Management of Disastrous Complications of Penile Implant Surgery.

RATIONALE: Penile Prosthesis Implantation (PPI) is the definitive treatment for Erectile Dysfunction not responsive to conservative management strategies. Furthermore, it is a staple of surgical treatment of severe Peyronie's Disease (PD) and phallic reconstruction. Expert implantologists occasionally face disastrous complications of penile implant surgery which can prove to be very challenging. In this article we present a selected number of case reports which exemplify this kind of situations and discuss management strategies while also commenting on plausible aetiologies. PATIENTS' CONCERNS: The first case describes a PPI performed in end-stage fibrotic corpora after multiple instances of implantation/explant. The second and third cases show two diametrically opposed approaches to the management of glans necrosis after PPI in post-radical cystectomy patients. The fourth case describes the history of a diabetic patient suffering from glandular, corporal and urethral necrosis after a complicated PPI procedure. The fifth case reports the surgical treatment of a case of recurring PD due to severe scarring and shrinking of a vascular Dacron patch applied in a previous operation. DIAGNOSIS: Complication diagnosis in all patient was mainly clinical, intra- and postoperative, with Penile Color Doppler Ultrasonography performed when needed in order to demonstrate penile blood flow. INTERVENTIONS: The patients underwent complex surgical procedures that addressed each specific complication. Complex penile implants with fibrosis-related complications, penile prosthesis explant with and without surgical debridement of necrotic areas, penile prosthesis explant with necrotic penile shaft and urethral amputation with perineostomy, and complex corporoplasty with scar tissue excision and patch application with PPI were performed in the five patients. OUTCOMES: Penile anatomy and erectile function with PPI was achieved in 4 out of 5 patients. 1 of 5 patient is scheduled to undergo a total phallic reconstruction procedure at the time of this writing. LESSONS: Management of disastrous complications of penile implant surgery can be very challenging even in expert hands. In-and-out knowledge of possible PPI and PD complications is required to achieve an acceptable outcome. Bettocchi C, Osmonov D, van Renterghem K, et al. Management of Disastrous Complications of Penile Implant Surgery. J Sex Med 2021;18:1145-1157.

Analysis of the effects of different surgical approaches on corporotomy localization in inflatable penile implant surgery performed by expert implant surgeons.

Inflatable penile prostheses may be a solution for patients with erectile dysfunction. To our knowledge, no data exist regarding the effect of different surgical approaches used during implantation on the site of the corporotomy. The main purpose of this multicentre study was to investigate the influence of different surgical approaches on the corporotomy site.Data were collected from six expert implant surgeons. Surgical notes were searched for the incision site, proximal, distal and total corporal length measurement, total cylinder length, length of rear tip extenders, surgery time, type of implant, and reservoir placement. The association between the proximal/distal corporal length and the recorded covariates was examined using a linear mixed model.A total of 1757 patients who underwent virgin prosthesis implantation were included in the analysis. Analysis of proximal/distal measurements was performed on 1709 patients. The proximal/distal ratio had a mean of 0.8 ± 0.3 in penoscrotal incisions (n = 391), 0.7 ± 0.2 in infrapubic incisions (n = 832) and 0.7 ± 0.2 in subcoronal (n = 486) incisions. We observed no significant differences in proximal/distal measurements between the highest-volume surgeons.We could not draw a firm conclusion about the difference in corporotomy site between different surgical approaches, but we found no significant difference between the highest-volume surgeons using different techniques.

Anatomic considerations of inflatable penile prosthetics: lessons gleaned from surgical body donor workshops.

Surgical implantation of an inflatable penile prosthesis (IPP) remains the gold-standard treatment for severe erectile dysfunction. The ideal surgical technique requires a thorough understanding of the relevant anatomy. This includes anatomic considerations related to, but not limited to, dissection and exposure of penoscrotal fasciae and tissues, corporal configuration, and abdominal structures. Insights obtained from pre-dissected anatomic specimens can obviate urethral injury, nerve damage, corporal perforation, inappropriate sizing, crossover, or implant malposition. We present penile implant-specific anatomic dissections and topographic landmarks identified over the last decade in the course of surgical training programs provided for IPP implantation.

Value of prolonged scrotal drainage after penile prosthesis implantation: a multicenter prospective nonrandomized pilot study.

We aimed to understand the risks and benefits of post-inflatable penile prosthesis (IPP) implantation drainage and optimal duration. Our patients were divided into 3 groups: Group 1 (n = 114) had no drain placed, Group 2 had a drain placed for 24 h (n = 114) and Group 3 had a drain placed for 72 h (n = 117). Postoperative scrotal hematoma and prosthesis infection rates were compared between the groups. The patients from Group 3 demonstrated a statistically significant lower incidence of hematoma on the 10th postoperative day: (n = 1, 0.9%) compared to Group 2: (n = 11, 9.6%) and Group 1: (n = 8, 7%), (p = 0.013). However, on the 3rd postoperative day, there was a statistically significant lower incidence of hematoma in both Groups 3 and 2: (0.9% and 6.1%, respectively) vs. Group 1: (11.4%), (p = 0.004). Hematoma rates followed the same group order after the first day of surgery: 1.7% (n = 2), 5.3% (n = 6), and 8.8% (n = 10), respectively, (p = 0.05). Five patients (4.4%) in Group 1 and four patients (3.5%) in Group 2 developed an IPP associated infection, opposed to only a single patient (0.85%) in Group 3, (p = 0.210). We concluded that prolonged scrotal drainage for 72 h after virgin IPP implantation significantly reduces hematoma and infection rates.

[Quality of life in patients who suffered erectile dysfunction and underwent penile implant surgery in terms of sexual satisfaction of the patient and partner]. / Lebensqualität von Patienten mit hydraulischen penilen Implantaten bei erektiler Dysfunktion in Bezug auf die sexuelle Zufriedenheit des Patienten und seinem/seiner Partner/Partnerin.

BACKGROUND: Erectile dysfunction is a condition that shows a continuously growing prevalence in the male population. The penis prosthesis implant (PPI) qualifies as an effective form of therapy. OBJECTIVES: The aim of this study was to analyze the sexual satisfaction rate and quality of life in patients who had suffered from erectile dysfunction and who were treated with a penile prosthesis. The patient's partners were also surveyed. METHODS: We collected data from patients who underwent surgery in the Center of Excellence for Penile Implants, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany. Questionnaires with validated scores (EDITS, EDITS Partner) were sent to all patients and their partners via mail. RESULTS: The satisfaction rate in this study was high which shows that the patients and partners are pleased, and the high sexual satisfaction rate led to a higher quality of life. CONCLUSION: The penile prosthesis implantation as a last option of therapy for erectile dysfunction is useful and brings more than adequate results.

[Symptomatic testicular metastasis of acinar adenocarcinoma of the prostate]. / Symptomatische Hodenmetastase eines azinären Adenokarzinoms der Prostata.

We report about the rare occurrence of symptomatic testicular metastasis of an acinar adenocarcinoma of the prostate. Testicular metastases are usually incidentally detected in patients treated with bilateral orchiectomy or more often during autopsy. In the literature, there are only a few clinical cases describing symptomatic testicular metastases. However, the possibility of such metastases should be considered in patients diagnosed with advanced prostate cancer. Testicular examination should be performed regularly, even in patients with low prostate-specific antigen levels.

High-submuscular vs. space of Retzius reservoir placement during implantation of inflatable penile implants.

We have evaluated the data of patients who underwent ectopic high submuscular reservoir placement during implantation of inflatable penile prostheses and compared them to those of patients who underwent to traditional reservoir placement in the space of Retzius (SR). The main focus was on evaluating complications and patient satisfaction rates in both methods of RP. One hundred and forty-two patients underwent implantation of the Coloplast Titan OTR prosthesis with exclusive use of the "Clover Leaf" reservoir. We performed a retrospective evaluation, analyzing the treatment-associated complications by means of the Clavien-Dindo classification. All patients as well as their partners received questionnaires with validated scores. Group I: 70 (49.3%) patients who underwent HSM RP. Group II: 72 (50.7%) patients who underwent SR RP. Neither grade IV nor grade V Clavien-Dindo complications were documented. In total, we observed 4 (3.3%) cases grade III b complications, which resulted in revision. Distribution was as follows: infected device (n = 4), scrotal hematoma (n = 2), scrotal seroma (n = 1), and scrotal skin fistula (n = 1). 88% of the patients with ectopic HSM RP and 81% with traditional SR RP were satisfied with their implant. Of the patients with HSM RP, 64.3% (n = 45; BMI range: 18.5-28.8) reported that they were able to feel their reservoir by palpation immediately after surgery. Palpability disappeared in 80% of the patients in this group (BMI > 26.5) after capsule formation at 3 months post-surgery. Only one patient (1.4%; BMI 20.5) reported that he was able to see the reservoir. Our findings suggest that the novel reservoir placement is safe, efficient and results in excellent patient satisfaction, even if the reservoir is initially palpable or visible.

[Multicenter comparison of complications after robot-assisted and open simple prostatectomy]. / Multizentrischer Vergleich von Komplikationen nach roboterassistierter und offen chirurgischer Prostataadenomenukleation.

INTRODUCTION: Robot-assisted simple prostatectomy (RASP) is a relatively new minimally invasive procedure for surgical treatment to manage symptomatic, therapy-refractory benign prostate hyperplasia (BPH) in prostate volumes >80 cm3. Thus, postoperative morbidity based on Clavien-Dindo and hematological parameters in RASP and open simple prostatectomy (OSP) procedures are examined. PATIENTS AND METHODS: We retrospectively reviewed a total of 78 patients: 39 patients underwent RAPS and 39 OSP. The following parameters were statistically evaluated and compared: age, PSA value, prostate volume, ASA score, duration of hospital stay, operative time, Hb decrease on postoperative (po) day 1 and in the 5 five po days, CRP peak in the first 5 po days and transfusion rate. RESULTS: The comparison between RASP and standard OSP showed no significant differences regarding the mean patient age (73 vs. 74 years; p =0.54), PSA values (7.7 vs. 10.7 ng/ml; p =0.17), ASA score (2.2 vs. 2.3; p =0.26) and prostate volume (130 vs. 113 cm3; p =0.07). Patients in the RAPAE group had statistically significant longer surgery (178 vs. 110 min; p =<0.01) with a significantly smaller decrease in Hb on po day 1 (1.9 vs. 3.3 g/dl; p ≤0.01) and in the first 5 po days (2.4 vs. 4.2 g/dl; p ≤0.01), lower need for preserved blood (3% vs. 26%; p =0.01) and number of blood bags (0.1 vs. 1.3; p =0.01), a lower po Clavien-Dindo score (0.44 vs. 1.23; p =0.003) and lower CRP values (52 vs. 104 mg/l; p ≤0.01) in the first 5 po days. CONCLUSION: RASP is a safe procedure that offers the advantage of reduced blood loss and blood bag consumption and rare complications due to the minimally invasive surgical method. The OSP group showed an increased occurrence of complications due to bleeding, leading to prolonged hospitalization and significantly increased need for blood transfusion. The lesser increase of CRP in RASP group is a result of the lower invasiveness of the robot-assisted procedure.

[Mixed epithelial and stromal tumour of the kidney: a case report]. / Gemischt epithelial-stromaler Tumor der Niere ­ Ein Fallbericht.

Mixed epithelial and stromal tumours of the kidney are rare. Histologically, they are characterised by a complex of epithelium and stroma with cystic and solid areas. They usually occur in perimenopausal women receiving hormone replacement with oestrogen. Typical symptoms are haematuria, flank pain and a palpable mass, with more and more authors reporting incidentally diagnosed tumours. This also applies to our case report. We are reporting the first published case in Germany: a 60-year-old female with a mixed epithelial and stromal tumour of the right kidney. The tumour was removed through complete nephrectomy.

[Sarcomatoid renal cell carcinoma. A rare and aggressive variation of primary renal cell carcinoma]. / Das sarkomatoide Nierenzellkarzinom. Eine seltene und aggressive Variante des primären Nierenzellkarzinoms.

Every year, renal cell carcinoma (RCC) is responsible for the highest proportion of cancer-associated deaths in relation to all other malignant urological diseases. Initially called carcinosarcoma, the sarcomatoid differentiation confers higher aggressiveness on any of the different subtypes of RCC, with a frequency of ca. 1%. The presence of a sarcomatoid component makes the disease locally aggressive, which typically presents an advanced grade that is associated with fast progression and fatal outcome in a vast proportion of cases, with median survival lower than 1 year. This is important for predicting the outcome for patients undergoing nephrectomy due to RCC, since chemotherapy in a certain group of patients with progressive disease can be a reasonable alternative to the failure of immunotherapy in sarcomatoid renal carcinoma. We report our experience with sarcomatoid RCC in four patients with extensive tumor progression in comparison to the literature.

[Mesonephroid carcinoma of the urinary bladder (clear cell carcinoma). Two case reports and review of the literature in a rare variation of the primary adenocarcinoma]. / Das mesonephroide Karzinom der Harnblase (Klarzellkarzinom). Zwei Kasuistiken und Literaturübersicht über eine seltene Variante des primären Adenokarzinoms.

Mesonephroid adenocarcinoma of the bladder may be a malignant form of nephrogenic adenoma or nephroid metaplasia. The lesion is extremely rare in the urinary bladder, and to our knowledge 19 cases have been reported in the literature. We report two cases of mesonephroid adenocarcinoma of the bladder which were treated by radical cystectomy.

[Induction of spermatogenesis in patients with non-obstructive azoospermia after antegrade sclerotherapy]. / Induktion der Spermiogenese nach antegrader Varikozelensklerosierung bei Patienten mit nicht-obstruktiver Azoospermie.

PURPOSE: The aim of this study was to prove the efficacy of antegrade sclerotherapy for varicocele testis in patients with azoospermia and in patients with cryptozoospermia (less than 0.1 million spermatozoons/mL ejaculate). We have investigated the induction of spermatogenesis in patients with non-obstructive azoospermia after antegrade sclerotherapy. MATERIALS AND METHODS: 20 consecutive patients who had been trying to beget a child over a period of one year or longer were chosen for this study. All patients suffered from non-obstructive azoospermia or from cryptozoospermia. We produced a control spermiogram for each patient before, 3 and 6 months after antegrade sclerotherapy. The postoperative spermiogram was done according to WHO criteria and was then compared to the preoperative data. RESULTS: 15 patients (75 %) were found to suffer from azoospermia preoperatively and 5 patients (25 %) from cryptozoospermia. Out of the 15 patients with initial azoospermia 8 (53 %) showed cryptozoospermia (OAT/OT syndrome) after antegrade sclerotherapy. Out of the 5 patients with the initial cryptozoospermia 3 (60 %) showed an improvement in the sperm count and motility criteria. CONCLUSIONS: Antegrade sclerotherapy for varicocele testis is a valid treatment option to isolate the spermatozoons from the ejaculate for extracorporeal fertilisation in patients with non-obstructive azoospermia. Complete normalisation of the spermiogram parameters, i.e., sufficient for natural child conception, cannot safely be achieved by this method.

[Significance and Importance of Pelvic Lymphadenectomy in Low-Risk Prostate Cancer Patients]. / Bedeutung und Notwendigkeit der pelvinen Lymphadenektomie bei Low-Risk Prostatakarzinompatienten.

BACKGROUND: The most frequent carcinoma in male patients is prostate cancer. D'Amico and colleagues (1998) set up a classification to assess the aggressiveness of prostate cancer growth and the risk of metastatic spread, taking into account the following parameters: PSA, Gleason Score (GS), and tumour spread (T). The combination of these parameters results in a classification of low-, intermediate- and high-risk patients.In the context of a larger heuristic study entitled "Low-Risk Prostate Cancer Patients: Significance And Importance Of Pelvic Lymphadenectomy in Localized Prostate Carcinomas", we observed the correlation of the parameters PSA, GS and T stage with the occurrence of lymph node metastases in low-risk-patients who underwent lymphadenectomy during radical prostatectomy. PATIENTS/MATERIALS AND METHODS: Due to a lack of evidence - none of the confirmed LR (low-risk=LR) patients was diagnosed with metastases - we set up a subclassification for LR patients for the following corridor transition zone between low-risk and high-risk patients (based on the D'Amico classification):PSA≤10 ng/ml and GS≤7a (c: 7a) and clinical stage T1a-T2c (c: T2b, T2c): The population consists of 288 prostate cancer patients (60 low-risk (LR) patients, 228 corridor (c) patients). We analysed the number and frequency of removed lymph nodes and lymph node metastases. Moreover, we analysed the population with a view to a postoperative GS upgrade. The results are based on heuristic methods. RESULTS: The situation regarding the data in the transition zone, i. e. in the corridor area, and in the verified low-risk range is very complicated:In total, 3 743 lymph nodes were removed in 288 patients (mean: 13 lymph nodes). Of these only 7 lymph nodes in 5 patients from the corridor group were metastatic. The overall number of removed lymph nodes in these 5 patients lies within a small interval [23,32]; 26 lymph nodes were removed on average. A postoperative Gleason Score upgrade was found in 20.14% of the whole patient population. CONCLUSION: A postoperative Gleason Score upgrade in every fifth patient shows a highly relevant preoperative undergrading in these patients, which may lead to inadequate treatment. An opening of the D'Amico classification to include a corridor category of patients could be an opportunity to minimise preoperative undergrading. In this context, pelvic lymphadenectomy must be considered, at least for corridor patients.

[Mucinous adenocarcinoma of the Urachus: A Case Report]. / Muzinöses Adenokarzinom des Urachus--Ein Fallbericht.

Urachal carcinoma is a rare form of cancer. It often is diagnosed incidentally, like in our case report, because its cardinal symptom also occurs in a number of other urological diseases. We report the case of a 26-year-old man with a mucinous adenocarcinoma of the urachus. The carcinoma was removed via partial cystectomy with umbilical tumour excision.

[Salvage lymphadenectomy in patients with prostate cancer recurrence: A review]. / Salvagelymphadenektomie beim Rezidiv eines Prostatakarzinoms : Eine Übersicht.

BACKGROUND: Salvage extended pelvic lymph node dissection (salvage ePLND) in patients with prostate cancer (PCa) biochemical recurrence is an alternative to the commonly used androgen deprivation therapy (ADT) and/or chemotherapy. Small patient number, insufficient accuracy of contemporary imaging methods for lymph node relapse diagnostics, and the lack of prospective data present limiting factors for a wider application of salvage ePLND. The purpose of this publication is to review German and European data and studies on the subject of salvage ePLND and to discuss future perspectives. MATERIALS AND METHODS: We analyzed available studies up to October 2014 from Medline with the keywords "salvage lymph node dissection prostate cancer". RESULTS: A total of 51 publications since 1984 (up to October 2014) meeting the search criteria were found. Ten of these were studies that analyzed the results of salvage ePLND. Of these 10 studies, 6 originated from German clinics. Furthermore, among these 51 publications, there were 2 clinical case reports (1 from Germany) and 3 reviews (none from Germany). CONCLUSIONS: The available data show insufficient evidence-based validity. There have been no prospective studies and just one multicenter study. However, single-center retrospective studies have shown promising results. Salvage ePLND leads to biochemical remission, freedom from clinical recurrence, and probably also to renewed response to ADT in patients with castration-resistant PCa. Multicenter prospective studies should be conducted in Germany (where most of the available studies have been performed). The selection of patients should be analyzed in order to identify clear selection criteria for salvage ePLND.

[A serious complication after bladder embolisation due to massive tissue necrosis in the gluteal region]. / Eine schwerwiegende Komplikation in Form massiver Gewebenekrosen in der glutealen Region nach Embolisation der Harnblase.

Adequate and successful treatment of Hb-relevant macrohaematuria in bladder cancer patients is a frequent problem in clinical routine. It is often not easy to identify a good treatment option for inoperable older patients. A possible option is transcatheter-based arterial embolisation of the vesical artery. Unfortunately there are only few publications about this procedure; a detailed analysis of bladder embolisation is difficult to find in the literature. Our report illustrates the embolisation of the vesical artery in an 84-year-old patient with bladder cancer with an Hb-relevant, transurethral non-curable macrohaematuria. Massive necrosis of the M. gluteus maximus developed after embolisation of the vesical artery. During the ensuing surgery, the entire musculature of the gluteal region was removed, and the N. ischiadicus was cut. The patient was supervised first in the intensive care and then in the palliative care ward. The patient's prognosis is unfavourable due to the localisation and size of the wound and consecutive life-long immobility. Embolisation of the vesical artery is a viable procedure, but only if alternative therapeutic strategies are impossible. It should only be performed by an experienced radiologist and it is strongly recommended not to apply liquid embolisation agents. Inadequate embolisation of the vesical artery can lead to extensive necrosis. Radiological diagnostics help to identify the margins of the necrotic region. During the intervention, maximum attention should be paid to saving the entirety of N. ischiadicus, especially in patients with large necrotic areas.