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Review of Penile Prosthetic Reservoir: Complications and Presentation of a Modified Reservoir Placement Technique
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Review of Penile Prosthetic Reservoir: Complications and Presentation of a Modified Reservoir Placement Technique
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Laurence A. Levine, MD and Michael P. Hoeh, MD Department of Urology, Rush University Medical Center, Chicago, IL, USA DOI: 10.1111/j.1743-6109.2012.02807.x
ABSTRACT
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. Levine LA and Hoeh MP. Review of penile prosthetic reservoir: Complications and presentation of a modified reservoir Placement technique. J Sex Med **;**:**–**. Key Words. Penile Prosthesis Complications; Penile Prosthesis Reservoir; Reservoir Complications; Three-Piece Inflatable Prosthesis
Introduction
I
nflatable penile prostheses (IPPs) have been a successful method for treating men with erectile dysfunction (ED) since the early 1970s. Multiple modifications have been made to improve their function, reliability, cosmesis, and reduce infection. These modifications have made it such that the likelihood of a reservoir mechanical mal© 2012 International Society for Sexual Medicine
function is highly unusual. Advances in mechanical reliability have primarily been focused on the cylinders, pump, and tubing. The most significant early reservoir modifications that improved device survival were the developments of a seamless, spherical reservoir in 1978 and multiple improvements that had been instituted by 1983, including the development of kink resistant tubing and elimination of the internal reinforcing rod or stem J Sex Med **;**:**–**
2 in the reservoir. There is a paucity of long-term IPP device survival studies, the longest of which is by Dhar et al. In this study, 380 patients that had received either an American Medical Systems (AMS) 700CX/CXM IPP (Minneapolis, MN, USA) between April 1986 and July 2004 were contacted. Thirty-nine of those patients (10.3%) experienced device failure because of mechanical problems. The only reservoir-related problems were three leaks [1]. Another large scale study demonstrating the mechanical reliability of the reservoir is a report by Wilson et al. in 1988 on 395 patients using both AMS and Mentor prostheses where no reservoir malfunctions were noted [2,3]. Complications or unexpected events associated with penile prosthesis reservoirs have not been reviewed recently, and it is the intent of this article to review our own experience and that found in the published English literature since 1980. Although these complications occur infrequently, it would behoove the implanting surgeon to be aware of their presentation and current approaches to resolve or prevent their occurrence. The following will review our reservoir-related complications over the past 10 years.
Case I This 56-year-old man had undergone previous open bladder surgery for excision of a bladder diverticulum via a midline hypogastric incision. He underwent subsequent placement of a 700CX three-piece prosthesis with a 65 cc spherical reservoir via a penoscrotal incision, which failed after 4 years due to a tubing fracture. The patient waited approximately 1 year before undergoing revision surgery. At the time of addressing the original reservoir, it was elected to leave it in place if it was intact and refill it with fresh saline. Presumably, a dense pseudocapsule had formed around the reservoir, as it was noted that there was difficulty in refilling the reservoir to its normal capacity, and therefore gentle pressure was applied to the filling syringe until there was a sudden give. This phenomenon typically occurs with formation of a pseudocapsule around an otherwise normal indwelling reservoir. Blood was subsequently noted in the urine draining from the catheter in the recovery room. Flexible cystoscopy was performed which provided visualization of the reservoir through a laceration in the bladder wall. As there was a clear bladder disruption, we elected to immediately return to the operating room to remove the reservoir from the bladder via a suprapubic incision, repair the bladder injury, plug the J Sex Med **;**:**–**
Levine and Hoeh tubing from the reservoir to the pump, irrigate the field copiously with Rifampin (600 mg/L) and Bacitracin (50,000 units/L) solutions, close the incision and replace a fresh Foley catheter. Ten days postoperatively a cystogram was performed demonstrating no leakage, and the Foley catheter was removed. A new reservoir was placed 8 weeks later via a suprapubic incision without difficulty. Although an ectopic reservoir placement could have been performed at the time of bladder repair, this was not our practice at that time, and we had added concern for placing the device in a nonsterile field. This case demonstrates the importance of recognizing that a contracted pseudocapsule, which is adjacent to a resistant tissue plane, may predispose to tissue laceration during redilation of the pseudocapsule. In this circumstance, because of the abdominal/pelvic scarring the patient had from earlier surgery, these tissues had diminished elasticity and did not stretch during reservoir filling, which ultimately resulted in the ruptured bladder. Multiple clues can be taken from this case regarding the refilling of existing deflated reservoirs. This procedure should be considered carefully, especially in those with previous abdominal or pelvic surgery, including radical prostatectomy and cystoprostatectomy.
Case II This 68-year-old patient had an uneventful placement of a Titan (Coloplast, Minneapolis, MN, USA) penile prosthesis with a 75 cc reservoir through a penoscrotal approach and had the reservoir placed through the left external inguinal ring. There did not appear to be any laxity within the inguinal area. A small rent was made with Metzenbaum scissors through the transversalis fascia, as digital dissection failed. The reservoir was inserted into the space of Retzius. This patient did well with no complaints at his 1 and 3 months follow-up visits. But he did note the recent onset of an uncomfortable bulge in his inguinal area 6 months postoperatively, which was most bothersome when the prosthesis was in the flaccid state. On examination, the reservoir appeared to have partially extruded into the inguinal canal and could be palpated. With inflation of the prosthesis, the inguinal mass notably decompressed. It was subsequently found during surgical exploration that the tubing between the pump and the reservoir was trimmed without any redundancy, such that when the patient was manipulating the pump it was assumed that he was inadvertently pulling down on
Penile Prosthesis Reservoir Complications the reservoir. This patient was subsequently operated upon through an inguinal incision, which confirmed the reservoir herniation. There was no evidence of an inguinal hernia and therefore a new reservoir was placed with longer tubing into the same space of Retzius. The conjoined tendon and external oblique fascia were brought over the inguinal defect so as to reinforce the inguinal canal. There have been no inguinal or reservoirrelated problems in the 4 years since the revision procedure.
Case III This 58-year-old patient had an uneventful placement of a Titan three-piece inflatable prosthesis with standard 75 cc reservoir via a penoscrotal approach. The reservoir was placed through the left external ring into the space of Retzius. No hernia was noted, nor was there any prior history of inguinal hernia. It was noted during digital piercing of the transversalis fascia that the tissues in this area were somewhat lax. The space of Retzius was entered by digital dissection. The space was dilated digitally, irrigated with antibiotics, and the reservoir was placed within this space. The patient did well in the initial postoperative period but returned in 4 months with what appeared to be an inguinal hernia with no palpable reservoir. On exploration with a general surgeon, a large direct hernia was identified and repaired using a mesh-patch onlay technique through a left inguinal incision. The original reservoir was removed and the space of Retzius was reentered medially through a midline incision in the rectus fascia, which allowed placement of a new reservoir as well as positioning the tubing well away from the repaired hernia. This patient was discharged as an outpatient and did well postoperatively with a functional prosthesis and no recurrence of his hernia with follow-up of 18 months. Case IV This 40-year-old paraplegic man developed neurogenic ED. He did not respond to phosphodiesterase type 5 inhibitors and found use of intracavernosal injection therapy undesirable. He therefore elected to have placement of a 700CX three-piece penile prosthesis with a spherical 65 cc reservoir at an outside facility that was reported to proceed without difficulty via a penoscrotal approach. The reservoir was placed through the left external inguinal ring after digital entry through the transversalis fascia. Within 3 months postoperatively, the patient had persistent discom-
3 fort in the inguinal area, particularly after prolonged sitting in his wheelchair. He then noted that by the end of his workday his left lower extremity would be edematous with pitting edema. During physical exam, the prosthetic cylinders were in the proper location, as was the pump, and the reservoir could not be palpated. It was suspected that as the patient was quite slender, that when the patient was in the sitting position the full reservoir created pressure on the external iliac venous system. Therefore, a lower extremity duplex ultrasound was performed and readily demonstrated reduced venous flow when the prosthesis was deflated and which was exacerbated when he was in the sitting position (Figure 1A–C). The patient was subsequently explored via a midline hypogastric incision. The existing spherical 65 cc reservoir was removed and a new 100 cc Conceal flat reservoir (AMS) was placed ectopically by making a transverse incision in the anterior sheath of the rectus fascia. The space deep to the rectus muscle was developed, allowing placement of the reservoir which was filled to 65 cc. This was placed in a position such that it would not interfere with the Crede maneuver, which he used to empty his bladder. Over the following 6 months, the patient noted no subsequent lower extremity edema.
Case V A 67-year-old morbidly obese man requested penile prosthesis placement not only for sexual function but to aid in identification of the penis for urination. A Titan three-piece device was placed through a transverse penoscrotal incision. The penile cylinders and pump were placed without difficulty, but because of the extreme thickness of his adipose tissue, the external ring could not be reached. Rather than make a separate incision, it was elected to place a 75 cc Cloverleaf (Coloplast) reservoir into the subcutaneous fatty tissue. This plane was carefully developed as deep as possible but superficial to the rectus fascia. Gentle reapproximation of the fatty tissue was performed to prevent migration of the reservoir. This patient currently has a functional prosthesis with no palpable or visible irregularity caused by the reservoir. Case VI This 62-year-old male with diabetes and hypertension developed drug refractory ED and had placement of a penile prosthesis 11 years ago. The device subsequently failed mechanically and remained nonfunctional for approximately 6 months before the patient presented for revision. J Sex Med **;**:**–**
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Levine and Hoeh A
B
incised with cautery on its medial aspect, but the reservoir still could not be delivered from the space of Retzius. Therefore, a counter-incision was made over the area of the inguinal canal, which allowed exposure of the canal. In an effort to open the space to deliver the reservoir, there was sudden onset of significant venous bleeding, which ultimately was controlled by expanding the wound, allowing identification of a large branch of the external iliac vein, likely the external superficial pudendal. This vein was secured with a Satinsky clamp and then using Prolene (Ethicon, Somerville, NJ, USA) in a running fashion, the rent in the vein was repaired. The preexisting pseudocapsule was gently dilated and found to accommodate a 65 cc spherical reservoir with no difficulty. The new prosthesis was placed in continuity and found to be functional with no subsequent complications. Discussion
C
Figures 1 Case IV Doppler flow study of lower extremity. (A) Right iliac venous Doppler showing unobstructed flow. Left iliac venous Doppler showing markedly diminished flow while patient sitting upright (B) and supine (C) with prosthesis deflated.
At the time of exploration, the 700CX prosthesis cylinders and pump were removed without difficulty, but because the device was over 10 years old, we elected to remove and replace a fresh reservoir. The dissection to remove the reservoir was complicated by significant scarring following the tubing through the upper aspect of the left hemiscrotum and up into the inguinal canal, where even more dense scar was noted. The scar was carefully J Sex Med **;**:**–**
Penile prosthesis reservoir complications are unusual, and mechanical failure or spontaneous rupture of the reservoir is almost unheard of in the modern era. Once the seamless and stemless reservoirs were developed, the problems appeared to be primarily with cylinder, pump, or tubing failure [4]. But reservoir complications may occur, should be recognized, and if possible, prevented. We present six cases that were treated at our center over a 10-year period where over 400 devices were implanted. Recent reservoir modifications including the Conceal and Cloverleaf should make alternative location reservoir placement easier and provide better cosmesis due to their revised configuration. The new reservoir dimensions with similar fluid volumes are noted in Table 1.
Infection The most serious and feared complication with IPPs is infection, with the reported incidence after primary placement 1–3% and after revision surgery 8–18% [5]. During revision surgery, prolonged operating time, presence of scar tissue, and decreased blood flow may all contribute to the Table 1 Reservoir dimensions filled with 100 cc saline (inches) AMS Conceal MS spherical Coloplast Cloverleaf Coloplast Standard
3.66 2.73 4.27 3.4
x x x x
2.57 2.27 1.97 1.7
x x x x
0.90 2.27 1.97 1.7
Penile Prosthesis Reservoir Complications increased incidence of infection [6]. The most common organism associated with penile implant infections is coagulase negative staphylococcus comprising 58% in a large series. Less common organisms include Pseudomonas aeruginosa, Serratia marcescens, Enterococcus, Proteus mirabilis, and methicillin-resistant Staphylococcus aureus. In rare circumstances, fungal infections such as Candida albicans and anaerobic infections such as Bacteroides fragilis may be seen [7]. Multiple studies have evaluated the incidence of infection in diabetic patients with conflicting results. Jarrow and Wilson et al. found no difference in the incidence of implant infections among diabetic patients compared with a group without diabetes whereas Fallon and Ghanem found diabetic patients had a threefold increase in the risk of infection and Bishop et al. also found that diabetics had an increased risk of infection [8–11]. When revision surgery is indicated to address prosthetic malfunctions, including the reservoir, we do recommend performing an antibiotic washout, which has been shown to reduce the risk of postoperative infection [4,5,12]. Although there is no globally accepted revision washout protocol, our approach is to use copious amounts of Rifampin (600 mg/1 L water) and Bacitracin (50,000 units/1 L saline). In diabetic patients, we also routinely use amphotericin (50 mg/1 L water).
Herniation Reservoir extrusion through the inguinal canal is quite unusual. This may occur as a result of repetitive Valsalva, which may occur with cough or straining, or, as we believe in case II, by not providing enough redundant tubing between the pump and reservoir, such that when the patient is manipulating the pump during inflation or deflation he may be inadvertently pulling the reservoir caudally through the external inguinal canal. Direct inguinal herniation of the reservoir is another unusual complication, which may develop as a result of dissection or retraction in the area of the inguinal canal with or without preexisting tissue laxity, all of which may encourage subsequent direct hernia to occur. Other populations who may be at increased risk of reservoir herniation include the obese man or those who perform repetitive Valsalva maneuvers, such as men with chronic and obstructive pulmonary disease, or those who strain to void or defecate. SadeghiNejad et al. report a multi-item self-addressed questionnaire that was mailed to the members of the Society for the Study of Impotence question-
5 ing the occurrence of reservoir migration from the prevesical space to the inguinal canal or scrotum. A minority of respondents (28%) had experienced this problem. Of those who had the occurrence, it was felt to be very rare and usually appeared in the immediate postoperative period, often in association with vigorous coughing spells or vomiting. The responders also indicated that imperfect surgical technique might have been implicated in some cases. Management usually consisted of reservoir replacement or repositioning through an inguinal incision with repair of the defect. Alternatively, several surgeons used the existing scrotal incision if the patient presented in the immediate postoperative period. The incidence of reservoir herniation was 0.7% [13].
Erosion into Visceral Structures Reservoir erosion into the bladder or bowel is unusual. Certain predisposing conditions are believed to increase the risk of reservoir erosion, including prior pelvic surgery or radiation. In addition to our case I, there are 17 other cases of reservoir erosion into the bladder that have been published over the past 25 years occurring acutely or remotely after implantation [14–23]. As an example of a recognized acute bladder laceration, Eldefrawy and Kava presented a 67-year-old man status post radical prostatectomy who underwent placement of an IPP via a transscrotal incision. In the recovery room, the patient was noted to have gross hematuria and computed tomography scan revealed that the reservoir was within the urinary bladder. The patient was immediately taken back for exploration. The injury was repaired and a new reservoir was placed on the contralateral side [14]. Dupont and Hochman and Munoz and Ellswort reported on two separate cases of reservoir erosion presenting as irritative voiding symptoms in patients 3–4 years after IPP placement [18,19]. In a large review of more than 2,000 cases, Furlow and Goldwasser found erosion of the reservoir in eight patients (0.4%) [20]. Additional case reports describing reservoir erosion into the bladder are summarized in Table 2. Bowel injury has been reported as a reservoir complication in several articles [20,22,23,26–29]. For example, a case reported by Singh and Godec describes a 46-year-old man who had previously undergone left colectomy for colon cancer presenting 2 years after penile prosthesis insertion with small bowel obstruction. The reservoir had migrated intraperitoneally and had invaginated into the small bowel causing intussusception with J Sex Med **;**:**–**
6 Table 2
Bladder 1 case 2 cases
1 case
1 case
1 case
1 case
6 cases
1 case
2 cases
1 case Bowel 1 case
1 case
1 case
1 case
Levine and Hoeh Erosion into visceral structures Presentation
Management
Source
H/o RALP, presenting immediately post-IPP insertion with hematuria + CT confirming erosion. Both with h/o IPP insertion ~3 years prior, underwent revision for leak with existing reservoir left in place and refilled, immediate post-op hematuria. Reservoir erosion noted immediately and 4 weeks post-op via cysto. H/o IPP insertion 3 years prior, underwent revision for cylinder leak. Immediately post-op developed hematuria. Cysto performed 1 week later confirmed erosion. H/o IPP insertion 7 years prior, underwent revision of pump and tubing for leak 2 years later without incident. Underwent revision again and immediately post-op developed hematuria. Lost to follow-up until 14 months later with hematura/ dysuria. Cysto and CT confirmed reservoir in bladder. H/o IPP insertion 4 years prior. Developed bladder stones and reservoir erosion presenting with severe frequency, dysuria, hematuria.
Exploration, bladder repair, reservoir placement on contralateral side. Exploration once diagnosed with erosion, bladder repair, reservoir placement on contralateral side.
Eldefrawy and Kava [14] Kramer et al. [15]
Suprapubic exploration, bladder repair, reservoir placement on contralateral side.
Fitch and Roddy [16]
Exploration 2 weeks later, bladder repair, reservoir placement on contralateral side.
Park et al. [17]
Upon cystotomy for large bladder stone extraction the reservoir was identified with tubing entering from anterior wall. All IPP components removed. Cystotomy, reservoir removal, SP tube placement.
Dupont and Hochman [18]
All underwent repositioning of reservoir and repair of bladder.
Furlow and Goldwasser [20]
Cysto and cystogram showing intravesical reservoir with no bladder perforation. Subsequent removal of old reservoir and residual tubing. New IPP left in place.
Brusky et al. [21]
Exploration, bladder repair, reservoir placement on contralateral side.
O’Brien et al. [22]
Exploration, bladder repair, IPP removal.
Leach et al. [23]
Failed conservative treatment. Underwent exploratory laparotomy where reservoir was found adherent to a loop of small bowel. Underwent small bowel resection and reservoir was secured to lateral abdominal wall. Wound exploration revealed abscess cavity and large opening in sigmoid colon with no reservoir. Remainder of IPP removed, abscess drained, and diverting colostomy performed and later reversed.
O’Brien et al. [22]
Exploratory laparotomy, small bowel resection with re-anastomosis. Pt discharged with functioning IPP.
Luks et al. [26]
Exploratory laparotomy found reservoir adherent to several loops of small bowel requiring ileal resection and IPP removal.
Nelson [27]
H/o IPP insertion 4 years prior. Two years later developed autoinflation, switched to two-piece, leaving reservoir in situ. One year later dysuria, hematuria, pyuria with negative cultures and no response to antibiotics. Cysto showed intravesical reservoir. Four patients with prior RRP, one patient with diabetes, and one with neurogenic ED underwent IPP placement and subsequently developed reservoir erosion into bladder. H/o sigmoid colectomy. IPP placed 2 years later. XRT of prostate performed 8 years later for prostate cancer. IPP replaced shortly after XRT. Revision performed with old reservoir left in place. New reservoir placed in contralateral space of Retzius. Pt developed gross hematuria ~1 year later. Both with h/o IPP insertion, underwent revision several years later with existing reservoir refilled. Both p/w post-operative hematuria. Cysto showed reservoir in bladder. Underwent IPP placement; 21 mo later p/w hematuria; cysto showed erosion. H/o RRP with subsequent IPP placement; 2 years later p/w n/v, abdominal pain.
H/o cystoprostatectomy with ileal conduit. IPP inserted 2 years later with reservoir placement deep to transversalis fascia. Two months later pt developed right groin/scrotal swelling, fevers and non-functioning IPP. Pt reported passing spherical mass per rectum 2 days before admission. H/o LAR, shortly thereafter developed ED requiring IPP. Three years later p/w several days abdominal pain. Barium study showed reservoir within small bowel. H/o radical cystoprostatectomy. Received malleable prosthesis 2 years later, which eroded 1 month later. Then removed and immediately replaced with IPP. Presented 18 months later with abdominal pain, n/v.
J Sex Med **;**:**–**
Munoz and Ellswort [19]
Leach et al. [23]
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Penile Prosthesis Reservoir Complications Table 2
1 case
2 cases
1 case
Ureter 1 case
1 case
Continued Presentation
Management
Source
H/o left colectomy. Subsequently underwent IPP placement for ED. Two years later hospitalized with small bowel obstruction. Reservoir found intraperitoneally and caused small bowel intussusception. Reservoir placed in right space of Retzius. Six months later presented with wound abscess with exposed tubing. Two patients with prior cystectomy with ileal conduit underwent IPP placement and subsequently developed erosion into ileal conduit. H/o radical cystectomy with ileal conduit. Eight years later underwent IPP placement. Six years later developed severe left flank pain. Loop endoscopy showed that the reservoir had migrated into the conduit.
Local exploration revealed reservoir had completely entered right colon. Pt underwent partial colon resection with colostomy and IPP removal. Colostomy closed 6 months later.
Singh and Godec [28]
Both underwent revision of conduit and removal of reservoir.
Furlow and Goldwasser [20] Godiwalla et al. [29]
H/o RRP 4 years prior IPP insertion the following year. P/w foul smelling urine 3 years after IPP insertion. IVP showed left hydroureteronephrosis. CT scan confirmed left ureteral compression from IPP reservoir. H/o IPP insertion 11 years ago. IPP replaced with semirigid prosthesis 7 years later for device failure. Reservoir left in situ. P/w several weeks left flank pain. CT scan showed retained reservoir with surrounding capsule compressing the left lower ureter with mild hydroureteronephrosis.
Retrograde with double J stent insertion. Once negative urine culture confirmed pt underwent IPP cylinder/pump removal. Reservoir left in situ. Two-piece IPP inserted. Retrograde with double J stent insertion. Subsequent reservoir retrieval from prior lower abdominal incision.
Hudak and Mora [24]
Exploration and reservoir moved into new position. Postoperative ultrasound showed DVT. Pt subsequently underwent venous thrombectomy and IVC filter placement.
Brison et al. [34]
Exploration showed a capsule surrounding the reservoir adherent to iliac vein. The reservoir was freed and secured in another location. Pt’s swelling immediately improved with no subsequent problems. IVC filter inserted. IPP inflated to decompress reservoir and emergent exploration; 100 cc reservoir removed and a new 65 cc reservoir placed in ectopic position. Intraoperative ultrasound showed normal flow in artery. Received treatment for DVT. IVC filter inserted. Reservoir removed with new one replaced. Received treatment for DVT.
Flanagan et al. [35]
Vascular injury 1 case H/o radiation and large bowel diversion with subsequent IPP placement. Presented several days later with LLE swelling. Ultrasound showed sluggish flow consistent with a prethrombotic state in the left distal external iliac and common femoral veins. 1 case H/o T6 spinal cord injury with subsequent IPP placement. Two years later developed severe RLE edema. Ultrasound did not show DVT. Pelvic CT showed right external iliac vein compression from the reservoir. 1 case H/o IPP. Three years later underwent replacement for mechanical failure with new reservoir placed in right space of Retzius. That evening pt developed severe RLE pain and swelling. Ultrasound and CT showed DVT and stenosis of external iliac vein and artery. 1 case H/o RRP, 3 days following IPP placement p/w LLE edema, tenderness, and shortness of breath. Ultrasound confirmed DVT. V/Q scan did not indicate pulmonary embolism. CT scan showed reservoir compressing external iliac vein.
Reservoir was removed endoscopically and pt required creation of new conduit.
Jiang et al. [25]
Deho et al. [36]
da Justa et al. [37]
h/o = history of; pt = patient; RALP = robotically assisted laparoscopic prostatectomy; n/v = nausea/vomiting; LLE = left lower extremity, RLE = right lower extremity; IPP = inflatable penile prosthesis (three-piece unless otherwise specified); cysto = cystoscopy; ED = erectile dysfunction; p/w = presented with; LAR = low anterior resection; SP = suprapubic; DVT = deep vein thrombosis; CT = computed tomography; IVC = inferior vena cava; RRP = radical retropubic prostatectomy; XRT = external beam radiation; v/q = ventilation/perfusion
ischemia. The patient underwent small bowel resection and the reservoir was placed extraperitoneally on the right side of the bladder. Six months later, the patient presented with purulent discharge from the suprapubic incision. Exploration revealed that the reservoir had completely entered the right colon. The patient had colostomy placement and prosthesis removal [28]. Other bowelrelated and erosion cases are noted in Table 2.
The concern regarding leaving an empty reservoir during implant revision cases remains controversial. Jiann et al. and Munoz and Ellswort described retained reservoirs causing complications many years after the removal of the original IPP. On the other hand, Rajpurkar et al. performed a retrospective review of 85 patients who underwent 98 procedures for replacement or removal of malfunctioning three-piece IPPs. In J Sex Med **;**:**–**
8 their review, no patients had complications due to a retained reservoir [30]. Recently Hsi et al. recently reported an infection of a decommissioned reservoir with Actinomyces neuii presenting 3 months after IPP revision [31]. One may conclude from these studies that rare, retained reservoirs may potentially lead to complications. Pursuing a retained reservoir may be difficult due to extensive scar and may require extra time as well as a secondary incision to extract. It remains to be at the discretion of the surgeon as to whether the reservoir should be removed at the time of revision surgery. Inadvertent intraperitoneal placement of reservoirs has been noted during penile prosthesis surgery, particularly since the advent of roboticassisted radical prostatectomy (RALP). SadeghiNejad et al. reported a 68-year-old man who underwent RALP with subsequent IPP insertion. Immediately, following IPP placement, the patient underwent laparoscopic right lower abdominal hernia repair and the reservoir was found overlying the sigmoid colon. It was felt that the altered anatomy of the space of Retzius following RALP significantly increased the chances of intraperitoneal placement of the IPP reservoir, which may potentially result in bowel compression, laceration, or erosion [32]. In some instances, the reservoir may be intentionally placed within the peritoneal cavity. German physicians have routinely placed reservoirs in the peritoneal cavity to preclude development of autoinflation. Foreign bodies placed within the peritoneal cavity have been reported to not stimulate capsule formation, and the large intraperitoneal space prevents the transmission of intra-abdominal pressure to the reservoir. Mulcahy has suggested two caveats when intraperitoneal placement is considered as bowel can readily be intertwined around a reservoir that floats freely within the peritoneal cavity, which can result in bowel obstruction. Therefore, the reservoir should be secured against the pelvic wall and the tubing should remain loose to reduce the risk of erosion into a surrounding visceral structure [33].
Vascular Injury Vascular injury during or following placement of a reservoir is certainly possible during the digital or sharp dissection to enter the space of Retzius, as the external iliac system is in close proximity. Five cases including the one noted in this article have been reported, where pressure of the reservoir J Sex Med **;**:**–**
Levine and Hoeh caused subsequent partial venous obstruction with subsequent lower extremity edema [34–37]. Brison et al. reported a case of a 51-year-old man with a prior history of radiation therapy and large bowel diversion for rectal cancer who underwent IPP placement. The patient presented several days later with acute lower extremity swelling and pain. Venous Doppler revealed sluggish flow consistent with a prethrombotic state in the left distal external iliac and common femoral veins due to reservoir compression. The patient was immediately taken to the operating room and underwent reservoir repositioning through a suprapubic incision. Repeat ultrasound showed that a deep vein thrombosis had developed, resulting in subsequent venous thrombectomy with inferior vena cava filter placement. This complication was attributed to lateral displacement of the reservoir secondary to severe scarring from the previous pelvic surgery and radiation [34]. Other cases are outlined in Table 2. Pelvic vessel complications may be avoided by ensuring that an adequate space has been created both anterior and lateral to the bladder such that there is not compression of the adjacent venous structures. If inadequate space is encountered, alternate reservoir placement outside the space of Retzius should be considered. When a vascular tear occurs, either during placement of a fresh prosthesis or during a difficult removal of a reservoir during a revision procedure, the vessel most commonly lacerated is a branch of the external iliac such as the inferior epigastric, external superficial pudendal, or cremasteric vessels. In this circumstance, if exposure is not adequate via the primary incision, a secondary incision should be performed while maintaining pressure on the bleeding site, allowing better exposure where the vessel can be ligated if small or repaired with running Prolene.
Autoinflation Autoinflation occurs when the fluid pressure within the reservoir exceeds the backpressure limits of the pump assembly. If this elevated pressure remains, the fluid will inflate the cylinders causing autoinflation. The most common cause for autoinflation is insufficient space created for the reservoir at the time of placement, although incomplete emptying of the cylinders in the postoperative period may also contribute to this problem [38]. While autoinflation is typically only an annoying or embarrassing mechanical problem, it may also result in more severe clinical
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Penile Prosthesis Reservoir Complications consequences—notably cylinder erosion. Kobayashi et al. presented a case in which the right cylinder eroded through the corpora caused by chronic cylinder pressure secondary to autoinflation [39]. It is estimated that autoinflation occurs in up to 2–3% of patients receiving the 700CX implant and 3–5% of total prosthetics implanted within the last decade. The lockout valves found on the current pumps and reservoirs should further reduce this problem [40–43]. If autoinflation does occur, capsulotomy may be performed by disrupting the capsule or repositioning the reservoir. Abbosh et al. describe a laparoscopic technique wherein patients without a history of prostatectomy an infra-umbilical incision is made and the prevesical space is developed, whereas in patients with a history of prostatectomy the peritoneum is insufflated and a transabdominal approach is used to identify the reservoir and open the capsule. Patients were advised to keep the prosthesis completely deflated for 3 weeks following the procedure [44].
A
B
Modified Reservoir Placement Technique To reduce the creation of inguinal floor weakness and to reduce the potential risk of visceral injury particularly after prior pelvic surgery, it is our current practice to enter the space of Retzius sharply. This is accomplished with curved Jorgensen scissors, which are placed just over the superior aspect of the pubis, and then with lifting the scissors in an upward motion, the transversalis fascia is perforated. The tips of the scissors are therefore pointing away from the vessels and bladder or bowel, which may descend into this area following prior pelvic surgery. This technique typically makes a hole just large enough for the index finger to gain entry and complete the dissection. (Figures 2A, B, and 3). Placement of the reservoir into this space can also be facilitated by placing a long-nose nasal speculum through the defect into the retropubic space. If the space of Retzius cannot be entered due to extensive scarring, then ectopic placement may be considered via a separate transverse hypogastric incision through the anterior rectus sheath with placement of a Cloverleaf or Conceal flat reservoir deep to the rectus muscle but superficial to the posterior rectus sheath. Other options include the lateral placement between the transversus abdominus muscle and the transversalis fascia through a separate small incision just above the anterior superior iliac spine as described by Hartman et al.
Figure 2 (A) Intraoperative photograph demonstrating positioning of Jorgensen scissors through scrotal incision to enter the space of Retzius. (B) Scissors are elevated to allow controlled perforation of transversalis fascia away from bladder, bowel, and iliac vessels.
or through the original infrapubic or scrotal incision as noted by Perito [45–47]. Conclusion
This case report series and literature review demonstrates the most common penile prosthesis reservoir complications. Interestingly, these events do not occur in the modern era of prosthetics due to mechanical failure of the reservoir; rather, it appears that they occur due to surgical technique, injury to local tissues at the time of implantation, J Sex Med **;**:**–**
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Figure 3 Anatomical drawing demonstrating Jorgensen scissors piercing transversalis fascia just cephalad to superior aspect of pubis.
or due to chronic pressure. The risk of erosion of the reservoir into surrounding visceral structures appears to be greatly increased in patients with a prior history of abdominopelvic surgery, radiation or prior penile prosthetic devices. While the reservoir can be placed intra-abdominally, there may be an increased risk of visceral injury. If intraabdominal placement is attempted, the surgeon should ensure that the reservoir is secured to the abdominal wall and that the tubing is not too tight. When there is blood in the urine, either intraoperatively or postoperatively, or a change in voiding or bowel symptoms, this should alert the physician to consider a visceral injury from the reservoir. The implanting prosthetic surgeon should be aware of these potential events, how they may present, and prevent them from occurring if possible. In addition, we present our modified Jorgensen scissors technique for placement of a reservoir into the space of Retzius, which can also be attempted in men who have undergone radical prostatectomy. Corresponding Author: Laurence A. Levine, MD, Department of Urology, Rush University Medical Center, 1725 W Harrison Street Suite 352, Chicago, IL 60612, USA. Tel: 312-563-5000; Fax: 312-563-5007; E-mail: [email protected] Conflict of Interest: Laurence A. Levine, MD: — Auxilium: speaker, consultant, investigator, clinical trial J Sex Med **;**:**–**
— AMS: speaker, consultant — Coloplast: speaker, consultant — Lilly: speaker — Astellas: speaker Michael P. Hoeh, MD: none. Statement of Authorship
Category 1 (a) Conception and Design Laurence A. Levine; Michael P. Hoeh (b) Acquisition of Data Laurence A. Levine; Michael P. Hoeh (c) Analysis and Interpretation of Data Laurence A. Levine; Michael P. Hoeh
Category 2 (a) Drafting the Article Laurence A. Levine; Michael P. Hoeh (b) Revising It for Intellectual Content Laurence A. Levine; Michael P. Hoeh
Category 3 (a) Final Approval of the Completed Article Laurence A. Levine; Michael P. Hoeh References 1 Dhar NB, Angermeier KW, Montague DK. Long-term mechanical reliability of AMS 700CX/CXM inflatable penile prosthesis. J Urol 2006;176(6 Pt 1):2599–601. discussion 2601. 2 Wilson SK, Wahman GE, Lange JL. Eleven years of experience with the inflatable penile prosthesis. J Urol 1988;139: 951–2.
Penile Prosthesis Reservoir Complications 3 Wilson SK, Delk JR, Salem EA, Cleves MA. Long-term survival of inflatable penile prosthesis: Single surgical group experience with 2,384 first-time implants spanning two decades. J Sex Med 2007;4:1074–9. 4 Montague DK. Experience with semirigid rod and inflatable penile prostheses. J Urol 1983;129:967–8. 5 Wilson SK, Delk JR 2nd. Inflatable penile implant infection: Predisposing factors and treatment suggestions. J Urol 1995;153:659–61. 6 Mulcahy JJ. Current approach to the treatment of penile implant infections. Ther Adv Urol 2010;2:69–75. 7 Mulcahy JJ. Long-term experience with salvage of infected penile implants. J Urol 2000;163:481–2. 8 Jarrow JP. Risk factors for penile prosthesis infection. J Urol 1996;156(2 Pt 1):402–4. 9 Wilson SK, Carson CC, Cleves MA, Delk JR 2nd. Quantifying risk of penile prosthesis infection with elevated glycosylated hemoglobin. 1998;159:1537–9. 10 Fallon B, Ghanem H. Sexual performance and satisfaction with penile prostheses in impotence of various etrologies. Int J Imp Res 1990;2:35–42. 11 Bishop JR, Moul JW, Sehelnik SA, Peppas DS, Gormley TS, McLeod DG. Use of glycosylated hemoglobin to identify diabetics at high risk for penile prosthetic infections. J Urol 1992;147:386–8. 12 Henry GD, Wilson SK, Delk JR 2nd, Carson CC, Wiygul J, Tornehl C, Cleves MA, Silverstein A, Donatucci CF. Revision washout decreases penile prosthesis infection in revision surgery: A multicenter study. J Urol 2005;173:89–92. 13 Sadeghi-Nejad H, Sharma A, Irwin RJ, Wilson SK, Delk JR. Reservoir herniation as a complication of three-piece penile prosthesis insertion. Urology 2001;57:142–5. 14 Eldefrawy A, Kava BR. An unusual complication during inflatable penile prosthesis implantation. Urology 2010;76:847. 15 Kramer AC, Chason JK, Kusakabe A. Report of two cases of bladder perforation caused by reservoir of inflatable penile prosthesis. J Sex Med 2009;6:2064–7. 16 Fitch WP, Roddy T. Erosion of inflatable penile prosthesis reservoir into bladder. J Urol 1986;36:1080. 17 Park JK, Jang SW, Lee SW, Cui Y. Rare complication of multiple revision surgeries of penile prosthesis. J Sex Med 2005;2:735–6. 18 Dupont MC, Hochman HI. Erosion of an inflatable penile prosthesis reservoir into the bladder, presenting as bladder calculi. J Urol 1988;139:367–8. 19 Munoz JJ, Ellswort PI. The retained penile prosthesis reservoir: A risk. Urology 2000;55:949. 20 Furlow WL, Goldwasser B. Salvage of the eroded inflatable penile prosthesis: A new concept. J Urol 1987;138:312. 21 Brusky J, Dikranin A, Aboseif S. Retrieval of inflatable penile prosthesis reservoir from the bladder. Int J Impot Res 2005;17: 302–3. 22 O’Brien DP III, Walton KN, Amerson JR, Walther M. Unusual complications of the inflatable penile prosthesis. J Urol 1984;131:234A. 23 Leach GE, Shapiro CE, Hadley R, Raz S. Erosion of inflatable penile prosthesis reservoir into bladder and bowel. J Urol 1984;131:1177. 24 Hudak SJ, Mora RV. Unilateral ureteral obstruction due to a migrated inflatable penile prosthesis reservoir. J Urol 2008;180:336. 25 Jiann BP, Ou CW, Lin JT, Huang JK. Compression of ureter caused by a retained reservoir of penile prosthesis. Int J Impot Res 2006;18:316–7. 26 Luks FI, Huntley N, Tula JC, Pizzi WF. Small-bowel obstruction by an inflatable penile prosthesis reservoir. Surgery 1989;106:101–4.
11 27 Nelson RP. Small bowel obstruction secondary to migration of an inflatable penile prosthesis reservoir: Recognition and prevention. J Urol 1988;139:1053–4. 28 Singh I, Godec CJ. Asynchronous erosion of inflatable penile prosthesis into small and large bowel. J Urol 1992;147:709–10. 29 Godiwalla SY, Beres J, Jacobs SC. Erosion of an inflatable penile prosthesis reservoir into an ileal conduit. J Urol 1987; 137:297–8. 30 Rajpurkar A, Bianco FF Jr, Al-Omar O, Terlecki R, Dhabuwala C. Fate of the retained reservoir after replacement of 3-piece penile prosthesis. J Urol 2004;172:664–6. 31 Hsi RS, Hotaling JM, Spencer ES, Bollky PL, Walsh TJ. Isolated infection of a decommissioned penile prosthesis reservoir with Actinomyces neuii. J Sex Med 2011;8:923–6. 32 Sadeghi-Nehjad H, Munarriz R, Shah N. Intra-abdominal reservoir placement during penile prosthesis surgery in post-robotically assisted laparoscopic radical prostatectomy patients: A case report and practical considerations. J Sex Med 2011;8:1547–50. 33 Mulcahy JJ. Male Sexual Function: A Guide to Clinical Management. 2nd edition. Totowa, NJ: Humana Press Inc.; 2006. 34 Brison D, Ilbeigi P, Sadeghi-Nejad H. Reservoir repositioning and successful thrombectomy for deep venous thrombosis secondary to compression of pelvic veins by an inflatable penile prosthesis reservoir. J Sex Med 2007;4:1185–7. 35 Flanagan MJ, Krisch EB, Gerber WL. Complication of a penile prosthesis reservoir: Venous compression masquerading as a deep venous thrombosis. 1991;146:847–8. 36 Deho F, Henry GD, Marone EM, Sacca A, Chiesa R, Rigatti P, Montorsi F. Severe vascular complication after implantation of a three-piece inflatable penile prosthesis. J Sex Med 2008;5:2956–9. 37 da Justa DG, Bianco FJ Jr, Ogle A, Dhabuwala CB. Deep venous thrombosis due to compression of external iliac vein by the penile prosthesis reservoir. J Urol 2003;61:462. 38 Govier FE. The surgical management of erectile dysfunction utilizing inflatable prosthetic devices. AUA Update Ser 1996;XV(Ch 10):77–84. 39 Kobayashi K, Hisasue S, Shimizu T, Itoh N, Tsuksamoto T. Erosion of an inflatable penile prosthesis due to autoinflation. J Urol 2004;50:515–7. 40 Knoll LD, Henry G, Culkin D, Ohl DA, Otheguy J, Shabsigh R, Wilson SK, Delk J. Physician and patient satisfaction with the new AMS 700 momentary squeeze inflatable penile prosthesis. J Sex Med 2009;6:1773–8. 41 Carson CC, Mulcahy JJ, Govier FE. Efficacy, safety, and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis: Results of a long-term multicenter study. AMS 700CX Study Group. J Urol 2000;164:376–80. 42 Hollenbeck BK, Miller DC, Ohl DA. The utility of lockout valve reservoirs in preventing autoinflation in penile prostheses. Int Urol Nephrol 2002;34:379–83. 43 Govier FE, McClure RD, Weissman RM, Kramer-Levien D. Back-pressure testing to prevent autoinflation of penile prosthetic devices. J Urol 1996;48:779–80. 44 Abbosh PH, Thom MR, Bullock A. Laparoscopic capsulotomy to treat autoinflation of inflatable penile prostheses. J Sex Med 2012;9:1212–5. 45 Hartman RJ Jr, Helfand BT, McVary KT. Outcomes of lateral retroperitoneal reservoir placement of three-piece penile prosthesis in patients following radical prostatectomy. Int J Imp Res 2010;22:279–83. 46 Perito PE. Ectopic reservoir placement—No longer in the space of Retzius. J Sex Med 2011;8:2395–8. 47 Perito PE, Wilson SK. Traditional (retroperitoneal) and abdominal wall (ectopic) reservoir placement. J Sex Med 2011;8:656–9.
J Sex Med **;**:**–**
Review of Penile Prosthetic Reservoir: Complications and Presentation of a Modified Reservoir Placement Technique
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Laurence A. Levine, MD and Michael P. Hoeh, MD Department of Urology, Rush University Medical Center, Chicago, IL, USA DOI: 10.1111/j.1743-6109.2012.02807.x
ABSTRACT
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. Levine LA and Hoeh MP. Review of penile prosthetic reservoir: Complications and presentation of a modified reservoir Placement technique. J Sex Med **;**:**–**. Key Words. Penile Prosthesis Complications; Penile Prosthesis Reservoir; Reservoir Complications; Three-Piece Inflatable Prosthesis
Introduction
I
nflatable penile prostheses (IPPs) have been a successful method for treating men with erectile dysfunction (ED) since the early 1970s. Multiple modifications have been made to improve their function, reliability, cosmesis, and reduce infection. These modifications have made it such that the likelihood of a reservoir mechanical mal© 2012 International Society for Sexual Medicine
function is highly unusual. Advances in mechanical reliability have primarily been focused on the cylinders, pump, and tubing. The most significant early reservoir modifications that improved device survival were the developments of a seamless, spherical reservoir in 1978 and multiple improvements that had been instituted by 1983, including the development of kink resistant tubing and elimination of the internal reinforcing rod or stem J Sex Med **;**:**–**
2 in the reservoir. There is a paucity of long-term IPP device survival studies, the longest of which is by Dhar et al. In this study, 380 patients that had received either an American Medical Systems (AMS) 700CX/CXM IPP (Minneapolis, MN, USA) between April 1986 and July 2004 were contacted. Thirty-nine of those patients (10.3%) experienced device failure because of mechanical problems. The only reservoir-related problems were three leaks [1]. Another large scale study demonstrating the mechanical reliability of the reservoir is a report by Wilson et al. in 1988 on 395 patients using both AMS and Mentor prostheses where no reservoir malfunctions were noted [2,3]. Complications or unexpected events associated with penile prosthesis reservoirs have not been reviewed recently, and it is the intent of this article to review our own experience and that found in the published English literature since 1980. Although these complications occur infrequently, it would behoove the implanting surgeon to be aware of their presentation and current approaches to resolve or prevent their occurrence. The following will review our reservoir-related complications over the past 10 years.
Case I This 56-year-old man had undergone previous open bladder surgery for excision of a bladder diverticulum via a midline hypogastric incision. He underwent subsequent placement of a 700CX three-piece prosthesis with a 65 cc spherical reservoir via a penoscrotal incision, which failed after 4 years due to a tubing fracture. The patient waited approximately 1 year before undergoing revision surgery. At the time of addressing the original reservoir, it was elected to leave it in place if it was intact and refill it with fresh saline. Presumably, a dense pseudocapsule had formed around the reservoir, as it was noted that there was difficulty in refilling the reservoir to its normal capacity, and therefore gentle pressure was applied to the filling syringe until there was a sudden give. This phenomenon typically occurs with formation of a pseudocapsule around an otherwise normal indwelling reservoir. Blood was subsequently noted in the urine draining from the catheter in the recovery room. Flexible cystoscopy was performed which provided visualization of the reservoir through a laceration in the bladder wall. As there was a clear bladder disruption, we elected to immediately return to the operating room to remove the reservoir from the bladder via a suprapubic incision, repair the bladder injury, plug the J Sex Med **;**:**–**
Levine and Hoeh tubing from the reservoir to the pump, irrigate the field copiously with Rifampin (600 mg/L) and Bacitracin (50,000 units/L) solutions, close the incision and replace a fresh Foley catheter. Ten days postoperatively a cystogram was performed demonstrating no leakage, and the Foley catheter was removed. A new reservoir was placed 8 weeks later via a suprapubic incision without difficulty. Although an ectopic reservoir placement could have been performed at the time of bladder repair, this was not our practice at that time, and we had added concern for placing the device in a nonsterile field. This case demonstrates the importance of recognizing that a contracted pseudocapsule, which is adjacent to a resistant tissue plane, may predispose to tissue laceration during redilation of the pseudocapsule. In this circumstance, because of the abdominal/pelvic scarring the patient had from earlier surgery, these tissues had diminished elasticity and did not stretch during reservoir filling, which ultimately resulted in the ruptured bladder. Multiple clues can be taken from this case regarding the refilling of existing deflated reservoirs. This procedure should be considered carefully, especially in those with previous abdominal or pelvic surgery, including radical prostatectomy and cystoprostatectomy.
Case II This 68-year-old patient had an uneventful placement of a Titan (Coloplast, Minneapolis, MN, USA) penile prosthesis with a 75 cc reservoir through a penoscrotal approach and had the reservoir placed through the left external inguinal ring. There did not appear to be any laxity within the inguinal area. A small rent was made with Metzenbaum scissors through the transversalis fascia, as digital dissection failed. The reservoir was inserted into the space of Retzius. This patient did well with no complaints at his 1 and 3 months follow-up visits. But he did note the recent onset of an uncomfortable bulge in his inguinal area 6 months postoperatively, which was most bothersome when the prosthesis was in the flaccid state. On examination, the reservoir appeared to have partially extruded into the inguinal canal and could be palpated. With inflation of the prosthesis, the inguinal mass notably decompressed. It was subsequently found during surgical exploration that the tubing between the pump and the reservoir was trimmed without any redundancy, such that when the patient was manipulating the pump it was assumed that he was inadvertently pulling down on
Penile Prosthesis Reservoir Complications the reservoir. This patient was subsequently operated upon through an inguinal incision, which confirmed the reservoir herniation. There was no evidence of an inguinal hernia and therefore a new reservoir was placed with longer tubing into the same space of Retzius. The conjoined tendon and external oblique fascia were brought over the inguinal defect so as to reinforce the inguinal canal. There have been no inguinal or reservoirrelated problems in the 4 years since the revision procedure.
Case III This 58-year-old patient had an uneventful placement of a Titan three-piece inflatable prosthesis with standard 75 cc reservoir via a penoscrotal approach. The reservoir was placed through the left external ring into the space of Retzius. No hernia was noted, nor was there any prior history of inguinal hernia. It was noted during digital piercing of the transversalis fascia that the tissues in this area were somewhat lax. The space of Retzius was entered by digital dissection. The space was dilated digitally, irrigated with antibiotics, and the reservoir was placed within this space. The patient did well in the initial postoperative period but returned in 4 months with what appeared to be an inguinal hernia with no palpable reservoir. On exploration with a general surgeon, a large direct hernia was identified and repaired using a mesh-patch onlay technique through a left inguinal incision. The original reservoir was removed and the space of Retzius was reentered medially through a midline incision in the rectus fascia, which allowed placement of a new reservoir as well as positioning the tubing well away from the repaired hernia. This patient was discharged as an outpatient and did well postoperatively with a functional prosthesis and no recurrence of his hernia with follow-up of 18 months. Case IV This 40-year-old paraplegic man developed neurogenic ED. He did not respond to phosphodiesterase type 5 inhibitors and found use of intracavernosal injection therapy undesirable. He therefore elected to have placement of a 700CX three-piece penile prosthesis with a spherical 65 cc reservoir at an outside facility that was reported to proceed without difficulty via a penoscrotal approach. The reservoir was placed through the left external inguinal ring after digital entry through the transversalis fascia. Within 3 months postoperatively, the patient had persistent discom-
3 fort in the inguinal area, particularly after prolonged sitting in his wheelchair. He then noted that by the end of his workday his left lower extremity would be edematous with pitting edema. During physical exam, the prosthetic cylinders were in the proper location, as was the pump, and the reservoir could not be palpated. It was suspected that as the patient was quite slender, that when the patient was in the sitting position the full reservoir created pressure on the external iliac venous system. Therefore, a lower extremity duplex ultrasound was performed and readily demonstrated reduced venous flow when the prosthesis was deflated and which was exacerbated when he was in the sitting position (Figure 1A–C). The patient was subsequently explored via a midline hypogastric incision. The existing spherical 65 cc reservoir was removed and a new 100 cc Conceal flat reservoir (AMS) was placed ectopically by making a transverse incision in the anterior sheath of the rectus fascia. The space deep to the rectus muscle was developed, allowing placement of the reservoir which was filled to 65 cc. This was placed in a position such that it would not interfere with the Crede maneuver, which he used to empty his bladder. Over the following 6 months, the patient noted no subsequent lower extremity edema.
Case V A 67-year-old morbidly obese man requested penile prosthesis placement not only for sexual function but to aid in identification of the penis for urination. A Titan three-piece device was placed through a transverse penoscrotal incision. The penile cylinders and pump were placed without difficulty, but because of the extreme thickness of his adipose tissue, the external ring could not be reached. Rather than make a separate incision, it was elected to place a 75 cc Cloverleaf (Coloplast) reservoir into the subcutaneous fatty tissue. This plane was carefully developed as deep as possible but superficial to the rectus fascia. Gentle reapproximation of the fatty tissue was performed to prevent migration of the reservoir. This patient currently has a functional prosthesis with no palpable or visible irregularity caused by the reservoir. Case VI This 62-year-old male with diabetes and hypertension developed drug refractory ED and had placement of a penile prosthesis 11 years ago. The device subsequently failed mechanically and remained nonfunctional for approximately 6 months before the patient presented for revision. J Sex Med **;**:**–**
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B
incised with cautery on its medial aspect, but the reservoir still could not be delivered from the space of Retzius. Therefore, a counter-incision was made over the area of the inguinal canal, which allowed exposure of the canal. In an effort to open the space to deliver the reservoir, there was sudden onset of significant venous bleeding, which ultimately was controlled by expanding the wound, allowing identification of a large branch of the external iliac vein, likely the external superficial pudendal. This vein was secured with a Satinsky clamp and then using Prolene (Ethicon, Somerville, NJ, USA) in a running fashion, the rent in the vein was repaired. The preexisting pseudocapsule was gently dilated and found to accommodate a 65 cc spherical reservoir with no difficulty. The new prosthesis was placed in continuity and found to be functional with no subsequent complications. Discussion
C
Figures 1 Case IV Doppler flow study of lower extremity. (A) Right iliac venous Doppler showing unobstructed flow. Left iliac venous Doppler showing markedly diminished flow while patient sitting upright (B) and supine (C) with prosthesis deflated.
At the time of exploration, the 700CX prosthesis cylinders and pump were removed without difficulty, but because the device was over 10 years old, we elected to remove and replace a fresh reservoir. The dissection to remove the reservoir was complicated by significant scarring following the tubing through the upper aspect of the left hemiscrotum and up into the inguinal canal, where even more dense scar was noted. The scar was carefully J Sex Med **;**:**–**
Penile prosthesis reservoir complications are unusual, and mechanical failure or spontaneous rupture of the reservoir is almost unheard of in the modern era. Once the seamless and stemless reservoirs were developed, the problems appeared to be primarily with cylinder, pump, or tubing failure [4]. But reservoir complications may occur, should be recognized, and if possible, prevented. We present six cases that were treated at our center over a 10-year period where over 400 devices were implanted. Recent reservoir modifications including the Conceal and Cloverleaf should make alternative location reservoir placement easier and provide better cosmesis due to their revised configuration. The new reservoir dimensions with similar fluid volumes are noted in Table 1.
Infection The most serious and feared complication with IPPs is infection, with the reported incidence after primary placement 1–3% and after revision surgery 8–18% [5]. During revision surgery, prolonged operating time, presence of scar tissue, and decreased blood flow may all contribute to the Table 1 Reservoir dimensions filled with 100 cc saline (inches) AMS Conceal MS spherical Coloplast Cloverleaf Coloplast Standard
3.66 2.73 4.27 3.4
x x x x
2.57 2.27 1.97 1.7
x x x x
0.90 2.27 1.97 1.7
Penile Prosthesis Reservoir Complications increased incidence of infection [6]. The most common organism associated with penile implant infections is coagulase negative staphylococcus comprising 58% in a large series. Less common organisms include Pseudomonas aeruginosa, Serratia marcescens, Enterococcus, Proteus mirabilis, and methicillin-resistant Staphylococcus aureus. In rare circumstances, fungal infections such as Candida albicans and anaerobic infections such as Bacteroides fragilis may be seen [7]. Multiple studies have evaluated the incidence of infection in diabetic patients with conflicting results. Jarrow and Wilson et al. found no difference in the incidence of implant infections among diabetic patients compared with a group without diabetes whereas Fallon and Ghanem found diabetic patients had a threefold increase in the risk of infection and Bishop et al. also found that diabetics had an increased risk of infection [8–11]. When revision surgery is indicated to address prosthetic malfunctions, including the reservoir, we do recommend performing an antibiotic washout, which has been shown to reduce the risk of postoperative infection [4,5,12]. Although there is no globally accepted revision washout protocol, our approach is to use copious amounts of Rifampin (600 mg/1 L water) and Bacitracin (50,000 units/1 L saline). In diabetic patients, we also routinely use amphotericin (50 mg/1 L water).
Herniation Reservoir extrusion through the inguinal canal is quite unusual. This may occur as a result of repetitive Valsalva, which may occur with cough or straining, or, as we believe in case II, by not providing enough redundant tubing between the pump and reservoir, such that when the patient is manipulating the pump during inflation or deflation he may be inadvertently pulling the reservoir caudally through the external inguinal canal. Direct inguinal herniation of the reservoir is another unusual complication, which may develop as a result of dissection or retraction in the area of the inguinal canal with or without preexisting tissue laxity, all of which may encourage subsequent direct hernia to occur. Other populations who may be at increased risk of reservoir herniation include the obese man or those who perform repetitive Valsalva maneuvers, such as men with chronic and obstructive pulmonary disease, or those who strain to void or defecate. SadeghiNejad et al. report a multi-item self-addressed questionnaire that was mailed to the members of the Society for the Study of Impotence question-
5 ing the occurrence of reservoir migration from the prevesical space to the inguinal canal or scrotum. A minority of respondents (28%) had experienced this problem. Of those who had the occurrence, it was felt to be very rare and usually appeared in the immediate postoperative period, often in association with vigorous coughing spells or vomiting. The responders also indicated that imperfect surgical technique might have been implicated in some cases. Management usually consisted of reservoir replacement or repositioning through an inguinal incision with repair of the defect. Alternatively, several surgeons used the existing scrotal incision if the patient presented in the immediate postoperative period. The incidence of reservoir herniation was 0.7% [13].
Erosion into Visceral Structures Reservoir erosion into the bladder or bowel is unusual. Certain predisposing conditions are believed to increase the risk of reservoir erosion, including prior pelvic surgery or radiation. In addition to our case I, there are 17 other cases of reservoir erosion into the bladder that have been published over the past 25 years occurring acutely or remotely after implantation [14–23]. As an example of a recognized acute bladder laceration, Eldefrawy and Kava presented a 67-year-old man status post radical prostatectomy who underwent placement of an IPP via a transscrotal incision. In the recovery room, the patient was noted to have gross hematuria and computed tomography scan revealed that the reservoir was within the urinary bladder. The patient was immediately taken back for exploration. The injury was repaired and a new reservoir was placed on the contralateral side [14]. Dupont and Hochman and Munoz and Ellswort reported on two separate cases of reservoir erosion presenting as irritative voiding symptoms in patients 3–4 years after IPP placement [18,19]. In a large review of more than 2,000 cases, Furlow and Goldwasser found erosion of the reservoir in eight patients (0.4%) [20]. Additional case reports describing reservoir erosion into the bladder are summarized in Table 2. Bowel injury has been reported as a reservoir complication in several articles [20,22,23,26–29]. For example, a case reported by Singh and Godec describes a 46-year-old man who had previously undergone left colectomy for colon cancer presenting 2 years after penile prosthesis insertion with small bowel obstruction. The reservoir had migrated intraperitoneally and had invaginated into the small bowel causing intussusception with J Sex Med **;**:**–**
6 Table 2
Bladder 1 case 2 cases
1 case
1 case
1 case
1 case
6 cases
1 case
2 cases
1 case Bowel 1 case
1 case
1 case
1 case
Levine and Hoeh Erosion into visceral structures Presentation
Management
Source
H/o RALP, presenting immediately post-IPP insertion with hematuria + CT confirming erosion. Both with h/o IPP insertion ~3 years prior, underwent revision for leak with existing reservoir left in place and refilled, immediate post-op hematuria. Reservoir erosion noted immediately and 4 weeks post-op via cysto. H/o IPP insertion 3 years prior, underwent revision for cylinder leak. Immediately post-op developed hematuria. Cysto performed 1 week later confirmed erosion. H/o IPP insertion 7 years prior, underwent revision of pump and tubing for leak 2 years later without incident. Underwent revision again and immediately post-op developed hematuria. Lost to follow-up until 14 months later with hematura/ dysuria. Cysto and CT confirmed reservoir in bladder. H/o IPP insertion 4 years prior. Developed bladder stones and reservoir erosion presenting with severe frequency, dysuria, hematuria.
Exploration, bladder repair, reservoir placement on contralateral side. Exploration once diagnosed with erosion, bladder repair, reservoir placement on contralateral side.
Eldefrawy and Kava [14] Kramer et al. [15]
Suprapubic exploration, bladder repair, reservoir placement on contralateral side.
Fitch and Roddy [16]
Exploration 2 weeks later, bladder repair, reservoir placement on contralateral side.
Park et al. [17]
Upon cystotomy for large bladder stone extraction the reservoir was identified with tubing entering from anterior wall. All IPP components removed. Cystotomy, reservoir removal, SP tube placement.
Dupont and Hochman [18]
All underwent repositioning of reservoir and repair of bladder.
Furlow and Goldwasser [20]
Cysto and cystogram showing intravesical reservoir with no bladder perforation. Subsequent removal of old reservoir and residual tubing. New IPP left in place.
Brusky et al. [21]
Exploration, bladder repair, reservoir placement on contralateral side.
O’Brien et al. [22]
Exploration, bladder repair, IPP removal.
Leach et al. [23]
Failed conservative treatment. Underwent exploratory laparotomy where reservoir was found adherent to a loop of small bowel. Underwent small bowel resection and reservoir was secured to lateral abdominal wall. Wound exploration revealed abscess cavity and large opening in sigmoid colon with no reservoir. Remainder of IPP removed, abscess drained, and diverting colostomy performed and later reversed.
O’Brien et al. [22]
Exploratory laparotomy, small bowel resection with re-anastomosis. Pt discharged with functioning IPP.
Luks et al. [26]
Exploratory laparotomy found reservoir adherent to several loops of small bowel requiring ileal resection and IPP removal.
Nelson [27]
H/o IPP insertion 4 years prior. Two years later developed autoinflation, switched to two-piece, leaving reservoir in situ. One year later dysuria, hematuria, pyuria with negative cultures and no response to antibiotics. Cysto showed intravesical reservoir. Four patients with prior RRP, one patient with diabetes, and one with neurogenic ED underwent IPP placement and subsequently developed reservoir erosion into bladder. H/o sigmoid colectomy. IPP placed 2 years later. XRT of prostate performed 8 years later for prostate cancer. IPP replaced shortly after XRT. Revision performed with old reservoir left in place. New reservoir placed in contralateral space of Retzius. Pt developed gross hematuria ~1 year later. Both with h/o IPP insertion, underwent revision several years later with existing reservoir refilled. Both p/w post-operative hematuria. Cysto showed reservoir in bladder. Underwent IPP placement; 21 mo later p/w hematuria; cysto showed erosion. H/o RRP with subsequent IPP placement; 2 years later p/w n/v, abdominal pain.
H/o cystoprostatectomy with ileal conduit. IPP inserted 2 years later with reservoir placement deep to transversalis fascia. Two months later pt developed right groin/scrotal swelling, fevers and non-functioning IPP. Pt reported passing spherical mass per rectum 2 days before admission. H/o LAR, shortly thereafter developed ED requiring IPP. Three years later p/w several days abdominal pain. Barium study showed reservoir within small bowel. H/o radical cystoprostatectomy. Received malleable prosthesis 2 years later, which eroded 1 month later. Then removed and immediately replaced with IPP. Presented 18 months later with abdominal pain, n/v.
J Sex Med **;**:**–**
Munoz and Ellswort [19]
Leach et al. [23]
7
Penile Prosthesis Reservoir Complications Table 2
1 case
2 cases
1 case
Ureter 1 case
1 case
Continued Presentation
Management
Source
H/o left colectomy. Subsequently underwent IPP placement for ED. Two years later hospitalized with small bowel obstruction. Reservoir found intraperitoneally and caused small bowel intussusception. Reservoir placed in right space of Retzius. Six months later presented with wound abscess with exposed tubing. Two patients with prior cystectomy with ileal conduit underwent IPP placement and subsequently developed erosion into ileal conduit. H/o radical cystectomy with ileal conduit. Eight years later underwent IPP placement. Six years later developed severe left flank pain. Loop endoscopy showed that the reservoir had migrated into the conduit.
Local exploration revealed reservoir had completely entered right colon. Pt underwent partial colon resection with colostomy and IPP removal. Colostomy closed 6 months later.
Singh and Godec [28]
Both underwent revision of conduit and removal of reservoir.
Furlow and Goldwasser [20] Godiwalla et al. [29]
H/o RRP 4 years prior IPP insertion the following year. P/w foul smelling urine 3 years after IPP insertion. IVP showed left hydroureteronephrosis. CT scan confirmed left ureteral compression from IPP reservoir. H/o IPP insertion 11 years ago. IPP replaced with semirigid prosthesis 7 years later for device failure. Reservoir left in situ. P/w several weeks left flank pain. CT scan showed retained reservoir with surrounding capsule compressing the left lower ureter with mild hydroureteronephrosis.
Retrograde with double J stent insertion. Once negative urine culture confirmed pt underwent IPP cylinder/pump removal. Reservoir left in situ. Two-piece IPP inserted. Retrograde with double J stent insertion. Subsequent reservoir retrieval from prior lower abdominal incision.
Hudak and Mora [24]
Exploration and reservoir moved into new position. Postoperative ultrasound showed DVT. Pt subsequently underwent venous thrombectomy and IVC filter placement.
Brison et al. [34]
Exploration showed a capsule surrounding the reservoir adherent to iliac vein. The reservoir was freed and secured in another location. Pt’s swelling immediately improved with no subsequent problems. IVC filter inserted. IPP inflated to decompress reservoir and emergent exploration; 100 cc reservoir removed and a new 65 cc reservoir placed in ectopic position. Intraoperative ultrasound showed normal flow in artery. Received treatment for DVT. IVC filter inserted. Reservoir removed with new one replaced. Received treatment for DVT.
Flanagan et al. [35]
Vascular injury 1 case H/o radiation and large bowel diversion with subsequent IPP placement. Presented several days later with LLE swelling. Ultrasound showed sluggish flow consistent with a prethrombotic state in the left distal external iliac and common femoral veins. 1 case H/o T6 spinal cord injury with subsequent IPP placement. Two years later developed severe RLE edema. Ultrasound did not show DVT. Pelvic CT showed right external iliac vein compression from the reservoir. 1 case H/o IPP. Three years later underwent replacement for mechanical failure with new reservoir placed in right space of Retzius. That evening pt developed severe RLE pain and swelling. Ultrasound and CT showed DVT and stenosis of external iliac vein and artery. 1 case H/o RRP, 3 days following IPP placement p/w LLE edema, tenderness, and shortness of breath. Ultrasound confirmed DVT. V/Q scan did not indicate pulmonary embolism. CT scan showed reservoir compressing external iliac vein.
Reservoir was removed endoscopically and pt required creation of new conduit.
Jiang et al. [25]
Deho et al. [36]
da Justa et al. [37]
h/o = history of; pt = patient; RALP = robotically assisted laparoscopic prostatectomy; n/v = nausea/vomiting; LLE = left lower extremity, RLE = right lower extremity; IPP = inflatable penile prosthesis (three-piece unless otherwise specified); cysto = cystoscopy; ED = erectile dysfunction; p/w = presented with; LAR = low anterior resection; SP = suprapubic; DVT = deep vein thrombosis; CT = computed tomography; IVC = inferior vena cava; RRP = radical retropubic prostatectomy; XRT = external beam radiation; v/q = ventilation/perfusion
ischemia. The patient underwent small bowel resection and the reservoir was placed extraperitoneally on the right side of the bladder. Six months later, the patient presented with purulent discharge from the suprapubic incision. Exploration revealed that the reservoir had completely entered the right colon. The patient had colostomy placement and prosthesis removal [28]. Other bowelrelated and erosion cases are noted in Table 2.
The concern regarding leaving an empty reservoir during implant revision cases remains controversial. Jiann et al. and Munoz and Ellswort described retained reservoirs causing complications many years after the removal of the original IPP. On the other hand, Rajpurkar et al. performed a retrospective review of 85 patients who underwent 98 procedures for replacement or removal of malfunctioning three-piece IPPs. In J Sex Med **;**:**–**
8 their review, no patients had complications due to a retained reservoir [30]. Recently Hsi et al. recently reported an infection of a decommissioned reservoir with Actinomyces neuii presenting 3 months after IPP revision [31]. One may conclude from these studies that rare, retained reservoirs may potentially lead to complications. Pursuing a retained reservoir may be difficult due to extensive scar and may require extra time as well as a secondary incision to extract. It remains to be at the discretion of the surgeon as to whether the reservoir should be removed at the time of revision surgery. Inadvertent intraperitoneal placement of reservoirs has been noted during penile prosthesis surgery, particularly since the advent of roboticassisted radical prostatectomy (RALP). SadeghiNejad et al. reported a 68-year-old man who underwent RALP with subsequent IPP insertion. Immediately, following IPP placement, the patient underwent laparoscopic right lower abdominal hernia repair and the reservoir was found overlying the sigmoid colon. It was felt that the altered anatomy of the space of Retzius following RALP significantly increased the chances of intraperitoneal placement of the IPP reservoir, which may potentially result in bowel compression, laceration, or erosion [32]. In some instances, the reservoir may be intentionally placed within the peritoneal cavity. German physicians have routinely placed reservoirs in the peritoneal cavity to preclude development of autoinflation. Foreign bodies placed within the peritoneal cavity have been reported to not stimulate capsule formation, and the large intraperitoneal space prevents the transmission of intra-abdominal pressure to the reservoir. Mulcahy has suggested two caveats when intraperitoneal placement is considered as bowel can readily be intertwined around a reservoir that floats freely within the peritoneal cavity, which can result in bowel obstruction. Therefore, the reservoir should be secured against the pelvic wall and the tubing should remain loose to reduce the risk of erosion into a surrounding visceral structure [33].
Vascular Injury Vascular injury during or following placement of a reservoir is certainly possible during the digital or sharp dissection to enter the space of Retzius, as the external iliac system is in close proximity. Five cases including the one noted in this article have been reported, where pressure of the reservoir J Sex Med **;**:**–**
Levine and Hoeh caused subsequent partial venous obstruction with subsequent lower extremity edema [34–37]. Brison et al. reported a case of a 51-year-old man with a prior history of radiation therapy and large bowel diversion for rectal cancer who underwent IPP placement. The patient presented several days later with acute lower extremity swelling and pain. Venous Doppler revealed sluggish flow consistent with a prethrombotic state in the left distal external iliac and common femoral veins due to reservoir compression. The patient was immediately taken to the operating room and underwent reservoir repositioning through a suprapubic incision. Repeat ultrasound showed that a deep vein thrombosis had developed, resulting in subsequent venous thrombectomy with inferior vena cava filter placement. This complication was attributed to lateral displacement of the reservoir secondary to severe scarring from the previous pelvic surgery and radiation [34]. Other cases are outlined in Table 2. Pelvic vessel complications may be avoided by ensuring that an adequate space has been created both anterior and lateral to the bladder such that there is not compression of the adjacent venous structures. If inadequate space is encountered, alternate reservoir placement outside the space of Retzius should be considered. When a vascular tear occurs, either during placement of a fresh prosthesis or during a difficult removal of a reservoir during a revision procedure, the vessel most commonly lacerated is a branch of the external iliac such as the inferior epigastric, external superficial pudendal, or cremasteric vessels. In this circumstance, if exposure is not adequate via the primary incision, a secondary incision should be performed while maintaining pressure on the bleeding site, allowing better exposure where the vessel can be ligated if small or repaired with running Prolene.
Autoinflation Autoinflation occurs when the fluid pressure within the reservoir exceeds the backpressure limits of the pump assembly. If this elevated pressure remains, the fluid will inflate the cylinders causing autoinflation. The most common cause for autoinflation is insufficient space created for the reservoir at the time of placement, although incomplete emptying of the cylinders in the postoperative period may also contribute to this problem [38]. While autoinflation is typically only an annoying or embarrassing mechanical problem, it may also result in more severe clinical
9
Penile Prosthesis Reservoir Complications consequences—notably cylinder erosion. Kobayashi et al. presented a case in which the right cylinder eroded through the corpora caused by chronic cylinder pressure secondary to autoinflation [39]. It is estimated that autoinflation occurs in up to 2–3% of patients receiving the 700CX implant and 3–5% of total prosthetics implanted within the last decade. The lockout valves found on the current pumps and reservoirs should further reduce this problem [40–43]. If autoinflation does occur, capsulotomy may be performed by disrupting the capsule or repositioning the reservoir. Abbosh et al. describe a laparoscopic technique wherein patients without a history of prostatectomy an infra-umbilical incision is made and the prevesical space is developed, whereas in patients with a history of prostatectomy the peritoneum is insufflated and a transabdominal approach is used to identify the reservoir and open the capsule. Patients were advised to keep the prosthesis completely deflated for 3 weeks following the procedure [44].
A
B
Modified Reservoir Placement Technique To reduce the creation of inguinal floor weakness and to reduce the potential risk of visceral injury particularly after prior pelvic surgery, it is our current practice to enter the space of Retzius sharply. This is accomplished with curved Jorgensen scissors, which are placed just over the superior aspect of the pubis, and then with lifting the scissors in an upward motion, the transversalis fascia is perforated. The tips of the scissors are therefore pointing away from the vessels and bladder or bowel, which may descend into this area following prior pelvic surgery. This technique typically makes a hole just large enough for the index finger to gain entry and complete the dissection. (Figures 2A, B, and 3). Placement of the reservoir into this space can also be facilitated by placing a long-nose nasal speculum through the defect into the retropubic space. If the space of Retzius cannot be entered due to extensive scarring, then ectopic placement may be considered via a separate transverse hypogastric incision through the anterior rectus sheath with placement of a Cloverleaf or Conceal flat reservoir deep to the rectus muscle but superficial to the posterior rectus sheath. Other options include the lateral placement between the transversus abdominus muscle and the transversalis fascia through a separate small incision just above the anterior superior iliac spine as described by Hartman et al.
Figure 2 (A) Intraoperative photograph demonstrating positioning of Jorgensen scissors through scrotal incision to enter the space of Retzius. (B) Scissors are elevated to allow controlled perforation of transversalis fascia away from bladder, bowel, and iliac vessels.
or through the original infrapubic or scrotal incision as noted by Perito [45–47]. Conclusion
This case report series and literature review demonstrates the most common penile prosthesis reservoir complications. Interestingly, these events do not occur in the modern era of prosthetics due to mechanical failure of the reservoir; rather, it appears that they occur due to surgical technique, injury to local tissues at the time of implantation, J Sex Med **;**:**–**
10
Levine and Hoeh
Figure 3 Anatomical drawing demonstrating Jorgensen scissors piercing transversalis fascia just cephalad to superior aspect of pubis.
or due to chronic pressure. The risk of erosion of the reservoir into surrounding visceral structures appears to be greatly increased in patients with a prior history of abdominopelvic surgery, radiation or prior penile prosthetic devices. While the reservoir can be placed intra-abdominally, there may be an increased risk of visceral injury. If intraabdominal placement is attempted, the surgeon should ensure that the reservoir is secured to the abdominal wall and that the tubing is not too tight. When there is blood in the urine, either intraoperatively or postoperatively, or a change in voiding or bowel symptoms, this should alert the physician to consider a visceral injury from the reservoir. The implanting prosthetic surgeon should be aware of these potential events, how they may present, and prevent them from occurring if possible. In addition, we present our modified Jorgensen scissors technique for placement of a reservoir into the space of Retzius, which can also be attempted in men who have undergone radical prostatectomy. Corresponding Author: Laurence A. Levine, MD, Department of Urology, Rush University Medical Center, 1725 W Harrison Street Suite 352, Chicago, IL 60612, USA. Tel: 312-563-5000; Fax: 312-563-5007; E-mail: [email protected] Conflict of Interest: Laurence A. Levine, MD: — Auxilium: speaker, consultant, investigator, clinical trial J Sex Med **;**:**–**
— AMS: speaker, consultant — Coloplast: speaker, consultant — Lilly: speaker — Astellas: speaker Michael P. Hoeh, MD: none. Statement of Authorship
Category 1 (a) Conception and Design Laurence A. Levine; Michael P. Hoeh (b) Acquisition of Data Laurence A. Levine; Michael P. Hoeh (c) Analysis and Interpretation of Data Laurence A. Levine; Michael P. Hoeh
Category 2 (a) Drafting the Article Laurence A. Levine; Michael P. Hoeh (b) Revising It for Intellectual Content Laurence A. Levine; Michael P. Hoeh
Category 3 (a) Final Approval of the Completed Article Laurence A. Levine; Michael P. Hoeh References 1 Dhar NB, Angermeier KW, Montague DK. Long-term mechanical reliability of AMS 700CX/CXM inflatable penile prosthesis. J Urol 2006;176(6 Pt 1):2599–601. discussion 2601. 2 Wilson SK, Wahman GE, Lange JL. Eleven years of experience with the inflatable penile prosthesis. J Urol 1988;139: 951–2.
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