Home Current issue Ahead of print Search About us Editorial board Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 361
  • Home
  • Print this page
  • Email this page

 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  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


Department of General Surgery, Division of Urology, University of Utah, Salt Lake City, Utah, USA

Date of Web Publication24-Apr-2015

Correspondence Address:
Ross E Anderson
Department of General Surgery, Division of Urology, University of Utah, 50 N Medical Drive, Salt Lake City, Utah 84132
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2225-1243.155777

Rights and Permissions
  Abstract 

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 Top


In the United States, there are over 3000 artificial urinary sphincters (AUSs) implanted each year. [1] 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. [2],[3] 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 Top


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)

Click here to view
Figure 2: Mechanical thrombectomy and thrombolysis of right femoral vein thrombus

Click here to view


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)

Click here to view



  Discussion Top


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. [4] Fifteen years following radiation therapy for localized prostate cancer 9.4% of men reported no control or frequent urinary leakage. [5] 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%). [6]

Long term follow-up data following AUS placement demonstrates that between 20% and 36% of devices will require surgical revision. [7],[8] In a single center retrospective study with 13 years follow-up, the median time to surgical revision of AUS was 89 months. [9] 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. [10]

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. [9] 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. [11] 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 Top

1.
Matsushita K, Chughtai BI, Maschino AC, Lee RK, Sandhu JS. International variation in artificial urinary sphincter use. Urology 2012;80:667-72.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
    
5.
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.  Back to cited text no. 5
[PUBMED]    
6.
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.  Back to cited text no. 6
    
7.
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.  Back to cited text no. 7
    
8.
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.  Back to cited text no. 8
    
9.
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.  Back to cited text no. 9
    
10.
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.  Back to cited text no. 10
    
11.
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.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


This article has been cited by
1 Ectopic Penile Prosthesis Reservoir Placement: An Anatomic Cadaver Model of the High Submuscular Technique
Matthew J. Ziegelmann,Boyd R. Viers,Derek J. Lomas,Mary E. Westerman,Landon W. Trost
The Journal of Sexual Medicine. 2016;
[Pubmed] | [DOI]
2 Infrequent Reservoir-Related Complications of Urologic Prosthetics: A Case Series and Literature Review
Tao Cui,Ryan Terlecki,Majid Mirzazadeh
Sexual Medicine. 2015; 3(4): 334
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed2392    
    Printed39    
    Emailed0    
    PDF Downloaded100    
    Comments [Add]    
    Cited by others 2    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]