Complex reimplantation of an inflatable penile prosthesis with scar tissue excision and distal corporal defect repair with Tutoplast^® pericardium allograft

Abstract

Background: Patients with inflatable penile prostheses (IPP) may experience erosions after years of use or after indwelling Foley catheter placement. IPP erosions should be managed as an infection with the entire IPP removed. Replacing IPPs in erosion patients can be challenging due to extensive scarring development. Using proper graft materials may be necessary to close and reinforce the corporal defect after difficult corporal dilation or significant scar removal for the long-term success of IPP reimplantation.

Case Presentation: Herein we report a patient with a history of IPP placement in 2007 for erectile dysfunction and Peyronie's disease, presenting in 2018 with dysuria and a feeling of IPP displacement following Foley catheter placement for coronary artery bypass graft surgery. The left cylinder of the IPP was observed by physical examination and a defect near the fossa navicularis was discovered during office cystoscopy. A complete explantation of IPP was then performed. Reimplantation of the IPP was performed in 2021 which required excision of corporal scar tissue and repair of a left distal corporal defect using a Tutoplast^® pericardium allograft. The procedure was successful with proper IPP position and good function without any penile deformity.

Conclusion: The use of graft materials in the management of corporeal defects should be considered in the setting of complex IPP revision. The Tutoplast^® pericardium allograft reinforcement can provide long-term durability, flexibility, and a lower risk of infection.

Graphical abstract

Keywords

corporal erosion / distal corporal perforation / inflatable penile prosthesis / Peyronie's disease / Tutoplast^® pericardium allograft

1 INTRODUCTION

Inflatable penile prosthesis (IPP) implantation is considered the gold standard treatment for patients with refractory erectile dysfunction (ED), unresponsive to phosphodiesterase-5 (PDE5) inhibitors, penile injections, intraurethral suppositories, and vacuum erection devices (VEDs)[1]. While many patients report satisfaction with their IPPs, complications may arise over time, often necessitating revision or explantation procedures. Complications associated with IPPs include infection, bleeding, and device malfunction, with corporal perforations and erosions being less common but more severe complications[2]. Risk factors for delayed distal corporal perforations include diabetes, prolonged pressure on the tunica albuginea, and conditions that lead to decreased peripheral sensitivity. Moreover, Foley catheter placement has been associated with distal perforations in IPP patients. Identifying these risk factors for corporal perforations is crucial in the management of patients with IPPs, and proper repair of these defects during reimplantation surgery is essential for long-term success.

Repair materials for fibrosis, defects, and other tunica albuginea injuries must be carefully selected. The chosen grafting material should have low rates of postoperative infection. It must also possess sufficient durability to withstand pressure and erosion from prosthetic devices within the corpora. Additionally, the material should be flexible and elastic enough to allow for proper erection. Lastly, it should be readily available and cost-effective. Previous cases of tunica albuginea repair have utilized synthetic materials, autologous grafts, cadaveric allograft materials, and Tutoplast® pericardium allograft. Here, we present a case involving the use of Tutoplast^® pericardium allograft for the repair of a corporeal defect during a complex reimplantation with scar excision.

2 CASE PRESENTATION

Our patient is a 64-year-old man with a past medical history of coronary artery disease, type-2 diabetes mellitus, and hypertension initially presenting in 2007 for IPP placement indicated for ED and Peyronie's disease. At that time, the patient had an uncomplicated implantation surgery and recovery. In 2018, the patient presented with dysuria and felt as if his IPP was out of place after a coronary artery bypass graft following Foley catheter placement. The left cylinder tip of the IPP was observed by physical examination at the urethral meatus. Office cystoscopy revealed a defect near the fossa navicularis with the left cylinder eroded into the urethra. The proximal urethra was intact. An explantation of the patient's IPP with all components was subsequently performed using a modified Mulcahy antibiotic washout. The patient was instructed to begin using a VED a month after the incision was healed.

Unfortunately, there was a delay in the patient's return for reimplantation. This was in part due to the COVID pandemic paired with other personal medical events. By the time the patient presented for reimplantation, it was 2021, approximately 3 years after explantation.

Once the patient was again cleared, the reimplantation was performed in the same year. After prepping the surgical area in the usual sterile fashion, a vertical incision was made at the penoscrotal junction. The dissection of dartos was performed to expose bilateral corpora. Bilateral corporotomies were then made. However, dilation of corpora was extremely difficult due to severe scar tissue bilaterally. The Carrion–Rossello cavernotome was used to remove scar tissues. The right corpora were eventually dilated to 11mm in diameter. However, the left corpora dilation resulted in a distal corporeal perforation due to severe fibrosis and scar in the entire distal corpora. A separate incision was then made at the left distal penile shaft to expose the left distal corpora. The scar tissue was excised and the corporeal dilation was performed under the direct vision. The dilation was tunneled more medium and eventually, the entire left corpora were dilated to 11mm in diameter. The corporal lengths were measured as 18 cm bilaterally. The AMS CXR IPP with cylinders of 16 + 2 cm rear tip extenders was selected. After placement of the IPP device, the left distal tunica albuginea was weak and thin over the cylinder. A Tutoplast^® pericardium graft (6 cm × 3 cm) was used to cover and enforce the weak and thin tunica albuginea (Figures 1–3). The incision was then closed. The penile implant was partially inflated, dressings were applied, and a protective collar was used to protect the erected penis.

There were no postoperative complications, and the patient was discharged. At the 6-week postoperative visit, the patient had no complaints. On physical examination, the device was in a good position and cycled appropriately. The patient was noted to have a 10° leftward curvature with no dorsal or ventral deviation. The patient was instructed to use the device. The patient was followed for 1 year. There is no penile deformity and IPP is functioning well. The patient remains satisfied with a sexual health inventory for men (SHIM) score of 25.

3 DISCUSSION

Penile prosthesis can provide high patient and partner satisfaction for severe ED. However, complications do occur with this therapy. One common complication of long-standing IPP placement, particularly in patients using Foley catheters, is the erosion of the IPP cylinder into the distal urethra[3]. The eroded IPP needs to be removed and the reimplantation is required at a later date. However, IPP reimplantation is a complex procedure, especially when dealing with corporal scarring, perforations, or severe fibrosis. Various materials have been employed to address corporeal weakening or defects during complex IPP reimplantation. We like to use a human cadaver pericardium (Tutoplast®) graft to enforce or repair tunica albuginea when a graft is needed.

To reduce postoperative complications when dealing with tunica albuginea defects or weakening, it is crucial to select suitable materials for corporal repair. While synthetic materials have been extensively used in IPP-related procedures and repairs[4], they can often lead to complications such as increased infection rates and fibrosis. Autologous grafting options like dermis and tunica vaginalis have been employed for corporal defect repair, showing lower infection rates compared to synthetic alternatives, but requiring longer and more complex procedures for harvesting the material. Cadaveric allograft materials such as skin and dura mater have also been described[4,5]. In some cases, a plication of excess tunica albuginea or pseudo capsule can be used to reinforce the repair[6]. The use of the pseudo capsule, if reliable tissue, can be a simple and effective technique. However, due to the thin and weak tissue of the left distal tunica and pseudo capsule, a durable pericardium allograft was thought to be more reliable. The application of Tutoplast^® pericardium allograft, as described in our case, represents an easy and effective option.

Tutoplast^® pericardium graft has been previously utilized in various urological procedures. The Tutoplast® process involves the purification and sterilization of human tissue to create a safe and durable grafting material[7]. Compared to other processing techniques like freeze-drying, the Tutoplast^® process provides increased strength and stiffness[8]. In the management of urological conditions, the flexibility and durability of this material make it an excellent choice for repairing the tunica albuginea, considering the physiological changes associated with erections and the required durability in the context of an IPP. Furthermore, the Tutoplast^® process ensures a sterile graft, reducing the risk of infection. In cases where tunica albuginea repair is needed in patients with complex IPP reimplantations, Tutoplast^® pericardium allograft could offer the necessary qualities for a successful graft material.

4 CONCLUSION

The use of graft materials in the management of corporeal defects should be considered in the setting of complex IPP revision. The Tutoplast^® pericardium allograft reinforcement can provide long-term durability, flexibility, and a lower risk of infection.

References

[1] Trost L, Wanzek P, Bailey G. A practical overview of considerations for penile prosthesis placement. Nat Rev Urol. 2016; 13(1): 33-46.

[2] Muneer A, Fowler S, Ralph DJ, Summerton DJ, Rees RW. UK practice for penile prosthesis surgery: baseline analysis of the British Association of Urological Surgeons (BAUS) Penile Prosthesis Audit. BJU Int. 2021; 127(3): 326-31.

[3] Panuganti S, Dhanji S, Wang R. Erosion of inflatable penile prosthesis with prolonged Foley catheterization in the COVID-19 era. Sex Med. 2021; 9(3): 100371.

[4] Chung E. Penile reconstructive surgery in Peyronie disease: challenges in restoring normal penis size, shape, and function. World J Men's Health. 2020; 38(1): 1-8.

[5] Chung E, Bettocchi C, Egydio P, Love C, Osmonov D, Park S, et al. The International Penile Prosthesis Implant Consensus Forum: clinical recommendations and surgical principles on the inflatable 3-piece penile prosthesis implant. Nat Rev Urol. 2022; 19(9): 534-46.

[6] Swerdloff D, Mahon J, Welliver C. Corporoplasty using pseudo-capsule for repair of penile implant erosion: case report. J Vis Surg. 2021; 7: 2-4.

[7] Schoepf C. The Tutoplast^® process: a review of efficacy. Zimmer Dental. 2008; 17: 40-50.

[8] Hosseini J, Hosseini S, Hosseini MA, Rezaei Y. Pericardium in reconstructive urologic surgeries: a systematic review and meta-analysis. Urol Int. 2019; 102(2): 131-44.

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2023 The Authors. UroPrecision published by John Wiley & Sons Australia, Ltd on behalf of Higher Education Press.