PRE-OPERATIVE PREPARATION: The patient was seen in the weeks before surgery. He had his pre-operative laboratory testing performed, had a urine specimen collected for culture and sensitivity. He was instructed then to use Chlorhexidine scrub once per day while showering for the 7 days before surgery. He was also instructed to take Bactrim DS 1 tab PO BID for the 48 hours before surgery. On the morning of surgery, he was admitted to the pre-operative holding area having been NPO post-midnight. He had an intravenous line commenced and had the administration of Gentamicin at 5mg/kg as well as Vancomycin.
OPERATION: The patient was brought into the operating room, he had the administration of general anesthesia, and the patient was placed on the OR table with his legs in a "frog-like position" with the knees slightly bent outward and feet touching on the midline.
SKIN PREPARATION: The lower inguinal and penoscrotal area was shaved completely and prepped with a complete skin cleansing with Chlorhexidine soap wash followed by two Chloraprep (Chlorhexidine/70% alcohol) applicators. The alcohol was allowed to evaporate for 3 minutes, and the patient was subsequently draped in the routine sterile fashion.
He was given bilateral pudendal blocks with 10 mL in each peri-crural space using a mixture of 0.5% Marcaine plain – 30 mL/ dexamethasone – 4mg (1mL).
He was then draped in the standard multi-layer fashion. Throughout the procedure, copious amounts of Irrisept solution (chlorhexidine 0.05% in sterile water) was used, and for exposure, a Lonestar retractor with yellow elastic stays were utilized.
INCISION: An infrapubic incision was made, extending approximately 2-3 cm across the infrapubic area, making sure to stay away from the penile pubic junction. Once dissection was carried down to the level of the corporal bodies bilaterally, making sure to spare the superficial epigastrics lateral to this dissection. Once down to the corpora, a 16F catheter was placed into the bladder with clear return of yellow urine when connected to the drainage bag. We then setup for the no-touch technique.
NO-TOUCH TECHNIQUE OF SKIN ISOLATION: At this point, surgical gloves, instruments, and sponges that had touched the patient's skin were removed and isolated from the surgical field. New sterile gloves were utilized to place the loose transparent cassette surgical drape over the entire surgical field. A small opening was made in the drape exactly over the skin incision. The drape was then secured to the edges of the surgical wound with an additional four blunt yellow hooks also secured to the Scott retractor. The skin was thus completely covered, and further dissection and complete insertion of the prosthesis device could be performed through the aperture of the transparent drape without direct contact with the patient's skin.
CORPORAL DILATION AND SIZING: 2-0 Monocryl stay sutures x2 on a UR-6 needle were placed bilaterally making sure the sutures were placed as lateral as possible, on each individual corpus clearly away from the neurovascular bundles. Bilateral corporotomies were performed measuring 1.5 cm using a 12 blade. Dilation was conducted with a Furlow drive with uneventful dilation into the crus and the glans penis for both corporal bodies. No crural perforation or urethral perforation was encountered. Each corpus cavernosum was measured independently utilizing the blunt Furlow. Both the right and left corpora were measured two times alternating sides between measurements. A total corporal length was measured at 21 cm on bilaterally. After the corpora had been measured a second time, a decision was made to use an 20 cm AMS 700 LGX, MS pump, prosthesis with 1 cm rear tip extenders.
RESERVOIR SPACE CREATION: The bladder was completely emptied via the Foley catheter. Through the incision, using the index finger, a tunnel was fashioned between the inguinal cord and the base of the penis. The left external ring was subsequently easily identified by palpation. Blunt dissection was used to make a small opening in the floor of the left inguinal canal. The opening was further dilated to allow the operator’s index finger and a narrow deaver retractor. A 100 cc reservoir was placed in the left submuscular space and filled with 100 mL of normal saline.
CYLINDER PLACEMENT: At this point, the prosthesis was brought into the field and delivered from its sterile package. The prosthesis was prepared for insertion by purging all air out of the system. The device was then sized properly by adding the correct size of rear tip extenders. The cylinders were placed in the standard fashion using a Keith needle/Furlow passer system. The cylinders were lined up so that the tubing from each cylinder to the pump did not cross over each other. The cylinders were nicely seated within each corporal body.
SURROGATE SALINE TEST: Before closure of the corporotomy a surrogate test was performed with a filled 60 mL syringe. When fully pumped the distal tip of each cylinder reached the glans penis. Also, no effacement of the groove between the glans penis and penile shaft was noted and no overriding of cylinders identified. The prosthesis was appropriately sized with an excellent erection and no evidence of under or over sizing. With detumescence, minimal folding of cylinders was noted indicating that the cylinders again were appropriately sized. It took 73 mL of saline to inflate the device fully. Patient was found to have natural penile curvature of 50 degrees dorsal and to the left. No peyronies plaque was identified.
PENILE MODELING: The cylinders were inflated to the maximum. Rubber-shod clamps were placed on the cylinder tubing to protect the pump. While holding the corporotomies, the penis was then bent hard in the direction opposite to the curvature for 90 seconds. After 90 seconds, the clamps were removed, and we were able to inflate the prosthesis. The penile curvature was decreased and was close to 40° curvature.
CLOSURE OF THE CORPOROTOMIES: The prosthesis was deflated and Surgicel Fibrillar was placed inside the corporotomies. They were then closed with the 2-0 Monocryl preplaced sutures. Each corporotomy was then examined for hemostasis and felt to be grossly watertight.
PUMP PLACEMENT: A nasal speculum was then utilized to develop the midline posterior dependent pouch in the scrotum after first perforating Colles fascia with the nasal speculum and then developing the space with one spread of the nasal speculum. The pump was then placed in the most dependent portion of the scrotum along the midline. The pump was then pulled up in order to allow for any redundancy in the tubing to be non-existent after the connections were made. The redundant tubing was excised and the reservoir and pump tubing were connected in a standard fashion with the connectors in the assembly kit. The pump was then finally pulled down to the most dependent portion of the scrotum without any difficulty.
PROSTHESIS CYCLING: The pump was activated and deactivated, the penis was examined and cylinder size and erection reassessed. Good cosmesis of the flaccid and erect penis was present. Antibiotic irrigation was used to wash out the incision.
INCISION CLOSURE: A 15 Fr round hubless Jackson-Pratt drain was brought out through a separate stab wound lateral to the incision through the surgical field into the scrotum. The wound was irrigated with copious amounts of Irrisept fluid throughout the procedure. Following the achievement of complete hemostasis and final irrigation with Irrisept solution, we placed additional Surgicel Fibrillar into the surgical incision. The fascia was closed in two layers with 3-0 Vicryl in a running fashion. The skin was closed with 4-0 Monocryl in an interrupted fashion. The incisions were infiltrated with the mixture of using a mixture of 0.25% Marcaine plain – 30 mL/ dexamethasone – 4mg. Dermabond was applied over the wound, xeroform gauze was placed on the surgical incision, dry sterile gauze mummy wrap dressing was applied around the penis and scrotum, and fluff gauze pads were unraveled acting as extra support within a scrotal support.