Tratamiento de la disfuncion erectil sin video

presentación sobre el tratamiento medico y quirúrgico de la disfunción erectil.

1. Tratamiento mdx/ qx de la disfunción eréctil DR. ALFONSO MONTES DE OCA R5U ISSSTE, MONTERREY 03/AGOSTO/2020

2. OBJETIVOS repaso Tx medico oral Intracavernoso intrauretral Qx Vascular Prótesis Mecanismo de vacío LiESWT 2

3. Figure 27-10. Treatment algorithm for erectile dysfunction recommended by the International Consultations on Sexual Medicine. PDE5, phosphodiesterase type 5. 3

4. Hackett G et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men – 2017. J Sex Med 2018;15:430-57. 4

5. Énfasis Cambios del estilo de vida Evitar tabaquismo Obesidad Realizar ejercicio regularmente Abuso de alcohol Considerar cambio de fármacos que intervienen en función eréctil Optimizar el tx de dm2, has, enfermedades cardiacas Dieta sana In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 5

6. RECOMENDACIONES 7. Clinicians should counsel men with ED who have comorbidities known to negatively affect erectile function that lifestyle modifications, including changes in diet and increased physical activity, improve overall health and may improve erectile function. (Moderate Recommendation; Evidence Level: Grade C)  Initiate lifestyle changes and risk factor modification prior to or at the same time as initiating erectile dysfunction (ED) treatments. Strong Arthur L. Burnett, MD; Ajay Nehra, MD; Rodney H. Breau , MD; Daniel J. Culkin , MD; Martha M. Faraday, PhD; Lawrence S. Hakim, MD; Joel Heidelbaugh , MD; Mohit Khera , MD; Kevin T. McVary , MD; Martin M. Miner, MD; Christian J. Nelson, PhD; Hossein Sadeghi- Nejad , MD; Allen D. Seftel , MD; Alan W. Shindel , MD. Erectile Dysfunction: AUA Guideline (2018). EAU Guidelines. Edn . presented at the EAU Annual Congress Amsterdam 2020. ISBN 978-94-92671-07-3. 6

7. Tratamiento psicológico Comienza 1era consulta Aclarar las expectativas propias y el miedo al fracaso Explicar fácilmente la fisiología de la erección Se considera que son factores de mal pronostico para la respuesta al tratamiento psicológico. los problemas de larga evolución severos en la relación de pareja una marcada perdida de la libido In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 7

8. Terapia psicosexual: reducción / desensibilización sistemática de la ansiedad abordaje sensible terapia interpersonal terapia de comportamiento cognitivo educación sexual comunicación de la pareja y entrenamiento de habilidades sexuales ejercicios de masturbación In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 8

9. Modificación de la medicación Es muy posible que determinados medicamentos sean un factor prejudicial que resulte en la presentación clínica de disfunción eréctil . efectos adversos en forma de disfunción sexual tras la utilización de inhibidores selectivos de la recaptación de serotonina (p. ej ., disfunción eréctil , eyaculación retardada ) In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 9

10. CLASE MEDICAMENTO ALTERNATIVA SUG. ANTIHIPERTENSIVO DIURETICO TIAZIDICOS BETA BLOQUEADORES NO SELECTIVOS BLOQUEADOR DE CANAL DE CALCIO BETA BLOQUEADORES ESPECIFICOS ARA II IECAS PSICOTROPICO ANTISICOTICOS ANTIDEPRESIVOS ANSIOLITICOS RECIENTES ANSIOLITOCOS (BUPROPION, BUSPIRONA) ANTIANDROGENO ANTIANDROGENOS AGONISTAS DE LHRH INHIBIDORES DE 5 A REDUCTASA OPIOIDES ANTIRRETROVIRALES In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 10

11. In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 11

12. Hackett G et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men – 2017. J Sex Med 2018;15:430-57. 12

13. Tratamiento hormonal Testosterona El reemplazo androgénico aborda de modo directo el problema clínico asociado con el hipogonadismo Pg los niveles séricos hormonales de forma ideal durante el día deben aproximarse a los valores normales de referencia y simular el patrón diurno normal La eficacia del tx hormonal se determina mejor evaluando la respuesta clínica en vez de a través de una determinación precisa de los niveles de testosterona Las recomendaciones actuales sugieren que es mejor un tratamiento inicial corto (p. ej ., 3 meses ) y ante la ausencia de respuesta se debe interrumpir la administración de testosterona In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 13

14. El control de los pacientes en tratamiento consiste en una evaluación inicial que incluyen : tacto rectal APE niveles de hemoglobina / hematocrito pruebas de función hepatica nivel de colesterol y perfillipídico In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 14

15. In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 15

16. In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 16

17. Tratamientos farmacológicos simulan los mecanismos de acción bioquímicos y moleculares que rigen la respuesta eréctil . De modo conceptual, estos tratamientos actúan estratégicamente sobre el eje neurovascular responsable de la erección promoviendo los mecanismos que la favorece o contrarresta los mecanismos que la inhiben , tanto en el nivel periférico como en el nivel central In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 17

18. In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 18

19. Pocket Guide to Urology, 5th Edition, Jeff A.Wieder , J. Wieder Medical, 2014 19

20. Type 5 Phosphodiesterase (PDE5) Inhibitors 20

21. 21

22. MARCA ABSORCION VIAGRA ® x CIALIS® LEVITRA® x STAXYN TM STENDRA TM ALIMENTOS GRASOS In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 22

23. T-MAX (HRS) MARCA HORAS VIAGRA ® 1 CIALIS® 2 LEVITRA® 1 STAXYN TM 1.5 STENDRA TM .5-.75 In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 23

24. T 1/2 MARCA HORAS VIAGRA ® 4 CIALIS® 17.5 LEVITRA® 4-5 STAXYN TM 4-6 STENDRA TM 5 In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 24

25. DURACION MARCA HORAS VIAGRA ® 6-8 CIALIS® 24-36 LEVITRA® 6-8 STAXYN TM 6-8 STENDRA TM 6 In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 25

26. INTERVALO QT MARCA VIAGRA ® CIALIS® LEVITRA® SI STAXYN TM SI STENDRA TM In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 26

27. POSOLOGIA MARCA VIAGRA ® PRN CIALIS® PRN O DIARIA LEVITRA® PRN STAXYN TM PRN STENDRA TM PRN In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 27

28. VIA ORAL MARCA VIAGRA ® ZUIT ® LAMINILLA CIALIS® LEVITRA® STAXYN TM Se disuelve en la lengua STENDRA TM In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 28

29. Interacciones con otras pde MARCA ISOENZIMA VIAGRA ® 6 CIALIS® 11 LEVITRA® 6 STAXYN TM 6 STENDRA TM In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 29

30. Efectos adversos cefalea (15-16 %) Dispepsia (4-10%) enrojecimiento (4-10%) congestión nasal (3-4%) mialgia /dolor de espalda (0-3%), trastornos visuales (p. ej ., fotofobia , vision azul ) (0-3 %). In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 30

31. Hackett G et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men – 2017. J Sex Med 2018;15:430-57. 31

32. RECOMENDACIONES AUA 9. When men are prescribed an oral PDE5i for the treatment of ED, instructions should be provided to maximize benefit/efficacy . (Strong Recommendation; Evidence Level: Grade C)  10. For men who are prescribed PDE5i, the dose should be titrated to provide optimal efficacy . (Strong Recommen-dation ; Evidence Level: Grade B)  Arthur L. Burnett, MD; Ajay Nehra, MD; Rodney H. Breau , MD; Daniel J. Culkin , MD; Martha M. Faraday, PhD; Lawrence S. Hakim, MD; Joel Heidelbaugh , MD; Mohit Khera , MD; Kevin T. McVary , MD; Martin M. Miner, MD; Christian J. Nelson, PhD; Hossein Sadeghi- Nejad , MD; Allen D. Seftel , MD; Alan W. Shindel , MD. Erectile Dysfunction: AUA Guideline (2018). 32

33. RECOMENDACIONES Use PDE5Is as first-line therapeutic option. Strong Use topical/intraurethral alprostadil as an alternative first-line therapy in well-informed patients who do not wish or are not suitable for oral vasoactive therapy. Use topical/ intraurethral alprostadil as an alternative therapy to intracavernous injections in patients who prefer a less-invasive therapy. Weak EAU Guidelines. Edn . presented at the EAU Annual Congress Amsterdam 2020. ISBN 978-94-92671-07-3. 33

34. 11. Men who desire preservation of erectile function after treatment for prostate cancer by radical prostatectomy ( RP ) or radiotherapy ( RT ) should be informed that early use of PDE5i post-treatment may not improve spontaneous , unassisted erectile function. (Moderate Recommendation; Evidence Level: Grade C)  Arthur L. Burnett, MD; Ajay Nehra, MD; Rodney H. Breau , MD; Daniel J. Culkin , MD; Martha M. Faraday, PhD; Lawrence S. Hakim, MD; Joel Heidelbaugh , MD; Mohit Khera , MD; Kevin T. McVary , MD; Martin M. Miner, MD; Christian J. Nelson, PhD; Hossein Sadeghi- Nejad , MD; Allen D. Seftel , MD; Alan W. Shindel , MD. Erectile Dysfunction: AUA Guideline (2018). 34

35. 35

36. Pocket Guide to Urology, 5th Edition, Jeff A.Wieder , J. Wieder Medical, 2014 36

37. Antagonista ⍺ adrenérgico Mesasilato de fentolamina eficacia de alrededor del 40% Tomar una tableta al día de 40 mg aproximada - mente 30 minutos antes de realizar actividades sexuales . Tomarla una o dos horas después de los alimentos In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 37

38. Precauciones Administrar con cautela en pacientes con arritmias , con espasmo vascular cerebral, hipotensión arterial y con taquicardia . Reacciones adversas Congestión nasal, taquicardia , hipotensión arterial, debilidad , mareos , depresión del SNC, náusea , vómito y diarrea . In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 38

39. Antagonista ⍺ adrenérgico clorhidrato de yohimbina Yocon ® oral en dosis de 5,4 mg 3 veces por día , con observación de una mejoría luego de 1 mes por lo menos . In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 39

40. Pocket Guide to Urology, 5th Edition, Jeff A.Wieder , J. Wieder Medical, 2014 40

41. intrauretrales Sistema Uretral Medicado para la Erección (MUSE®) Vitaros ® In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 41

42. El alprostadil se absorbe en 80% a través de la mucosa uretral . El inicio de la erección del pene se presenta a los 5 a 10 minutos . La duración del efecto es de aproximadamente 30 a 60 minutos . Vida media es de 5 - 10 minutos dosis 5 -10 minutos antes de tener relaciones sexuales . In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 42

43. Se recomienda iniciar con dosis menores ( supositorios con 250 o 500 μ g de alprostadil ) por el riesgo de hipotensión . Ajustar gradualmente la dosis hasta lograr una erección sin reacciones adversas importantes hasta un máximo de 1000 μ g. Los supositorios deben conservarse en refrigeración a una temperatura entre 2 -8°C usarse 30 minutos después de sacarlo del refrigerador In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 43

44. Precauciones Se recomienda realizar una cuidadosa exploración clínica del pene antes de prescribir alprostadil trasuretral . En caso de priapismo o erecciones prolongadas se recomienda la atención inmediata y descontinuar la terapia . Interacciones medicamentosas Evitar la combinación con anticoagulantes por el riesgo de sangrado . In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 44

45. Efectos adversos Frecuentes : dolor peneano (32%) testicular (5%) ardor uretral (12%) sangrado uretral (5%) bradicardia (7%) Raros : anemia, trombocitopenia . Poco frecuentes : mareos , taquicardia . In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 45

46. Arthur L. Burnett, MD; Ajay Nehra, MD; Rodney H. Breau , MD; Daniel J. Culkin , MD; Martha M. Faraday, PhD; Lawrence S. Hakim, MD; Joel Heidelbaugh , MD; Mohit Khera , MD; Kevin T. McVary , MD; Martin M. Miner, MD; Christian J. Nelson, PhD; Hossein Sadeghi- Nejad , MD; Allen D. Seftel , MD; Alan W. Shindel , MD. Erectile Dysfunction: AUA Guideline (2018). 46

47. Hackett G et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men – 2017. J Sex Med 2018;15:430-57. 47

48. transdérmica / tópica Topiglan ® alprostadilo al 1% + SEPA AlproxTD alprostadilo + NexACT 48

49. Agonistas dopaminérgicos UPRIMA ® Apomorfina vía sublingual, con un rango de dosis de 2, 4 Y 6 mg y no tiene eficacia eréctil si es ingerida Accion rapida 12 min. para la ereccion actividad sexual exitosa del 50,6% con una dosis de 4 mg, 49

50. efectos adversos incluyen náusea (16,9%) Mareo (8,3%), bostezo (7,9%), somnolencia (5,8%), sudoración (5%) Vómito (3,7 %) síncope (0,6%) In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016).  Campbell-Walsh urology . 50

51. Agonistas del receptor de melanocortina Melanotan-2 Pt 141( bremelanotida ) OTROS L- arginina (AA precursor del óxido nítrico ) L-dopa (precursor de la dopamina ) limaprost ( prostaglandina E 1 ) naltrexona ( antagonista opiáceo ) 51

52. Inyección intracavernosa 52

53. Pocket Guide to Urology, 5th Edition, Jeff A.Wieder , J. Wieder Medical, 2014 53

54. 54 In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016). Campbell-Walsh urology.

55. 55 In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016). Campbell-Walsh urology.

56. ventajas incidencia disminuida erección prolongada efectos adversos sistémicos fibrosis peniana . desventaja mayor incidencia de erección dolorosa mayor costo una vez reconstituido en líquido se acorta su vida media si no se o mantiene refrigerado . 56 In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016). Campbell-Walsh urology.

57. PAPAVERINA Bimix • Papaverine • Phentolamine Trimix • Papaverine • Phentolamine • Alprostadil 57

58. metaboliza en el hígado vida media plasmáticaes de 1 a 2 horas. El fármaco es economico y estable a temperatura ambiente . Su eficacia es menor al 55%. Sin embargo, su utilización como monoterapia se ha abandonado debido a efectos adversos : elevaciones de enzimas hepáticas riesgo depriapismo (hasta el 35%) riesgo de fibrosis peniana (1 a 33%) 58

59. contraindicados inestabilidad psicológica Antecedentes priapismo o factores de riesgo para este antecedentes decoagulopatía enfermedad cardiovascular inestable Destreza manual reducida ( aunque se puede enseñar la técnica de inyección a la pareja ) utilizan inhibidores de la monoaminooxidasa 59

60. Hackett G et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men – 2017. J Sex Med 2018;15:430-57. 60

61. RECOMENDACIONES Use intracavernous injections as an alternative first-line therapy in wellinformed patients or as second-line therapy. Strong EAU Guidelines. Edn . presented at the EAU Annual Congress Amsterdam 2020. ISBN 978-94-92671-07-3. 61

62. 62

63. Figure 27-10. Treatment algorithm for erectile dysfunction recommended by the International Consultations on Sexual Medicine. PDE5, phosphodiesterase type 5. 63

64. PROTESIS PENANA Primeras protesis peneanas Pipa de madera Ambroise Pare – siglo 16 Protesis peneanas modernas inflable – 1973, Dr. Scott Semi-Rigid – 1978, Drs . Small and Carrion Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 64

65. Con frecuencia se aplican lesión peniana secundario a traumatismo genital o pelviano deformidad estructural en asociación con la enfermedad de La Peyronie fibrosis cavernosa secundaria a priapismo isquémico prolongado y/o infección . Asimismo , se consideran cuando el tratamiento médico de la disfunción eréctil está contraindicado , no tiene éxito o no es deseable Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 65

66. indicaciones • Failure or rejection of first- and second-line therapy of ED • Peyronie disease with severe erectile deformity • Irreversible organic cause of ED • Penile fibrosis • Post priapism, not responding to nonsurgical treatments • Phalloplasty, following penile penectomy or gender change Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 66

67. contraindications  There are only three true contraindications listed on the package insert of penile implants: (I) active infection present anywhere in the body, especially urinary tract or genital skin infection (II) patients unwilling to undergo any further surgery for device revision (III) unresolved problems affecting urination.  Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 67

68. Work up Pre- operative imaging rarely necessary • Penile duplex US • If suspected cavernosal arterial insufficiency or Peyronie’s • If concerning 🡪 consider pudendal arteriography or CTA MRI or CT potentially useful in complex revisions Urine culture Previous operative reports for revision cases Cardiac risk assessment & optimization when risk factors Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 68

69. Glucose assessment in DM – HbA1c cutoff ? - 〈 8.5 Habous M et al BJUI 2017 69

70. Expectation management = key to success What will the device improve ? Erections Spontaneity What may not improve ( or could actually be worse )? Ejaculation Orgasm Sensation Length & girth Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 70

71. equipos Inflables Dos piezas Tres piezas Cilindros Sistema de bombeo Reservorio Maleables Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 71

72. 72

73. 73

74. Cirugía protésica peniana 74

75. Infection Control Strategies Pre- operative washes Optimize DM control Pre- op hair removal with razor High alcohol based prep *** Peri- operative antibiotics Consider + fungal coverage for high risk patients Efficient surgery Limit room traffic Decrease device handling (no or minimal touch technique ) Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 75

76. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 76

77. Penoescrotal 77

78. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 78

79. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 79

80. 4 Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 80

81. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 81

82. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 82

83. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 83

84. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 84

85. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 85

86. Corporotomy   Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 86

87. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 87

88. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 88

89. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 89

90. Reservoir placement: retropubic space  Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 90

91. Ectopic (aka intraabdominal wall or high submuscular )  Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 91

92. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 92

93. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 93

94. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 94

95. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 95

96. Post- qx Urinary catheter It can be removed at the end of the procedure or retained for 24 hours after surgery. Drain Some surgeons prefer to use a drain to reduce the edema and to facilitate drainage of hematoma. These drains are usually removed on postoperative day 1 or day 2. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 96

97. Infrapubic 97

98. Wound care The penis is positioned over the suprapubic region pointing toward the umbilicus. The patient is reviewed in theoutpatient clinic after 2 weeks to check the wound and torule out autoinflation . Pain It may be aggravated by preexisting conditions. For most patients, pain is no longer bothersome by 4–6weeks. Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 98

99. A reasonable method is to leave the prosthesis partially (50-60%) inflated at the conclusion of the procedurE this will encourage proper modeling of the penis and also maintain good hemostasis • Cycling starts between 4-6 weeks ( allow corporotomy healing ) • Have patient pump to maximum inflation twice daily for >15 minutes Break in the device Stretch capsule during healing to prevent constriction Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement.  Translational Andrology and Urology ,  6 (4), 628–638. https:// doi.org /10.21037/tau.2017.07.32 99

100. Arthur L. Burnett, MD; Ajay Nehra, MD; Rodney H. Breau , MD; Daniel J. Culkin , MD; Martha M. Faraday, PhD; Lawrence S. Hakim, MD; Joel Heidelbaugh , MD; Mohit Khera , MD; Kevin T. McVary , MD; Martin M. Miner, MD; Christian J. Nelson, PhD; Hossein Sadeghi- Nejad , MD; Allen D. Seftel , MD; Alan W. Shindel , MD. Erectile Dysfunction: AUA Guideline (2018). 100

101. complicaciones INSERTION OF PENIL PROTHESES (IMPLANTS) FOR ERECTIL DYSFUCTION, BAUS, JUNE 2017, Leaflet No: 16/082 ,  http:// www.baus.org.uk /_ userfiles /pages/files/Patients/Leaflets/Penile prostheses.pdf   101

102. INSERTION OF PENIL PROTHESES (IMPLANTS) FOR ERECTIL DYSFUCTION, BAUS, JUNE 2017, Leaflet No: 16/082 ,  http:// www.baus.org.uk /_ userfiles /pages/files/Patients/Leaflets/Penile prostheses.pdf   102

103. Prosthesis infections: ~0.5-3% of primary placements Options: Device removal with delayed reimplantation Loss of penile length/girth due to fibrosis More difficult reimplantation Washout with salvage replacement May preserve penile length/girth Potentially higher rate of infection, need for removal 103

104. Washout Remove all prosthesis components & foreign material Culture spaces with swab and/or aspiration Copious irrigation of all sites Change all gowns, gloves, drapes and instruments Place new implant – MPP (consider IPP) Close wounds, consider temporary drain Oral antibiotics empirically 104

105. RECOMENDACIONES 20. Penile prosthetic surgery should not be performed in the presence of systemic, cutaneous, or urinary tract infection. (Clinical Principle)  Use implantation of a penile prosthesis if other treatments fail or based upon patient preference. Strong Arthur L. Burnett, MD; Ajay Nehra, MD; Rodney H. Breau , MD; Daniel J. Culkin , MD; Martha M. Faraday, PhD; Lawrence S. Hakim, MD; Joel Heidelbaugh , MD; Mohit Khera , MD; Kevin T. McVary , MD; Martin M. Miner, MD; Christian J. Nelson, PhD; Hossein Sadeghi- Nejad , MD; Allen D. Seftel , MD; Alan W. Shindel , MD. Erectile Dysfunction: AUA Guideline (2018). EAU Guidelines. Edn . presented at the EAU Annual Congress Amsterdam 2020. ISBN 978-94-92671-07-3. 105

106. REVASCULARIZACION Trost LW, Munarriz R, Wang R, Morey A, Levine L. External Mechanical Devices and Vascular Surgery for Erectile Dysfunction.  J Sex Med . 2016;13(11):1579-1617. doi:10.1016/j.jsxm.2016.09.008 106

107. Work-up Penile duplex US If concerning 🡪 selective angiogram or CTA Cavernosometry to rule out veno -occlusive disease techniques Trost , L. W., Munarriz , R., Wang, R., Morey, A., & Levine, L. (2016). External Mechanical Devices and Vascular Surgery for Erectile Dysfunction.  The Journal of Sexual Medicine ,  13 (11), 1579–1617. https:// doi.org /10.1016/j.jsxm.2016.09.008 107

108. • ↑ volume of antegrade arterial or retrograde venous flow Most commonly inferior epigastric art 🡪 dorsal penile and/or cavernosal art MICHAEL II CRESPO • Reported success rates 36-91% Trost , L. W., Munarriz , R., Wang, R., Morey, A., & Levine, L. (2016). External Mechanical Devices and Vascular Surgery for Erectile Dysfunction.  The Journal of Sexual Medicine ,  13 (11), 1579–1617. https:// doi.org /10.1016/j.jsxm.2016.09.008 108

109. RECOMENDACIONES 21. For young men with ED and focal pelvic/penile arterial occlusion and without documented generalized vascular disease or veno -occlusive dysfunction, penile arterial reconstruction may be considered. (Conditional Recommendation; Evidence Level: Grade C)  22. For men with ED, penile venous surgery is not recommended. (Moderate Recommendation; Evidence Level: Grade C)  Arthur L. Burnett, MD; Ajay Nehra, MD; Rodney H. Breau , MD; Daniel J. Culkin , MD; Martha M. Faraday, PhD; Lawrence S. Hakim, MD; Joel Heidelbaugh , MD; Mohit Khera , MD; Kevin T. McVary , MD; Martin M. Miner, MD; Christian J. Nelson, PhD; Hossein Sadeghi- Nejad , MD; Allen D. Seftel , MD; Alan W. Shindel , MD. Erectile Dysfunction: AUA Guideline (2018). EAU Guidelines. Edn . presented at the EAU Annual Congress Amsterdam 2020. ISBN 978-94-92671-07-3. 109

110. Although early proposed mechanisms suggested that tumescence was achieved by passive retrograde venous flow, more recent data have indicated: penile oxygen saturations reached 79.2% immediately after VED placement 58% arterial 42% venous Vacuum /BOMBA DE VACIO Trost , L. W., Munarriz , R., Wang, R., Morey, A., & Levine, L. (2016). External Mechanical Devices and Vascular Surgery for Erectile Dysfunction.  The Journal of Sexual Medicine ,  13 (11), 1579–1617. https:// doi.org /10.1016/j.jsxm.2016.09.008 110

111. water-soluble lubricants are applied to the base of the penis to create a tight seal between the device and pelvis. Then, negative pressure (100 - 225 mm Hg) is generated through a manual or an automatic pump, and an artificial erection is created. The time required to achieve an erection ranges from 30 s - 7 m Trost , L. W., Munarriz , R., Wang, R., Morey, A., & Levine, L. (2016). External Mechanical Devices and Vascular Surgery for Erectile Dysfunction.  The Journal of Sexual Medicine ,  13 (11), 1579–1617. https:// doi.org /10.1016/j.jsxm.2016.09.008 111

112. Hackett G et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men – 2017. J Sex Med 2018;15:430-57. 112

113. RECOMENDACIONES Use vacuum erection devices as a first-line therapy in well-informed patients with infrequent sexual intercourse and comorbidities requiring non-invasive, drugfree management of ED. Weak  The vacuum erection device ( VED) is effective in creating an erection satisfactory for intercourse, even in difficult-to-treat populations such as DM, spinal cord injury, and after radical proctectomy (RP; LOE .  2; strength of recommendation . B; recommended). EAU Guidelines. Edn . presented at the EAU Annual Congress Amsterdam 2020. ISBN 978-94-92671-07-3. 113

114. Es importante señalar que la terapia de ondas de choque ( SWT ) está aprobada por la FDA para la fasceítis plantar crónica úlceras del pie diabético epicondilitis lateral crónica pero no para la disfunción eréctil 114 low-intensity extracorporeal shock wave therapy ( LI-ESWT ) 

115. Mediante el microtrauma hay una promoción de neo- angiogénesis como resultado de la regulación factor de crecimiento endotelial vascular la mejora de la microcirculación regeneración nerviosa remodelación del tejido eréctil estos efectos beneficiosos parecen estar mediados por el reclutamiento de células madre mesenquimales endógenas y la regeneración de los nervios de óxido nítrico sintasa neuronal positivos . Yang, H., & Seftel , A. D. (2019). Controversies in low intensity extracorporeal shockwave therapy for erectile dysfunction.  International Journal of Impotence Research ,  31 (3), 239–242. https:// doi.org /10.1038/s41443-019-0124-0 115

116. The most prevalent practice is to split treatments into two batches 3 - 4 week break in between . The commonly used “ twice 3 weeks ” protocol 6 treatment sessions over 3 weeks followed by a period of rest and then another 6 treatments over 3 weeks has been shown to be effective in several studies Alternatively , Kalyvianakis et al. Was also able to demonstrate that 12 consecutive sessions over 6 weeks provides good outcomes Yang, H., & Seftel , A. D. (2019). Controversies in low intensity extracorporeal shockwave therapy for erectile dysfunction.  International Journal of Impotence Research ,  31 (3), 239–242. https:// doi.org /10.1038/s41443-019-0124-0 116

117. The optimal candidate for Li-ESWT is yet to be determined . Currently , only vasculogenic ED patients have been evaluated as candidates for Li-ESWT Yang, H., & Seftel , A. D. (2019). Controversies in low intensity extracorporeal shockwave therapy for erectile dysfunction.  International Journal of Impotence Research ,  31 (3), 239–242. https:// doi.org /10.1038/s41443-019-0124-0 117

118. RECOMENDACIONES For men with ED, low-intensity extracorporeal shock wave therapy (ESWT) should be considered investigational. (Conditional Recommendation; Evidence Level: Grade C)  Arthur L. Burnett, MD; Ajay Nehra, MD; Rodney H. Breau , MD; Daniel J. Culkin , MD; Martha M. Faraday, PhD; Lawrence S. Hakim, MD; Joel Heidelbaugh , MD; Mohit Khera , MD; Kevin T. McVary , MD; Martin M. Miner, MD; Christian J. Nelson, PhD; Hossein Sadeghi- Nejad , MD; Allen D. Seftel , MD; Alan W. Shindel , MD. Erectile Dysfunction: AUA Guideline (2018). 118

119. bibliografia Arthur L. Burnett, MD; Ajay Nehra, MD; Rodney H. Breau , MD; Daniel J. Culkin , MD; Martha M. Faraday, PhD; Lawrence S. Hakim, MD; Joel Heidelbaugh , MD; Mohit Khera , MD; Kevin T. McVary , MD; Martin M. Miner, MD; Christian J. Nelson, PhD; Hossein Sadeghi- Nejad , MD; Allen D. Seftel , MD; Alan W. Shindel , MD. Erectile Dysfunction: AUA Guideline (2018). EAU Guidelines. Edn . presented at the EAU Annual Congress Amsterdam 2020. ISBN 978-94-92671-07-3. Hackett G et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men – 2017. J Sex Med 2018;15:430-57. Trost , L. W., Munarriz , R., Wang, R., Morey, A., & Levine, L. (2016). External Mechanical Devices and Vascular Surgery for Erectile Dysfunction. The Journal of Sexual Medicine, 13(11), 1579–1617. https://doi.org/10.1016/j.jsxm.2016.09.008 Arthur L. Burnett, MD; Ajay Nehra, MD; Rodney H. Breau , MD; Daniel J. Culkin , MD; Martha M. Faraday, PhD; Lawrence S. Hakim, MD; Joel Heidelbaugh , MD; Mohit Khera , MD; Kevin T. McVary , MD; Martin M. Miner, MD; Christian J. Nelson, PhD; Hossein Sadeghi- Nejad , MD; Allen D. Seftel , MD; Alan W. Shindel , MD. Erectile Dysfunction: AUA Guideline (2018). Trost , L. W., Munarriz , R., Wang, R., Morey, A., & Levine, L. (2016). External Mechanical Devices and Vascular Surgery for Erectile Dysfunction. The Journal of Sexual Medicine, 13(11), 1579–1617. https://doi.org/10.1016/j.jsxm.2016.09.008 Gupta, N. K., Ring, J., Trost , L., Wilson, S. K., & Köhler, T. S. (2017). The penoscrotal surgical approach for inflatable penile prosthesis placement. Translational Andrology and Urology, 6(4), 628–638. https://doi.org/10.21037/tau.2017.07.32 In Wein, A. J., In Kavoussi , L. R., Campbell, M. F., & Walsh, P. C. (2016). Campbell-Walsh urology. Pocket Guide to Urology, 5th Edition, Jeff A.Wieder , J. Wieder Medical, 2014 Hackett G et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men – 2017. J Sex Med 2018;15:430-57. 119

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