Penile prosthesis implantation is an important treatment for erectile dysfunction. Although the success rate and patient satisfaction are high, there are still specific surgical risks and potential postoperative complications.
Common Early Postoperative Complications
During the initial postoperative period, patients typically undergo a recovery phase for wound healing.
- Pain and Swelling: Temporary pain occurs in 100% of cases, usually fully resolving within 4–12 weeks postoperatively.
- Bleeding and Hematoma: The incidence rate is 1–5%; severe hematomas may require surgical evacuation of blood clots (<1–3%).
- Wound Healing: Delayed healing or minor wound issues occur in 2–5% of cases; severe poor healing requiring debridement or skin grafting occurs in <1%.
Infection Risks
Infection is considered a catastrophic complication, usually requiring the removal of the implanted penile prosthesis device.
- Inflatable Penile Prosthesis: Primary implantation infection rate is 1–3%; revision surgery infection rate is 5–10%.
- Semi-rigid Penile Prosthesis: Primary implantation infection rate is 1–2%; revision surgery infection rate is 3–7%.
- High-Risk Groups: Patients with poorly controlled diabetes (HbA1c > 8–8.5%) or immunosuppressed patients have a higher infection risk of 3–10%.
- Coping Measures: If an infection occurs, a “Salvage procedure” can be attempted, which involves immediate implantation of a new device after extensive antibiotic irrigation. If this is not feasible, the device must be removed, and a new one can be reimplanted after 6 weeks to 6 months of tissue healing.
Mechanical Failure
- Inflatable Penile Prosthesis: The 5-year failure rate is 5–15%, and the 10-year failure rate is 15–30%.
- Causes of Failure: Usually due to the leakage of fluid (sterile normal saline) within the device, resulting in an inability to achieve an erection.
- Pump Problems: These include displacement of the switch, or device malfunction causing the inability to inflate for an erection or to deflate, which requires surgery to readjust or replace the device.
- Long-term Data: According to a 2007 long-term follow-up report by Wilson et al. on 2,384 patients receiving their first inflatable penile prosthesis implantation, the 1-year mechanical survival (failure-free) rate was as high as 90.0%. The 5-year survival rate remained at 79.1%; however, a 10-year follow-up showed the survival rate dropped to 68.5%, and after 15 years, it further declined to 59.7%.
- Semi-rigid Penile Prosthesis: These have a simpler structure, with a mechanical failure rate of < 5%.
Morphological Changes and Functional Outcomes
- Penile Shortening: Perception of penile shortening occurs in 30–72% of cases. Although patients subjectively feel a shortening, the actual loss measured when stretched averages no more than 1 cm. This is typically due to the loss of tissue elasticity from a prolonged absence of erections, rather than the surgery itself shortening the penis. Obesity or the penile prosthesis device making the pubic area appear larger and obscuring the penis can also make the penis look shorter.
- Decreased Penile Girth: Subjective feeling of reduced girth is reported in <10% of cases.
- Altered Penile Appearance: Subjective feeling of altered appearance occurs variably in 5–15% of cases. Minor appearance changes are usually gradually corrected during the tissue expansion and repair process 6–9 months postoperatively.
- Ejaculation and Sensation: This is similar to natural erections, but some patients may require a longer period of sexual stimulation to reach orgasm.
- Glans Engorgement: Incomplete glans engorgement, where the head of the penis feels cold to the touch (cold glans syndrome), occurs in 10–40% of cases.
- Dissatisfaction with Appearance/Function: Reported at 5–20%. However, overall patient and partner satisfaction with penile prosthesis surgery is generally above 85%, and it significantly improves the quality of sexual life.
Other Risks
- Tissue Erosion or Device Extrusion: Caused by compression and poor tissue healing leading to erosion, exposure, or breaking out of the prosthesis. Inflatable penile prosthesis: 1–3%; Semi-rigid penile prosthesis: 2–5%; Revision surgery: 3–8%.
- Higher risk in cases with spinal cord injury, revision surgery and infection
- Dorsal Nerve Injury (Numbness): < 1–2%.
- Arterial Insufficiency: < 1%.
- Prepuce Ischemia / Necrosis: < 1%.
- Hypertrophic Scarring: < 5%.
- Local Anesthesia Considerations: Pain during cavernous dilation occurs in 10.2% of cases; severe allergic reactions to anesthetic drugs are extremely rare.
Consequences of Removing the Penile Prosthesis
Corporal fibrosis leads to penile shortening and the inability to achieve spontaneous erections, resulting in permanent erectile dysfunction. Furthermore, should a revision implantation surgery be attempted, it will increase the surgical difficulty and elevate the complication rate.
References
- Carson, C. C., & Mulcahy, J. J. (2019). Penile prostheses: Current recommendations. Urologic Clinics of North America, 46 (4), 541–553. https://doi.org/10.1016/j.ucl.2019.07.002
- Barton, G. J., Carlos, E. C., & Lentz, A. C. (2019). Sexual quality of life and satisfaction with penile prostheses. Sexual Medicine Reviews, 7(1), 178–188. https://doi.org/10.1016/j.sxmr.2018.10.003
- Mulcahy, J. J. (2000). Long-term experience with salvage of infected penile implants. The Journal of Urology, 163 (2), 481–482. https://doi.org/10.1016/S0022-5347(05)67910-2
- Henry, G. D., Wilson, S. K., Delk, J. R., et al. (2012). Revision washout decreases penile prosthesis infection in revision surgery: A multicenter study. The Journal of Urology, 188 (4), 126–131.
- Montague, D. K., Angermeier, K. W., & Lakin, M. M. (2001). Penile prosthesis implantation. Urologic Clinics of North America, 28 (2), 355–361.
- Eid, J. F., Wilson, S. K., Cleves, M., & Salem, E. A. (2012). Coated implants and infection reduction. The Journal of Urology, 188 (2), 504–508.
- Salonia, A., Bettocchi, C., Boeri, L., et al. (2023). European Association of Urology guidelines on sexual and reproductive health. European Urology, 84 (1), 1–54.
- Wilson, S. K., & Delk, J. R. (1995). Inflatable penile implant infection: Predisposing factors and treatment suggestions. The Journal of Urology, 153 (3), 659–661.