Dr. Paul Perito Talks about His Minimally Invasive Penile Implant Technique®


[Read the full transcript below]

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Coloplast Video Library: Evolution in Penile Implantation Technique & Patient Outcomes

FULL INTERVIEW TRANSCRIPT:
Perito Minimally Invasive Penile Implant Technique® featuring Paul E. Perito, MD

DR. IRWIN GOLDSTEIN:
We have Dr. Paul Perito from Coral Gables. Paul has mastered a surgical technique of fifteen minutes. A minimally invasive procedure. Paul, you are awesome. Take it away.

DR. PAUL PERITO:
Thank you very much. It’s great being with you guys again. Dr. Kramer is joining us this time in Las Vegas. Last time was Coral Gables. We’ll see—maybe we’ll be on the West Coast next time. Basically I’d like to go over some things that have been published and thrown out there—new concepts and new ideas that will help the patient find the best modality for him in order to achieve his erections again. We’ve had some really wonderful papers that have come out from all of us over the past five years. I’d like to go over a few that I think are very important to the patient.

If you look at this first slide, Dr. Goldstein, it’s a very busy slide. I looked at about one thousand patients and this was maybe the first two years after we had our webcast. When I looked at those one thousand patients, our morbidity was as good as or better than anybody else’s. Our complication rate was extremely low—in other words, our infection rates were less than one percent. We have great numbers. But the number that really impressed me, the thing that I really started to strive for, is the number on the bottom right which is 82 percent of patients are resuming normal sexual function at four weeks.

Now I don’t know if you remember, last time we talked about how there is 300,000 breast implants in the United States but there’s only 20,000 penile implants across the globe—of which I’m doing 500. There is something wrong with those numbers. This is one thing that I was really aiming toward—which is making our patients have a real quick rehabilitative period and they resume normal function as quickly as possible like orthopedic surgeons do for knees and hips.

DR. IRWIN GOLDSTEIN:
So you link, Paul, the minimally invasive, faster surgery to quicker recovery?

DR. PAUL PERITO:
Absolutely. Everything else, when it comes to looking at serious implanters was similar—infection rates, other complication rates—which were extremely low. But the one thing that I saw different was time to resuming normal sexual function.

DR. IRWIN GOLDSTEIN:
I’ve heard you mention the importance of your team, the pit team, the crew—doing this repetitively, frequently. Do you buy into that as well?

DR. PAUL PERITO:
Oh, totally. My back table, they’re my heart and soul. And by my back table I mean the girl that hands me my instrument, the guy that’s preparing the implant. It is a team. The racetrack metaphor—I’ve never heard that but it’s very apropos for what we do. There are a couple of concepts that I think are extremely important. This one right here is one that you helped me identify. In 2009, collaborating with Baylor University and Dr. Mohit Khera, we were looking at ectopic placement of a penile implant reservoir. Ectopic placement meaning in the place where it has not normally been placed.

This was utilized because patients who had had significant pelvic surgery, in order to avoid very disastrous complications (bowel, bladder, and vascular complications), we were looking for another place to put the reservoir. I flew out to Baylor. I was leaning over Dr. Khera’s shoulder. It is so simple to place these things in that ectopic position that we decided we were going to write a small paper.

DR. IRWIN GOLDSTEIN:
So the normal place is next to the bladder? Where is the normal place?

DR. PAUL PERITO:
The normal place is behind the pubic bone. That is not where I’ve ever placed it. I’ve always put it transversalis fascia – behind your abdominal wall. If a gentleman has had, for example a robotic prostatectomy, the anatomy in that area has changed. It has changed so significantly that we’re seeing a lot more complications when it comes to reservoir placement.

I want to quickly show you how we do this. If you look, I do an infra-pubic incision slightly different than Dr. Eid in that it’s above the penis. But you see I mark the external inguinal ring on the right-hand side. Where this reservoir goes is you take your nasal speculum and you gently slide it in-between the abdominal wall layers that are called the interior rectus fascia or transversalis fascia. Then you turn your blades upright and there’s this beautiful place to place the reservoir where it’s impossible to have one of those catastrophic —.

DR. IRWIN GOLDSTEIN:
There’s no bowel, no bladder.

DR. PAUL PERITO:
There’s no bowel, no bladder, no vascular structure. So it’s impossible to have one of those complications occur. To me it’s a no-brainer. Every single patient that has had significant pelvic surgery, I’m doing ectopic placement.

I want to go over very quickly things not to do. Try not to place that reservoir too obliquely along the abdominal wall because it tends to be more palpable. You can see, if you drive that nasal speculum up toward the head, you are going to be in the proper place where it won’t be palpable. One thing not to do is go down. Do not go down. If you go down it’s a bad place to be. We used to use our finger in order to drive the reservoir up towards the shoulder—and I’ll show you later we’re now using a yankauer suction. Now you can see how it’s dropped in quite nicely, adding no time to the procedure.

This is a paper that I authored with Dr. Wilson where we’ve shown that these ectopic placements can be done using Dr. Eid’s procedure or my procedure.

DR. IRWIN GOLDSTEIN:
And Coloplast has done unique design to the reservoir.

DR. PAUL PERITO:
That’s what this slide is about. If you look at the new reservoir that they’ve developed, this cloverleaf reservoir, when you pull it out and you lay it flat, and then you slightly under fill it, this reservoir is barely palpable, if at all palpable. Out of hundreds, probably over 200 that I have placed in this position, I’ve had two guys where they can feel it, where it’s enough to slightly bother them. But believe me, to avoid a catastrophic complication, it’s much better to go ectopically.

DR. IRWIN GOLDSTEIN:
So the cloverleaf adds volume. So for a given amount of fluid, there is not this same expansion.

DR. PAUL PERITO:
Exactly. It lays low profile. It also has sort of a flange affect so it won’t migrate down.

DR. IRWIN GOLDSTEIN:
Excellent.

DR. PAUL PERITO:
It’s the perfect reservoir for ectopic placement.

DR. IRWIN GOLDSTEIN:
So when we did this five years ago this—.

DR. PAUL PERITO:
It was not available.

DR. IRWIN GOLDSTEIN:
So the reason why we’re doing—.

DR. PAUL PERITO:
One of the reasons why we’re showing the new stuff—. This slide basically reiterates the fact that when I do place it ectopically I under-fill it so that it’s barely palpable—if at all palpable. It’s a perfect reservoir for that patient.

DR. IRWIN GOLDSTEIN:
This doesn’t make your 15 minutes now 20 minutes?

DR. PAUL PERITO:
No. No. It’s down to 11. It doesn’t add any time. Actually, you talk about teams. The guy who assists me on most of my implants, he one day took the—you can see the yankauer suction on the bottom left picture, he took the yankauer suction and gently drove it up into the patient’s abdominal wall. It’s the slickest thing I’ve ever seen. So I’m going to give him the credit for that.

This slide, to me, means a lot because probably the most important thing I’ve learned after doing 4,000 of these things is that the biggest complaint that I’ve encountered has been penis size. Now, if you go on the internet and you are looking at blogs you will see patients talking about their penile size after penile implantation, it suggests that the penile implant makes the penis smaller. Now in reality, we know that is not true. There has been research since we last spoke, that has shown where, when we render a patient impotent, the first day he is rendered impotent with a radical prostatectomy, and we follow them, what do you think they lose?

DR. IRWIN GOLDSTEIN:
They get shrinkage. They blame the penile implant.

DR. PAUL PERITO:
[They lose] 0.5 to 5 centimeters every 18 months. That’s 30 feet on a boat. That’s a lot of loss for penile length. What I do is I tell patients, “If you are starting to have problems, there is nothing better than using your own penis. So PDE-5 inhibitors, active injections—they’re all great. But once you’re rendered impotent you need to start to move. Because, otherwise, you will lose 0.5 to 5 centimeters.

What I wanted to find was a good, predictive indicator for what are you going to have post-operatively? So since we last saw each other in this venue, what I did was I went inter-operatively and I would create an artificial erection which is part of my procedure, if you remember. If you look here, here is the artificial erection. So this is what he would have if he were having an erection. So I measured that. Then I measured the penile stretch test.

Now there is one you taught for years, 30 years at Boston University. You know how they say “never” or “always” is the wrong answer? Well, there is one question in medicine that is always answered the same way. When I do a penile stretch test and I pull on the patient’s penis and I say, “You know what? I’ll bet your penis used to be this long,” and I’ll go an inch longer than where I’m pulling it—100 percent of the time they say, “No, it used to be this long.” And they go two inches. One hundred percent of the time. I’ve never had a guy who says, “No, actually, it’s actually right where it is.” Well, what we did was with the inter-operative stretch test and then we measure the penis after the penile implant was in place we found that the best predictive indicator for penile size after a penile implant is the penile stretch test.

DR. IRWIN GOLDSTEIN:
Okay, good.

DR. PAUL PERITO:
So I’ve gotten to the point now where a patient comes in and I do a penile stretch test and I say, “This is what you are going to have. If you wait another year …then I’ll push it up against his abdomen, and I’ll show them where it’s going to be. If they say, “No, it has to be bigger,” then you really can make the patient’s expectations appropriate for what they’re going to see post-operatively.

DR. IRWIN GOLDSTEIN:
So for someone who is impotent and doesn’t respond to treatments, there may be a price for indecision is what you’re saying.

DR. PAUL PERITO:
Yes, totally. It’s a well-defined price. Since I’ve been doing that, I’ve noticed that I’m not having that unhappy patient where he’s upset. His expectations are set properly and actually it lends an urgency to having their implant performed—which I think is appropriate. We’re not selling implants; we’re helping a guy out. You’re giving him the facts. This slide here—this was a statistically significant finding which is great. To be able to give a patient within 95 percent certainty of where they’re going to be—.

This is a slide from your most recent trip down. I was honored to have Dr. Goldstein come in for my new office opening. We have a concierge service. It’s a great facility where we pay attention to patient’s fitness, patient hormone levels—not just doing the penile implant. It’s a men’s health center.

DR. IRWIN GOLDSTEIN:
Well, congratulations. The two of you are the epitome of the serious implanter and subspecialty of prosthetic urology. It’s awesome. Both of you are great human beings.