Surgical Treatment of Erectile Dysfunction in .NET framework

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Surgical Treatment of Erectile Dysfunction
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(c) (b) Mentor-Alpha 1 (c) Mentor Titan with ResistTM-Coating (here, colour-
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Fig 122 (a) AMS 700CX InhibiZone enhanced with methylene-blue)
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select the model that best ts the patient s needs and anatomy Patients who are eligible for a penile implant should be assessed with a detailed systemic medical and sexologic history [14] Candidates for penile prosthesis implantation should ful ll the following criteria: Good general health Failure of medical therapy for ED or, Contra-indication to medical therapy of ED Psychologic stability Patient and partner fully informed Informed consent for surgery Unsuccessful trial of vacuum devices or at least consideration of these devices [14,55] The complete medical assessment may include the following elements if they are available: The international index of erectile function (IIEF) or other validated questionnaires to objectively assess severity of ED and subsequent postoperative outcome Penile colour Doppler sonography with intracorporal pharmacologic injection Nocturnal penile tumescence test, especially when the initial medical evaluation suggests the possibility that the patient s ED is predominantly psychogenic In cases with medico legal questions, a comprehensive diagnostic work up should be done [14] A thorough physical examination is very important This should include an assessment or actual mea-
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surement of the length of the penis The length after prosthetic implantation is usually similar to the length of a completely stretched accid penis It is worthwhile to spend time with the patient illustrating this concept because, commonly, patients have unrealistic expectations of penile length that cannot be met by any form of therapy The physical examination may also allow the detection of areas of significant scarring within the corpora cavernosa Patients with Peyronie s disease may not report a penile bend even though they may have extensive corporal brosis, which can ultimately limit the intraoperative dilatation of the penis In such cases, the nal penile length and girth may be unsatisfactory to the patient [55] Preoperative identi cation of corporal brosis and other factors that impact on postoperative results, plays a very important role in reducing or eliminating patients disappointment with postoperative length and girth During the physical examination, the manual dexterity of the patient should be assessed, as it must be suf cient when an in atable prosthesis is used Obesity may be a factor making the use of any prosthesis more dif cult; this is a physical feature that must be addressed [14] In patients with poorly-controlled or treated diabetes mellitus, it is wise to obtain a preliminary diabetologic consultation to normalize their glucose metabolism There is controversy as to whether abnormally high serum glycosylated hemoglobin is a marker for higher risk of postoperative infection
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12 abdominal, rather than retropubic, placement of the reservoir of a three-piece device can be chosen for the patient with retropubic brosis [25]
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Several investigators suggest that patients with uncompensated diabetes mellitus may have an implant placed safely [23,55,57] A critical point in the evaluation of the candidate for an implant is to identify active infections at the time of surgery A urine culture is mandatory in all patients Patients who have infectious lesions in the genital area or other local infections, and patients who have active systemic infections, should defer surgery until the infection has resolved It has been suggested that patients should scrub their genitalia with an antiseptic solution during the ve days prior to hospital admission, and should take an oral quinolone during the same period [14] When an AMS three-piece implant is planned for a patient with long penile length, the CX device should be used because CX devices provide better rigidity than Ultrex devices at longer penile length [56] Patients with limited dexterity should be offered malleable devices If the limited dexterity is due to a neurologic condition in which there is reduced penile sensation, there is an increased risk of urethral or cutaneous erosion of the implant In such cases, the surgeon should consider implanting somewhat shorter cylinders, to reduce the risk of erosion In patients with severely scarred corpora, CXR or Mentor narrow-based devices should be used If patients are disappointed postoperatively with their penile length, they can be advised that daily in ation of the prosthesis may produce corporal dilatation, and that surgical replacement with longer cylinders may be possible at a later time [24] In patients undergoing secondary or repeat prosthesis implantation, the Ultrex device may be considered if preoperative physical examination reveals a 2 cm or more difference between the nonstretched and stretched penile length However, Ultrex cylinders should not be used in patients with Peyronie s disease In patients who have had retropubic prostatectomy, cystectomy or other causes of perivesical scarring, two-piece implants offer the advantage of not requiring retropubic placement of an implant reservoir However, the difference in rigidity and girth between the in ated and de ated states of two-piece penile prostheses is limited compared to three-piece implants Alternatively, intra-
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