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Re: Review of Penile Prosthetic Reservoir: Complications and Presentation of a Modified Reservoir Placement Technique
TRAUMA AND GENITAL AND URETHRAL RECONSTRUCTION
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diseases, the pathogenetic mechanisms and risk factors associated with urolithiasis in this population remain partially unsolved. Materials and Methods: The present study retrospectively analyzed the determinants of urolithiasis in 51 patients with fat malabsorption due to different intestinal diseases. Anthropometric, clinical, blood, 24-hour urinary parameters, and dietary intake were assessed. Results:The resection rate (ie, pancreatic and/or bowel resection) differed significantly between stone formers (SF; n⫽10) and nonstone formers (NSF; n⫽41; 70% vs 29%; P⫽.027). Urinary citrate was lower (1.606⫾1.824 vs 3.156⫾1.968 mmol/24 h; P⫽.027), while oxalate excretion (0.659⫾0.292 vs 0.378⫾0.168 mmol/24 h; P⫽.002) and the relative supersaturation of calcium oxalate were greater in SF than NSF (8.16⫾4.61 vs 3.94⫾2.93; P⫽.003). Total cholesterol and low-density lipoprotein cholesterol, but also high-density lipoprotein cholesterol, plasma -carotene, and vitamin E concentrations, were significantly diminished, whereas serum aspartate aminotransferase activity was significantly greater in SF compared with NSF. Binary logistic regression analysis revealed resection status as a major extrarenal risk factor for stone formation (odds ratio 5.639). Conclusion: Increased urinary oxalate and decreased citrate excretion, probably resulting from pancreatic and/or bowel resection with mainly preserved colon, were identified as the most crucial urinary risk factors for stone formation in patients with fat malabsorption. The findings suggest that hyperoxaluria predominantly results from increased colonic permeability for oxalate due to disturbed bile acid metabolism. The impaired status of fat-soluble antioxidants -carotene and vitamin E indicates severe malabsorptive states associated with an enhanced stone-forming propensity. Editorial Comment: Bowel disease and pancreatic insufficiency may result in malabsorption, leading to increased intestinal oxalate transport, augmenting urinary oxalate excretion and calcium oxalate stone risk. Diarrhea may also be present in this cohort, which promotes bicarbonate wasting, diminished urinary citrate excretion and heightened stone risk. The authors demonstrated these risk factors in this population. The lower levels of serum fat-soluble antioxidants provide indirect evidence of malabsorption. Urologists need to be aware of these relationships so that they can assign appropriate therapy to attenuate stone risk in these patients. Dean G. Assimos, M.D.
Suggested Reading Maalouf NM, Tondapu P, Guth ES et al: Hypocitraturia and hyperoxaluria after Roux-en-Y gastric bypass surgery. J Urol 2010; 183: 1026. Ciacci C, Spagnuolo G, Tortora R et al: Urinary stone disease in adults with celiac disease: prevalence, incidence and urinary determinants. J Urol 2008; 180: 974.
Trauma/Reconstruction/Diversion Urological Survey Trauma, and Genital and Urethral Reconstruction Re: Review of Penile Prosthetic Reservoir: Complications and Presentation of a Modified Reservoir Placement Technique L. A. Levine and M. P. Hoeh Department of Urology, Rush University Medical Center, Chicago, Illinois J Sex Med 2012; 9: 2759 –2769.
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
2166
TRAUMA AND GENITAL AND URETHRAL RECONSTRUCTION
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. Editorial Comment: IPP reservoir placement carries a long list of possible complications, which can be broken down into the broad categories of herniation, erosion into visceral structures (primarily bowel and bladder), infection, ureteral compression, vascular injury and autoinflation. Dozens of case reports can be found in the literature detailing the many problems that can arise not only from reservoir placement, but also from removal at revision surgery. An alternative technique involving use of Jorgenson scissors to pierce the transversalis fascia is suggested. We continue to be quite satisfied with high submuscular reservoir placement using a long lung grasping clamp to elevate the rectus abdominis muscle transscrotally, a technique we have used in nearly 200 consecutive cases for exactly the reasons outlined in this article. Allen F. Morey, M.D.
Re: Laparascopic Capsulotomy to Treat Autoinflation of Inflatable Penile Prostheses P. H. Abbosh, M. R. Thom and A. Bullock Division of Urology, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri J Sex Med 2012; 9: 1212–1215.
Introduction: Inflatable penile prosthetic implants are a reliable treatment for erectile dysfunction. Mechanical failures now are the most common reason for revision of this type of device, and autoinflation is a common cause for device revision. There are currently no published surgical treatments for this malfunction. Aim: To describe a simple outpatient surgical revision for an automatically inflating device using laparascopic dissection. Main Outcome Measures: Complete deflation of penile prosthesis on follow-up visit, intraoperative and postsurgical complications, and length of procedure. Methods: We performed a retrospective review of patients treated for inflatable penile prosthesis autoinflation with laparascopic capsulotomy to release constricting connective tissue rind surrounding the device reservoir at a single institution. We collected information about etiology of impotence, surgical procedures relating to implant and revision of prosthetic devices, and follow-up evaluations. Results: Four patients underwent laparascopic capsulotomy to treat autoinflation. Mean operative time was 45 minutes, and no adverse surgical or perioperative outcomes
2165
diseases, the pathogenetic mechanisms and risk factors associated with urolithiasis in this population remain partially unsolved. Materials and Methods: The present study retrospectively analyzed the determinants of urolithiasis in 51 patients with fat malabsorption due to different intestinal diseases. Anthropometric, clinical, blood, 24-hour urinary parameters, and dietary intake were assessed. Results:The resection rate (ie, pancreatic and/or bowel resection) differed significantly between stone formers (SF; n⫽10) and nonstone formers (NSF; n⫽41; 70% vs 29%; P⫽.027). Urinary citrate was lower (1.606⫾1.824 vs 3.156⫾1.968 mmol/24 h; P⫽.027), while oxalate excretion (0.659⫾0.292 vs 0.378⫾0.168 mmol/24 h; P⫽.002) and the relative supersaturation of calcium oxalate were greater in SF than NSF (8.16⫾4.61 vs 3.94⫾2.93; P⫽.003). Total cholesterol and low-density lipoprotein cholesterol, but also high-density lipoprotein cholesterol, plasma -carotene, and vitamin E concentrations, were significantly diminished, whereas serum aspartate aminotransferase activity was significantly greater in SF compared with NSF. Binary logistic regression analysis revealed resection status as a major extrarenal risk factor for stone formation (odds ratio 5.639). Conclusion: Increased urinary oxalate and decreased citrate excretion, probably resulting from pancreatic and/or bowel resection with mainly preserved colon, were identified as the most crucial urinary risk factors for stone formation in patients with fat malabsorption. The findings suggest that hyperoxaluria predominantly results from increased colonic permeability for oxalate due to disturbed bile acid metabolism. The impaired status of fat-soluble antioxidants -carotene and vitamin E indicates severe malabsorptive states associated with an enhanced stone-forming propensity. Editorial Comment: Bowel disease and pancreatic insufficiency may result in malabsorption, leading to increased intestinal oxalate transport, augmenting urinary oxalate excretion and calcium oxalate stone risk. Diarrhea may also be present in this cohort, which promotes bicarbonate wasting, diminished urinary citrate excretion and heightened stone risk. The authors demonstrated these risk factors in this population. The lower levels of serum fat-soluble antioxidants provide indirect evidence of malabsorption. Urologists need to be aware of these relationships so that they can assign appropriate therapy to attenuate stone risk in these patients. Dean G. Assimos, M.D.
Suggested Reading Maalouf NM, Tondapu P, Guth ES et al: Hypocitraturia and hyperoxaluria after Roux-en-Y gastric bypass surgery. J Urol 2010; 183: 1026. Ciacci C, Spagnuolo G, Tortora R et al: Urinary stone disease in adults with celiac disease: prevalence, incidence and urinary determinants. J Urol 2008; 180: 974.
Trauma/Reconstruction/Diversion Urological Survey Trauma, and Genital and Urethral Reconstruction Re: Review of Penile Prosthetic Reservoir: Complications and Presentation of a Modified Reservoir Placement Technique L. A. Levine and M. P. Hoeh Department of Urology, Rush University Medical Center, Chicago, Illinois J Sex Med 2012; 9: 2759 –2769.
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
2166
TRAUMA AND GENITAL AND URETHRAL RECONSTRUCTION
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. Editorial Comment: IPP reservoir placement carries a long list of possible complications, which can be broken down into the broad categories of herniation, erosion into visceral structures (primarily bowel and bladder), infection, ureteral compression, vascular injury and autoinflation. Dozens of case reports can be found in the literature detailing the many problems that can arise not only from reservoir placement, but also from removal at revision surgery. An alternative technique involving use of Jorgenson scissors to pierce the transversalis fascia is suggested. We continue to be quite satisfied with high submuscular reservoir placement using a long lung grasping clamp to elevate the rectus abdominis muscle transscrotally, a technique we have used in nearly 200 consecutive cases for exactly the reasons outlined in this article. Allen F. Morey, M.D.
Re: Laparascopic Capsulotomy to Treat Autoinflation of Inflatable Penile Prostheses P. H. Abbosh, M. R. Thom and A. Bullock Division of Urology, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri J Sex Med 2012; 9: 1212–1215.
Introduction: Inflatable penile prosthetic implants are a reliable treatment for erectile dysfunction. Mechanical failures now are the most common reason for revision of this type of device, and autoinflation is a common cause for device revision. There are currently no published surgical treatments for this malfunction. Aim: To describe a simple outpatient surgical revision for an automatically inflating device using laparascopic dissection. Main Outcome Measures: Complete deflation of penile prosthesis on follow-up visit, intraoperative and postsurgical complications, and length of procedure. Methods: We performed a retrospective review of patients treated for inflatable penile prosthesis autoinflation with laparascopic capsulotomy to release constricting connective tissue rind surrounding the device reservoir at a single institution. We collected information about etiology of impotence, surgical procedures relating to implant and revision of prosthetic devices, and follow-up evaluations. Results: Four patients underwent laparascopic capsulotomy to treat autoinflation. Mean operative time was 45 minutes, and no adverse surgical or perioperative outcomes