Frequently Asked Questions
How Common Is Penile Implant Surgery?
Between 2005 and 2012, 63,013 penile implants were inserted, with the vast majority of them (85.9%) being done in the United States. The most common etiologies that required penile implant surgery include radical prostatectomy (28%), diabetes (21.6%), cardiovascular disease (19.6%) and Peyronie’s disease (8.9%).
Why does it Matter who does the surgery?
High volume penile implant surgeons, defined by >50 implants per year, account for <1% of urologist. Accordingly, 75% of inflatable penile implant surgeries in the United States are done by Urologists who perform 4 or fewer implant operations per year. Studies have shown that surgeon experience is the primary predictor of higher patient satisfaction scores. Additionally, centers of excellence are more likely to place longer penile implant cylinders with shorter operative times and less avoidable failures (such as infection, erosions, or poor positioning of the implant) compared to less experienced surgeons.
ARES-XL surgeons are all certified by the Hismeros Center of Excellence, thoroughly vetted for their ability to maximize length and girth during their surgeries, and also evaluated on their ability to adhere to ARES-XL recommendations and technically perform ARES-XL adjunctive procedures.
Does it matter what type of penile prosthesis is used?
There are three types of penile prosthesis readily available on the market. All three implants are placed within the corpora cavernosa (the spongy tissue that fills with blood to form an erection).
- Malleable Penile Implants are semi-rigid rods that manually create an erection after placement. These implants do not have the ability to expand (inflate or deflate) but can be manipulated and bent to make it concealable when not in use and ready for when needed.
- Inflatable implants use saline fluid that channels between a hidden fluid storage pouch (reservoir) and the cylinders within the corpora cavernosa to allow patients to gain and lose their erection at whim. Most inflatable implants are 3-piece devices that include two cylinders, a fluid reservoir, and a pump that activates and deactivates the erection.
- Men who are at high-risk for reservoir complications may choose a 2-piece device, in which the fluid is housed with the cylinders and the pump, and no reservoir is needed.
In a recent Journal of Sexual Medicine study, researchers evaluated satisfaction between two-piece inflatable penile implants, three piece inflatable penile implants, and malleable implants. They also looked at implant complications and mechanical reliability. The retrospective study evaluated 883 men (349 had malleable penile implants placed, 26 have 2-piece inflatable implants, 508 had inflatable 3-piece implants).
Among patient’s satisfaction rates, 99.2% of patients who underwent inflatable penile implant were either somewhat satisfied (8.3%) or very satisfied (90.9%), the highest among the three implant types. 96.1% and 90.3% of patients with either 2-piece inflatable penile implants of malleable penile implants were either somewhat satisfied (11.5% and 19.5%) or very satisfied (84.6% and 70.8%) respectfully. Partner dissatisfaction rates were 3.8% and 11.2% for the two-piece inflatable and the malleable respectfully. Additionally, in this study, almost 8% of the patients with malleable implants were dissatisfied enough to have their implant replaced with a 3-piece version. Only one patient chose to replace a 3-piece implant with a malleable version. The average follow-up period in this study was 6-8 months.
Based on our experience, we generally recommend the use of an inflatable 3-piece penile implant, as these implants have shown to have the highest satisfaction with the most girth expansion. Additionally, we feel the ability to cycle the prosthesis post-operatively will allow the erectile bodies to continue to expand over the next several months after completion of your ARES procedure.
Does the Brand Matter?
The same study above also compared satisfaction rates between the AMS 700Cx implants, the AMS 700 LGX implant, and the Coloplast Titan. While patient satisfaction rates for both the Titan and the 700Cx were >90% with no statistical difference between the two, AMS 700 LGX patient satisfaction rates appeared to be considerably lower at 82.9%.
Additionally, a literature review directly compared the AMS 700 series implants and the Coloplast Titan. The Coloplast Titan had increased horizontal load (rigidity) on testing with better rigidity in longer phalluses compared to both the AMS Cx and the AMS LGX while the AMS Cx appeared to have better rigidity in the shortest phallus.
The study also compared infection rates between the of coloplast titan penile implants with either vancomycin/gentamycin or rifampin/gentamycin applied to the hydrophyllic outer layer during surgery vs. the InhibizoneTM-impegnated AMS penile implants. While infection rates were 4.4% with the vancomycin/gentamycin coated Titan implants, 1.3% with the the InhibizoneTM-impegnated AMS implants, and 0% with the Rifampin/gentamycin coated Titan implants, no statistical difference was found between the three groups.
When it comes to length and girth maximization, we feel implants that maximize the horizontal load with the combination of the ARES procedure will allow the patient to maximize the girth of their respective implant penile girth. While we favor either the coloplast titan or the AMS Cx over other AMS 700 series implants because of their improved axial rigidity, we believe that the prosthesis choice should be tailored based on the discussions between the individual patient and their surgeon.
What complications should I worry about?
Cayan et al’s comparison of penile implants showed the highest rate of revision surgery due to penile corporal perforation was in patients who had undergone placement of a malleable penile implant. Long term rates of revision surgery due to penile implant malfunction in patients with 3-piece penile implants was 5.5%. Penile implant malfunction was due to rupture of the cylinders (0.8%), pump failure (3.1%), reservoir tear (1%) and blowout in the reservoir to pump tubing (0.8%).
Additionally, infection risk in the literature varies from 0-15% in the literature. Generally, infection risks for first time implants is 1-2% for first time, low risk populations and 2-3% for high risk groups. Subsequent revision surgeries do pose an increase in infection risk.
What are the recommended pre-operative and post-operative protocol?
There have been several preoperative protocols that help promote length and girth maximization. Judicious use of penile traction or a vacuum erectile device (VED) have shown to promote post-penile implant surgery penile length. This concept was initially presented by Sellers et al, who suggested use of a VED in efforts to limit penile length reduction after IPP surgery. In this protocol, patients were instructed to use a VED for 10 minutes at least once daily for up to 2 months before surgery. In addition, patients were instructed to inflate the device within 2 weeks of the surgery. The authors reported an average cylinder length increase by more than 3.5 cm based on these practice patterns.
Levine and Rybak use of a penile traction device daily for 2–4 hours a day for up to 4 months. They reported length gains of up to 1.5 cm, compared with baseline pretraction preoperative stretched penile length. Although this protocol was tedious, their high compliance rate suggests the importance of penile length to patients.
Based on our experience, we strongly encourage those patients concerned about their penile length or girth, to use a VED daily for up to two months in preparation for penile implant surgery. The thought is to minimize or reverse disuse atrophy and restore any lost corporal length and girth that may have already been lost prior to surgery.
By choosing an Ares-XL surgeon, you are avoiding surgical size reduction secondary to conservative implant sizing. Post-operatively, we encourage patients to start early post-operative cycling of their penile implant in effort to maximize the girth of pseudocapsule that will inevitably form around the implant.
What are the most common reasons to seek out penile implant revision?
Common reasons for penile implant revision include:
- Loss of Penile Length
- Penile Infection or Chronic Pain associated with their implant
- Abnormal or Uncomfortable positioning of parts of the penile implant
- Malfunctioning of the penile implant itself