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Urethral Perforation During Penile Implant Surgery: What to Do?
INVITED COMMENTARY
Urethral Perforation During Penile Implant Surgery: What to Do? Suks Minhas, MD, FRCS(Urol)
INTRODUCTION The introduction of penile implants has revolutionized the management of male erectile dysfunction. There have been a number of technologic advances in prosthetic design, which have resulted in lower complication rates and high patient satisfaction.1 Nonetheless, a number of intraoperative complications can occur, which can have a major impact on clinical outcomes with the potential for immediate or delayed explantation. The commonest and most devastating complication for any prosthetic surgeon is implant infection, although prosthetic infection rates have decreased considerably in the past 10 years, from 1% to 3% in most contemporary series.2 Although postoperative glandular and urethral erosion of implants has been described,3 the management of urethral injury intraoperatively has not been extensively reported and is one of the most challenging surgical dilemmas, with a prevalence of 1.6%.4 Often, these type of injuries occur during cavernosal dilatation and go unrecognized, particularly distal injuries, and it is only when the patient presents with an early prosthetic infection or erosion of the implant (glandular or urethral) that the injury becomes apparent. In men with Peyronie disease, urethral injury also can occur at the time of penile modeling in those men with residual curvature after implantation. However, if a urethral perforation is recognized intraoperatively, this creates a major management dilemma for the surgeon: should the procedure be abandoned and delayed for 3 months until the urethral injury has healed or should the injury be repaired and a penile implant inserted simultaneously? If the former management option is chosen, then this will convert a relatively easy primary procedure to a difficult secondary procedure, with its inherent risk of early explantation because of the increased risk of prosthetic infection. Even if the implant is successfully placed, patients might complain of penile shortening. Historical surgical teaching is that if a urethral injury is recognized intraoperatively, then the procedure should be abandoned and delayed. However, there could be a surgical alternative. There are a number of key preoperative and perioperative factors that should be considered to try and minimize the risk of urethral perforation at the time of the primary procedure. Received March 12, 2017. Accepted May 9, 2017. University College Hospital, London, UK Copyright ª 2017, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsxm.2017.05.003
J Sex Med 2017;14:867e869
PATIENT COUNSELING AND PREOPERATIVE PREPARATION Patient counseling and preoperative preparation are very important; the patient must always be advised about urethral injury. Even the most experienced implanters will at some stage experience this complication.
THE DIFFICULT IMPLANT As with any surgery, some operative procedures will be more challenging than others. Those patients who are undergoing revision surgery or have fibrotic corpora (eg, after priapism, after infection, or with Peyronie disease) will have a higher risk of urethral perforation. This will be related to previous scarring and the difficultly in dilating scarred and fibrotic corpora with its inherent risk of corporal crossover and urethral perforation. Urethral perforation also has been described at the time of penile modeling, with a risk of urethral injury in 4%.5
AVOIDING URETHRAL PERFORATION Anticipating potentially difficult cases is helpful and important in surgical planning. In this context, good surgical exposure, particularly with revision cases, is mandatory. Always ensure that the patient has been catheterized to minimize the risk of injury and to anatomically recognize the urethra during dilatation. Ensuring that the surgeon has the correct instrumentation also is very important and can minimize the risk of injury. If the crura are fibrotic, it might be useful to use cavernotomes, such as the Rossello (Coloplast, Minneapolis, MN, USA), to facilitate corporal dilatation. During dilatation, the surgeon should ensure the dilator is pushed laterally to minimize the risk of urethral perforation and crossover. It also has been suggested that, during penile modeling, placing the bending hand on the shaft of the penis, as opposed to the glans, with the other hand firmly holding pressure down over the corporotomies could decrease the likelihood of urethral injury.5
RECOGNIZING URETHRAL PERFORATION Distal or glandular injuries might be difficult to recognize, although there might be a few intraoperative signs that indicate perforation has occurred, including bleeding through the urethra with or without distal corporal perforation being evident. More proximal perforations can be directly visualized intraoperatively with spongiose tears or bleeding from the spongiosum. 867
868
For a suspected urethral injury, some researchers have advocated the use of irrigation of antibiotic solution into the corpora. If a perforation has occurred, then fluid might “leak out” at the urethral meatus and the diagnosis can be confirmed by cystoscopy.6 Bettocchi et al6 advocated that the treatment option in such cases is immediate urethral repair for proximal perforations, but if the injury is of the urethral meatus, then the procedure should be abandoned and delayed.
MANAGEMENT OF URETHRAL PERFORATION This is where the management dilemma lies. As mentioned earlier, one option (which would be perfectly acceptable) is to abandon the surgical procedure, repair the urethral defect if proximal, and divert the urine with delayed implantation with the assumption that the surgeon has contaminated the surgical field secondary to urinary extravasation, thus increasing the risk of postoperative infection. Smaller injuries can be managed with urethral catheterization only. The problem with adopting this approach is that, invariably, once the injury has occurred, the corpora have been dilated, such that when the secondary procedure is undertaken, the procedure becomes a much more technically challenging implantation because of fibrosis of the corpora. So, what is the alternative surgical solution? Anele et al4 reported the prevalence of urethral injury after penile prosthesis implantation of 1.6%. In a series of 243 patients, 4 had recognized intraoperative urethral perforation. Management protocol consisted of primary urethral injury repair and completion of the penile implant surgery and urinary diversion with suprapubic catheterization for a 4- to 8-week period. Intraoperative urethral injury occurred during penile straightening maneuvers (ie, penile manipulation, corporal dissection, and corporal dilation). Primary urethral reconstruction consisted of a pedicled vascular penile skin flap, direct anastomotic reapproximation of separated portions of the urethra, opening of the distal side of the penis with a separate corporotomy with primary urethral repair, and closure of the distal corporal bodies with primary repair of the urethra. Using this protocol, at 6-month follow-up there were no complications. Certainly, this report challenges the traditional surgical teaching that the operative procedure should be abandoned if urethral perforation occurs and is recognized intraoperatively. Perito7 described a novel urethral repair after penile prosthesis insertion for distal injuries. An iatrogenic hypospadiac defect is created to access the injury, which is primarily repaired. A catheter is left in place for 3 to 5 days and the prosthesis is not cycled for 4 to 6 weeks. After 6 weeks the hypospadiac meatus is repaired. Although this describes a novel technique, the concerns with repairs of this nature are poor healing of the native urethra and risk of subsequent fistula formation. In all these case studies, a secondary procedure is undertaken to repair the injury at the time of prosthesis implantation. This
Minhas
results in a much more complex procedure and a longer operating time, which could place the patient at an increased risk of prosthetic infection, although this is very difficult to say given the limited number of reports of this nature. An equally challenging clinical situation is if a urethral injury occurs and the contralateral dilatation has not been undertaken. Should the entire procedure be abandoned, the injury repaired, and the implant inserted as outlined earlier or could a single malleable implant be inserted as a temporary or even permanent surgical solution? Again, this is a challenging clinical scenario. The author’s view is that a single malleable rod could be inserted as a temporizing procedure after salvage washout and the contralateral malleable rod could be implanted or an inflatable device could be placed electively if the implant is not infected. Interestingly, some patients can have adequate sexual function even with a single malleable rod and might be satisfied with this as a long-term solution. Fortunately, intraurethral perforation during penile prosthesis implantation is relatively rare. There are very limited reports in the literature offering management protocols. As such, most evidence remains anecdotal or at best limited to small case series only. However, the traditional dogma of delaying implantation has been challenged. It would be reasonable to delay implantation to a secondary procedure if the injury were extensive. Although primary repair and urinary diversion with suprapubic catheterization is a novel option, the challenge is not so much for proximal injuries, which occur during dissection and the injury is more accessible and easier to repair, but rather those that are distal or glandular. These types of injuries will require mobilization of glandular structures, with the potential for glandular injury and/or fistula formation. The management of urethral injuries is very much dependent on the experience of the surgeon. If the procedure is abandoned, then the surgeon must realize that the secondary surgery will be difficult. The author’s belief is that small localized proximal injuries can be managed with urethral repair, primary implantation, and urinary diversion with a suprapubic catheter. The distal or glandular injuries pose a very difficult management dilemma, because they are difficult to isolate anatomically. Even if these injuries are recognized intraoperatively, an extensive concurrent procedure is required, which is not without significant risk of postoperative glandular injury or cavernosal fistula. Corresponding Author: Suks Minhas, MD, FRCS(Urol), Consultant Urologist and Andrologist, University College Hospital, 235 Euston Road, Bloomsbury, London NW1 2BU, UK; E-mail: [email protected] Conflicts of Interest: The authors report no conflicts of interest. Funding: None. J Sex Med 2017;14:867e869
869
Urethral Perforation During Penile Implant Surgery
STATEMENT OF AUTHORSHIP Category 1 (a) Conception and Design Suks Minhas (b) Acquisition of Data Not applicable (c) Analysis and Interpretation of Data Not applicable Category 2 (a) Drafting the Article Suks Minhas (b) Revising It for Intellectual Content Suks Minhas Category 3 (a) Final Approval of the Completed Article Suks Minhas
correlates with female partner satisfaction. J Sex Med 2013; 10:2774-2781. 2. Trost LW, McCaslin R, Linder B, et al. Long-term outcomes of penile prostheses for the treatment of erectile dysfunction. Expert Rev Med Devices 2013;10:353-366. 3. Carrino M, Chiancone F, Battaglia G, et al. Distal corporoplasty for distal cylinders extrusion after penile prosthesis implantation. Urologia 2017;84:38-39. 4. Anele UA, Le BV, Burnett AL. Suprapubic cystostomy for the management of urethral injuries during penile prosthesis implantation. Sex Med 2014;2:178-181. 5. Anaissie J, Yafi FA. A review of surgical strategies for penile prosthesis implantation in patients with Peyronie’s disease. Transl Androl Urol 2016;5:342-350. 6. Bettocchi C, Ditonno P, Palumbo F, et al. Penile prosthesis: what should we do about complications? Adv Urol 2008;
REFERENCES 1. Vakalopoulos I, Kampantais S, Ioannidis S, et al. High patient satisfaction after inflatable penile prostheses implantation
J Sex Med 2017;14:867e869
573560:2008. 7. Perito P. Urethral injury during inflatable penile prosthesis: a new repair. Video J Prosthet Urol 2014;1:034.
Urethral Perforation During Penile Implant Surgery: What to Do? Suks Minhas, MD, FRCS(Urol)
INTRODUCTION The introduction of penile implants has revolutionized the management of male erectile dysfunction. There have been a number of technologic advances in prosthetic design, which have resulted in lower complication rates and high patient satisfaction.1 Nonetheless, a number of intraoperative complications can occur, which can have a major impact on clinical outcomes with the potential for immediate or delayed explantation. The commonest and most devastating complication for any prosthetic surgeon is implant infection, although prosthetic infection rates have decreased considerably in the past 10 years, from 1% to 3% in most contemporary series.2 Although postoperative glandular and urethral erosion of implants has been described,3 the management of urethral injury intraoperatively has not been extensively reported and is one of the most challenging surgical dilemmas, with a prevalence of 1.6%.4 Often, these type of injuries occur during cavernosal dilatation and go unrecognized, particularly distal injuries, and it is only when the patient presents with an early prosthetic infection or erosion of the implant (glandular or urethral) that the injury becomes apparent. In men with Peyronie disease, urethral injury also can occur at the time of penile modeling in those men with residual curvature after implantation. However, if a urethral perforation is recognized intraoperatively, this creates a major management dilemma for the surgeon: should the procedure be abandoned and delayed for 3 months until the urethral injury has healed or should the injury be repaired and a penile implant inserted simultaneously? If the former management option is chosen, then this will convert a relatively easy primary procedure to a difficult secondary procedure, with its inherent risk of early explantation because of the increased risk of prosthetic infection. Even if the implant is successfully placed, patients might complain of penile shortening. Historical surgical teaching is that if a urethral injury is recognized intraoperatively, then the procedure should be abandoned and delayed. However, there could be a surgical alternative. There are a number of key preoperative and perioperative factors that should be considered to try and minimize the risk of urethral perforation at the time of the primary procedure. Received March 12, 2017. Accepted May 9, 2017. University College Hospital, London, UK Copyright ª 2017, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsxm.2017.05.003
J Sex Med 2017;14:867e869
PATIENT COUNSELING AND PREOPERATIVE PREPARATION Patient counseling and preoperative preparation are very important; the patient must always be advised about urethral injury. Even the most experienced implanters will at some stage experience this complication.
THE DIFFICULT IMPLANT As with any surgery, some operative procedures will be more challenging than others. Those patients who are undergoing revision surgery or have fibrotic corpora (eg, after priapism, after infection, or with Peyronie disease) will have a higher risk of urethral perforation. This will be related to previous scarring and the difficultly in dilating scarred and fibrotic corpora with its inherent risk of corporal crossover and urethral perforation. Urethral perforation also has been described at the time of penile modeling, with a risk of urethral injury in 4%.5
AVOIDING URETHRAL PERFORATION Anticipating potentially difficult cases is helpful and important in surgical planning. In this context, good surgical exposure, particularly with revision cases, is mandatory. Always ensure that the patient has been catheterized to minimize the risk of injury and to anatomically recognize the urethra during dilatation. Ensuring that the surgeon has the correct instrumentation also is very important and can minimize the risk of injury. If the crura are fibrotic, it might be useful to use cavernotomes, such as the Rossello (Coloplast, Minneapolis, MN, USA), to facilitate corporal dilatation. During dilatation, the surgeon should ensure the dilator is pushed laterally to minimize the risk of urethral perforation and crossover. It also has been suggested that, during penile modeling, placing the bending hand on the shaft of the penis, as opposed to the glans, with the other hand firmly holding pressure down over the corporotomies could decrease the likelihood of urethral injury.5
RECOGNIZING URETHRAL PERFORATION Distal or glandular injuries might be difficult to recognize, although there might be a few intraoperative signs that indicate perforation has occurred, including bleeding through the urethra with or without distal corporal perforation being evident. More proximal perforations can be directly visualized intraoperatively with spongiose tears or bleeding from the spongiosum. 867
868
For a suspected urethral injury, some researchers have advocated the use of irrigation of antibiotic solution into the corpora. If a perforation has occurred, then fluid might “leak out” at the urethral meatus and the diagnosis can be confirmed by cystoscopy.6 Bettocchi et al6 advocated that the treatment option in such cases is immediate urethral repair for proximal perforations, but if the injury is of the urethral meatus, then the procedure should be abandoned and delayed.
MANAGEMENT OF URETHRAL PERFORATION This is where the management dilemma lies. As mentioned earlier, one option (which would be perfectly acceptable) is to abandon the surgical procedure, repair the urethral defect if proximal, and divert the urine with delayed implantation with the assumption that the surgeon has contaminated the surgical field secondary to urinary extravasation, thus increasing the risk of postoperative infection. Smaller injuries can be managed with urethral catheterization only. The problem with adopting this approach is that, invariably, once the injury has occurred, the corpora have been dilated, such that when the secondary procedure is undertaken, the procedure becomes a much more technically challenging implantation because of fibrosis of the corpora. So, what is the alternative surgical solution? Anele et al4 reported the prevalence of urethral injury after penile prosthesis implantation of 1.6%. In a series of 243 patients, 4 had recognized intraoperative urethral perforation. Management protocol consisted of primary urethral injury repair and completion of the penile implant surgery and urinary diversion with suprapubic catheterization for a 4- to 8-week period. Intraoperative urethral injury occurred during penile straightening maneuvers (ie, penile manipulation, corporal dissection, and corporal dilation). Primary urethral reconstruction consisted of a pedicled vascular penile skin flap, direct anastomotic reapproximation of separated portions of the urethra, opening of the distal side of the penis with a separate corporotomy with primary urethral repair, and closure of the distal corporal bodies with primary repair of the urethra. Using this protocol, at 6-month follow-up there were no complications. Certainly, this report challenges the traditional surgical teaching that the operative procedure should be abandoned if urethral perforation occurs and is recognized intraoperatively. Perito7 described a novel urethral repair after penile prosthesis insertion for distal injuries. An iatrogenic hypospadiac defect is created to access the injury, which is primarily repaired. A catheter is left in place for 3 to 5 days and the prosthesis is not cycled for 4 to 6 weeks. After 6 weeks the hypospadiac meatus is repaired. Although this describes a novel technique, the concerns with repairs of this nature are poor healing of the native urethra and risk of subsequent fistula formation. In all these case studies, a secondary procedure is undertaken to repair the injury at the time of prosthesis implantation. This
Minhas
results in a much more complex procedure and a longer operating time, which could place the patient at an increased risk of prosthetic infection, although this is very difficult to say given the limited number of reports of this nature. An equally challenging clinical situation is if a urethral injury occurs and the contralateral dilatation has not been undertaken. Should the entire procedure be abandoned, the injury repaired, and the implant inserted as outlined earlier or could a single malleable implant be inserted as a temporary or even permanent surgical solution? Again, this is a challenging clinical scenario. The author’s view is that a single malleable rod could be inserted as a temporizing procedure after salvage washout and the contralateral malleable rod could be implanted or an inflatable device could be placed electively if the implant is not infected. Interestingly, some patients can have adequate sexual function even with a single malleable rod and might be satisfied with this as a long-term solution. Fortunately, intraurethral perforation during penile prosthesis implantation is relatively rare. There are very limited reports in the literature offering management protocols. As such, most evidence remains anecdotal or at best limited to small case series only. However, the traditional dogma of delaying implantation has been challenged. It would be reasonable to delay implantation to a secondary procedure if the injury were extensive. Although primary repair and urinary diversion with suprapubic catheterization is a novel option, the challenge is not so much for proximal injuries, which occur during dissection and the injury is more accessible and easier to repair, but rather those that are distal or glandular. These types of injuries will require mobilization of glandular structures, with the potential for glandular injury and/or fistula formation. The management of urethral injuries is very much dependent on the experience of the surgeon. If the procedure is abandoned, then the surgeon must realize that the secondary surgery will be difficult. The author’s belief is that small localized proximal injuries can be managed with urethral repair, primary implantation, and urinary diversion with a suprapubic catheter. The distal or glandular injuries pose a very difficult management dilemma, because they are difficult to isolate anatomically. Even if these injuries are recognized intraoperatively, an extensive concurrent procedure is required, which is not without significant risk of postoperative glandular injury or cavernosal fistula. Corresponding Author: Suks Minhas, MD, FRCS(Urol), Consultant Urologist and Andrologist, University College Hospital, 235 Euston Road, Bloomsbury, London NW1 2BU, UK; E-mail: [email protected] Conflicts of Interest: The authors report no conflicts of interest. Funding: None. J Sex Med 2017;14:867e869
869
Urethral Perforation During Penile Implant Surgery
STATEMENT OF AUTHORSHIP Category 1 (a) Conception and Design Suks Minhas (b) Acquisition of Data Not applicable (c) Analysis and Interpretation of Data Not applicable Category 2 (a) Drafting the Article Suks Minhas (b) Revising It for Intellectual Content Suks Minhas Category 3 (a) Final Approval of the Completed Article Suks Minhas
correlates with female partner satisfaction. J Sex Med 2013; 10:2774-2781. 2. Trost LW, McCaslin R, Linder B, et al. Long-term outcomes of penile prostheses for the treatment of erectile dysfunction. Expert Rev Med Devices 2013;10:353-366. 3. Carrino M, Chiancone F, Battaglia G, et al. Distal corporoplasty for distal cylinders extrusion after penile prosthesis implantation. Urologia 2017;84:38-39. 4. Anele UA, Le BV, Burnett AL. Suprapubic cystostomy for the management of urethral injuries during penile prosthesis implantation. Sex Med 2014;2:178-181. 5. Anaissie J, Yafi FA. A review of surgical strategies for penile prosthesis implantation in patients with Peyronie’s disease. Transl Androl Urol 2016;5:342-350. 6. Bettocchi C, Ditonno P, Palumbo F, et al. Penile prosthesis: what should we do about complications? Adv Urol 2008;
REFERENCES 1. Vakalopoulos I, Kampantais S, Ioannidis S, et al. High patient satisfaction after inflatable penile prostheses implantation
J Sex Med 2017;14:867e869
573560:2008. 7. Perito P. Urethral injury during inflatable penile prosthesis: a new repair. Video J Prosthet Urol 2014;1:034.