Michael Bickell

Delayed Postoperative Hematoma Formation after Inflatable Penile Prosthesis Implantation

INTRODUCTION Infrequent but serious postoperative complications following inflatable penile prosthesis (IPP) insertion include infection, malfunction, and bleeding. Although prior publications report methods to reduce immediate postoperative bleeding, there is little in the literature concerning the etiology, diagnosis, imaging, and management of delayed bleeding after IPP insertion. AIM The aim of the study was to review cases of delayed postoperative bleeding following IPP insertion in a large single-surgeon series. METHODS We carried out a retrospective chart review of 600 patients implanted with a Coloplast Titan IPP with One-Touch Release pump by a single surgeon, and analyzed cases of delayed postoperative bleeding. MAIN OUTCOME MEASURE The main outcome measure was an analysis of the incidence, causes, diagnostic methods, treatment, and final outcome of these cases. RESULTS Three out of 600 consecutive patients (0.5%) developed a delayed (defined as >5 days postoperative) hematoma following IPP insertion. All patients presented postoperatively with a swollen surgical site, and all were evaluated with a pelvic computed tomography scan to completely define the extent of the hematoma. Two patients developed a delayed hematoma because of excessive physical activity; the remaining patient bled because of premature administration of enoxaparin sodium (Lovenox) by his cardiologist. All three patients were successfully treated with hospital admission, intravenous antibiotics, wound exploration, hematoma evacuation, and antibiotic washout. All three IPPs were successfully salvaged; none developed peri-prosthetic infection. CONCLUSIONS The incidence of delayed postoperative hematoma following IPP surgery was 0.5% in our series of 600 cases. All cases were successfully managed with intravenous antibiotics, hematoma evacuation, and antibiotic washout. Because of the low incidence of this complication, definitive statements concerning prevention and management cannot be made. However, we now recommend avoiding postoperative anticoagulants for at least 5 days if possible, and avoiding vigorous physical activity for at least 3 weeks.

Subcutaneous Placement of Inflatable Penile Prosthesis Reservoirs.

OBJECTIVE To review our experience with subcutaneous inflatable penile prosthesis reservoir insertion in a large, single-surgeon series. MATERIALS AND METHODS We carried out a retrospective review of 1000 consecutive Coloplast Titan inflatable penile implant procedures carried out by a single high-volume surgeon. Eight patients underwent subcutaneous reservoir placement (SRP) and are the subject of this review. RESULTS Eight of our last 1000 patients underwent SRP. SRP was only employed in patients with a thick subcutaneous abdominal fat layer, which would be capable of concealing the reservoir. Seven patients recovered uneventfully, and none reported a palpable or visible reservoir. One patient, who had 5 prior penile implant procedures, developed peri-prosthetic infection, and required complete device removal. Reservoir removal in this obese patient was facilitated by the devices subcutaneous location. CONCLUSION SRP is a viable option for carefully selected obese patients. We suggest that this approach only be utilized in those with high body mass index and a thick subcutaneous abdominal fat layer. In thinner patients, the reservoir will be visible and/or palpable; we do not recommend subcutaneous placement under those circumstances.

Advances in Surgical Reconstructive Techniques in the Management of Penile, Urethral, and Scrotal Cancer

This article reviews the most up-to-date surgical treatment options for the reconstructive management of patients with penile, urethral, and scrotal cancer. Each organ system is examined individually. Techniques and discussion for penile cancer reconstruction include Mohs surgery, glans resurfacing, partial and total glansectomy, and phalloplasty. Included in the penile cancer reconstruction section is the use of penile prosthesis in phalloplasty patients after penectomy, tissue engineering in phallic regeneration, and penile transplantation. Reconstruction following treatment of primary urethral carcinoma and current techniques for scrotal cancer reconstruction using split-thickness skin grafts and flaps are described.

A History of the Penile Implant to 1974

Impotence has plagued mankind for over a millennium. One of the earliest references on record was found in India, in the Sushruta Samhita, around the eighth century BC. Historically, it was an ailment believed to have its roots in psychogenic, religious, and supernatural etiologies. Therefore, the treatment of impotence involved the use of potions, aphrodisiacs, ointments, and prayers, which to this day still play a large role in certain cultures. This mindset of impotence secondary to non-organic causes remained the mainstay in the scientific community until well into the 20th century. In fact, in the early to mid-1900s, psychologists or psychiatrists treated impotence more than 95% of the time, often with the use of empiric treatment with testosterone. As David Stafford-Clark, described in his article, “The Etiology and Treatment of Impotence,” published in 1954, “A dogmatic, but reasonably safe generalization would be that at least 90% of all cases of impotence, relative or complete, are psychogenic in origin.” Before 1974, very few urologists were involved in the management and treatment of erectile dysfunction (ED), because the underlying pathophysiology of impotence remained to be elucidated.

Suspected Penile Fracture After Xiaflex Injection and Use of a VED

CLINICAL PRESENTATION A62-year-old Caucasian man presented to the emergency department for evaluation of penile pain and swelling. The patient had a history of Peyronie’s disease and elected to undergo collagenase clostridium histolyticum (CCH) injections in an effort to decrease his approximately 40° leftward phallic curvature. The patient had received multiple cycles of treatment and most recently finished cycle number 3, injection 2. Two days after this injection, in direct violation of the recommendations from the treating urologist, the patient used a vacuum erection device (VED) on the left lateral aspect of his penis, which caused the sudden onset of stabbing pain and eventual detumescence. The patient’s symptoms ultimately prompted the patient to present to the hospital 7 days after the injury. During that week, the patient had increasing penile swelling and ecchymosis. The patient did have 3 nocturnal erections over this time, but described each event as painful and achieving only partial rigidity. At the time of presentation to the hospital, the patient’s physical examination revealed swelling and significant ecchymosis of the phallus extending into the penoscrotal area (Fig. 1). The bruising affected the patient’s glans penis and discolored the right side of his penis more than the left. On the left lateral midshaft of the patient’s phallus, however, there was a tender, mobile, indurated mass with overlying ecchymosis most consistent with a subcutaneous hematoma. There was no blood per urethra and the patient denied hematuria. Given the patient’s history and physical examination, high concern was raised for a penile fracture vs a penile hematoma. Discordant factors for a corporal rupture in the clinical history were the slow loss of erection at the time of injury and the spontaneous partial erections the patient had experienced since the incident. Considering the confounding factors above, magnetic resonance imaging (MRI) was utilized to further elucidate the extent of the patient’s injury. An MRI of the pelvis without contrast was obtained, which revealed a focal disruption along the ventrallateral aspect of the left tunica albuginea (Fig. 2). The defect measured 1.1 cm in length and was associated with a small overlying hematoma in the same area where the patient had received his CCH injection and used his VED. The underlying corpus cavernosa appeared otherwise normal; the tunica albuginea on the right appeared normal without disruption. No urethral injury was identified and the urinary bladder was normal.

V9-11 SUPRAPUBIC FAT PAD EXCISION WITH SIMULTANEOUS PLACEMENT OF INFLATABLE PENILE PROSTHESIS

18 items, each on a 5-point Likert scale. Trainee scores were assessed and compared for improvement over the course of the training course. RESULTS: The most common mistakes made by our trainees revolved around sitting position, hand tremor, instrument handling, needle control, suture placement, and knot tying. The errors were most prevalent early on and there were statistically significant improvements across all domains by the end of the MIM training course (Table). CONCLUSIONS: A MIM training program is an effective tool for teaching MIM skills. By incorporating intense supervision and continuous evaluation into an MIM training program, MIM trainees can avoid the development of bad habits that may be difficult to overcome and potentially have a negative impact on surgical outcomes.

Upper Tract Obstruction and Management in Patients With Blood Cell Dyscrasias

cute bilateral renal obstruction secondary to spontaneous bleeding and clot formation is a Arare complication of patients with blood cell dyscrasias. This can occur at any time despite medical therapy and treatment. Decompression of the renal system and relief of obstruction are critical to improve renal function. Once the coagulopathy is treated and hemostasis achieved, evaluation of the upper tracts is necessary using ultrasonography, computed tomography (CT), and endoscopic direct visualization. There are few case reports in the literature that describe management of this difficult clinical scenario.