Dr. Jean-Francois Eid, of New York City’s Advanced Urological Care, is a urologist who specializes in treating advanced erectile dysfunction.
Prostatepedia spoke with him recently about penile prostheses after prostate cancer.
How did you became involved in treating men with erectile dysfunction (ED)?
Dr. Jean-Francois Eid: When I was a third-year medical student, I did a general surgery rotation in urology, and I went to a lecture about penile implants. I was fascinated that such a device could be made. Because I have an engineering background (I’m a material science engineer), I felt then it would be a dream to work with the industry that produces these magnificent devices, to continue to improve them, and invent surgical equipment to facilitate implantation. My dream came true.
I work with Boston Scientific and Coloplast, companies that make penile implant devices for men who suffer from ED. I’m on their advisory committee, and we collaborate in order to improve these devices. I have a few patents to my name as well. It’s been a great ride for the last thirty years.
I, of course, learned from a lot of many great implant surgeons and have benefited from their experience. I also felt that it was time for me to give back and I was very honored when I was asked to write a chapter on penile implants in the Campbell- Walsh urology textbook, required reading for all Urology Residents.
How common is ED after prostate cancer?
Dr. Eid: It varies depending on the treatment that the patient received and the level of erectile function the patient had before treatment. For example, if a patient had normal erections before radical prostatectomy, studies show that about 7 to 10% of these patients will have normal unassisted erections after the prostate operation. About 30% of these gentlemen will respond to oral therapy such as sildenafil or tadalafil. The remaining 60% will need a more advanced ED treatment option, such as a penile self-injection or a penile implant.
Patients who undergo radiation therapy fair a little bit better. They develop ED about a year to a year and a half after the radiation, and about 50% of these patients will respond to oral medications. The remaining will also need more advanced treatment options such as penile self-injection or penile implant.
What is the progression? You try medication first, and if that doesn’t work, then you go to injections, and finally something like a prosthesis?
Dr. Eid: Exactly. Patients who undergo radical or robotic prostatectomy tend to be younger and healthier, and we recommend a period of penile rehabilitation with either oral therapy, vacuum device or penile self-injections. The data supporting penile rehabilitation is not very robust, nevertheless if a patient had normal unassisted erections prior to the cancer treatment, I would recommend a 12 to 18 month waiting period before proceeding with a penile implant. He is unlikely to recover spontaneous erections beyond the 2-year period, however. Conversely, if a patient relied on oral medications or penile self-injection for satisfactory sexual intercourse prior to the prostatectomy, it is then very unlikely for erectile function to return. In that case, one may proceed with a penile implant before the 12 month waiting period. Oral medications and a trial of penile self-injection is always recommended before proceeding with a penile implant.
If a man struggled with ED before going into prostate cancer treatment, will that impact if he has ED after treatment?
Dr. Eid: Yes, the ED is more likely to be advanced and be more difficult to treat. Penile atrophy, deformity and permanent shrinkage are more likely to occur. Early placement of a penile implant may in that circumstance be a better option as it will prevent further penile deformity and shrinkage while restoring erectile function.
What is penile implant prosthesis, and what are the different types?
Dr. Eid: There are basically two types of penile implants: malleable and inflatable implants. Malleable implants are always firm and positional so that they can be concealed by manually bending it down when not in use. These are the simplest of the penile implant devices. However, the feel of the penis is not as natural as for the inflatable devices. Because the shaft of the penis is always firm, pressure atrophy of the flesh of the penis will occur over the long run.
The inflatable devices can be further divided into two groups: devices with a self-contained reservoir, also referred to as a two-piece implant and the multi-component implant with cylinders, pump, and a separate reservoir referred to as the three piece implant. The reservoir is needed in order to store the saline when an erection is not desired. The two-piece devices are comprised of a pair of penile cylinders with a small saline reservoir built into the back of each cylinder and a scrotal pump. To obtain an erection the scrotal pump is squeezed, transferring the saline from the reservoir into the cylinders. The volume of saline is limited, which means there’s a compromise between penile rigidity when inflated, and the flaccidity of the penis when the cylinders are deflated.
The three-piece inflatable implants are the more physiological devices with a better erection when inflated and better flaccidity when deflated. The separate reservoir is easily concealed and because it contains a much larger volume of saline it enables the bearer to have a much firmer erection.
There are approximately 25,000 implants performed in the United States every year of which 90% are the multi-component inflatable devices. These devices were invented in 1973, and they’ve been refined since. There are only two companies that make them: American Medical Systems, (Boston Scientific), and Coloplast. Both are excellent companies and current implants have an average life expectancy of 8 to 12 years. When they fail, they are easily replaceable. The procedure to remove and replace it is a lot less cumbersome for the patient because the space inside the penis is already fashioned. There’s less pain and swelling than for the original implant placement.
Is there a difference in performance between the two types of devices?
Dr. Eid: The multi-component inflatable devices give the most natural feel of the erection and are a lot more comfortable when the patient no longer wants to have an erection. The malleable implants have a very firm and abnormal feel to them. Over time, the flesh of the penis will become looser over the rigid cylinders. This renders the malleable implant to be less firm than the inflatable device. On the other hand, when the inflatable devices are deflated the cylinders no longer apply pressure on surrounding penile flesh, preventing long-term penile atrophy
When is a penile implant prosthesis a possible solution for men with ED? When is it not a viable solution?
Dr. Eid: Any man that can have an erection on his own or respond well to oral medications may forgo the need for a penile implant
We don’t expect patients who rely on penile self-injections to stay on them for the rest of their lives, and even if the response to injections is very good, it is not unreasonable to proceed to a penile implant. There are very few circumstances that contraindicate placement of a penile implant; these are the presence of an infection or in situations where the patient is medically unstable.
What is the procedure once he decides this is what he wants to do?
Dr. Eid: It is most important to seek the most experienced surgeon that one can find. That surgeon may not be necessarily the one closest to one’s home or in one’s insurance plan. A penile implant specialist is preferable to a general urologist. A penile implant specialist has a much greater success with fewer complications. Each specialist will have their individual pre-operative protocol.