HEELKUNDIGE BEHANDELING VAN ERECTIELE DYSFUNCTIE

Transcription

1 HEELKUNDIGE BEHANDELING VAN ERECTIELE DYSFUNCTIE KOENRAAD van RENTERGHEM M.D. Ph.D. FEBU JESSA HOSPITAL HASSELT UNIVERSITY HOSPITALS LEUVEN UNIVERSITY HASSELT PENTALFA 18 OKTOBER 2018

2 PEYRONIE S DISEASE PENILE IMPLANT

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4 Francois Gigot de la Peyronie (1743) Cause usually unknown: idiopathic; genetically predisposition? Repetitive (micro)traumata? Associated with cardio-vascular disease and other co-morbidities such as DM; AHT; hyperlipidemia; smoking; ethylism; Damage of tunica albuginea Prevalence 0,4-9 %; incidence increases Usually after age of 40 Sometimes with morbus Dupuytren, Ledderhose. De la Peyronie F. Sur quelques obstacles qui s'opposent a l'ejaculation naturelle de la semence. Mem Acad R Chir 1743; 1: 425

5 ACUTE PHASE: Pain 90 % disappears first year; 100 % after 24 months CHRONIC PHASE: Plaque Calcification Palpable nodule Deformation/curvature/hourglass Surgical repair at this time Veno-occlusive dysfunction (draining venules)

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7 Correction curvature Technique selection based upon surgeon preference, expertise,experience. Surgery is gold standard Making intercourse possible Preferable when 6 months stable disease Penile shortening procedures versus penile lengthening procedures Penile implant

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9 EXCISION tunica albuginea convex side Pryor en Fitzpatrick 1979 Rehman 1997

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11 PLICATION tunica albuginea convex side WITHOUT incision tunica albuginea (LUE 16 - dots) WITH longitudinal incision (Yachia (Heineke Mikulicz principle))

12 PENILE LENGTHENING: Graft (autologous v. saphena; tutoplast - bovine; SIS - porcine; etc.) Cave veno-occlusive dysfunction Shrinkening of graft (Kadioglu) Nerve damage (neuro-vascular bundle) with dimished glandular sensation T. F. Lue, Venous patch graft for peyronie's disease. Part I: technique, Journal of Urology, vol. 160, no. 6 I, pp , 1998 A. Kadioglu, O. Sanli, T. Akman, M. Cakan, B. Erol, and F. Mamadov, Surgical treatment of Peyronie's disease: a single center experience with 145 patients, European Urology, vol. 53, no. 2, pp , 2008 E. C. Serefoglu and W. J. G. Hellstrom, Treatment of Peyronie's disease: 2012 update, Current Urology Reports, vol. 12, pp , 2011 F. Montorsi, A. Salonia, T. Maga et al., Evidence based assessment of long-term results of plaque incision and vein grafting for Peyronie's disease, Journal of Urology, vol. 163, no. 6, pp , 2000

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16 PENILE IMPLANT IN PEYRONIE S DISEASE

17 CHINESE STAIRWAY Multiple small incisions on short side Cauter less than 35 No grafting MUST (Multiple-Slit Technique) (Egydio) PICS: Tachosil (Hatzichristodoulou) Mulcahy JJ, Rowland RG. Tunica wedge excision to correct penile curvature associated with the inflatable penile prosthesis. J Urol 1987; 138: Egydio PH, Kuhhas FE. The Multiple-Slit Technique for penile length and girth restoration. J Sex Med 2018 Feb; 15(2): Hatzichristodoulou G. The PICS Technique: A novel approach for residual curvature correction during penile prosthesis implantation in patients with severe Peyronie s disease using the collagen fleece TachSil. J Sex Med 2018 Mar; 15(3):

18 PLICATION STITCHES Multiple stitches Plication Tied after cylinder inflation Morey A. High patient satisfaction of inflatable penile prosthesis insertion with synchronous penile plication for erectile dysfunction and Peyronie s disease. J Urol 2015, 193:

19 MODELING PROCEDURE: Steve Wilson Fully inflated cylinders Break plaque Protection of pump Cave sutures corporotomies Bend penis 90 seconds (can be done twice) Remove clamps and inflate 2-3 times extra Same procedure in some cases Pull strings cylinders for adequate placement Over time (8-12 mnths.) cylinders will act as tissue expanders (rapid activation) (<30 ) Cave urethral damage (<4%) Wilson SK, Delk JR. A new treatment for Peyronie's disease: modeling the penis over an inflatable prosthesis. J Urol 1994; 152:

20 IPP + remodelling - The method of prosthesis implantation with post implantation manual modelling allows the surgeon to repeat manipulation to achieve maximal correction but runs the risk of possible urethral injury - IPP implantation with grafting can be indicated for severe persistent curvature >30 with severe indentation or penile shortening - Steve Wilson maneuver

21 INTRA CORPORAL CORRECTION Normal dilation (Brooks) Rossello dilators Uramix cavernotomes Hooked knife scratch technique Otis urethrotome

22 COMPLEX PROSTHETIC SURGERY Sliding technique Penile disassembly Implant with grafting Very selected cases Highly experienced expert centres Non negligible complications: it s only about sex Simultaneous total corporal reconstruction and implantation of a penile prosthesis in patients with erectile dysfunction and severe fibrosis of the corpora cavernosa. Sansalone et al. J. Sex Med 2012 Jul; 9(7): The penile disassembly technique in the surgical treatment of Peyronie's disease. Perovic et al. BJUI 2001; nov, 88(7): Penile lengthening and widening without grafting according to a modified 'sliding' technique. Egydio et al. BJUI 2015 Jan 28

23 TO TAKE INTO ACCOUNT WHEN GRAFTING WITH IPP The penis should be straighter and not completely straight (1) This increases operating time (infection risk) (1) Cave hypo-esthesia! (NVB) (1) Risk of perforation of implant when suturing graft (1) Combination of two different types of foreign material (1) Wilson s pearls, perils and pitfalls of penile prosthesis surgery 2018.

24 PENILE DISASSEMBLY Perovic SV, Djordjevic ML :The penile disassembly technique in the surgical treatment of Peyronie's disease. BJU Int Nov;88(7):731-8.

25 SLIDING TECHNIQUE Rolle L, Sedigh O, Ceruti C., Fontana D : New, innovative, lengthening surgical procedure for Peyronie's disease by penile prosthesis implantation with double dorsal-ventral patch graft: the "sliding technique. J Sex Med Sep;9(9): A

26 Hatzimouraditis et al; Eur Urol 2012 Sep; 62(3):543-52

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28 HISTORICAL OVERVIEW

29 18 DE EEUW ELECTROTHERAPY - COLD THERAPY 1889 BROWN SEQUARD - INJECTION TESTIC.EXTRACT DOGS 1892 STANLEY - IDEM EXP. ON PRISONERS 1900 VASECTOMY 1902 WOOTEN C.C LYDSSTON IDEM 1918 LESPINASSE 1935 LOWSLEY TESTIC.EXTRACT IN RECTUS ABDOMINUS PLICATURATION BULBO-ISCHIO CAVERNOSUS 1936 BOGORAS RIB CARTILAGUE

30 1950 SCARDIN0 FIRST SYNTHET. IMPLANT 1952 GOODWIN / SCOTT 5 PAT INTRACAVERNEOUS IMPLANT 1968 PEARLMAN SILICONE 1970 MULTICOMPONENT PROTHESIS 1973 SCOTT BRADLEY TIMM FIRST INFLAT. PROTH TWO PUMPS 1974 AMS PIECE 1980 JONAS SEMI-RIGID 1983 AMS COLOPL REAR TIP EXTENDER POLY-URETHANE

31 Erectile dysfunction (ED) is a common disorder affecting > 50 % of male patients aged yrs. (1) ED = inability to achieve and maintain an erection sufficient for satisfactory sexual intercourse (2) Penile implant introduced in 1973 by Scott EAU guidelines: (2) Third line option In patients not responding to medical therapy and vacuüm devices = ineffective, unsatisfactory, contra-indicated by comorbidities (1) Feldman HA et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994 Jan; 151 (1): (2) Hatzimouratidis K et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. EAU guidelines 2016

32 STANDARDISED WORK UP Integration of the couple!!! IIEF (SHIM)- SEP Hormonal evaluation DOPPLER (Nocturnal penile tumescence measurements)

33 Have clear documentation to give to the patient Show demo and let the patient touch the model let the patient use the pump Pre-op counselling with nurse practioner

34 Mention guarantee Explain IPP is cheap solution Give possibility to call anonymous patient who underwent implant surgery Inform patient on life expectancy of IPP and explain on re-operation risk Explain complication rates are low Explain this is a small operation

35 ED induces reduction of penile size : indication for surgery should not be proposed to late / explain effect on esthetic and functional outcome IPP is irreversible procedure Does not interfere with ejaculation or orgasm Low pre-operative expectations correlate with high post-op satisfaction scores (Kramer-J Sex Med-2010)

36 STANDARDISED PERI-OPERATIVE PROCEDURE Create fast track : try to improve this multi-modal intervention Pre-operative : well instructed and well experienced nurses on ward (isobetadine shower-shaving-antibiotics-etc.) Well trained surgical team (assemble prosthesis) Clear post-op instructions on ward (TUC-ice-bandage-deflation-etc.)

37 Instruct patient when dismissed Arrange quick control on opd Involvement of nurse practioner

38 RIGID PROSTHESIS CONSTANT RIGIDITY SIMPLE PROCEDURE RARE TECHNICAL PROBLEMS CON ESTHETIC EROSION

39 MALLEABELE PROSTHESIS AMS COLOPLAST- PORGES

40 INFLATABLE PROSTHESIS

41 THREE PIECE INFLAT. PROSTH.

42 PENIS PROTHESE ERECTIEPROTHESE INFLATABLE PENILE IMPLANT ERECTIE IMPLANTAAT!!!

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44 Three-piece inflatable penile prosthesis: Highest patient satisfaction rates (> 90%) Lowest mechanical revision rates (96% at 5 yrs.) (1) 1998 introduction Sildenafil => penile implant sale drops 50% (2) Nowadays implant sales exceed pre-sildenafil era (1) Wilson et al.-j Sex Med 2007;4: (2) Stanley et al. South Med J 2000;76:1153-6

45 THREE PIECE INFLAT. PROTH. CYLINDERS + PUMP + RESERVOIR AMS 700 CX-CXR ULTREX (EXPANSION) LGX COLOPLAST-PORGES TITAN TITAN NB

46 INFRA PUBIC PROCEDURE LONGITUDINAL VS TRANSVERSE CAVE N. DORSALIS PENIS

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48 PENOSCROTAL PROCEDURE GOOD EXPOSURE CORPORA OBESE PATIENTS

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50 Retrospective study N = 126 (long term ( > 1 year) results available in 95 patients) First time inflatable penile prosthesis Single surgeon September 2011 August 2016 Coloplast (46 %) / Boston Scientific ( 54 %) Infrapubic approach (41,3 %) / penoscrotal (58,7 %) Mean operation time infrapubic 52,8 min / penoscrotal 47,01 min Cylinder length cm / RTE 1-5 cm Drain post-operative in 1 patient (0,8 %)

51 OVERALL COMPLAINTS / COMPLICATIONS Loss of penile length 23 (18,25%) Post-operative pain 15 (11,9%) Altered sensation 11 (8,73%) Mechanical failure 9 (7,14%) Auto-inflation 8 (6,35%) Hematoma 7 (5,56%) Floppy glans/cold glans syndrome 6 (4,76%) Penile deformity 5 (3,97%) Possible signs of infection 3 (2,38%) Infection 0 (0%) Imminent erosion 1 (0,79%) Chronic pain after 6 weeks 0 (0%)

52 Mechanical failure: Pump dysfunction,leakage, cylinder malfunction Minor auto-inflation: zero patients with inconvenience Post-operative hematoma: 7 patients (5,6%) spontaneous resolvement in all patients Prolonged antibiotic treatment in 3 patients: zero infection Imminent erosion in single patient treated with repositioning Revision surgery in 15 patients (11,9%): Impending erosion, mechanical failure, herniation implant component, Only difference floppy glans infrapubic versus penoscrotal: 9,61 % versus 1,35 % (p<0,o5)

53 TIME TO FIRST INTERCOURSE AFTER ACIVATION (n=95) n % < 2 weeks 36 37,89% 2-4 weeks 14 14,74% 5-8 weeks 24 25,26% > 8 weeks 18 18,95% No intercourse 3 3,16%

54 TIME TO FIRST ORGASM AFTER ACTIVATION (n=95) n % < 2 weeks 25 26,32% 2-4 weeks 12 12,63% 5-8 weeks 20 21,05% > 8 weeks 30 31,58% No orgasm 8 8,42%

55 Mechanical failure: Most frequent fluid leakage, pump dysfunction, cylinder rupture, Prospective multi centric study (n=2384): 5 year survival implant 88,9% and 10 year survival 79,4% (1) Our study comparable result Complications and complaints: Infection: severe complication; mostly immediate post-op; sometimes low grade even years after surgery; 0,6-8,9%; risk factors (diabetes, spinal cord injury, revision surgery, ); Staphylococcus; explant; salvage procedure. (2). Our study 0% Erosion: major complication;always infected; not immediate complication Loss of penile length: important negative impact (3) Pain: frequent until 4-6 weeks; correlates with lower satisfaction rates (p<0,05) Floppy glans: correlates with lower satisfaction rates (p<0,05) (4); lower in penoscrotal approach (p<0,05) (1) Wilson et al.long term survival of inflatable penile prosthesis: single surgical group experience with 2384 first time implants spanning two decades. J Sex Med 2007 Jul; 4: (2) Mulcahy et al. Current management of penile implant infections, device reliability and optimizing cosmetic outcome. Current Urology reports. 2014(15): (3) Lee et al. Strategies for maintaining penile size following penile implant. Trans Androl Urol 2012;2(1):67-73 (4) Bickell et al. Floppy glans syndrome: pathogenesis and treatment. Sex Med Rev 2016;4(2):

56 Patient and partner satisfaction: Affected by patient expectations, comorbidities,partner attitudes, surgical complications,etc. (1) Our study: QoL, scale 1-5 Overall satisfaction 83,2%; 84,2% would recommend to friend 3-piece highest satisfaction rates Partner satisfaction important, our study: only 2 patients satisfied without partner satisfaction; conversely 1 partner satisfied without patient satisfaction. Pre-op counselling, realistic expectations Implant usage: Average activation after 6 weeks Minimal or no effect on patient s orgasm, in our study 72% had orgasm during first sexual encounter. (1) Vakalopoulos et al. High patient satisfaction after inflatable penile prosthesis implantation correlates with female partner satisfaction. J Sex Med 2013;10(11):

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58 3-piece IPP effective third line treatment for ED Safe procedure High patient and partner satisfaction Pre- operative counselling of utmost importance Better outcome with penoscrotal? Upcoming European (EAU) survey: PHOENIX

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