Paul Perito

Traditional (Retroperitoneal) and Abdominal Wall (Ectopic) Reservoir Placement

FIGURE 1 For traditional retroperitoneal reservoir placement into the space of Retzius through a scrotal or infrapubic incision, first evacuate the bladder. Displace the incision over the right or left inguinal ring. Palpate the pubic tubercle for orientation and pass the finger cephalad into the medial aspect of the inguinal ring, piercing fascia downward and slightly medial with finger, scissors, pointed clamp or nasal speculum. The medial orientation helps avoid damage to underlying lateral large vessels. Place the reservoir in the retroperitoneal space (feel retroperitoneal fat), keeping the valve anterior and avoiding kinking the tubing or reservoir neck. This prevents invalidation of the Coloplast lockout valve; the American Medical Systems (AMS) lockout valve is in the pump. The reservoir lies behind the pubic bone (scrotal placement) or more toward the head (infrapubic placement). Finger palpates medial aspect of external inguinal ring Speculum perforates transversalis fascia

Outcomes of Abdominal Wall Reservoir Placement in Inflatable Penile Prosthesis Implantation: A Safe and Efficacious Alternative to the Space of Retzius

INTRODUCTION Inflatable penile prosthesis (IPP) surgery is a successful therapeutic option for men with erectile dysfunction. Traditional placement of the reservoir in the retropubic space of Retzius is associated with the rare occurrence of significant complications including bladder, bowel, and vascular injury. An alternative site, posterior to the abdominal wall musculature, has been identified as a potentially safer location for reservoir placement. AIMS The aim of this study was to describe our technique of abdominal reservoir placement during infrapubic IPP surgery and present our outcomes data. METHODS We retrospectively reviewed our experience with abdominal reservoir placement during virgin IPP cases. Reservoirs placed anterior and posterior to transversalis fascia were analyzed separately. MAIN OUTCOME MEASURE The main outcome measures was assessment of reservoir-related complications including palpable reservoir, reservoir herniation, and injuries to bowel, bladder, or major blood vessels. RESULTS There were no injuries to bowel or major blood vessels with abdominal reservoir placement posterior or anterior to the transversalis fascia in properly segregated patients. CONCLUSION Abdominal reservoir placement is a safe and simple surgical method that can be recommended for most men undergoing IPP placement. Men with a history of pelvic surgery can have the reservoir placed between the rectus abdominis musculature and transversalis fascia, while other men can have the reservoir placed between transversalis fascia and peritoneum in order to avoid a palpable reservoir. By applying this protocol, the catastrophic injuries that occur rarely with retropubic reservoir placement can be reliably avoided.

JSM HIGHLIGHTSSurgical Techniques: Traditional (Retroperitoneal) and Abdominal Wall (Ectopic) Reservoir Placement

FIGURE 1 For traditional retroperitoneal reservoir placement into the space of Retzius through a scrotal or infrapubic incision, first evacuate the bladder. Displace the incision over the right or left inguinal ring. Palpate the pubic tubercle for orientation and pass the finger cephalad into the medial aspect of the inguinal ring, piercing fascia downward and slightly medial with finger, scissors, pointed clamp or nasal speculum. The medial orientation helps avoid damage to underlying lateral large vessels. Place the reservoir in the retroperitoneal space (feel retroperitoneal fat), keeping the valve anterior and avoiding kinking the tubing or reservoir neck. This prevents invalidation of the Coloplast lockout valve; the American Medical Systems (AMS) lockout valve is in the pump. The reservoir lies behind the pubic bone (scrotal placement) or more toward the head (infrapubic placement). Finger palpates medial aspect of external inguinal ring Speculum perforates transversalis fascia

Ectopic Reservoir Placement—No Longer in the Space of Retzius

FIGURE 1 Traditionally, the inflatable penile prosthesis reservoir has been placed blindly within the space of Retzius. Technically, the index finger/blunt instrument entered the external inguinal ring, perforated the transversalis fascia inguinal canal floor, allowing the reservoir to be placed within the fat of the space of Retzius. Space of Retzius reservoir placement has been difficult after hernia andmesh surgery, and pelvic surgery (robotic prostatectomy, cystectomy, and kidney transplantation). Complications of space of Retzius reservoir placement have included bladder, vascular, and bowel injuries. Finger palpates medial aspect of external inguinal ring Finger perforates bladder

Gangrene of the Penis after Implantation of Penile Prosthesis: Case Reports, Treatment Recommendations and Review of the Literature

We report 3 cases of gangrene of the penis seen at our institution after penile prosthesis implantation. All 3 patients had insulin-dependent diabetes mellitus. Amputation was required in 2 patients. Aggressive debridement in conjunction with hyperbaric oxygen prevented amputation in the third patient.

Minimally invasive infrapubic inflatable penile prosthesis implant for erectile dysfunction: evaluation of efficacy, satisfaction profile and complications

Erectile dysfunction (ED), the second most common male sexual disorder, has an important impact on man sexuality and quality of life affecting also female partner’s sexual life. ED is usually related to cardiovascular disease or is an iatrogenic cause of pelvic surgery. Many non-surgical treatments have been developed with results that are controversial, while surgical treatment has reached high levels of satisfaction. The aim is to evaluate outcomes and complications related to prosthesis implant in patients suffering from ED not responding to conventional medical therapy or reporting side effects with such a therapy. One hundred eighty Caucasian male suffering from ED were selected. The patient population were divided into two groups: 84 patients with diabetes and metabolic syndrome (group A) and 96 patients with dysfunction following laparoscopic radical prostatectomy for prostate cancer (group B). All subjects underwent primary inflatable penile prosthesis implant with an infrapubic minimally invasive approach. During 12 months of follow-up, we reported 3 (1.67%) explants for infection, 1 (0.56%) urethral erosion, 1 (0.56%) prosthesis extrusion while no intraoperative complications were reported. Mean International Index of Erectile Function-5 (IIEF-5) was 8.2±4.0 and after the surgery (12 months later) was 20.6±2.7. The improvement after the implant is significant in both groups without a statistically significant difference between the two groups (P-value 0.65). Mean Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) score 1 year after the implant is 72.2±20.7, and there was no statistically significant difference between groups A and B (P-value 0.55). Implantation of an inflatable prosthesis, for treatment of ED, is a safe and efficacious approach; and the patient and partner satisfaction is very high. Surgical technique should be minimally invasive and latest technology equipment should be implanted in order to decrease after surgery common complications (infection and mechanical failure).

Surgical Techniques: Minimally Invasive Infrapubic Inflatable Penile Implant

A surgical procedure was developed, designed to minimize time and maximize efficiency. The hope is that this procedure reduces the morbidity of penile prosthesis implantation. In all drawings, the primary skin incision will be represented larger than reality in order to facilitate schematic identification of vital structures. The artificial erection serves three purposes in expediting the implant process: (i) identify pathology needing correction; (ii) “true” dilation of the corpora supplanting serial dilations; and (iii) facilitate the identification of the dorsal nerve and lateral placement of stay sutures. The 1.5-cm corporotomy accommodates the widest part of the implant. Placement of color-coded stay sutures lateral to the dorsal nerve Corporotomy incision using #12 blade Dorsal nerves within neurovascular bundle medial to corporotomy incisions

Sertoli-Leydig cell testicular tumor : case report and review of sex cord/gonadal stromal tumor histogenesis

We describe a case of well differentiated Sertoli-Leydig cell tumor in a testicle. Previously, this tumor has only been illustrated histologically. The existence of a male homologue to the female arrhenoblastoma containing Sertoli and Leydig cells again supports the current hypothesis of gonadal development, and the common steps found in the male and female pathways.

Tips and Tricks of Inflatable Penile Prosthesis Reservoir Placement: A Case Presentation and Discussion

INTRODUCTION There have been many advances in the inflatable penile prosthesis (IPP) since the 1970s. While these devices were initially fraught with mechanical malfunction, the most recent models prove to be much more reliable. Although reservoir complications are not common, when they do occur, it typically involves damage to the surrounding tissues. The ability to recognize and treat these complications is paramount for any surgeon that routinely places IPPs. AIM The aim of this article was to present a unique reservoir-related complication as well as perform a literature review of reservoir-related complications and techniques for reservoir placement, and provide a summary of dimensions and technical aspects of commonly used reservoirs. METHODS We reviewed a unique reservoir-related complication that presented to our institution with urinary retention and constipation. We also reviewed reservoir-related complications since 1984, reviewed the most recent surgical techniques involved in reservoir placement, and summarized the dimensions and technical characteristics of both the American Medical System and Coloplast reservoirs. MAIN OUTCOME MEASURE A reservoir-related complication that resulted in urinary retention and constipation is the main outcome measure. RESULTS Although uncommon, reservoir complications do occur. The most common case report complication in the published literature is bladder erosion followed by external iliac compression, ileal conduit erosion, and small bowel obstruction. The case that presented at our institution was the result of a reservoir that was improperly placed in the perineum, causing urinary retention and constipation due to the compression of the bulbar urethra and rectum. CONCLUSIONS In this era, mechanical failures of IPP reservoirs are rare as most complications occur due to damage of the surrounding tissues. Prevention, diagnosis, and treatment of these complications are important for any surgeon that implants IPPs.

JSM HIGHLIGHTSSurgical Techniques: Minimally Invasive Infrapubic Inflatable Penile Implant

A surgical procedure was developed, designed to minimize time and maximize efficiency. The hope is that this procedure reduces the morbidity of penile prosthesis implantation. In all drawings, the primary skin incision will be represented larger than reality in order to facilitate schematic identification of vital structures. The artificial erection serves three purposes in expediting the implant process: (i) identify pathology needing correction; (ii) “true” dilation of the corpora supplanting serial dilations; and (iii) facilitate the identification of the dorsal nerve and lateral placement of stay sutures. The 1.5-cm corporotomy accommodates the widest part of the implant. Placement of color-coded stay sutures lateral to the dorsal nerve Corporotomy incision using #12 blade Dorsal nerves within neurovascular bundle medial to corporotomy incisions