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Management of Complications in Penile Prosthesis Surgery
Justin Parker, MDAssistant Professor of UrologyUniversity of South FloridaJames A. Haley VA Hospital
Disclosure
I am a consultant/speaker for Coloplast but have no conflicts regarding this presentation.
Objectives
Identify potential complications related to penile prosthesis surgery Understand treatment approaches for
management of prosthesis complications
Overview
Patients undergoing penile prosthesis placement overall have a high revision-free satisfaction rate– 69-98%1
Despite improvements in surgical technique and device design, complications are inevitable2-5
Perforation During Dilation
Can occur distal, proximal, lateral What do you do?
IMPLANT PERFORATION
•PROXIMAL•CAN CONTINUE WITH SURGERY•USE CONTRALATERAL CORPORA TO SIZE IMPLANT•DIFFERENT SURGICAL TECHNIQUES DESCRIBED TO CORRECT DEFECT:
•SUTURE SLING•DACRON SOCK•SUTURE SRPP TO TUNICA
2-0 PROLENE GOING THROUGH TUNICA-REAR TIP-TUNICA
IMPLANT PERFORATION
DISTAL• GENERAL RECOMMENDATION TO ABORT PENILE
IMPLANTATION• REMOVE CONTRALATERAL CYLINDER (if already placed)• PLACEMENT OF FOLEY CATHETER (3-5 DAYS)• ORAL ANTIMICROBIAL THERAPY
• SPECIAL CASES IMPLANT CAN BE PERFORMED• SEVERE FIBROSIS IN WHICH THE CORPORAL BODIES ARE
SEPARATE CHAMBERS• CREATION OF A HYPOSPADIAS AND PRIMARY REPAIR WITH
IMPLANT PLACEMENT HAS BEEN PERFORMED IN SELECT CENTERS
Corporotomy Plug Technique
Postero-lateral perforation during dissection of fibrotic corpora
“Plug” perforation with a small Hegar dilator and dissect a new corporal tunnel
Corporotomy Plug Technique
Floppy glans syndrome
Due to hypermobility of the glans penis despite shaft erection– Makes penetration difficult– Patients may complain of painful and unsatisfactory
intercourse Incidence difficult to determine due to uncommon
nature of FGS In addition to treatment, goal is to minimize
occurrence by utilizing proper technique at placement
Floppy Glans Syndrome- Manifestations
Ventral– SST or Concorde deformity
• Due to undersized or poorly positioned cylinders– True hypermobility
• Result from poor structural support of the glans by the tips of the corpora cavernosa
• Occurs in patients with appropriately sized cylinders
Floppy Glans Syndrome-Manifestations Dorsal
– Reverse SST• May be caused by a relative tightness of the dorsal penile
tissue compared to ventral• Notable dorsal glans angle when both inflated and deflated
– May be due to oversized cylinders– Owl Eye Deformity- appearance of impending erosion
Lateral– Secondary to intraoperative crossover
Flail penis- glans and distal shaft hypermobile– Due to significant undersizing
Dorsal deflection- Reverse SST
Owl Eye Deformity
Flail penis due to inadequate dilation
Floppy Glans Syndrome- Medical Management Improve erectile firmness
– PDE5’s– Intra-urethral Muse– Compounded intraurethral gel
• Preliminary results in post IPP patients with subjective benefit to symptoms and quality of life
• Penile pain is a limiting side effect– VED
Glans Fixation or Glanulopexy
Plication sutures placed on the dorsal aspect of the glanular Bucks fascia and secured proximally to the tunica albuginea.
Permanency of the glans position enhanced by deep scarring from dissecting the glans from cylinder dips
Mulhall et al.6– 90% patient satisfaction
Penoplasty
Glans realigned with the distal shaft with clamps on the hypermobile skin and dartos Excess skin and dartos excised in elliptical
fashion with large defect Closed in multiple layers to maintain the
realignment of the glans over the distal tips May be particularly effective in reverse SST
Dorsal Penoplasty
Distal Corporoplasty
Definitive surgical management of FGS as a result of improper sizing or placement is removal with resizing and reimplantation +/-corporoplasty Consider if evidence of Owl Eye deformity
and pending erosion with FGS May add penoplasty for definitive correction
if necessary
Distal Crossover- Lateral droop
Patient 1- Undersized implant
Patient 1- Correctly sized implant
Patient 2- Incorrect sizing and high riding pump
Patient 2
Patient 2
Patient 2
Cylinder Aneurysm
Cylinder Aneurysm
AMS (fabric cylinder with parylene coating)– May also occur with Coloplast Bioflex but more
unusual May occur secondary to corporotomy breakdown Requires removal and replacement of implant Tunica wall is now a weak point and has
increased chance of recurrence May require placement of SRPP or a hybrid
prosthesis if recurs
Impending Distal Erosion
May be due to infection, perforation at time to of dilation, “microperforations” with small dilators, oversizing, continuous pressure (especially SCI patients)
Try to prevent
Modification in Technique
Patient with impending distal lateral cylinder erosion
Implant tip removed and incision made through medial floor of
tunica
Dilation of new corporal space
Implant re-inserted and inflated, Tuttoplast is placed over the
distal edge of tunica and sewn to the lateral edges
Tuttoplast Windsock
Tuttoplast Windsock
Transglanular repair of impending erosion Shindel et al. J Sex Med.
2010
Fixation of the tip of the implant to the fibrotic capsule opposite to the side of impending erosion with synthetic, non-absorbable suture
Implant Erosion
Prosthetic clearly exposed, need to evaluate closely for infection
SRPP– Removal of ipsilateral cylinder– Foley and antibiotics
IPP– Removal of all components or ipsilateral cylinder– Possible SRPP on contralateral side- need to carefully
evaluate integrity of cylinder space– Foley and antibiotics
Pump Erosion
Pump Erosion
Prosthesis Infection
Most bacteria colonize prosthesis at time of implantation
Biofilm layer protects the bacteria from antibiotic activity and host defenses
Bacteria colonize the device and remain in a low-energy state for years before infection manifests itself
Infections- Management
Systemic antibiotics alone Explantation of entire prosthesis Removal of only a portion of prosthesis Explantation with reinsertion delayed for 72 hours
after continuous antibiotic irrigation Explantation with reinsertion delayed for 3 to 6
months Salvage protocol: explantation, vigorous irrigation
of wound, and reinsertion of device during same procedure
Mulcahy Salvage Protocol7
1. 80 mg/L Kanamycin and 50K units/L bacitracin in NS
2. ½ strength hydrogen peroxide3. ½ strength povidone-iodine solution4. Pressure irrigation with 5L NS with 1gm
vancomycin and 80mg gentamicin5. ½ strength povidone-iodine solution6. ½ strength hydrogen peroxide7. 80 mg/L Kanamycin and 50K units/L bacitracin
in NS
CHARACTERISTICS OF IPP INFECTIONS
Onset may occur at any time.– Acute: within days.– Latent: after months or even years.
Routes of infection:– Contamination during surgery.– Systemic (from bloodstream).– Local extention
Site of infection may occur on any part of device.
Contributing Factors
Length of procedure. Pre-operative patient preparation. Level of physician’s experience with
procedure. Hospital protocols (infection control). Traffic in operating room Patient’s health status
FREQUENCY OF IPP INFECTIONS
Reported infection rate for virgin implants is 3-5% (classic rate, now estimated at approximately 1% with “newer implants”)
Reported infection rate for revision surgeries is 5-15%. Although rare, infections can be severe.
– Average MD may only see one in five years.– IPP Infections are traumatic to both MD and patient.
NOTE: Because this is a surgery, infection rates will likely never reach 0%.
Abouassaly R., et. Al. Curr Urol Rep. 2004 Dec;5(6):460-6.
Infection prevention
Preoperative antibiotics choice Shave day of surgery Preoperative scrub- chloraprep superior to
betadine– USF prep
• Prescrub with 4% chlorhexidine scrub brushes• 2 chloraprep sticks• 3rd chloraprep after draping (caution with cautery)• Change gloves after foley placement and final prep
Postoperative antibiotics?
Eid- No Touch Technique
1511 implants performed from 2006-2010 with “No Touch Technique”– Infection rate of 0.46%
2% infection rate with standard technique
Eid JF. No-touch Technique. J Sex Med. 2011 8(1) 5-8.
Eid JF. No-touch Technique. J Sex Med. 2011 8(1) 5-8.
Eid JF. No-touch Technique. J Sex Med. 2011 8(1) 5-8.
Eid JF. No-touch Technique. J Sex Med. 2011 8(1) 5-8.
No touch variation
Severe Prosthesis Infection- not a candidate for salvage
Stimulan
Stimulan
Stimulan
Reservoir Issues
Placement during virgin cases– Space of Retzius– Ectopic placement– Improper position
Removal during revision surgery– Perils of injury to bladder, bowel, vessels– Cadaver studies noted inguinal ring 5-8 cm
from distended bladder, 2-4 cm from full bladder, and 2.5-4cm from external iliac vein8
– Drain and retain?
Midplaced Reservoir
Selective CT image of the perineal placed reservoir as demonstrated by the red arrow
Reservoir PlacementCaution when Removing!
Reservoir Erosion Into Bladder
Salvage after infection- Thoughts?
Worst Case Scenario
Summary
Penile prosthesis surgery has a high rate of satisfaction but complications can be devastating Surgical options exist to correct the various
complications of prosthetic surgery Ideally, proper technique should be utilized
to minimize postoperative issues If complications occur, action should be
take promptly to prevent need to device removal
References
1. Bernal RM, Henry GD. Contemporary patient satisfaction rates for three-piece inflatable penile prostheses. Adv Urol[Internet]. 2012;2012:707321.
2. Montague DK. Prosthetic Surgery for Erectile Dysfunction [Internet]. Tenth Edit. Campbell-Walsh Urology. Elsevier Inc.; 2012. 780-791.e2
3. Burnett AL. Evaluation and Management of Erectile Dysfunction [Internet]. Tenth Edit. Campbell-Walsh Urology. Elsevier Inc.; 2012. 721-748.e7
4. Lazarou S. Surgical treatment of erectile dysfunction. Erectile Dysfunction: Disease-Associated Mechanisms and Novel Insights into Therapy [Internet]. 2012. p. 162–84
5. Henry GD, Donatucci CF, Conners W, Greenfield JM, Carson CC, Wilson SK, et al. An outcomes analysis of over 200 revision surgeries for penile prosthesis implantation: a multicenter study. J Sex Med [Internet]. 2012;9(1):309–15.
6. Mulhall JP, Kim FJ. Reconstructing penile supersonic transporter (SST) deformity using glanulopexy (glans fixation). Urology. 2001;57(6):1160–2.
7. Mulcahy JJ, Brant, MD, Ludlow JK. Management of infected penile implants. Tech Urol. 1995. 1: 115-9. 8. Henry G et al. A guide for inflatable penile prosthesis reservoir placement: pertinent anatomical measurements of
the retropubic space. J Sex Med. 2014. 11(1) 273-8.