# Penile Corporeal Reconstruction during Difficult  Placement of a Penile Prosthesis

Authors: Viet Q. Tran; Timothy F. Lesser; Dennis H. Kim; Sherif R. Aboseif
Journal: Advances in Urology
 (2008)

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## Abstract

For some patients with impotence and concomitant severe tunical/corporeal tissue fibrosis, insertion of a penile prosthesis is the only option to restore erectile function. Closing the tunica over an inflatable penile prosthesis in these patients can be challenging. We review our previous study which included 15 patients with severe corporeal or tunical fibrosis who underwent corporeal reconstruction with autologous rectus fascia to allow placement of an inflatable penile prosthesis. At a mean follow-up of 18 months (range 12 to 64), all patients had a prosthesis that was functioning properly without evidence of separation, herniation, or erosion of the graft. Sexual activity resumed at a mean time of 9 weeks (range 8 to 10). There were no adverse events related to the graft or its harvest. Use of rectus fascia graft for coverage of a tunical defect during a difficult penile prosthesis placement is surgically feasible, safe, and efficacious.


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## Body

## 1. Introduction

For some
patients with both impotence and concomitant penile fibrosis, placement of a
penile prosthesis is the only viable therapy to allow restoration of erectile
function. Placement of a penile prosthesis in the setting of severe corporeal or
tunica albuginea fibrosis can be very difficult and challenging. This may hinder
the surgeon from satisfactorily dilating the corporeal bodies to accommodate
the prosthesis and/or closing the tunica albuginea over the cylinders. This in
turn may negatively affect the function of the prosthesis, limit the size of
the prosthesis, and ultimately negatively impact the patient’s overall
satisfaction [1].Several etiologies
of corporeal fibrosis have been identified including multiple penile surgeries,
prior removal of an implant for infection, erosion or malfunction, priapism,
chronic intracavernous injections, penile trauma, or Peyronie’s disease
[2–5].
In phalluses with extreme fibrosis where satisfactory dilatation of the corpora
and/or closure of the tunica albuginea is not feasible, several techniques have
been described to allow for placement of a penile implant. One option is to use
readily available downsized implants [6]. The Otis urethrotome has
been used to perform an extended corporotomy with extensive tunical excision to
facilitate placement of an implant [7].When
these various techniques are unsuccessful, penile reconstruction with or
without graft material is necessary [8].Grafting of
the penile corpora is a valuable tool that can help surgeons in penile
reconstructive surgery. In 1950, Lowsley and Boyce described the first usage of
a fat graft to surgically repair Peyronie’s disease [9]. Since then,
various grafts have been explored in search of an ideal graft that best mimics
the properties of the tunica albuginea. These characteristics should include good
compliance and pliability, minimal inflammation, high tensile strength to
prevent bulging or aneurysmal dilatation, low antigenicity risk, low infection
transmission risk, availability in various sizes, packaging, and cost [10].
Modern graft materials described in the
literature include fat, vein, rectus fascia, tunica vaginalis, temporalis
fascia, dermis, cadaveric dura, cadaveric pericardium, porcine small intestine
submucosa (SIS), and synthetic grafts such as Dacron and Gore-Tex [11–20].
Choosing an appropriate graft material and technique is a crucial aspect for
successful tunical/corporeal reconstruction and ideal functional outcome of
prosthetic surgery.The use of
rectus fascia is well documented in the literature for a variety of uses in
reconstructive surgery. As we previously reported, we evaluated the functional
outcomes and patient satisfaction in patients who underwent rectus fascia
grafting for reconstruction of the corporeal bodies in the setting of severe
tunical/corporeal fibrosis in order to facilitate the placement of a penile
prosthesis [21].


## 2. Material and Methods

As
previously reported, 15 patients who underwent placement of an inflatable
penile implant and corporeal/tunica reconstruction using autologous rectus
sheath were included into the study [21]. The patients were divided into two groups. Group I included seven patients who had tunica fibrosis secondary to Peyronie’s disease
and associated severe erectile dysfunction. These patients had penile curvature
and erectile dysfunction for more than 12 months (mean 14 months) and had
exhausted all medical forms of treatment. None in this group had prior surgery
for correction of penile curvature or impotence. Group II was composed of eight patients who had severe corporeal
fibrosis related to a history of penile prosthesis removal secondary to
malfunction (n=1), infection (n=3), or
erosion (n=4). Patients had their devices placed at least 24 months
prior to reinsertion (mean 36 months). Six of these eight patients had more than one implant surgery in the past.All patients ingroups
I and II underwent placement of a three-piece inflatable penile prosthesis. Seven
were recipients of a Mentor
Alpha I inflatable penile implant and the other eight were recipients of
an AMS 700 inflatable implant. Patients in both groups had a significant
tunical albuginea defect after the placement of the prosthesis, requiring corporeal
reconstruction with graft material to provide adequate corporeal coverage and
closure. The defect size was determined at
the time of surgery and a corresponding sized graft was harvested from rectus
fascia. Postoperative evaluations and
exams focused on the function of the prosthesis, with attention to any findings
suggesting herniation or erosion. Also, patients’ abdomens were closely
examined for any evidence of hernia or wound infection related to the graft
harvest site. Follow-up clinical exams
and interviews were conducted at 1, 6, and 12 months, and yearly visits thereafter.


### 2.1. Surgical Technique

The
surgical technique is detailed here as we have previously described [21].
Preoperative intravenous antibiotics,
including 1 gram of Vancomycin and 160 mg of Gentamicin (adjusted for patient
weight and renal function), were administered to all patients. Patients were positioned
supine on the operating room table. A 16 French Foley catheter was inserted
prior to making the skin incision.Group I
After making a circumcision
incision, the penile skin was degloved exposing both corpora cavernosa and
neurovascular bundles. An artificial erection was induced using injectable
saline with compression at the base of the penis. Both neurovascular bundles
were dissected and reflected laterally and the tunical plaque was exposed. The point of maximum curvature was marked and
an H-incision was made at this site: two lateral, longitudinal incisions for
placement of the prosthetic cylinders, and a transverse incision on the plaque
to release the curvature as previously described by Aboseif et al. [22]. After corporeal dilation and proper sizing of
the implant, the rectus fascial graft was harvested through a transverse
suprapubic incision. The grafts were excised as rectangular strip to correspond
with the tunica albuginea defect size (mean 2 cm × 8 cm). The reservoir was then placed in the
retroperitoneal space through the same incision. The graft was then fashioned
to cover the defect, and secured using 4-0 Maxon suture in a running fashion
(Figure 1). Caution was taken to prevent injury to the underlying inflatable
implant during this step.Figure 1
Augmentation of the tunica albuginea is shown here with a rectus fascia
graft sewn in place allowing coverage of the penile prosthesis.Group II
A midline penoscrotal incision was
made to expose both corpora cavernosa. A
longitudinal incision was made on the ventrolateral surface of each corpus, extending from
the glans penis to the most proximal position possible. Caution was taken to
avoid cutting through the full thickness of the corporeal bodies, as there is
usually dense scar tissue obliterating the normal planes and possibly the
intracorporeal tissue. Once in good position, the intracorporeal space was
dilated both proximally and distally using Metzenbaum scissors. After proper
sizing of the implant, the tunical defect was measured, and the rectus fascia
was harvested and secured with 4-0 Maxon as described earlier.
This
technique is similar in concept to an on-lay urethroplasty for urethral
stricture disease. By incising the
tunica and placing a graft, the size of the corporeal bodies conceivably is enlarged which
allows its closure without any tension or ischemia to the tissues.
Once the tunical defect was closed
with the rectus fascia graft, inflation of the prosthesis was performed to ensure
correction of the defect and proper function of the new prosthesis. The penile and the suprapubic wounds were
closed in a normal fashion. Penile dressing and scrotal fluff were then
applied.
Patients
were admitted overnight for postoperative observation and continued on intravenous
antibiotics. Average hospital stay was
one day. The foley catheter was removed
prior to the discharge. Patients were instructed to keep the device deflated
for 6 weeks. Subsequent follow-up appointments
were scheduled for 1-, 6-, and 12-month intervals, followed by yearly
visits. Clinical data concerning the
prosthesis function, integrity of the graft, wound healing, patient
satisfaction and complications were evaluated during each follow-up visit.


## 2.1. Surgical Technique

The
surgical technique is detailed here as we have previously described [21].
Preoperative intravenous antibiotics,
including 1 gram of Vancomycin and 160 mg of Gentamicin (adjusted for patient
weight and renal function), were administered to all patients. Patients were positioned
supine on the operating room table. A 16 French Foley catheter was inserted
prior to making the skin incision.Group I
After making a circumcision
incision, the penile skin was degloved exposing both corpora cavernosa and
neurovascular bundles. An artificial erection was induced using injectable
saline with compression at the base of the penis. Both neurovascular bundles
were dissected and reflected laterally and the tunical plaque was exposed. The point of maximum curvature was marked and
an H-incision was made at this site: two lateral, longitudinal incisions for
placement of the prosthetic cylinders, and a transverse incision on the plaque
to release the curvature as previously described by Aboseif et al. [22]. After corporeal dilation and proper sizing of
the implant, the rectus fascial graft was harvested through a transverse
suprapubic incision. The grafts were excised as rectangular strip to correspond
with the tunica albuginea defect size (mean 2 cm × 8 cm). The reservoir was then placed in the
retroperitoneal space through the same incision. The graft was then fashioned
to cover the defect, and secured using 4-0 Maxon suture in a running fashion
(Figure 1). Caution was taken to prevent injury to the underlying inflatable
implant during this step.Figure 1
Augmentation of the tunica albuginea is shown here with a rectus fascia
graft sewn in place allowing coverage of the penile prosthesis.Group II
A midline penoscrotal incision was
made to expose both corpora cavernosa. A
longitudinal incision was made on the ventrolateral surface of each corpus, extending from
the glans penis to the most proximal position possible. Caution was taken to
avoid cutting through the full thickness of the corporeal bodies, as there is
usually dense scar tissue obliterating the normal planes and possibly the
intracorporeal tissue. Once in good position, the intracorporeal space was
dilated both proximally and distally using Metzenbaum scissors. After proper
sizing of the implant, the tunical defect was measured, and the rectus fascia
was harvested and secured with 4-0 Maxon as described earlier.
This
technique is similar in concept to an on-lay urethroplasty for urethral
stricture disease. By incising the
tunica and placing a graft, the size of the corporeal bodies conceivably is enlarged which
allows its closure without any tension or ischemia to the tissues.
Once the tunical defect was closed
with the rectus fascia graft, inflation of the prosthesis was performed to ensure
correction of the defect and proper function of the new prosthesis. The penile and the suprapubic wounds were
closed in a normal fashion. Penile dressing and scrotal fluff were then
applied.
Patients
were admitted overnight for postoperative observation and continued on intravenous
antibiotics. Average hospital stay was
one day. The foley catheter was removed
prior to the discharge. Patients were instructed to keep the device deflated
for 6 weeks. Subsequent follow-up appointments
were scheduled for 1-, 6-, and 12-month intervals, followed by yearly
visits. Clinical data concerning the
prosthesis function, integrity of the graft, wound healing, patient
satisfaction and complications were evaluated during each follow-up visit.


## 3. Results

Fourteen
out of fifteen patients were available for evaluation, while the remaining
patient was lost to follow-up. Placement of a functioning inflatable penile
prosthesis with reconstruction of the tunical deficiency with autologous rectus
fascia was successful in all 14 patients at a mean follow-up of 18 months
(range 3 to 36). All of the implanted prostheses were functioning
appropriately, with all 14 patients reporting satisfactory sexual intercourse. Six
patients reported suprapubic discomfort with moderate-level activity in the
first 3–6 months, which
resolved in 5 of the 6 patients. Four
patients had penile hypoesthesia of the glans, which eventually resolved in 2
patients but persisted in the other 2.
One patient complained of shortening of his penis, but he was still able
to have satisfactory intercourse. There
was no evidence of rectus fascia graft compromise since no kinking or
herniation of the prostheses was found. Furthermore, there were no adverse
events such as infection, prosthesis malfunction, incisional hernia, or fluid
collections at the site of graft harvest that resulted from the harvesting of
the rectus fascia.


## 4. Discussion

In a subset
of patients with impotence and concomitant severe tunical and cavernous tissue
fibrosis, reestablishment of erectile function is dependent on implantation of
a penile prosthesis. In this setting, a
sizable tunical defect may be encountered during penile prosthesis implantation
and corporeal reconstruction may become necessary. Several surgical techniques have been
described to handle such situations. Corporeal
reconstruction with graft material is an acceptable option. Various materials
for such reconstructive repairs have been used and described in the
literature.The use of
nonautologous grafts for corporeal reconstruction has been widely reported in
the literature. Commercially available human cadaveric fascia or porcine
tissues are viable options for graft material.These free tissue grafts
have been used extensively in various urologic procedures for other
applications such as placement of a pubovaginal sling or during the surgical
correction of Peyronie’s disease [23, 24]. The use of the various
porcine tissue grafts (including dermis, pericardium, and small intestinal
submucosal) has been published, showing good results [18, 25]. These
graft materials provide off-the-shelf availability, decreased operative time,
and no donor site morbidity, however they are quite expensive.Synthetic grafts
(i.e., Gortex, dacron, prolene) are readily available, come prepackaged in
various sizes, and do not require a second incision to harvest from a donor
site. The drawbacks to using a synthetic graft are that they are costly, may
predispose the patient to infection, and behave physiologically different
than the tunica albuginea [6, 26].
The tensile strength of the synthetic graft is much greater than the native
tunica albuginea resulting in limited expandability. These characteristics limit the full
expansion potential of the cylinders [27].Harvesting autologous
grafts is performed for various urologic and nonurologic reconstructive surgeries.
These grafts include rectus fascia, fascia lata, dermis, saphenous vein,
temporalis fascia, and tunica albuginea. They have the advantage of being
noninfectious and nonimmunogenic, possess good tensile strength, and are
readily abundant to close any size tunical defect. The potential disadvantages
of using autologous grafts may include increased operative time secondary to
harvest time, bleeding, and morbidity related to the harvest site [10]. Venous grafts have been shown to be superior
to other autologous tissues in the repair of Peyronie’s disease owing to its
physiologic properties that better mimic the vascular intercorporeal space [28, 29]. It is more elastic and is less likely to contract than other
autologous tissues, and the venous endothelium offers the theoretical advantage
of nitric oxide secretion to maintain normal erectile physiology [28].
When tissue graft material is used to reconstruct the corpora in facilitating
implantation of a prosthesis, reconstructing the corpora with tissue material that
is nonsynthetic and has high tensile strength is crucial in providing adequate
tissue support for the inflatable penile prosthesis. In our reported study, we elected to use autologous
rectus fascia because it fulfills these requirements and it also allowed
harvesting of the graft to occur through the same suprapubic incision that is
made for the placement of the inflatable prosthesis reservoir without having to
make a separate incision [21].Using an
autologous rectus fascial graft for corporeal reconstruction helps facilitate
the placement of a penile prosthesis when encountering severe tunical/corporeal
fibrosis. This is similar in concept to on-lay urethroplasty for stricture disease;
the graft allows the overall corporeal body circumference to increase which in
turn allows the implant to inflate better. Furthermore, it allows closure of
the tunica without tension, thus avoiding any possible ischemia of the tissues
with its risk of infection and complications. All patients in the study
incurred no complications related to the use or harvesting of the graft. Long-term follow-up
demonstrated that all the patients in the study had excellent prosthetic
function and were satisfied with their overall outcomes.


## 5. Conclusion

We concluded in our study that the
use of rectus fascia grafts for the augmentation of the tunical deficiencies
and corporeal reconstruction during difficult penile prosthesis implantation
yielded excellent clinical results. Long-term
outcomes demonstrated high overall patient satisfaction. Ease of harvesting,
reduced cost, elimination of the synthetic and xenographic materials make this graft an excellent
anatomic and functional tunical substitute. Rectus fascia graft is a valuable addition
to the reconstructive urological repertoire and should be considered when
tunical defect precludes adequate tunical closure during penile prosthesis
implantation.



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