SURGICAL TREATMENT OF ERECTILE DYSFUNCTION

Dr N Anandan MS.,FRCS.,Dip Uro(Lond)

Urologist & Andrologist

Malar Hospitals, Chennai

Venkataeswara Hospitals, Chennai

PREVALENCE OF ED

• MMAS study

40 to 70 years: 52%

• Mild :17%

• Moderate: 25%

• Severe: 10%

• National health & Social life survey

18 to 60 years: 31%

• ITALIAN STUDY

39 years: 2%

>70 years:48%

• GERMAN SUDY

Incidence:19.2%

INCIDENC OF ED IN INDIA

• 72.4 million Indian males aged between 45 to 60 years are estimated to be suffering from ED

MAINTAINING ERECTILE FUNCTION

• Treatment of Fracture corpora cavernosa

• Treatment of priapism

FRACTURE OF PENIS

• CAUSE

– Forceful manipulation

– Bl unt injury

– History of fall

• PRESENTATION

– Sudden loss of erection

– Penile and scrotal haematoma

– Click is heard

• TREATMENT

– Immediate surgical repair of torn tunica albuginea of C C

PROLONGED ERECTION

• Low flow rate Cavernosal anoxia

• Paralysis of smooth muscle

• Occlusion of venous channels

• Persistant erection

PRIAPISM TRT : DRAINAGE

• Place 18 scalp vein needle into one of corpora cavernosa

• Initially dark blood, followed by fresh blood

• Detumascene in 5 to 40 mts

TREATMENT OF PRIAPISM

• Circulation through C C

• Reoxygenation of C C

• Return of muscle contraction

• Reopening of venous channels

• Resolution of priapism

FACILITATING ERECTILE FUNCTION

• Treatment of phimosis

• Treatment of congenital short urethra

• Treatment of hypospadias with chordee

• Treatment of ventral curvature of penis

PHIMOSIS

• Discomfort in performing

• Reduced pleasure

• Risk of penile cancer

CONGENITAL SHORT URETHRA

• Urethral meatus is normally placed

• Urethra is short compared to normally developed Corp cavernosa

• Excise all fibrous tissue, Divide urethra in the midline , proceed

to urethroplsty

HYPOSPADIAS WITH CHORDEE

• Meatus is at penile,penoscrotal level

• Chordee due to fibrosis

TREATMENT:

• Correction of chordee

• Urethroplasty

PENILE CURVATURE

– Urethra is normal

– Dense fibrous tissue involving dartos & Bucks fascia

– Curvature seen only during erection

– Ventral / lateral curvature

– Excise all fibrous tissue and mobilise urethra if required

– Nesbit procedure

– Simple plication

INDICATIONS FOR IMPLANT

• Failure of medical treatment

• Fear of injection

• Failure of injection treatment

• Severe vasculogenic

• Patients who cannot take PDE inhibitors

PENILE PROSTHESIS

SEMIRIGID

INFLATABLE

PENILE IMPLANT

• Prior counseling

• Patients expectations must be assessed

SEMIRIGID PROSTHESIS

ADVANTAGES:

less prone to malfunction

Technically easy

SEMIRIGID PROSTHESIS

DISADVANTAGES:

Inconvenient during physical activity

Endoscopy is difficult

INFLATABLE PROSTHESIS

• AMX 700

• AMX CX

• AMX CXR

• AMS 700 ULTREX

PENILE IMPLANT

• Obese, hardly visible penis, poor manual dexterity: Semi rigid or malleable

• Normal , no corporal scarring: Inflatable

• Reduced penile sensitivity: Inflatable

PENILE IMPLANT

• Prophylactic antibiotics

• Better surgical technique

• Copious wound irrigation

PENILE IMPLANT

• Incidence of infection 1 to 6.5%

• Prosthesis removal leads to:

• Corporal fibrosis

• Shortening

• Reimplantation is difficult

REIMPLANTATION PROCEDURE

Satisfaction decreases due to penile shortening

COMPLICATIONS OF PENILE IMPLANT

Pain, perforation, infection

Cylinder leak,tube leak,

mechanical failure

LONG TERM RESULT
AMS 650 76% Satisfactory rigidity

80% Ease of concealing

• INFLATABLE CX CXM- CXM ultrex

Excellent 58 17

Satisfactory 50 66

P oor 2 17

PEYRONIE’S DISEASE

• Incidence 3.2%

• Aetiology

• Repeated trauma

• Autoimmune disease

• Arterial disease

PEYRONIE’S DIS EASE

• Pain

• Plaque : Dorsal -two thirds

Ventral – one third

• ED 41 to 55%

PEYRONIE’s DISEASE

• Nonsurgical treatment;

• Counselling

• P Aminobenzoic acid

• Vitamin E

• Oral colchicine

• Verapamil local injection

PLAQUE EXCISION

• 17% Repeat surgery for curvature

• 20% Significant ED

PLAQUE INCISION & GRAFTING

• Straight penis : 75 to 96%

• ED : 5 to 12%

• Penile shortening

VENOUS LIGATION SURGERY

Details	6 months	1 yr	5 yr
Spontaneous erection	38.8	19.4	11.4
Response to drugs	18.6	14.9	14.3
No improvement	42.5	65.6	74.3

ARTERIAL SURGERY

• Young male

• History of pelvic fracture, perineal trauma

• Penile Doppler : Arterial disease

• Selective angiogram: Arterial occlusion

PHALLOPLASTY

Penile lengthening

Penile girth enhancement

GIRTH ENHANCEMENT

Free fat transfer

Allograft dermal matrix graft

Dermal fat graft

FREE FAT TRANSFER

Liposuctionfromsuprapubic area, injected under the penile shaft

May require two sessions

Iregularities in the shaft (Lumpy areas)

Fat cells can get absorbed loss of enhancement

ALLOGRAFT DERMAL MATRIX

Grafts are processed from human tissue

Readily available

Rolled into several layers around the shaft

Graft gets incorporated in 2 to 3 months Expensive

DERMAL FAT GRAFT

Abdominal or gluteal area is chosen Epidermis is removed, dermis

along with underlying fat is used Survival of the graft is better

SIX MONTHS POST OPSILDANEFIL

• 68 to 71% Achieve erction

• 65% Satisfied

• Effective Vasculogenic : 86%

• Psychogenic : 89%

• Nerve sparing RP : 35%

• Diabetes : 58%

• Neurological : 56%