A Complicated and Educational Implant Scenario

[staphylococcusecoli]

Bionic mates,

At a recent 15 minute appointment, I asked my surgeon about a complicated case he dealt with, and he gave me a 50,000-foot overview in a 6 minute rundown. I then asked ChatGPT to explain the same with details, and this is what it came up with. I personally found it super educational (and a bit hallucinatory lol) and wanted to share it with any interested readers.

Sometimes, the phrase "high-volume implanter" gets thrown around without much insight into what that actually means, but this is the kind of thing your surgeon should be capable of.

Please consider sending a thank-you note to your surgeon.

Their skills truly impact our quality of life!

A Successful Complex Implant Re-do - Educational Case Study:

Here’s a challenging penile prosthesis case, the kind that makes even high-volume implanters slow down, re-check the plan, and line up backup options. I’ll walk it like a real clinical narrative: what makes it complicated, how the team thinks through it, what can go wrong, and how they try to keep the patient safe and functional.

THE PATIENT: WHY THIS IS ALREADY A NIGHTMARE (MEDICALLY)

55-year-old man with severe erectile dysfunction and deformity, but the real complexity is his history:

1. Radical prostatectomy + pelvic radiation (for prostate cancer).

* Radiation damages small blood vessels and tissue healing capacity.
* Pelvic surgery/radiation makes standard reservoir placement risky.

2. Type 2 diabetes (even “well controlled” still raises infection risk).

3. Chronic anticoagulation (e.g., atrial fibrillation or prior DVT/PE).

4. Five prior penile prosthesis surgeries:

* Primary inflatable penile prosthesis (IPP) -> mechanical failure
* Revision #1 -> infection “treated,” later recurrent pain
* Revision #2 -> cylinder downsized due to fibrosis
* Revision #3 -> distal erosion, repaired
* Revision #4 -> salvage for infection with malleable placed temporarily
* Now he presents after revision #5 attempt elsewhere was aborted due to “can’t dilate corpora”

5. Current presentation:

* Fever-ish symptoms, scrotal tenderness, drainage from prior incision.
* Pain along the shaft.
* New urinary symptoms: burning, possible leakage.

So before anyone touches a scalpel, the “complicated” part is already visible: infection + scar + compromised blood supply + altered anatomy + prior failures + anticoagulation.

THE EXAM AND WORKUP: WHAT YOU’RE HUNTING FOR

The surgeon isn’t just asking “is the device broken?” They’re asking:

1. Is there active infection? Or a smoldering biofilm problem?
Penile prostheses can develop bacterial biofilm (organized bacteria on the device surface) that doesn’t always cause dramatic sepsis but causes pain, tenderness, recurrent swelling, and later overt infection.

Clues:

* Drainage, redness, fluctuance
* Elevated WBC/CRP (helpful but not definitive)
* Pain out of proportion
* History of repeated revisions (biofilm probability climbs)

2. Is there erosion into urethra or skin?
This changes everything.

Red flags:

* Urinary leakage from incision
* Dysuria, hematuria
* Cylinder palpable too close to skin or glans
* New curvature + pain + distal thinning

Often, the surgeon will do cystoscopy (camera into urethra/bladder) to check:

* Urethral integrity
* Prior erosion sites
* Strictures from radiation

3. How bad is corporal fibrosis?
Repeated surgery + infection + ischemia -> the corporal bodies can become dense scar tubes. Instead of dilating like a firm sponge, it’s like trying to tunnel through old tire rubber.

They may use:

* Ultrasound (limited)
* MRI (sometimes helpful but not always routine)
* Mostly: intraoperative assessment is the truth serum

4. Reservoir placement feasibility (because of pelvic surgery/radiation)
Standard reservoir placement in the space of Retzius becomes higher risk for:

* Bladder injury
* Vascular injury
* Bowel injury (rare but catastrophic)

So the team pre-plans alternatives:

* Ectopic reservoir placement (higher/submuscular)
* Or choosing a 2-piece inflatable (no separate reservoir) in some scenarios
* Or staged approach if infection/fibrosis dominates

THE “MOST COMPLICATED” INTRAOPERATIVE FINDING COMBO

Now the case becomes legendary when the surgeon opens and finds multiple simultaneous disasters:

1. Infected device with pus and biofilm slime
2. Cylinder eroded into the urethra (or impending erosion)
3. Near-obliterative corporal fibrosis
4. Distal corporal perforation or a “blown-out” corporal tip
5. Compromised glans blood supply from prior surgery/radiation (risk of glans necrosis)
6. Scarring around prior pump/reservoir sites
7. Possibly a fragile urethra with stricture disease

This is where the case stops being “implant surgery” and becomes reconstructive salvage surgery.

THE CORE DECISION FORK: SALVAGE NOW VS STAGED RECONSTRUCTION

The surgeon has two broad strategic options, and the “right” answer depends on contamination severity, tissue health, and urethral status:

OPTION A:
Immediate salvage (remove infected device, clean aggressively, place new device same setting)
This is sometimes called a “salvage washout” strategy in general terms.

Why it’s tempting:

* Avoids penile shortening that happens when corpora scar down after explant
* Maintains a corporal “space”
* Reduces the nightmare of re-entering months later into worse fibrosis

Why it may be unsafe here:

* If there is urethral erosion, placing an inflatable device immediately can be dangerous:

* Higher reinfection risk
* Poor healing around urethral repair
* Re-erosion risk

OPTION B:
Staged approach (explant + infection control + spacer -> later definitive IPP)
In ultra-complicated cases, this is often the “safer biology” choice.

Stage 1 goals:

* Eradicate infection
* Repair urethra if eroded
* Preserve penile length as much as possible
* Prevent total corporal collapse

A common “space-preserving” concept is using a temporary internal spacer (often malleable) when appropriate, because it’s simpler and keeps the corporal bodies from sealing shut into scar.

But if the urethra is badly injured, even a malleable spacer might be deferred and the priority becomes healing and infection clearance.

STAGE 1 IN DETAIL: WHAT MAKES IT HARD

1. Removing the device can be treacherous
With dense scar:

* Tubing is stuck.
* Cylinders can be cemented in place.
* Removing them risks corporal perforation or tearing into urethra.

2. Debridement vs preserving tissue
Infection pushes you toward debridement. But blood supply is already compromised by radiation. Remove too much and you risk:

* Poor wound healing
* Skin breakdown
* Future erosion
* Glans ischemia

So the surgeon is constantly balancing:
“Remove infected material” vs “Don’t devascularize the penis”

3. Urethral erosion repair
If a cylinder is in the urethra:

* The surgeon may need to repair the urethral defect and divert urine (sometimes with catheter strategies depending on extent).
* Radiation makes urethral healing less reliable.
* Infection makes it worse.

This is one of the biggest reasons staged approaches exist.

4. Managing anticoagulation/bleeding
Bleeding isn’t just “messy.” In implant surgery, hematoma strongly correlates with infection risk because:

* Blood is an excellent bacterial growth medium.
* Hematoma increases pressure and compromises tissue oxygenation.

So perioperative anticoagulation management becomes part of the complication web.

THE FIBROSIS PROBLEM: WHY REIMPLANTATION LATER CAN BE BRUTALLY DIFFICULT


Months later, Stage 2 arrives. The patient is afebrile, tissues look quiet. Now the surgeon faces the “stone tunnel” corpora:

What fibrosis does mechanically:
Normally, the corpora are dilated to create symmetric channels for cylinders. With fibrosis:

* The corporal lumen is narrowed or obliterated.
* The surgeon can create a false passage (perforation).
* There can be asymmetry causing curvature, buckling, or pain.

What fibrosis does functionally:
Even if cylinders are placed:

* Risk of undersizing (shorter/less rigid)
* Higher risk of malposition
* Higher risk of erosion because the corporal tissue is thin and scarred

Reconstructive tools surgeons may consider (conceptually):
Without getting into “how-to” surgical instruction, the toolbox can include:

* Specialized dilation strategies for fibrotic corpora
* Corporal reconstruction (patch/graft concepts) when the tunica is deficient
* Choosing cylinder types suited for scarred anatomy (more controlled expansion profiles)
* Accepting tradeoffs: “function and safety” over “max length restoration”

THE RESERVOIR PROBLEM: THE PELVIS IS HOSTILE TERRITORY NOW


Because of prostatectomy+radiation and prior reservoir work:

* The standard reservoir location may be unsafe.
* The surgeon may plan an alternative reservoir site (ectopic/submuscular concepts) or a different device configuration if anatomy demands it.

This part matters because reservoir injury can involve:

* Bladder
* Iliac vessels
* Bowel (rare, but very serious)

So the “complicated case” isn’t just the penis—it’s the whole pelvic surgical map.

THE NIGHTMARE COMPLICATIONS THE TEAM IS ACTIVELY TRYING TO AVOID

In a case like this, the feared complications aren’t theoretical:

1. Reinfection

* Risk rises with prior revisions, diabetes, hematoma, prior radiation, and urethral injury history.

2. Urethral injury/stricture

* Particularly after erosion and radiation.

3. Glans ischemia/necrosis

* Rare, but devastating. Risk increases with vascular compromise and aggressive length restoration maneuvers.

4. Cylinder erosion

* Scarred/thin distal tissues can’t buffer pressure well.

5. Penile shortening

* A biologic reality after explant and fibrosis; even with best efforts, length restoration has limits.

6. Mechanical issues

* Revisions carry higher mechanical risk simply because tissues are abnormal and components may need creative routing.

7. Chronic pain

* Sometimes neuropathic, sometimes from malposition, sometimes from scar tethering.

WHAT “SUCCESS” REALISTICALLY LOOKS LIKE IN THIS KIND OF CASE

A very honest (and psychologically important) reframing:

* The goal often shifts from “like a first-time implant result” to:

* A reliable erection adequate for penetration
* A device that stays uninfected
* Skin/glans safety
* Minimized pain
* Acceptable length/straightness, not perfection

In other words: stable function beats heroic optimization when biology is hostile.

WHY THIS IS THE “MOST COMPLICATED” KIND OF IMPLANT CASE


Because it’s not one problem. It’s an interacting system:

Infection <-> scar <-> poor blood supply <-> urethral fragility <-> bleeding risk <-> altered pelvic anatomy
And each attempted “fix” can amplify another risk.

The surgeon is essentially doing high-stakes engineering inside living tissue that has already been damaged, rebuilt, and inflamed multiple times.

BRIEF CONCLUSION
The most complicated penile implant cases are usually salvage reconstructions: infected and/or eroded devices in a penis with severe corporal fibrosis, compounded by radiation, diabetes, anticoagulation, and multiple prior revisions.

The complexity isn’t just technical, it’s strategic: choosing staged vs immediate salvage, protecting urethra and blood supply, preserving corporal space, and accepting tradeoffs where the safest and most successful outcome can be durable function rather than “ideal” anatomy.

[LeTigre88]

Very detailed, I learned quite a bit. Thank you for sharing.