell] So I am one that I do a wash out. I use iricept, uh, that has chlorhexidine. Uh, it's like, I think it's like 0.05%. Uh, so I use, uh, I use iricept with antibiotic solution. I'm just basically alternating, alternating both. I have a really good friend, he uses another, uh, solution called , chlorpractin, it's basically like bleach, but tissue friendly.
I want to use that in the hospitals where I work on it. They just don't have it available yet. Um, and as soon as we have it available, I'm definitely going to start using it. I do not use betadine. I do not use hydrogen peroxide. I believe these will damage the tissues and they're really not that great.
Uh, so again, I use whatever is available. but again, it's just a matter of actually irrigating those tissues more than what you're actually irrigating with. So the most important thing is you make sure that you wash out everything very well. I do not remove all the biofilm, for example. I mean, sometimes I place, you know, for these infected implants, I wash everything out very well.
And I placed the implant within that same surgical capsule inside the corporates. There is no Dr. Shair again, the guy for that, that doctor from Egypt, uh, he, he also, uh, uses the extra capsular tunneling. So basically creating a new space behind that capsule in order to avoid contact, uh, of the new implant with the surgical capsule.
And that's something that works for him, uh, in several cases that he published. So again, there's multiple things that we can try. Uh, for example, another thing like for these infected IPPs, Uh, you know, carry ons. He used to keep publishes, carry on cast, which is basically like a spacer, what, what he uses with that is a solution called stimulant, which is calcium sulfate.
And you can actually combine it with antibiotic solution. So it's like a powder that you just combine it with vancomycin or tobramycin or whatever other powder antibiotic, you mix everything together, you get the water in, or saline, and it will create, uh, this paste that forms like a cast. Um, and this cast usually dissolves within six weeks.
So basically you can leave that cast in there and come back six weeks later. So we will create a, like a spacer inside to make sure that, that, that, that corporal tissue doesn't collapse and start causing fibrosis. So whenever you come back, it's going to be easier for you to get an implant in that being said, it's easier said than done.
Um, I believe that right now he's working on a new protocol to, to see how he can optimize that. Cause you have like a five minute window, to get that cast in and it will create a mess if you don’t do it quickly.

[Dr. Jose Silva]
Yeah. Well, I was in residency. I, I did, I think we would call up. I remember I was with him or a \couple cases And I saw, and definitely at that time it was 10 years ago or nine years ago. And it was actually, we were injecting in the same syringe and sometimes he will calcify in the same syringe. So it wasn't as easy the application. I, mean, definitely. I mean, I'm sure he has by now, uh, made it better or easier to apply, but it wasn't that easy.

[Dr. Jonathan Clavell]
I know, I know, I know there's people that, uh, like one of his previous fellows, Dr. Aaron Lobe, he's right now in Cleveland. So if he's listening to this, hi man. Uh, um, so one of the things that he, that he started using for example, was a chest tube and he would get, you know, the pace, you know, the, all the, the stimulant with the antibiotics inside it, and then he would cut the chest tube into little pieces, take the actual plastic from the chest tube out, and they just start getting these pieces inside the corporal tissue. That being said, it's easier said than done. Um, and it's really not that fun to, to do this. So again, I remember I did one in fellowship and it was such a headache that I'm like, I mean, fortunately my infection rate is very low, so I don't have to be, I don't have to be dealing with these cases often.

[Dr. Jose Silva]
And in those cases, what broad-spectrum antibiotic will you give them?

[Dr. Jonathan Clavell]
So I usually try to keep them, you know, something similar, of course. if you have a guy who comes into your office, he, you see that there's pus get a culture right there in your office, send it out for culture. So you know what you're dealing with and that way you can tailor your antibiotics to cover for that bacteria specifically, if it's still broad spectrum, I would still do, you know, the, the regular vanc and gent.
Sometimes I, uh, I combined it with vancomycin and sozan, uh, instead of the gentamycin, uh, and I also put in an antifungal, because again, you can also get these fungal infections and we're not that we're not paying attention to at the time of the. The first thing that I do, as soon as I make my incision, I get a swab of that tissue or send a little bit of that biofilm tissue out for culture to make sure that you know, what you're dealing with in case that you have to come back in the future, you know, six weeks, three months down the road to get an implant in, you know, what bacteria, you know, was in there and what, and what resistance that bacteria had.

[Dr. Jose Silva]
And for those cases that you have extrusion through the, either the glans or the urethra, will you put another one at the same time? Will you close the defect and come back at another time?

[Dr. Jonathan Clavell]
Depends. if the, this is, again, this is all my opinion, do not take this as scripture. I mean, these cases are extremely rare. So again, there's, we, we are still learning, but if there is a complete extrusion, right. There's a complete erosion that I can actually see the implant. If it's through the glans, it is very unlikely that I will place an implant in again, if it's in contact with the urethra, I would not, again, this is just me. I would not place an implant back in, at least in that side. if it's on the side, right? If it's like, you know, on the actual side of the shaft, if there is no gross signs of infection, I would just, you know, wash everything out and I would place an implant in and just close it. And I would just keep that implant deflated until everything heals.
Sometimes one of the things that we can do is let's say that it eroded into the urethra. Um, but there's no gross signs of infection. and it's only one side that eroded. You can take that side out and just leave that other side. You know, the, let's say that the right side eroded, you can leave the left implant that left cylinder inside.
And sometimes you can actually get away with it. And I've seen guys in my office again, not my patients, but I've seen guys who've had implants done before that they have one cylinder and they're happy with it. So again, they can still be functional with one cylinder. Uh, so again, sometimes it's just a matter of setting proper expectations and telling them, hey, man, we just want to get you functional. This is not for you to be, you know, feeling like when you were 20 years old is just trying to get you functional and we can always come back and fight another day.

[Dr. Jose Silva]
And I think that's, that's the most important talk that the expectation at first, because they always see the videos on, they, they go to you to YouTube, not your channel, but just Boston scientific, for example, the video great erection, just like there were 20 years old.
And, hey, that's not true. I mean, like I said, its’s just a matter of being functional. Are you doing drainage on those patients? Let's say you do a wash out. You put on new implant. do you leave a drainage?

[Dr. Jonathan Clavell]
Yes, I will do that for those patients. I will definitely. I mean, even if I don't leave an implant in, I would leave a drain in for several days. Because again, those you are washing them out a lot. Uh, you're using a lot of fluid. You want to make sure that you set yourself up for success. You don't want these guys to have edema and then, you know, the edema accumulates into a pocket, and then you have a pocket of fluid that will, that could potentially get infected.
Uh, so for those, I would usually just leave a drain in. Yes.

(5) Glans Hypermobility during Penile Implant Surgery

[Dr. Jose Silva]
Let's talk about an interesting topic. And sometimes, I mean, for me, it has happened right there in the, or, those patients that have a hyper mobile glans or, and you see that, uh, as, as, as the, the, for me the, uh, the if you didn't know about this prior to the surgery, uh, we'll do any correction at the moment and just tell them, hey, I had to do another incision.

[Dr. Jonathan Clavell]
It's very tricky, um, that we actually, uh, with it was Toby Kohler, Paul Prieto, and myself. We did a combination cohort, um, about two years ago in which we looked at how frequent that glans hypermobility was. Again, we were three. experts combining data. We knew that we were dilating to the max and sometimes you will still have these guys just like you're saying that they still have these hypermobile glans. And then we looked at, should we be fixing these at the time of surgery or she would just observe them. And the true answer to that is like, it really depends on the surgeon. I am one that it really depends on how bad it is.
Um, if it's mild. Uh, and we actually even put that we had like a grading system on how bad that hypermobile glans was. Um, if it's mild, sometimes I would just leave it. Cause sometimes they do well and they’re not, they're not going to complain about it. I also take into consideration their insurance status. If I have a guy who's paying out of pocket, that I know that I don't want him to have to pay another few extra thousand dollars to get into the operating room, uh, to come back and fix it for those guys, I would have a lower threshold to fix them right there. Versus a guy who's older, who's again, the guy is just super excited to have his implant, you know, his implant that he did really doesn't care how it looks. He just wants to be able to have intimacy with his wife. and he has insurance. Usually for those guys, I might actually just leave it if it's just mild. Um, if it's severe, I will definitely fix it. Cause again, I want, I, I, and I would just, you know, explain to him like, hey man, just like you're saying, I would, uh, I would just tell him like, hey man, we, I had to make a second decision and we had to get that.
Uh, we needed to fix that in order for you to be able to, for you to be happier
.
[Dr. Jose Silva]
And will that give, I mean, let's say you don't correct it. Uh, they, they see how the mobility will happen. They will, it will pull your risk of any, Tunica rupture or something like that, or any, uh, exclusion at some point assuming that is, that is a true hypermobile glans.

[Dr. Jonathan Clavell]
I mean, sometimes if it's chronic some and, and you, and, and the implants actually going towards the skin of the shaft, you will have an impending erosion. Um, so you have to be aware of those of those cases. Um, again, usually those are guys who have, who tend to have a worse hypermobility.
Right? And sometimes these guys are under size. I mean, I've seen many, many guys who come in to see me. He's like, Hey doc, I have the SST, the formatting, when I see them as like, they have like two to three centimeters off. Um, and for those guys, again, you want to be able to fix them because if they start using that implant, it will create an impending erosion.

(6) Impending Erosions in Penile Implant Surgery

And now that we're actually talking about impending erosion, so I was like, I'm not, I'm not sure if we've talked about it, but yes. I mean, uh, I want to talk about this. I'm very passionate about the impending erosion. That was actually my latest research. Uh, there are multiple ways to treat these one very popular way and probably the most commonly used technique out there is performing a distal corporoplasty in which we make an incision on the side of the erosion.
Uh, or, or the impending extrusion, and the surgeon finds, you know, the surgical capsule, you incise the surgical capsule and you re direct just the tip of the implant behind that capsule. Then you can even use the capsule to close it. almost two years ago, uh, one easier technique. This was published by Karpman, uh, Eddie Karpman in, in, California and Rafael Carrion. They published the use of a, they call it the distal biologic cap in which they use a tutoplast or, or some other categoric tissue. And they place it as if it was like a condom around the tip of the implant. And when you bring that implant all the way through, it will give an extra layer of tissue to prevent that implant from eroding.
And what I published earlier this year was the use of the extra capsular, uh, or the extra capsular tunneling. So through the proximal corpotomy incision, you can incise the capsule, create a channel behind that surgical capsule, and you basically create a new tunnel for that, for that implant. And the good thing about that, you don't need to use any extra tissue. You don't have to make any alternate incisions, distally that could potentially increase your risk of, uh, infection.

[Dr. Jose Silva]
So you will go where you did the, or more or less where you did the corporotomy, take out the tubing. The implant on that side, and then just recreate another channel right along the other one.

[Dr. Jonathan Clavell]
So it depends again, I take many things into consideration, if it's a self pay patient who the implant was recently placed or, uh, it's just like something that' easier to just get or tackle through a proximal corporotomy, sorry, sorry through a distal corporoplasty, I would just do the distal corporoplasty. If the implant has been there for many years or, or the implants not inflating now to the max as the guy has lost a little bit of fluid or the implants not working, then I will, I would just take everything out, do that, you know, on that side, I will do that extra capsular tunnel and then just get the implant in.
I've had guys, for example, that they have two, you know, both sides are creating an impending erosion. And for those guys, I will do that extra capsular tunnel. Bilaterally. And again, the good thing about it is you're creating, you're going through a different space within the corporal tissue, that new space will collapse the previous space.
There's no risk of that implant being in contact with that capsule. And it should buy them several years without them having any problems with, you know, with impending erosions.

[Dr. Jose Silva]
So, if impending erosion is, let's say lateral in the lateral axis, or, uh, would you try to go medially then to use that tissue as a barrier?

[Dr. Jonathan Clavell]
Yeah. So you can, yeah, you can definitely do that again. The extra capsule tunnel does not work for everybody. I’ve had guys, for example, who have like very thin corpora and there's literally no space around that capsule. Um, and for those patients, I have to make a distal corporoplasty, especially for that scenario that you just described.
If the impending erosion is lateral. Sometimes the easiest thing to do is just do a distal corporoplasty. You incise that capsule, both laterally and medially direct that implant, you know, behind that medial capsule and just use that capsule as an extra layer to cover it.

[Dr. Jose Silva]
And in those cases, would you do a ventral incision? Uh, how would you will expose the penis?

[Dr. Jonathan Clavell]
So usually for those distal corporoplasty, I do a lateral incision. Just straight lateral right next to that, that impending erosion.

[Dr. Jose Silva]
Okay. And that won’t cause any problems. I mean, any problems in the skin, in that area that, that will create infection or something? I don't know.

[Dr. Jonathan Clavell]
Everything is possible,

[Dr. Jose Silva]
Okay. Okay. But probably definitely easier to expose that area you want to work on.

[Dr. Jonathan Clavell]
Of course, of course. I mean, for those cases, again, you treat it like if it was a full [00:55:00] removal, uh, you're going to wash it off very well. Uh, make sure that that doesn't get infected. there's one of the techniques that's used for these distal corporoplasty is actually use a stitch to fix it at the level of the glans.
And again, I mean, there are there's research articles describing all of these techniques, and I think there's even videos. And the VJP, the Video Journal of Prosthetic Urology, and these are free access, open access, you don't need to subscribe or anything. You just go in there and everything is accessible to you guys.

[Dr. Jose Silva]
Perfect. So we definitely need to check those videos out, including your videos for the patients. And what do you do? You give the patient, I mean like a card of your YouTube channel, you just tell him, hey, go to YouTube.

[Dr. Jonathan Clavell] I just tell him, Hey man, go to YouTube, put my name, you will find the videos. Uh, and again, it really, I mean, know your audience. Uh, there are guys who do not want to see, you know, videos. They don't want to see they're like doc just fix it. I don't, I don't have the gut to know to see such a surgery.
So for those guys, I try to avoid them from, you know, giving, you know, telling them about my YouTube channel. But I, I have many guys who come in that they found me through that YouTube channel. And for those, I tell him like, hey man, there's a video about that. Um, or they are wondering, say, hey doc, well, how can you fix this?
Like we haven't talked for example about proximal perforations. How do you fix that? I mean, I, there's a I have a video explaining how I fix those things and that way these guys know what they're getting themselves into. I tell him like, hey man, exactly what you saw in that video is what I plan on doing on you. And that way, you know, I mean, I have before and after pictures. I have before and after pictures in my phone and I show them, um, and that way, you know, they have a better understanding of what they're getting themselves into.

[Dr. Jose Silva]
Yeah. And I guess, I mean, also for the educational videos, I mean, that's very, very helpful in terms of, of, of that patient having some questions and, and you'll give, provide the answer through the educational video. So finally I want, I mean, and like you mentioned, I mean, we can talk about a couple of hours about each topic of this or any situation.
Uh, but let's talk about probably the most serious, complication of all, which is the glans ischemia. And you mentioned a little bit before, what type of patient do you have to have a high suspicion that it might happen, or, or is it, it is something that might happen because of pure technique.
It is something just that the patient, because of poor vascular flow or conditions. he’s more prone for that?

(7) Glans Ischemia after Penile Implant Surgery

[Dr. Jonathan Clavell]
I mean, fortunately, my, fortunately for me, before I started practice, uh, Steve Wilson and a group of other surgeons, they, they, they wrote this article back in 2017. Um, and they were looking specifically at what were the pre-operative risk factors. And what were the intraoperative risk factors for developing glans ischemia. I've only seen one, in my patient cohort. And the guy had all the risk factors. So, uh, I wasn't surprised when it happened and I'll tell you how I managed it. But before that, what you were talking about, what are the risk factors, again, a chronic smoker, you know, a guy who smokes two packs a day, and he's also diabetic and you had to do a degloving incision for Peyronie's disease. And you had to do a complex reconstruction, you know, for that, uh, Peyronie's disease. Again, that's the guy who is an extremely, uh, high risk of developing glans ischemia. Uh, so again, you know, make sure that if you have a guy who's, you know, a chronic smoker try to get them to at least quit for several weeks or at least tone it down, or at least those first few days don't smoke.
Cause again, it can be difficult to reverse it once it starts developing. Right. In terms of my patient. I mean, I'll tell you the story with my patient. He was a chronic smoker. Uh, he wasn't diabetic fortunately, but he was a chronic smoker and he had really bad Peyronie’s 90 degree curvature and I had to do multiple incisions like I described to, to fix his Peyronie's disease. I did not do a degloving incision, fortunately. But the guy I remember, I will never forget. I mean, that they would, that was early on, uh, when I was in practice and the guy I used to admit my patients post-op and post op day number one, I go in to round on this guy and the guy's nowhere to be found, the guy was outside smoking.
So I'm like, dude, I mean, you can not smoke. I mean, this, you had a really high risk surgery. Um, you have to avoid that. The guy was doing well one week later, again, this was one week, not several days. And again, usually for my patients, I tell them, hey, send me a picture of the glans for all my Peyronie's patients I have them sent them pictures of their glance in the first 48 hours. Because most of the time you will start seeing changes in the, in the first 48 hours. This guy was doing what was doing well. But one week after his surgery, he called me. He’s like hey doc, my glans feels very, very cold and I'm like, oh, red flag.
Right? I tell him like, hey, send me a picture. And it looked kind of dusky. He already looked kind of dusky was a little bit grayish. So what I started doing for that guy, I started him on daily Cialis right away to start bringing some blood flow into his glans. And then several days later, this was the day that I was in Dallas preparing for my oral boards. I receive a call with a picture, he said, hey doc, look at my, you know, look at my penis. And he, you know, lo and behold. He had ischemic changes in his glans. Fortunately there were just patches. And I told him to go to the emergency room right away.
I called my partners like, hey man, I have this guy, you know, please go in and see him. And I can even show you the pictures. His entire ventral incision was black, like black. And then the glans, he just had like a few spots, but they look very, very superficial. The rest of the glans looked nice and pink and healthy.
So I kept them in the, in the hospital, I deflated the implant, you know, all the way. And I told him, hey man, what we should do is take this implant out. But we can, you know, risk it and see how you do. Cause again, it looked very superficial and it was already calcified. I mean, he had like a dark, you know, it was already dry. It wasn't wet. Uh, so he had like a dry gangrene right at the top of the glans. So I told him like, hey man, let's see how you do. I started him on every other day. He was taking 20 milligrams of Cialis for like three weeks. And the guy ended up doing well. Then, those scabs, they fell off.

[Dr. Jose Silva]
So you never had to remove the implant.

[Dr. Jonathan Clavell]
I never had to remove the implant.

[Dr. Jose Silva]
And that's part of what I wanted to ask you. I mean, cause before you, you can round on the patient the next day. I mean, those patients usually stay one more one night. Uh, well now most patients are males. I'd say almost all patients are discharged that same day. So if you get that planning ischemia next day, if they're not looking for it, maybe, I mean, if you leave a bunch of band-aids around and they don't see the glans is more difficult, really to, to, to diagnose at the moment.

[Dr. Jonathan Clavell]
And thank you for mentioning that because that's another thing that I actually even forgot to mention. So yes, I mean, if you have a compressive bandage, if you have a coban, don't leave that, you know, uh, super tight, even if it's right after surgery, you're concerned about edema. You can place a, I always place a coban for these Peyronie's cases, but I place it very, very loose and I tell them the first thing you're going to do tomorrow morning is take that bandage off. Um, you don't want to be compressing the shaft for too long, especially if you did the gloving incision. Uh, you want to make sure that you minimize the risk of that glans ischemia, because when it happens, it happens. And I've heard so many disasters, uh, from, from colleagues. And again, fortunately, that has had, that has been my only, the only time that I've seen it, uh, in my patient cohort. And again, I told the guy, as soon as he stopped smoking, I told him stop smoking, or your penis is gonna fall off. And the guy, I mean from two packs a day to zero cigarettes.

[Dr. Jose Silva]
I think that doesn't get you to quit, nothing will.

[Dr. Jonathan Clavell]
The guy, I mean, he ended up doing very well. and, and yeah, I mean, he was successful.

[Dr. Jose Silva]
Good. So Jonathan then I think that's it for now. Uh, thanks for being here on backtable again. I'll have you again in the future and we'll talk about something else or more penile implant, testosterone, men's health. I mean, you, you do all those things. Uh, so, so we have definitely a bunch of topics to talk.

[Dr. Jonathan Clavell]
Of course, of course. Thank you for having me. Thank you for the, everybody in the background for backtable urology. I am a believer. I'm a follower, I'm a subscriber. Um, and, uh, and hopefully this can continue to grow again. You guys are doing an amazing job and yes, man, have me back and we can talk about Peyronie's and everything that we can do for these guys, uh, when we're still learning from all these things. So, uh, about these topics. So it's good to have a refresher.

[Dr. Jose Silva]
Perfect. Thanks, man. Take care have a good week.

[Dr. Jonathan Clavell] You too, man.

Podcast Contributors

Dr. Jonathan Clavell discusses Complex Penile Implants on the BackTable 23 Podcast

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 discusses Complex Penile Implants on the BackTable 23 Podcast

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

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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