Critical Appraisal and Review of Management Strategies for Severe Fibrosis During Penile Implant Surgery

Abstract

Introduction Penile corporal fibrosis represents a challenging clinical scenario for surgeons placing penile prostheses (PP). Because of its rarity, a small number of series with limited follow-up have reported outcomes in this cohort. Aim The aim of this study was to perform a critical appraisal of the corporal excavation technique, discuss its relevance to contemporary practice, and review alternative surgical methods and outcomes. Methods A critical review was performed of the 2006 article by Montague and Angermeier, “Corporeal excavation: new technique for penile prosthesis implantation in men with severe corporeal fibrosis.” Notable inclusions and omissions were described, with emphasis placed on methodology and outcomes. A PubMed search from 1990 to June 2015 was then performed to review and summarize the literature on managing corporal fibrosis during PP surgery. Main Outcome Measures The main outcome measures used were the major contributions and limitations of the 2006 article describing outcomes of the corporal excavation technique. Results Corporal excavation is a relevant surgical technique for managing severe corporal fibrosis. Compared with alternatives, excavation achieves successful placement of PP without need for grafting and with few complications. The article was limited by several notable omissions including relevant patient demographic and disease characteristics, patient selection, and minimal descriptions of complications and outcomes. Alternative techniques include use of specialized dilators, counter incisions, reconstruction with graft placement, minimal scar tissue excision, and endoscopic resection. Because of limited data, no specific algorithm for managing corporal fibrosis can be prescribed. Conclusions Corporal fibrosis is a challenging clinical scenario and requires surgical experience and specialized techniques to manage appropriately. Corporal excavation represents one of several viable techniques, which may be chosen based on surgeon’s preference and clinical factors.

Extracorporeal Transseptal Penile Prosthesis Implantation for Extreme Cases of Corporeal Fibrosis: Shaeer Implantation Technique

“…In a review article on critical appraisal of management strategies for severe fibrosis during penile prosthesis surgery, 12 corporal excavation 5,6,13 was found to have the virtues of maintaining the rigidity and structure of the native tunical tissue. 12 The value of maintaining this structure is-in our opinion-conferring stability upon axial pressure, as well as containment such that the rigid penis is within the expected norm. These virtues can be provided by the technique at hand.…”

“…Reconstruction with grafting 2,9,14e19 is an important choice in the armamentarium since it may enable implantation of standard diameter cylinders, though frequently was time-consuming, and included the use of synthetic graft materials with high revision and infection rates. 12 Revisions range from 0e22% and satisfaction 71e100% at follow-ups of 10e91 months. 12 Extracorporeal transseptal implantation allows a brief operative time and minimal exposure, and obviates the need for graft material, thereby decreasing infection rate, while providing adequate girth from the collective volume of the implant limbs and the corpora cavernosa.…”

“…12 Revisions range from 0e22% and satisfaction 71e100% at follow-ups of 10e91 months. 12 Extracorporeal transseptal implantation allows a brief operative time and minimal exposure, and obviates the need for graft material, thereby decreasing infection rate, while providing adequate girth from the collective volume of the implant limbs and the corpora cavernosa. Another option is widening an established track-if any-with specialized cavernotomes, though less successful in creating initial tracts for dissection.…”

“…Outcomes with the Mooreville 3 dilator included 38% proximal and 25% distal perforations (delayed recognition). 3,12 Extracorporeal transseptal implantation minimizes the possibility of perforation and urethral injury. The review article confirmed that it is not yet possible to suggest a definitive optimal strategy or algorithm for management with the exception of avoiding the use of synthetic graft materials because of their association with elevated infection rates.…”

“…The review article confirmed that it is not yet possible to suggest a definitive optimal strategy or algorithm for management with the exception of avoiding the use of synthetic graft materials because of their association with elevated infection rates. 12 The future trends suggested by the authors were mainly preventive, avoiding the formation of severe corporal fibrosis.…”