V-Neck Technique Offers Possible Solution to Tubing Problem in IPP Placement

V-Neck Technique: A Novel Improvement to the Infra-Pubic Placement of an Inflatable Penile Implant

Bhavik B. Shah MD; Adam S. Baumgarten MD; Kevin Morgan MD; Jonathan A. Beilan MD; Michael Bickell DO; Ricardo Munarriz MD; Justin Parker MD; Rafael Carrion, MD

ONLINE: May 22, 2017 – The Journal of Sexual Medicine

DOI: http://dx.doi.org/10.1016/j.jsxm.2017.04.674


Introduction

Many men with erectile dysfunction (ED) choose to undergo implantation of three-piece inflatable penile prosthesis (IPP) when conservative and nonsurgical therapies have not been successful. The IPP procedure is considered the standard treatment.

In some cases, the IPP is implanted through the infra-pubic approach.  One problem with this method is a “configuration deformity” that occurs on the ipsilateral side of the penis, where three tubes are routed down to the pump in the scrotum.  After surgery, the tubing might be palpable or visible under the skin. Some patients experience discomfort.

“We believe that the contralateral cylinder tubing that has to loop around to the contralateral side accentuates this defect,” the authors of the current study wrote.  Few papers have analyzed this issue.

The study discusses the V-neck technique (VNT), a modification to the traditional infra-pubic approach that may improve appearance and comfort in men with IPPs.

Methods

The study involved five men who underwent for IPP placement with the VNT technique between May 2016 and June 2016.  Previous ED strategies, including phosphodiesterase type 5 (PDE5) inhibitors, intracavernosal injections, and vacuum devices had failed for all the men. None of the patients had previously undergone ED-related surgery.

Two patients underwent suprapubic fat pad excision at the same time as infra-pubic IPP placement. The rest had infra-pubic IPP placement only.

In their paper, the study authors described the surgical procedure as follows:

Insertion Technique
For those patients undergoing suprapubic fat pad excision with IPP placement, the fat pad was excised and this provided excellent exposure of the proximal bilateral corpora cavernosum. For the standard infra-pubic IPP placement cases, we used the protocol and technique described and popularized by Perito.6 In either instance, once the corpora were identified, corporotomy incisions were made laterally. The corpora were dilated proximally and distally through these incisions. After the corpora were irrigated, we obtained the accurate corporal length measurements and selected the PP size. While the scrub technician prepared the prosthetic, we placed the reservoir in the space of Retzius. We returned to the corporotomies to place the cylinders, resulting in the configuration shown in Figure 3. We used a disconnected pump kit, if available, when we performed the VNT, which is represented by the free tubing ends shown in Figure 3. If we only had a pre-connected IPP kit, then the contralateral cylinder (green) tubing was disconnected with a rubber-shod clamp.



Figure 3
Standard infra-pubic approach, as popularized by Perito,6 demonstrating placement of the reservoir and cylinders. The ipsilateral (pink) and contralateral (green) cylinders and the reservoir (blue) are clamped and unconnected. 

At this stage, the VNT diverts from the standard technique. Blunt finger dissection was used to create a sub-phallic window (Figure 4), and a U-shaped aortic clamp was used to pass the contralateral cylinder tubing to the side where the pump will pass down the gutter to the dartos pouch.

Figure 4
Illustration of finger dissection used to create a sub-phallic window. 

After passing the contralateral tubing through the window using the aortic clamp (Figure 5), all connections were made in the usual fashion. The pump was placed through the ipsilateral gutter toward the raphe, into the most dependent portion of the scrotum, as previously described.



Figure 5
Passage of U-shaped aortic clamp followed by passage of contralateral tubing through sub-phallic window. Note the U-shaped aortic clamp with rubber-shod tips. 


Figure 6 illustrates the passage of the right and left cylinder tubes down their own respective ipsilateral sides with the contralateral (green) tubing passing directly into the scrotum and connecting to the pump.



Figure 6
Illustration of the final configuration after the V-neck technique and standard connections. Note elimination of tubing crossover dorsally, creating a V-neck appearance as the right and left cylinders pass down their respective gutters.

The corporotomies were closed with 3-0 Vicryl suture in standard fashion. Two drains were left in patients who underwent fat pad excision—one in the scrotum and one in the subcuticular space under the closure. One scrotal drain was placed if the patient underwent only IPP placement. The Scarpa fascia was closed using interrupted 3-0 Vicryl sutures and the skin was closed with staples or subcutaneous 4-0 Monocryl suture.

Results

At a five-month follow-up point, no tubing was visible in any of the patients. The tubing was palpable, but only with deep palpation.

Adding the V-neck technique added one minute of procedure time.

Patients reported satisfaction with the cosmetic results, with no discomfort from the tubing. No complications were reported.

Discussion and Conclusion

The authors acknowledged some limitations, including the small population size and the fact that two of the patients had simultaneous fat pad excision.  Also, any mechanical or infectious complications could not be addressed in the short follow-up period.  It is not clear whether the VNT would be suitable for IPP revision or whether using the VNT would make future revision procedures more difficult.

They concluded the VNT was a “simple maneuver” that could “help prevent the discomfort of tubing crossover deformity commonly seen after infra-pubic placement of an IPP.”

VNT is “a novel step . . . that adds minimal operative time and could eliminate visible tubing,” the authors added.