44. Penile Prosthesis Implantation: Penoscrotal Approach
KeywordsErectile dysfunctionPenile prosthesisPenoscrotal
Patients with erectile dysfunction (ED) are often initially managed with lifestyle changes, oral pharmacotherapy and Vacuum Erection Device (VED). If these measures fail, patients maybe commenced on intracavernosal injections or intraurethral medications consisting of Alprostadil. Examples of intracavernosal and intraurethral medications are Caverject® and MUSE® respectively.
Indications for penile prosthesis insertion
Indications and Patient Selection
Refractory erectile dysfunction
Failure to tolerate pharmacotherapy/patient choice
Refractory ischaemic priapism
Difficulty with using condom sheath for incontinence
Neurological conditions/spinal injury
44.2 Patient Selection and Counselling
Consent proforma , potential risks associated with penile prosthesis insertion
Soft glans/Super-Sonic Tilt (SST)
It will not increase penile length
Urethra, bladder, bowel injury
Patient factors to be considered before choosing the most suitable penile prosthesis
Spinal cord injury
Previous pelvic surgery
Presence of Artificial Urinary Sphincter (AUS)
Penile conditions e.g. Peyronie’s disease, acute or chronic priapism, phimosis
Stretched penile length
Abdominal scars/presence of stoma
Absolute indications for penoscrotal approach
Absolute indications for penoscrotal approach
Presence of artificial urinary sphincter
44.3 Penile Prosthesis Types and Options
The current and most commonly used inflatable penile prostheses are from two companies, Coloplast Coroporation (Denmark) and Boston Scientific (USA).
Coloplast currently markets Titan® Touch, a self-contained three-piece fluid filled system with an incorporated hydrophilic coating on all components. It is made from the durable Bioflex® and silicone materials. The coating allows for soaking of the device in an antibiotic solution according to the surgeons’ preferred choice of antibiotics prior to implantation to reduce infection risk and aid in surgical placement. The Titan IPP products are available in a variety of lengths ranging from 11 cm to 28 cm.
Coloplast has also designed a hydrophilic coated Cloverleaf™ reservoir with a lock-out™ valve mechanism to reduce risk of auto-inflation. The reservoir comes in two volumes, 75 ml and 125 ml for the larger cylinders. The one touch pump with the deflate button allows for easy deflation of the device. The narrow base version of the Titan® Touch allows implantation of prosthesis in patients with fibrosed and or narrow corpora.
Comparably, Boston Scientific manufactures AMS 700™ three-piece inflatable prosthesis. There are 3 variations available in the AMS 700™ inflatable penile prosthesis line.
AMS 700™CX is the standard IPP with controlled expansion of cylinders aiming to optimize girth and offer additional length options.
AMS 700™LGX is the only marketed penile implant with cylinders designed to expand in girth and length of up to 25%.
AMS 700™CXR is the equivalent to the Coloplast narrow base IPP, for narrower or fibrosed corpora.
The AMS 700™ inflatable penile prosthesis line is available in a variety of lengths ranging from 12 cm to 24 cm.
The AMS 700™ spherical reservoir comes in two volumes, 65 ml and 100 ml. Whereas AMS™ Conceal™ flat reservoir comes in 100 ml only. The Conceal™ low-profile reservoir is Parylene coated to enhance durability and optimises fit and flexibility. The AMS Momentary Squeeze (MS) pump™ offers one-touch button designed for easy deflation, it also has a lock-out valve incorporated within the pump mechanism to resist auto inflation.
AMS 700™ is the only antibiotic impregnated inflatable penile prosthesis on the market, it is precoated with Inhibizone™ antibiotic surface treatment. Inhibizone™ is a combination of Rifampicin and Minocycline, it aims to create a zone of inhibition against bacteria that are commonly associated with penile prosthesis infection.
Boston Scientific also markets the only two-piece inflatable penile prosthesis currently available, the AMS Ambicor™. This pre-filled, pre-connected device eliminates the need for a separate reservoir, resulting in a two-piece designed for ease of placement. This device is particularly useful in patients with a history of complex abdomino-pelvic surgery, where retropubic or intraabdominal reservoir placement can be very difficult and to be avoided.
Coloplast and Boston Scientific penile prosthesis types
Titan One-Touch Release (OTR)
Titan One-Touch Release (OTR) Narrow-base
9.5, 11 & 13
AMS 700 CX
AMS 700 CXR
AMS 700 LGX
9.5, 12 & 14