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BackTable / Urology / Podcast / Transcript #8
Podcast Transcript: Men's Sexual Health
with Dr. Jonathan Clavell and Dr. Jose Silva
Dr. Jose Silva interviews Dr. Jonathan Clavell, a high-volume prosthetic urology surgeon and assistant professor of urology at UT Health Science Center Houston, about erectile dysfunction counseling and penile implants. Dr. Clavell goes into detail about his journey as a men’s health specialist, ED workup and medical counseling, advantages and limitations of different penile implants, implants for complex ED patients (diabetics, cancer patients, etc.), and post-operative care for penile implant patients You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Marketing Yourself as a Men’s Health Specialist
(2) Erectile Dysfunction Patient Workup
(3) Comparing Penile Implants: Coloplast vs. AMS 700
(4) Infrapubic vs. Penoscrotal Surgical Approach to Prosthetic Implantation
(5) Complex Penile Implant Patients: Mini-Slings and Ectopic (Alternative) Reservoir Placements
(6) Dealing with Penile Implantation Difficulties: Coloplast Pump Placement Adjustments, Urethral Perforations, and Prostate Obstructions
(7) Post-Operative Antibiotics and Bandages
(8) Cycling and Using Penile Implants
(9) Special Considerations for Diabetic Patients: HbA1c and Glucose
(10) Post-Operative Pain Medications
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[Dr. Jose Silva]
Hello, everyone, and welcome back to BackTable Urology, your source for all things urology. You can find all previous episodes of our podcast on iTunes, Spotify, and at backtable.com. This is Jose Oche Silva as your host this week, and I'm very excited to introduce our guest today, Dr. Jonathan Clavell.
Dr. Clavell is a men's health specialist and assistant professor of urology for UT Houston. He did urology residency at UT Houston then did a fellowship in sexual medicine, andrology, and prosthetic urology at the same institution and at MD Anderson Cancer Center. Jonathan, how are you doing?
[Dr. Jonathan Clavell]
I'm doing great, man. How are you? It's been a long time.
[Dr. Jose Silva]
It has been a long time. Was it for Boston Scientific or for Rezum? We just had a talk about our experience with those products and it was good to get in touch with you.
[Dr. Jonathan Clavell]
Definitely. Definitely. I still remember when I was an intern--when I was doing a preliminary year in general surgery back in Puerto Rico--you were a chief resident. And yeah, we had good times back then.
[Dr. Jose Silva]
And then you got the opportunity to go to UT Houston and you did. Talk to us about how you entered the sexual medicine world. Was it something you were thinking about before residency, or was it while you were in residency that you fell in love with this?
[Dr. Jonathan Clavell]
I think it would be a little bit creepy if I told you that I went into urology thinking that I wanted to be messing with penises all the time.
[Dr. Jose Silva]
True.
[Dr. Jonathan Clavell]
But you probably don't know this, but the very first case I saw when I was doing my sub-I as a medical student was a radical cystectomy with an ileal conduit and you were doing that with Manuel Omar and Dr. Purras. I thought it was really cool to create a bladder out of a piece of bowel. I'm like, "I want to do that."
But then during residency, I was actually more into endourology and peds. I love stone cases. I love doing my rotation here at Texas Children's. However, most of my research was actually on penile rehab after prostate cancer treatment. That's how I was basically exposed to the sexual medicine world.
Out of that, I was given an opportunity to go to a prosthetics cadaver course at the SMSNA, which is the Sexual Medicine Society, for those that don't know. Actually, that society provides a course for residents to be working on cadavers with prosthetic experts. And I was a PGY-4 at the time and the meeting was in Scottsdale and there, I learned about what others did in the sexual medicine world and saw the passion in which other sex med experts spoke and gave their presentations. That's when I knew that this specialty was for me.
It's crazy how things work because this year's meeting is going to be in Scottsdale. We're finally going to be able to present in-person--they actually invited me to give a presentation on how to manage complications related to prosthetics.
[Dr. Jose Silva]
That's awesome. Congratulations on your work.
[Dr. Jonathan Clavell]
Oh, thank you. Thank you.
(1) Marketing Yourself as a Men’s Health Specialist
[Dr. Jose Silva]
You definitely have been working for this and just living the life of a men's health specialist in that sense. Jonathan, how's your week? Talk to us about what a week of a men's health specialist looks like.
[Dr. Jonathan Clavell]
I've been really fortunate to be able to build my practice around men's health. Right now, 95% of what I do is men's health related, be it erectile dysfunction and Peyronie's disease, low testosterone, BPH, circumcisions, vasectomies, and we also do a little bit of cosmetics on the side. I hope that it will be an entirely different show.
[Dr. Jose Silva]
Exactly. But we will. We will. We will talk about that.
[Dr. Jonathan Clavell]
But in terms of the weekly schedule, I have three clinic days, usually Mondays, Thursdays, and Fridays. I'm in the clinic all day from 8:30 to 5:00. Then up until maybe six months ago, I was only doing one day, the OR, which was Wednesday. Probably around September or October of 2020, my numbers ramped up exponentially. I had to add a second day.
Now, I'm operating both Tuesdays and Wednesdays. And occasionally, I can squeeze in an outpatient case early in the morning prior to going to the clinic if I need to. And then afternoon is just trying to grind and try to find ways to attract more patients to our practice.
My practice is very different from most urologists. For most urologists, you have referrals from a lot of primary care doctors, cardiologists, or even partners in your field. Right now, in my office, it's only two of us and the other guy who's with me, he's also a high volume prosthetic surgeon. So I had to find ways in order for me to attract patients and I've been able to do that basically through marketing.
[Dr. Jose Silva]
Marketing. I also see you have a YouTube channel. You also have a radio channel. How did you start that process of marketing yourself and competing in a big city like Houston?
[Dr. Jonathan Clavell]
For that, I could tell you two words: sweat and grind. When I finished my fellowship, I had to stay here in Houston because my wife is a dermatologist. So I had to stay here in Houston at least for a couple of years and I told my wife, if I'm going to develop my practice here, we're just going to stay. She loves it here as well. So it was great. But anyways, coming out of fellowship, I joined, believe it or not, the highest volume prosthetic surgeon in the city. He had many patients who came in to see him. So I felt the need to create a name for myself early on. I couldn't be a Robin when there's a Batman in the office, right?
I did everything I could to market myself. I started knocking on doors here in our building to let other doctors know I was here. I created a website for myself. My partner was kind enough to allow me to do that. He's like, "Hey, if you really want to do this, you have to create a name for yourself." I created my website, I started creating my own content in order for me to differentiate myself. I had to create content for myself then I started going to social media. I created a Facebook page, Instagram. YouTube has been great. And then the radio show because I'm here in Houston, half of the population speaks Spanish and nobody was targeting that population. I was fortunate enough to get into the radio in a Spanish station and everything has been booming since.
[Dr. Jose Silva]
Good. Being at the right place at the right time and definitely sweating it, doing the work, and just grinding it.
[Dr. Jonathan Clavell]
That's right.
[Dr. Jose Silva]
One thing is going to an academic setting where you're sitting there, waiting for patients to come. You have your own steady salary, but if you're going to go into private practice, you need to do that. You cannot just sit on the chair and just wait. You need to definitely grind and work for those patients.
[Dr. Jonathan Clavell]
That is correct. Actually, I was listening to a previous podcast from BackTable Urology, and I heard your story that you started paging yourself. You started paging yourself in the hospital.
[Dr. Jose Silva]
You remember Dr. Walker. He was the one that gave me the idea and definitely, I did it. I did it and people started hearing my name.
[Dr. Jonathan Clavell]
That's what you need. You need people to know that you're here because otherwise people won't know. Especially if you're starting out in a new practice, people won't even respect you initially. You're the new guy out. People will still see you as a resident, especially if you're in a big hospital with a lot of attendings around.
And here in my hospital, for example, there's three older urologists and nobody was going to start consulting you when you're straight out of training. So I had to quickly create a name for myself and even among urologists. I started calling urologists and telling them, "I know you don't want to talk to guys about erectile dysfunction because it will consume 20 or 30 minutes out of your appointment. So just send those over to me. I'm happy to have that conversation with them."
Same thing with endocrinologists. All their patients have diabetes, half of those guys are going to have ED. Same thing with cardiologists and cancer specialists. And that's how you're going to be able to create a name for yourself.
(2) Erectile Dysfunction Patient Workup
[Dr. Jose Silva]
So you get the patient to the office. He has ED. He hasn't been on any medication or anything. How's the process? Do you do a SHIM score? How do you work up that patient?
[Dr. Jonathan Clavell]
Every single new patient, if you're a guy coming into our office, you're going to fill out a SHIM score. Of course, if you have a guy who has a SHIM score of 22 to 25, you're not even going to bring up the conversation. But for everybody below that 22, I'll start asking them. Everybody above 45, 50 years old, I'm going to say 45, because I know you're below that.
[Dr. Jose Silva]
Thank you. Thank you.
[Dr. Jonathan Clavell]
Yeah, everybody above 45 years old, I will ask them, "How strong is your erection?" And if they tell me, "Doc, it's strong as a bull." I'm like, "On a scale from one to 10, 0 being on your honeymoon, what would you give it?" "Oh, doc, you know it's not going to be the same as it was before." And that's when they start saying, "It's probably a seven or an eight." They need an extra push.
That's how I usually start that conversation with them. That's basically for every guy who comes into our office. But a guy who comes in specifically for ED, for me, the most important thing to remember, for everybody who's hearing this, is we need to remember and understand that these guys come in to see you in a very vulnerable state, and we need to take that into consideration. These guys basically had a really bad experience last night, and they made a fool of themselves. So the following morning, they're going to be looking and calling you.
For example, here in my office, I have a policy. Everybody who calls in for ED, whenever they ask for an appointment, you're going to give it to them. Why? If you don't give them the appointment that they want, they're going to go somewhere else to be seen because they want this fixed ASAP.
That's basically what I do. I start asking them about everything from when symptoms occurred, again, how strong is the erection, if they have presence or absence of a curvature, duration of the erection, any change when having sex versus when they masturbate. You want to rule out those psychogenic factors. If you have a guy who's 18, 20 years old coming in for ED, it is very likely that it is something psychogenic other than organic.
I also start asking them can they ejaculate, what treatments have they tried before, and have they seen anybody else before, because again if you have a guy who's already seen three urologists, you want to really go deep into that conversation and find out why he hasn't been able to find the answers he's been looking for.
[Dr. Jose Silva]
Do you usually start them on doses of Viagra or Cialis, or do you try to go slow first and see what helps. How long does the process of treating these patients last?
[Dr. Jonathan Clavell]
It actually depends. That has changed. Every year, I do something different. Initially, I will start them on medications, have them follow up in a few weeks, depending on the severity of their ED or if they have a lot of comorbidities. I will do a penile Doppler and duplex ultrasound which will give both the urologist and also the patient better answers of what's really happening.
But now, things have changed. I found out that you can bill for the ultrasound and do it the same day and it's not going to be bundled to the first visit.
[Dr. Jose Silva]
First visit. Okay. That's awesome.
[Dr. Jonathan Clavell]
Now, basically what I do is, again, the same thing. You basically take it by ear. If you have a guy who has mild ED, he's 60, 70% without any treatment, it is very likely that pills are going to work. I'm not going to order an ultrasound for that guy. But if you have a guy who's like, "Doc, I haven't had sex in three years," then that's the guy you're going to be, " can give you the prescriptions but let's do that test today. Try the medications first. And then, you can come back in two or three weeks and we'll discuss everything."
In terms of what dosage I give them, usually, I either give them both now with GoodRx and compounding pharmacies, you can get these medications very cheap.
[Dr. Jose Silva]
It's unbelievable. It doesn't make any sense how big pharmacies charge $50 for a pill and GoodRx gives you $20 for 30-day supply.
[Dr. Jonathan Clavell]
That's correct.
[Dr. Jose Silva]
Doesn't make any sense. But that's another topic.
[Dr. Jonathan Clavell]
Usually, for a dose, what I tell them is, "You can try both Cialis and Viagra." I have a document that I created here in my office and it describes all the side effects, how to take the medications. That's the most important thing. These guys think that these pills are magic, that they take the medication and five minutes later, they're going to be carrying on like a cannon. And I'm like, "Dude, you need to be stimulated."
Usually, what I tell them is depending on how bad they are, I either do them full 20 mg of Cialis or full 100 mg of Viagra. Or sometimes I tell them, "Just take the daily tadalafil 5 mg every single day. And on your way out of work. If tonight is going to be your lucky night, you're going to take that 100 mg of Viagra on your way to work, that way you're not timing yourself. You just get home and you can get busy right away."
(3) Comparing Penile Implants: Coloplast vs. AMS 700
[Dr. Jose Silva]
That's awesome. Let's talk about the patient that fails medications, they fail the vacuum, they fail everything. So you end up doing a prosthesis. What type of implant do you use? What company? What brand? Coloplast? AMS, or Boston Scientific? How do you decide which way to go?
[Dr. Jonathan Clavell]
I use both. Both companies hate me for that. I'm a consultant with both companies. I have great relationships with both territorial managers from both companies here. They actually even get along, which is great for me. There's no tension here, at least here in my office, or in the OR.
Basically, I use both companies equally. I really don't have a preference between one or the other. I do try to always use a three-piece as long as I can, unless the guy doesn't have hands to pump it up. I know there's many surgeons out there who are worried about, for example, a transplant patient who has a pelvic kidney and they're worried about injuring it with a reservoir. I try with all my might to be able to get them a three-piece just to give them the most natural device that they actually can.
Usually, whenever they come in specifically asking for a penile prosthesis, I show them both. I tell them, "This is the AMS. This is the Coloplast. These are two great cars. You're comparing a Mercedes to a BMW. You're going to have a great car regardless. But of course, they have their specific features that you really want to know about before you get yourself into this."
Most guys are going to ask, "Oh, Doc, you're the expert. Which one would you recommend for me?” If they’re younger, sometimes I tend to go with a Coloplast because again they want something that will give them a really, really hard erection.” They really don't care how it feels when it's placid.
For older guys, I usually go with Boston Scientific, just because it's easier for them to find that deflate button because of the shape of that pump. And then guys who have really big phalluses, I try to give them a Coloplast because again it has more girth.
But I basically just tell them, "Hey, man, what do you want? What are you looking for?" And depending on what their goals are, that's basically how I go. And that's actually even going back to the previous question. You asked me, "How do you evaluate these guys?" At the end of the visit, I always ask them, "What is your goal?" It's like, "Oh, Doc, my goal is to be able to satisfy my partner." I'm like, "I just want to let you know that one way or the other, we're going to get you there."
And whenever they hear that, because again, most of these guys are hopeless. They go in here, they come into your office, and they're freaking out. They're like, "My wife is going to leave me," or "I'm not going to be able to have sex ever again. What the heck is going on? I tried pills. Pills are not working. What else can I do?" And whenever you start showing them their options, they will know that you have their back.
Even me in their first visit, everybody knows about all the options and that way I can tell them like, "You have pills, you have vacuum, you have suppositories, you have the injection, and you have the prosthesis. Don't feel like you have to go through every single step before you reach your prosthetic. If you fail pills or you're having really bad side effects from the pills, all the options are open for you. You decide what you want for yourself."
(4) Infrapubic vs. Penoscrotal Surgical Approach to Prosthetic Implantation
[Dr. Jose Silva]
Good. Definitely good advice. Technically, in terms of surgery, what approach do you use? Do you go penoscrotal? Infrapubic? What do you do?
[Dr. Jonathan Clavell]
I go 98% penoscrotal. Both approaches are great. Both approaches have been mastered by now. They both have their pros and cons.
[Dr. Jose Silva]
You trained both?
[Dr. Jonathan Clavell]
Yeah. When I was doing my training, I was with Run Wang at MD Anderson and University of Texas here in Houston. He does mostly penoscrotal and most of what I know, I owe it to him. The guy's a magician at operating. And he was very quick and efficient through the penoscrotal approach. Usually, that's the big benefit that you get from the infrapubic approach and that was basically mastered by Paul Perito. He revolutionized the field since he started bringing up his infrapubic approach. He could do the surgery in 15, 20 minutes and I didn't believe it until I went there and saw him myself. I saw it firsthand.
[Dr. Jose Silva]
Yeah, it was unbelievable seeing it.
[Dr. Jonathan Clavell]
I know. Exactly. The benefits of infrapubic, for example, it is a quicker procedure, you have direct access for the reservoir whenever you're going to place it. The recovery also can be quicker because you're not opening the scrotum--guys are going to be able to cycle their implant a lot sooner than guys who go through a penoscrotal.
The reason I go penoscrotal is that I can be just as efficient and quick with that approach. I'm able to place that pump in a really good dependent position and don't have to worry about high-riding pumps or anything like that. If I get into trouble and there's something else that needs to be done, I can just extend that incision all the way up and do whatever needs to be done. I don't have to make an alternate incision. But again, that's just me.
I have guys coming in all the time to come to train and they ask me, "Which was better?" "There's really not a better one. It's whatever you feel comfortable with."
(5) Complex Penile Implant Patients: Mini-Slings and Ectopic (Alternative) Reservoir Placements
[Dr. Jose Silva]
Good. Jonathan, let's talk about some special considerations. Let's talk about a patient with urinary incontinence. Are you doing a prosthesis at the same time? Or are you just treating incontinence first? What are you doing with those patients?
[Dr. Jonathan Clavell]
Nowadays, it's been actually limited by hospitals more than anything else. In the past, we were able to do both. But now we all know that whenever you do a procedure and you add an additional procedure to that, the second procedure is only going to be reimbursed by only half. Many surgeons... Here in our hospitals, they actually don't even allow us to do both, for example, an implant and an AUS at the same time.
However, of course, in terms of recovery, it's a little bit better for the patient. They only have to recover once instead of recovering twice. But most of the time, I tried to fix the waterworks before I start fixing the implant, and we try to avoid doing both together.
There's actually this new procedure for guys who have minimal incontinence--basically one or two pads a day or guys who are leaking whenever they reach orgasm, also known as "climacturia" in prostate cancer survivors or guys who had a TURP who now have minimal leakage.
There's a procedure called the mini sling. Basically, under corporotomies, you place this little graft and when the patients pump that implant, that graft will basically compress that urethra and doesn't allow the urethra to leak. It actually works very well.
[Dr. Jose Silva]
I think the other name is the mini-jupette.
[Dr. Jonathan Clavell]
The mini-jupette, that's right.
[Dr. Jose Silva]
One of our attendings here, one of my partners, he's a reconstruction specialist and he's definitely doing it. I went to see a couple of procedures with him and yeah, it works. It's something new and you can definitely do that at the same time.
[Dr. Jonathan Clavell]
People always ask me about billing. For that one, you just bill for a sling, it gets reimbursed. And again, it's minimal morbidity. You're right there. You don't have to make any additional decisions or anything like that, and you're not burning any bridges. Even if it doesn't work, you can go back there and do a sling, whatsoever.
[Dr. Jose Silva]
In terms of patients, you mentioned the patients with kidney transplants, post-radiation, and inguinal surgery. What about ectopic placements? The Conceal Reservoir? What are your thoughts on that?
[Dr. Jonathan Clavell]
I am all about ectopic placement. Most of my latest research is actually on ectopic placement, and if Paul Perito listens to this podcast, he's probably going to ding me for it. He hates the word ectopic. The word we use is alternative reservoir placement.
But anyways, post-radiation, I'm really not that concerned. Of course, post radical surgery in the pelvis, post pelvic surgery--either cystectomy, prostatectomy--once that retroperitoneal space in the pubic area in the pelvic area is compromised, we want to avoid that space. You don't want to injure anything down there. Usually for those, the ectopic is definitely recommended. For me personally, I always do alternative reservoir placement. I go ectopic for all of them, be it the Conceal Reservoir or even with the Coloplast Cloverleaf.
What I usually do, for example, is in order to avoid palpation, I always use the 125 mL--basically the large Cloverleaf reservoir. I underfill it so you don't have a big ball there because again, if you use a 75, most implants are going to require somewhere between 50 and 70 cc. You're going to have a small ball right there.
Palpation is very minimal and patients really are not really bothered by it. They probably complain about it for about a week and you just tell him, "You're going to have some lower abdominal pain for a few days," but they're probably mostly focused on their penile pain.
(6) Dealing with Penile Implantation Difficulties: Coloplast Pump Placement Adjustments, Urethral Perforations, and Prostate Obstructions
[Dr. Jose Silva]
That's great advice. When I have gone ectopic, I have never gone bigger, thinking bigger is going to be more noticeable. But definitely, if you under-inflate, it should be nicer in that sense to palpation.
Let’s say you're doing the procedure, specifically with the Coloplast, which has the pump connected to the cylinders. Sometimes the pump is longer and maybe doesn't fit on the scrotum. It's already open. You don't want to go ahead and open another prosthesis. Has that happened to you? Or have you seen it?
[Dr. Jonathan Clavell]
Yes. Definitely. There are some guys that have tiny scrotums and really tight scrotums especially those guys who have been on testosterone for decades. You really have no space to place a pump. The good thing about these devices is that they have multiple connectors. So I just cut the tubing and then just reposition it to whatever is good for the patient. I've done that several times.
The other thing about that is the way to avoid that is basically trying to avoid the rear tip extenders. The good thing is now, for both companies, they have longer tubings. As long as the edge of that proximal corpora on the bottom is within the single digits, it's 9 or 10 cm or below, you should have enough length that you can even avoid using a rear tip. And now we know that the extra rigidity is a lot better in the penis. It feels more natural for them if we avoid those rear tip extenders.
[Dr. Jose Silva]
Is there a situation where you go the other way around and actually put extenders instead of just going big?
[Dr. Jonathan Clavell]
Yeah. For guys who are really deep and for these obese guys-
[Dr. Jose Silva]
For 10 or 11 and deeper and then a little bit outside?
[Dr. Jonathan Clavell]
Not even 10, 11. I've had guys who have 14 or 15 cm, and for those guys, there's no way you'll be able to avoid rear tip extenders. For those, I undersized the cylinder and just added a little bit more rear tip. But again, those situations are rare. Most important thing is that whenever you're doing your dissection make sure that you go very, very low to do that.
[Dr. Jose Silva]
Good. I have had patients that come to me and they complain that it's not rigid. Obese patients, like you mentioned, they don't have the actual erection. That's what most likely happened: instead of just using some extender, they went down, and now they have just a little bit coming on the outside and they don't get that extension or that erectile sensation.
[Dr. Jonathan Clavell]
Yeah. For those, there's really not much you can do.
[Dr. Jose Silva]
Yeah. Jonathan, when is it time to abort? Let's say you do a perforation. You're dilating the corporas, and you go through the urethra, what do you do? Do you just abort? You go from one side? What do you do?
[Dr. Jonathan Clavell]
That's a really tough situation. Fortunately, I haven't had a case in which I dilated through the urethra. First of all, I was trying to avoid that. How do you avoid that? Whenever you're using dilators, don't use anything smaller than a 9 mm because anything above a 9 mm Brooks or Hegar, You're asking for trouble. And of course, try to stay lateral whenever you're dilating.
Usually for those guys who do have a urethral injury, I would either do a single cylinder or just come back and fight another day because again, if you haven't dilated if it was just that initial dilation, I would just abort and come back another day because you're just asking yourself for trouble. You don't want a guy who comes in with an infection later on.
[Dr. Jose Silva]
I had this patient. He had Peyronie's disease. I dilated one side which was very good. Then he had a curvature distally on the other side. I did a perforation with the Metzenbaum while trying to dilate that and to go more distally in the glands. I was between go and abort. I didn't know what to do. I just put in one cylinder and he's doing great. His expectations were not met in the sense that I put in a Titan, and he wanted a little bit more girth.
[Dr. Jonathan Clavell]
But that was actually a really good decision on your behalf. You already had dilated one side-
[Dr. Jose Silva]
And it was perfect.
[Dr. Jonathan Clavell]
And it was good. For those guys, I would even tell him, "Man, you have something and your case was difficult. You had a lot of fibrosis there. At least you have a Titan and not something shorter."
[Dr. Jose Silva]
And the urethra is good. So he's good. He wants a little bit more so we're talking about it.
[Dr. Jonathan Clavell]
I can't imagine going back there. I will never forget I had a guy who had an implant done by somebody else and he also had a bladder neck contracture. They placed the implant without fixing the bladder neck contracture. He comes in to see me, he's like, "Doc, I can't pee," and he has this implant, it was recently placed two months ago.
I did an incision of the bladder neck and placed a catheter. However, the issue was that the guy had problems with walking and during his recovery because the catheter was basically pulling the leg back on one side for several days. When we took the catheter out, he was fine. Then, he went in to have sex with his wife and boom--it perforated into his urethra.
I told him, "Man, now, it got infected so we had to take everything out. We'll come back and fight another day." He was really eager to get it back. So we went three months in to go see him and I always induce an erection at the beginning of a case, whenever I placed my needle in order for me to dilate the corpora, and everything just started squirting out from his urethra.
I'm like, "Man, I'm not going to go in and place something." We had to abort five minutes into the case and we went back basically until he completed the six months, and that's when we were able to place everything. The guy's doing great now.
But it was a good lesson for everyone. You want to fix the water works before you start messing with implants.
[Dr. Jose Silva]
Let's say you have a young patient here with diabetes who is obstructed from the prostate. What are the options?
[Dr. Jonathan Clavell]
All the options are open for him. The important thing is that you want to do something that will try to avoid long-term catheterization. Don't go out doing a suprapubic prostatectomy. The guy's going to require a catheter for a week or two or whatever. Try to do something that will let you take the catheter out sooner rather than later.
For example, you already know this, but I do a lot of Rezums. I've been able to do Rezums for these guys, and they've done well. I haven't had any problems with any of my patients. That being said, doing those Rezums, especially guys who have longer penises, sometimes you struggle to get to that bladder neck just because of that prosthesis because their penis won't compress. That's some things to take into consideration. If you have a guy who has a really big penis, at least don't do it in the office while he's awake.
And then whenever... If you are going to do a procedure, my recommendation would be just to avoid, from what I told you about that other guy, the perforation. You don't want the catheter to be rubbing against the same side all the time. If they are wearing a leg bag, I tell them, "Every 24 hours, you're going to be alternating the leg bag from leg to leg. In that way, it's not going to be rubbing against the same side at all times."
[Dr. Jose Silva]
Do you tell them there's always a possibility of damage to the implant? They have to know.
[Dr. Jonathan Clavell]
Definitely. I always undersell and overdeliver.
(7) Post-Operative Antibiotics and Bandages
[Dr. Jose Silva]
That's definitely good advice. Let's talk about the logistics of proceedings in terms of after the procedure. How long do you give them antibiotics for? When do you see them after the procedure?
[Dr. Jonathan Clavell]
Of course, we all know that the most common risk is infection. I actually start them on an antibiotic a day before the surgery. They take an antibiotic and they continue with the antibiotics for one week after the surgery. I think it's voodoo. I think it's just for me to be able to sleep better at night.
[Dr. Jose Silva]
To sleep better, yeah, that's important.
[Dr. Jonathan Clavell]
Because whenever they start calling your office, "Hey, Doc. I'm still a little bit swollen." I'm like, "You're still on antibiotics so it's not an infection."
[Dr. Jose Silva]
Which one do you use? What antibiotic?
[Dr. Jonathan Clavell]
I use fluoroquinolone, Levaquin, Keflex, and cephalosporin. I've been thinking about going off fluoroquinolones just because of the side effects. But again, I tell them, "It's just for a few days." If I'm concerned about their joints or anything like that, I give them something else just to cover for gram negatives.
[Dr. Jose Silva]
Also, I think there's some implants that use a couple of days of antifungal medication.
[Dr. Jonathan Clavell]
That is correct.
[Dr. Jose Silva]
Do you use it always or just sometimes?
[Dr. Jonathan Clavell]
I do use them for preop and basically preop in the operating room. In the operating room, I give them vancomycin, gentamicin, and Diflucan. Initially, I was just using Diflucan for only diabetics and guys who had Coloplast because they don't have the InhibiZone from Boston Scientific. But now I just started telling the staff, "Just give it to everyone." That would just to make it easier for the staff because they were always asking, "Oh, are we getting Diflucan or not?" Just do it for everyone.
In terms of postop, I really don't give them that unless I'm really concerned that they will have it. I haven't been burned by it before though. I've had two infections and they were both bacterial.
In terms of the ambulatory procedures, I used to keep everybody overnight. And then after COVID, I actually started discharging everyone. It's better. Believe it or not, Oche, I would say 99% percent of my implant patients have my personal cell phone number. That's how I tell them, "Man, I'm doing this surgery for you. I'm not going to throw you under the bus. I'm here for you. Just text. Don't call. I have a family." Most of them actually respect that very well. I really don't get bothered much, and I also sleep better at night. I would rather have them contact me than then having problems and going somewhere else with somebody who has no idea what to do with them.
[Dr. Jose Silva]
Definitely, that's part of your selling ball also. Word of mouth. They will go to all their friends. Hey, go to Clavell.
[Dr. Jonathan Clavell]
Except when you have a guy who's crazy and you're like, "Uh, I don't want to give you my cell phone."
[Dr. Jose Silva]
Jonathan, any special bandages after the procedure?
[Dr. Jonathan Clavell]
I do what we call the mummy wrap but I modify it. The mummy wrap basically goes all the way up to the head of the penis. My mummy wrap basically just covers the scrotum and keeps the penis exposed. The reason I do that is because I want them to keep that dressing for 48 hours. I keep that dressing that's basically keeping the scrotum under compression for two days. They take it out at home at two days after they've already processed all the fluids that we gave them in the operating room, and that way I avoid hematomas and severe scrotal swelling and they do very well.
I actually don't drain. I know that's the big debate if we drain or not. I don't leave any drains for these guys and they do very well.
[Dr. Jose Silva]
No Foley or anything?
[Dr. Jonathan Clavell]
I take the Foley out before they wake up. And if they are not able to pee, I put the catheter back in and they can just take it out at home. And most of the time we just teach them, "Just take it out early in the morning and you'll be fine."
[Dr. Jose Silva]
I've been doing the mummy wrap of the scrotum. I definitely think they’re able to start cycling the pump earlier. Or at least they're able to touch the scrotum earlier.
[Dr. Jonathan Clavell]
That is correct.
(8) Cycling and Using Penile Implants
[Dr. Jose Silva]
And tell them to just move it forward and just try to keep it closer to the skin. When do you see the patients afterwards?
[Dr. Jonathan Clavell]
I usually see my patients at six weeks. I did that during fellowship. My partner has his patients come back in four weeks. If you go penoscrotal they will sometimes still be sore at four weeks.
That's why I tell them, "Man, go at six weeks," and they have my cell phone so I just text them, "If you feel great by four or five weeks, just shoot me a picture of your incision. If the incision looks fine and you feel comfortable cycling the implant, just go ahead and cycle." The good thing is that I was able to create a really good video on how to best inflate and deflate both devices, both the AMS and Coloplast.
[Dr. Jose Silva]
That's on your YouTube channel?
[Dr. Jonathan Clavell]
They’re on my YouTube channels. It's actually my two latest videos. Yeah, it's a great resource. It's saved me a lot of conversations with patients.
[Dr. Jose Silva]
You can go to YouTube and just put Jonathan Clavell?
[Dr. Jonathan Clavell]
Yeah, that's right. You just put my name Jonathan Clavell, C-L-A-V-E-L-L, and you'll be able to find basically most of my work.
I've had colleagues tell me, "Don't put your videos like that. You're basically spilling out all your secrets." Again, that's the way that I show and tell patients, "This is how I do it and this is what you're going to get yourself into." And they know. It's actually even brought more patients in to see me.
[Dr. Jose Silva]
That's awesome. I'll definitely look into them. I have seen a few. After six weeks, you see them, they start cycling, how long does it take prior to start using it?
[Dr. Jonathan Clavell]
At six weeks, I tell them, "You're good to use it." Usually, by four or five weeks, they should be okay. For those that do infrapubic, guys were able to cycle a lot sooner two or three weeks. I know there are docs that, as soon as you can start cycling, they allow them to have sex. I don't encourage that because again, I want those corporotomies to hold well and not burst open.
I've actually seen, not my patient, but patients who started having sex beforehand. The corporotomy opened up, and the cylinder just slipped right through that corporotomy. Again, it wasn't my patient but it's actually a really cool video that I actually have to post at some point.
[Dr. Jose Silva]
And do you leave the cylinder a little bit full?
[Dr. Jonathan Clavell]
All my patients are about 70% inflated post op.
[Dr. Jose Silva]
They're going to be like that for six weeks?
[Dr. Jonathan Clavell]
Especially whenever you have a thin guy who has a big penis, I tell them, "Your recovery is going to suck, but in a good way." Of course, by two or three weeks, if they say, "Doc, I just can't take it." Then I tell them, "You can start cycling if you feel comfortable doing it." They can start cycling up to six weeks, and then at five or six weeks, that's when I tell them, "You can start having sex."
(9) Special Considerations for Diabetic Patients: HbA1c and Glucose
[Dr. Jose Silva]
Good. I usually go for four weeks. I tell them to start using it, cycling it a couple of minutes a day at two or three weeks. Then, at more or less from six to eight weeks, they can start using it. Usually with diabetics, they tend to take a little bit longer depending on how the glucose is. Do you do an A1c prior to surgery for diabetics?
[Dr. Jonathan Clavell]
Yes, I do, and it's just so that I have an idea. I really don't have a cut off for them to undergo surgery. The most important thing is that they are compliant with their medications. For example, if you have a guy who had his last A1c three months ago, and it was 8 and now it's 10, you don’t want to take a guy like that into the operating room.
There's been recent studies showing that the preop glucose is actually more important than the hemoglobin A1c. It's very important that you have them at least seeing an endocrinologist or seeing their primary care doctor and you have to tell them, "Man, I did my part. Now, it's on you. If you get infected, it's because of you. I did this and this and this and that to avoid infections. If you get infected, it's all on you." That way, by giving them responsibility, they tend to respond a bit better.
[Dr. Jose Silva]
Do you have any cutoff for that patient in preop? Say if his blood sugar is 400, will you still go ahead?
[Dr. Jonathan Clavell]
To be honest, I don't even ask.
[Dr. Jose Silva]
Okay, okay, okay.
[Dr. Jonathan Clavell]
Of course. If anesthesia calls me, "This guy is 350." I will ask him if he is insulin-dependent. If he's insulin dependent, I will still proceed. Again, they come in without even eating or anything like that so they haven't used their medications. It's hard, man. That was a tough decision.
[Dr. Jose Silva]
Yeah, just speak to them and give them some responsibility in that part. Do you do different in terms of the antibiotic for these patients?
[Dr. Jonathan Clavell]
Not really. Not really. Of course, for those, I really want to use Diflucan for sure. I make sure they have their antibiotics. The vancomycin, I want completely 100% in before I make my incision. But other than that, I just take him out on the fly.
For example, for the last infection that I actually had, he was a diabetic but he decided that he didn't want to take his medications because he could control it with diet and he came in every morning. In the morning, it was 180 or something, he's like, "Oh, no, Doc, I'm below 200." I'm like, "Yeah, but you eat breakfast and that's 400 the rest of the day." That guy got infected. I told him, "Man, I told you. I told you."
But in terms of A1c, I've done 10, 11s, and they do fairly well. For 12 and 13s, I would encourage them to wait a little bit longer.
[Dr. Jose Silva]
Do you see any difference in terms of pain afterwards with those patients?
[Dr. Jonathan Clavell]
It's actually a great question and I haven't looked into that. So good question.
[Dr. Jose Silva]
Some patients with neuropathy are more sensitive. After you do an intervention, they continue to complain about that urethral persistent pain so I don't know. I haven't looked into it, but definitely, it's a good thing to see if there's a difference in terms of pain medication after which.
(10) Post-Operative Pain Medications
[Dr. Jonathan Clavell]
That said, all my patients, I give them gabapentin post op.
[Dr. Jose Silva]
For how long?
[Dr. Jonathan Clavell]
My post op regimen is meloxicam and gabapentin. Meloxicam, I give them for two weeks. I don't want them to be longer than two weeks just to avoid kidney damage. But the gabapentin I usually tell them that's your go-to. And Tylenol. And then I also give them tramadol for breakthrough. But most patients don't need it because the hospital that I'm doing my surgeries at allows me to use Exparel.
[Dr. Jose Silva]
Exactly. Are you injecting in the corpora during the procedure?
[Dr. Jonathan Clavell]
Yes. I do a full block and I also do intracavernosal injection. I induce an erection for all my patients. I just do so many Peyronie's cases that I don't want any surprises. I basically induce everybody with the Exparel.
[Dr. Jose Silva]
When you're doing the artificial erection, you're using Exparel at that moment?
[Dr. Jonathan Clavell]
That's right. I combine Exparel with saline. I tell anesthesia, "You're going to have some changes in your EKG. Don't freak out." And I haven't had any issues.
[Dr. Jose Silva]
I think using that is the key to just not giving Percocet or anything stronger. I was doing it before but now, the hospital lets me use the Exparel and it's a game changer in that sense.
[Dr. Jonathan Clavell]
Yeah, I've only prescribed narcotics twice since I started practicing. The only patients that needed it were guys who were already taking narcotics for chronic back pain issues. Their pain tolerance was very low, and I told them, "Man, I'll just give it to you." But again, most of the time, they don't need it. They don't need it.
[Dr. Jose Silva]
Good. Jonathan, we'll continue to talk about other cases--the long term complications, andrology, Rezum, or special considerations. Any other suggestions or anything you want to say, in terms of that initial evaluation or that initial first implant procedure?
[Dr. Jonathan Clavell]
Again, the most important thing is just remember that these guys are very vulnerable. They are hopeless and are just looking for answers or for somebody who can actually listen to them. The other thing that I would make sure of is that, if they have a partner who supports them, try to involve them in the conversation. These guys are going to leave your office super pumped, super happy and excited that they're going to have a solution, and then they go home. Their partner then asks them, "What did the doctor say?" And then they don't remember anything that you told them.
And then they say, "Oh, yeah. He talked about pills and if not pills, we're going to have some implant that we can use and I'm going to be able to use it any time that I want." And their partners are going to be like, "What the heck are you guys talking about?"
Always, always try to involve the partner in these conversations. It's going to go a long way. It's going to even save you a lot of long conversations. Again, you have this conversation for 30 minutes, and then the partner comes back, and you have to repeat the exact same conversation so the partner can now understand.So I always encourage them to bring in their partners from the waiting area. Bring them in. They can wear a mask and we can both sit down and talk.
[Dr. Jose Silva]
For those patients that go to the office the first time, do you have videos? Do you play videos for them while they're waiting in the room while you're seeing other patients?
[Dr. Jonathan Clavell]
I don't. The only ones that I use videos for are the Rezum patients. Whenever I do the cysto, they watch the video and get dressed. It actually gives me time to see another patient while they're looking at the video.
[Dr. Jose Silva]
I use those two. I use the GreenLight for UroLift. The reps are great giving us those small video boxes. That's good, but there should be something for ED that will be better and easier for us to explain the procedure. They can maybe take some time off from our part.
[Dr. Jonathan Clavell]
There are videos. I know Boston Scientific definitely has a video that you can show them. But again, I wouldn't give that video on the first visit. They're going to freak out if the first thing they hear is, "Oh, yeah, you need surgery."
[Dr. Jose Silva]
True. That's true. That's true.
Jonathan, thanks for being here in BackTable. We're definitely looking forward to seeing you again and talking about other things that you do. We can talk about the Rezum and it’s complications. You're going to talk about sexual medicine in the conference you mentioned earlier, so that's definitely one topic we can talk about afterwards.
Podcast Contributors
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, June 2). Ep. 8 – Men's Sexual Health [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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