1 INTRODUCTION
Radical cystectomy (RC) is the gold standard treatment for nonmetastatic muscle‐invasive or high‐grade/intravesical therapy refractory bladder cancer[
1]. The rate of urethral recurrence after RC is about 4%[
2] and in such conditions, patients need further urethrectomy procedures to control the disease. It was found that the rate of erectile dysfunction (ED) following RC is high, reaching up to 89% compared with 32% in men with the same age group[
3]. Many post‐RC patients with refractory ED would ultimately require placement of an inflatable penile prosthesis (IPP), which is considered as an excellent definitive treatment option. The tunica albuginea of the corpus cavernosa measures on average 2 mm when flaccid and thins to 0.25 mm when erect[
4]. It is known that the thinnest aspect of the tunica albuginea is along its ventral aspect. In fact, penile fractures most commonly involve tears on the ventral penile shaft at this thinnest and weakest region[
5].
The urethrectomy procedure involves the surgical excision of the entire urethra and may involve part of the ventral tunica albuginea, which results in further thinning of this layer.
For post‐RC patients who underwent IPP placement, the urethrectomy procedure possesses a risk for ventral corporal weakening and might theoretically affect the long‐term functionality of the device, especially due to the resulted increased risk of cylinders aneurysm[
6], which is one of the known mechanical complications reported by long‐term data[
7]. The literature currently does not have sufficient studies investigating the long‐term functionality of IPP device following a urethrectomy. The aim of this case report is to bridge this literature gap by presenting a unique surgical technique used for corporal reinforcement in the setting of a urethrectomy procedure with an in situ IPP.
2 CLINICAL PRESENTATION
A 74‐year‐old male patient who had undergone the robotic‐assisted RC and ileal conduit for Bacillus Calmette‐Guerin‐refractory Carcinoma In‐Situ of bladder in 2015, which was followed by the placement of an IPP for refractory ED in 2017. Patient was doing well until 2023 when he started to complain of recurrent bleeding from the meatus. The magnetic resonance imaging of the penis was obtained and showed two masses measuring 1.7 cm × 2.2 cm × 7 cm and 1.3 cm × 1.3 cm × 3.4 cm on the posterior penile urethra and anterior bulbar urethra, respectively (Figure 1). Further staging imaging with computed tomography chest and abdomen did not show any metastatic disease. A debris from urethral meatus was observed on physical examination and sent for pathological analysis. The results showed necrotic fibro purulent tissue. The penile prosthesis was fully functional with normal inflation and deflation.
The case was discussed in a multidisciplinary team meeting, and the plan was for a total urethrectomy due to suspected urethral recurrence of urothelial carcinoma.
Intraoperatively, significant thinning of the ventral tunica albuginea was noted after excision of the corpus spongiosum and urethra. The decision was then made to repair and reinforce the thin tunica albuginea to prevent the risk of tunica and device aneurysm or mechanical failure. The thin tunica albuginea was covered with Tutoplast graft (a human‐derived pericardium allograft). Two graft pieces were used and sutured to the lateral, superior, and inferior aspects of both corpora, covering a total area of 3 cm × 10 cm (Figures 2 and 3). To ensure IPP cylinders integrity during graft suture, we inflated them to minimize kinks and we used a pick‐up instrument to catch and raise the corpora for safe needle passage.
Final pathology of the urethra showed high‐grade papillary urothelial carcinoma with invasion of the corpus spongiosum, negative margins.
At the 6‐week follow‐up visit, the patient was recovering well. Cycling of the IPP was done smoothly and the patient was given permission to start using the device. Patient was seen again at 6 months, he was using the implant without issues and the examination showed good functionality of the implant (Figure 4).
3 DISCUSSION
ED is one of the major negative consequences following RC, with a significant negative impact on a patient's well‐being. For cases refractory to medical therapies, including failing phosphodiesterase 5 inhibitors oral medications and intracorporal injections, IPP placement is considered a good option for definitive management. Following RC, the urethra becomes a potential site for cancer recurrence[
8]. In such cases, a urethrectomy may be necessary to control the disease.
As the tunica albuginea is the thinnest along its ventral aspect[
5], urethrectomy procedure would further weaken this area. This is particularly important in patients who have existing IPP, as urethrectomy may theoretically lead to an increased risk of corporal disruption and device cylinder aneurysm due to the thinned tunica.
This case report outlines a unique simple surgical technique not previously described in the current literature involving Tutoplast, a human‐derived pericardium allograft, to support the ventral aspect of corporal bodies, thus protecting the in situ IPP cylinders. The graft creates a tissue reaction resulting in fibrous tissue formation that constitutes a protective extra layer[
9]. Tutoplast has been previously described for use in transgender neophallus IPP placement[
10] and Peyronie's disease[
11], but no current studies outline its use in the prevention of IPP device malfunction in the setting of urethrectomy.
During the urethrectomy, there was a significant thinning in the ventral aspect of the tunica albuginea that was then supported and reinforced with Tutoplast graft. Even if no visible defect was seen, it may be advantageous to cover the ventral tunica with Tutoplast as a preemptive measure to prevent the development of cylinder aneurysm. Incorporating Tutoplast to the ventral tunica was not technically challenging to perform, able to be completed at the same time of the urethrectomy, and only added about 25–30 min of operative time.
Because this case report is the first of its kind to describe the use of Tutoplast at the time of urethrectomy to prevent corporal and IPP cylinder aneurysm, there are no other studies available to outline possible long‐term outcomes of such a procedure. A possible risk of such a procedure is IPP cylinder damage when suturing Tutoplast into the ventral tunica, but this was not observed in this case report. Because of short‐term follow‐up (6 months), data on the long‐term outcomes are not yet available. Further studies on larger patient population with long‐term follow‐up are needed to investigate the use of grafts during the urethrectomy procedure with an IPP in place to prevent the risk of corporal disruption and corporal and IPP cylinder aneurysms.
4 CONCLUSION
Corporal reinforcement using Tutoplast graft at the time of urethrectomy in patients with an IPP in place is a simple and cost‐effective technique that protects the corporal bodies and IPP cylinders, and reduces the risk of corporal disruption and device malfunction due to cylinders aneurysm.
Further studies are needed to investigate the long‐term outcomes of such a procedure.
2024 The Authors. UroPrecision published by John Wiley & Sons Australia, Ltd on behalf of Higher Education Press.
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