Phone Consult w/ Dr Chen Q&A (Stage 2)

The following is my best recollection from my notes following my phone consultation on August 25th, 2016 with Dr Chen regarding my quickly approaching “Stage Two” Semi Rigid Erectile Rod and Testicular implant surgery on October 11th, 2016. This is by no means a word-for-word account. Rather this is the closest I can share with you of the full extent of our conversation that makes sense to present via this type of platform. This also covers some questions that I have that are unrelated to the specifics of implants but I thought some of you might still be curious about regardless.

Dr Chen is a great guy and an extremely talented and innovative surgeon. I always appreciate speaking with him because he shares information with me that I haven’t had the opportunity to hear or learn about elsewhere. I value how receptive he is to the person he’s speaking with and how willing he is to go into greater detail when he senses someone’s desire to know more than just the glossy basics. I hope you come away with that feeling as well after reading this and learn something new today.

Me: I’ve been experiencing a disturbing dripping sensation internally at the place where I imagine the vaginectomy/colpocleisis was performed. I’m worried that this is a sign that a piece of mucosa that was missed during the initial procedure and that fluid is now building up in this space.

Dr Chen: We actually hear about a lot of weird sensations being reported within the first 6-12 months in that area. And that’s because we cut a lot of nerves in order to close up that area. You’re the first person that I’ve heard describe the sensation of wetness, whereas most others are describing the sensation of tingling or discomfort off and on. If you’d like I’m happy to write an order for a CT scan to take a closer look at that area, I’m not sure if insurance would approve it, but I’m happy to write an order for one and see if they’ll approve it because I’d be curious to see what it would show. But in general, odd sensations in this area are quite common up to around the 12 month mark since the nerves are the things that take the longest to heal.

Also, there is a technique that we used to use when creating the urethra that put the patient at a higher risk for having a urethral diverticulum. We used to use this technique because it minimized how many incision lines there are in the urethra. However, it created “outpouchings” (or side pockets) where urine could collect. It also made it necessary for a camera to be used to help guide a catheter because the the tip could caught in one of the outpouchings instead of continuing along the urethra. What we found is that very rarely, urine would pool and collect in this pocket and cause an infection. If this was the case it would require surgical correction. But we’ve only had one case where surgery was needed. However, I spent a lot of time thinking about how we could do this differently but in a safe way. Beginning August 1st, I started using a new technique. Since using this new technique which no longer creates pockets along the urethra – a catheter can now be inserted no problem without a camera! I mention this because I don’t know if these more recent patients might report a different kind of internal sensation in the first 12 months with this technique since it’s still so new.

Me: This is more of an aside question but just so I’m clear, does this mean that anyone that had surgery with the Brownstein Crane team (you or Dr Crane) before August 1st, would need a camera assisted catheterization?

Dr Chen: Yes, it wouldn’t have to be myself or Dr Crane that did the catheterization, but just as long as they used a camera to avoid those little pouches and be guided into the bladder it wouldn’t be an issue.

Me: I’m guess I’m most concerned about a situation where I might have some kind of emergency need for a catheterization but not be awake to let someone know that it must be camera assisted. If someone didn’t use a camera could they potentially damage my urethra if they tried to insert the catheter?

Dr Chen: It’s possible. I’ll say though that most health care providers are very gun-shy when it comes to new things and a neo phallus is a new thing. It’s much more likely that they would probably just automatically call a urologist.

Me: The other sensation I notice sometimes too is an odd buildup of pressure along the perineum. I’ve sort of asked around and I know that there have been some other reports of wetness sensation from other guys that have had the colpocleisis type of vaginectomy which only partially removes the lower part of the canal and then fulgurates (or burns) the remaining mucosa layer that cannot be safely removed with scissors, which would increase the risk for things like bladder, ureter, urethra, or rectal injuries. But I don’t know that I’ve heard of these same odd sensations being reported by those having a full vaginectomy, which is I guess is a more typical procedure in cases of vaginal cancer where it’s much more crucial that the entire structure be removed and thus the higher risks associated with that procedure are more warranted.

Dr Chen: The way we do it now, I’m VERY confident that I get all the mucosa. I check 2 or 3 times before I close up the vaginectomy site. The one CT scan we got for someone post-op where we used this technique I think is the only CT scan we have on record, which I believe was for a differently related reason. But I looked at the vaginectomy site to see if there was anything going on one month post-op in that area and I didn’t see anything, it was completely closed, totally obliterated. But of course, that’s only a sample size of one.

Me: I guess then I will wait out the odd sensations for now and see if that improves on it’s own. So I do have a very small divet where the hole along my perineum took so long to close/heal. Ideally I would like a flat surface rather than a dip at my perineum. I’m wondering how easily this might be revised during my implant surgery?

Dr Chen: We could. The only downside with that is that it lengthens the time of the surgery and it gets into the area behind the scrotum that’s closer to the anus which could put you at higher risk of infection of some sort. I try to do avoid that area is possible when I do these implants because that’s where a lot of bacteria lay. Now I’m not going to do anything silly like have the implant exposed while I’m doing the perineal revision. I do whatever I can to minimize the risk of infection, so the risk I think, overall is low, but it’s slightly higher when we do revisions in that area.

Me: I see what you mean, so there’s a higher risk of infection with regards to the IMPLANTATION area getting infected, not the perineal area?!

Dr Chen: Yeah, exactly.

Me: Ok, I think I’ll give that some thought then and make a final decision when I come out there to see you for pre-op and you have the opportunity to take a look at that area in person. Maybe in the meantime we can still add those tentative insurance codes to the pre-authorization just in case I decide to move forward with that procedure?

Dr Chen: Yeah, sure.

Me: So in terms of implants, I know I want the largest testicular implants that you can fit. And it seemed like you thought that I could probably accommodate the largest one. In terms of the erectile device I’m probably leaning more towards semi rigid rod than the inflatable, I’m not going to have insurance past around the December mark so I’m trying to think about what is going to give me the best shot at not having complications and also having something that’s going to last for a while. I’m not quite sure when I’ll have insurance again that would cover this. Girth is really the biggest thing for me and obviously I want an erectile implant because I want to be able to have penetrative sex but girth and fullness is really a big concern for me. All the fat grafting melted away and at about 4 or 5 weeks out it was totally gone. I was well informed that there was a high likelihood of that happening, but it was something I was willing to try. So really at this point I’m just focussed on coming up with a solution for what the best option is for giving me the most all around girth and fullness. Not even being super thick, but an all around very full appearing penis and I feel like it has kind of more of a deflated look than I want and so I’m wondering is the rod the best option in terms of fullness? I know you mentioned that the rod is about 30cc in size, what would you say the pump is when it’s fully inflated?

Dr Chen: The measurements for the fully inflated pump, the circumference is slightly larger than the semi rigid. That being said, the inflatable, we can’t wrap it in a sheath all the way to the tip, whereas with the semi rigid we are. So when we add the sheath over the semi rigid, they’re about the same size in terms of girth even though on paper it’s higher for the inflatable. I think girth-wise they’re gonna be the same but it’s basically which one are you more excited about. Is it the inflatable one that’s more natural with more moving parts and a high potential for revisions and surgery sometime in the near future? Or would you want something that’s always semi hard but has a lower chance of mechanical breakdown?

Me: I am leaning MUCH more towards the malleable rod, mostly because it’d be 100% the same girth all the time and then also I would be able to have two symmetrical testicles which feels pretty important to me… Is it possible, you said you wrap it in a gortex sheath, is it possible to layer up on that, to add more Gortex to give even a fuller look?

Dr Chen: We potentially could. I haven’t done that before but, we could. I don’t know what the performance characteristics would look like because we’ve never done that. But if it’s safe to do so we can try that.

Me: The other question I had in terms of girth and being creative and trying to find a solution for that problem because I know you have to be careful about how close to the tip you get with the rod with both the pump and the malleable, but have you thought about or has anyone asked you about using some kind of permanent filler like Juvederm as an extra or addition to the IPP to kind of fill out areas that the rod or inflatable might not reach, like the head?

Dr Chen: No we haven’t tried that. I think that’s a reasonable thought. I would think though that adding any foreign body into that area would require sticking a needle to get the Juvederm there and that then introduces a passageway for bacteria to get to that area. So, I’m not super excited about that, but that’s the main reason why. That’s the only hesitation I have for that. Bacteria.

Me: Ok, well then it probably makes the most sense to do just do the rod, layer up on the Gortex sheath if it’s safe and possible to do so, get the testicular implants, heal up, and then see where that leaves me a few months down the road once any remaining edema has subsided… In terms of how the rod is mounted, a couple of questions, 1.) Will the rod change the angle/direction of the base of my shaft, kind of making the penis come out in front of my body a little bit more?

Dr Chen: It could, for some patients it does, for others it stays the same so I can’t tell you for sure but that’s definitely a possibility.

Me: I enjoy doing a lot of yoga and I’m wondering if anyone reports issues with laying on their stomach? In terms of where the rod is mounted I’m worried that I might displace the mounting point even after it’s fully healed months and months down the road, even after I’m cleared for sex. What am I looking at in terms of mobility?

Dr Chen: Yeah, it can limit how active you can be because it’s always there. Certain positions are not good for it. Belly down might not be comfortable. If it’s not comfortable you shouldn’t do it. The biggest complication we’ve had lately is the attachment rips off the pubic bone. And that’s in guys who are unlucky that get kicked in the groin or pulled to hard, something along those lines. We’ve changed our technique a little bit as we’ve seen that. We’re now using stronger metal wire as opposed to the thick silk suture which is what we used before and usually that worked just fine. But we’re starting to use metal wire now to make sure that that risk goes down.

Me: I’m planning to take a full 6-8 weeks off of work and being incredibly sedentary and immobile during that time to ensure I don’t cause any added strain on the connection points, is it true that even going for a long walk is not advised?

Dr Chen: Yes, anything that causes discomfort. If it’s uncomfortable or painful, stop.

Me: I think those are most of my questions. I did want to also ask though about my SP scar. When I touch it and try to move the skin it feels like it’s completely adhered to my bladder? Would that be correct or maybe it’s muscle?

Dr Chen: Muscle.

Me: Is that something that can be released fairly easily? I know you had mentioned that it’s wise to let the scar mature for a year but I’m trying to finish everything up in this October surgery.

Dr Chen: It’s actually really close to the incision that I make to put the implant in, so there is a good chance that it would just be gone as a part of our procedure. But if it’s too high from where I make the incision I can easily just dissect that way and break the adhesion.

Me: In terms of making sure that I get the largest testicular implants that can safely fit, is that something that needs to be ordered ahead of time? I know a decision about erectile device needs to be made a couple weeks in advance so that it can be ordered.

Dr Chen: Nope, we have all the sizes here and I’ll put the biggest and safest ones in as possible. Safety will always take precedent, though.

          *           *           *           *           *

Well, that was pretty much the bulk of our conversation. There were a couple other minor things that I left out and will spare you, but nothing major. I will however be in the office next week for pre-op, so if there are any lingering or unique questions that anyone has that they haven’t been able to find answers for elsewhere I’m always especially eager to toss those out.

 

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