# Penile Prosthesis: What Should We Do about Complications?

Authors: C. Bettocchi; P. Ditonno; F. Palumbo; G. Lucarelli; G. Garaffa; B. Giammusso; M. Battaglia
Journal: Advances in Urology
 (2008)

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## Abstract

Even in the era of phoshodiesterase type 5 inhibitors, penile implants are considered the definitive solution for the treatment of organic erectile disfunction. The advent of new surgical tools and new infection-resistant materials has significantly reduced the risk of intra and post-operative complications and the need for revision surgery. Various companies have also improved their mechanical systems in order to reduce the risk of failures, and their products are now so good they may last lifelong. In this article, we evaluate the intraoperative and postoperative complications recorded in our experience and in literature reports, and make some suggestions as to how to prevent or correct them.


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## Body

## 1. Introduction

Nowadays implanting a penile prosthesis is the definitive solution for the treatment of
organic erectile dysfunction (ED), even in the era of effective and safe oral
medications [1]. The types of prosthesis most commonly implanted are the three-piece
inflatable device, the two-piece inflatable device, and the soft and malleable
prosthesis. In the last few
years, the three-piece inflatable device has been used for preference, as it
improves the erection, the flaccid, and
appearance of the penis and as it yields a more acceptable and cosmetical functional
results [2]. On the other hand, the relative complexity of this last device is
also the source of mechanical failures and patients’ difficulties in managing
the device. In the last decade, there has been a continuous improvement in the mechanical
function of the devices and in the composition of the materials used but device-related complications still occur.Some complications can be prevented by a correct preoperative assessment. The
surgeon has to understand the patient’s real needs and expectations, as well as
those of his partner in order to be able to choose the right device. The
counselling must also include a complete, clear explanation of how the device
functions and the obvious changes that will arise in the sexual life of the
couple. Informed consent to the procedure is mandatory, and when discussing the
option of a penile implant with the patient, issues such as complications and
the irreversibility of the procedure should be exhaustively discussed.In this paper, we evaluate the
intraoperative and postoperative complications recorded in our experience and in
literature reports, and make some suggestions as to how to prevent or correct
them.


## 2. Intraoperative Complications

### 2.1. Cylinders Positioning

During the implant procedure, after having exposed the corpora cavernosa
and performed the corporotomy, the first critical step is dilating the corpora.
In most patients the corpus cavernosum cavity is
dilated to the maximum capacity using Hegar dilators of various sizes. The
dilator must be introduced through the corpus by pushing it in an outward direction in order to avoid
cross-over perforation. In cases of fibrotic corpora, special dilators may be
useful to create an appropriate space (Rossello dilators or Otis urethrotome)
because perforation is especially risky in this case.A distal corpora perforation can be
corrected first of all by exposing the damaged corpus apex. Then, if it is only
a small hole, the tip can be closed with separate PDS stitches. The way to
manage distal perforation in cases of larger holes is by covering the damaged
apex with a dacron or gore-tex sleeve.Proximal corpora perforation usually
occurs during dilatation of the corpus cavernosum crura. A possible way to
evaluate a proximal perforation intraoperatively is by positioning dilators in
both crura and checking whether they are at different heights, showing that one
has penetrated too deeply inside the corpus. If not discovered during the
operation, a postoperative MRI scan is the best evaluation to confirm a
proximal perforation. One of the two ways of managing this complication is by
creating dacron or gore-tex socks, especially in cases of a malleable or soft
prosthesis (Figure1). The other possibility, indicated for inflatable devices,
is to fix the cylinders to the surrounding corpora tissue, placing stitches
above and below the tubes input. The anchored cylinder tends not to protrude,
allowing healing of the perforation. Another similar solution involves fashioning
a sling through the tip extender using nonabsorbable sutures.Figure 1
A dacron sock created around the tip of a malleable prosthesis in a case of
proximal corpus cavernosum perforation.Incorrect introduction of the
dilators is the main cause of cross-over perforation. It is important to
recognise this kind of perforation as soon as possible so as to implant two
cylinders in the same corpus. Usually a redo correct ipsilateral dilatation is
sufficient to correct the cross-over perforation.Another consequence of incorrect
dilators introduction is urethral perforation. To check for urethral injuries,
it is always best to irrigate the corpora with a saline plus antibiotic
solution: if the fluid leaks through the urethral meatus, a perforation has
occurred. The diagnosis can be confirmed by cystoscopy. The treatment option in
such cases is urethral repair for proximal perforations. If the laceration
involves the urethral meatus, it is advisable to postpone the procedure. It is
possible to position a urethral catheter if necessary with a suprapubic
catheter, delaying insertion of the cylinder or positioning of a malleable
prosthesis until the damaged urethra has healed. The malleable prosthesis will
be replaced by the inflatable cylinder at a later date during a second
operation.A rare complication has been
described by Hatzimouratidis et al. [3]; it occurred during dilation of the
corpora cavernosa with Brooks dilators: the
head detached and stuck to the tip of the corpus cavernosum. The case
was managed by incising the distal lateral part of the corpora cavernosa and
then removing the head of the dilators. In any case, we strongly recommend
examining all surgical tools carefully before using them.


### 2.2. Reservoir Positioning

The possible complications occurring
during the reservoir positioning step are mostly due to this peculiar blind
procedure. If the fascia is not completely opened, the reservoir may not pass
through, remaining outside: this is a typical postoperative complication.
Another possibility is to open the peritoneum: in this case, it is mandatory to
check for bowel injuries.During reservoir positioning, it is
very important to have positioned a urethral catheter and ensured that the
patient has completely emptied his bladder. If not, the risk of bladder
perforation is high. This complication can also occur in patients who have previously
undergone pelvic surgery, such as radical prostatectomy. If a bladder
perforation occurs, cystoscopy can confirm the damage severity; usually leaving
a catheter in place for a few days is sufficient to treat such complications.
In rare cases of wide perforation, an open bladder repair can be performed.


### 2.3. Component Failure/Breakage

In order to avoid a malfunctioning
device, it is always advisable to check correct device functioning before
placement and to activate the pump with cylinders connected after the
placement. At this surgical stage, it is easy to substitute a nonfunctioning
device.Another possible complication is
breakage of device components during cavernotomy closure or during
repositioning of Scott retractor's hooks during the operation. One way to
prevent device perforation is to put the stitches in before performing the
corporotomy and before positioning the cylinders.


## 2.1. Cylinders Positioning

During the implant procedure, after having exposed the corpora cavernosa
and performed the corporotomy, the first critical step is dilating the corpora.
In most patients the corpus cavernosum cavity is
dilated to the maximum capacity using Hegar dilators of various sizes. The
dilator must be introduced through the corpus by pushing it in an outward direction in order to avoid
cross-over perforation. In cases of fibrotic corpora, special dilators may be
useful to create an appropriate space (Rossello dilators or Otis urethrotome)
because perforation is especially risky in this case.A distal corpora perforation can be
corrected first of all by exposing the damaged corpus apex. Then, if it is only
a small hole, the tip can be closed with separate PDS stitches. The way to
manage distal perforation in cases of larger holes is by covering the damaged
apex with a dacron or gore-tex sleeve.Proximal corpora perforation usually
occurs during dilatation of the corpus cavernosum crura. A possible way to
evaluate a proximal perforation intraoperatively is by positioning dilators in
both crura and checking whether they are at different heights, showing that one
has penetrated too deeply inside the corpus. If not discovered during the
operation, a postoperative MRI scan is the best evaluation to confirm a
proximal perforation. One of the two ways of managing this complication is by
creating dacron or gore-tex socks, especially in cases of a malleable or soft
prosthesis (Figure1). The other possibility, indicated for inflatable devices,
is to fix the cylinders to the surrounding corpora tissue, placing stitches
above and below the tubes input. The anchored cylinder tends not to protrude,
allowing healing of the perforation. Another similar solution involves fashioning
a sling through the tip extender using nonabsorbable sutures.Figure 1
A dacron sock created around the tip of a malleable prosthesis in a case of
proximal corpus cavernosum perforation.Incorrect introduction of the
dilators is the main cause of cross-over perforation. It is important to
recognise this kind of perforation as soon as possible so as to implant two
cylinders in the same corpus. Usually a redo correct ipsilateral dilatation is
sufficient to correct the cross-over perforation.Another consequence of incorrect
dilators introduction is urethral perforation. To check for urethral injuries,
it is always best to irrigate the corpora with a saline plus antibiotic
solution: if the fluid leaks through the urethral meatus, a perforation has
occurred. The diagnosis can be confirmed by cystoscopy. The treatment option in
such cases is urethral repair for proximal perforations. If the laceration
involves the urethral meatus, it is advisable to postpone the procedure. It is
possible to position a urethral catheter if necessary with a suprapubic
catheter, delaying insertion of the cylinder or positioning of a malleable
prosthesis until the damaged urethra has healed. The malleable prosthesis will
be replaced by the inflatable cylinder at a later date during a second
operation.A rare complication has been
described by Hatzimouratidis et al. [3]; it occurred during dilation of the
corpora cavernosa with Brooks dilators: the
head detached and stuck to the tip of the corpus cavernosum. The case
was managed by incising the distal lateral part of the corpora cavernosa and
then removing the head of the dilators. In any case, we strongly recommend
examining all surgical tools carefully before using them.


## 2.2. Reservoir Positioning

The possible complications occurring
during the reservoir positioning step are mostly due to this peculiar blind
procedure. If the fascia is not completely opened, the reservoir may not pass
through, remaining outside: this is a typical postoperative complication.
Another possibility is to open the peritoneum: in this case, it is mandatory to
check for bowel injuries.During reservoir positioning, it is
very important to have positioned a urethral catheter and ensured that the
patient has completely emptied his bladder. If not, the risk of bladder
perforation is high. This complication can also occur in patients who have previously
undergone pelvic surgery, such as radical prostatectomy. If a bladder
perforation occurs, cystoscopy can confirm the damage severity; usually leaving
a catheter in place for a few days is sufficient to treat such complications.
In rare cases of wide perforation, an open bladder repair can be performed.


## 2.3. Component Failure/Breakage

In order to avoid a malfunctioning
device, it is always advisable to check correct device functioning before
placement and to activate the pump with cylinders connected after the
placement. At this surgical stage, it is easy to substitute a nonfunctioning
device.Another possible complication is
breakage of device components during cavernotomy closure or during
repositioning of Scott retractor's hooks during the operation. One way to
prevent device perforation is to put the stitches in before performing the
corporotomy and before positioning the cylinders.


## 3. Postoperative Complications

### 3.1. Cylinders Complications

Infections
Infection is one of the most fearsome complications, having an incidence
of 8 to 20%, as reported in large series of implants [2–4]. Infections can
occur a few months after surgery and a typical sign is persistent, unchanging,
or even increasing pain. The pain could be exacerbated by activating the
device. Other signs of infection are penile or scrotal erythema, fever,
purulent drainage from the wound, or skin erosion. Diabetic patients are more
likely to develop an infection, even if the previous concept that poor glycemic
control increases the risk has not been confirmed [5]. Moreover, insulin
dependency and hemoglobin A1C serum levels are not considered additional risk
factors. Other conditions, possibly associated with an increased risk of
infection, are the use of immunosuppressive drugs and steroids, and the
presence of spinal cord injury.
When the presence of infection is confirmed, the use of systemic
antibiotics therapy is not sufficient in the vast majority of cases. This is
due to the infectious agent’s ability to create a biofilm surrounding the
prosthesis components, protecting bacteria from the antibiotic action. In most
cases, the infection is sustained by opportunistic bacteria such asStaphylococcus
epidermidis or Streptococcus agalactie; more rarely, toxic bacteria
like Escherichia coli, Staphylococcus
aureus, Enterococcus faecalis, or Pseudomonas are involved. The
latter agents tend to present early in the postoperative period, with fever,
deep tissue penetration, and abundant purulent drainage.
The classical approach to an infected device is the immediate removal of
all the components and placement of a new implant after some delay for healing.
The advantage of this solution is that the new implant is scheduled only when
the infection has completely cleared. The main disadvantage is the scarring
process that occurs inside the penis and hence penile retraction causing more
difficult surgery later. In the last years salvage procedures have been
proposed that allow positioning of a new penile prosthesis at the same time as
removal of the infected one [6, 7]. The immediate salvage procedure consists of
removal of the infected prosthesis and wound irrigation with seven different
antiseptic solutions including antibiotics (Kanamycin, Bacitracin, Vancomycin,
and Gentamycin), hydrogen peroxide, and betadine. A new prosthesis is then
easily placed, and the overall success rate is more than 80%. The delayed
salvage procedure consists of placement of a drainage tube after removal of the
prosthesis; antibiotic solution is irrigated through the drain and a new
prosthesis is placed about 3 days later. Actually, no advantage has been
demonstrated for the delayed salvage procedure over the immediate one. A few
years ago, based on the evidence that some antibiotics are particularly
indicated to protect silicone graft materials, the American Medical System Company
developed a minocycline-rifampicin-coated penile prosthesis called Inhibizone
[8]. Early experiences with this new device have demonstrated an evident
reduction of overall infections, and no infections at all in primary implanted
patients [9]. Another local approach to prevent device infection has been
proposed by the Mentor Corporation Company and consists of applying a special
hydrophilic coating that seems to inhibit bacterial adherence. The prosthesis is then soaked in antibiotics
and the combined effect should reduce the risk of infection. In an initial experience, the Mentor Titan
prosthesis has also demonstrated effectiveness in reducing the infection rate
[10].
In some patients, the infection could be associated with important
tissue necrosis: in this case, a salvage procedure is not advisable. Severe
distal tissue necrosis is a dramatic event that may even require penile
glansectomy or amputation (Figures2 and 3) after prosthesis removal.Figure 2
Distal erosion with massive glans necrosis.Figure 3
Penile amputation to eliminate all the necrotic tissue surrounding the extruded cylinders.Wrong Sizing
Using an oversized cylinder can lead to an S-shaped deformity and
buckling. As reported by Moncada et al. [11], an oversized cylinder is
responsible for constant pain and exposes the patient to the risk of erosion.
The solution in such cases is to replace the device. The opposite problem is
undersizing, which will have the effect of a so-called “concorde deformity” (Figure 4) with excess mobility of the glans. In this case, cylinder removal is not
necessary and it is possible to mobilize the glans with a subcoronal incision.
When the cylinder tip becomes visible, nonabsorbable sutures can be used to
hitch the glans and anchor it to the tunica albuginea, in order to completely
cover the head of the prosthesis.Figure 4
A “Concorde” effect due to undersized cylinders.Erosion
In the era of hydraulic inflatable devices, erosions are considered a
rare complication. Distal erosion can be due to an excessive intraoperative
corpora cavernosa dilatation, when oversized cylinders are used, in patients
with loss of penile sensation (cold glans syndrome) and in patients unable to
deflate the device when not in use. To manage distal erosion, it is necessary
to remove the cylinder if oversized and replace it with a smaller prosthesis.
The new device has to be placed far from the scar tissue, performing a new dilatation. Cavernosa
reconstruction can be performed with albugineal surgery, as proposed by Mulcahy
[12]. The cylinder can usually be readily reseated in an area of spongy
tissue behind the back wall of the sheath containing the extruded cylinder.
This is done by making a corporotomy over the cylinder laterally, about half
the distance towards the penoscrotal junction, retracting the cylinder to the
side, incising the back wall of the cylinder sheath, and dilating a new cavity
behind this back wall up to the subglandular area. The cylinder can then be
reseated in this new cavity and the back wall of the cylinder sheath will act
as the outer covering of the cylinder. A second layer consisting of the outer
wall of the cylinder sheath can also be closed to create a more secure barrier
against the extrusion of parts. The corporotomy is closed with long-term
adsorbable suture. The cylinder is now secured in its proper location by two
tough layers comprising the back wall of the original sheath and the
corporotomy closure. Cavernosa reconstruction can also be made using synthetic
materials like dacron or Gore-Tex.
A peculiar kind of distal erosion is urethral erosion. A possible
solution is to remove the cylinder and to position a suprapubic catheter to
allow healing of the urethral perforation. A single-stage procedure has been
described by Shaeer [13]: having mobilized the glans off the tip of the corpus
cavernosum, the caverno-urethral fistula is disconnected and sealed by primary
sutures. The perforation on the corpus cavernosum side is corrected by double
breasting or by grafting. The prosthesis
is then reimplanted.
Proximal erosion and cross-over erosion are usually intraoperative
complications. MRI will confirm the diagnosis: the management consists of
removal of the protruded cylinder. A cavernosa reconstruction with a dacron
sock is necessary before inserting a new prosthesis.Mechanical Failure
Cylinders mechanical failure would involve loss of fluid due to
breakage, bulging, or aneurysmatic dilatation. The only solution to manage such
cases is to remove the broken device and replace it with a new penile
prosthesis. The introduction of new covering materials like Parylene has
dramatically reduced the risk of cylinders bulging.


### 3.2. Pump Complications

Pump infections require the same management as described above for
cylinders. Prevention of hematoma and swelling with closed-suction drains has
been shown not to increase the infection rate and to promote an earlier
recovery time. In a large series of 425 consecutive primary three-piece penile
prosthesis implantations, there were a total of 14 (3.3%) infections and three
hematomas (0.7%) during a mean follow-up of 18 months [14].Pump or connecting tubes erosion is usually associated with infections.
If the infection is not extensive and not associated with severe tissue
necrosis, a salvage procedure can be performed locally and a new pump can be
inserted. In cases of considerable loss of tissue, poor patient conditions, and
fever, it is advisable to remove the prosthesis and delay the reimplant.Pump migration or incorrect positioning is mainly due to insufficient
closure of the scrotal space. If the pump is no longer useful because of its
incorrect position, a new operation is required to fix it in the correct
scrotal place.


### 3.3. Reservoir Complications

Reservoir complications are not frequent but include positioning of the
reservoir over the fascia. Migration is a rare event and usually occurs when a too
big space is created through the fascia to access the Retzius space. With a
suprapubic incision, the reservoir can be replaced in the correct paravesical
space.A difficult or failed device deflation can be due to pseudocapsule
formation around a partially emptied reservoir. To prevent capsule formation, it
is usually sufficient to leave the reservoir half-filled for 24 hours after the
operation. Early hospital testing of the
prosthesis function is also advisable. When a pseudocapsule is present, surgical
revision will be needed to access the Retzius space once more, to break the
capsule, and to replace the reservoir. If the previous side is no longer
available, it is best to replace the reservoir in the other paravesical space
or, if necessary, in the peritoneum.


## 3.1. Cylinders Complications

Infections
Infection is one of the most fearsome complications, having an incidence
of 8 to 20%, as reported in large series of implants [2–4]. Infections can
occur a few months after surgery and a typical sign is persistent, unchanging,
or even increasing pain. The pain could be exacerbated by activating the
device. Other signs of infection are penile or scrotal erythema, fever,
purulent drainage from the wound, or skin erosion. Diabetic patients are more
likely to develop an infection, even if the previous concept that poor glycemic
control increases the risk has not been confirmed [5]. Moreover, insulin
dependency and hemoglobin A1C serum levels are not considered additional risk
factors. Other conditions, possibly associated with an increased risk of
infection, are the use of immunosuppressive drugs and steroids, and the
presence of spinal cord injury.
When the presence of infection is confirmed, the use of systemic
antibiotics therapy is not sufficient in the vast majority of cases. This is
due to the infectious agent’s ability to create a biofilm surrounding the
prosthesis components, protecting bacteria from the antibiotic action. In most
cases, the infection is sustained by opportunistic bacteria such asStaphylococcus
epidermidis or Streptococcus agalactie; more rarely, toxic bacteria
like Escherichia coli, Staphylococcus
aureus, Enterococcus faecalis, or Pseudomonas are involved. The
latter agents tend to present early in the postoperative period, with fever,
deep tissue penetration, and abundant purulent drainage.
The classical approach to an infected device is the immediate removal of
all the components and placement of a new implant after some delay for healing.
The advantage of this solution is that the new implant is scheduled only when
the infection has completely cleared. The main disadvantage is the scarring
process that occurs inside the penis and hence penile retraction causing more
difficult surgery later. In the last years salvage procedures have been
proposed that allow positioning of a new penile prosthesis at the same time as
removal of the infected one [6, 7]. The immediate salvage procedure consists of
removal of the infected prosthesis and wound irrigation with seven different
antiseptic solutions including antibiotics (Kanamycin, Bacitracin, Vancomycin,
and Gentamycin), hydrogen peroxide, and betadine. A new prosthesis is then
easily placed, and the overall success rate is more than 80%. The delayed
salvage procedure consists of placement of a drainage tube after removal of the
prosthesis; antibiotic solution is irrigated through the drain and a new
prosthesis is placed about 3 days later. Actually, no advantage has been
demonstrated for the delayed salvage procedure over the immediate one. A few
years ago, based on the evidence that some antibiotics are particularly
indicated to protect silicone graft materials, the American Medical System Company
developed a minocycline-rifampicin-coated penile prosthesis called Inhibizone
[8]. Early experiences with this new device have demonstrated an evident
reduction of overall infections, and no infections at all in primary implanted
patients [9]. Another local approach to prevent device infection has been
proposed by the Mentor Corporation Company and consists of applying a special
hydrophilic coating that seems to inhibit bacterial adherence. The prosthesis is then soaked in antibiotics
and the combined effect should reduce the risk of infection. In an initial experience, the Mentor Titan
prosthesis has also demonstrated effectiveness in reducing the infection rate
[10].
In some patients, the infection could be associated with important
tissue necrosis: in this case, a salvage procedure is not advisable. Severe
distal tissue necrosis is a dramatic event that may even require penile
glansectomy or amputation (Figures2 and 3) after prosthesis removal.Figure 2
Distal erosion with massive glans necrosis.Figure 3
Penile amputation to eliminate all the necrotic tissue surrounding the extruded cylinders.Wrong Sizing
Using an oversized cylinder can lead to an S-shaped deformity and
buckling. As reported by Moncada et al. [11], an oversized cylinder is
responsible for constant pain and exposes the patient to the risk of erosion.
The solution in such cases is to replace the device. The opposite problem is
undersizing, which will have the effect of a so-called “concorde deformity” (Figure 4) with excess mobility of the glans. In this case, cylinder removal is not
necessary and it is possible to mobilize the glans with a subcoronal incision.
When the cylinder tip becomes visible, nonabsorbable sutures can be used to
hitch the glans and anchor it to the tunica albuginea, in order to completely
cover the head of the prosthesis.Figure 4
A “Concorde” effect due to undersized cylinders.Erosion
In the era of hydraulic inflatable devices, erosions are considered a
rare complication. Distal erosion can be due to an excessive intraoperative
corpora cavernosa dilatation, when oversized cylinders are used, in patients
with loss of penile sensation (cold glans syndrome) and in patients unable to
deflate the device when not in use. To manage distal erosion, it is necessary
to remove the cylinder if oversized and replace it with a smaller prosthesis.
The new device has to be placed far from the scar tissue, performing a new dilatation. Cavernosa
reconstruction can be performed with albugineal surgery, as proposed by Mulcahy
[12]. The cylinder can usually be readily reseated in an area of spongy
tissue behind the back wall of the sheath containing the extruded cylinder.
This is done by making a corporotomy over the cylinder laterally, about half
the distance towards the penoscrotal junction, retracting the cylinder to the
side, incising the back wall of the cylinder sheath, and dilating a new cavity
behind this back wall up to the subglandular area. The cylinder can then be
reseated in this new cavity and the back wall of the cylinder sheath will act
as the outer covering of the cylinder. A second layer consisting of the outer
wall of the cylinder sheath can also be closed to create a more secure barrier
against the extrusion of parts. The corporotomy is closed with long-term
adsorbable suture. The cylinder is now secured in its proper location by two
tough layers comprising the back wall of the original sheath and the
corporotomy closure. Cavernosa reconstruction can also be made using synthetic
materials like dacron or Gore-Tex.
A peculiar kind of distal erosion is urethral erosion. A possible
solution is to remove the cylinder and to position a suprapubic catheter to
allow healing of the urethral perforation. A single-stage procedure has been
described by Shaeer [13]: having mobilized the glans off the tip of the corpus
cavernosum, the caverno-urethral fistula is disconnected and sealed by primary
sutures. The perforation on the corpus cavernosum side is corrected by double
breasting or by grafting. The prosthesis
is then reimplanted.
Proximal erosion and cross-over erosion are usually intraoperative
complications. MRI will confirm the diagnosis: the management consists of
removal of the protruded cylinder. A cavernosa reconstruction with a dacron
sock is necessary before inserting a new prosthesis.Mechanical Failure
Cylinders mechanical failure would involve loss of fluid due to
breakage, bulging, or aneurysmatic dilatation. The only solution to manage such
cases is to remove the broken device and replace it with a new penile
prosthesis. The introduction of new covering materials like Parylene has
dramatically reduced the risk of cylinders bulging.


## 3.2. Pump Complications

Pump infections require the same management as described above for
cylinders. Prevention of hematoma and swelling with closed-suction drains has
been shown not to increase the infection rate and to promote an earlier
recovery time. In a large series of 425 consecutive primary three-piece penile
prosthesis implantations, there were a total of 14 (3.3%) infections and three
hematomas (0.7%) during a mean follow-up of 18 months [14].Pump or connecting tubes erosion is usually associated with infections.
If the infection is not extensive and not associated with severe tissue
necrosis, a salvage procedure can be performed locally and a new pump can be
inserted. In cases of considerable loss of tissue, poor patient conditions, and
fever, it is advisable to remove the prosthesis and delay the reimplant.Pump migration or incorrect positioning is mainly due to insufficient
closure of the scrotal space. If the pump is no longer useful because of its
incorrect position, a new operation is required to fix it in the correct
scrotal place.


## 3.3. Reservoir Complications

Reservoir complications are not frequent but include positioning of the
reservoir over the fascia. Migration is a rare event and usually occurs when a too
big space is created through the fascia to access the Retzius space. With a
suprapubic incision, the reservoir can be replaced in the correct paravesical
space.A difficult or failed device deflation can be due to pseudocapsule
formation around a partially emptied reservoir. To prevent capsule formation, it
is usually sufficient to leave the reservoir half-filled for 24 hours after the
operation. Early hospital testing of the
prosthesis function is also advisable. When a pseudocapsule is present, surgical
revision will be needed to access the Retzius space once more, to break the
capsule, and to replace the reservoir. If the previous side is no longer
available, it is best to replace the reservoir in the other paravesical space
or, if necessary, in the peritoneum.


## 4. Conclusions

Penile prosthesis implantation is a fascinating surgical technique that
has gained an important role in the treatment of severe erectile dysfunction.
The advent of new surgical tools and new infection-resistant materials has
significantly reduced the risk of intra- and postoperative complications and
the need for revision surgery. Various companies have also improved their
mechanical systems in order to reduce the risk of failures, and their products
are now very good as they may last lifelong. Nevertheless, surgical skill and a meticulous respect
for sterility rules remain fundamental requirements to guarantee the success of
a penile prosthesis implant.



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*Source: 573560-2008-11-04.xml*