|Year : 2014 | Volume
| Issue : 2 | Page : 79-81
Radiation Related Inflatable Penile Prosthesis Complex Erosions
Gavin N Wagenheim1, Navanimitkul Niti1, Haocheng Lin1, Run Wang2
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 Publication||27-Oct-2014|
University of Texas Medical School at Houston, MD Anderson Cancer Center, 6431 Fannin Street, Suite 6.018, Houston, Texas 77030
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
The placement of inflatable penile prosthesis (IPP) for management of refractory erectile dysfunction (ED) has been documented as early as 1973.  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.  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.  However, mechanical failure, infection and implant erosion do occur and will require surgical intervention in many cases.  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.  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.  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|| |
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.
| Discussion|| |
Even though, trans-scrotal reservoir placement during prosthetic implantation is safe, bladder injury by the reservoir has been described as a rare complication. ,,, 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. ,,,
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.  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. 
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[Figure 1], [Figure 2]