External Iliac Vein Injury from Penile Implant Reservoir Removal: How can it be managed or avoided in the future?

Author(s): Alexandra Laps, BS, MS3, Andrew Kramer, MD

Introduction: Catastrophic venous bleeding from the iliac veins during reservoir placement or removal remains an infrequent but most feared intraoperative issue for penile implant surgeons.  A stepwise surgeon’s guide to manage this has never been described.

Objective: To give a best practice “how to” guide to technically manage intraoperative iliac vein bleeding for Urologists who encounter this during penile implant reservoir placement/removal.

Methods: An in-depth study of high definition video of an actual cases of external iliac vein bleeding intraoperatively, and its repair and management, is dissected and analyzed.  Then discussion of real time surgical thinking and actions taken that both succeed and fail are assessed, with video confirmation of which maneuvers gain control and which make the situation worse.  A best practice and discussion will be generated from real life cases captured in real time, high definition footage. 

Results: After reviewing maneuvers that are both ineffective and effective, adequate counter incision or extension of incision is first needed.  The vein above and below the laceration must be visualized to have any chance of repairing it- otherwise worse venous bleeding ensues and the vein shreds.  Proximal and distal pressure without immediate suturing of the venous laceration should be done.  Alice or other gentle clamping/coupling clamps should approximate the venous edges bringing them closer together while holding proximal/distal control.  Then a back and forth running prolene suture should be done.

Conclusions: This is a challenging vascular surgical procedure.  Many maneuvers will fail.  Certain stepwise surgical steps will be successful, and these are described.    Real time video makes a theoretical clinical scenario an easy to follow and instructive guide.   This live surgery real-time approach to venous control can be applied to a vast array of surgical scenarios involving venous bleeding, and should start a discussion on how best to control major venous bleeding.