Allen F. Morey, MD
a member of the Urology Times
Editorial Council, is professor of urology at the University of Texas Southwestern Medical Center, Dallas.
Patient dissatisfaction rates of 10% after inflatable penile prosthesis (IPP) placement may appear low but represent an important reason for concern.
A prospective follow–up analysis examined several hundred IPP cases done in centers of excellence by high-volume implanters who presumably optimized their counseling and surgical processes after continual refinement over many years (see article).
The occasional implanter likely will not attain these results. What causes of IPP dissatisfaction can general urologists anticipate in community practice? How can patient dissatisfaction be avoided? Three big categories of problems are suggested in this study:
• Patient health decline and partner issues.
These appear to be obvious and unavoidable. It is intuitive that some men may experience an unanticipated downturn in their health or relationship situation, or may have no current sexual partner.
• Device-related problems.
The pump was singled out as a major focus of patient complaints, perhaps due to the bulky shoulders of the implant disturbing other sensitive structures within the scrotum or perhaps due to difficult pumping related to tenderness or a “sticky pump” in which fluid movement becomes impaired. Fortunately, true mechanical problems are rare.
We believe that pumping difficulties result from prolonged periods of inactivity, likely causing fluid sludging and improper valve movement within the pump. To prevent this, we advise daily or at least regular inflation and deflation of the system. To troubleshoot, we have found that an aggressive “forced deflation” two-handed maneuver almost always reactivates the pump without the need for surgical intervention.
• Expectations relating to penile length.
Patients must understand in advance all comorbid conditions that may impair perceived penile length after IPP, including radical prostatectomy, cardiovascular disease, scar or Peyronie’s plaques, penoscrotal webbing from aggressive circumcision, and obesity. Resection of the suprapubic fat pad with phalloplasty may help the penis project more optimally in obese patients. We have observed that the IPP cylinders tend to act as a tissue expander over time and routinely can add several centimeters to the total corporal length in reimplant cases done after 1 to 2 years.
The bottom line is to “underpromise and overdeliver” when it comes to penile length issues in your IPP patients so their expectations are appropriate.
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