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Intraoperative management algorithm for urethral injury at the time of PP placement

Shah, B1; Loeb, A1; Beilan, J1; Baumgarten, A1Slongo, J1; Parker, J1; Carrion, R1

1: University of South Florida, United States

Objective(s): Urethral Injury (UI) is an uncommon complication of penile prosthesis (PP) surgery, with reported rates of 0.1-3%. Historically, the dogma has been in the setting of UI, prosthetic surgery is to be aborted and all implant material is to be removed to avoid the increased risk of prosthesis infection. A salvage procedure is planned for after a healing period of several weeks, which inevitably leads to corporal fibrosis, penile shortening, and a difficult salvage operation. Recent case reports have endorsed primary urethral repair with immediate PP placement in order to prevent these complications. We present our series and provide an algorithm for the management of UI in the setting of a PP.

Method(s): Placement of a PP is performed at three sites at our institution. We performed a retrospective analysis of the 871 PP procedures performed at a single site between 10/2011 and 04/17. Nine iatrogenic UIs (1.03%) were identified during that period. Among those, 7 patients underwent primary urethral repair and in the remaining two, the UI was left to heal by secondary intention. Preoperative demographics, intra-op characteristics, and post-op outcomes were evaluated.

Result(s): Among the 9 patients with an identified UI at the time of their PP procedure, 5 underwent primary urethral repair with bilateral cylinders placed (semirigid:1, inflatable:4) and 4 had a solitary contralateral cylinder placed (semirigid:2 and inflatable:2). Intraoperative decision making was based on our proposed treatment algorithm (Figure 1). Confirmation of a watertight closure at the time of primary urethral repair was performed by a combination of either methylene blue retrograde urethrogram, cystourethroscopy, and/or fluoroscopic retrograde urethrogram. Median follow up time was 253 days (56-709 days) from the time of surgery. There were no signs of post-operative infection at most recent follow up. Of the four patients who had a solitary contralateral cylinder placed, two opted to undergo subsequent revision surgery for attempted placement of a second cylinder.

Conclusion(s): Placement of PP with bilateral cylinders can be performed safely in the setting of a UI if a watertight closure is achievable during primary urethral repair. We present the largest known series of urethral injuries during PP surgery and our algorithm for the management of such cases.

Figure 1: Intraoperative management algorithm for urethral injury at the time of PP placement. *Foley catheter placed for 3-4 weeks. ¥Suprapubic tube or Foley catheter placed for 3-4 weeks. Foley catheter placed for 1 week. Decision between IPP or SRPP was based on preoperative counselling and patient’s wishes prior to surgery.

Disclosure:

Work supported by industry: no. The presenter or any of the authors act as a consultant, employee (part time or full time) or shareholder of an industry.

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