Penile prosthesis implantation is a critical intervention for men who experience persistent erectile dysfunction (ED) following radical prostatectomy (RP) for prostate cancer. The timing and selection of the appropriate prosthesis type are essential factors that influence the success of the procedure and overall patient satisfaction. This decision involves carefully considering the patient’s recovery, the degree of nerve preservation, and the presence of other health conditions.

Early implantation may prevent complications like penile fibrosis, while delaying the procedure allows for potential recovery of erectile function. The choice between inflatable and malleable penile prostheses further impacts both functional outcomes and partner satisfaction.

Indications of penile prosthesis implantation after radical prostatectomy

The indications for penile prosthesis implantation after RP primarily revolve around the persistence of ED despite other treatment attempts. Here are the key indications:

• Persistent ED
• Nerve-sparing procedure
• Penile length preservation
• Psychological ımpact
• Advanced fibrosis or severe ED
• Patient preference
• Failed penile rehabilitation attempts

Is timing important for penile prosthesis surgery after RP?

Yes, timing is crucial for penile prosthesis implantation after RP because it affects surgical outcomes, fibrosis development, penile length preservation, and overall patient satisfaction.

Why Timing Matters?

Natural Erectile Recovery Period

• After RP, some men—especially those who had a nerve-sparing procedure—may regain erectile function within 12-24 months.
  • Implanting a prosthesis too early may prevent potential natural recovery.

Fibrosis & Penile Shortening

• Prolonged ED (>12 months) leads to cavernosal fibrosis and penile shrinkage, making implantation technically more difficult and potentially reducing penile length.
  • Early implantation (3-6 months post-RP) in non-responders may help prevent tissue fibrosis and penile shortening.

Patient Satisfaction & Psychological Well-being

• Delayed implantation (12-24 months) allows patients to explore other treatment options, but prolonged ED can cause emotional distress and lower quality of life.
  • Some men prefer earlier implantation to regain sexual function faster.

Surgical Considerations & Complications

• Immediate or very early implantation (at the time of RP or within 3 months) may increase the risk of infection, improper healing, and prosthesis complications.
  • Delaying beyond 2 years may lead to severe fibrosis, making implantation more complex.

Best timing approach based on patient condition

The decision to perform penile prosthesis surgery depends on factors such as the patient’s pre-surgery erectile quality and whether the nerves are preserved during the surgery.

• For most patients → Waiting 12-24 months is ideal to allow for natural recovery.
• For severe ED cases (no response to therapy, early fibrosis) → Implantation as early as 3-6 months can be beneficial.
• Delaying too long (>2 years) can make implantation more challenging due to fibrosis.

Optimal timing for penile prosthesis implantation

The timing of implantation varies based on factors like tissue healing, fibrosis development, and patient preference. Here are the main approaches:

Early Implantation (3-6 Months Post-RP)

• Some experts advocate for early penile prosthesis placement (as early as 3–6 months after RP) to prevent fibrosis and penile shortening.
  • Early intervention may help preserve cavernosal tissue elasticity and improve prosthesis outcomes.
  • However, it is generally reserved for patients with severe ED not responding to any conservative therapies.

Delayed Implantation (12-24 Months Post-RP)

• Most urologists recommend waiting at least 12 months to allow for natural recovery of erectile function.
  • This approach is particularly relevant for nerve-sparing prostatectomy patients, who may regain some erectile function over time.
  • Waiting too long (>2 years) may increase fibrosis and penile shortening, making implantation more difficult.

Immediate Implantation (same time as prostatectomy)

• Rarely performed but has been proposed in select cases.
  • The main advantage is avoiding multiple surgeries, but it may have higher complication risks due to ongoing healing and potential infections.

Key Considerations

• Degree of Nerve Damage: Patients with bilateral nerve-sparing RP may have a better chance of spontaneous recovery compared to those with non-nerve-sparing procedures.
• Fibrosis Risk: Delaying too long (>2 years) can lead to cavernosal fibrosis, making later implantation technically challenging.
• Patient Expectations & Psychological Impact: Severe ED post-RP can significantly affect quality of life, making early implantation a reasonable option in motivated patients.

Which types of penile prosthesis is preferred after RP?

After RP, the preferred type of penile prosthesis depends on factors such as erectile tissue condition, patient dexterity, and personal preference. However, most experts recommend inflatable penile prostheses (IPPs) due to their superior natural appearance, rigidity, and concealability.

Types of penile prostheses preferred after RP

1. Inflatable Penile Prostheses (IPPs) – Most Preferred
   ✅ Advantages:
   • Better rigidity & flaccidity control → Provides a more natural erection and a soft, flaccid state when deflated.
   • Penile length & girth preservation → Important for post-RP patients who are at risk of fibrosis and shrinkage.
   • Psychological & partner satisfaction → Closest to a natural erection.

❌ Disadvantages:

1. Requires manual dexterity → Some patients, especially older individuals, may find it difficult to operate the pump.
2. More expensive than malleable implants.
3. Surgical complexity is higher than malleable implants, but outcomes are generally better.

Best Candidates:

1. Men who want a more natural erection appearance and function.
2. Those who have no issues with hand strength/dexterity to operate the pump.
3. Malleable (Semi-Rigid) Penile Prostheses – Secondary Option
   ✅ Advantages:
   • Easier to use → No pump mechanism, making it ideal for men with limited hand dexterity (e.g., elderly patients, those with neuropathy).
   • Surgical implantation is simpler and generally has a lower risk of mechanical failure compared to IPPs.
   • Less expensive than IPPs.

❌ Disadvantages:

2. Less natural appearance → The penis remains semi-rigid all the time, which may cause discomfort or embarrassment.
3. Higher risk of erosion over time due to continuous pressure on tissues.
4. Not ideal for fibrosis prevention since it does not expand like IPPs.

Best Candidates:

2. Patients who have difficulty using an inflatable device.
3. Men who prioritize simplicity and durability over a natural look.

General informations about penile prosthesis

We can summarize general information about penile prostheses as follows:

Final recommendation

• For most men after RP → 3-piece inflatable penile prosthesis (IPP) is the gold standard.
• For men with limited hand function → Malleable prosthesis is a good alternative.
• If fibrosis is present or penile length is a concern → IPP is strongly preferred over malleable implants.

Satisfection after penile implant

Patient and partner satisfaction after penile prosthesis implantation following RP generally shows high levels of satisfaction, especially with IPPs. The satisfaction rates can vary depending on the type of implant, surgical outcomes, and the patient’s psychological and emotional state.

Here’s an overview of patient and partner satisfaction following penile prosthesis implantation:

• Patient satisfaction after penile prosthesis implantation, especially with IPPs, tends to be very high, typically in the 70-90% range. This is due to the restoration of sexual function, improved quality of life, and psychological benefits.
• Partner satisfaction also tends to be high, particularly when the device allows for a natural sexual experience. Satisfaction is generally higher with inflatable prostheses compared to malleable prostheses due to the more natural appearance and feel.

Factors affecting satisfaction

Device Type:  IPPs generally result in higher patient and partner satisfaction compared to malleable implants due to their natural appearance, ease of concealment, and ability to control erection firmness.

Psychological and Emotional Support: Patients who receive counseling or psychological support before and after surgery tend to have higher satisfaction rates, as this helps them manage expectations and deal with any emotional or relationship concerns.

Recovery and Healing: Satisfaction may be impacted by the recovery process. Complications such as infection, device malfunction, or length loss can affect outcomes, but these are generally rare and can be mitigated with careful surgical technique and postoperative care.

Patient Age and Health: Younger patients and those with better overall health typically report higher satisfaction. Older patients or those with comorbid conditions may have lower satisfaction, particularly if they have limited manual dexterity (making IPP use difficult) or complications during recovery.

Expectations and Communication: Clear communication about the potential results and limitations of the surgery can improve satisfaction, as unrealistic expectations are a common cause of dissatisfaction. Ensuring that both the patient and their partner understand what to expect is crucial.

Summary

Penile prosthesis implantation after RP is a key treatment for patients with persistent ED. The timing of implantation plays a crucial role, with early placement (3-6 months) helping prevent penile fibrosis and shortening, while delayed implantation (12-24 months) allows for potential natural recovery. The choice between IPPs and malleable implants depends on factors such as patient preference, hand dexterity, and desired outcomes. IPPs are generally preferred due to their natural look and function, but malleable implants may be suitable for patients with limited manual dexterity. Both timing and prosthesis selection significantly affect patient and partner satisfaction, sexual function, and overall quality of life post-surgery.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE