International Journal of Impotence Research (2006) 18, 316–317 & 2006 Nature Publishing Group All rights reserved 0955-9930/06 $30.00
www.nature.com/ijir
CASE REPORT
Compression of ureter caused by a retained reservoir of penile prosthesis B-P Jiann, C-W Ou, J-T Lin and J-K Huang Department of Surgery, Division of Urology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Taiwan
Routine removal of the reservoir in explanting a malfunctioning three-piece penile implant raises debates because that the retained reservoir has little risk of erosion and it often needs a second incision to remove the reservoir. We reported a case whose retained reservoir resulted in nonbacterial inflammation around it and caused an ipsilateral hydronephrosis. International Journal of Impotence Research (2006) 18, 316–317. doi:10.1038/sj.ijir.3901402; published online 6 October 2005 Keywords: penile prosthesis; reservoir; hydronephrosis; complication
Brief history A 70-year-old male presented with left flank pain for several weeks. Physical examination showed knocking tenderness on the left costovertebral angle. Laboratory tests including blood routine, urine analysis and serum biochemistry tests did not show abnormality, except that c-reactive protein in the serum was elevated to 10.6 mg/dl (normal value o1.0 mg/dl). An abdominal computed tomography demonstrated the presence of a retained reservoir of penile prosthesis in the retropubic space, in which there was some fluid and around which there was some inflammatory change that compressed left lower ureter with moderate degree hydronephrosis (Figure 1). Retrograde pyelography disclosed the dilatation in upper urinary tract due to an external compression over lower ureter (Figure 2). He received three-piece penile prosthesis (American Medical System, AMS, 700 CXM) implantation for the treatment of erectile dysfunction at our hospital 11 years ago. The reservoir was positioned on the left side of retropubic space through a separate incision on low abdomen. On account of mechanical failure, the inflatable device was replaced by semirigid prosthesis while the reservoir
Correspondence: Dr B-P Jiann, Department of Surgery, Division of Urology, Kaohsiung Veterans General Hospital, 386 Ta-chung 1st Road, Kaohsiung, Taiwan 813, Taiwan. E-mail:
[email protected] Received 8 August 2005; revised 23 August 2005; accepted 23 August 2005; published online 6 October 2005
was left in situ 4 years ago. Except these procedures, he denied having any pelvic surgery. Management started from retrograde placement of a JJ-catheter into left collecting system through cystoscope for drainage of urine. Surgical approach through the old abdominal incision was made to remove the retained reservoir that was found to contain 10 cm3 turbid fluid inside. A pseudocapsule with a thin wall formation around the reservoir and fibrosis change of surrounding adipose tissue was noted. Bacterial culture of the contained fluid yielded no growth. His symptoms resolved after removal of the reservoir. JJ-catheter was removed 1 month later.
Figure 1 Pelvic computed tomography demonstrates proximity of prosthetic reservoir to the ureter. Some inflammatory change is noted around the reservoir.
Compression of ureter caused by a retained reservoir of penile prosthesis B-P Jiann et al 317
Figure 3 Postoperative sonography of left kidney reveals no dilatation of collecting system.
Figure 2 Retrograde pyelography on left collecting system shows moderate hydronephrosis and hydroureter with a tortuous change of ureter. The arrows indicate the site compressed by the prosthetic reservoir.
A follow-up of abdominal sonography 3 months postoperatively demonstrated that left renal pelvis had returned to normal contour (Figure 3) and c-reactive protein in serum declined to normal range too.
have known risk factor for erosion.4,5 The complication of a ureteral compression leading to hydronephrosis by a retained reservoir has never been reported in literature to date, while a case of venous compression by a functioning reservoir was ever reported.6 In our case, in addition to the inflammatory change around the reservoir, the fluid in the reservoir also had some contribution to the bulky effect, which lead to compression of the ureter. Therefore, evacuation of fluid in the reservoir during explantation of penile implant should be emphasized to minimize the bulky effect, which might compress adjacent organs. Although rarely occurred, potential complication for a retrained reservoir does exist. Whether to remove it or not, the benefit should be weighed against the risk. When the reservoir is to be retained, the fluid inside should be evacuated as completely as possible.
Discussion Owing to mechanical and material design changes, the function and safety of penile implants improved greatly in the last few decades.1,2 The devices are made of silicon and polyurethane, which are considered inert to human body. Severe inflammatory response to them has not been reported in literature. In explanting a malfunctioning three-piece penile implant, removing the reservoir often needs a second incision since it is deeply buried in the retropubic space. Some surgeons advocate that routine removal of the reservoir is not necessary because retaining it is not associated with a significant risk of erosion unless there is a prior pelvic surgery or infection.3 However, there were five cases ever reported to have erosion of retained reservoir into urinary bladder in 2–15 years after explantation of penile implant, and they did not
References 1 Goldstein I, Newman L, Baum N, Brooks M, Chaikin L, Goldberg K et al. Safety and efficacy outcome of Mentor alpha-I inflatable penile prosthesis implantation for impotence treatment. J Urol 1997; 157: 833–839. 2 Carson CC, Mulcahy JJ, Govier FE. Efficacy, safety and patient satisfaction outcomes of the ANS 700CX inflatable penile prosthesis: results of a long-term multicenter study. J Urol 2000; 164: 376–380. 3 Rajpurkar A, Bianco FF, Al-Omar Jr O, Terlecki R, Dhabuwala C. Fate of the retained reservoir after replacement of 3-piece penile prosthesis. J Urol 2004; 172: 664–666. 4 Munoz JJ, Ellsworth PI. The retained penile prosthesis reservoir: a risk. Urology 2000; 55: 949. 5 Jones L, Ryan R, Ghobriel A. The retrained reservoir in inflatable penile prosthesis explanation. J Urol 2002; 167(Suppl): 150 (abstract 601). 6 Flanagan MJ, Krisch EV, Gerber WL. Complication of a penile prosthesis reservoir: venous compression masquerading as a deep venous thrombosis. J Urol 1991; 146: 847–848.
International Journal of Impotence Research
