PREOPERATIVE DIAGNOSIS: Organic erectile dysfunction.
POSTOPERATIVE DIAGNOSIS: Organic erectile dysfunction.
PROCEDURE PERFORMED: Insertion of inflatable penile prosthesis.
John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 65 mL.
DESCRIPTION OF PROCEDURE: Following induction of general anesthesia, the patient was shaved and skin prepped for 10 minutes with iodine scrub followed by Betadine paint. The patient was draped in a sterile fashion including U drape and previous dressing between the legs, which were placed in frog-leg position. A sub penoscrotal incision was made with sharp dissection carried through the dartos muscle with Lone Star retractor placed with double rings, large above and small below. The transverse Deaver retractor was positioned at the base of the penis and the Foley catheter was inserted into the bladder with some difficulty, requiring downsize to a 16 French catheter. Once the catheter was in position in the bladder, a hook was placed on the inside of the dorsal aspect of the meatus and the penis drawn cephalad over the transverse retractor. The penoscrotal incision was deepened and hooks were used to retract the skin superior to inferior and to either side. The corpora cavernosa was dissected free of surrounding adventitial tissue on the patient's left, and the soft tissues were then retracted to the patient's right, allowing exposure of the contralateral corpora cavernosa.
Once exposure was achieved, stay sutures of 0 PDS suture were placed in each corpora x2 and a vertical incision was placed between corpora extending approximately 2-3 cm in length. Metzenbaum scissors was passed distally and then proximally into the corpora on either side with the points of the scissors hugging the internal aspect of the corpora cavernosa, tunica albuginea. Next, Hegar dilators were positioned proximal and distal with gradual increase in dilator size to 13. Once dilation was complete, the corpora were irrigated with antibiotic solution consisting of vancomycin and gentamicin. The assembly was prepared on the back table, including the Ambicor inflatable penile prosthesis and pump. The corpora cavernosa were measured at 19 cm total with 10 cm distal and 9 cm proximal. We chose a 15 cm prosthesis with 4 cm extensions and 12 mm caliber. The Furlow insertion device was then positioned with a Keith needle and positioned to position the distal end of the prosthesis through the glans penis. This was performed on each side and the proximal prosthesis was then inserted into the proximal corpora cavernosa.
Once the prosthesis was seated, the tubing was cleared of air and the rubber-shod clamp removed allowing inflation of the prosthesis to assure that there was no kinking or cross-over of the prosthesis. Once we were assured of this, the prosthesis was then emptied and the tubing re-clamped while the stay sutures were tied transversely to close the corpora cavernosa. The Lone Star retractor was removed and a subdartos pocket was identified and created with insertion of gauze soaked in 1% lidocaine with epinephrine. A 65 mL reservoir was then cycled with water and emptied. The external ring was traversed with the index finger of the left hand and a Deaver retractor was positioned, retracting the external oblique fascia of the external ring cephalad and Metzenbaum scissors then punctured through the transversalis fascia into the retroperitoneal space. A finger created space within the retroperitoneal tissues and the reservoir was positioned in the retropubic space and filled with 65 mL of saline.
The pump was then positioned in the subdartos pocket and the tubing between the reservoir and the pump was clamped with rubber shods and excess tubing was cut. The connecting device was then placed and the crimper was used to secure connection between the reservoir and the pump. The prosthesis was cycled, showing again good evidence of erection without kinking or aneurysm. The corpora cavernosa cylinders were left at approximately 70% filled and the subdartos tissues were closed over the pump, which was secured in the anterior-inferior aspect of the scrotum. The Lone Star retractor was replaced with retractors extending the transverse penoscrotal incision to either side and a round Blake drain was placed through a separate stab incision into the subdartos space adjacent to the tunica vaginalis.
The dartos and skin were closed in one layer with interrupted 3-0 chromic sutures, and upon completion of skin closure, a fluff gauze dressing with Telfa was placed over the incision and a stretch tape dressing was placed over the scrotum, first vertical and then transverse. The Foley catheter was taped to the anterior abdominal wall and the Blake drain attached to a vacuum bulb. The patient was then transferred to the recovery room in satisfactory condition.