Kenneth W. Angermeier

Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi

From June 1984 to September 1989, 43 patients with large vena caval tumor thrombi from retroperitoneal malignancies underwent surgical treatment with cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). The primary malignancies were renal cell carcinoma (RCC) (n = 39), renal pelvic transitional cell carcinoma (n = 1), adrenal pheochromocytoma (n = 1), and renal (n = 1) or retroperitoneal (n = 1) sarcoma. The level of the caval thrombus was either suprahepatic (n = 27), intrahepatic (n = 14), or subhepatic (n = 2). In all cases the primary tumor and caval thrombus were completely removed. Concomitant procedures included coronary artery bypass grafting (n = 5), pulmonary resection (n = 2), and hepatic lobectomy (n = 1). The time of circulatory arrest ranged from 10 to 44 minutes (mean, 23.5 minutes). There were two operative deaths (4.7%), neither of them due to to the use of DHCA. Major postoperative complications occurred in 13 patients (30.2%). There were no ischemic or neurologic complications and no cases of perioperative tumor embolization. The median postoperative hospital stay was 9 days. Twenty-two patients (51%) are alive and enjoying a good quality of life. The 3-year patient survival rates in patients with localized (n = 24) versus metastatic (n = 15) RCC are 63.9% and 10.9%, respectively (p = 0.02). We conclude that CPB with DHCA facilities excision of retroperitoneal malignancies with large caval thrombi and provides the potential for cure with low morbidity and mortality rates.

LONG-TERM CONTINENCE AND PATIENT SATISFACTION AFTER ARTIFICIAL SPHINCTER IMPLANTATION FOR URINARY INCONTINENCE AFTER PROSTATECTOMY

PURPOSE We assess long-term continence and patient satisfaction after implantation of the AMS Sphincter 800 (American Medical Systems, Minnetonka, Minnesota) in men who were incontinent after total and subtotal prostatectomy. MATERIALS AND METHODS Patients who had an artificial urinary sphincter implanted for urinary incontinence after prostatectomy and a minimum of 20 months of followup were identified from a patient database. The medical records of these 209 patients were reviewed, and a questionnaire was mailed. Telephone contact was attempted with patients who did not respond to the questionnaire. Of the 209 patients 11 (5%) had undergone device removal, 34 (16%) were deceased and an additional 51 (24%) could not be contacted for followup. Our study group consisted of the 113 patients with artificial urinary sphincters who could be contacted for followup. Mean followup was 73 months (range 20 to 170). RESULTS There were 4 (4%) patients who were dry and continent and 68 (60%) were incontinent using 0 to 1 pad daily. An additional 35 (31%) patients required 2 to 3 pads daily and 5 (4%) used more than 3 daily. There were 14 (12%) patients who had undergone surgical revision of the device. Of the 113 patients 31 (28%) were very satisfied, 50 (45%) satisfied, 20 (18%) neutral, 7 (6%) dissatisfied and 4 (4%) very dissatisfied. One patient was not using his device to control continence. CONCLUSIONS Artificial urinary sphincter implantation offers men who are incontinent after prostatectomy a reasonable chance for obtaining long-term satisfactory urinary control, although complete continence is unusual.

Review of cleveland clinic experience with penile fracture

OBJECTIVES Fracture of the penis is an uncommon injury that results from trauma to the erect penis, usually during sexual intercourse. In some cases, the urethra is injured as well. To determine the outcome of immediate surgical management, we reviewed the cases of 8 patients with fracture of the penis who presented to the Cleveland Clinic from 1992 to 1998. METHODS Trauma was encountered during intercourse in all our patients. A concomitant urethral injury was found in 3 cases (38%); 1 was a complete disruption, and the other 2 were partial injuries. Patients were treated with immediate surgical exploration and repair, with preoperative urethrography in patients suspected of having a urethral injury. RESULTS All patients had a successful outcome, with preservation of sexual function and without significant penile curvature. Patients with urethral injuries reported normal voiding without the need for additional procedures. CONCLUSIONS Immediate surgical repair offers complete recovery for patients with penile fracture in most cases, even in the presence of urethral injury. We present our recommendations for treatment of this condition.

Management of Radiotherapy Induced Rectourethral Fistula

PURPOSE An increasing number of men are being treated with BT or a combination of external beam radiation therapy and BT for localized prostate cancer. Although uncommon, the most severe complication following these procedures is RUF. We reviewed our recent experience with RUF following radiotherapy for prostate cancer to clarify treatment in these patients. MATERIALS AND METHODS We recently treated 22 men with RUF following primary radiotherapy for adenocarcinoma of the prostate in 21 and adjuvant external beam radiation therapy following radical prostatectomy in 1. Time from the last radiation treatment to fistula presentation was 6 months to 20 years. RESULTS Four patients underwent proctectomy with permanent fecal and urinary diversion. RUF repair in 5 patients was performed with preservation of fecal or urinary function. Six patients were candidates for reconstruction with preservation of urinary and rectal function, including 5 who underwent proctectomy, staged colo-anal pull-through and BMG repair of the urethral defect. The additional patient underwent primary closure of the rectum, BMG repair of the urethra and gracilis muscle interposition. Successful fistula closure was achieved in the 9 patients who underwent urethral reconstruction. All 8 candidates for rectal reconstruction showed radiological and clinical bowel integrity postoperatively with 2 awaiting final diverting stoma closure. CONCLUSIONS With the increasing use of prostate BT the number of patients with severe rectal injury will likely continue to increase. Radiotherapy induced RUF carries significant morbidity and most patients are treated initially with fecal and urinary diversion. In properly selected patients good outcomes can be expected following repair using BMG for the urethral defect along with colo-anal pull-through or primary rectal repair and gracilis muscle interposition.

Cultures From Genitourinary Prostheses at Reoperation: Questioning the Role of Staphylococcus Epidermidis in Periprosthetic Infection

PURPOSE We determine the colony counts of organisms present on culture of clinically uninfected genitourinary prostheses at reoperation for reasons other than infection. These results served as control data for comparison with cultures from infected devices to determine the relative incidence of organisms involved. MATERIALS AND METHODS Cultures were prospectively obtained from 65 penile prostheses and 22 artificial urinary sphincters. Patients were followed for a minimum of 12 months after reoperation or until development of infection (mean 27 months) at which time cultures were again obtained. RESULTS Low colony counts of Staphylococcus epidermidis were isolated from 40% of uninfected penile prostheses and 36% of artificial urinary sphincters. Only 3 of these devices later became infected (9%) and in all cases a higher colony count of another organism was found at explanation. CONCLUSIONS While Staph. epidermidis can cause prosthesis infection, low colony counts of the organism may not be associated with clinical infection. Therefore, the high incidence of infection attributed to this organism may be overestimated.

LONG-TERM MECHANICAL RELIABILITY OF AMS 700 SERIES INFLATABLE PENILE PROSTHESES: COMPARISON OF CX/CXM AND ULTREX CYLINDERS

PURPOSE Recently, we have noted an increasing incidence of revisions being performed in patients implanted with the length and girth expanding AMS 700 Ultrex* inflatable penile prosthesis. This observation prompted us to compare the long-term mechanical reliability of the AMS Ultrex inflatable penile prosthesis versus the girth-expanding AMS 700 CX* or CXM* inflatable penile prosthesis in men with organic erectile dysfunction. MATERIALS AND METHODS Using chart review, mailed questionnaires and telephone interviews, we obtained accurate followup on 111 of 142 (78.2%) patients with CX/CXM implanted between June 1986 and September 1995, and on 152 of 179 (84.9%) patients implanted with Ultrex between October 1989 and September 1995. The CX/CXM and Ultrex groups were compared with regard to 3 end points: 1) mechanical failure caused by any malfunctioning component, 2) device failure caused by any cylinder complication and 3) cylinder aneurysms/leaks. RESULTS Followup ranged from 1.0 to 112.0 months for the CX/CXM group (mean 47.2 months), and 0.7 to 71.5 months for the Ultrex group (mean 34.4 months). CX/CXM versus Ultrex group comparison demonstrated 10 CX/CXM mechanical failures (9.0%) versus 26 Ultrex failures (17.1%), p = 0.001; 5 CX/CXM cylinder complications (4.5%) versus 13 Ultrex cylinder complications (8.6%), p = 0.0292; and 3 CX/CXM cylinder aneurysms/leaks (2.7%) versus 9 in the Ultrex group (5.9%), p = 0.0162. Kaplan-Meier estimates demonstrated significantly decreased mechanical survival in all 3 categories for Ultrex inflatable penile prosthesis versus CX/CXM inflatable penile prosthesis. CONCLUSIONS Although Ultrex cylinders provide length and girth expansion, Ultrex cylinders exhibit an increased mechanical failure rate at shorter followup compared with CX/CXM cylinders. This increased propensity for Ultrex cylinder problems should be closely monitored.

AMS 3-Piece Inflatable Penile Prosthesis Implantation in Men with Peyronie's Disease: Comparison of CX and Ultrex Cylinders

PURPOSE We compared the ability of the CX and Ultrex cylinders to straighten the penis in men who received a 3-piece AMS 700 series inflatable penile prosthesis for erectile dysfunction and erectile deformity due to Peyronies disease. MATERIALS AND METHODS The records of 34 and 38 patients receiving devices CX and Ultrex cylinders, respectively, were reviewed. RESULTS All 34 patients receiving the CX cylinders achieved complete penile straightening with cylinder inflation and bending alone. In 10 of 38 patients receiving the Ultrex cylinders complete straightening with cylinder inflation and bending could not be achieved, and simultaneous corporoplasty was necessary. CONCLUSIONS Girth expanding CX cylinders have better penile straightening properties than girth and length expanding Ultrex cylinders. We recommend use of CX cylinders for 3-piece AMS 700 series inflatable penile prosthesis implantation in men with Peyronies disease.

Penile Prosthesis Implantation

The development of effective systemic therapy for the treatment of erectile dysfunction has resulted in a significant increase in the number of men presenting for treatment. Not all men with erectile dysfunction will respond to systemic therapy; those who fail may be candidates for penile prosthesis implantation if second and third lines of treatment also fail or are rejected by the patient and his partner. Penile prosthesis implantation continues to play a role in the treatment of erectile dysfunction. There is a potential for the number of penile prosthesis implantation procedures to actually increase. The ideal penile prosthesis is a three-piece inflatable device that permits good penile flaccidity and increases in size and becomes rigid with inflation.

MODIFIED CORPOROPLASTY FOR PENILE CURVATURE: LONG-TERM RESULTS AND PATIENT SATISFACTION

PURPOSE In 1994 we began performing the modified corporoplasty technique in patients undergoing surgery to correct penile curvature. The procedure consists of transverse closure of the longitudinal tunical incisions. This technique allows minimal mobilization of the neurovascular bundles or corpus spongiosum and potentially decreases the risk of injury to underlying erectile tissue. We report long-term results of and patient satisfaction with this procedure. MATERIALS AND METHODS From June 1994 to June 1997, 28 consecutive patients 16 to 65 years old (mean age 45) selected for corporoplasty underwent a total of 29 operative procedures for disabling penile curvature. The etiology of curvature was Peyronies disease in 19 patients (68%) and congenital curvature in 9 (32%). Results were obtained by retrospective chart review and telephone interview. Long-term followup available for 19 patients ranged from 11 to 46 months (mean 24.1). RESULTS Penile straightening was excellent in 25 patients (89%) and good with less than 20 degrees of residual curvature in 2 (7%). In 1 patient in whom the procedure failed excellent straightening was achieved after a repeat procedure. A total of 27 patients (96%) reported no change in erectile rigidity or maintenance postoperatively, while 1 described early detumescence. We contacted 19 patients at long-term followup, of whom 17 and 2 reported excellent and good penile straightening results, respectively. In 18 cases there was no change in erectile rigidity, while in 1 there was early detumescence. Some element of erectile shortening without functional problems was noticed by 11 patients, of whom 1 was bothered by shortening but achieves successful intercourse. Eight patients denied shortening. In regard to the overall result 9 patients were very satisfied, 6 satisfied, 2 neutral and 2 unsatisfied. CONCLUSIONS In select patients modified corporoplasty as described is an effective and durable procedure with a high rate of patient satisfaction. Patients should be counseled preoperatively concerning postoperative erectile shortening.

Mechanical Failure of the American Medical Systems Ultrex Inflatable Penile Prosthesis: Before and After 1993 Structural Modification

PURPOSE The 700 Ultrex (American Medical Systems, Minnetonka, Minnesota) is the only penile prosthesis capable of length and girth expansion. Early experience with the 700 Ultrex showed an increased mechanical failure rate compared with the 700CX, mostly secondary to cylinder failure. In 1993 the Ultrex cylinders were modified. We examined the performance of the Ultrex device before and after modification. MATERIALS AND METHODS We compared our results with the Ultrex prosthesis before (group 1) and after (group 2) the 1993 modification. We implanted 239 devices from October 1989 to December 1999. A total of 26 patients have died. Followup was obtained on the results of 137 of the remaining 213 implants (64%), including 85 pre-modification devices in 85 patients and 52 post-modification devices in 51, via a mailed questionnaire, telephone survey or chart review. The questionnaire and survey included a 5-point satisfaction scale. Groups 1 and 2 were compared in regard to 3 end points, namely cylinder, mechanical and overall failure. RESULTS Followup was less than 1 to 136 months (median 92, 25th to 75th percentiles 43 to 108) in group 1 and less than 1 to 92 months (median 46, 25th to 75th percentiles 21 to 75) in group 2. The 5-year Kaplan-Meier estimates of overall, mechanical and cylinder survival in groups 1 and 2 were 64.7%, 70.7% and 80.2%, and 77.7% (p = 0.23), 93.7% (p = 0.017) and 96.2% (p = 0.008), respectively. Overall satisfaction was similarly high in groups 1 and 2 (mean 3.9 and 4 points). CONCLUSIONS On long-term followup the 1993 modification of the Ultrex cylinders appears to have significantly decreased the propensity of cylinder failure of the pre-modification device.