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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 1  |  Issue : 2  |  Page : 79-81

Radiation Related Inflatable Penile Prosthesis Complex Erosions


1 University of Texas Medical School, Division of Urology, Houston, Texas, USA
2 University of Texas Medical School, Division of Urology; MD Anderson Cancer Center, Department of Urology, Houston, Texas, USA

Date of Web Publication27-Oct-2014

Correspondence Address:
Run Wang
University of Texas Medical School at Houston, MD Anderson Cancer Center, 6431 Fannin Street, Suite 6.018, Houston, Texas 77030
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2225-1243.143390

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  Abstract 

Delayed erosion of components of an inflatable penile prosthesis (IPP) is a rare complication after placement. Both erosion of the cylinders into the urethra, and the reservoir into the bladder, as a complication of radiation has not been previously reported. We report the case of a 71 year-old male with post-prostatectomy erectile dysfunction treated with an IPP, with subsequent biochemical recurrence requiring radiation therapy, complicated by erosion of his IPP cylinder into his distal urethra, and reservoir into the bladder.

Keywords: Inflatable penile prosthesis, erosion, radiation


How to cite this article:
Wagenheim GN, Niti N, Lin H, Wang R. Radiation Related Inflatable Penile Prosthesis Complex Erosions. J Integr Nephrol Androl 2014;1:79-81

How to cite this URL:
Wagenheim GN, Niti N, Lin H, Wang R. Radiation Related Inflatable Penile Prosthesis Complex Erosions. J Integr Nephrol Androl [serial online] 2014 [cited 2019 Sep 18];1:79-81. Available from: http://www.journal-ina.com/text.asp?2014/1/2/79/143390


  Introduction Top


The placement of inflatable penile prosthesis (IPP) for management of refractory erectile dysfunction (ED) has been documented as early as 1973. [1] Much technological advancement has been made, and, as a result, the mechanical failure rates for IPP have declined. Recent report cited 15% and 30% mechanical failure rates at 5 and 10 years, respectively. [2] The infection rate has also significantly decreased with the use of antibiotic coated IPP to a level of 1.1% at up to 7.7 years of follow-ups. [3] However, mechanical failure, infection and implant erosion do occur and will require surgical intervention in many cases. [4] In the event of mechanical failure, erosion or infection, the prosthetic device will need to be removed. This may include removal of the entire device including the reservoir, as with infection, or may be limited to the removal of the cylinders and pump leaving the reservoir intact, as with mechanical failure or cylinder erosion. [5] The volume of published reports concerning various medical complications associated with IPP is large; however limited literature exists regarding the complication of delayed reservoir erosions related to radiation years after implantation of three-piece IPP. [6] Furthermore, a review of current literature did not reveal any reported cases of reservoir erosion into the bladder associated with cylinder erosion into the distal urethra. We present a case of both reservoir erosion into the bladder, and distal urethral cylinder erosion related to radiation therapy for prostate cancer.


  Case report Top


The patient is a 71-year-old male with a history of Gleason 4 + 3 = 7 prostate cancer treated by robotic assisted radical prostatectomy with bilateral nonnerve sparing. He developed postprostatectomy ED that was treated with implantation of Coloplast Titan IPP after he failed nonsurgical treatment 1 year after his prostatectomy at outside hospital. The penile implant worked very well for 2 years. Unfortunately, biochemical recurrence of the prostate cancer was discovered 2 years after the IPP placement. This was treated with intensity modulated radiation therapy, 70 Gy, at the outside facility. Three months after radiation therapy, the patient presented to our clinic with complaints of urinary frequency, urgency and nocturia. He also reported distal urethral pain, discomfort, and occasional discharge. Exam identified IPP cylinder erosion into the distal urethral lumen [Figure 1]. However, there was no obvious sign of penile/scrotal infection. The patient was then scheduled for surgical removal of the IPP.
Figure 1: Inflatable penile prosthesis cylinder erosion into distal urethra

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A median raphe scrotal incision was used, in the site of the previous procedure's incision. After the tubes between the IPP pump and the IPP cylinders were identified and exposed, purulent fluid was encountered. Therefore, the decision was made to remove the entire device, including the reservoir in the space of Retzius. Dissection was carried down to the bilateral cylinders proximally. The cylinders were removed and a modified Mulcahy antibiotic irrigation was performed. During this irrigation, it was confirmed that the distal left cylinder was the implant responsible for the distal urethral erosion. However, after removal of the scrotal and corporal components, the dissection of the reservoir was noted to be especially challenging. Deeper dissection along the tube to reservoir encountered a small channel with clear fluid, thought to be urine. The dissection was then discontinued at this point, and flexible cystoscopy was performed. This identified a previously undiagnosed erosion of the entire reservoir into the bladder through the anterior lateral bladder wall [Figure 2]. The dissection was then continued, the reservoir removed, and the cystotomy repaired. A 20 F Foley catheter was placed.
Figure 2: Cystoscopic image of reservoir erosion into bladder

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  Discussion Top


Even though, trans-scrotal reservoir placement during prosthetic implantation is safe, bladder injury by the reservoir has been described as a rare complication. [7],[8],[9],[10] However, the majority of these cases were recognized intraoperatively or in the recovery unit and, therefore, addressed in the acute setting. Postoperatively, this injury may manifest as incontinence, urinary tract infections, or hematuria. In addition, this may be recognized chronically as the patient may report urinary frequency, urgency, and incomplete bladder is emptying. [5],[11],[12],[13]

Our case represents the rare combination of both erosion of the reservoir into the bladder as well as distal urethral cylinder erosion approximately 3 years from implantation of an IPP. The patient's symptoms are obviously related to salvage radiation therapy for his biochemical recurrence prostate cancer, as they arose only 3 months after radiation was completed. This case highlights the importance of having a high index of suspicion for bladder injury if a patient presents with urinary complaints associated with an IPP placement, regardless of the status of the rest of the implant or concomitant erosion.

In recent times, ectopic placement of the reservoir as an alternative to the space of Retzius has been reported. [14] We have been using sub-Scarpa's fascia or high submuscular space placement of the reservoir for the last 5 years without any early or delayed reservoir injury/erosion into the bladder or intra-abdominal organs. We recommend avoiding the placement of reservoirs into the space of Retzius for all patients undergoing IPP implantation. [15]

 
  References Top

1.
Scott FB, Bradley WE, Timm GW. Management of erectile impotence. Use of implantable inflatable prosthesis. Urology 1973;2:80-2.  Back to cited text no. 1
[PUBMED]    
2.
Carson CC, Mulcahy JJ, Govier FE. Efficacy, safety and patient satisfaction outcomes of the AMS 700CX inflatable penile prosthesis: Results of a long-term multicenter study. AMS 700CX Study Group. J Urol 2000;164:376-80.  Back to cited text no. 2
    
3.
Carson CC 3 rd , Mulcahy JJ, Harsch MR. Long-term infection outcomes after original antibiotic impregnated inflatable penile prosthesis implants: Up to 7.7 years of followup. J Urol 2011;185:614-8.  Back to cited text no. 3
    
4.
Sadeghi-Nejad H. Penile prosthesis surgery: A review of prosthetic devices and associated complications. J Sex Med 2007;4:296-309.  Back to cited text no. 4
[PUBMED]    
5.
Munoz JJ, Ellsworth PI. The retained penile prosthesis reservoir: A risk. Urology 2000;55:949.  Back to cited text no. 5
    
6.
Sadeghi-Nejad H, Sharma A, Irwin RJ, Wilson SK, Delk JR. Reservoir herniation as a complication of three-piece penile prosthesis insertion. Urology 2001;57:142-5.  Back to cited text no. 6
    
7.
Lane BR, Abouassaly R, Angermeier KW, Montague DK. Three-piece inflatable penile prostheses can be safely implanted after radical prostatectomy through a transverse scrotal incision. Urology 2007;70:539-42.  Back to cited text no. 7
    
8.
Brusky J, Dikranin A, Aboseif S. Retrieval of inflatable penile prosthesis reservoir from the bladder. Int J Impot Res 2005;17:302-3.  Back to cited text no. 8
    
9.
Park JK, Jang SW, Lee SW, Cui Y. Rare complication of multiple revision surgeries of penile prosthesis. J Sex Med 2005;2:735-6.  Back to cited text no. 9
    
10.
Kramer AC, Chason J, Kusakabe A. Report of two cases of bladder perforation caused by reservoir of inflatable penile prosthesis. J Sex Med 2009;6:2064-7.  Back to cited text no. 10
    
11.
Fitch WP 3 rd , Roddy T. Erosion of inflatable penile prosthesis reservoir into bladder. J Urol 1986;136:1080.  Back to cited text no. 11
    
12.
Leach GE, Shapiro CE, Hadley R, Raz S. Erosion of inflatable penile prosthesis reservoir into bladder and bowel. J Urol 1984;131:1177-8.  Back to cited text no. 12
[PUBMED]    
13.
Dupont MC, Hochman HI. Erosion of an inflatable penile prosthesis reservoir into the bladder, presenting as bladder calculi. J Urol 1988;139:367-8.  Back to cited text no. 13
    
14.
Stember DS, Garber BB, Perito PE. Outcomes of abdominal wall reservoir placement in inflatable penile prosthesis implantation: A safe and efficacious alternative to the space of Retzius. J Sex Med 2014;11:605-12.  Back to cited text no. 14
    
15.
Wang R, Lin HC. Sub-Scarpa′s facia placement of the penile prosthesis reservoir: A new surgical technique. J Sex Med 2010;7 Suppl 4:180. [Abstract #085].  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]


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