Penile Prosthesis Surgery

What is penile prosthesis (penile implant)?

“Penile prosthesis” is a cylindrical structure made of a special material placed on the penis and has the same size as the length of the erect penis in cases where there is no improvement in men with erectile dysfunction (impotence, impotence, erection problem) with drug therapy, vacuum therapy and penile injection treatments and other treatment methods

How many types of penile prosthesis are there?

There are 3 types of penile prosthesis, each of which has a different way of working.

Malleable penile prostheses: These prostheses are prostheses that are in permanent erection. It is also known as one-piece penile prostheses. It only consists of 2 structures placed in a cylindrical shape on both corpus cavernosum (penis internal structure). Its length is the same as the length of the penis in normal erection. Since the system is simple, there is no deterioration or prosthesis failure.

Two-piece penile prostheses: These consist of 2 cylindrical tubes placed on the penis and a pump system placed next to the testis (scrotum). They are also known as “two-piece inflatable penile prostheses”. When the patient will have intercourse, he creates an erection, and the erection is terminated after intercourse. Since the system is not so complicated, the failure situation is less compared to the three-piece, but the erection quality is somewhat poor compared to the three-piece.

Three-piece penile prostheses: It consists of two cylinders placed in the penis, a reserve placed in the lower abdomen and a pump system placed in the scrotum. They are also known as “inflatable three-piece prostheses”. Patients only inflate when they have intercourse, and deflate after intercourse. A natural erection is achieved. The erection quality in this prosthesis is better than the two-piece one.

Three-piece prostheses are also divided into 2 groups:

• Three-piece prostheses that expand only transversely
• 3-piece penile prostheses that expand both transversely and longitudinally

What are the differences between penile prostheses?

• Multi-piece prostheses are activated when intercourse is desired, and can be restored to normal after intercourse. In other words, multi-piece prostheses do not stay in permanent erection. This is an advantage.
• One-piece implants remain in permanent erection. This is a disadvantage.
• Multi-part implants are expensive in terms of cost
• Single pieces are cheaper.
• The failure rate of prostheses is higher in multi-piece prostheses.
• There is no possibility of failure in one-piece prostheses

Who should get a penile prosthesis?

• In cases where drug therapy is ineffective
• In long-term diabetes patients
• If impotence developed as a result of nerve and vascular damage in those who had surgery such as trauma, prostate, bladder, bowel cancer
• If there is severe insufficiency in the penile vessels
• If drug therapy is ineffective in elderly patients

Who should not candidate for a penile prosthesis?

• Cases that do not really have erectile dysfunction, are temporary or occur due to the conditions of the person, with the possibility of returning
• If there is an active infection (penile, scrotal or active urinary tract infection)
• Those with severe diabetes that is not well controlled.
• Those who are mentally unstable and have serious psychological problems
• Men who are not married or do not have a chance to have a regular relationship.

How should the prosthesis be chosen, which type of prosthesis should be fitted to which patient?

• Multi-piece prostheses are more suitable for young patients with suitable intellectual status.
• Multi-piece prosthesis should be preferred for diabetic patients if the patient is young and their intellectual level is appropriate.
• One-piece penile prostheses are more suitable for elderly patients.
• One-piece prosthesis is more suitable for the elderly or patients who cannot use their hands to use the multi-piece prosthesis.
• One-piece is preferred for those who cannot afford a multi-piece prosthesis for economic reasons.
• Malleable penile prostheses are good options for patients with spinal cord trauma (paralysis in the legs) and who cannot use their hands well.

Are penile prostheses visible from the outside in daily life?

Since the inflatable prostheses are deflated after intercourse, no symptoms or swelling of the erect penis are seen from the outside in the daily lives of the patients, that is, it is not noticed or understood from the outside. Malleable prostheses (non-inflatable prostheses) they remain in permanent erection, patients can hide the prosthesis in their daily life by laying the prosthesis towards the lower part of the abdomen or between the legs and with tight underwear. If it is well hidden, it will not be noticed from the outside, it can sometimes be seen from the outside in the form of very light fullness.

How about sex life (sexual life) with a penile prosthesis?

With the activation of the system in inflatable prostheses, an erection occurs faster than a natural erection and the patient becomes ready for intercourse. Penile prostheses do not affect the sensory perception of the penis or skin, they have no effect on reaching orgasm. There is no extra growth in the head of the penis.

Natural erections do not occur in patients with prostheses. Patients who have prosthesis removed do not have an erection in the normal way. In this respect, patients should be told that the prosthesis is irreversible and the prosthesis should be offered to patients as the last option.

Prosthesis types do not affect pleasure from sexual intercourse, orgasm or ejaculation, and do not increase sexual desire.

Do penile prostheses lengthen the penis?

No, penile prostheses have no effect on penile length. The length of the prosthesis is as long as the length of the penis in a normal erection.

Can patients having penile prosthesis have children?

Penile prosthesis has no direct effect on having children. If there is no obstacle for the patients to have children before the prosthesis, there will be no negative effects after the prosthesis, or the patients who cannot have a child cannot have a child after having a prosthesis.

Is it possible to give up and remove the prosthesis after surgery it?

In patients who have a penile prosthesis, the prosthesis can be removed at any time, this is a simple procedure. However, patients should be told that they will not have a chance to have an erection after removing the prosthesis. In fact, penile prosthesis insertion is the last option for patients who do not respond to any treatment.

How is the patient informed before penile prosthesis?

It is better to evaluate the patients together with their spouses, and the woman should also be informed. All tests related to erection should be done and it should be explained that the last option is penile prosthesis. The patient should be told that surgery is irreversible. If necessary, psychiatric consultation should be requested.

What are the advantages of penile prosthesis?

Patients can have intercourse whenever they want, there are no restrictions or difficulties.

Both parties get sexual pleasure. All kinds of prostheses have a high success rate in terms of sexual happiness and partner satisfaction. Inflatable prostheses have patient satisfaction close to natural erections.

How much do penile prostheses cost?

The cost varies according to the type of prosthesis.

Inflatable prostheses are more costly.

One-piece malleable prostheses are cheaper prostheses.

How effective are penile prostheses?

With both types (rigid and inflatable) prostheses, patients can have intercourse whenever they want. The satisfaction rate of patients using prosthesis is 80-90%.

What type of anesthesia is given?

Prosthesis surgery is performed under general anesthesia or spinal anesthesia.

How many days do patients stay in the hospital?

Patients stay in the hospital for 1 day or 2 days.

How long does the surgery take?

The operation time is approximately 1.5 hours for 2- and 3-piece prostheses, and 1 hour for single-piece prostheses.

Is a catheter inserted into the patients during the surgery?

The catheter is inserted in the surgery, the catheter is removed in the morning after the patient’s stool.

How is penile prosthesis surgery performed?

These prostheses are surgically placed inside the structures called the corpus cavernosum (spongy structure), which are two pieces on the right and left inside the penis, which normally allow erections to occur by filling them with blood. During the operation, the corpus cavernosum is enlarged with metal plugs of different sizes and thicknesses, and prostheses are placed inside. If a 3-piece prosthesis is to be fitted, a 100 cc reserve is placed in the lower abdomen and a pump is placed in the scrotum (next to the testicles). In 2-piece inflatable prostheses, a pump and a system that will act as a reserve are placed only in the scrotum. The surgical incision is 2-3 cm, dissolving stitches are used and it is not visible from the outside.

How do penile prostheses work?

Inflatable prostheses consist of two cylinders placed on the penis, a tube suitable for the size of the penis during erection, a reservoir and a pump. The reservoir is placed in the lower part of the abdomen, and the pump is placed next to the testis, into the scrotum in the same session as the surgery. Since it consists of 3 parts, this type of inflatable prosthesis is called “3-piece inflatable penile prosthesis”. In the 2-piece inflatable penile prostheses, there is only a pump system in the scrotum, apart from the cylinders that are inserted into the penis. The difference from the 3-piece is that there is no reservoir placed in the lower abdomen, so the 2-piece prosthesis is less complicated and less likely to fail. The disadvantage is that some patients may have less erection, since the reserve is smaller than the 3-piece.

When the patients will have intercourse, by applying pressure to the pump by hand, it ensures that the liquid in the reserve passes into the cylinders in the penis and creates an erection, and the patient enters the intercourse. After intercourse, the patient presses the pump again and the fluid in the cylinders is returned to the reserve, and as a result, the erection decreases.

What are the complications of penile prostheses?

Penile prostheses, like other prostheses, are foreign bodies placed outside the body. In this regard, some undesirable situations (complications) may occur in long-term situations.

• Infection: As in every surgical procedure, there is a risk of infection in prosthetic surgery. This risk is higher in patients with poorly controlled diabetes. The most important complication is prosthesis infection. In severe cases, the prosthesis must be removed.
• Prosthesis-related problems: Especially in multi-piece prostheses, malfunctions such as the prosthesis not working can be seen. In this case, revision or replacement of the prosthesis is required.
• Erosions on the penile skin: These are erosions that occur due to long and careless use, especially on the head. Skin erosions can sometimes cause infection and protrusion from the penis. It is more common in one-piece prostheses.
• Internal erosion or adhesions: Sometimes due to infection, the prosthesis can open out of the penile skin or into the urethra.

What are the points to be considered in the early postoperative period?

There may be pain, swelling and bruising for 2-3 weeks after the surgery, these are temporary. During the first week, the operating area should be kept dry. You should not have intercourse for 4-6 weeks after the operation. If there is pain, swelling, discharge from the operation site, fever in the penis after the operation, a doctor should be consulted. In the first periods, there may be difficulty in urination as a result of the pressure of the implants on the urinary canal, if there is a case of inability to urinate, a donor should be consulted.

How long do prostheses last?

60-80% of penile prostheses work for 10 years.

How long after the operation is intercourse possible?

Normal intercourse can be done 4-6 weeks after the operation.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY

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