When I was a resident over 50 years ago, I asked one of my mentors where and how should I set up my urology practice. His response was straightforward and simple: Pick a place where you and your wife want to live and hang up your shingle. The local bank will lend you whatever money you’ll need to start your practice, and you’ll be an instant success.

Circumstances have changed dramatically since then, and young urologists who wish to develop a specialty practice in prosthetics must be proactive in developing a niche where they can be considered the referral source for complex cases. Patients are very active online and a website tastefully created will be a must. Search engine optimization will bring your site to the forefront of Google and other searches. Presenting your clinical research results, especially at AUA Section meetings, will tell other urologists in your state and the surrounding ones that you have interest and expertise in such complex prosthetic cases. Informational health talks at your office or local venues will bring in couples who are seeking to know the options for their erectile dysfunction and/or urinary incontinence. A patient satisfied with the result of his prosthetic placement will be extremely helpful in answering the couples’ questions at such meetings.

The experienced implanter should be able to handle complex cases. Knowing both the penoscrotal and suprapubic approaches well is vital, as cases will present where one approach would be more definitively indicated. The same should be said of reservoir placement. After multiple repairs and exchanges of an implant, a favored reservoir site may be inaccessible and an alternate site indicated.

During surgery, investigate thoroughly when signs of an adverse event present. Don’t assume blood in the urine is due to the Foley balloon rubbing against the bladder neck. The reservoir may have been inadvertently placed in the bladder.

Thorough informed consent is critical. Many patients presenting for penile implant placement are “peno-focused” and, if their member isn’t close to perfect, they can be very upset. If litigation occurs due to an unwanted outcome, documentation of this informed consent in the record will help the defense attorney considerably. A booklet or standard multipage exposition of the outcomes and expectations of the surgery, which can be given to each patient, will save time and cover this important topic.

John J. Mulcahy, MD

Of the many hard lessons my complications and unhappy patients have taught me, here are some I have found to be the most valuable. First, the patient (and the surgeon) must know the most likely sources of inflatable penile prosthesis (IPP) dissatisfaction, which invariably fall into 1 of 2 camps–false expectations of a hydraulic device (it neither fixes relationships nor restores the full majesty of erections of yesteryear) and surgical complications. Second, the surgeon must have a knowledge of (and plan for) whether there is any penile curve to address and where the reservoir can safely go. Third, operative time matters in the grand scheme of infection, so performing certain maneuvers and perseverating on making things perfect can be counterproductive. Fourth, when replacing old uninfected devices, it is very reasonable to leave the old reservoir behind (with certain exceptions) and it pays to test inflate the old cylinders to assess for distal seating of the device, assess for corporal weakness from aneurysms and help make an accurate new corporotomy. Finally, never rush to revision. I rarely will touch a new implant within the first year unless it is obviously infected or completely unusable. It is very important to convey the sense of “good enough” to the patient as many annoyances from the patient resolve with a tincture of time.

Toby Kohler, MD

Never Implant a Stranger

Twenty years ago, my practice was limited to prosthetics; I was doing 300 IPPs at home and 200 additional procedures on the road proctoring other surgeons. I was confident and considered myself bulletproof. After all, at that time I was one of the highest volume IPP surgeons in the country. I basically implanted anyone who wanted an IPP, frequently booking the surgery on the first visit. Now I realize that some of those hasty surgeries resulted in unhappy patients; they had unrealistic expectations that I did not discover in my rush to book the surgery. I learned “the last guy that touches the patient gets him.” When you perform surgery on a man’s penis whose expectations are not achieved, you generate disappointment for life. “You created Frankenstein; now you have to live with the monster.” These unhappy patients taught me that just because the patient wants an IPP doesn’t necessarily mean they get one.

I have learned to get to know my patients and scrutinize for unrealistic expectations. I also preach realism when describing the postoperative result: “It will be functional for sex but will not look or perform like you were 25 years of age.” I have realized not to operate on the patient who breaks into tears when describing his penis. I have figured out that the patient who admonishes me to “make it as long as you can, Doc” will be high maintenance postoperatively. He will be dissatisfied with his outcome unless you mitigate his anticipations.

For those men who desire the longest member, I have a unique treatment plan that successfully achieves a patient who never questions why his implanted penis isn’t longer. I tell him that to achieve the maximum penile size we use a treatment program that will require delaying his surgery 2 months. Twice a day he places his penis in a vacuum erection device (VED) for 10 minutes without the rubber band (fig. 1). Every week he documents the length of his erection on the VED. His erect penis will lengthen 2–4 cm because we believe the VED erection improves compliance of his tunica.

Figure 1. Penis expansion with 7 weeks of vacuum therapy (photo courtesy of M. Dineen).

Figure 2. Figure used with permission of Elsevier / The Journal of Sexual Medicine.

At the subsequent implantation surgery, we deliberately oversize the patient 2 cm. After his postoperative pain has subsided, we ask the patient to daily pump his prosthesis to the point of discomfort and maintain the erection for 3 hours. This nightly inflation is mandatory for 9 months to fully stretch out the penis.¹ I can honestly say that I have never had a patient who followed this regimen complain about his resultant size. By performing this pre- and postoperative penile rehabilitation, our man has “skin in the game.” He is either satisfied with the result or secretly blames himself because he did not religiously follow the aggressive vacuum and device inflation discipline.

Steven K. Wilson MD, FACS, FRCS

As the moderator of this AUA plenary session, I had the privilege of reading my expert panelists’ tips and comments. Not surprisingly, I found them all wise and relevant to my own practice. The following are a few additional lessons I have learned in my years of practice:

1. Though exceedingly rare, have a high index of suspicion for vascular or ischemic complications in patients who have had prior penoscrotal surgeries and circumcising incisions, diabetics with any penile discoloration or persistent pain, and patients complaining of unilateral lower extremity swelling, which may be due to iliac vein compression by the laterally placed reservoir. These patients must be seen and evaluated immediately.
2. When a patient is referred by a colleague to fix an initial failed implant (infection, malfunction etc), remember that the referring surgeon may not do things the way you always do. Check the operative report and have a low threshold to obtain imaging if you are concerned that some hardware may have been left behind. I clearly remember a case when a high index of suspicion and computerized tomography (CT) imaging saved the day and helped identify 2 rear-tip extenders (with frankly purulent fluid sandwiched in between) that had been left behind when the referring surgeon had explanted an infected prosthesis (fig. 2).²
3. Placing an implant in a patient with post-priapism erectile dysfunction or one who has previously had a prosthesis explantation because of infection is a significantly more challenging operation and not one for the inexperienced implanter. Do not hesitate to refer these patients or invite a more experienced colleague to scrub in. Check your ego at the door and never hesitate to ask for help.
4. Never leave any components behind in an infected case. When retrieving a reservoir in an infection or replacement case, be mindful of the tension applied to the tubing and do not pull too assertively until you have reached the “fat” part of the tubing just distal to the reservoir.
5. To build on Dr. Wilson’s advice about not implanting a “stranger,” I have learned that there is no replacement for time spent with our patients. There is simply no way to establish trust and a rapport with your patient in a rushed and brief visit. Going back to the basics, I am reminded of what I learned in my very first clinical clerkship at McGill more than 20 years ago: get a proper history and listen to your patients.

Hossein Sadeghi-Nejad, MD, FACS