|Year : 2015 | Volume
| Issue : 2 | Page : 61-63
A Rare Complication of Artificial Urinary Sphincter: Deep Venous Thrombosis Due to Compression of Femoral Vein by Pressure Regulating Balloon
Ross E Anderson, Jeremy B Myers, James M Hotaling, William O Brant
Department of General Surgery, Division of Urology, University of Utah, Salt Lake City, Utah, USA
|Date of Web Publication||24-Apr-2015|
Ross E Anderson
Department of General Surgery, Division of Urology, University of Utah, 50 N Medical Drive, Salt Lake City, Utah 84132
Source of Support: None, Conflict of Interest: None
The placement of artificial urinary sphincters (AUSs) is a common procedure for stress incontinence following treatment for prostate cancer. Complications are relatively rare, and the most common reasons for device removal and revision are cuff erosion, infection, and mechanical failure. We present a case of a 66-year-old male with a history of radiation therapy for prostate cancer that developed a deep venous thrombosis (DVT) and pulmonary embolism (PE) following his second AUS due to compression by a pressure regulating balloon (PRB). Compression of the femoral vein was not originally diagnosed as the cause for DVT on initial hospitalization, and there was an additional hospitalization due to worsening symptoms prior to identification of PRB compression. This is the first published case of migrating PRB causing femoral DVT and PE following the placement of a second AUS in an irradiated tissue field, and one of two published cases of DVT due to PRB compression.
Keywords: Artificial urinary sphincter, deep venous thrombosis, incontinence, prostate cancer
|How to cite this article:|
Anderson RE, Myers JB, Hotaling JM, Brant WO. A Rare Complication of Artificial Urinary Sphincter: Deep Venous Thrombosis Due to Compression of Femoral Vein by Pressure Regulating Balloon. J Integr Nephrol Androl 2015;2:61-3
|How to cite this URL:|
Anderson RE, Myers JB, Hotaling JM, Brant WO. A Rare Complication of Artificial Urinary Sphincter: Deep Venous Thrombosis Due to Compression of Femoral Vein by Pressure Regulating Balloon. J Integr Nephrol Androl [serial online] 2015 [cited 2018 Dec 14];2:61-3. Available from: http://www.journal-ina.com/text.asp?2015/2/2/61/155777
| Introduction|| |
In the United States, there are over 3000 artificial urinary sphincters (AUSs) implanted each year.  Complications involving the AUS pressure regulating balloon (PRB) are exceptionally rare, with one published case of compression of the femoral vein causing a deep venous thrombosis (DVT) and pulmonary embolism (PE) in a post-prostatectomy patient. , We present a case of a 66-year-old male with a history of radiation therapy for prostate cancer that developed a DVT and PE following his second AUS due to compression by a PRB.
| Case Report|| |
We present a case of a 66-year-old male who was originally referred for AUS consultation due to 3-4 pads/day incontinence and multiple episodes of nocturia. He has past medical history of radical nephrectomy for renal cell carcinoma with a baseline creatinine of 1.77 mg/dL, radiation therapy for prostate cancer, transurethral resection of the prostate and urethral dilation for postradiation stricture. Initial cystoscopy demonstrated radiation changes of the bladder, prostate, and urethra. Due to the patient's poor quality of life he desired to undergo placement of AUS.
In June of 2013, a 4 cm cuff AUS was inserted via a perineal, transcorporal approach with the PRB placed posterior to the transversalis fascia through a right groin incision. He experienced chronic scrotal pain in the months following surgery, but for the first 9 months he had minor leakage and was no longer using pads. In March of 2014, he represented with constant leakage requiring three diapers a day. Cystoscopy revealed poor coaptation of the AUS without erosion.
Therefore in April of 2014 the AUS was removed and replaced. The old PRB was first removed through the old right groin incision and then a new PRB was replaced in the same position. His postoperative course was uncomplicated and he was discharged on postoperative day one. It is not our routine practice to provide thromboembolic prophylaxis following this surgery.
Six days after surgery, the patient woke up in the middle of the night with shortness of breath and chest pain. He presented to the emergency department with a severely swollen right leg and duplex ultrasound revealed DVT of right common femoral vein. This ultrasound did not mention any masses obstructing or compressing the femoral vein. On exam there was diffuse scrotal and penile edema. Scrotal ultrasound was only significant for edema. Due to his chronic kidney disease, computed tomography-angiography (CT) was not performed. Therapeutic anticoagulation with heparin was initiated for presumed PE. Ultimately he was bridged with coumadin and discharged home 4 days later with an INR of 2.9.
Ten days later he represented to the emergency room with increased leg swelling and a sub-therapeutic INR of 1.1. Repeat duplex ultrasound revealed extension of the right femoral vein thrombosis into the external iliac vein [Figure 1]. An interventional radiologist performed mechanical thrombectomy and thrombolysis during this admission [Figure 2]. The interventional radiologist noted external compression of the femoral vein by the PRB at the time of fluoroscopy, and he communicated this to the patient's urologist immediately.
|Figure 1: Duplex ultrasound demonstrating common femoral vein thrombosis (red arrow) and zero forward flow (green arrow)|
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|Figure 2: Mechanical thrombectomy and thrombolysis of right femoral vein thrombus|
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The patient was later preadmitted for a heparin drip prior to removal and replacement of the AUS. The operative report noted that the PRB had migrated laterally and compressed the femoral vein. After removal, the area was washed out and a piece of Nu-Knit surgical was placed in the cavity. See [Figure 3] for postoperative CT-abdomen and pelvis demonstrating the new PRB placement and the former PRB cavity with residual compression of the femoral vein.
|Figure 3: Computed tomography-abdomen and pelvis demonstrating the new pressure regulating balloon (PRB) placement (green arrow) and the former PRB cavity with residual compression of the femoral vein (red arrow)|
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| Discussion|| |
To our knowledge, this is the first published case of migrating pressure regulating balloon causing femoral DVT and PE following the placement of a second AUS in an irradiated tissue field, and the second published case of DVT due to PRB compression. Treatment of prostate cancer is a common cause of stress urinary incontinence, and up to one-third of men with postradical prostatectomy stress urinary incontinence that undergo surgical intervention receive an AUS.  Fifteen years following radiation therapy for localized prostate cancer 9.4% of men reported no control or frequent urinary leakage.  Placement of AUS at 5 years following radiation therapy for prostate cancer is much more rare compared with postradical prostatectomy (0.2% vs. 5.2%). 
Long term follow-up data following AUS placement demonstrates that between 20% and 36% of devices will require surgical revision. , In a single center retrospective study with 13 years follow-up, the median time to surgical revision of AUS was 89 months.  Comparing AUS revisions to 1 st time AUS, the risk of erosion was 4 times greater in the revision group, but interestingly there is no difference in the risk of leakage, need for re-operation, urethral atrophy, or infection. 
Radiation therapy induces cancer cell death by damaging DNA, while nearby healthy tissue undergoes fibrosis and microvascular cell damage. This results in distorted tissue plains and increased surgical difficulty. There is some disagreement in the literature regarding the affects of radiation on AUS complication rates. One study showed that in patients who underwent both prostatectomy and radiation versus prostatectomy alone, there was no difference in the rate of cuff erosion, infections, mechanical failure, or need for revision.  While a prospective analysis of over 300 AUS patients demonstrated that prior pelvic radiation was the strongest predictor of explantation, with almost 5 times the risk on multivariable analysis.  This is usually due to cuff erosion into the urethra and not issues with the PRB.
Our patient had multiple venous thromboembolism risk factors: history of both renal and prostate cancer, recent surgery, and relatively poor mobility. This may have contributed to initially missing the mechanical obstruction as the primary cause of the DVT, and treating it with anticoagulation alone. It was during the second admission in the setting of worsening symptoms, that the interventional radiologist diagnosed the mechanical outflow obstruction caused by the PRB. While PRB migration into the femoral vessels causing mechanical obstruction and DVT is extremely rare, it should be kept in the differential for postoperative DVT in any patient with recent implantation of devices near the inguinal canal.
| References|| |
Matsushita K, Chughtai BI, Maschino AC, Lee RK, Sandhu JS. International variation in artificial urinary sphincter use. Urology 2012;80:667-72.
Levine LA, Hoeh MP. Review of penile prosthetic reservoir: Complications and presentation of a modified reservoir placement technique. J Sex Med 2012;9:2759-69.
Selph JP, McKim SE, Langston JP, Carson CC. Deep venous thrombosis as a complication of reservoir placement in post-prostatectomy erectile dysfunction and urinary incontinence prosthetic surgery. Sex Med Rev 2014;2:59-63.
Kim PH, Pinheiro LC, Atoria CL, Eastham JA, Sandhu JS, Elkin EB. Trends in the use of incontinence procedures after radical prostatectomy: A population based analysis. J Urol 2013;189:602-8.
Resnick MJ, Koyama T, Fan KH, Albertsen PC, Goodman M, Hamilton AS, et al.
Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med 2013;368:436-45.
Berge V, Thompson T, Blackman D. Additional surgical intervention after radical prostatectomy, radiation therapy, androgen-deprivation therapy, or watchful waiting. Eur Urol 2007;52:1036-43.
Raj GV, Peterson AC, Toh KL, Webster GD. Outcomes following revisions and secondary implantation of the artificial urinary sphincter. J Urol 2005;173:1242-5.
Kim SP, Sarmast Z, Daignault S, Faerber GJ, McGuire EJ, Latini JM. Long-term durability and functional outcomes among patients with artificial urinary sphincters: A 10-year retrospective review from the University of Michigan. J Urol 2008;179:1912-6.
Lai HH, Hsu EI, Teh BS, Butler EB, Boone TB. 13 years of experience with artificial urinary sphincter implantation at Baylor College of Medicine. J Urol 2007;177:1021-5.
Lai HH, Boone TB. Complex artificial urinary sphincter revision and reimplantation cases - how do they fare compared to virgin cases? J Urol 2012;187:951-5.
Brant WO, Erickson BA, Elliott SP, Powell C, Alsikafi N, McClung C, et al
. Reconstructive urology risk factors for erosion of artificial urinary sphincters: A Multicenter Prospective Study. Urology 2014;84:934-9.
[Figure 1], [Figure 2], [Figure 3]