Ep. 23 Complex Penile Implants with Dr. Jonathan Clavell

Dr. Jose Silva brings Dr. Jonathan Clavell back onto the show to discuss complex penile implant cases. They cover how to deal with mechanical complications of AMS700 and Coloplast Titan, penile implants in Peyronie's disease, penile implants in priapism, tips for successful revision surgery, and how to manage post-operative infections.

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SHOW NOTES

First, the doctors discussed mechanical complications with three-piece inflatable penile implant devices. Dr. Clavell always directs post-operative patients to his Youtube videos where he explains how to cycle penile implants. Because older patients may have trouble finding and operating the pump, Dr. Clavell prefers to place an AMS 700, as it is easier to deflate. Additionally, he tries to place the pump as anteriorly as possible for ease of patient usage. If he notices that the tubing of the implant is too long at the time of surgery, he cuts the tubing and reconnects it again at the appropriate length. Finally, to avoid autoinflation, he takes great care in making sure that the lock-out valve of the Coloplast Titan does not hit the pubic bone.

Next, Dr. Clavell discusses different approaches to placing penile implants in complex patients. First, he tackles patients with chronic priapism, a common consequence of sickle cell disease. With priapism patients, he emphasizes the importance of severity and timing; waiting a longer time period since the patient’s last priapism episode means that there will be more scar tissue in the corpora. For these complex patients, Dr. Clavell encourages surgeons to set proper expectations with their patients, try to operate as soon as possible, and encourage their patients to use a vacuum erection device to keep corporal space open and maximize the size of implant. Additionally, he recommends coming into the operation with adequate tools that are able to drill through the fibrosis and being ready to use a counter incision or to extend the incision distally.

In patients with Peyronie’s disease, Dr. Clavell always assesses the degree of curvature first. For patients with mild curvature (under 45 degrees), he places the penile implant and uses manual remodeling techniques intraoperatively to straighten the penis. For patients with more severe curvature (more than 60 degrees), he performs a plaque incision with grafting (PIG) through a ventral non-degloving incision to avoid the risk of glans ischemia. In these severe Peyronie’s patients, he will do the PIG first and then place the implant in order to minimize implant exposure time and infection risk.

In the event where a revision surgery is necessary, Dr. Clavell orders a CT scan if the problem cannot be found upon physical examination or if he was not the surgeon who placed the original implant. He usually takes some fibrous tissue out around the pump and then places the pump in a different pocket to make sure there is no contact between the capsule and the new pump. Although he tries to take the reservoir out, he simply drains and retains reservoirs that have migrated too deep in order to avoid damaging major structures.

In patients who develop post-operative penile implant infections, Dr. Clavell usually completely removes and replaces the implant if pus is present. He notes that it is important to swab the biofilm at the time of implant removal in order to culture and identify the type of bacterial infection. He prefers to administer culture-specific antibiotics and antifungal for 2-3 weeks. Also at the time of removal, he will irrigate the patient’s corporas with Irrisept and an antibiotic solution. Research has shown that patients who develop a post-operative infection will have a 50% chance of success with another 3-piece implant.

Dr. Clavell also discusses other post-operative complications, including impending erosions and glans ischemia.