CASE REPORTS: Report of Two Cases of Bladder Perforation Caused by Reservoir of Inflatable Penile Prosthesis

Management of the Inflatable Penile Prosthesis Reservoir at time of revision surgery: remove, retain, or recycle?

BACKGROUND

Three common strategies exist for managing the inflatable penile prosthesis reservoir during revision surgery: the original reservoir can be (a) removed, (b) deactivated and left in situ, sometimes referred to as "drain and retain" (DR), or (c) validated and reconnected to new cylinders, which we have termed "reservoir recycling" (RR).

AIM

To compare the efficacy and safety of the RR approach to penile prosthesis revision against DR and the recommended approach of complete device removal and replacement.

METHODS

A retrospective chart review of our single-surgeon inflatable penile prosthesis database between 2007 and 2022 was performed, identifying revision surgeries. Cases were stratified by reservoir management technique. Patients who had undergone at least 1 follow-up visit and had complete documentation regarding reservoir handling were included. Reservoir-related complications necessitating surgical intervention such as infection and device failure were compared between the 3 groups using a chi-square test. Mean follow-up duration, time to revision, and operative time were also assessed.

OUTCOMES

The primary outcome was the incidence of reservoir-related complications requiring surgical intervention and secondary outcomes included time to revision surgery and operative time.

RESULTS

Among 140 patients meeting inclusion criteria, 62 underwent full reservoir replacement (FR), 48 DR, and 30 RR. Compared to FR, DR and RR groups had similar mean time to revision and intraoperative time. Follow-up duration was similarly limited for all 3 groups at a median of approximately 4.5 months. There were no postoperative infections in the RR cohort. However, when compared to the DR and FR groups, this did not reach significance (P = .398). There was no difference in mechanical failure rate between the 3 groups (P = .059). Nonmechanical failure was also similar between all 3 groups (P = .165).

CLINICAL IMPLICATIONS

These results suggest that RR exhibits comparable outcomes to DR and FR, making it a viable option during select penile prosthesis revision surgeries, potentially decreasing morbidity without compromising outcomes.

STRENGTHS AND LIMITATIONS

This is the first study to evaluate outcomes after RR. Limitations include small sample size, limited follow-up, and single-surgeon experience.

CONCLUSION

There was no difference in reservoir-related complications when comparing the 3 methods. These preliminary results suggest that reservoir recycling may provide a safe and effective reservoir-handling alternative in inflatable penile prosthesis revision surgery.

A propensity score-matched analysis of intra- and postoperative penile prosthetic complications in the solid organ transplant population

INTRODUCTION

Solid organ transplant (SOT) has an anticipated higher risk of penile prosthesis (PP) complications related to immunosuppression and surgical approach post-SOT. It is still not determined if PP surgery in the SOT population incurs these same higher risks.

OBJECTIVES

To observe differences in intra- and postoperative PP complications between SOT and non-SOT cases from the TriNetX US Collaborative Network, a large real-world database of deidentified patient data from 56 health care organizations within the United States.

METHODS

We used the TriNetX database to perform a propensity score-matched cohort study comparing 10-year outcomes between patients with and without a SOT (kidney, heart, lung, liver, pancreas, and intestine) who underwent a PP procedure. Cohorts were matched on age, race/ethnicity, history of pelvic and abdominal surgery, overweight and obesity status, type 2 diabetes mellitus, atherosclerosis, substance use disorders, socioeconomic difficulties, anticoagulant/antiplatelet medications, and spinal cord injury. Outcomes included intra- and perioperative complications as well as prosthetic complications (mechanical malfunction, fibrosis, displacement, hemorrhage, pain, stenosis, removal with or without replacement, and complex [all postoperative complications]).

RESULTS

There were 233 patients in each group after matching (SOT and non-SOT). The mean ± SD age at the prosthesis procedure was 59.7 ± 9.89 years, and 44% of patients were White (P > .05). There was no significant difference for incidence of intra- and perioperative complications (2.62% vs 2.19%, P = .76). The SOT group did not have a higher 10-year incidence of complex complications (30.58% vs 27.51%, P = .11) or mechanical malfunction (10.35% vs 11.62%, P = .25) when compared with the non-SOT group. No difference was found for other prosthetic-related complications (P > .05).

CONCLUSION

In our analysis, patients with a SOT were not more likely to experience long-term complications related to PP. Surgeons performing PP surgery in the SOT population may consider this procedure a potentially safe and viable option for restoring erectile function.

Inflatable penile prosthesis reservoir placement-Are we ready for a paradigm change?

In 2002, Steve Wilson pioneered new procedures for alternative placement of reservoirs for inflatable prostheses in patients who have suffered damage to the space of Retzius following pelvic surgery or obliteration of the transversalis fascia by mesh hernia repair. Since then, surgical techniques and tools for ectopic reservoir placement have gradually gained acceptance to minimize palpability, and the risk of visceral and vascular lesions for high risk patients has been all but eliminated. Lockout valves and high submuscular placement techniques are now recommended, and reports of vascular, bowel or bladder injuries are uncommonly rare. While surgeons continue their search for safer and more effective placement methods, new skills and instruments are constantly being introduced to make recommendations to minimize complications and provide safety and functionality. Additional studies and comparisons of techniques are needed to achieve a consensus of best practice for reservoir placement solutions.

Distance from Critical Pelvic Structures: Radiographic Comparison of High Submuscular and Space of Retzius IPP Reservoir Placement Techniques

OBJECTIVES

To evaluate the distance from critical pelvic structures (CPS, defined as bladder and iliac vessels) among inflatable penile prosthesis (IPP) reservoirs placed into the space of Retzius (SOR) and high submuscular (HSM) locations using cross-sectional imaging. IPP reservoir placement into the HSM location has been proposed as a strategy to prevent injury due to greater distance from CPS.

METHODS

Our institutional database was retrospectively reviewed to identify men who underwent IPP insertion between 2007 and 2020 and had available cross-sectional abdominopelvic imaging after the time of surgery. Patients were grouped based on reservoir placement technique (SOR vs. HSM). Staff radiologists blinded to placement technique evaluated reservoir position to determine the shortest distance between CPS and the reservoir and if a mass effect was present on CPS. Variables were analyzed using chi-squared, Fisher's exact, and student's T-tests as indicated.

RESULTS

Among 1,010 IPP cases performed during the study interval, 139 (13%) were imaged. Compared with SOR reservoirs (n = 32), HSM reservoirs (n =107) were significantly less likely to induce a mass effect on the bladder (72 vs. 9%, p = <0.01) or iliac vessels (34 vs. 4%, p = <0.01) and were located roughly five times further from the bladder (10 ± 22 vs. 49 ± 36 mm, p = <0.01) and iliac vessels (5 ± 9 vs. 23 ± 26 mm, p = <0.01).

CONCLUSIONS

This study radiographically confirms that IPP reservoirs are located significantly further away from CPS following HSM placement compared to SOR placement.

Penile implant surgery-managing complications

Penile prosthesis surgery represents the end-stage treatment for erectile dysfunction. It is conventionally used only in cases of erectile dysfunction refractory to pharmacological treatments or vacuum constriction devices. Contemporary literature suggests that penile prothesis surgery is associated with a high satisfaction rate and a low complication profile. However, it must be appreciated that the complications of surgery can have devastating consequences on a patient’s quality of life and satisfaction and include infection, prosthesis malfunction, penile corporal perforation and penile length loss. Several factors – such as appropriate patient selection, methodical preoperative assessment and patient optimization, specific intraoperative protocols and postoperative recommendations – can reduce the risk of surgical complications. This narrative review discusses the diagnosis and management of both intraoperative and postoperative complications of penile prosthesis surgery.

The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis

BACKGROUND

The 3-piece inflatable penile prosthesis includes an easy-to-use pump and fluid filled reservoir which is placed in either the space of Retzius (SOR) or in an alternative ectopic location. Reservoir placement in the SOR is a blind procedure despite the SOR being surrounded by many critical structures. To date only a handful of cadaveric studies have described the relevant anatomy.

AIM

To use magnetic resonance imaging (MRI) as an in-vivo model to study relevant retropubic anatomy critical for SOR reservoir placement.

METHODS

The study population included men with elevated prostate specific antigen or biopsy proven prostate cancer who (i) underwent pelvic MRI, (ii) without prior pelvic or inguinal surgery, and (iii) without pelvic radiation therapy. All MRIs were completed with a 3-Tesla scanner and endorectal coil. Both T1 and T2 weighted images were captured in both axial and sagittal planes. All images were reviewed by 2 independent reviewers under the supervision of a dedicated body MRI radiologist. Bladder volume was calculated using an ellipsoid formula.

OUTCOMES

Relevant measurements included (i) the distance between the external inguinal ring (EIR) at the level of the pubic tubercle to the external iliac vein (EIV), (ii) the distance from the EIR at the pubic tubercle to the bladder (accounting for bladder volume) and (iii) the distance from the midline pubic symphysis to the bladder (accounting for bladder volume). Pearson correlation was used to determine correlated measurements.

RESULTS

A total of 24 patients were included. Median participant age was 63 years (interquartile range, 59-66). The mean EIR-EIV distance was 3.0 ± 0.4 cm, the mean EIR-bladder distance was 1.8 ± 1.0 cm and the mean distance from the superior pubic symphysis to bladder was 0.9 ± 0.3 cm. There was a weak correlation between bladder volume and distance between the EIR and bladder (r = -0.30, P = .16).

CLINICAL IMPLICATIONS

The use of MRI as an in-vivo model is a high-fidelity tool to study real time unaltered anatomy and allows for surgical preparation, diagnosis of anatomic variants and acts as a valuable teaching tool.

STRENGTHS & LIMITATIONS

This is the first in-vivo model to report relevant retropubic anatomy in penile implant surgery. Our study is limited by sample size and inclusion of participants with no history of prior pelvic intervention.

CONCLUSION

We demonstrate the utility of MRI as an in-vivo model, as opposed to cadaveric models, for the understanding of relevant retropubic anatomy for implant surgeons. Punjani N, Monteiro L, Sullivan J F et al. The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis. J Sex Med 2021;18:1830-1834.

Damage Control Considerations During IPP Surgery

PURPOSE OF REVIEW

This review summarizes the latest reports in inflatable penile prosthesis (IPP) complication management.

RECENT FINDINGS

IPP complications are rare, and reports are limited to retrospective studies. However, recent multi-institutional studies and use of national databases have provided further insight into risk factors for complications. Guidance on complication management is largely limited to techniques recommended by experts within the field. American Urological Association guidelines place IPP implantation as a first line erectile dysfunction treatment. However, the majority of cases are performed by low-volume (≤ 4 cases/year) surgeons. Herein, we summarize the IPP literature and our personal experience to provide guidance on managing IPP complications.

Pararectal Migration of a Malleable Rod: An Unusual Late Complication

A 75-year-old male had failed to respond conservative therapy for erectile dysfunction and had undergone insertion of a malleable penile prosthesis in 1995. Twenty years after the initial implant he presented with right-sided prosthesis localized in the buttock. There was no infection. The prosthesis was extracted through an incision in the right hip. As in the recent case, mechanical failures in malleable penile prosthesis models, can occur. Penile implant migration back to the buttock without a curve deformity is an extremely rare complication. Clinicians should be alert about possible late complications of penile prosthesis.

Does Pressure Regulating Balloon Location Make a Difference in Functional Outcomes of Artificial Urinary Sphincter?

PURPOSE

We compared functional outcomes in patients who received an artificial urinary sphincter in the space of Retzius vs the same device placed at a high submuscular location.

MATERIALS AND METHODS

We reviewed a prospectively maintained database of patients who received an artificial urinary sphincter between July 2007 and December 2014. After cuff placement was completed via a perineal incision, a 61 to 70 cm H2O pressure regulating balloon was placed through a separate high scrotal incision in the space of Retzius or in a high submuscular tunnel. Demographics, perioperative comorbidities and functional outcomes were compared between the groups.

RESULTS

A total of 294 consecutive patients underwent artificial urinary sphincter placement. Mean followup was 23 months. Space of Retzius and high submuscular placement was performed in 140 (48%) and 154 patients (52%), respectively. Functional outcomes were similar between the groups, including the continence rate (defined as 0 or 1 pad daily) in 81% vs 88% (p = 0.11), the erosion rate in 9% vs 8% (p = 0.66) and the explantation rate in 10% vs 11% (p = 0.62). Artificial urinary sphincter revision for persistent incontinence was required in a similar proportion of the 2 groups (13% vs 8%, p = 0.16) with a comparable mean followup (24 vs 23 months, p = 0.30). Kaplan-Meier analysis revealed no difference between the groups in the rate of explantation (p = 0.70) or revision (p = 0.06).

CONCLUSIONS

High submuscular placement of a pressure regulating balloon at artificial urinary sphincter surgery is a safe, effective alternative with functional outcomes equivalent to those of traditional placement in the space of Retzius.

Outcomes of abdominal wall reservoir placement in inflatable penile prosthesis implantation: a safe and efficacious alternative to the space of Retzius

INTRODUCTION

Inflatable penile prosthesis (IPP) surgery is a successful therapeutic option for men with erectile dysfunction. Traditional placement of the reservoir in the retropubic space of Retzius is associated with the rare occurrence of significant complications including bladder, bowel, and vascular injury. An alternative site, posterior to the abdominal wall musculature, has been identified as a potentially safer location for reservoir placement.

AIMS

The aim of this study was to describe our technique of abdominal reservoir placement during infrapubic IPP surgery and present our outcomes data.

METHODS

We retrospectively reviewed our experience with abdominal reservoir placement during virgin IPP cases. Reservoirs placed anterior and posterior to transversalis fascia were analyzed separately.

MAIN OUTCOME MEASURE

The main outcome measures was assessment of reservoir-related complications including palpable reservoir, reservoir herniation, and injuries to bowel, bladder, or major blood vessels.

RESULTS

There were no injuries to bowel or major blood vessels with abdominal reservoir placement posterior or anterior to the transversalis fascia in properly segregated patients.

CONCLUSION

Abdominal reservoir placement is a safe and simple surgical method that can be recommended for most men undergoing IPP placement. Men with a history of pelvic surgery can have the reservoir placed between the rectus abdominis musculature and transversalis fascia, while other men can have the reservoir placed between transversalis fascia and peritoneum in order to avoid a palpable reservoir. By applying this protocol, the catastrophic injuries that occur rarely with retropubic reservoir placement can be reliably avoided.

Current opinions on alternative reservoir placement for inflatable penile prosthesis among members of the Sexual Medicine Society of North America

INTRODUCTION

The Sexual Medicine Society of North America (SMSNA) includes as its members the most experienced prosthetic surgeons in North America who implant inflatable penile prostheses (IPPs). Obliteration of the space of Retzius (SOR) resulting from robotic-assisted laparoscopic prostatectomy (RALP) is a growing concern that has prompted many surgeons to look for alternative locations for reservoir placement during IPP implantation.

AIM

The aim of this article is to educate the community of prosthetic urologists about potential complications and alternative locations for IPP reservoir placement.

METHODS

A panel of high-volume experienced prosthetic surgeons discussed their views on alternative IPP reservoir implantation during a symposium focused on this topic. After reviewing reservoir complications, physician members of the SMSNA in attendance were surveyed using an audience response system (ARS) to facilitate sharing of knowledge, opinions, and recommendations related to reservoir implantation.

MAIN OUTCOME MEASURES

Six ARS questions were used to identify the percentages of SMSNA member physicians with concerns about traditional IPP reservoir placement and utilizing alternative reservoir placement (ARP), and the impact of changing practice patterns on patient safety.

RESULTS

A majority (81%) of experienced implant surgeons surveyed think that RALP sometimes or frequently makes traditional IPP reservoir placement more difficult. Placement of the reservoir in an alternative location is sometimes or frequently advantageous for patient safety. A vast majority (97%) of the 95 respondents indicated that ARP techniques should be included in physician training courses.

CONCLUSIONS

Physicians have concerns about reservoir placement in the SOR in RALP patients, which may explain why ARP is popular among SMSNA members. Device manufacturers should support physician training that provides for ARP. Clinical outcomes in RALP patients are needed to better understand the risks and benefits, and define the ideal location of reservoir placement in this population.

High submuscular placement of urologic prosthetic balloons and reservoirs via transscrotal approach

INTRODUCTION

Traditional placement of inflatable penile prosthesis (IPP) reservoirs and/or artificial urinary sphincter (AUS) balloons into the space of Retzius may be challenging following major pelvic surgery.

AIM

The aim of this study is to report our 1-year experience using a novel technique for high balloon/reservoir placement beneath the rectus abdominus muscle, thus completely obviating deep pelvic dissection during prosthetic urologic surgery.

METHODS

A retrospective review of all patients who underwent IPP and/or AUS placement between June 2011 and June 2012 was performed. All had AUS balloons and/or IPP reservoirs placed in a submuscular location by bluntly tunneling through the external inguinal ring into a potential space between the transversalis fascia and the rectus abdominus muscle using a long, angled, lung grasping clamp.

MAIN OUTCOME MEASURES

Patient demographics, perioperative outcomes, and initial follow-up patient-reported outcomes were reviewed.

RESULTS

During the study period, 120 submuscular balloons/reservoirs were inserted in 107 consecutive patients who underwent placement of an IPP (61 patients), AUS (33 patients), or both (13 patients). Among our 48 most recent patients, 41 (85%) reported they were totally unable to feel their balloon/reservoir, and all but two patients reported no bother from the submuscular balloon/reservoir placement. Of the 120 total submuscular balloons and reservoirs, surgical time and outcomes of the prosthetic procedures appeared similar to those placed using traditional methods; two reservoirs required revision surgery for repositioning.

CONCLUSIONS

High submuscular placement of genitourinary prosthetic balloons and reservoirs via a transscrotal approach is both safely and effective, while avoiding deep retropubic dissection.

Intentionally retained pressure-regulating balloon in artificial urinary sphincter revision

INTRODUCTION

The traditional surgical approach for revision of a malfunctioning artificial urinary sphincter (AUS) includes removal and replacement of all device components, identical to that employed in the setting of an infected or eroded AUS.

AIMS

  To describe outcomes of our technique in which we intentionally leave behind the original pressure-regulating balloon (PRB) at time of AUS revision in a clinically non-infected setting.

METHODS

We retrospectively reviewed our combined institutional series of 35 patients who underwent 36 AUS revisions in which the original pressure-regulating balloon was left undisturbed. We removed and replaced the defective cuff and pump through a single peno-scrotal incision for most patients requiring revision of a non-infected AUS. The new PRB was then placed on the opposite side through this single incision.

MAIN OUTCOME MEASURES

Assessment of outcomes, complication, and infection rate of this surgical series.

RESULTS

All of the patients had the original pressure-regulating balloon placed through an inguinal counter-incision. Mean follow-up time was 14 months (2-33 months). Overall complication rate for the revision series was 11%. No infections or complications occurred secondary to the retained PRB.

CONCLUSION

Follow-up of our series provides evidence that retention of the original PRB at the time of non-infected AUS revision is safe. Potential advantages include elimination of a counter incision and technically challenging exploration. By eliminating these aspects, the potentially resultant decreased operative time may help counter the theoretical yet unproven risk of infection from leaving the old PRB in place.

Review of penile prosthetic reservoir: complications and presentation of a modified reservoir placement technique

INTRODUCTION

Multiple modifications have been made to the inflatable penile prosthesis (IPP) since its inception in the 1970s. These modifications have made reservoir-related mechanical malfunctions highly unlikely in current IPP models. Although these complications are rare, it would be incumbent upon the implanting surgeon to be aware of these potential complications, how they present, how they are best treated, and how to prevent them from occurring.

AIMS

The aim of this article was to present our experience with complications associated with penile prosthesis reservoirs, perform a review of the literature regarding reservoir-related complications, and present our modified technique to place the reservoir into the space of Retzius.

MAIN OUTCOME MEASURES

Reservoir-related complications including inguinal herniation, erosion into bladder or bowel, intraperitoneal reservoir placement with subsequent visceral injury, vascular injury, autoinflation, and infection.

METHODS

We retrospectively reviewed our experience with penile prosthesis reservoir complications or procedures requiring an alternative implantation approach at our center over the past 10 years where over 400 devices were implanted. We also review reservoir-related complications published in the English literature since the 1980s.

RESULTS

While exceedingly rare, reservoir complications do occur. Six cases from our institution are presented including one reservoir herniation, one postoperative direct inguinal hernia, one bladder laceration during revision surgery, one ectopic reservoir placement due to morbid obesity, one iliac vein compression syndrome, and one vascular laceration during reservoir revision. Reported reservoir complications include inguinal herniation, erosion into the bladder or bowel, intraperitoneal reservoir placement with subsequent injury to the ureter or bowel, vascular injury, autoinflation, and infection.

CONCLUSION

Penile prosthesis reservoirs rarely fail mechanically but are associated with a variety of complications or may require alternate implantation technique. In our experience, the Jorgensen scissors technique allows safe entry into the space of Retzius with diminished risk of hernia as well as vascular, bladder, or bowel injury.

Practice patterns of urologists performing penile prosthesis surgery vary based on surgeon volume: results of a practice pattern survey

Inflatable penile prostheses (IPPs) are widely accepted as a means of surgical treatment of erectile dysfunction. It has been suggested that surgeon volume influences patient outcomes after IPP implantation. We used a written questionnaire to ask urologists who perform IPP surgery about their practice patterns. Our analysis correlated specific practices to self-reported IPP volume. A written questionnaire was distributed to 1968 urologists. Responses were collated and analyzed. Respondents were defined as high volume implanters (HVIs) if they placed >or=20 IPPs in the year preceding the survey, or low volume implanters (LVIs) if they placed <or=19. Our main outcome measures were surgeon volume, approach to initial IPP placement (penoscrotal vs infrapubic), strategy for reservoir management during IPP revision surgery, strategy for reservoir replacement when deemed necessary, approach to suspected IPP infections, and utilization of revision washout protocols. This study does not require institutional review board approval from our institution, given that patient information is not used at all, this is a practitioner survey only. HVIs were significantly more likely to incorporate both penoscrotal and suprapubic approaches into their armamentarium, more likely to manipulate previously placed IPP reservoirs during revision surgery, and more likely to operate immediately when confronted with a suspected IPP infection. They were also more likely than LVIs to use the Mulcahy revision washout protocol. There are significant differences in the self-reported practice patterns of HVIs and LVIs. The importance of these differences for patient outcomes remains undefined.