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A New Access for Implantation of a Malleable Penile Prosthesis During Perineal Radical Prostatectomy

ABSTRACT

The present 67-year-old male had clinically localized prostate cancer and needed a perineal radical prostatectomy. He also needed prosthesis implantation for severe erectile dysfunction. We describe a new perineal access for implantation of a malleable penile prosthesis during the prostatectomy surgery that does not require a second incision. The prostatectomy technique was not altered. Prosthesis implantation began after removal of the prostate and before performing the vesicourethral anastomosis. The procedure is described. Dilatation of the cavernous bodies and prosthesis implantation were performed without technical problems. Transoperative bleeding was similar to that observed for prosthesis implantation through a penile access. No shortening of the urethral stump was observed and vesicourethral anastomosis was performed without difficulty. Surgical time was 40 minutes. Use of the same access for the 2 procedures is easy and has low morbidity. This approach should be considered by other surgeons for patients with prostate cancer and severe erectile dysfunction.

Mario Paranhos, Enrico Andrade, Luiz Carlos Neves de Oliveira, Marcos Dall`Oglio, Alberto Antunes, Joaquim A Claro, Miguel Srougi

Division of Urology, University of São Paulo Medical School, São Paulo, Brazil

Submitted September 10, 2010 - Accepted for Publication October 9, 2010

KEYWORDS: Erectile dysfunction; Penile prosthesis; Prostatic cancer; Radical perineal

CORRESPONDENCE: Dr. Mario Paranhos, Rua Mapuá¡, 16 – Chá¡cara Inglesa, CEP-04647-030, São Paulo, Brazil ().

CITATION: Urotoday Int J. 2010 Dec;3(6). doi:10.3834/uij.1944-5784.2010.12.05

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INTRODUCTION

Almost all men with erectile dysfunction prefer to receive treatment with a systemic medication. With the introduction in 1998 of effective systemic therapy in the form of sildenafil citrate, oral medication has rapidly become the first-line therapy for erectile dysfunction [1]. When systemic therapy fails or is contraindicated, second-line treatments are considered. These include sexual therapy, vacuum erection devices, intraurethral medications, and penile injection. Men with erectile dysfunction who reject or have failed second-line therapies should be considered for penile prosthesis implantation, provided that the erectile dysfunction is not primarily psychogenic [2]. Many men with mild-to-moderate erectile dysfunction benefit from oral therapy for a number of years and then relapse, as the organic factors (usually vascular disease) causing the erectile dysfunction advance [3]. Clearly, penile prosthesis implantation will continue to have an important, albeit changing role in the treatment of erectile dysfunction [4].

Patients with clinically localized prostate cancer with indication for perineal radical prostatectomy sometimes have severe erectile dysfunction and a need for prosthesis implantation. The technique for radical prostatectomy has developed, and the perineal approach has won followers in recent years [5,6,7]. However, the necessity for a second incision for implantation can increase surgical time and surgical morbidity.

The present authors developed a new penile prosthesis implantation technique for patients that already have severe erectile dysfunction and are candidates for radical perineal prostatectomy. The technique uses perineal access for implantation of a malleable penile prosthesis, eliminating the necessity for a second incision. The procedure is described in the following case report. We also analyzed if prosthesis implantation during perineal radical prostatectomy would shorten the urethral stump or lead to technical difficulties in performing vesicourethral anastomosis.

CASE REPORT

The patient was a 67-year-old male. He had a prostate-specific antigen of 8.3 ng/mL. He had clinically localized prostate cancer with indication for perineal radical prostatectomy. He also had severe erectile dysfunction and a need for prosthesis implantation. He was selected for concomitant surgery.

Surgical Procedure

The surgical technique used for penile prosthesis implantation did not alter the perineal radical prostatectomy procedure. Prosthesis implantation began after removal of the prostate and before performing the vesicourethral anastomosis.

An 18-Fr urethral catheter was placed and the surgical incision was enlarged for 3 cm along the median line, toward the scrotum. This made an inverted “Y” in the perineum (Figure 1).

The opening of cavernous bodies in their proximal extremities was done with a 3 cm longitudinal incision. The edges were separated with a 2.0 polyglactin repair suture (Figure 2; Figure 3). The first cavernous body was dilated toward the distal extremity until the prosthetic thickness was reached [8]. The same procedure was repeated in the other cavernous body.

The prosthetic length measurement was determined by the prosthesis itself, as its proximal extremity was inserted under direct view of the proximal cavernous body extremity. The contralateral prosthesis implantation was performed in the same way. The fitness of the distal prosthesis extremity inside the cavernous body was verified, and the closure of the cavernous bodies was initiated with a 2.0 polyglactin suture (Figure 4).

The prostatectomy field showed that there was no shortening of the urethral length. The subcutaneous tissue of the prolonged incision was closed with a 4.0 catgut suture and the vesicourethral anastomosis was then completed.

Outcome

The surgical time for implantation of the malleable prosthesis was 40 minutes. During the surgical procedure, the dilatation of the cavernous bodies and the implantation of the prosthesis were performed without technical problems. The transoperative bleeding was similar to that observed for prosthesis implantation through a penile access. Return of sexual activity was advised 2 months after surgery.

There was no interference with the radical perineal prostatectomy technique. No shortening of the urethral stump was observed. Vesicourethral anastomosis was performed without difficulty.

DISCUSSION

The authors described a new procedure for a malleable penile prosthesis implantation through a perineal access during radical prostactecomy. Before the procedure, there was some concern regarding a possible shortening of the urethral stump or the appearance tension along the vesicourethral anastomosis. These potential problems did not occur.

Rectal injury is a possible complication during perineal radical prostatectomy. If a rectal injury occurs, the penis is the preferred access for prosthesis implantation [9]. Therefore, prosthesis implantation should be performed only after prostate removal, as in the present technique.

During perineal radical prostatectomy we use the Young’s retractor, which cannot be placed if a penile prosthesis is inserted. This is another reason that prosthesis implantation should only be done after prostate removal. The same limitation is observed if the prosthesis is to be inserted through the penile access.

CONCLUSION

Use of the same access for implantation of a penile prosthesis during perineal radical prostatectomy is easy and has a low morbidity. This approach does not interfere with the perineal prostatectomy and should be considered by other surgeons for patients with prostate cancer and severe erectile dysfunction.

REFERENCES

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