An unforeseen problem during penile prosthesis surgery: the ghost fibrosis

Maurizio Carrino1, Francesco Chiancone1, Luigi Pucci1, Gaetano Battaglia1, Daniele Mattace Raso1, Francesco Persico1, Paolo Fedelini1
  • 1 AORN A. Cardarelli, U.O.S.D. Andrologia (Napoli)

Objective

Fibrosis in the corpora cavernosa, is usually related with well known anamnestic risk factors. Causes of corporal fibrosis include complications from an infected implant such as explantation, priapism, penile trauma, Peyronie's disease, and prolonged use of an intracavernosal injection agent (1-2-3).
Despite this, in our experience we have found significant fibrosis in the corpora cavernosa of patients without any well know risk factors. The aim of our study was to investigate the causes of significant penile fibrosis in our penile prosthesis implantation experience.

Materials and Methods

We enrolled 132 patients whose underwent a penile prosthesis implantation from January 2010 to December 2015. We classified the patients according to the indication for the implantation and to the intraoperative discovery of significant corpora cavernosa fibrosis. We classified the patients in two groups. In “group A” we enrolled 43 patients with high risk of prevedible significant fibrosis and In “group b” we enrolled 89 patients with low risk of prevedible significant fibrosis. We considered “significant fibrosis” if during the surgery we needed the help of additional straightening procedures like incision or excision of the scar, multiple corporotomies with or without grafting, the use of the Rossello dilator, implant downsizing, and transcorporeal resection (4). Arduos dilatation has not been considered as a paremeter of “significant fibrosis” because it can be related to the surgeon experience. Categorical data were collected in a database and they were compared using pearson's chi-squared test (χ2).

Results

In our series 47 out of 132 (35,6%) patients experienced significant fibrosis. 14 out of 43 patients (32,6%) were in group A and 33 out 89 patiens (37,1%) in group B (p=0,6112). Table 1 shows in details anamnestic features of the patients who underwent a penile prosthesis implantation and the rate of significant fibrosis. The most important rate (60%) of significant fibrosis was found in the group of patients with an history of radical prostatectomy. Significant fibrosis was found in 31,8% of diabetic patients, in 20% of patients with cardiovascular disease, in 44,4% of paraplegic patients, in 25% of patients with Peyronie's disease, in 22,2% of patients who underwent radiotherapy for prostate cancer, in 27,8% of patients with an history of priapism, in 23% of patients with veno-occlusive dysfunction, in 20% of the patients who underwent a previous penile prosthesis implantation and 5 patients had no clear causes of fibrosis.

Discussions

The primary pathophysiological event in the development of penile fibrosis is over-expression of plasminogen activator inhibitor 1, TGF β1, and reactive oxygen species that lead to the increased activity of myofibroblasts and the elevated production, deposition and accumulation of collagen (5). As expected, significant fibrosis was found frequently in priapism and in patients affected by peyronie's disease. Significant fibrosis was surprisingly found in a big rate of patients with veno- occlusive disfunction, paraplegia and others no well know risk factors. 4 out of the 20 patients (20%) in the group of previous radical prostatectomy underwent continuative therapy with intracavernosal injection agent. All these patients experienced significant fibrosis. In more than a quarter of patients who are waiting for a penile prosthesis implantation without important risk factor for significant fibrosis, addictional straightening procedures can be necessary to permorm a correct implantation.

Conclusion

In conclusion, during a penile prosthesis implantation procedure, we can found significant fibrosis in the corpora cavernosa also in patients with no well know risk factors related to fibrosis. As a consequence it is imperative to have all needful surgical instrumentary (like the Rossello dilator) in simple clinical cases too. Last but not least it is imperative to have a good property of management of these complex cases. This preliminary study can suggest the use of a chronic preventive medical therapy with phosphodiesterase-5 inhibitors or pentoxifylline in this new risk categories of patients who are waiting for a penile prosthesis implantation.

References

1-Kabalin JN Corporeal fibrosis as a result of priapism prohibiting function of self-contained inflatable penile prosthesis. Urology. 1994 Mar;43(3):401-3.
2-Wilson SK Reimplantation of inflatable penile prosthesis into scarred corporeal bodies. Int J Impot Res. 2003 Oct;15 Suppl 5:S125-8.
3- Bilgutay AN, Pastuszak AW. Peyronie's disease: a review of etiology, diagnosis, and management. Curr Sex Health Rep. 2015 Jun 1;7(2):117-131.

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