management of infectious and non infectious complications ... · • penile prosthesis infection...
TRANSCRIPT
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Management of Infectious and Non‐infectious complications of penile
implants
Rafael Carrion, MDAssociate Professor of Urology
Program Director
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Infections
• Still a signifcant concern• Different risks for virgins and revisions• Comorbidities play a role
– Diabetes Mellitus• Improved outcomes with coated implants• Improved techniques with evolution• Current rates vary
– Not 0%!
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InfectionsClinical Manifestations
• Pain– Cylinders– pump
• Erythema• Induration• Fixation
– Pump fixation to skin• Drainage
– purulent
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Early Presentation
Remove only –VS‐ Remove and Salvage Placement
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Choices
• Removal– When to place implant
• Salvage Prosthesis– Malleable– Inflatable
• Stimulan
Gross, M; Levine, L; Carrion, R; Eid, J, Martinez, D; Perito, P; Munariz, R. ISSM Abstract #045, Improved Infection outcomes after mulcahy salvageProcedure and replacement of infected IPP with malleable prosthesis.
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• Penile prosthesis infection risk 1‐3%– “No touch” 0.7%
• Devastating complication– Decrease penile size– Increase pain– Loss sexual function
• Management– “Mulcahy Salvage
Protocol”/Immediate Implant– Removal/Delayed Implant– “Carrion Cast”/Delayed
Implant
• Updated series “Carrion Cast”– Antimicrobial spacer – Maintains size– Treating infection– Bridging gap between
explant and reimplant
• Not candidates for immediate salvage– Failed immediate salvage – Bacteremia/septicaemia
THE CARRION CAST: AN UPDATE ON THE USAGE OF THE INTRACORPORAL ANTIMICROBIAL DOPED SPACER FOR THE TREATMENT OF PENILE IMPLANT INFECTION
Daniel R. Martinez, Eihab Alhammali, Justin Emtage, Justin Parker and Rafael E. CarrionDepartment of Urology, University of South Florida, Tampa, Florida
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• 5/2012 ‐ 2/2014• 9 cases
– 5 Coloplast Genesis SemirigidPenile Prosthesis (SRPP)
– 2 Coloplast Titan Inflatable Penile Prosthesis (IPP)
– 2 narrow SRPP’s• Size range 17cm to 23cm
• CaSO4 cast size – 20‐30cc, split between corpora
• Serum calcium, vancomycin and tobramycin levels stable
THE CARRION CAST: AN UPDATE ON THE USAGE OF THE INTRACORPORAL ANTIMICROBIAL DOPED SPACER FOR THE TREATMENT OF PENILE IMPLANT INFECTION
Daniel R. Martinez, Eihab Alhammali, Justin Emtage, Justin Parker and Rafael E. CarrionDepartment of Urology, University of South Florida, Tampa, Florida
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• Time to reimplantation– 6‐18 weeks
• 6 weeks cast dissolves
• All had prosthesis replaced – 1 SRPP– 3 IPP’s– 2 narrow SRPP’s– 1 narrow IPP
• Size range 17cm ‐ 20cm
• Mean loss prosthesis length 1.1cm
• Average penile length maintained 95%
THE CARRION CAST: AN UPDATE ON THE USAGE OF THE INTRACORPORAL ANTIMICROBIAL DOPED SPACER FOR THE TREATMENT OF PENILE IMPLANT INFECTION
Daniel R. Martinez, Eihab Alhammali, Justin Emtage, Justin Parker and Rafael E. CarrionDepartment of Urology, University of South Florida, Tampa, Florida
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Infections
North American Consensus Document on Infection of Penile ProsthesesDarouiche RO, Bella AJ, Boone TB, Brock G, Broderick GA, Burnett AL, Carrion R, Carson C 3rd, Christine B, Dhabuwala CB, Hakim LS, Henry G, Jones LA, Khera M, Montague DK, Nehra A.
Urology. 2013 Aug 16. pii: S0090‐4295(13)00822‐4. doi: 10.1016/j.urology.2013.05.048.
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Surgical Approach
• 2 Standard Approaches– Penoscrotal
• Better corporeal exposure (fibrosis)• No dorsal nerve injury• Pump fixation possible
– Infrapubic• Resevoir placement under direct vision• Can be more efficient
– Subcoronal• Only for malleable
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Surgical Approach:Complications
• 2 Standard Approaches– Penoscrotal
• ?Higher risk of bleeding and complications assocwith pump and tubing
• ?More difficult to place resevoir or requires counter incision
– Infrapubic• ?Injury to Dorsal neurovascular bundle• ?Suboptimal pump placement (underestimated)
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HematomaPreventive Strategies
• Henry Mummy Wrap• Closed Suction Drain
– Blake (round)– Jackson Pratt (flat)
• Sealants– Evicel– Tisseal
• Sand Bags• Keep Implant Inflated for period of time• Many types of pressure dressings
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Complications(Intra-op and Post-op)
• Mechanical– Autoinflation– Aneurysm/Sigmoid Deformity– Leakage– Difficulties dilating (underestimated)– Perforation/Erosion (related to dilation)– Improper Sizing (poss related to dilation)– Difficulties inflating/deflating– Cross-over
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Inadequate Dilation
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Distal Crossover
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Patient “A”
Incorrect Dilation/Sizing, High Riding Pump
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Patient “A”
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Patient “A”
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Patient “A”
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Perforation• Can occur distal, proximal, lateral• What do you do?• Wind sock (Gortex, Dacron, Tissue)• Repair Corpora• Suture in rear tip
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IMPLANT PERFORATION
•PROXIMAL•CAN CONTINUE WITH SURGERY•USE CONTRALATERAL CORPORA TO SIZE IMPLANT•DIFFERENT SURGICAL TECHNIQUES DESCRIBED TO CORRECT DEFECT:
•SUTURE SLING•DACRON SOCK 2-0 PROLENE GOING
THROUGH TUNICA-REAR TIP-TUNICA
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IMPLANT PERFORATION
• DISTAL• GENERAL RECOMMENDATION TO ABORT PENILE IMPLANTATION
• REMOVE CONTRALATERAL CYLINDER (if already placed)• PLACEMENT OF FOLEY CATHETER (3‐5 DAYS)• ORAL ANTIMICROBIAL THERAPY
• SPECIAL CASES IMPLANT CAN STILL BE PERFORMED• SEVERE FIBROSIS IN WHICH THE CORPORAL BODIES ARE SEPARATE CHAMBERS
• REVISION SURGERY
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Patient with impending distal lateral cylinder erosion
Impending Distal Erosion
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Implant tip removed and incision made through medial floor of tunica
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Dilation of new corporal space
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Implant re‐inserted and inflated, Tutoplast is placed over the distal edge of
tunica and sewn to the lateral edges
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Trying to Prevent!
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Complications‐Erosion(Proximal)
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Complications‐Erosion(Proximal)
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No Proximal Perforation!
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Newer Diagnostic Modalities
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Complications-Erosion
Management Scheme for This Case?
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Reservoir Issues
• Removal during revision surgery– Perils of injury to bladder, bowel, vessels– When to decide to deactivate the reservoir
• Placement during virgin cases– Space of Retzius– Ectopic placement– Improper position
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Reservoir PlacementCaution when Removing!
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Complications-Erosion
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Complications-Erosion
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Selective CT image of the perineal placed reservoir as demonstrated by the red arrow
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Obrigado!