J. Francois Eid, MD, a New York urologist, specializes in the treatment of sexual and urinary dysfunction and is one of the foremost experts in penile implants.
He performs more than 300 penile implant operations each year—3,000 such surgeries in the past 20 years—more than any surgeon in the world.
In an interview with Renal & Urology News, Dr. Eid spoke about the options available to men with erectile dysfunction, the indications for penile implants, and the latest advances in penile implant technology.
What proportion of ED patients do not respond to PDE5 inhibitors and may be candidates for a penile implant/inflatable penile pump? [00:19]
DR. EID: I find that approximately 40 percent of men who suffer from ED do not respond to first-line therapy, meaning Viagra, Levitra, or Cialis. There are certain groups of patients that we define as difficult to treat. Those are patients who suffer from diabetes. In that patient population, if a patient has diabetes and ED, there’s probably less than 50 percent chance that oral medication will work.
If a patient sustained prostate cancer (PCa) treatment in the form of either open prostatectomy or robotic prostatectomy, in that patient population, only 40 percent will actually respond to Viagra, Levitra, or Cialis. So that defines a group of patients that we feel will benefit the most from a more advanced treatment option.
Incidentally, we find that about 10 percent of men after radical prostatectomy will have normal erections if they’re potent before their prostatectomy. So we know that 90 percent will need help. Of that 90 percent, a good chunk will respond to oral medication. We feel that 60 percent of patients after PCa treatment will need either penile injections or penile implants to recover their ability to make love.
What are some other treatment options after failing oral meds? [01:43]
DR. EID: We also offer patients vacuum pumps, urethral suppositories, when oral medications fail. I’ve actually sat with a lot of patients, alone in the room, trying to get the erectile vacuum devices to work.
It’s very, very difficult. I invite physicians to actually try to use these things. Just to get the rubber band on the vacuum chamber is extremely difficult and actually painful. At times, I’ve actually snapped a rubber band on the base of the penis and then tried to get the vacuum pump off the penis.
It’s also quite painful. Those options which, to us doctors, seem like a quick fix, are not so simple. And I invite doctors to actually take it a step further.
Who is the appropriate or ideal candidate for a penile implant? [02:35]
DR. EID: I think the ideal candidate for a penile implant is a motivated patient. A patient who wants to be cured. A patient who has tried other options and has failed. And, of course, we want a patient that is medically safe, a patient that doesn’t have a lot of underlying medical issues that will make it a problem for that individual to have a penile implant.
What are the penile implant options? [03:07]
DR. EID: There are several types of cylinders. I find that the Coloplast Titan cylinders give a great axial rigidity and what I really appreciate about that cylinder line is that I can really tailor the cylinder to the patient. It comes in many, many different sizes starting at the 12 cm all the way to 20 cm. So having this flexibility to use the right size for the right patient is something that I really like.
I don’t particularly recommend using rear-tip extenders. The rear-tip extenders do not inflate, and the pseudo-capsule of scar tissue that forms around the base of the implant, over time, loosens up. So even though the patient is able to get a good erection by pumping the implant, the base of the cylinder will start to wobble over time and the patient will complain that the erection drops down instead of pointing up.
When a patient gets an erection, the whole cavernosa chamber fills with blood. So really the best cylinder is a cylinder that actually inflates completely, so the rear of the cylinder should also inflate in order to buttress the penis against the pubic ramus and the ischial bone.
Have there been any significant advances in recent years in penile implant technology? [04:26]
DR. EID: There have been significant advances in the implants over the years, beginning with the antibiotic coating, the lubricious coating makes it easy to use as well. The device is very slippery so it’s easy to insert.
Fortunately for us, skin bacteria that comes into contact with the devices are very benign. Infections are relatively uncommon. We feel that approximately we could number between 2 to 5 percent infection rate, an overall infection rate more perhaps towards the 2 percent rate.
However, we also know that infections tend to be underreported. When an infection occurs, the whole device needs to be removed. And what we find is by adding an extra step to the surgical regimen, including intravenous antibiotics, careful preparation of the skin with the alcohol chlorhexidine chemical, and in addition using an antibiotic-coated implant, an extra step is to use the “No Touch Technique” where the device is never really exposed either directly or indirectly with skin flora.
Because skin bacteria are benign, the “No Touch Technique” makes a difference. It makes a difference in that it takes you one other level and we’ve achieved an infection rate of 0.38 percent based on 2,336 consecutive penile implants since 2006 using the “No Touch Technique” in combination with the antibiotic-coated implants. One of the big risks of infection is being handled quite effectively.
What is the downside of getting a penile implant? [06:44]
DR. EID: There are some downsides to getting a penile implant. For any surgical procedure, there is the risk of infection as we’ve discussed. Every implant at some point is going to malfunction, when it breaks, we’ll take it out and put in a new one. The devices are filled with saline. Again this is something that patients need to be informed, and it’s the same saline as one would use for intravenous medication, so it’s very safe when the patient experiences mechanical failure and the device will leak, then it will not be harmful to the patient.
One of the big benefits of an inflatable penile prosthesis is that it’s actually deflated most of the time. What we’ve learned from the experience with rigid or semi-malleable implants is that over time the layer of scar tissue that forms around the cylinders, the pseudo-capsule will become looser, and so the erection will loosen up, it will wobble. The space inside the cavernosa chamber where the cylinder is located will expand from the motion of the patient.
There is an atrophy that occurs of the flesh of the penis. There is actually an atrophy also of the glans penis. The benefit of an inflatable cylinder is that you can actually deflate it and prevent this atrophy, so that when the patient inflates the cylinder, it is well-secured in the cavernosa space of the penis.
In a similar fashion, the reservoir must be maintained, especially in the first two to three months after the surgery in order to form a healthy capsule of scar tissue which will accommodate the appropriate volume.
One common complaint is auto-inflation, in other words the patient deflates the implant and then the implant will inflate by itself. Patients tend to blame the mechanical components of the device for this occurrence.
However, what happens is that the implant was left inflated in the immediate post-operative period, and eventually at about two to three months after the surgery, the patient becomes adept at deflating the implant, and the patient is actually transferring more fluid into the reservoir than the reservoir can accommodate because scar tissue formed around a partially-filled reservoir.
Over time, the increased pressure around the reservoir will push the fluid back into the cylinders and the patient will complain that an erection has occured. Auto-inflation is more of a management issue of the penile implant in the immediate post-operative period.
Are IPP patients satisfied with the result? For how long? [09:25]
DR. EID: What is really remarkable about a patient who gets a penile implant is that the first word out of their mouth is how free they feel. And it took me a while to understand what the patients meant, and they all used the same words: “I’m a new man / I feel like a free man”. This is what they taught me: when a man suffers from ED, he thinks about it all the time. And there’s only one treatment that really fixes the problem completely, and that is a penile implant.
Other treatment options — what these gentlemen have told me — actually remind them that they have ED. So even if a patient is taking Viagra, each time that he pops a pill, it’ll actually remind him that he has ED. And what fatigues a gentleman who suffers from ED is that at some point during the day, they’re going to think about their ED whether they see a commercial for lingerie, or somebody’s making a joke at the dinner table that has some sexual undertones, they’re going to be reminded they have ED.
When you fix their ED, they feel so free. So it’s a little bit surprising because you would think that they would come to you and say, “I have this device and I’m able to have great sex, thank you so much” — that comes with it.
But the main appreciation of this treatment is the feeling of freedom, the feeling of not having the burden, not being shackled by ED. Knowing this, I think, is important because it helps the physician in counselling the patient, especially our younger, diabetic males who don’t respond to oral therapy and who are annoyed at having to do a penile injection each time they want to make love.
A lot of the urologists, at times, when they see a patient who’s in his mid- to late-40s, understandably so, want to delay the penile implant option for fear of infection or complication.
However, there is a cost to that, and those patients are more likely to use the implant more often, and those patients are more likely to love the penile implant.