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Penile implant success in patients with corporal fibrosis using multiple incisions and minimal scar tissue excision
LETTERS TO THE EDITOR
Penile Implant Success in Patients with Corporal Fibrosis Using Multiple Incisions and Minimal Scar Tissue Excision TO THE EDITOR:
Dr. Rajpurkar and colleagues are to be commended for presenting their additional experience with penile implant insertion in a difficult group of patients with corporal fibrosis.1 In their first publication2 the authors mentioned a perineoscrotal incision, and in this article they mention only a perineal incision. What is the patient positioning? Where and how long is the incision and how can the retropubic space be accessed for reservoir insertion through the perineum, or is a separate suprapubic incision required? Regarding the complications encountered with difficult implants, the authors rightly point out that the complication rate, especially infection, is higher than that with straightforward procedures.3 Although they quote a 31% intraoperative complication rate in two abstracts,3,4 there were no intraoperative complications reported in one of the abstracts.3 The authors theorize that excision of corporal scar compromises penile blood supply, contributing to poor surgical healing and inadequate delivery of antibiotic to the surgical site, which results in a high rate of postoperative infection. Unfortunately, they offer no proof for this theory. Poorly vascularized corporal scar tissue may have lower levels of antibiotics compared with the high levels seen in normal cavernous tissue after intravenous administration,5 thereby contributing to a higher rate of infection. As prosthesis infection occurs with surface biofilm production,6 a Gore-Tex graft may increase the likelihood of infection because of the larger surface area. Other factors previously identified include long duration of surgery and revisional surgery.7 The authors quote four references3,4,7,8 with high infection rates, which they attribute to scar excision. However, scar excision is not mentioned as a risk factor in two of these papers.3,7 The urologist who takes on these difficult cases must work through a number of maneuvers, from simple to complex, to create spaces within the tunica albuginea or use additional graft material. These have been well elucidated.9 The technique described by the authors, involving distal corporal incisions to facilitate distal dilatation, was also previously reported as a surgical technique10 and in clinical cases.11 It is one of a number of methods, including the use of downsized cylinders, that may have to be applied for successful prosthesis insertion.
Sender Herschorn, M.D. Sunnybrook and Women’s College Health Sciences Centre 2075 Bayview Avenue, Suite MG-408 Toronto, Ontario M4N 3M5, Canada PII S0090-4295(99)00432-X © 2000, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
REFERENCES 1. Rajpurkar A, Li H, and Dhabuwala CB: Penile implant success in patients with corporal fibrosis using multiple incisions and minimal scar tissue excision. Urology 54: 145–147, 1999. 2. George VK, Shah GS, Mills R, et al: The management of extensive penile fibrosis: a new technique of ‘minimal scar excision’. Br J Urol 77: 282–284, 1996. 3. Boyd S, and Martin F: Simultaneous Ultrex penile prosthesis re-implantation and Gore-Tex grafting corporoplasty— functional outcome of a surgical challenge (abstract). Presented at the American Urological Association Annual Meeting, Las Vegas, Nevada, April 22–27, 1995. 4. Goldstein I, Nehra A, Wener M, et al: Technique and follow-up of sharp corporal tissue excision procedure for prosthesis implantation with bilateral severe diffuse corporal fibrosis (abstract). Presented at the American Urological Association Annual Meeting, Las Vegas, Nevada, April 22–27, 1995. 5. Walters FP, Neal DE Jr, Rege AB, et al: Cavernous tissue antibiotic levels in penile prosthesis surgery. J Urol 147: 1282–1284, 1992. 6. Nickel JC, Heaton J, Morales A, et al: Bacterial biofilm in persistent penile prosthesis associated infection. J Urol 135: 586 –588, 1986. 7. Jarow JP: Risk factors for penile prosthetic infection. J Urol 156: 402– 404, 1996. 8. Knoll LD, and Furlow WL: Corporeal reconstruction and prosthetic implantation for impotence associated with non-dilatable corporeal cavernosal fibrosis. Acta Urol Belg 60: 15–25, 1992. 9. Montague DK, and Lakin MM: Penile prostheses, in Bennett AH (Ed): Impotence—Diagnosis and Management of Erectile Dysfunction. Philadelphia, WB Saunders, 1994, pp 257–295. 10. Herschorn S, Barkin M, and Comisarow R: A new technique for difficult penile implants. Urology 27: 463– 464, 1986. 11. Herschorn S, and Ordorica RC: Penile prosthesis insertion with corporal reconstruction with synthetic vascular graft material. J Urol 124: 80 – 84, 1995.
REPLY BY THE AUTHORS: All the surgeries were performed with patients in the lithotomy position and incision was midline one-third on the scrotum and two-thirds on the perineum. The incision is approximately 2 inches long. Placement of the reservoir can be done through this incision by sneaking a finger along the side of the corpora over the pubic bone through the external ring and then hooking it posteriorly to break through the fascia by blunt dissection. Boyd and Martin1 cite postoperative complications in 11 of 17 patients (64.7%), whereas Goldstein et al.2 describe intraoperative complications in 31% of the patients. We agree with Dr. Herschorn that the concept that excising the scar tissue leads to poor blood supply and high infection rate is theoretical; so is his suggestion that poorly vascularized corporal scar tissue may have lower levels of antibiotics compared with the high levels seen in normal cavernous tissue after intravenous administration. To our knowledge, no such studies to determine the levels of antibiotics in corporal scar tissue have been performed. That use of Gore-Tex graft leads to a higher infection rate because of larger surface area is another hypothesis that is not substantiated by the experience described in our paper. We used Gore-Tex graft in 13 of the 34 cases. None of the 34 patients developed postoperative infection. The purpose of our paper was to demonstrate that this com-
UROLOGY 55: 299 –300, 2000 • 0090-4295/00/$20.00 299
Penile Implant Success in Patients with Corporal Fibrosis Using Multiple Incisions and Minimal Scar Tissue Excision TO THE EDITOR:
Dr. Rajpurkar and colleagues are to be commended for presenting their additional experience with penile implant insertion in a difficult group of patients with corporal fibrosis.1 In their first publication2 the authors mentioned a perineoscrotal incision, and in this article they mention only a perineal incision. What is the patient positioning? Where and how long is the incision and how can the retropubic space be accessed for reservoir insertion through the perineum, or is a separate suprapubic incision required? Regarding the complications encountered with difficult implants, the authors rightly point out that the complication rate, especially infection, is higher than that with straightforward procedures.3 Although they quote a 31% intraoperative complication rate in two abstracts,3,4 there were no intraoperative complications reported in one of the abstracts.3 The authors theorize that excision of corporal scar compromises penile blood supply, contributing to poor surgical healing and inadequate delivery of antibiotic to the surgical site, which results in a high rate of postoperative infection. Unfortunately, they offer no proof for this theory. Poorly vascularized corporal scar tissue may have lower levels of antibiotics compared with the high levels seen in normal cavernous tissue after intravenous administration,5 thereby contributing to a higher rate of infection. As prosthesis infection occurs with surface biofilm production,6 a Gore-Tex graft may increase the likelihood of infection because of the larger surface area. Other factors previously identified include long duration of surgery and revisional surgery.7 The authors quote four references3,4,7,8 with high infection rates, which they attribute to scar excision. However, scar excision is not mentioned as a risk factor in two of these papers.3,7 The urologist who takes on these difficult cases must work through a number of maneuvers, from simple to complex, to create spaces within the tunica albuginea or use additional graft material. These have been well elucidated.9 The technique described by the authors, involving distal corporal incisions to facilitate distal dilatation, was also previously reported as a surgical technique10 and in clinical cases.11 It is one of a number of methods, including the use of downsized cylinders, that may have to be applied for successful prosthesis insertion.
Sender Herschorn, M.D. Sunnybrook and Women’s College Health Sciences Centre 2075 Bayview Avenue, Suite MG-408 Toronto, Ontario M4N 3M5, Canada PII S0090-4295(99)00432-X © 2000, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
REFERENCES 1. Rajpurkar A, Li H, and Dhabuwala CB: Penile implant success in patients with corporal fibrosis using multiple incisions and minimal scar tissue excision. Urology 54: 145–147, 1999. 2. George VK, Shah GS, Mills R, et al: The management of extensive penile fibrosis: a new technique of ‘minimal scar excision’. Br J Urol 77: 282–284, 1996. 3. Boyd S, and Martin F: Simultaneous Ultrex penile prosthesis re-implantation and Gore-Tex grafting corporoplasty— functional outcome of a surgical challenge (abstract). Presented at the American Urological Association Annual Meeting, Las Vegas, Nevada, April 22–27, 1995. 4. Goldstein I, Nehra A, Wener M, et al: Technique and follow-up of sharp corporal tissue excision procedure for prosthesis implantation with bilateral severe diffuse corporal fibrosis (abstract). Presented at the American Urological Association Annual Meeting, Las Vegas, Nevada, April 22–27, 1995. 5. Walters FP, Neal DE Jr, Rege AB, et al: Cavernous tissue antibiotic levels in penile prosthesis surgery. J Urol 147: 1282–1284, 1992. 6. Nickel JC, Heaton J, Morales A, et al: Bacterial biofilm in persistent penile prosthesis associated infection. J Urol 135: 586 –588, 1986. 7. Jarow JP: Risk factors for penile prosthetic infection. J Urol 156: 402– 404, 1996. 8. Knoll LD, and Furlow WL: Corporeal reconstruction and prosthetic implantation for impotence associated with non-dilatable corporeal cavernosal fibrosis. Acta Urol Belg 60: 15–25, 1992. 9. Montague DK, and Lakin MM: Penile prostheses, in Bennett AH (Ed): Impotence—Diagnosis and Management of Erectile Dysfunction. Philadelphia, WB Saunders, 1994, pp 257–295. 10. Herschorn S, Barkin M, and Comisarow R: A new technique for difficult penile implants. Urology 27: 463– 464, 1986. 11. Herschorn S, and Ordorica RC: Penile prosthesis insertion with corporal reconstruction with synthetic vascular graft material. J Urol 124: 80 – 84, 1995.
REPLY BY THE AUTHORS: All the surgeries were performed with patients in the lithotomy position and incision was midline one-third on the scrotum and two-thirds on the perineum. The incision is approximately 2 inches long. Placement of the reservoir can be done through this incision by sneaking a finger along the side of the corpora over the pubic bone through the external ring and then hooking it posteriorly to break through the fascia by blunt dissection. Boyd and Martin1 cite postoperative complications in 11 of 17 patients (64.7%), whereas Goldstein et al.2 describe intraoperative complications in 31% of the patients. We agree with Dr. Herschorn that the concept that excising the scar tissue leads to poor blood supply and high infection rate is theoretical; so is his suggestion that poorly vascularized corporal scar tissue may have lower levels of antibiotics compared with the high levels seen in normal cavernous tissue after intravenous administration. To our knowledge, no such studies to determine the levels of antibiotics in corporal scar tissue have been performed. That use of Gore-Tex graft leads to a higher infection rate because of larger surface area is another hypothesis that is not substantiated by the experience described in our paper. We used Gore-Tex graft in 13 of the 34 cases. None of the 34 patients developed postoperative infection. The purpose of our paper was to demonstrate that this com-
UROLOGY 55: 299 –300, 2000 • 0090-4295/00/$20.00 299