A Multicenter Study On The Single Incision Perineal Approach For Placement Of An Artificial Urinary Sphincter Appears To Be Safe And With Better Pump Placement Than The Traditional Two Incision Method
INTRODUCTION AND OBJECTIVES: The classic perineal approach for placement of an artificial urinary sphincter (AUS) requires 2 separate incisions: one for the cuff, and the other for the pump and reservoir placement. Now a second approach, through a single penoscrotal (also known as transscrotal approach) incision, for AUS placement exists that is advocated to be faster and easier than the traditional method. A recently published paper shows that when the AUS cuff is placed through a perineal approach there appears to be a higher completely dry rate and fewer subsequent tandem cuff additions than when the AUS cuff is placed through a penoscrotal incision (J Urol. 179, 1475-1479: 2008). That paper and subsequent accepted debating letters to the editor of the Journal of Urology describe and advocate for demonstration of the single incision perineal approach of AUS placement. Therefore a multicenter study and video demonstrating the method were performed.
METHODS: We reviewed the charts of 47 patients at three centers who underwent these procedures from 11/2006 till 7/2008. The entire AUS device was placed thru a single perineal incision with pressure regulating balloon (PRB) placement done similarly to “blind” reservoir placement of a penoscrotal IPP placement. This is accomplished by simply reaching up from the perineal incision with the patient in deep reverse Trendelenburg, which tilts the pelvis towards the surgeon allowing easier access to the retropubic space. If unable to obtain adequate retropubic position of the PRB, a small counter incision was made in the groin similar to the traditional counter incision. In this single perineal incision approach, the pump is placed in a sub-dartos pouch in the scrotum from below, the exact opposite of transscrotal pump placement, with a purse string suture to secure it in place.
RESULTS: 2 (4%) of the 47 patients had erosion / infection with no mechanical failures or revisions for other reasons. With the direct vision sub-dartos pouch method of pump placement; there is no issue with pump migration / high riding pump position in any of the patients. In five cases, the surgeon was unable to achieve satisfactory retropubic PRB placement and a counter incision was used to place the PRB, but not the pump.
CONCLUSIONS: The single incision perineal approach for placement of an artificial urinary sphincter appears to be safe and with better pump position than with the traditional two incision method.
Capsule-To-Capsule Closure May Have Less Urethral Stricture Rates Than Muscosa-To-Muscosa Closure For Surgical Management Of Artificial Urinary Sphincter Erosion: A Prelimary Five-Center Study
INTRODUCTION AND OBJECTIVES: Urethral erosion after artificial urinary sphincter (AUS) cuff placement can occur in as many as 5% of patients. Customary practice is to completely remove the AUS and allow the urethra to heal over a Foley catheter. Subsequent urethral complications and their management have not been reported. We examined our experience with surgical management of urethral complications following AUS erosion to try to determine the best way to manage these complicated cases.
METHODS: A retrospective database of AUS erosion cases, performed by five high-volume surgeons was analyzed. From 2004- 2011, 22 men were identified as having urethral erosions from an incontinence procedure: 21 from a AUS, 1 after an Invance sling, and were followed up for significant urethral complications after repair of their urethral erosion. Repair type was noted. Urethral complications were defined as: urethral stricture, urethral diverticulum, and/or fistula. Bladder neck contractures were excluded. All patients had post-prostatectomy incontinence.
RESULTS: Urethral complications included 5 urethral strictures, 2 urethrocutaneous fistula, 2 urethral diverticulum, and 2 with both a fistula and diverticulum. Surgical management of the complication included a ventral onlay buccal mucosa graft in 5 patients, urethral diverticulum and fistula were excised and primarily repaired in multiple layers (one patient had buccal mucosa and a tunica vaginalis flap). Currently, 12 patients have had successful tertiary AUS cuff placement at a different urethral site, 5 patients are managed with a chronic catheter after AUS replacement and subsequent erosion required explants (5/19: 26% erosion rate), 1 patient with a history of radiation required cystectomy, and 3 patients declined further surgery. Repair technique revealed: 1 of 2 patients that had no repair of the urethra (erosion site only had a Foley catheter placed after AUS removal) developed a diverticulum, but no stricture; with mucosa-to-mucosa repair 5/9 patients developed urethral strictures, whereas capsule-tocapsule repair revealed no urethral strictures at follow up.
CONCLUSIONS: AUS erosion can result in complex urethral complications requiring surgical management. While the urethra can heal properly over a Foley catheter, capsule-to-capsule repair may lead to fewer urethral stricture rates than mucosa-to-mucosa repair. A larger study is needed on this subject, as there are essentially no published data currently.
Infection Retardant Coated Versus Non-Coated Penile Prosthesis Cultures During Revision Surgery: A Multicenter Study
INTRODUCTION AND OBJECTIVES: Previously published papers have shown that the majority of clinically uninfected penile prostheses have organisms growing in the implant spaces at reoperation (J Urol 172: 153, 2004). Virtually all 3-piece penile prostheses (IPP) placed in the United States have infection retardant coatings; InhibiZone on the American Medical Systems 700 series and hydrophilic coating on the Coloplast Titan series. These coated penile prostheses appear to reduce infection rates by close to half in published studies in primary implantation. However, these infection retardant coated prostheses have not been shown to reduce revision / replacement infection rates without the addition of a revision washout (J Urol 173: 89, 2005). This is the first investigation of whether these infection retardant coated implants have lower cultures rates at the time of clinically uninfected revision surgery as compared to penile prostheses without coating.
METHODS: At four institutions, cultures were prospectively obtained from clinically uninfected penile prostheses at revision surgery. Immediately upon surgical exposure of the pump, cultures were obtained. If a bacterial biofilm was noted on any component, it was additionally cultured. We compared the original paper’s 77 patients, none of whom had coated penile prostheses, to 20 patients with infection retardant coatings on their IPP. Culture positivity rates, culture isolates of patients with Staphylococcus species and number of patients with more than one isolate cultured was compared.
RESULTS: During revision surgery for non-infected IPPs, culture positive bacteria had been found in 54 of 77 (70%) patients with non coated IPP. A similar number, 12 of 20 (60%), of patients with coated IPPs showed positive cultures. Of the 54 non-coated patients, 49 (90%) had positive culture for Staphylococcus genus, while 10 (83%) of the 12 patients with coated IPP had a cultured isolate of the Staphylococcus genus. 3 (5.5%) of the 54 non-coated patients grew more than one culture isolate versus none (0%) of the 12 coated IPP patients having more than one isolate cultured.
CONCLUSIONS: Positive cultures and visible bacterial biofilm have been shown to be present on clinically uninfected IPPs at the time of revision surgery in the majority of patients whether or not the IPP is coated with infection retardant coating.
Positive Culture Growths From Infection Retardant-Coated Penile Prostheses At The Time Of Revision/Savlage Surgery: A Multicenter Study
INTRODUCTION AND OBJECTIVES: Traditionally, the most common bacteria found at the time of inflatable penile prosthesis (IPP) infection was staphylococcus (S.) species. In the past few years, infection retardant-coated IPPs have been shown to reduce primary (virgin) infection rates by about half. There has been speculation that these infection retardant-coatings may change the nature of what culture isolates will grow in the presence of these coating that are suppose to help prevent colonization of the implants. The majority of penile prostheses have culture positive bacteria at the time of revision surgery (J Urol 172: 153). We evaluated culture isolates from patients with known infection retardant-coated IPPs to evaluate the bacterial profile.
METHODS: At 4 institutions, more than 200 patients with a penile prosthesis underwent revision surgery between November 2000 and November 2009. Only those patients who already had infection retardant-coated penile prostheses placed and grew out positive culture isolates were included in the study. Patients were further broken down into two groups: clinically uninfected revision/replacement (group 1 = 40 patients) and overtly infected undergoing salvage rescue or removal (group 2 = 17 patients). In addition, sensitivities to the combination of tetracycline and rifampin were evaluated (sensitive = sens; resistant = R).
RESULTS: A total of 38 isolates were cultured out these patients with 25 from group 1 and 13 from group 2; some patients grew out more than one isolate. Culture positive isolates from the clinically uninfected revisions (group 1) were 16 S. Epi (all sens), 3 S. Lugdenesis (all sens), enterococcus faecalis (intermediate sens), Klebsiella pneumonia (sens), yeast, Micrococcus species, Gram + rods, peptostreptococcus species. Culture positive isolates from overtly infected patients (group 2) were 4 S. Epi (all sens), 2 MRSA (sens), 2 Enterococcus Faecalis (sens), S. Haemolyicus, S. Warneri, yeast, E. Coli (tetracycline R), Citrobacter Freudii (R to rifampin).
CONCLUSIONS: Culture isolates grown from patients undergoing revision surgery for clinically uninfected (group 1) reasons appear to have a more traditional bacteria profile; meanwhile, those patients with overt infections (group 2) may have a non-traditional bacterial profile.
Review Of 1103 Inflatable Penile Prosthetic Surgeries Performed In 2009 Demonstrates Almost Complete Variability For Irrigation And Antibiotic Practice Amongst Eleven High-Volume Reconstructive Surgeons
INTRODUCTION AND OBJECTIVES: Irrigation during inflatable penile prosthesis (IPP) surgery is considered routine as part of the effort to decrease infection rates. However, little evaluation of this practice has been performed, and there is wide variation between surgeons and sites regarding the type of irrigant utilized (with or without single or combination antimicrobials). There is also a trend toward irrigant type determined by hospital surgical committees. To date, there is little agreement whether to cease irrigation when the IPP is introduced into the penis (this may or may not be a factor for antibiotic impregnated devices) or continue until the end of the procedure. We report a contemporary series focusing on irrigation practices, antiobiotic usage and overall rates of infection in both virgin and revision IPP surgeries.
METHODS: 11 high volume penile implant surgeons provided 2009 data for number of cases performed and the primary endpoint of device infection. Type of irrigation fluid utilized, usage of irrigant intraoperatively (cessation at IPP placement versus end of case), and antibiotic regimen (pre-and post- surgery) were determined.
RESULTS: A total of 732 virgin prostheses and 371 revision surgeries comprised this cohort. For the first-time implant cohort, 7 infections occurred (1%), whilst 14 (3.8%) were identified in the revision group. Of the 11 surgeons, only two shared a common irrigation protocol with type and manner of use varying between centers. Rates of infection were below those in contemporary published literature. Antiobiotic usage was variable as well, with a higher percentage of agent selection mandated by the surgeon’s institution.
CONCLUSIONS: The lack of uniformity across strategies thought to decrease infection rates for penile prosthesis insertion is of concern; for a 11-surgeon high volume implanter cohort, there was no identifiable consistency for irrigant or antibiotic use. The authors strongly support the formation of an AUA, SMSNA/SUPS or equivalent panel to rigorously review available evidence and offer best-practice guidance regarding use of irrigation and antibiotics. This may be of particular utility to a lower-volume prosthetic surgeon.
Revision Washout Appears To Improve Mechanical Failure Rates In An Outcomes Analysis Of Over 200 Revision Surgeries For Penile Prosthesis Implantation: A Multicenter Study
INTRODUCTION AND OBJECTIVES: The majority of penile prostheses have culture positive bacteria at the time of revision surgery (J Urol 172: 153). Revision washout appears to decreases penile prosthesis infection at the time of revision surgery (J Urol 173: 89). Revision washout decreases implant capsule tissue culture positivity (J Urol 179(1): 186.) The original biofilm paper above showed that those revision cases that had positive swab cultures had significantly lower survival time for mechanical failure than those revision cases with negative swab cultures begs the question: does revision washout improve mechanical survival rates of revision/replacement penile prostheses versus those revision/ replacement cases where no revision washout was done?
METHODS: At 4 institutions, 195 patients with a penile prosthesis underwent revision surgery between November 2000 and November 2007. This review of penile prosthesis revisions entailed 201 cases, however, there was incomplete data for 28 of the cases (14%) and one center closed with data was truncated at that date for those patients. Patients were separated into 2 groups for this analysis, group 1—those who did not undergo a revision washout and group 2—those patients who did undergo a revision washout. Nonparametric revision-free duration curves were calculated using the Kaplan-Meier product limit method.
RESULTS: Those patients who received a revision washout at the time of revision / replacement surgery for their penile prosthesis had better mechanical survival rates (p < 0.001) as compared to those who had no washout (see graph).
CONCLUSIONS: Revision washout has been shown to decrease infection rates, implant capsule bacterial positively, and now appears to improve mechanical survival rates at the time of revision surgery for penile prostheses.
Single Component Exchange During Penile Prosthesis Revision Appears To Have Higher Infection Rates And Lower Overall Device Survival Rates Than Complete Component Replacement: A Multicenter Analysis
INTRODUCTION AND OBJECTIVES: Anecdotally, many prosthetic urology surgeons have strong feelings about single component exchange versus complete replacement of a three-piece inflatable penile prosthesis (IPP), in terms of infection and device survival rates, but there is a dearth of knowledge in the published literature on the subject. In addition, it is now known that the majority of penile prostheses have culture-positive bacteria at the time of revision surgery, indicating that bacteria probably exists on any IPP components that are retained (J Urol 172: 153). We evaluated infection rates and overall device survival rates, comparing single component exchange and complete replacement of IPPs at the time of revision surgery for non-infectious reasons.
METHODS: At 4 institutions, 227 patients with a penile prosthesis underwent revision surgery between November 2000 and April 2011. Strict criteria were utilized. Only patients who were undergoing single component exchange of their existing IPP or complete removal and replacement with a new IPP and had adequate follow-up were included. Patients were excluded if their revision surgery was for infection, erosion, impending erosion, extrusion, hemotoma removal, grafting, hydrocapsulotomy, bladder erosion, or concurrent surgeries. Of the 227 patients, 148 (65%) qualified for analysis: 13 in the single component exchange (group 1) and 135 in the complete removal and replacement with a new IPP (group 2). Infection rates and overall device survival rates were calculated by a PhD-level statistician.
RESULTS: Though not powered enough for statistical significance, the results trended towards better outcomes with the complete replacement patients (group 2). For overall device survival (any complication), 8 of the 135 (5.93%) in group 2 failed, while 2 of the 13 (15.38%) in group 1 failed, with Fisher’s exact p-value = 0.214 and Log-rank test p-value = 0.475. A greater trend towards significance was found when evaluating for infection rates with 5 of the 135 (3.7%) in group 2 becoming infected and 2 of the 13 (15.38%) in group 1 becoming infected, a Fisher’s exact p-value = 0.116 and a Log-rank test p-value = 0.254.
CONCLUSIONS: Complete penile prosthesis removal and replacement may have lower infection and higher device survival rates as compared with exchange of a single component. A causal factor may be bacteria on the retained component(s). A larger study group is needed to determine statistical significance.