Surgical Removal of Hard-to-Reach IPP Reservoir: New Technique Discussed
Penile Prosthesis Reservoir Removal: Surgical Description and Patient Outcomes
Jonathan Clavell-Hernández, MD; Samuel G. Aly, MD; Run Wang, MD; Hossein Sadeghi-Nejad, MD
FIRST PUBLISHED: December 12, 2018 – The Journal of Sexual Medicine
When a 3-piece inflatable penile prosthesis becomes infected, all device components are usually removed. If located deep in the pelvis or high in the abdominal wall, the reservoir component can be challenging to remove, especially if the surgeon is trying to remove all pieces with a single incision.
This study describes an approach for the safe removal of a reservoir located either in the space of Retzius or an alternative/ectopic space through the original penoscrotal incision.
Surgeons should obtain a patient’s complete medical history, conduct a thorough physical exam, and read the original operative report, if available. Antibiotics are started one hour before incision and continued up to 24 hours after surgery, unless the patient is on scheduled antibiotics for a known infection.
The procedure is described as follows:
Removal of the device is approached through the original penoscrotal incision at the time of surgical revision. The surgeon should ensure the appropriate materials are at his or her disposal, which in addition to a standard tray should include pediatric deavers and a lighted retractor, if available. After skin incision, dissection is carried through the subcutaneous tissues using Bovie electrocautery. The scrotal pump is first dissected out. Swab culture of the fluid around the pump and any visible biofilm of the IPP are obtained as soon as the capsule surrounding the scrotal pump is incised. The tubings between the pump and the cylinders are then followed to each corpora. Bilateral corporotomies are performed with care to avoid injury to the urethra. Bilateral cylinders are then removed. The tubing connected to the reservoir is then transected, and fluid from the reservoir is aspirated.
Reservoir removal begins by using the surgeon’s fingers on the distal end of the reservoir tubing for gentle traction. Excessive tension should be strictly avoided because it may lead to rupture of the tubing and loss of control of the reservoir tubing path, thereby adding considerably to the operative time and necessitating a more extensive dissection for device retrieval. With a long-tip Bovie, dissection is carried out using electrocautery on a coagulation current along the anterior aspect of the tubing, ensuring that it does not stray away from the tubing and injure surrounding tissues. As the dissection deepens, a lighted retractor is used for more optimal visualization. It is extremely important to continue the dissection along the tubing until the proximal thickened area of tubing is encountered. Otherwise, it can result in damage to the tubing and further challenges as described earlier. A Kelly clamp can then be safely placed on the wider part of tubing to allow for more control, as well as increased traction. It is also critical to aspirate the reservoir using a syringe and the appropriately sized needle to ensure a completely empty reservoir before the final removal steps. Once the wider part of the tubing is secured, dissection continues until the surgeon is able to safely remove the reservoir completely intact without risk of damaging surrounding structures.
It should be remembered that in almost all cases of retropubic reservoir placement, the surgeon will experience dense fibrotic tissue. As such, the dissection will often progress somewhat slowly, and the inability to quickly retrieve the reservoir should not prompt unnecessarily aggressive maneuvers. This notwithstanding, there will be cases when the dissection is too difficult for safe reservoir removal. In these cases, an alternate incision should be performed. With the surgeon’s finger coming from the scrotal incision under the tubing and applying pressure anteriorly toward the abdomen/inguinal area, an incision is made just above the pubic bone, and the tubing is palpated over the emerging finger, thereby allowing regrasping of the tubing from above. This step avoids the need for a large incision and allows the surgeon now to follow the tubing down into the retropubic space directly over the reservoir and remove it under direct vision.
The wound and all surgical spaces including the reservoir space are copiously irrigated with a modified Mulcahy salvage solution washout (25% peroxide/25% povidone-iodine/50% normal saline, 40-mg tobramycin sulfate/80-mg gentamicin sulfate/50,000 units of bacitracin in 500 mL of normal saline solution). If a salvage/replacement procedure is being considered, we advocate placing the reservoir in the contralateral space of Retzius or in an alternate/ectopic space. However, if the reservoir is being removed because of malfunction from the submuscular space and there are no signs of infection, we may consider replacing the reservoir in the same, previously created, submuscular space. Although drain placement is optional, in the setting of infection and obvious purulence, we advocate the use of closed suction drainage.
Postoperative Management and Follow-up
If reservoir removal was due to device malfunction, the patient is kept for observation for 24 hours. The transurethral catheter is removed in the early morning of postoperative day 1. Antibiotic prophylaxis in encouraged perioperatively and for 7 days after the procedure.
If reservoir removal was due to infection, the patient should remain in the hospital until he is stable and exhibits no signs of sepsis. The patient should be reevaluated at the clinic after 2 weeks, with a follow-up appointment 6 weeks later. Sexual intercourse should be avoided until the 6-week follow up has taken place.
Outcomes and Complications
Data was collected for 34 patients who had their inflatable penile prosthesis devices (including the reservoir) removed with the technique described above. Surgeries occurred between January 2013 and May 2018.
The patients’ mean age was 65.6 years. Twenty-three men had their devices removed because of malfunction; eleven did so because of infection. The average time between original implant placement and reservoir removal was 59.4 months.
Eighteen reservoirs were found in the space of Retzius, and 16 were in an alternative/ectopic space. Two of the patients required a counterincision for reservoir removal.
Mean operative time was 96.2 minutes. Removals from the space of Retzius took longer than those from an ectopic space (109.9 minutes and 75.4 minutes, respectively).
There were no immediate or late complications associated with reservoir removal and no reported cases of infection at a mean follow-up point of nine months.
In this study, infected devices took less time to remove than devices that had malfunctioned (88.4 minutes vs. 102.0 minutes). However, men whose devices malfunctioned were more likely to have a replacement device implanted at the time of removal.
Experts are often concerned about the difficulty of removing and exchanging a reservoir found in an ectopic location. The technique described in this study required no counterincision. “It is likely that knowing important pelvic structures are away from the reservoir permitted the surgeon to perform a faster and easier dissection,” the authors wrote.
Surgeons must be prepared to troubleshoot as the need arises. In cases of infection, intraoperative ultrasonography may be used to help identify a reservoir’s location. If revision surgery occurs due to malfunction, the reservoir may be left in situ, as further dissection could damage pelvic structures.
The following limitations were acknowledged:
- The study had a retrospective design.
- Patient satisfaction was not assessed with a validated questionnaire.
- Follow-up appointments after 6 weeks are not typically scheduled, so long-term complications are unknown.
“We hereby present a detailed surgical technique and algorithm that allows for safe dissection and removal of the reservoir completely intact to avoid complications and, if possible, the need for a secondary incision,” the authors wrote.