Hello, my name is Paul Perito. I’m a urologist in Coral Gables, Florida. I specialize in sexual medicine and have a large aspect of my practice dedicated to assist men who suffer from ED. Through my development of the Perito Minimally Invasive Penile Implant Technique, I’ve become the single busiest implant center in the world.
A few years ago, I posted a brief video of my surgical technique online. Since then I’ve received daily inquiries about the technique and my implant of choice. Over the following few minutes I will explain the outcome of my personal research of available penile implant technology. Hopefully my suggestions can assist patients in this important decision.
I want to clarify that I developed the minimally invasive approach not to be fast but as a refinement in surgical technique and the methodical conservation of operating room motion. I do not speed through the procedure. I’ve greatly refined previous approaches to create the Perito Minimally Invasive Implant Technique which, in my hands, is usually a 12-minute procedure. For example, that is less time than it usually takes to get a cavity filled.
I created the Perito Minimally Invasive Technique to emphasize the main features of the particular penile implant that I use in my practice—the Coloplast Titan penile prosthesis. If you are viewing this, you probably are researching the procedure which I commend. You likely know that the entire implant is internal and all done through a small incision just above the waist or beltline.
The inflatable penile implant includes cylinders that fill with saline and provide the erect shaft of the penis. A small reservoir or balloon that holds the saline fluid in a pump that is located in the scrotum and used to send fluid to the cylinders or back to the reservoir when the patient wants the cylinders to once again be flaccid.
After thorough personal research, I decided to only use the Titan implant for three significant reasons. First, the Titan cylinders. The portion of the device are actually in the shaft of the penis, expand and engirth nearly 20 percent greater than other devices available. Girth is extremely important as the outcome of increased girth in any structure equates to actual rigidity.
I noticed early on in my nearly 4,000 implant cases that the Titan girth capacity provided my patients with column strength whereas the patients I’ve implanted with the AMS device in its limited girth expansion provided a weaker, floppy girth capacity.
Through the years I’ve revised many former AMS patients for mechanical revisions and provided patients with a Coloplast Titan replacement almost universally. I’ve learned from those patients that they notice the difference in their erectile capacity and are ecstatic with the increased girth and with their new device.
The second reason that I like the Coloplast Titan is it is constructed from a durable medical grade of basically polyurethane called Bioflex. The AMS devices utilize a softer silicone polymer. The simple clinical data in urologic journals shows the long-term outcomes and differences between an implant with Bioflex vs. silicone.
The clinical data that I felt was most important was a comprehensive review from 2007 of over 2,300 patients that showed the 15-year durability and freedom from mechanical revision with the Mentor Alpha 1 (which is now called the Titan) to be 76 percent while the corresponding AMS device at only 10 years was 67 percent. This difference was astounding to me as I felt it was inappropriate to implant patients with a device that literally was proven to fail.
In my opinion, were the devices cardiologic pacemakers and there was a substantial difference of a mechanical revision rate, the device would be removed from the market.
I will note that both the Titan and the AMS devices have had technological enhancements since the 2007 paper. However, I continue to see significant need for mechanical revisions in lack of satisfaction for cylinder girth—especially in larger patients—with the AMS device in my practice and will not subject my patients to this potential revision rate.
The most important thing to keep in mind with my minimally invasive approach is that I utilize a small abdominal incision as opposed to any incision upon the scrotum which was the most common historical approach for the implant procedure. It is still quite popular globally. However, when coupled with the combination of axial rigidity and a Bioflex cylinder, my approach allows the urologist to use as long of a natural cylinder as possible and limits the use of hard, molded, rear-tip extenders, or RTEs, to help size and position the implant.
This combination allows the Titan to best replicate a physiologic erection for a patient’s outcome. In my opinion, after several thousand of these procedures, my technique and the Coloplast Titan device can replace the patient’s former capacity for blood-filling with as long a cylinder as possible which will fill with saline and provide a strong, firm erection.
Finally, the Titan pump is available in two models: the Titan pump that I most commonly use is a relatively small but reliable and convenient method for the patient to easily inflate and deflate the implant. With my technique, the surgeon can consistently place the pump into the most dependent or lower portion of the scrotum and the patient is able to keep it easily concealed while maintaining easy access for pumping.
It is important to note that patients commonly write to me or mention during an office visit about their concern of reduced penile length with the implant or any implant procedure. Let’s face it: guys are always concerned about length. Over time, the penis will shrink a little—especially if the patient has had any sort of pelvic surgery (for example, a prostectomy). I feel it is important to let patients know exactly what to expect after receiving an implant.
In 2009 I presented a clinical paper showing a predictive index that allows me to help patients visualize post-operative length. With this clinical measurement nearly 76 percent of the time I can show to within 1.5cm what the resulting patient’s length will be. My predictive index confirmed that a simple penile stretch test will show the patient, in advance, what his expected post-operative length will be.
This concept is very important, as patients who expect their penile length to resemble what their anatomy was like when they were 18 or 19 years old may be disappointed. The girth is easily enhanced by the Titan implant but patients will meet with me pre-operatively and if they are not satisfied with my estimates of the stretch test I will not proceed with their implant.
That said, there’s an available implant that claims to lengthen the penis. This is the AMS device. It’s called the Ultrex, or LGX, and was historically fraught with the need for mechanical revision. Anatomically the cylinders can have a difficult time stretching the inside of the penile shaft—also called the tunica—to lengthen. If the cylinders can’t exert enough pressure to lengthen, they tend to buckle upon themselves.
I had a couple of patients ask for the LGX device and I implanted one to see if there were any changes from the original Ultrex model. That patient necessitated mechanical revision within a year due to poor cylinder control and lack of rigidity with his device. I will not subject any patient to this device. Although I’ve had patients ask for this device I do not consider it an option.
I compliment you for taking the time to research the appropriate implant which best fits you. You’ve taken an important step. The area of prosthetic urology is relatively small as only a few hundred urologists focus on this art. The key is to find a specialist or come to us in Miami or online at PeritoUrology.com.
Thank you very much.
