Digest of recent discussions on ISSM mail (September 2006 - December 2006)
Amr El-Meliegy, M.D.
Discussion Digest
The ISSM List discussions continued to be active and lively through the end of 2006. Dr. Eduardo Bertero presented 3 interesting surgical cases. Dr. Hossein Sadeghi-Nejad discussed a rare case of penile mass, while Dr. Andy McCullough presented a case of prosthesis auto-inflation.
Cases
- Early mechanical failure of an inflatable prosthesis
- Persistent Penile mass
- Prosthesis Auto-Inflation
- Penile Aneurysm!
- Prosthesis extrusion case
 Dr. Eduardo Bertero presented a patient who had implanted a 3 piece inflatable (Titan pre-connected device) 3 months later, the device was not working with suspicion of leakage from the connectors.
Dr. Santiago Richter advised re-exploration with changing of the device if it was punctured. If not, and connections were opened then to test the reservoir by filling it completely, waiting for about 15 minutes, emptying and measuring if you did not loose fluid, then to send a sample for culturing then refilling. The same to be done with the pump and cylinders. Then to reconnect cutting the tip of both ends of the tubing before putting a new connector. Dr. Ignacio Moncada agreed with Dr. Richter and added to do the procedure as a mini salvage procedure with abundant antibiotic wash due to the high risk of infection in revision surgery. Dr. Carlos Araujo Pinto also advised to check the whole penile implant. Dr. Hossein Sadeghi-Nejad agreed with these views and pointed out the high possibility of inadvertent cylinder puncture.
Dr Shedeed Ashour thought this might be due to that occurred because of an over inflated cylinder that rubbed against a deeply pre-placed suture in the corporotomy.
Dr. Laurence A Levine experienced the same problem with an AMS CX 700. The quick-connect separated between the pump and the reservoir. He advised Dr. Eduardo to reoperate quickly to simply check for the cause and if there is a separation to irrigate out the system and reconnect after refilling.
Dr. Eduardo reoperated the patient and found that the connector was perfect, but there was a rupture in the part of the tubing between the left cylinder and the pump. There was no puncture in the cylinders. He changed the whole device leaving the original reservoir. The surgery was uneventful.
Detailed Discussion
Hello,
I have implanted a 3 piece inflatable in July. Surgery was uneventful. He was engaged in sexual intercourse after 6 weeks. I have inflated and deflated myself at the office and was working properly. After 10-12 intercourses, last week he came to the office and said it was not working anymore. It seems it had leaked. My thought is that it might have leaked from the connection (Titan preconnected device). I was surprised and very disappointed: only 3 months after implantation! Your input is welcome.
Regards
Dr. Eduardo Bertero
Urologia
Sao Paulo, SP
Brazil
Dear Eduardo,
There is no doubt that the patient must be re-explored. Not necessarily the device replaced. If punctured, most probably done at one of the cylinders while closing the corpora. And then you have to replace !! If connection opened, fill completely the reservoir, wait for about 15 minutes, empty and measure if you did not loose fluid, send a sample for culture, refill. Do the same with the pump and cylinders.
If everything is OK, reconnect but cut the tip of both ends of the tubing before putting a new connector (Mentor does not have Quick-connect or regular connectors, as do AMS).
I hope I have been helpful. Good luck.
Santiago Richter, M.D.
Chairman, Israel Society for Sexual Health
Kfar Sava, Israel
Dear Bertero
"Nice" picture. I�ve seen this particular situation roughly between 6- 10 y fw-up. Keep us informed, please, regarding Mentor comments on, because it sounds so strange.
Best regards
Dr. Eduardo Bertero
Urologia
Rua Vieira de Moraes, 420 cj 117
Sao Paulo, SP
Brasil
hi Eduardo
please le us know what was the real cuse after revision.
In my opinion partial gradual leakage ccured because of an over inflated cylinder that rubbed aganist adeeply Pre-placed suture in the corporotomy.
thanks
SHEDEED ASHOUR SHEDEED
Asst professor Andrology CAiro UNiversity
Cairo EGYPT
Thanks for your response. The connection was working properly after 60 days of implantation.
Anyways I have booked the revision next week and will update the colleagues interested.
Regards,
Dr. Eduardo Bertero
Urologia
Rua Vieira de Moraes, 420 cj 117
Sao Paulo, SP
Brasil
Dear Bertero,
I think that the 3 piece inflatable Titan preconnected prostheses are very safe. Unfortunately this kind of problem appears with surgeons that use to perform this kind of procedure. When we have this complication, we need to go back and check the hole penile implant.
Three problems might have happened:
1) Puncture of the cylinders
2) Puncture of tubing
3) The connection was not properly connected
If you cant find the point of problem, I personnaly sugest to change the complete penile prostheses.
Best regards
Carlos Araujo Pinto
SP - Brazil
Dear Eduardo,
Nice picture, very demonstrative. I agree with Santiago that is strange to have this type of rupture so early after the implantation, probably is a manufacturing defect. Whenever I have a mechanical failure I do the same, normally I change cylinders and Pump (they come pre-connected) and use the same reservoir.
It is very important, in my view, to treat this type of case as a �mini-salvage� procedure because the risk of infection in revision surgery (even in mechanical failure) is double the normal, you can see very well in your picture the capsule around the prosthesis: IV antibiotics do not reach the periprosthetic space because of this capsule and the percentage of positive cultures in the fluid around the prosthesis is 70% (Wilson). So you need to wash abundantly with antibiotics, betadine, peroxide (with a waterpik if possible) and implant an antibiotic coated prosthesis, otherwise the risk of infection is too high.
I prefer not to use the �blue� hooks in prosthetic surgery because are very sharp, I like the �yellow� ones, bigger and blunt-tipped, much more safe for the prosthesis.
Best regards,
Ignacio Moncada MD
Urology/Andrology
Hospital Gregorio Mara��n, Madrid Spain
Eduardo
The company under microscopy is going to examine the device and let you know what happened!
Replacement is required and wait for the report with micro photo.
The statement that patient has been using the prosthesis does not mean anything. If something has partially "hurt" the cylinder, leaking is going to happen in 3,6 or more months.
Regards
I also preplace my corporal sutures. I have noted on occasion that the
hooks that I use with the Scott retractor will almost catch the
prosthesis cylinder as I am feeding it into the corpora. Could this be
a possibility?
Bruce Kava MD
Department of Urology
University of Miami School of Medicine
I do not think I have punctured the cylinder while closing the corpora. First of all, because I place the sutures before locating the cylinders exactly to avoid the risk. Secondly, the patient used the device for 10times and was functioning correctly.
Thanks for the helpful tips,
Dr. Eduardo Bertero
Urologia
Rua Vieira de Moraes, 420 cj 117
Sao Paulo, SP
Brasil
In fact both companies have their own quick-connect systems. I agree when reconnecting trim acm off and I wipe it down with saline as a voodoo move to reduce any slippery substance on the surface of the tubing.
Laurence A Levine MD,FACS
Professor of Urology
Rush University
Chicago,Illinois
I had this happen recently with a AMS CX 700. The quick-connect separated between the pump and the reservoir. If you can get back in there quickly you might be able to simply check for any other trouble and if there is a separation irrigate out the system and reconnect after refilling. I found in my patient who elected to wait 2 months that his device became contaminated with proteinaceous debris. As a result I had to replace the entire system for fear of clogging the pump down the road.
Laurence A Levine MD,FACS
Professor of Urology
Rush University
Chicago,Illinois
Dear Eduardo:
Because of the chronology of the events, I agree with the other views suggesting the high possiblity of inadvertent cylinder puncture. When you re-explore, if you see an obvious leakage from the area of the tubing connection, cut the ends and reconnect with new collets and connectors. As you know, with the Titan / Coloplast system, it is CRITICAL that you see the black lines of the tubing in the connector windows before you clip the ends together. Hope it works out well.
Best regards,
Hossein
Dear collegues,
I have just left the OR and my findings were:
1) The connector was perfect;
2) There was a rupture (I would call it almost broken) part of the tubing between the left cylinder and the pump. Very close to the pump. I have attached a picture for your observation.
3) I did not notice any puncture on the cylinders.
I tested the reservoir and was OK. I then changed the whole device leaving the original reservoir. The surgery was uneventful but I was very worried about this early failure. I will hand the implant to the manufacturer for their conclusions.
Regards for all of you who helped me with your thoughts,
Dr. Eduardo Bertero
Urologia
Rua Vieira de Moraes, 420 cj 117
Sao Paulo, SP
Brasil
Dear Eduardo,
Most interesting, thank you for the picture. It is the typical image of one of the places in which the tubes broke, only that when it happens, it usually happens after about 6-8 years of continuous use !!
I look forward to hear from you what explanation will Mentor give to this complication.
Best regards.
Santiago Richter, M.D.
Chairman, Israel Society for Sexual Health
Dr. Hossein Sadeghi-Nejad presented a very challenging case of a 65 years old man who had a radical prostatectomy done for a prostatic carcinoma and was then using caverject for 6 months. He presented with a penile mass on the right side. MRI showed a 1.7x 1.9 x 2.5 cm cystic lesion with peripheral enhancement and a thick peripheral ring of soft tissue; confined to subcutaneous tissue without involvement of the corpora. It was excised, the pathology revealed inflammatory nature of the lesion.
Recurrence of the fluid collection (entire right side of the shaft) occurred after another month, which was drained it in the office twice with 100-150 cc of dark red blood aspirated each time.
Dr. Hossein questioned if this was a reaction to caverject or if it was a hematoma induced by injections which became organized and fibrosed.
Dr. Sudhakar Krishnamurti asked if the walls of the cavity were curetted during the operation. Dr. Hossein answered that he did not curette the cavity because initially, it was a solid mass under the foreskin sitting on the tunica. The "cavity" has now been created because of the recurrent hematomas.
Dr. Santiago Richter suggested that perhaps the patient developed an A-V fistula and asked if a cavernosography was performed. Dr. Hossein commented that before doing the first excisional biopsy he did an ultrasound, but did not see an obvious AV fistula. He added that it is possible that an AV fistula had occurred and caused a local hematoma that later became a fibrotic mass.
Dr. Sudhakar Krishnamurti advised the use of a more rigid tube drain with a light compression dressing on the penile shaft, and maybe antibiotic cover, for about a week. Another suggestion is creating an internal shunt for drainage if it is not solved. Dr. Hussein Ghanem added a new differential diagnosis by suggesting the possibility of the mass being a penile hemangioma in spite of its rare occurrence. He also advised culturing and performing cytology on the aspirated blood and giving an empirical antibiotic course.
Detailed Discussion
Dear ISSM members:
I am very interested in your opinion about this unusual case:
65 y.o. AA male, referred for eval of a penile mass.
Past h/o prostate CA, treated with rad.prostatectomy; subsequently had developed ED, eventually treated successfuly with intracavernosal injections of alprostadil (caverject). 6 months prior to seeing me, the patient describes "an error in injection" and believes the needle was bent during injection. He is absolutely sure the needle did not break.
Over the next few days, he developed an approx 2x2 cm swelling on the right side of the penile shaft. He ignored the swelling and continued to use caverject periodically with good success. Eventually, he became concerned about the persistence of the mass and saw anoother urologist who referred him to me.
PMH notable for HTN and high cholesterol; prostate CA as described.
On exam , he had a firm 2 x 2 to 2x3 mass in the R mid shaft of the penis. Because of the unusual nature of the problem, I decided to get an MRI to better define the mass.
MRI showed a 1.7x 1.9 x 2.5 cm cystic lesion with peripheral enhancement and a thick peripheral rind of soft tissue; confined to subcutaneous tissue without involvement of the corpora (I was personally not 100% convinced of this and thought there may be a small connection between the mass and the right corpus cavernosum). There were no internal septations or mural nodules.
I decided to excise the mass. It was evident intra-op that this was very adherent to the surface of the tunica. The mass felt very firm and fibrotic. After excision, I injected saline through the distal corpus to make sure that there was no "leakage" or connection to this area and did not see any. The final pathology report was : "benign cystic inflammatory nodule, lined by lymphohistiocytes, foreign body type giant cells, and a few scatteredgranulomas without necrosis; no acid fast or fungal organisms present; no polarizable foreing body material present, ...findings most consistent with an inflammatory reaction to the injected material present."
He had a persistent collection of fluid post-operatively that I attributed to poor drainage/possible lymphedema. This did not respond to conservative management. I decided to aspirate the collection and noted dark red blood. The collection recurred despite compressive dressings. Interestingly, there were some residual (? new) fibrotic areas in the area of this recurrent fluid collection and we decided to take him back to the O.R. where we found small amounts of fibrotic tissue and old hematoma fluid. These were drained/removed wiothout difficulty.
The problem is that for the past month, he has again had recurrence of the fluid collection (entire right side of the shaft); I have drained it in the office twice and aspirated 100-150 ccs of dark red blood each time. Despite Coban dressings, he states that the collection reappears within 2-3 days after each aspiration.
QUESTIONS TO YOU:
1. Have you ever seen anything like this?
2. Can the original mass be truly a "reaction" to alprostadil/caverject (? perhaps had not been fully mixed and this is a reaction to the powdered medication???) Or is it morelikely that he had developed a hematoma after the injection and that it later became organized and fibrotic?
3. WHAT TO DO now? The options are continued conservative management with periodic aspiration vs. repeat intra-op evaluation and draiange of venous blood collection. Remember that because of the surgeries and the degloving of the penis to expose the area of the mass, he has a relatively large area along the entire right shaft that stores 100-150ccs of blood under the foreskin.
It seems to me that the problem now is mainly a skin and lymphatic drainage problem that are probably exacerbated by the combination of his RRP history and the excision of the mass and surrounding lymphatics. If we drain this again (and we will, because he gets very uncomfortable from the weight of the old blood under the foreskin), would you recommend placing a small penrose? If yes, for how long? Or making an incision and leaving it open to drainage??? Your ideas are GREATLY appreciated.
Thanks,
Hossein
Hossein Sadeghi-Nejad, M.D., F.A.C.S.
Associate Professor of Urology
UMDNJ New Jersey Medical School
Chief of Urology
NJ Veterans Affairs Hospitals
Director, Center for Male Reproductive Medicine
Hackensack University Medical Center
Dear Hossein:
If it was (is) a fistula, your histopath report would've been different ?
Sudhakar Krishnamurti.
If it would not be for the fact that the ICI is made through a very thin needle, I would think that perhaps your patient developed an A-V fistula Anyway, have you thought of performing Cavernosography?
That's it for now.
Please continue to inform us of your further thoughts. Good luck,
Santiago Richter, M.D.
Chairman, Israel Society of Sexual Medicine
Deputy Head, Dept. of Urology
Head, Sexual Medicine Clinic, Meir Medical Center
Dear Hossein:
Did you curette the walls of the cavity during operation ?
Thanks.
Sudhakar Krishnamurti
Hi Sudhakar.
Thanks for both responses. I did not curette the cavity because initially, this was a solid mass under the foreskin sitting on the tunica. The "cavity" has now been created because of the recurrent hematomas I am leaning more and more toward the idea of leaving a drain behind for a few days. I will wait to hear from a few others. Thanks again.
Hossein
Thanks. This is a great idea. I had thought of it before doing the first excisional biopsy and did an ultrasound, but did not see an obvious AV fistula. I guess it is possible that an AV fistula had occured and caused a local hematoma that later became a fibrotic mass (what was eventually excised when I first saw the pt 6 months after the initial incident). One can then hypothesize that with the "fibrotic mass" gone, the fistula continues to slowly feed the empty cavity, thus causing the recurrent hematomas.
I took him back to the O.R. onThursday and evacuated approx 150 ccs of hematoma and placed a drain (did this through a small upper scrotal incision to avoid a penile incision - plan on leaving the drain for a few days). If this does not definitively correct the problem, revisiting the idea of an AV fistula should be high on the list. Thanks again for your thoughtful suggestion.
Hossein
Hi Hossein
I think I'd use a slightly more rigid tube drain with a light compression dressing on the penile shaft, and maybe antibiotic cover, for about a week, watch what happens, and then review the situation. Maybe, we can create an internal shunt for drainage later if it continues unabated.
Sudhakar Krishnamurti
India
Dear Dr. Sadeghi-Nejad
Penile masses are rare lesions. Although penile hemangiomas are rarely described in the literature, this might be one! I also suggest culturing
and performing cytology on the aspirated blood and a possible course of empirical antibiotic therapy.
Hussein Ghanem
This is a case sent from Dr. Andy McCullough about a patient complaining of autoinflation of an ambicore implanted device , when sitting together with pain (4 months after surgery). This was replaced with a700cx.
Dr Roberto Campos had experienced same complaint with 2 cases. The first in a Peyronie�s disease patient with an implanted ambicore. Autoinflasion regressed 2 months after surgery. The second case, the patient had a big haematoma of the scrotum and perineum during the surgery, which probably caused some degree of fibrosis or compression, with autoinflation. It is also in regression.
Discussion
Dear All,
I recently replaced an ambicore (18 cm with .5cm rear tip) with a 700cx. He measured 19 cm introperatively Patient was complaining bitterly of autoinflation when sitting and pain (4 months out from surgery).
He has no pain when rendered flaccid but was always having to deflate himself.
All intraoperative cultures were negative.
I did a "Mulcahy washout" at the time of replacement and the patient is now pain free and autoinflation free.
He dilated very easily proximally to 14 so that I don't think the proximal corpora was fibrotic.
The folks at AMS "have never seen this". Has anyone out there seen this, autoinflation of ambicore with sitting.
Andy McCullough
NYU Urology, New York
Dear Andy
Recently I' ve changed a malleable rods for a inflatable prosthesis - Ambicor - in a patient with Peyronie Disease.
He also dilated easily until 13 proximally. He measured 19cm and I put him an Ambicor of 18cm x 11mm.
He presented autoinflation during the following two months after surgery, even in the stand position and I atributed it to fibrosis due to Peyronie and to the previous surgery causing difficulty for the reservoir to expands.
But surprisingly, now the autoinflation occurs much less. I think that the continous forced deflation made by the patient expanded the corpora promately diminishing the autoinflation fenomenon.
Wilson has recently published a paper where he mentions the substitution of a small prosthesis into a bigger one in fibrotic corpora, 1 year after a surgery since the corpora has expanded.
In one other case, the patient had a big haematoma of the scrotum and perineum during the surgery, which probably caused some degree of fibrosis or compression, with autoinflation. In this case, the same problem is also in regression.
Roberto Campos
Clinica Vaz - Rio de Janeiro - Brasil
Dr. Eduardo Bertero presented an interesting case of a 42 year old man who had a lifelong penile deformity. It is located on the base, bilateral and has an aneurysm like format. Penile US did not show any nodules or abnormality. The patient does not complain of ED but is very embarrassed in engaging in sexual activity. Dr. Eduardo thought of inserting a patch to cover or compress the aneurysm or to place some stitches on the defect in the tunica.
Dr. Claudio Teloken commented that this case was similar patients with Peyronie�s disease without ED. He added that the patient�s main problem is probably psychological due to inability to accept the deformity. He also recommended dynamic cavernosography and possibly CT angiography. Dr. Hussein Ghanem was also in the favor of performing cavernosography to know if it is intra or extra-cavernosal. He also added that it looked like Mondor�s disease but the lifelong history is against this diagnosis. Dr. Shedeed Ashour also suggested that the retrocoronal swelling can be a herniation from tunica following Mondor�s disease. While the deformity can just be a variant of different congenital penile shapes.
Dr. Laurence A Levine advised tapering the tunica with a placation technique and not to excise any tunica so long there is no hinge effect or rigidity issue. Dr. Carlos Cairoli also commented that it was easier and less complicated to do stitches. However Dr. Geng-Long Hsu and Dr. Eduardo Bertero suggested that tunical herniation/ weakening or ballooning were better wordings, and that lymphatic engorgement was unlikely to present in such a symmetrical fashion, while Dr. Younsoo LEE suggested that if there was no flow flowing PGE1 injection by penile doppler then the diagnosis will be lymphatic engorgement which will need aspiration.
Dr Eduardo presented a case of a spinal cord injured patient who implanted a 3 piece inflatable. One month after surgery one of the cylinders extruded through the urethra. He asked if it was possible to remove that cylinder, cut the tubing and block it, keeping the other side cylinder, as there were no signs of infection
Dr Irv Fishman suggested treating the patient aggressively with culture specific or broad spectrum antibiotics due to the high risk of infection in a neurogenic bladder patient. Dr. Andy McCullough agreed that there is a high chance of infection in such a case.
Dr Santiago Richter had a similar case but not in a spinal cord injury patient. He removed the extruded cylinder only, first cutting and clamping proximally the cylinder tube, then removing the cylinder in an "antegrade" fashion and made sure the patient had no infection. The patient managed well with one cylinder. Dr. Edgardo Becher also had the experience of preserving the system except the extruded cylinder in 2 patients.
Dr Laurence A Levine advised to remove the old device, perform salvage and go back with a single cylinder, after being sure that there is no continuity between the side of the erosion and the contra-lateral side. Another option is to pull everything, leave a catheter for several days and then come back in 4 weeks. Dr. Christopher Love also suggested an early salvage procedure with a single cylinder on the non-eroded side or total removal and replacement as the probability of infection is high. Dr Juza Chen was in favor of removal of the device until the urethra is either healed or repaired based on an unsuccessful case referred to him treated by removing only one cylinder for a normal ED patient.
Detailed Discussion
Dear Colleagues,
I have a urologist who is a friend of mine here in Brazil and called me this morning. He had a patient with spinal cord injury who implanted a 3-piece inflatable a month ago. However, he found out today that there was an extrusion from one cylinder through the urethra.The question: as the patient does not want to remove the whole device and there is not any sign of infection, is it possible to remove that cylinder, cut the tubing and block it, keeping the other side cylinder? Has anyone done that?
Input is welcome.
Regards,,
Dr. Eduardo Bertero
Urologia
Sao Paulo, SP ,Brasil
Dr. Bertero:
I believe that in view of the short interval between implant and extrusion of the cyinder, it is quite plausible that there may have been an injury to the corpora at the time of the implant without a complete perforation of the tunica initially. There is a good chance that in a patient with a neurogenic bladder there may already be some colonization with a "bad bug". Were the cylinders coated with antibiotics ? I have certainly taken single extruded cylinders out and either replaced the remaining cylinder (salvage) or taken a chance and left the original contralateral cylinder in place. I would treat the patient aggressively with culture specific or broad spectrum antibiotics. I would appraise the patient of the risks involved. Good luck .
Irv Fishman
Dear Eduardo,
Unfortunately, this prosthesis should be changed to new one, after healing/repair of the urethra.
I had one case referred to me from other surgeon, who changed only one cylinder due to same reason in "normal" ED patient, and outcome was unsuccessful.
Good luck,
Juza Chen
Dear Eduardo,
About four years ago I had a similar case, although not in a SCI patient. I removed the extruded cylinder only, first cutting and clamping proximately the cylinder tube, then removing the cylinder in an "antegrade" fashion. I cultured all surgery sites and started pre and perioperative Gentamicine, until culture results arrived. Fortunately there was no bacteria growing and the patient did well. This was a 75 years old man and while discussing the reimplantation of the missing cylinder, he said that he was managing very well with one cylinder only.
Good luck,
Santiago
Santiago Richter, M.D.
Chairman, Israel Society of Sexual Medicine
Deputy Head, Dept. of Urology
Head, Sexual Medicine Clinic, Meir Medical Center
By definition this implant is now infected and the chances of "bugs" tracking up along all components is very high in my experience.
I believe it all need to be removed, but an early salvage procedure with a single cylinder on the non-eroded side , as suggested by Dr. Levine, would be well worth trying.
Dr Christopher Love
Urological Surgeon,
Monash Medical Centre,
Melbourne,
Australia
I have not done this in a SCI patient especially with a urethral erosion.
The risk of diffuse infection throughout the device is high. So long as you offer informed consent you could remove the old device perform a salvage and
go back with a single cylinder. Be sure that there is no continuity between the side of the of the erosion and the contralateral side by irrigating distally into each corpus. If there is no leakage from the noneroded side consider the replacement. Another option is to pull everything leave a catheter for several days and then come back in 4 weeks- there will be less scarring but a single cylinder can only be placed so long as there is no continuity.
Larry
Laurence A Levine MD,FACS
Professor of Urology
Rush University
Chicago,Illinois
Eduardo,
If the patient is chronically infected the outlook is grim.
By definition if the implant is in his urethra he is infected. If he is on intermittent cath, it is probably infected with a bad bug.
An extrusion that soon is not a good sign.
Good luck.
Andy McCullough
Eduardo:
Most probably the whole implant is infected. However, I preserved the system except the extruded cylinder in 2 patients. In one case, I replaced the remaining components 3 months later using a salvage procedure and in the other case the patient still has the system working properly with one cylinder and does not want a new one. Of course, the urine needs to be drained with a SP tube. I think that if he doesn't find obvious purulent discharge, he might try a conservative approach. He will also need to contact the representative for a tube plug, which is the same used for sphincters.
Edgardo
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