Stesura Seveso Archivio Italiano di Urologia e Andrologia 2015; 87, 4322 NOTES ON SURGICAL TECHNIQUE Penile prosthesis implant for erectile dysfunction: A new minimally invasive infrapubic surgical technique Gabriele Antonini 1, Gian Maria Busetto 1, Ettore De Berardinis 1, Riccardo Giovannone 1, Patrizio Vicini 2, Vincenzo Gentile 1, Paul E. Perito 3 1 Department of Gynecological-Obstetrics Sciences and Urological Sciences, Sapienza Rome University, Policlinico Umberto I, Rome, Italy; 2 Department of Urology, “I.N.I.” Italian Neurotraumatologic Institute Grottaferrata, Rome, Italy; 3 Perito Urology, Coral Gables Hospital Miami, Florida, USA. Erectile dysfunction, the most common male sexual disorder after premature ejac- ulation, with its important impact on man and partner’s sexu- ality and quality of life is a persistent inability to obtain and maintain an erection sufficient to permit satisfactory sexual performance. Non-surgical treatments with controversial results are usually applyed before surgical treatment that has reached high levels of satisfaction. We describe a new surgical technique to implant three-pieces penile prosthesis in patients suffering from erectile dysfunc- tion (ED) not responding to conventional medical therapy or reporting side effects with such a therapy. Implantation of an inflatable prosthesis, for treatment of ED, is a safe and efficacious approach with high satisfaction reported by patients and partners. Surgical technique should be minimally invasive and latest technology equipment should be implanted in order to decrease common complications and to obtain a better aesthetic result. KEY WORDS: Erectile dysfunction; Penile prosthesis; Infrapubic access. Submitted 17 March; Accepted 30 June Summary No conflict of interest declared. requiring repair, explants or replacement are: fluid leak from the device, supersonic transport (SST) deformity, cylinder’s aneurismal dilatation or extrusion (8). Infections remain the most common and serious surgical complica- tions with the risk of further penile shortening, urethral injury with erosion and tissue loss (9, 10). Patients with comorbidities (diabetes, immunosuppression, spinal cord injury, etc.) are usually at increased risk of infectious com- plications (11). Infectious mechanism is characterized by bacterial implantation on the surface of the device creating a biofilm that avoid the immune system and antibiotics to exert their effect (12). At this time cylinders, pump and tubing of the three-piece IPP are impregnated with antibi- otics (rifampicin and minocycline) which have been asso- ciated with the reduction in post operative infections (13). SURGICAL TECHNIQUE We report a new surgical technique of penile prosthesis implant in patients suffering from erectile dysfunction not responding to conventional medical therapy or reporting side effects with such a therapy. All subjects underwent primary penile prosthesis implant and all the procedures had been carried out at Department of Urological Sciences of Sapienza Rome University by a sin- gle surgeon. The prostheses were either the AMS 700™ CX (AMS, Minnetonka, MN, USA) or the Coloplast Titan® OTR (Coloplast Corporation, Minneapolis, MN, USA) with controlled expansion cylinders optimize girth (14). The AMS prostheses are connected with an AMS Conceal™ low profile reservoir coated with parylene and are charac- terized by Momentary Squeeze pump with one-touch but- ton designed for easy deflation and lock-out valve designed to resist auto-inflation; InhibiZone™ antibiotic treatment (minocycline and rifampicin) creates a zone of inhibition effective against the bacteria commonly associ- ated with inflatable prosthesis infections. The Coloplast prostheses are connected with Coloplast Titan® CL reser- voir with a four-leaf clover shape and are characterized by lock-out™ safety valve designed to prevent auto-inflation and One Touch Release (OTR) for easy deflation of the device; hydrophilic coating decreases infection risk. The implants were performed by a minimally invasive technique and, after the patient was shaved, the skin DOI: 10.4081/aiua.2015.4.322 INTRODUCTION Erectile dysfunction (ED), the most common male sexu- al disorder after premature ejaculation, with its impor- tant impact on man and partner’s sexuality and quality of life is a persistent inability to obtain and maintain an erection sufficient to permit satisfactory sexual perform- ance. The incidence ranges between 2-28.9% in the age group from 30-39 to 41.9-83% in the age group from 70-80 (1-3). Regarding treatment, to date, first-line approach is per- formed with the usage of pharmaceuticals such as PDE5 inhibitors and second-line with intracavernous injection (ICI), vacuum devices or intraurethral alprostadil. Medical therapy has a high drop-out rate that is up to 80% (4, 5). Surgical treatment, as third-line therapy, can be performed after failure of all other options. Penile prosthesis implant, although invasive, has reached high levels of satisfaction and is associated with better sexual function, perception and with patient and partner’s high gratification (6, 7). Complications related to mechanical failure of prosthesis, 323Archivio Italiano di Urologia e Andrologia 2015; 87, 4 Penile prosthesis implant for erectile dysfunction: A new minimally invasive infrapubic surgical technique space for the reservoir (filled with 100 mL of saline solu- tion), posterior to transversalis fascia in cephalad to cau- dal position (Figures 5, 6), is created. After exposure, cylinders are placed using stay sutures for retraction and functional/cosmetic result are checked by rapidly inflating the prosthesis (Figure 7). Once again, the nasal speculum is utilized, this time, to develop the subdartos pouch into dependant portion of scrotum (Figure 8). After performing the hydraulic test (Figure 9) we finally close the corporotomies using the stay suture previously placed. We then connect the appropriate tubing and a Jackson-Pratt drain is placed in dependent portion of pepped for 10 minutes with a poviodone-iodine solution and intravenous cefazolin was administered. The first step is induction of an artificial erection that allows to identify any pathology needing correction, ver- ifies “true” dilation of the corpora supplanting serial dila- tions and facilitates the identification of the dorsal nerve and lateral placement of stay sutures. An infrapubic 3 cm skin incision followed by 1.5 cm bilateral corporotomy incision is applied (Figures 1, 2). Using the Furlow, the proximal and distal corpora caver- nosa are measured and dilated (Figures 3, 4). We place color-coded stay sutures in the corpora, lateral to the dorsal nerve. Using a 3½ inch nasal speculum a Figure 1. Figure 2. Figure 3. Figure 4. Figure 5. Figure 6. Figure 7. Figure 8. Archivio Italiano di Urologia e Andrologia 2015; 87, 4 G. Antonini, G.M. Busetto, E. De Berardinis, R. Giovannone, P. Vicini, V. Gentile, P.E. Perito 324 scrotum (Figure 10) and skin incision closed with sub- cuticular sutures (15). There were no reported intraop- erative complications and the median time to complete the implant was 39 min (26-74). Following the implant regular follow-up controls were scheduled; the first acti- vation of the prosthesis is applied 8-10 days after the implantation and the patient starts sexual intercourse after 6 weeks. After surgery ten days of cefazolin and a single dose of gentamycin are administered. All treatments applied are part of routine standard care and the surgical technique was conducted in line with European Urology and Good Clinical Practice guidelines, with ethical principles laid down in the latest version of the Declaration of Helsinki. Every patient has been informed and signed the consent. In accordance with lit- erature data, patients satisfaction and QoL is better after implant of a three-pieces device because inflatable penile prostheses are characterized by improved flaccidity and rigidity and are usually preferred because of the more “natural” erection obtained (16-18). Bernal et al. in a meta-analyzed 20 years of literature reached the conclu- sion that despite the variability of used methods and lack of approved questionnaire, patients are satisfied with the implant and with the subsequent sexual activity (19). Moskovic et al. analyzed partners satisfaction concluding that male satisfaction correlate positively with female’s one, while unsatisfied men have a relation with female suffering from sexual activity quality (20). We can conclude that our technique is very fast, safe and the aesthetic result is guaranteed with a small skin inci- sion of only 3 cm. 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Bernal RM, Henry GD. Contemporary patient satisfaction rates for three-piece inflatable penile prosthesis. Adv Urol 2012; 2012:707321. 20. Moskovic DJ, Gittens P, Avila D Jr, et al. Favorable female sex- ual function is associated with patient satisfaction after inflatable penile prosthesis implantation. J Sex Med. 2011; 8:1996-2001. Correspondence Gabriele Antonini, MD - Gian Maria Busetto, MD - Ettore De Berardins, MD Riccardo Giovannone, MD - Vincenzo Gentile, MD Department of Gynecological-Obstetrics Sciences and Urological Sciences, Sapienza Rome University, Policlinico Umberto I, Rome, Italy Patrizio Vicini, MD (Corresponding Author) patriziovicini@gmail.com Department of Urology, “I.N.I.” Italian Neurotraumatologic Institute Grottaferrata, Rome, Italy Paul E. Perito, MD Perito Urology, Coral Gables Hospital Miami, Florida (USA) Figure 9. Figure 10.