Prostheses in Urology

17 February 2018 LL Gwiliza

“The evolution of prosthetics is a long and storied history, from its primitive beginnings to its sophisticated present, to

the exciting visions of the future”Amputee Coalition

Outline

§ History§ Penile prosthesis§ Artificial urinary sphincter§ Testicular prosthesis§ Ureteric prosthesis§ The future

Introduction

§ Prosthesis is a device, either external or implanted, that substitutes for or supplements a missing or defective part of the body

History

§ Early evidence of prosthetic devices is found on ancient paintings

§ They were more for sense of “wholeness” than function

§ World’s “first” functional prosthesis was a toe seen on an Egyptian mummy

§ Ancient materials§ Wood§ Bronze and iron§ Fiber

History

§ First penile prosthesis § 16th century by Ambroise Pare’§ Made of wood§ Used to urinate, not for sexual

function

§ Sexual functionality§ 1936 by N.A Bogoras§ Reconstructed the penis using rib cartilage for rigidity within an

abdominal tube pedicle graft in a 4-stage procedure§ Reported satisfactory intercourse 4 months after procedure§ Not good material

§ infections§ Rib would cave in within 18 months and totally absorbed in

several years

History

§ Synthetic materials§ 1952, Goodwin and Scott used alloplastic implants§ 1960’s development of silicone rubber§ 1966, Dr Beheri achieved the first intracavernosal placement§ 1973, Dr Scott described an inflatable silicone device

§ Artificial urinary sphincters§ Foley described an artificial sphincter in 1947 that was an externally worn urethral cuff

attached to a pump kept in the patient's pocket§ The first artificial urinary sphincter to resemble the current model was developed by Dr

Brantley Scott in 1972

§ Artificial testis§ The first prosthesis used in 1941 was composed of vitallium§ A variety of materials have been used over the years

§ Metal (vitallium)§ Rubber§ Plastic§ Polyurethene§ Glass§ silicone

§ In 1993 concerns emerged regarding the safety of silicone

Prosthesis for erectile dysfunction (ED)

§ Definition§ It is a device, either external or implanted, that substitutes for or supplements the

function of the erectile bodies to achieve penile rigidity, thus simulating an erection§ Ideal device

§ Should mimic a native erection both in function and appearance§ When not in use it should mimic a flaccid state of the penis and discreet§ It should not interfere with urination or other daily activities§ Durable enough for many uses to match the patient’s lifespan§ Simple surgical procedure with quick recovery

§ Indications § Refractory ED§ Peyronie’s disease§ Priapism§ Phalloplasty post penectomy for penile cancer or gender reassignment

§ Relative Contraindications§ Situational ED§ Uncontrolled diabetes§ Spinal cord injury

§ Types of device§ Semi-rigid§ inflatable

§ Costs§ Complications

§ Infections§ Device malfunction§ Erosion§ Penile deformity

§ Patient Satisfaction§ Highest patient satisfaction for treatment of ED

Campbell-Walsh urology. 2016

Artificial urinary sphincter

§ An artificial urinary sphincter is the only device that closely simulates the function of a biological urinary sphincter

§ Indications § Patients with irreversible sphincter incompetence § Involuntary leakage of urine

§ Contra-indications§ Bladder disorders that jeopardize renal function

§ Poor vesical compliance § VUR at low intravesical pressure.

§ Inadequate tissue integrity at the bladder neck or urethra to accommodate AUS

§ Type of devices

§ Single cuff§ Double cuff§ FlowSecure

§ Complications§ Infection§ Urinary retention§ Urethral atrophy and erosion§ Mechanical failure

Campbell-Walsh urology. 2016

Campbell-Walsh urology. 2016

§ Objectives § Assess patient outcomes for combined vs singe device implantation

§ Study§ Retrospective§ 55 combined procedures§ 336 inflatable penile prosthesis and 279 artificial urinary sphincters

§ Results§ Rate of infections, erosion or malfunction was not increased irrespective of combined or staged

procedure

L Robert et al. Journal of urology. 2013

Artificial testis

§ Absence of testis occur in different circumstances§ Congenital § Acquired

§ It is associated with psychological distress§ Artificial testis are implanted for cosmetic and psychological reasons

§ Factors to consider§ Choice of incision§ Simultaneous vs delayed implantation§ Age of implantation

§ Objectives § To determine the risk factors of complications in cases of testicular prosthesis in children

§ Study § Retrospective study§ Early vs delayed implantation

§ Results§ Testicular prosthesis is safe in children§ Higher complication rate if implantation is delayed following an orchiectomy

M. Peycelon et al. Journal of pediatric urology 2016

§ Complications§ Infections§ Extrusions§ Upward migration of the prosthesis

M. Peycelon et al. Journal of pediatric urology 2016

Ureteric Prosthesis

§ Many patients suffer from irreversible unilateral or bilateral hydronephroses caused by benign and malignant processes

§ Therapy include§ Highly invasive procedures

§ ureterocystoneostomy, ureterocutaneostomy, ileal conduit§ Least invasive

§ JJ stent§ Nephrostomies

§ Subcutaneous pyelovesical bypass (Detour)§ Minimally invasive§ Allows patients to be free of external drainage devices § Improves their quality of life§ Decreased risk of infection§ Prevents regular hospitalizations

§ Two co-axial tube§ Outer porous polyetrafluoro-ethylene tube§ Inner silicone tube

Limiting factors for prosthesis in urology

§ Costs§ Stigma§ Surgical Skill § Few urologists perform these procedures regularly§ Awareness amongst primary care givers

Future…

§ The future of prosthesis in urology revolves around not just improved awareness and acceptance but mainly, and most importantly, financial accessibility

§ ED§ Competition with technologies that do not replace function of the native erectile bodies

but restore dysfunctional aspects§ Single-touch inflatable device

§ Bladder prosthesis§ Regenerative medicine and stem cell therapy

§ ??? Is this the future§ Will it replace the need for prosthesis

References

§ Brian Le, Arthur L. Evolution of penile prosthetic devices. Korean J Urology 2015;56:179-186§ Norton K. A brief history of prosthetics. Amputation coalition 2007;17: 7-16§ Gerard D, Edward K et al. The who, how and what of real-world penile implantation in 2015:

The PROPPER registry baseline data. The Journal of Urology 2016;195:427-433§ Segal R, Cabrina M et al. Combined Inflatable penile prosthesis-Artificial urinary sphincter

implantation: No increased risk of adverse events compared to single or staged device implantation. The Journal of Urology 2013;190:2183-2188

§ Peycelon M, Rossignol et al. Testicular prosthesis in children: is earlier better? Journal of Paediatric Urology 2016;12:237.e1-237.e6

§ Cordon B, Singla N et al. artificial urinary sphincter for male stress urinary incontinence: current perspectives. Medical Devices 2016;9:175-183

§ Campbell-Walsh urology. 11th edition

Thank You