Age is not a number when it comes to penile prosthesis surgery: A case series and mini literature review

Abstract

Backgound: Given the overall aging of the population, erectile dysfunction (ED) has become an increasingly relevant issue. When elective surgery is offered, the patient's age is often noted as a potential limiting factor. The aim of this study is to investigate the safety of implanting penile prostheses (PPs) in men 90 years and older, and report the potential complications associated with this population.

Methods: The database was screened between the years 2003 and 2023 to identify patients at least 90 years and older who underwent implantation of PP by a single surgeon at MD Anderson Cancer Center and Memorial Hermann Texas Medical Center. We collected demographic information, their anesthesia perioperative assessment, surgical procedure details, and postoperative pathway.

Results: Between 2003 and 2023, 2000 men underwent PP surgery. Three patients were 90 years or older at the time of PP surgeries. All surgeries were performed without intraoperative or postoperative complications. Following the surgery, patients were monitored, and the patients with implantations demonstrated the ability to use the device and reported satisfaction.

Conclusion: This case series demonstrates that implantation of PP is a safe and effective treatment for elderly men with ED. Maintaining a satisfactory sexual life in this age group is vital and achievable through inflatable PP insertion. There are several factors that must be considered prior to operating on an older patient. However, with proper patient selection and preoperative optimization, this operation can be effectively performed in these patients.

Keywords

erectile dysfunction / men's health / penile prosthesis

1 INTRODUCTION

Erectile dysfunction (ED) is defined as the inability to achieve or maintain an erection that is sufficient for sexual activity[1]. Due to continued medical advancements, there is an overall aging population. While overall the rates of ED increase with age, the desire for normal sexual activity does not decrease but remains the same[2]. Therefore, we see older adults increasingly focus on concerns regarding quality of life, such as sexual activity[2]. The etiology of ED can be categorized into organic causes, psychological causes, or both[3]. Organic causes are due to hormonal, vascular, anatomic, or neurologic dysfunction, while psychologic impacts can be due to mood disorders, partner-related intimacy issues, or dementia[3]. The primary contributors to the increase in ED seen in older men are primarily due to organic causes such as chronic disease, cardiovascular disease, and disorders of the prostate[2]. There are several reasons for this to occur in older men, such as decreased vascular supply to the penis, atherosclerosis of the penile vessels, decrease in endothelial function, androgen deficiency, and change in body composition[3]. There are several comorbid conditions that increase the risk of men to acquire ED, including diabetes mellitus, hypertension, hyperlipidemia, and cardiovascular disease[3]. Older men with coronary artery disease (CAD) have higher rates of ED compared to men without CAD[3]. Generally, the symptoms of ED precede the diagnosis of CAD by approximately 3 years[4].

The prevalence of ED is higher in men over the age of 70, with statistics showing that more than 75% of men in the United States in this age group have a component of sexual dysfunction. This is in comparison to 61% of men aged 40—69 that are affected by ED[3]. Despite the high rates of sexual dysfunction, the appetite for sexual activity has not been shown to substantially decrease in men over the age of 70[5].

According to the American Urological Association guideline for ED, men who present with ED should first undergo a thorough history (including the use of validated questionnaires), physical examination, and select laboratory testing[6]. The guidelines recommend counseling regarding lifestyle modifications and treatment options that include oral phosphodiesterase type 5 inhibitors, vacuum erection device (VED), intraurethral alprostadil, intracavernosal injections (ICIs), and penile prosthesis (PP) implantation[6].

When considering operating on an older adult, one must be aware of the morbidity and mortality associated with general anesthesia in this population. Older patients that undergo general anesthesia are at increased risk for postoperative cognitive dysfunction or postoperative delirium, which can be mitigated by using lower anesthetic dosing intraoperatively[7]. Additionally, the older cardiac conduction system is at increased risk for arrhythmias—most commonly atrial fibrillation—due to higher likelihood of ectopic beats[7]. By the age of 80, approximately 13% of adults will be diagnosed with atrial fibrillation[7]. This stems from increased fibrosis and diastolic dysfunction, which hinders conduction pathways[7]. Elderly adults are at increased risk for acute kidney injury and have inhibited feedback mechanisms to hormones such as renin, angiotensin, aldosterone, and vasopressin, increasing their vulnerability to volume status and electrolyte derangement[7]. Other considerations include airway management, positioning, and increased hypotensive responses to medications used for general anesthesia[7]. Elderly patients typically have a more extensive surgical history, take more medications, and have more medical comorbidities compared to younger patients. However, by working with a skilled team with trained individuals and through excellent communication, older patients can safely undergo general anesthesia[7].

While there have been articles published regarding the safety of implanting a PP in older adult males, there is a paucity of research detailing these procedures in men who are 90 years of age and above. In this paper, we aim to publish a case series regarding the implantation of PP in men who are 90 years and older, and report its outcome in that age cohort.

2 MATERIALS AND METHODS

The database of patients was screened between the years 2003 and 2023 to select patients of at least 90 years and older who underwent implantation of PP by a single surgeon at MD Anderson Cancer Center and Memorial Hermann Texas Medical Center. A total number of 2000 patients underwent PP placement with complete medical records during that time frame at the two centers. Out of the total 2000 number of patients, three were 90 years or older at the time of PP surgeries (two for implantation and one for explantation). At the time of writing this paper, one patient was still alive. The other patients passed away due to factors unrelated to the penile implant.

Each case was systematically reviewed for corresponding information, including age, demographics, past medical history (PMH), past surgical history, prior ED treatments, and their progress after implantation of the device (including complications, revisions, and hospitalizations). The perioperative protocol was also analyzed for these patients to compare to their younger counterparts.

3 CASE PRESENTATION

3.1 Case 1

A 91-year-old African American male presented with a past medical history of prostate cancer (Gleason 7). He underwent open prostatectomy with positive frozen section lymph nodes found intraoperatively. He then received external beam radiation therapy. He developed biochemical recurrence of his prostate cancer, so he underwent bilateral orchiectomy. His ED was acquired after the bilateral orchiectomy. He initially presented to the clinic in 2009 with a complaint of ED. His prior ED treatment was unknown. His other medical history included asthma, borderline diabetes, CAD, hypertension, gastroesophageal reflux disease, and urinary incontinence. He was taking the following medications: gabapentin, memantine, enalapril, buspirone, simvastatin, aspirin, hydrochlorothiazide, multivitamin, venlafaxine, furosemide, metoprolol, glipizide, omeprazole, and metformin. He had a neurostimulator device placed in 2008 but continued to report incontinence, which was managed with a condom catheter. The patient was evaluated by preoperative anesthesia prior to neurostimulator placement in 2008. He underwent stress testing and a carotid Doppler test. The Doppler test showed no evidence of significant disease; however, the stress test showed evidence of scarring and ischemia. His ejection fraction was 48%. It was felt that the procedure could be completed without complications.

On February 20, 2009, he underwent placement of American Medical Systems (AMS) Ambicor PP (Boston Scientific, Minnesota, USA). The surgical steps performed during the procedure followed the same protocol as typically done for all inflatable PP (IPP) cases at MD Anderson/Memorial Hermann Hospital. He remained under observation overnight after the surgery and was discharged the following morning without experiencing any complications.

During his routine 6-week postoperative visit, he had a favorable recovery without any complications or concerns. The surgical incision had healed well and the IPP cylinders were properly positioned along with the pump. He received instructions on how to cycle the device and was provided with guidance on regular usage of the implant.

At 7 months follow-up postsurgery, he reported no complications associated with PP. He confirmed that he was able to engage in sexual intercourse using the implant without any difficulty. He expressed satisfaction regarding sexual activity and intimacy. He was informed that follow up appointments were avaialble as needed.

Regrettably, in 2011, he received a diagnosis of adenocarcinoma of the stomach. Supportive care was recommended as a treatment for his condition. Sadly, he passed away in 2013 due to complications associated with adenocarcinoma of the stomach. During the 4 years following his surgery, he had a functional PP.

3.2 Case 2

A 91-year-old white male presented with a relevant surgical history of a laparoscopic nonnerve-sparing prostatectomy with bilateral pelvic lymph node dissection in May 2004. He was first seen in 2004 with a complaint of ED. Additional medical history included hypertension, chronic obstructive pulmonary disease, and left inguinal status after hernia repair. He was taking the following medications: albuterol, cyanocobalamin, fluticasone/salmeterol, tiotropium bromide, multivitamin, and valsartan.

He was first seen at 72 years old, in 2004, for initial ED treatment. He was trialed with a VED with ICI. This worked well initially; however, he began to develop minimal curvature to the penis in a ventral direction. In 2008, the ICI caused priapism, so this was discontinued.

In 2010, a penile Doppler was performed, which revealed a left dorsal curvature of approximately 30°, consistent with Peyronie's disease. Additionally, evidence of scarring at the base of the penis was observed, leading to constriction on the lateral aspects. Consequently, on February 23, 2010, at the age of 78, he underwent scrotoplasty, penoplasty, and the placement of an AMS 700 length girth expansion (CX) PP. He was discharged home on the same day. He was first seen in follow-up at the typical 6-week postoperative visit. He was doing well and was taught how to use the device.

He was doing well for several years, until October 2018, when he reported that his device had ceased working 2 weeks prior. He was evaluated preoperatively by anesthesia and internal medicine. He was deemed low cardiac risk for general anesthesia. On November 20, 2018, he underwent removal and replacement of his PP at 86 years old. Intraoperatively, it was noted that the left penile cylinder was broken at 1 cm distal to the tubing insertion site. The AMS 700 CX inflatable PP was placed. He was seen in follow-up 6 weeks later and was doing well. He was discharged home on the day of the procedure.

He was then seen in January 2023 when he reported a 1-week history of malfunction of his PP. At that time, he was 91 years old. He was evaluated by internal medicine prior and was deemed a candidate for surgery. On January 24, 2023, he underwent removal and replacement of his PP, and the AMS 700 CX prosthesis was placed. There was a ruptured left cylinder causing device malfunction. He was sent home after the procedure. He was initially seen at 6 weeks postprocedure, then at 6 months, and finally at 9 months. He was doing very well on all occasions. He had no issues or specific concerns, and both he and his 82-year-old spouse were extremely satisfied and reported successful intercourse at least once weekly.

3.3 Case 3

A 93-year-old white male presented with a history of PP placement in 2003 with an outside urologist. He has a history of prostate cancer status after open radical prostatectomy in 1996, hypertension, and chronic kidney disease, stage 3. On September 18, 2018, he underwent cystectomy and ileal conduit, with the removal of the PP reservoir for bladder cancer by a urologic oncologist.

He then presented to the emergency department on October 7, 2018, with left groin swelling, left scrotal pain, and a palpable fluid collection. Ultrasound showed a 13.2-cm partially septated fluid collection in the left groin. On October 9, 2018, he underwent a washout of his groin and removal of PP cylinders and pump. He was discharged home on postoperative day 2.

Four weeks later, he was seen for his postoperative visit and reported doing well. However, at his follow-up appointment in January 2018, he reported left-sided abdominal pain. A computed tomography (CT) scan showed a large fluid collection in the left lower quadrant. He underwent interventional radiology placement of a drain on that same day.

Unfortunately, he passed away, in July 2019, from complications due to progression of his bladder cancer.

4 DISCUSSION

The frequency of ED rises as men age; however, these men still maintain strong sexual desires. Studies have indicated that the prevalence of ED can reach up to 80% among men aged 70 and above[2]. The etiology of ED can be broadly categorized into either psychological or physical sources. Medical conditions such as cardiovascular disease, diabetes, and depression are primary contributors to physical causes of ED[2]. ED itself is an independent risk factor for the onset of cardiovascular disease[6]. As the elderly population grows, concerns regarding the quality of life for older adults, including sexual activity, are gaining increased attention. Consequently, addressing ED in older men has become exceptionally relevant. After proper patient selection and counseling, PP insertion remains one of the primary treatments for ED. Nevertheless, working with men of this age presents specific challenges. Administering general anesthesia to the elderly can be complicated due to their existing medical conditions, likely use of multiple medications, and overall aging of organs[8]. Advanced age itself constitutes an individual risk factor for developing hypertension, diabetes, and cardiovascular issues[8]. It is crucial to conduct thorough preoperative assessments and optimize these patients' conditions prior to proceeding with any surgical interventions.

Research has shown that both patient satisfaction rates and erectile function rates are higher in men who underwent placement of PP versus sildenafil or ICI[9]. Ali et al.[10] demonstrated that in men older than 65 years of age who underwent PP surgery, their postoperative satisfaction rates were comparable to younger men[10]. Additionally, over the past several decades, there has been a general increase in rates of PP placement for the treatment of ED[11].

ED is an issue that can affect men of any age; however, articles detailing the placement of a PP into an elderly male are lacking. Papers have been published regarding placement of the device for men into their 80s, but there is a deficiency of published research regarding men who are 90 years of age and older. In this case series, we describe men 90 years of age and older who underwent PP surgeries related to the treatment of ED.

In each of these cases, the patient was evaluated by anesthesia prior to PP placement or explantation. They were deemed eligible for the surgery and successfully underwent PP surgery. They recovered well and did not have complications relating to the devices. These are excellent examples of patients who should not have been ruled out for a PP simply due to their age, and the removal of PP is safe as well if it is necessary.

When deciding what type of device to implant, there are several considerations. One must evaluate manual dexterity for inflating and deflating the device, infection rates, comorbidities of the patient, and other factors[12]. The AMS 700 implant was used in Case 2; however, the AMS Ambicor implant was used in the first case. Upon literature review, some authors recommend using the AMS 700 for older adults due to the ease of deflation of the device[13]. The Ambicor device is a two-piece implant with prefilled cylinders that eliminate the need for a separate reservoir and deflation button.

Our surgeon's typical PP protocol consists of preoperative consultation, which includes in-depth questions regarding medical history, surgical history, ED history including prior treatments, physical exam, penile Doppler ultrasonography, laboratories (such as complete blood count, complete metabolic panel, and glycated hemoglobin test), and preoperative anesthesia evaluation. The standard anesthesia evaluation consists of laboratory tests (if not previously ordered), electrocardiogram, possible chest X-ray, or other testing to confirm fitness to undergo general anesthesia. After the surgery is performed, patients are discharged home the same day or the next day. They follow up at 6 weeks postoperatively, where they undergo wound check and PP device teaching. After this appointment, patients typically follow up yearly, if they follow the standard pathway.

The protocol utilized for older patients with implantations was no different from our surgeon's typical pathway with one exception. In Case 2, this patient was seen 6 months after surgery instead of the usual 1 year. This was because it was his third PP implantation, so the surgeon desired closer follow-up. Each patient received preoperative counseling and preoperative evaluation by anesthesia or a general medicine physician. These patients were deemed eligible to receive general anesthesia. Other studies are in agreeance that older age should not disqualify an otherwise worthy patient from receiving a PP[4,14,15].

There are several limitations to this paper. First, the sample number is small at only three patients. This can make it difficult to generalize our findings to a wider population of elderly patients. However, it is worthwhile noting that this is the only paper publishing data on the PP surgery in patients who are at least 90 years old, so is it likely that this patient population is not ample overall. Next, in Case 2, the postoperative follow-up period was less than 1 year due to his prior surgical history. Nevertheless, his perioperative period was unremarkable, and he and his partner are extremely satisfied with his result.

5 CONCLUSION

Each case presented represents a man who is at least 90 years old who received a PP surgery. These men successfully underwent PP-related surgeries without postoperative complications. While age should be a factor when deciding when to operate on someone, it should not be the sole determinant. We recommend that the patient should be properly evaluated preoperatively by anesthesia and/or internal medicine to determine the risk level of administering general anesthesia.

Even though implantation of a PP in the elderly population may be considered risky, this can be a safe and effective treatment for ED if there is appropriate preoperative counseling and assessment, if the procedure is performed by an experienced surgeon in a well-equipped institution with well-trained staff. As the elderly population is living longer than ever before, it is of the utmost importance that their quality of life be maintained as much as possible, including their sexual health.

This case series demonstrates that implantation of a PP is a viable option for men into their 90s. Removal of PP in this age group is also safe when it is necessary. Age should not be a precluding factor when deciding which patients are suitable candidates for this operation. While there are many elements that are involved in the decision to operate on a patient, this series suggests that otherwise healthy men in their 90s are candidates for a PP.

References

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2023 The Authors. UroPrecision published by John Wiley & Sons Australia, Ltd on behalf of Higher Education Press.