Careful planning, managing expectations keys to successful implant surgery

Most penile implant surgeries produce a positive outcome. Even problem cases can have a successful outcome with careful planning.

"It all starts with the pre-op history and exam," explained Tom Lue, MD, of the University of California, San Francisco. "That's when you start planning to avoid problems."

The most difficult patients usually present with severe penile fibrosis, severe curvature or large, calcified plaque, a history of urethral perforation, poor manual dexterity, unrealistic expectations with a small penis, poor penile sensation, or retarded ejaculation.

The single most important step is managing patient expectations, Dr. Lue told colleagues at the Urology Congress Saturday. If a patient starts with a small penis, it is important to explain that he will have a small penis after implantation.

If the patient has problems with manual dexterity, a semi-rigid mechanical device will be easier to manage.

"If you tell the patient these realities beforehand, you can save yourself a lot of trouble afterwards," Dr. Lue said.

Patients with more realistic expectations are more likely to be satisfied with the outcome.

If severe fibrosis is a problem, do not force dilation.

"If you feel a good resistance and try to force it, that's when you find the dilator in the urethra," Dr. Lue cautioned.

He advised opening the tunica to remove fibrous tissue and placing a graft to cover the prosthesis if needed.

Penile curvature is easily corrected. Mild to moderate curves may straighten after dilation. If not, the surgeon can model the penis after implantation.

Dr. Lue advised placing placation sutures on the convex side of the curve, leaving them untied. Insert the device, tie the placation sutures, excise or incise plaque as needed, and place a graft.

If the patient has a history of urethral perforation, obtain the operative report to identify the perforation site. To prevent further problems, Dr. Lue recommended a "preventive" corporotomy at the site of the previous perforation for distal dilation.

"If you spend an extra 10 minutes before surgery, you can avoid a lot of problems later," Dr. Lue said. "You have to plan around problems before they happen."