John J. Mulcahy

LONG-TERM EXPERIENCE WITH SALVAGE OF INFECTED PENILE IMPLANTS

PURPOSE The effectiveness of treating patients with an infected penile implant by removing the device, cleansing the wound with a series of antiseptic solutions and placing a new device at the same procedure was assessed. MATERIALS AND METHODS A total of 65 patients were included in the study. All foreign material was removed from the infected wound followed by copious wound irrigations with a protocol of 7 antibacterial solutions. A new prosthesis was inserted and the patient was placed on antibiotics. RESULTS Followup ranged from 6 to 93 months. Recent status was determined in 85% of cases (55 of 65). Of the 55 patients 45 (82%) showed no sign of infection. In 5 patients recurrent infection was documented and in 5 others erosion of parts to the exterior possibly related to infection was noted. CONCLUSIONS Salvage of an infected penile implant has been successful and is gaining in popularity among urologists to reduce morbidity associated with infection.

The Prosthesis Salvage Operation: Immediate Replacement of the Infected Penile Prosthesis

PURPOSE We describe our experience with salvage of the infected penile prosthesis at initial presentation in 11 patients. MATERIALS AND METHODS All patients with prosthesis infection who presented since 1991 were considered for salvage surgery. Contraindications to a salvage operation included necrotic infections, diabetic patients with purulence in the corporeal bodies, rapidly developing infections and erosion of the device cylinders. RESULTS In 1 patient in this group a salvage attempt was repeated after re-infection, for an overall success rate of 91%. Mean followup for the group was 21 months (range 9 to 42). Staphylococcus epidermidis was the infecting organism in 75% of our patients. CONCLUSIONS Our experience demonstrates the safety and advantages of the immediate salvage technique.

Infectious Complications of Penile Prosthetic Implants

An infectious complication involving placement of a penile prosthesis is a disastrous event. A review of more than 300 devices placed between 1979 and 1984 at this center reveals an infectious complication rate of 8.3 per cent. Perioperative risk factors predisposing to infection included reoperation for technical failures, inadequate antibiotic coverage (specifically for Staphylococcus epidermidis), failure to perform a circumcision at the time of placement in uncircumcised patients and simultaneous placement with an artificial urinary sphincter device. No group of patients nor type of prosthesis was more susceptible to the development of a postoperative infection.

Use of a Double Cuff AMS800 Urinary Sphincter for Severe Stress Incontinence

Stress urinary incontinence in the male patient has been successfully treated with the artificial urinary sphincter. However, approximately 15% of the patients treated are still significantly wet despite some improvement with this device. These patients usually are almost totally incontinent before artificial sphincter implantation. Of 15 such patients 80% were rendered satisfactorily dry by adding a second sphincter cuff around the bulbous urethra. This double cuff technique increases the success rate with the AMS800 sphincter to greater than 95%.

DISTAL CORPOROPLASTY FOR LATERAL EXTRUSION OF PENILE PROSTHESIS CYLINDERS

PURPOSE Lateral extrusion of a penile prosthesis cylinder is an uncommon but distressing problem. A technique is described to reseat the cylinder in a more medial and secure position under the glans penis by creating a new cavity for the cylinder behind the back wall of the fibrotic sheath containing it. MATERIALS AND METHODS A total of 14 patients underwent corporoplasty using this technique with followup as long as 2 years. RESULTS All patients had a satisfactory result with no recurrence of the original problem. CONCLUSION This method which places the cylinder behind 2 secure layers is straightforward, simple and reliable.

Use of anal sphincter electromyography during operations on the conus medullaris and sacral nerve roots.

The mechanical activity of the anal sphincter can be translated into electrical activity and recorded on graph paper or an oscilloscope. The activity of the anal sphincter may be extrapolated to activity of the external urethral sphincter because both are striated muscles innervated by the pudendal nerve that arises from S-2, S-3, and S-4. Stimulation of these nerves causes contraction of the sphincter muscles, and a deflection of the recording device occurs. This technique was employed intraoperatively in monitoring operations on the conus medullaris and sacral nerve roots in 10 patients with spinal dysraphism (age range, 3 weeks to 15 years). Their diagnoses were tethered conus, 4; lipomeningocele, 3; spinal hamartoma, 1; syringocele, 1; and sacral arachnoiditis, 1. With general anesthesia, and the patient in the prone position, an electrode-containing anal plug was inserted or two needle electrodes were inserted into the anal sphincter muscle. The electrodes were connected to the electromyography recording stylus of the urodynamic bladder diagnostic unit. During the spinal operation, whenever a structure could not be identified clearly, it was stimulated with the disposable electrical stimulator and, if oscillations of the stylus occurred (indicating contraction of the anal sphincter), the structure was preserved. This technique permitted spinal operations in these 10 patients without changes in neurological or urological function.

Successful reinsertion of the artificial urinary sphincter after removal for erosion or infection

We present 5 cases involving reinsertion of an artificial urinary sphincter after either erosion or infection. All 5 patients now have socially acceptable urinary continence.

Long-term experience with the double-cuff AMS 800 artificial urinary sphincter

OBJECTIVES To assess the efficacy and safety of the double-cuff artificial urinary sphincter over a long-term period. METHODS Ninety-five patients charts were reviewed from December 1986 to November 1995. Data on the degree of urinary incontinence and complications were compiled and tabulated. RESULTS There were 10 cuff erosions (10.5%) and one infection (1.1%) requiring removal of the double-cuff system, with one death from unrelated causes. Two patients in the erosion group had a double-cuff system reinserted at a later date. Eighty-six patients have a double-cuff system, with 97.6% remaining dry. CONCLUSIONS A tandemly placed double-cuff artificial urinary sphincter is safe and effective in the treatment of severe postprostatectomy urinary incontinence.

Salvage Procedure For Infected Noneroded Artificial Urinary Sphincters

PURPOSE We report our experience with removal, antiseptic irrigation and immediate reimplantation of infected noneroded artificial urinary sphincters. MATERIALS AND METHODS From April 1996 to October 2000, 8 patients with an infected artificial urinary sphincter underwent a total of 9 salvage operations. All patients underwent cystoscopy before salvage to ensure nonerosion of the sphincter cuff. All previously implanted material was removed, the wounds were copiously irrigated according to a 7 solution protocol and an identical new system was implanted. All patients were discharged home the following morning on oral antibiotics. RESULTS Followup was 5 to 66 months (mean 33). The predominant organisms cultured at salvage were gram-positive cocci. Time from implantation to salvage was from 2 weeks to 64 months (mean 13.7 months). Prostatectomy was the etiology of incontinence in all except 1 case. In 5 of the 8 men a double cuff system was placed and 3 underwent concurrent 3-piece inflatable penile prosthesis salvage. The salvage procedure was done twice in 1 patient 5 months apart. The system was removed 16 months later secondary to urethral erosion. At the most recent followup the other 7 patients were free of infection with a functioning artificial urinary sphincter. CONCLUSIONS Salvage and immediate reimplantation of an infected, noneroded single or double cuff artificial urinary sphincter appears to be a valid option. Our overall success rate was 87%. The usual offending organisms are gram-positive skin flora. An associated inflatable penile prosthesis does not prohibit simultaneous salvage of the 2 devices.

Erosion Rate of the Double Cuff AMS800 Artificial Urinary Sphincter: Long-Term Followup

PURPOSE We reviewed the erosion rate of the double cuff artificial urinary sphincter. MATERIALS AND METHODS Charts of 95 patients were evaluated for erosions and underlying etiology. RESULTS Ten patients had erosion of the cuffs, for an erosion rate of 10.5%. Of the 10 erosions 4 (40%) were secondary to iatrogenic injuries. CONCLUSIONS Addition of a second cuff to the artificial urinary sphincter remains a safe alternative for patients with severe urinary stress incontinence.