Complications of Prostate and Penile Surgery
John P. Mulhall, MD

Erectile Dysfunction as a Complication of Prostatectomy

Prostatectomy is an extremely effective procedure for the treatment of
localized prostate cancer, but it frequently causes impotence. Several
studies were presented at the 11th World Congress of the International
Society for Sexual and Impotence Research that touched on aspects of
this problem.

Bianco and colleagues[1] evaluated surgeon and surgeon volume as
predictors of long-term recovery of erectile function after
prostatectomy. The study population consisted of patients treated by
radical prostatectomy at one institution since 1983. A total of 1778
patients were deemed eligible. The surgeries were performed by 14
different surgeons over a mean period of 4 years. Of the 1778 patients,
455 had return of postoperative erectile function adequate for
penetrative relations. The actuarial estimates of erectile function
recovery at 2 and 5 years were 37% and 52%, respectively. On
multivariable analysis, factors found to be significant predictors of
erectile function included surgeon, patient age, and neurovascular
bundle status, but not surgical volume.

This analysis is important, particularly for the conduct of future
intervention trials. For example, if a pharmaceutical company is
interested in exploring the use of a medication for the preservation of
erectile function postoperatively, these data would suggest that
enrolling centers that have had high volume of bilateral nerve-sparing
surgery might not be the right strategy. A better strategy might be to
assess the erectile function outcomes of the individual surgeons, rather
than the volume, prior to permitting surgeons to enroll these patients.
The study authors have stated that this work will be expanded to a
multi-institutional setting.

Rabbani and colleagues[2] looked at erectile function recovery beyond 24
months using a validated inventory, the International Index of Erectile
Function (IIEF). One hundred and forty-one men who had not received any
neoadjuvant hormonal therapy or radiation therapy underwent bilateral
nerve-sparing surgery by 2 surgeons at this institution. Although
postoperative erectile function assessment was conducted using the IIEF,
the preoperative function was assessed using a 5-point erectile rigidity
scale. Erectile function recovery was assessed using 3 different
erectile function domain scores, of 17, 22, and 26. Recovery of erectile
function included patients who had responded to oral therapy. Patient
age ranged from 41 to 71 years, with a median age of 59 years. The
median follow-up was 18 months postoperatively. Using erectile function
domain scores of 22 and 26, at 24 months, 32% and 36% of patients had
return of erectile function, while at 48 months these figures were 70%
and 50%, respectively.

This is the first analysis to document continued improvement in erectile
function outcomes after 24 months. Although it is likely that a major
contributor to this is improvement in the psychological status of the
patient and increase in confidence, there is a suggestion that some of
the improvement may actually be based on continued neuroregeneration.
Complications of Penile Implants for Erectile Dysfunction

Patients with erectile dysfunction (ED) who show no benefit from the
phosphodiesterase-5 (PDE-5) inhibitors often opt for the surgical
implantation of prostheses. The efficacy and long-term safety of these
devices were the subjects of a number of other presentations.

Löffler and colleagues[3] reviewed the experience of clinicians who have
worked extensively with spinal cord injury patients and the use of
penile prosthesis. Between 1980 and 1996, 245 spinal cord injury
patients with a mean age of 41 years underwent implant of penile
prostheses. Over a 17-year period, 293 surgical procedures were
conducted in 245 patients using a variety of implants, including the
semi-rigid Jonas implant, the semi-flexible Dynaflex, and the flexible
AMS 800 prosthesis. More than a decade after the prostheses were
implanted, 195 patients were reevaluated. The treatment of ED was
considered to be successful in 83% of patients as defined by the ability
to have sexual intercourse. The complication rate included 43 revisions
for technical reasons; the infection rate was 5%; and the perforation
rates were noted to be different among the various devices, 1.8% for
semi-rigid devices, 2.4% for semi-flexible, and no erosions for the
flexible devices.

This is one of the largest series of reports of penile implant
experience in men with spinal cord injury. What is clear from this
analysis is that the semi-rigid devices should not be used because they
are subject to device erosion. These data should be of interest to
institutions that permit their surgeons to use only semi-rigid implants,
which may not be as cost-effective in the long run as they seem
initially, at least in the spinal cord injury population.

A report by Kendirci and colleagues[4] compares the implant infection
rates in patients who underwent 2 types of Mentor 3-piece prosthesis --
the original Alpha I device and the revised Titan device, which is
coated with a hydrophilic antiadherence lining. This latter substance
reduces bacterial adherence and absorbs and elutes antibiotics which the
device is immersed in at the time of surgery. The analysis was based on
data gathered by Mentor Corporation, the manufacturer of the devices,
between September 2002 and August 2003 on 482 Alpha I implants and 2357
Titan implants. The infection rate for the Alpha I group was 2% and was
1% for patients with the Titan device. The authors concluded that the
hydrophilic-coated Titan implant confers a significant advantage in
reducing the rate of infection over the noncoated device.

There is great interest in penile implants that are coated with either
antibiotics or antiadherence substances. Using retrospective internal
database analyses, both AMS and Mentor have demonstrated that there is
an advantage to coated implants. However, it must be kept in mind that
the superiority of the coated over the noncoated devices cannot be
considered definitive without prospective randomized analyses.

Although infection generally occurs in the immediate postoperative
period, Milbank and colleagues[5] presented 3 interesting cases in which
infection occurred relatively long after implantation. Two of these
cases involved 2 penile implants and the other involved an artificial
urinary sphincter. In all 3 cases, the devices, after working well for
more than a decade, abruptly failed for what were ultimately shown to be
mechanical reasons. The infections, which were likely caused by the
leakage of fluid into the periprosthetic space, necessitated removal of
the devices. The study authors believed that the biofilm biology was
disrupted when the devices leaked, favoring bacterial growth and
clinical infection. It was also suggested during discussion that the
fluid within the reservoir itself might have been infected and that this
might have been the inciting event for development of infection.

This study discusses an uncommon but well-recognized event -- the
occurrence of infection from an implanted device that has been fully
functional and trouble-free for more than a decade. This is most
commonly seen in patients who have undergone recent chemotherapy or are
immunosuppressed, but we now need to be aware of another such group --
those whose devices have failed for mechanical reasons. This study
raises the concern that all inflatable devices that malfunction due to
rupture may need to be removed immediately lest the device cause infection.

Surgery for Peyronie's Disease and Penile Length

Although progress is steadily being made in surgical treatment for
Peyronie's disease, one of the distressing side effects of such surgery
is loss of penile length.

Lucas and colleagues[6] studied 86 consecutive patients who underwent
plication procedures for either Peyronie's disease or chordee.
Preoperative data were gathered and an attempt was made to correlate
these factors with the degree of length loss. The mean age of the
patients was 53 years for the Peyronie's disease group and 24 years for
the chordee group. The mean loss of length between pre- and
postoperative measurements was approximately 0.4 cm, with percent length
loss of 2.4%. Predictors of length loss included degree of preoperative
curvature, preoperative length, and direction of curvature. It was noted
that the patients with the greatest amount of curvature were those with
either ventral or ventrolateral curvatures. However, plaque size, number
of plications, and age of patient were not predictive of degree of loss
of length. Overall, penile shortening occurred in only 8% of the group.

This study addresses a very important issue, as penile length loss is
one of the great concerns of the Peyronie's disease surgeon when doing
plication surgery, and is furthermore the number-one concern for
patients undergoing this procedure. Patients are informed of this
possibility before surgery, but estimating the exact length loss is
often very difficult. Dr. Lucas' group has nicely shown us factors that
predict length loss in this study. What is missing from this analysis is
breakdown of length loss in centimeters for different degrees of penile
curvature (based on the preoperative curvature magnitude using the
Kelami classification).

An analysis by Moncada-Iribarren and colleagues[7] looked at 28 men
(mean age, 58 years) who underwent penile reconstructive surgery for
Peyronie's disease. Half of the men, chosen in a nonrandomized fashion,
underwent treatment with a penile extender device (Andro-Penis)
following surgery. They used the device for 8-12 hours daily for a
4-month period postoperatively with a stretching force ranging from
900-1200 g. Penile length and girth were measured prior to surgery and
after surgery; patients had health-related quality of life assessed
using the Medical Outcomes Study Short Form-36 (SF-36) inventory. Penile
shortening ranged from 1 to 4 cm after surgery for the Peyronie's
disease. However, sustained treatment for 4 months with the stretching
device provided a length increase, which ranged from 1 to 2 cm, and
increases in girth ranging from 0.5 to 1.5 cm. There was a significant
difference in SF-36 scores between those patients who had used the
Andro-Penis device vs those who had not, with higher scores reported in
those who had used the extender.

This is the first report of the use of a mechanical device to stretch
the penis following penile implant surgery. Many practitioners have used
vacuum devices to minimize penile fibrosis -- particularly plaque
incision and grafting -- following penile reconstructive surgery. A
randomized controlled trial is warranted to define the true efficacy of
this device, but the preliminary results are encouraging.

References

   1. Bianco F, Kattan M, Eastham J, Scardino P, Mulhall JP. The
surgeon and surgical volume as predictors of erectile function and
outcomes following prostatectomy. J Sex Med. 2004;1(suppl 1):33.
Abstract O15.
   2. Rabbani F, Patel M, Mulhall JP, Scardino PT. Time course of
recovery of erectile function after radical prostatectomy. J Sex Med.
2004;1(suppl 1):33. Abstract O16.
   3. Löffler U, Kutzenberger J, Sauerwein D, Schubert J, Zermann DH.
Long-term follow-up of penile prosthesis in spinal cord injury patients:
treatment of erectile dysfunction and urinary problems. J Sex Med.
2004;1(suppl 1):33. Abstract MP65.
   4. Kendirci M, Wolter C, Rajpurkar A, Dhabuwala C, Hellstrom WJG.
Hydrophilic-coated inflatable penile prosthesis: one year experience. J
Sex Med. 2004;1(suppl 1):33. Abstract O22.
   5. Milbank AJ, Montague DK, Angermeier KW. The new mechanism for
delayed genitourinary prosthesis infection. J Sex Med. 2004;1(suppl
1):33. Abstract MP71.
   6. Lucas SM, Levine LA, Pinchofsky H. Factors affecting the loss of
length associated with tunica albuginea plication for correction of
penile curvature. J Sex Med. 2004;1(suppl 1):33. Abstract O19.
   7. Moncada-Iribarren I, Jara J, Martinez-Salamanca JI, Monzó JI,
Cabello R, Hernández C. Management of penile shortening after Peyronie's
disease surgery. J Sex Med. 2004;1(suppl 1):33. Abstract MP89.