Surgical Options to Treat ED
Even though conservative treatments for ED have recently become very advanced, there are still some patients who suffer from very severe erection issues and do not respond to conservative therapy and a surgical treatment is the only option (around 5% of patients).
Overall there are two broad categories of surgeries for erectile dysfunction. The first is vascular surgery, which aims to increase blood inflow to or reduce blood outflow from the penis. The second, is the penile prosthesis surgery, which offers a final and permanent solution to erectile dysfunction irrespective of the underlying causes.
Vascular Surgery
This type of surgery is only appropriate for a few select cases of patients with very specific symptoms.
Venoligation or Sclerotherapy
This type of operation aims to decrease the blood outflow from the penis during erections and it is only appropriate for young men with primary (i.e. lifelong) erectile dysfunction that exhibirt abnormal ultrasound parameters suggestive, of specific venous leak (increased End Diastolic Velocity). In such cases and before considering an implant, it might be appropriate to ligate or embolise the deep dorsal vein or a particular abnormal vein, established through cavernosography.
Penile Revascularisation
This type of operation aims to increase the blood inflow to the penis by increasing the level of vascularization. Appropriate candidates for this operation are patient suffering from lifelong ED and abnormal ultrasound parameters (decreased Peak Systolic Velocity) and localised stenosis, which has been established through an arteriography.
Penile Prosthesis Surgery
Penile prosthesis surgery involves replacing the damaged natural erection mechanism (corpora cavernosa), with a mechanical device, the penile prosthesis, that in effect allows the patient to induce erections on demand.
How Does the Penile Prosthesis Work?
The inflatable penile prosthesis consists of two attached cylinders – a reservoir and a pump – which are placed surgically in the body. The two cylinders are inserted in the penis and connected by tubing to a separate reservoir of fluid. The reservoir is implanted under the groin muscles. A pump is also connected to the system and sits under the loose skin of the scrotal sac, between the testicles.
This penile prosthesis is referred to as a 3-piece inflatable penile prosthesis, due to the three different components. A 2-piece inflatable penile prosthesis consists of only two components: the attached cylinders and the combined reservoir and pump unit. Instead of the reservoir being placed behind the groin, it is combined with the pump into one housing unit that fits comfortably within the scrotum. The advantage of a 2-piece prosthesis in that the surgery is shorter and less complicated and there is no device parts in the abdomen. The disadvantage of the 2-piece prosthesis is that the smaller reservoir may not result in adequate erections in some men.
To inflate the prosthesis, the man presses on the pump. The pump transfers fluid from the reservoir to the cylinders in the penis, inflating them and causing an erection. Pressing on a deflation valve at the base of the pump returns the fluid to the reservoir, deflating the penis and returning it to the normal flaccid state.
How Does the Penile Prosthesis Look and Feel?
The look, feel and function of the penis (both in flaccid and erect states including ejaculation and orgasm) is exactly the same after the prosthesis surgery with the exception that the patient can achieve an erection whenever he desires irrespective of sexual stimulation and without using any PDE-5’s or penile injections. More importantly, prosthesis implantation has the highest satisfaction rates (92-100% in patients and 91-95% in partners) among the treatment options for erectile dysfunction. Nonetheless, penile prosthesis will be usually considered in severe erectile dysfunction cases when patient response to PDE-5s and penile injections is unsatisfactory. In summary the advantages of penile prosthesis surgery are the following:
Advantages of penile prosthesis surgery
· Offers a final and permanent solution to erectile dysfunction irrespective of the underlying causes
· Exhibits the highest satisfaction rate among erectile dysfunction treatments
· Relatively simple day-care surgery with minimum discomfort and interruption for the patient if performed by experienced doctors
· Achievement of on demand erection
Naturally, as is the case with all medical operations there is a small possibility of complications. The two most severe complications is mechanical failure (less than 5%) and infection of the prosthesis (2-3%). In both cases, the complications can be resolved with a revision of the surgery and/or replacement of the prosthesis. Revision surgery has a success rate of 93%, bringing the total success rate of penile prosthesis surgery to over 99%, which is extremely high.