PENILE PROSTHESIS (IMPLANT) SURGERY

Implantation of a penile prosthesis is one of the options available for the treatment of erectile dysfunction, whatever the cause, and is, in many ways, the best option.

The penis consists of three hollow tubes running along the length of the shaft. One of these, the urethra, runs along the bottom of the penis and brings urine from the bladder out through the end of the penis. The other two matched tubes running side by side on the top of the penis are constructed much like a car tyre with an outer tube and an inner tube.

The erection is created by the two inner tubes filling and pushing against the outer tubes much like a tyre that is inflated with air.

Penile prosthesis or implant surgery is the placement of prosthetic inner tubes within the penis to mimic the inflation process and create an erection.

Penile implants were first used in the 1960s, and as time went on further advances occurred. Different types of prostheses were developed, and there have been many changes and advancements over the years and hundreds of thousands of men throughout the world have been successfully treated with a penile implant.

They are mechanically reliable, with 90% still working well after 10 years on a recent survey. 98% of patients reported that their prosthetic erection was good or excellent. More than 90% of their partners report being very satisfied with the penile implant. In the same survey, 88% of men with implants said they would recommend the same treatment to other patients.

Today there are three types of penile prostheses. These include the semirigid implant, the inflatable implant and a self contained inflatable implant. For virtually all men, the three-piece inflatable implant gives the best results and virtually returns the penis to a “normal” state.

INFLATABLE PENILE PROSTHESES

Inflatable prostheses are the most natural and best of the implants. These are soft-paired inner tubes made of silicone or bioflex, which are inert plastic materials. The inner tubes are surgically inserted into the natural tubes within the penis; much like an inner tube might be placed in a car tyre. A car tyre with an inner tube still looks and works like a car tyre, and a penis with “inner tubes” in it (penile implant) still looks and works like a penis. When a man wants an erection the implant inner tubes are filled with a saline solution that comes from a small reservoir placed under the muscles of the abdomen. A small pump, placed inside the scrotum, between the testicles, is used to transfer the fluid from the reservoir to the penile cylinders or inner tubes to cause the erection. This pump can easily be felt through the skin of the scrotal sac, and takes around 10 pumps (or 20 -30 seconds) to give a fully inflated hard erection. The more fluid that is pumped into the inner tubes, the firmer and larger the erection. When the erection is no longer desired, a small valve on the pump in the scrotum is pressed and the fluid returns to the reservoir leaving the penis soft and pliable. The whole implant device is inside the body and not noticeable by anyone else.

The major advantages of inflatable penile implant are a more natural erection with total patient control, both in the amount of fluid that is put into the penis, as well as the time the erection is desired. The erection will last indefinitely until the patient transfers the fluid back into the reservoir, effectively better than a “real” erection as it will stay inflated after ejaculation until the deflation valve is pressed. The penis will look normal when it is inflated and when it is deflated, and nobody else would be able to tell you have a penile implant in place. Sensation, ejaculation and orgasm are all able to take place normally with a penile implant.

ADVANTAGES OF IMPLANTS

Implants are effective in treating impotence due to almost every cause. Even patients who are not helped by Viagra or self-injection techniques can be treated with an implant. They are the most spontaneous of the treatments for erectile dysfunction and essentially get the penis back to something like a normal state again. There is a 90%+ success and satisfaction rate when both partners are informed of the nature and limitations of the prosthesis. Prostheses require no further treatment after implantation, and there is no external equipment that might have negative connotations to the partner. No medicines or injections are needed, there is nothing to carry around with you as the implant is permanently inside the body and once the prosthesis is placed and functioning, there is nothing further to do apart from use the device as you require. The newer prostheses are very reliable and the chance of mechanical failure is very low, in the range of only 10% by 10 years.

DISADVANTAGE OF IMPLANTS

Once an implant has been placed, natural erections usually no longer occur. If the prostheses were to be removed then normal erections will not return.

There is a small chance of infection (less than 2%) which would require removal of the prosthesis, although in many of these cases a new implant can be successfully re-inserted at the same time. Diabetics have a higher risk of infection, as does revision surgery.

Some patients can develop surgical complications or anaesthetic complications, but these are very uncommon.

Very occasionally patients will notice numbness at the head of their penis and intercourse can be uncomfortable.

Because the erection is no longer caused by increased blood flow to the penis, but rather the pumping up of the penile cylinders, the head of the penis is not part of the erection, and this softness may be bothersome to some patients. Some patients do get good engorgement of the head of the penis with stimulation, but many do not.

Some patients complain that the penis is shorter than before, but this only affects about 20% of men, and probably represents the fact that the penis has already lost length anyway before implantation, because of surgery, scarring or the erectile dysfunction itself which causes the penis to lose elasticity and size. No treatment can restore the penis to its “best ever” length, and the shortening issue has not been a problem in our patients when they are informed correctly and understand the reality of the situation.

With the multiple parts of a 3 – piece implant, there is a small chance of mechanical failure that might require revision or repair. Many of the companies manufacturing implants do have insurance policies to cover part or all of the costs of the prosthesis replacement but not the surgical or hospital fees.

COSTS

Private medical insurance policies will cover the cost of prostheses in Australia. Patients who are considering prosthesis should be aware that other types of therapy might be available, including vacuum devices and self-injection therapy and oral medication, but these are not subsidised by Medicare, so penile implants are the only subsidised treatment for erectile dysfunction in Australia.

Hospital costs will also be covered by private health funds and Dr Love will discuss with you the medical fees that will include an out-of-pocket cost consistent with his experience and expertise.

As one of the highest-volume penile implant surgeons in Australia, and in the top 30 implant surgeons in the world, and with more than 20 years experience in this surgery, Dr Love has done some 800 or more of these procedures.

SURGICAL APPROACH

Dr Love uses mainly the “Minimally-Invasive Penile Implant” technique developed by Dr Paul Perito from Miami, Florida, who Dr Love has worked with on many occasions in Australia and the USA. This involves a 3 cm horizontal incision on the lower abdomen, just above the penis, as the only incision required. All components of the implant are able to be placed via that incision. Sometimes an implant will be inserted via an incision of the scrotum.

Dr Love has further improved on Dr Perito’s technique by developing a “no-touch” approach, whereby the implant device never touches the patient’s skin and is only handled once by Dr Love as it is inserted, thereby reducing the chances of infection.

Patients remain in hospital for one night after surgery. Most are quite uncomfortable for 7 – 10 days after surgery and, when seen a 3 weeks after the operation, the majority are comfortable and able to inflate and deflate the device. Many patients can commence sexual activity at that time, although some take 6 – 8 weeks to become completely comfortable.

OTHER TYPES OF IMPLANT

SEMIRIGID PROSTHESES

Semirigid implants are paired silicone-covered malleable or bendable metal rods. The semirigid prosthesis allows the penis to be rigid enough for penetration, but the malleable rods allow it to be bent enough to allow concealment in a curved position. It is the simplest of all prostheses and has the least chance of mechanical failure. It is also the simplest to place.

The major limitations include the fact that the penis is always semi-erect. Even with the bendability, concealment is a potential problem when wearing some types of clothing. Another disadvantage is that the prosthesis does not inflate so the erection achieved is only from the size and rigidity of the prosthesis.

SELF CONTAINED (2-PIECE) INFLATABLE PROSTHESES

Self-contained inflatable implants are paired silicone cylinders that have a pump at the very tip of the prosthesis, along with a reservoir within the shaft that transfers fluid in such a way that the cylinder becomes firm. Some have a pump and reservoir combined into one in the scrotum.

The advantage of this type of prosthesis is that the surgery is somewhat simpler than the multi-component prosthesis, and there are less working parts.

The major disadvantage is that the inflatable portion of it does not really increase the girth of the penis significantly. It is also not as soft or concealable as the multicomponent implant when deflated.

Dr Love rarely implants semi-rigid or 2-piece inflatable devices as he does not feel they give the patient a satisfactory flaccid or erect penis.