Melissa Mendez MD1, Aaron Lentz MD1
1: Division of Urologic Surgery, Department of Surgery, Duke University Hospital, Durham, NC
Introduction: Complex incontinent patients post prostatectomy, radiation, inflatable penile prosthesis (IPP), and multiple previous urethral surgeries are becoming more prevalent as prostate cancer survivorship improves. One of the most challenging clinical scenarios is a patient with a high risk urethra and current IPP. Descriptions have been made that one could utilize a transcorporal approach by dissecting a plane between the IPP pseudocapsule and the tunica albuginea for AUS cuff placement, however in clinical practice, this rarely has proven feasible. Herein we present a novel technique of transcorporal AUS placement utilizing a 6-ply acellular graft to provide a barrier between the AUS and IPP components.
Case Presentation: Three patients have undergone this approach. All three have history of prostatectomy, three or more previous urethral surgeries, current inflatable penile prosthesis, and subcuff atrophy after placement of a 3.5cm cuff.
Protocol: Cystoscopy is utilized to ensure good urethral integrity and rule out presence of urethral stricture. Throughout the procedure a modified washout protocol is utilized given the risk of infection with increased operative time and exposure of IPP hardware. The urethra is dissected and a Jordan Perineal Bookwalter is placed for optimal exposure. Next the bovie settings are reduced to 25/25 and a 2cm corporotomy is made on each side. Transcorporal urethral measurement is obtained. Using the umbilical tape or penrose, sharp dissection is continued behind the urethra to allow for placement of the 6-ply acellular graft. Measurements for the graft are obtained and the graft is sized 10% larger than our measurements to allow for shrinkage. The graft is sutured in place over the IPP rear tip extenders to the lateral edges of the corporotomies. Next the AUS cuff is placed between the urethra and the acellular graft. The AUS components are connected in the usual fashion. Prior to closing the perineum in three layers, cystoscopy is utilized to confirm good urethral cooptation with activation and appropriate cuff cycling.
Outcome: In our current series, no perioperative complications have been encountered and the patients have done well post operatively.
Discussion: Several recent studies have demonstrated the efficacy and safety of a transcorporal AUS approach in both primary and salvage settings. This includes a substantially decreased risk of failure as compared to utilizing a 3.5cm cuff in high risk patients. Transcorporal AUS placement in the complex incontinent patient with current IPP utilizing a 6-ply acellular graft is an easy to learn technique that appears to be safe and effective. A larger patient cohort with follow-up data is needed to assess outcomes, rates of infection, and patient satisfaction.