Podcast Transcript: Complex Penile Implants

[Dr. Jose Silva]
And so, um, for patients that have Peyronie's, I mean, after using Trimix or whatever the reason is, how do you prepare for those cases? Uh, are you, do you try to do a modeling? Do you know beforehand that you're already going to do a, a graft?
[Dr. Jonathan Clavell] I mean for, I am for Peyronie's man. We can't, we can have a full two-hour podcast about Peyronie's disease, but yeah, when it comes to Peyroni's again, it's similar to priapism cases, I make sure to set proper expectations on a, you assess the severity of the curvature, make sure that you have at least an idea of how bad that curvature is.
I mean, don't tell them, it's like, oh yeah, we're going to be able to do a modeling, you know, procedure. And this is going to be a real straightforward case. And then all of a sudden you go in there and the guy has a, you know, 120 degree curvature. You want to make sure that you know what you're getting yourself into, make sure that both you and the patient are on the same page when it comes to, what are the goals of the surgery. Is a goal to make the penis straight like an arrow, or is he okay to be what we call functionally straight?
Right. Um, it's not the same thing for a guy to, to be a 20 degree curvature, which, which most of us have some degree of curvature. So again, you want to make sure that you set those proper expectations. Is his goal to get back as much length as possible. You need to make sure he understands what are the risks involved and what are the expectations to set yourself up for success?
So in a scenario, for example, like you mentioned, like if, if the patient has like a 90 degree curvature, like severe curvature and who, and he also has erectile dysfunction, I try to fix everything at the time of the implant surgery. There are different ways we can do this. Um, most of the time, again, with these severe curvatures.
Just placing the implant is not going to be enough. For example, a guy who has a, you know, a mild curvature, like those with a 45 degree, you can probably get away with just placing the implant and do, you know, very mild manual modeling, uh, or probably do, uh, Paul Parado. He uses a scratch technique in which he, uh, from inside the corpora, you can actually get a nasal speculum inside the corporotomy and then he uses either a 12 blade that has like a little hook or the tip of Metzenbaum scissors. You can just scratch the, that plaque from the inside. And sometimes you're able to, you're going to be able to, uh, to model that later and the penis will actually be kind of straight. Um, I've used it before you can actually bill for that, just like. Uh, you can, you can bill for that. Just like if it was an incision of the Peyroni’s plaque. It's just doing it from the inside instead of from the outside.
So again, you know, however, if there is a patient who has severe curvature, if it's 60 degrees or more, I personally prefer to do a plaque incision with, or without grafting. There's two approaches you can use to do this. Most people use a circumcision incision, they deglove the penis in order to access the tunica.
If you need to, uh, elevate the neurovascular bundle for dorsal plaques, you can do so. If you need to, you know, for ventral plaques and you need to, you know, elevate the urethra, you can definitely do it. So. Uh, me personally, I prefer to use a ventral incision. So instead of degloving the penis, I actually just, you know, make an incision, right along that ventral raphae, and I'm able to expose everything. There's also a video on YouTube about that. Um, and, and you can actually, uh, elevate both the skin dartos and to neurovascular. Altogether this way, we can keep the skin attached to the glans at all times. And theoretically we could avoid the risk of glans ischemia.
I mean, there was a study back in 2017, for example, that looked at the risk factors for cases with glans ischemia and they had 17 patients who had glans ischemia with penile prosthesis placement, and out of those 17 patients, 86% had a circumcision with the gloving. So for this reason, when we, when I was in my fellowship, uh, Dr. Wong, who's my mentor. Uh, and I, we published approaching these cases with the use of a ventral non degloving incision. And then another thing that I personally do for these cases, when it's severe curvatures and they do not have, you know, the plaque is not calcified, and there's no hourglass deformity.
I would, instead of doing one incision of the point of maximal curvature, I do multiple incisions. And instead of going at the point of maximal curvature, I should go around it. and that way with multiple incisions, I, the, those incisions are going to be smaller. And most of the time I don't even have to place a graft.
I'm actually, I actually plan to present my findings. Uh, I've done, you know, more than 35 cases, I believe now, using this approach and I'm actually presenting it next month.

[Dr. Jose Silva]
So you're not doing sutures you’re just doing the incisions.

[Dr. Jonathan Clavell]
So I, yeah, that is correct. So whenever, cause again, whenever we're placing a penile prosthesis, whenever we do Peyronie’s cases and we're doing a plaque incision with, with grafting again, the biggest risk with that is erectile dysfunction. The good thing about, uh, about these guys who also need a penile prothesis, you don't have to worry about that.
Uh, so in sometimes if the defect is less than two centimeters, uh, in, you know, in size, you can get away without having to place a graft. So what I do is because again, if you have a guy who has severe curvatures, again, 90 degrees, a hundred degree curvature, even 75 degree curvatures, and you make an incision to the point of maximum curvature.
When you get that penis straight, you will have a very large defect. Now you're probably going to have to graft. and in order for me to avoid that, what I started doing was making multiple smaller incisions and all of those incisions are probably a centimeter, a centimeter and a half. Again, you have to close the neurovascular bundle.
You have to close a box, you have to close dartos and all those will serve, enough there. They will serve as a scaffold to be able to cover those defects. And you don't have to worry about placing a graft. That being said nowadays, we have different types of grafts. There are these hemostatic patches. And the good thing about it is you don't have to worry about sewing a graft. Cause we all know that whenever we do these Peyronie’s cases and used to have to sew a graft that's 30 minutes that you have to add into your surgery in order for you to get that water tight.
Right? So I am one that uses a seal graft. Whenever I need to use it specifically for these, Peyronie's and erectile dysfunction cases that I'm using a penile implant.

[Dr. Jose Silva]
So, so you will then put the implant, see what you have left left after you, you put a, mean, you, you, you put the implant, you inflate it and then you see if there's a big gap, you will close those or,

[Dr. Jonathan Clavell]
Yes. Yes. So again, it really depends on what is your approach. Many surgeons, what they do is they place the implant first and then they do the reconstruction. I don't do it that way. I do my reconstruction first, and then I place the implant at the end, because again, I don't want it to. I don't want the implant to be exposed for a long time because that can increase the risk of infection.
Um, so I would place the implant. I will test it. And if the defect is not that big, I just close them. And again, I haven't had, you know, erosions, I haven't had, uh, any guys who have, uh, herniations or aneurism. And they've done very well.

[Dr. Jose Silva]
And I went to ask you for patients that, that you just also in the post-op period, let's say a patient comes to, I mean, after you, the implant, everything is working fine. What they say that is pointing down? That it doesn't go up. And when you see the anatomy it’s just because the fat pad is all over the penis.

[Dr. Jonathan Clavell]
I, I will never forget it. When I was in training, I was in fellowship. There was one guy who, I mean, he even threatened my mentor to, to sue him, uh, all because the, because this, his penis was just like, you're saying, it's like, it's pointing down. It's not pointing up. Um, and he's upset about that. Um, and we told him like, Hey man, this is on you.
I mean, you are the one who has that big fat pad. That's just creating weight on top of that implant. So now. We had that horrible experience during fellowship. I tell all my patients, whenever they have, you know, a large fat pad, I tell them like, Hey man, this might create weight on your implant and it will, your penis is not going to look like the mannequin.
So, so again, I mean, for those it's, it's just about trying to avoid these types of scenarios. Uh, cause these guys can sometimes be very difficult to manage. every patient with a large patch. I will try to set expectations prior to the surgery. As soon as the patient was properly sized, there are several tricks that we can try.
Uh, there, I mean, I Rafael Carrion. He published an article, uh, several years ago about placing an implant and at the same time, removing that suprapubic fat pad, I mean, you can do that. I don't do that. I usually tell him like, Hey, you can see a plastic surgeon, uh, for, you know, for you to do this just because I don't want to be dealing with it.
You know, post-op, uh, uh, and you can also try a ventral phalloplasty for guys who are complaining or worried about their size. Uh it's like, hey, my penis looks smaller. Uh, and I tell him like, Hey man. And I usually push the fat once the implants and I push the fat pad all against their bone. And like, you can see you have about three inches underneath, underneath your skin.
Um, and again, and I try to tell him like, Hey man, when you're having sex, Your partner will be creating pressure on top of that. So you will be able to penetrate more than why it actually looks like. and there's also another technique that we can use is called a dorsal phalloplasty. Uh, this was a technique developed by, uh, by a surgeon in Egypt, his name's Dr. Shair, and he places sutures from the dermis of the suprapubic fat pad, you know, that skin. And then he tacks it down to the periosteum of the pubic bone. And with, you know, what those stitches it's basically just like pulling the skin around the shaft down. He's able to expose the penis a little bit more. It will still be looking down, but again, at least it looks like they have a bigger penis.

[Dr. Jose Silva]
Hm. Okay. Good to know. Yeah. I wasn't aware of that one, so I need, I need to take a look at that one.

[Dr. Jonathan Clavell]
that just in case that, that one, if, especially if it's a redo case, it is painful.

[Dr. Jose Silva]
Okay. So, so forget it. I'll send it to you.

[Dr. Jonathan Clavell]
I remember I once had a guy like, oh yeah, let's do it. I'm like, oh, what am I doing here?

[Dr. Jose Silva]
So you mentioned re-do so in terms of redo, I mean, at some point, do you want an MRI or any special imaging? Or you just go straight into exchanging the depends on the situation

[Dr. Jonathan Clavell]
It really depends on what you're expecting and how curious you really are. I mean, if there is something that you can not explain with the physical exam, then MRI could definitely help, especially if it's something, uh, within the corporal bodies. And then if the patient had the implant done by someone else and needs a revision, um, I would always recommend to get a CT scan at least to make sure to know exactly where that reservoir is located.

[Dr. Jose Silva]
So let's say, let's say, uh, uh, you, you have a patient, a simple redo. Let's say the, the, the patient did the, it's not working anymore. How's the process, just a simple excision of that and a replacement. do you guys also venture, I mean, uh, penoscrotal approach?

[Dr. Jonathan Clavell]
So it depends. Um, it D just, I mean, one thing that everybody needs to understand, I mean, all surgeons out there listening to this podcast is that you do whatever you feel comfortable with. If the patient had an infrapubic, you know, implant, you can't. take it out and replace it through a penoscrotal incision and vice versa.
They get patient had a penoscrotal implant. You can still take it out through, uh, infrapubic incision. Um, yes, it's going to be, I mean, it's going to be a little bit different, but it's not, it's really not that difficult. That's one thing. The other good thing about going through the other approach is all the tissues will be virgin.
For example, if the patient had the, implant, I mean, I love to have guys who, who had their implants originally placed through the infra pubic approach. And then I go in to do my, my revision and everything, all the planes are virgin, right. Uh, so again, it's going to be a lot easier to do that. And you just do, whatever's comfortable for you.

[Dr. Jose Silva]
And do you tend to remove all the fibrous tissue on the capsule, for example, around the, the pump. Do you tend to remove that or do you actually use it, to put the new pump there?

[Dr. Jonathan Clavell]
So it's so sometimes, I mean, I'm going to be really honest with you. I, if it's something that looks, you know, that's very prominent and very hard and you know, fibrous in texture, I will try to take it out. At least some of it. I don't take all of it out sometimes I just ignore it. the one thing though that I, that I would say is that I try to place a pump in a different spot, you know, in a different, uh, pockets.
So I will create a new pocket and make sure that there is no contact between that capsule and the new pump.

[Dr. Jose Silva]
and in terms of the, of the reservoir, how aggressive are you removing it in this patient? That is not infected.

[Dr. Jonathan Clavell]
So, again, for those, it really depends. One, if I wasn't the one who placed it originally again, I would reiterate get imaging to see if it is actually accessible for you. Are there any surrounding structures? How close is it to the bladder? How close is it to the iliacs? I mean, there's a patient have a hernia repair on the other side that I won't be able to access if so, I would try to take it out in order to place a new reservoir in that same space.
If the implant malfunctioned within two years, I would probably reuse that same reservoir, especially if you're going to be using the same, you know, company, uh, if it's, if it was a previous AMS implant, I would just, you know, try to reuse the same, uh, reservoir if it's been within two or three years.
I am one again, this is just my personal opinion. I try to take it out. Uh, but if it is really deep and I am really, really struggling to take it out, sometimes the best thing is to just drain, you know, take all the fluid out and just retain it and just leave it there again, just be conscious of where it's located, because again, if the only downside to that is if the new implant now gets infected and you need to take everything out, trying to find that you will definitely need to do a counter incision, but I would rather do a counter incision later on without risking injury, to major structures than being too aggressive during your revision case for something that's probably not going to cause any problems down the road, and then you end up regretting it. So again, drain and retain is something that's definitely, uh, feasible is something that we can definitely do safely, again drain if in doubt, just drain the reservoir and leave it in place.