HEELKUNDIGE BEHANDELING VAN ERECTIELE DYSFUNCTIE

KOENRAAD van RENTERGHEM M.D. Ph.D. FEBUJESSA HOSPITAL HASSELT

UNIVERSITY HOSPITALS LEUVENUNIVERSITY HASSELT

PENTALFA 18 OKTOBER 2018

• PEYRONIE’S DISEASE

• PENILE IMPLANT

• Francois Gigot de la Peyronie (1743)• Cause usually unknown: idiopathic; genetically predisposition?• Repetitive (micro)traumata?• Associated with cardio-vascular disease and other co-morbidities such

as DM; AHT; hyperlipidemia; smoking; ethylism;…• Damage of tunica albuginea• Prevalence 0,4-9 %; incidence “increases”• Usually after age of 40• Sometimes with morbus Dupuytren, Ledderhose.

• De la Peyronie F. Sur quelques obstacles qui s'opposent a l'ejaculation naturelle de la semence. Mem Acad R Chir 1743; 1: 425

• ACUTE PHASE:• Pain• 90 % disappears first year; 100 % after 24 months

• CHRONIC PHASE:• Plaque• Calcification• Palpable nodule• Deformation/curvature/hourglass• Surgical repair at this time• Veno-occlusive dysfunction (draining venules)

• Correction curvature• Technique selection based upon surgeon preference,

expertise,experience.• Surgery is gold standard• Making intercourse possible• Preferable when 6 months stable disease• Penile “shortening” procedures versus penile “lengthening”

procedures• Penile implant

EXCISION tunica albuginea convex side

Pryor en Fitzpatrick 1979

Rehman 1997

PLICATION tunica albuginea convex side

• WITHOUT incision tunica albuginea (LUE 16 - dots)

• WITH longitudinal incision (Yachia (Heineke – Mikulicz principle))

• PENILE LENGTHENING:

• Graft (autologous – v. saphena; tutoplast - bovine; SIS - porcine; etc.)• Cave veno-occlusive dysfunction• Shrinkening of graft (Kadioglu)• Nerve damage (neuro-vascular bundle) with dimished glandular sensation

• T. F. Lue, “Venous patch graft for peyronie's disease. Part I: technique,” Journal of Urology, vol. 160, no. 6 I, pp. 2047–2049, 1998• A. Kadioglu, O. Sanli, T. Akman, M. Cakan, B. Erol, and F. Mamadov, “Surgical treatment of Peyronie's disease: a single center experience with 145 patients,” European Urology, vol. 53, no. 2, pp.

432–440, 2008

• E. C. Serefoglu and W. J. G. Hellstrom, “Treatment of Peyronie's disease: 2012 update,” Current Urology Reports, vol. 12, pp. 444–452, 2011

• F. Montorsi, A. Salonia, T. Maga et al., “Evidence based assessment of long-term results of plaque incision and vein grafting for Peyronie's disease,” Journal of Urology, vol. 163, no. 6, pp. 1704–1708, 2000

PENILE IMPLANT IN PEYRONIE’S DISEASE

• “CHINESE STAIRWAY”

• Multiple small incisions on short side

• Cauter less than 35

• No grafting

• MUST (Multiple-Slit Technique) (Egydio)

• PICS: Tachosil (Hatzichristodoulou)

• Mulcahy JJ, Rowland RG. Tunica wedge excision to correct penile curvature associated with the inflatable penile prosthesis. J Urol 1987; 138: 63-64• Egydio PH, Kuhhas FE. The Multiple-Slit Technique for penile length and girth restoration. J Sex Med 2018 Feb; 15(2):261-269• Hatzichristodoulou G. The PICS Technique: A novel approach for residual curvature correction during penile prosthesis implantation in patients with severe

Peyronie’s disease using the collagen fleece TachSil. J Sex Med 2018 Mar; 15(3): 416-421

• PLICATION STITCHES

• Multiple stitches

• Plication

• Tied after cylinder inflation

• Morey A. High patient satisfaction of inflatable penile prosthesis insertion with synchronous penile plication for erectile dysfunction and Peyronie’s disease. J Urol 2015, 193:906-908

• MODELING PROCEDURE:

• Steve Wilson• Fully inflated cylinders• Break plaque• Protection of pump• Cave sutures corporotomies• Bend penis 90 seconds (can be done twice)• Remove clamps and inflate 2-3 times extra• Same procedure in some cases• Pull strings cylinders for adequate placement• Over time (8-12 mnths.) cylinders will act as tissue expanders (rapid activation) (<30°)• Cave urethral damage (<4%)

• Wilson SK, Delk JR. A new treatment for Peyronie's disease: modeling the penis over an inflatable prosthesis. J Urol 1994; 152: 1121-1123

IPP + remodelling

- The method of prosthesis implantation with post implantation manual modelling allows the surgeon to repeat manipulation to achieve maximal correction but runs the risk of possible urethral injury

- IPP implantation with grafting can be indicated for severe persistent curvature >30° with severe indentation or penile shortening

- Steve Wilson maneuver

• INTRA CORPORAL CORRECTION

• Normal dilation (Brooks)• Rossello dilators• Uramix cavernotomes• Hooked knife “scratch technique”• Otis urethrotome

COMPLEX PROSTHETIC SURGERY

• Sliding technique• Penile disassembly• Implant with grafting

• Very selected cases• Highly experienced expert centres• Non negligible complications: “it’s only about sex”

• Simultaneous total corporal reconstruction and implantation of a penile prosthesis in patients with erectile dysfunction and severe fibrosis of the corpora cavernosa. Sansalone et al. J. Sex Med 2012 Jul; 9(7): 1937-44

• The penile disassembly technique in the surgical treatment of Peyronie's disease. Perovic et al. BJUI 2001; nov, 88(7): 731-8

• Penile lengthening and widening without grafting according to a modified 'sliding' technique. Egydio et al. BJUI 2015 Jan 28

TO TAKE INTO ACCOUNT WHEN GRAFTING WITH IPP

• The penis should be straighter and not completely straight (1)

• This increases operating time (infection risk) (1)

• Cave hypo-esthesia! (NVB) (1)

• Risk of perforation of implant when suturing graft (1)

• Combination of two different types of foreign material

• (1) Wilson’s pearls, perils and pitfalls of penile prosthesis surgery 2018.

Perovic SV, Djordjevic ML :The penile disassembly technique in the surgical treatment of Peyronie's disease.BJU Int. 2001 Nov;88(7):731-8.

PENILE DISASSEMBLY

Rolle L, Sedigh O, Ceruti C., Fontana D : New, innovative, lengthening surgical procedure for Peyronie's disease by penile prosthesisimplantation with double dorsal-ventral patch graft: the "sliding technique”. J Sex Med. 2012 Sep;9(9):2389-95A

SLIDING TECHNIQUE

Hatzimouraditis et al; Eur Urol 2012 Sep; 62(3):543-52

HISTORICAL OVERVIEW

18DE EEUW ELECTROTHERAPY - COLD THERAPY1889 BROWN SEQUARD - INJECTION TESTIC.EXTRACT

DOGS1892 STANLEY - IDEM EXP. ON PRISONERS

1900 VASECTOMY

1902 WOOTEN C.C.

1908 LYDSSTON IDEM

1918 LESPINASSE TESTIC.EXTRACT IN RECTUS

ABDOMINUS

1935 LOWSLEYPLICATURATION BULBO-ISCHIO

CAVERNOSUS

1936 BOGORAS RIB CARTILAGUE

1950 SCARDIN0 FIRST SYNTHET. IMPLANT1952 GOODWIN / SCOTT 5 PAT.

1960 INTRACAVERNEOUS IMPLANT

1968 PEARLMAN SILICONE

1970 MULTICOMPONENT PROTHESIS

1973 SCOTT – BRADLEY – TIMM FIRST INFLAT. PROTHTWO PUMPS

1974 AMS 700

3 PIECE

1980 JONAS SEMI-RIGID

1983 AMSCOLOPL

REAR TIP EXTENDERPOLY-URETHANE

• Erectile dysfunction (ED) is a common disorder affecting > 50 % of male patients aged 50-70 yrs. (1)

• ED = inability to achieve and maintain an erection sufficient for satisfactorysexual intercourse (2)

• Penile implant introduced in 1973 by Scott• EAU guidelines: (2)

• Third line option• In patients not responding to medical therapy and vacuüm devices = ineffective,

unsatisfactory, contra-indicated by comorbidities

• (1) Feldman HA et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994 Jan; 151 (1): 54-61

• (2) Hatzimouratidis K et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. EAU guidelines 2016

STANDARDISED WORK UP

• Integration of the couple !!!• IIEF (SHIM)- SEP• Hormonal evaluation• DOPPLER• (Nocturnal penile tumescence measurements)

• Have clear documentation to give to the patient

• Show demo and let the patient touch the model – let the patient use the pump

• Pre-op counselling with nurse practioner

• Mention guarantee

• Explain IPP is “cheap” solution

• Give possibility to call anonymous patient who underwent implant surgery

• Inform patient on life expectancy of IPP and explain on re-operationrisk

• Explain complication rates are low

• Explain this is a “small” operation

• ED induces reduction of penile size : indication forsurgery should not be proposed to late / explaineffect on esthetic and functional outcome

• IPP is “irreversible” procedure

• Does not interfere with ejaculation or orgasm

• Low pre-operative expectations correlate with high post-op satisfaction scores (Kramer-J Sex Med-2010)

STANDARDISED PERI-OPERATIVE PROCEDURE

• Create “fast track” : try to improve this multi-modal intervention

• Pre-operative : well instructed and well experienced nurses on ward(isobetadine shower-shaving-antibiotics-etc.)

• Well trained surgical team (assemble prosthesis)

• Clear post-op instructions on ward (TUC-ice-bandage-deflation-etc.)

• Instruct patient when dismissed

• Arrange quick control on opd

• Involvement of nurse practioner

RIGID PROSTHESIS

• CONSTANT RIGIDITY

• SIMPLE PROCEDURE

• RARE TECHNICAL PROBLEMS

• CON• ESTHETIC• EROSION

MALLEABELE PROSTHESIS

• AMS

• COLOPLAST-PORGES

INFLATABLE PROSTHESIS

THREE PIECE INFLAT. PROSTH.

• PENIS PROTHESE

• ERECTIEPROTHESE

• INFLATABLE PENILE IMPLANT

• ERECTIE IMPLANTAAT !!!

• Three-piece inflatable penile prosthesis:

• Highest patient satisfaction rates (> 90%)• Lowest mechanical revision rates (96% at 5 yrs.) (1)

• 1998 introduction Sildenafil => penileimplant sale drops 50% (2)

• Nowadays implant sales exceed pre-sildenafil era

• (1) Wilson et al.-J Sex Med 2007;4:1074-9

• (2) Stanley et al. –South Med J 2000;76:1153-6

THREE PIECE INFLAT. PROTH.• CYLINDERS + PUMP + RESERVOIR

• AMS• 700 CX-CXR• ULTREX (EXPANSION)• LGX

• COLOPLAST-PORGES• TITAN• TITAN NB

INFRA PUBIC PROCEDURE

• LONGITUDINAL VS TRANSVERSE

• CAVE N. DORSALIS PENIS

PENOSCROTAL PROCEDURE

• GOOD EXPOSURE CORPORA

• OBESE PATIENTS

• Retrospective study• N = 126 (long term ( > 1 year) results available in 95 patients)• First time inflatable penile prosthesis• Single surgeon• September 2011 – August 2016• Coloplast (46 %) / Boston Scientific ( 54 %)• Infrapubic approach (41,3 %) / penoscrotal (58,7 %)• Mean operation time infrapubic 52,8 min / penoscrotal 47,01 min• Cylinder length 12-22 cm / RTE 1-5 cm• Drain post-operative in 1 patient (0,8 %)

OVERALL COMPLAINTS / COMPLICATIONS

Loss of penile length 23 (18,25%)

Post-operative pain 15 (11,9%)

Altered sensation 11 (8,73%)

Mechanical failure 9 (7,14%)

Auto-inflation 8 (6,35%)

Hematoma 7 (5,56%)

Floppy glans/cold glans syndrome 6 (4,76%)

Penile deformity 5 (3,97%)

Possible signs of infection 3 (2,38%)

Infection 0 (0%)

Imminent erosion 1 (0,79%)

Chronic pain after 6 weeks 0 (0%)

• Mechanical failure:• Pump dysfunction,leakage, cylinder malfunction

• Minor auto-inflation: zero patients with inconvenience• Post-operative hematoma: 7 patients (5,6%) spontaneous resolvement

in all patients• Prolonged antibiotic treatment in 3 patients: zero infection• Imminent erosion in single patient treated with repositioning• Revision surgery in 15 patients (11,9%):

• Impending erosion, mechanical failure, herniation implant component,…

• Only difference floppy glans infrapubic versus penoscrotal: • 9,61 % versus 1,35 % (p<0,O5)

TIME TO FIRST INTERCOURSE AFTER ACIVATION (n=95)

n %

< 2 weeks 36 37,89%

2-4 weeks 14 14,74%

5-8 weeks 24 25,26%

> 8 weeks 18 18,95%

No intercourse 3 3,16%

TIME TO FIRST ORGASM AFTER ACTIVATION (n=95)

n %

< 2 weeks 25 26,32%

2-4 weeks 12 12,63%

5-8 weeks 20 21,05%

> 8 weeks 30 31,58%

No orgasm 8 8,42%

• Mechanical failure:• Most frequent fluid leakage, pump dysfunction, cylinder rupture,…• Prospective multi centric study (n=2384): 5 year survival implant 88,9% and 10

year survival 79,4% (1)• Our study comparable result

• Complications and complaints:• Infection: severe complication; mostly immediate post-op; sometimes low grade

even years after surgery; 0,6-8,9%; risk factors (diabetes, spinal cord injury, revision surgery,…); Staphylococcus; explant; salvage procedure. (2). Our study0%

• Erosion: major complication;always infected; not immediate complication• Loss of penile length: important negative impact (3)• Pain: frequent until 4-6 weeks; correlates with lower satisfaction rates (p<0,05)• Floppy glans: correlates with lower satisfaction rates (p<0,05) (4); lower in

penoscrotal approach (p<0,05)

• (1) Wilson et al.Long term survival of inflatable penile prosthesis: single surgical group experience with 2384 first time implants spanning two decades. J Sex Med2007 Jul; 4: 1074-9

• (2) Mulcahy et al. Current management of penile implant infections, device reliability and optimizing cosmetic outcome. Current Urology reports. 2014(15):413-20• (3) Lee et al. Strategies for maintaining penile size following penile implant. Trans Androl Urol 2012;2(1):67-73• (4) Bickell et al. Floppy glans syndrome: pathogenesis and treatment. Sex Med Rev 2016;4(2):149-156

• Patient and partner satisfaction:• Affected by patient expectations, comorbidities,partner attitudes, surgical

complications,etc. (1)• Our study: QoL, scale 1-5• Overall satisfaction 83,2%; 84,2% would recommend to friend• 3-piece highest satisfaction rates• Partner satisfaction important, our study: only 2 patients satisfied without

partner satisfaction; conversely 1 partner satisfied without patient satisfaction.• Pre-op counselling, realistic expectations

• Implant usage:• Average activation after 6 weeks• Minimal or no effect on patient’s orgasm, in our study 72% had orgasm during

first sexual encounter.

• (1) Vakalopoulos et al. High patient satisfaction after inflatable penile prosthesis implantation correlates with female partner satisfaction. J Sex Med2013;10(11): 2774-81

• 3-piece IPP effective third line treatment for ED• Safe procedure• High patient and partner satisfaction• Pre- operative counselling of utmost importance• Better outcome with penoscrotal?• Upcoming European (EAU) survey: PHOENIX