Counter Incision Research Articles

Iatrogenic Common Peroneal Nerve Injuries From Inside-out Lateral Meniscus Repair: A Report of 2 Cases.

We report 2 cases of common peroneal nerve (CPN) palsy after inside-out lateral meniscus (LM) repair with very different presentations, occurring despite the standard surgical precautions (open counter incision and proper retraction between the biceps femoris tendon, lateral gastrocnemius, and capsule). On exploration, needle was found to have penetrated the nerve in one case and the nerve sheath in the other case. Patient 1 had near-complete neurological recovery, while patient 2 had partial neurological recovery after suture removal and neurolysis. CPN palsy can occur despite following all precautions during LM repair and should be managed as an iatrogenic injury unless proven otherwise.

(022) Penile Implant Reservoir Placement: The Current Utilized Various Techniques and the Associated Outcome: Systematic Review and Meta-Analysis

Abstract Introduction Many innovations in the field of inflatable penile prosthesis (IPP) has been emerged. Since the introduction of the IPP, reservoir positioning in the space of Retzius (SOR) was considered the classical approach that had been utilized for many years. However, in certain group of patients, reservoir insertion in such space might be difficult or even risky. As a result, many alternatives for the reservoir placement outside the SOR has emerged with the intent of safe and reliable reservoir placement. Objective To conduct a systematic review for the studies evaluating the outcomes of different techniques used for IPP reservoir placement to look for possible superiority of any approach over others. Methods A systemic review was performed utilizing (PRISMA) statement. The PubMed and Google scholar were used to look for articles published up to January 2023. Original articles reporting different techniques for IPP reservoir placement and evaluating the associated outcomes were included. Data regarding study design, sample size, approach of reservoir placement, surgical technique, device type and reported outcomes (infection rate, bladder/bowel/vascular injury, reservoir herniation, mechanical failure, auto-inflation, reservoir palpability and patients’ satisfaction) were collected. Pooled proportion was calculated and included in the meta-analysis. The Newcastle-Ottawa scale was used for assessing the quality of the studies. Results A total of 23 articles meeting the inclusion criteria, all were retrospective reviews. 11 compared more than one technique for reservoir placement whereas 12 described a single technique. In total, techniques for 6 main different reservoir locations has been reported, including SOR (7 studies), submuscular/subrectus (6 studies), Lateral retroperitoneal (1 study), subcutaneous (1 study), sub external oblique (1 study) and intraperitoneal (1 study). Another 7 modifications have been described for the SOR technique (traditional SOR, accessing SOR using blunt scissor in post-prostatectomy patients, accessing SOR using blunt scissor in virgin cases, dilating SOR using catheter balloon, accessing SOR under direct vision, accessing SOR through external oblique fascia incision, and the addition of The Tubing Hitch&Lasso, Intussusception Anchor technique (THALIA)). Another 6 modifications for the submuscular/subrectus approach have been described (posterior to transversalis fascia (PTF), anterior to transversalis fascia (ATF), high submuscular, subrectus using counter incision, subrectus with the addition of THALIA, low submuscular with trans-fascial-fixation (TFF)). None of the studies have proven the superiority of one technique over others, with most of the techniques has comparable intra-operative and post-operative outcomes (table 1). The addition of anchoring step (THALIA or TFF) resulted in neglected risk of reservoir herniation, however, related studies has small sample size with no comparison groups. Meta-analysis for the studies of SOR (n=7) and submuscular/subrectus (n=6) groups showed a statistically significant difference only in the herniation rates (figure 1). 10 studies were of strong quality (8 stars) while the remaining 13 studies were of poor quality. Conclusions Modest evidence suggests a comparable favorable outcome of various approaches used for IPP reservoir placement. The lack of enough prospective trials, short term follow up, and diversity in the techniques prescribed prevent the ability to build strong evidence. For the purpose of supporting the superiority of any technique, further prospective studies on a larger number of patients with long-term follow up are needed to reach a solid verdict. Disclosure No.

(394) Penile Implant Reservoir Placement: The Current Utilized Various Techniques and the Associated Outcomes: Systematic Review and Meta-analysis

Abstract Introduction Many innovations in the field of inflatable penile prosthesis (IPP) has been emerged. Since the introduction of the IPP, reservoir positioning in the space of Retzius (SOR) was considered the classical approach that had been utilized for many years. However, in certain group of patients, reservoir insertion in such space might be difficult or even risky. As a result, many alternatives for the reservoir placement outside the SOR has emerged with the intent of safe and reliable reservoir placement. Objective To conduct a systematic review for the studies evaluating the outcomes of different techniques used for IPP reservoir placement to look for possible superiority of any approach over others. Methods A systemic review was performed utilizing (PRISMA) statement. The PubMed and Google scholar were used to look for articles published up to January 2023. Original articles reporting different techniques for IPP reservoir placement and evaluating the associated outcomes were included. Data regarding study design, sample size, approach of reservoir placement, surgical technique, device type and reported outcomes (infection rate, bladder/bowel/vascular injury, reservoir herniation, mechanical failure, auto-inflation, reservoir palpability and patients’ satisfaction) were collected. Pooled proportion was calculated and included in the meta-analysis. The Newcastle-Ottawa scale was used for assessing the quality of the studies. Results A total of 23 articles meeting the inclusion criteria, all were retrospective reviews. 11 compared more than one technique for reservoir placement whereas 12 described a single technique. In total, techniques for 6 main different reservoir locations has been reported, including SOR (7 studies), submuscular/subrectus (6 studies), Lateral retroperitoneal (1 study), subcutaneous (1 study), sub external oblique (1 study) and intraperitoneal (1 study). Another 7 modifications have been described for the SOR technique (traditional SOR, accessing SOR using blunt scissor in post-prostatectomy patients, accessing SOR using blunt scissor in virgin cases, dilating SOR using catheter balloon, accessing SOR under direct vision, accessing SOR through external oblique fascia incision, and the addition of The Tubing Hitch&Lasso, Intussusception Anchor technique (THALIA)). Another 6 modifications for the submuscular/subrectus approach have been described (posterior to transversalis fascia (PTF), anterior to transversalis fascia (ATF), high submuscular, subrectus using counter incision, subrectus with the addition of THALIA, low submuscular with trans-fascial-fixation (TFF)). None of the studies have proven the superiority of one technique over others, with most of the techniques has comparable intra-operative and post-operative outcomes (table 1). The addition of anchoring step (THALIA or TFF) resulted in neglected risk of reservoir herniation, however, related studies has small sample size with no comparison groups. Meta-analysis for the studies of SOR(n=7) and submuscular/subrectus(n=6) groups showed a statistically significant difference only in the herniation rates (figure 1). 10 studies were of strong quality (8 stars) while the remaining 13 studies were of poor quality. Conclusions Modest evidence suggests a comparable favorable outcome of various approaches used for IPP reservoir placement. The lack of enough prospective trials, short term follow up, and diversity in the techniques prescribed prevent the ability to build strong evidence. For the purpose of supporting the superiority of any technique, further prospective studies on a larger number of patients with long-term follow up are needed to reach a solid verdict. Disclosure No.

Cryostripping Versus Conventional Safenectomy in Chronic Venous Disease Treatment: A Single Center Retrospective Cohort Study.

This study presents a comparative analysis of cryostripping to conventional saphenectomy. Materials and Methods: The study included 2191 patients admitted in the Phlebology Department, 1st Surgical Department, Emergency County Hospital Timisoara, between September 2013 and April 2023, between September 2013 and April 2023, who underwent saphenectomy by cryostripping (1327 patients) or conventionally (864 patients). We compared the duration and costs of the procedure, hospitalization period, post-operative results, method feasibility, as well as the technical advantages of cryostripping compared to conventional surgery. Results: A smaller proximal incision, compared to the classic operation, as well the fact that distal counter incision is not necessary, represents technical advantages of this procedure. Average duration of the intervention was 41 +- 12.8 minutes, consumables costs were about 52 +- 10 EUR/intervention, with an average hospitalization period was 1.05 +- 0.41 days. The post-operative results were favourable, early complications rate being reduced (ecchymoses Phi; 2 cm - 33.23%; hematoma - 2.11%; deep vein thrombosis - 0.15%; transient paresthesias 3.01%). Compared to classic saphenectomy, the costs of consumables/intervention are similar, intervention time, hospitalization period and complication rate being statistically significantly lower. An advantage of the method is the fact that the cryo-probes can be sterilized, being reusable; from the economic point of view, the technique perfectly fits in both public hospitals and private clinics. Conclusions: Cryostripping is a radical surgical procedure which bring a significant number of advantages compared to the classic saphenectomy, being an effective alternative in CVD treatment.

(549) Case Report of an IPP Reservoir Salvage Following Infection

Abstract Introduction Inflatable penile prosthesis (IPP) infections are rare and devastating. IPP infections are treated with either explant or salvage, the latter with either a malleable or inflatable device. Isolated component infections are very rare in the literature. This is the first description of successful treatment of an isolated IPP reservoir infection, with preservation and eventual reuse of the patient’s uninfected pump and cylinders. Objective To report a case of successful IPP salvage after an isolated reservoir infection. Methods This is a case study of IPP reservoir explant and eventual reimplant in a 51-year-old male, with preservation of the implant pump and cylinders. Past medical history is notable for HIV, hypertension, and hyperlipidemia. The patient had a Coloplast Titan IPP placed penoscrotally in November 2020 for treatment of post-prostatectomy erectile dysfunction. The reservoir was placed ectopically in the patient’s right high submuscular space. Results In January 2021 the patient underwent emergent exploratory laparoscopic washout and drain placement at a different hospital for perforated appendicitis. The IPP reservoir was not encountered during this procedure. In March 2021 he presented to that same hospital with recurrent fevers and right lower quadrant pain. CT showed increased peritoneal stranding and thickening surrounding the IPP reservoir as well as multiple small, complex loculated fluid collections suspicious for abscesses external to the reservoir. There was no evidence of infection of the pump or cylinders on imaging or physical exam. He was transferred to Dartmouth-Hitchcock Medical Center for further care. Conservative treatment with intravenous vancomycin, Zosyn, and fluconazole yielded no change after 48 hours. Three days after initial presentation, the reservoir was explanted during a collaborative procedure with general surgery, during which the appendix remnant was also removed. Intraoperatively the penile prosthesis reservoir was encased in a dense rind that was incised and drained. Copious purulent material was sent for culture, which showed multi-organism aerobic and anerobic bacteria. The reservoir was removed and the remnant tubing to the pump was clamped. The abdomen was irrigated repeatedly with saline, dilute betadine, vancomycin, gentamicin, Zosyn, and amphotericin. The prothesis tubing was cut as low as possible, capped, and wrapped with a paste of vancomycin mixed with Zosyn and amphotericin. There were no intraoperative complications. The patient was discharged two days later. At his one-week postoperative visit, he was readmitted for interventional radiology drain placement due to abdominal abscess recurrence. Once the recurrent abscess had resolved, he underwent successful radiation treatment for recurrent prostate cancer. In March 2022, the reservoir was successfully replaced into the left high submuscular space via counter incision and the dormant cylinders and pump were reconnected. The patient continues to do well, with no signs of recurrent infection and with excellent device function. He is satisfied with the result of surgery. Conclusions To our knowledge this is the only case of isolated IPP reservoir infection successfully treated with reservoir explant and eventual replacement. The original IPP pump and cylinders were preserved without issue and eventually reused. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast.

(425) Counterincision for High Submuscular Penile Prosthesis Reservoir Placement

Abstract Introduction Inflatable penile prosthesis (IPP) reservoir placement into the high submuscular (HSM) space is safe and well tolerated. Recent studies have proposed that reservoirs placed via an abdominal counterincision (CI) may offer more precise positioning with herniation rates comparable to a transinguinal (TI) approach. Objective Our objective was to evaluate the CI-HSM technique with respect to operative time, pain control, and complications. Methods We retrospectively reviewed our patient database to identify all men who underwent IPP reservoir placement via the CI-HSM technique. From this database, a similarly sized and matched control group of TI-HSM patients was identified based on concomitant procedures, date of surgery, age, and medical history. Operative time, intraoperative and postoperative complications, morphine milligram equivalents (MME) prescribed, and postoperative patient phone calls were also compared between TI-HSM and CI-HSM patients. Statistical analysis was performed using Student’s T-test and Fisher’s Exact test for continuous and discrete variables, respectively. Results Among 580 IPP cases identified, CI-HSM technique was used in 44 (7.6%). Of these, thirty-five (80%) were primary implants, nine (20.4%) were remove/replace revisions, and seven (15.9%) were combined with other ancillary procedures (i.e. artificial urinary sphincter, urethral slings, or penile plications). The TI-HSM technique was used in 536 patients (92.4%); of these, 44 matched controls were identified for comparison to the CI-HSM cohort. Thirty-four (77%) of these patients underwent primary implants while ten (23%) were revision cases. Cases employing the CI-HSM technique had a longer mean operative time (90 minutes) compared to those using the TI-HSM technique (75 minutes) (Table). A similar number of CI-HSM patients (3/44, 6.8%) were treated for infection versus TI-HSM patients (1/44, 2.2%). Reservoir herniation was not observed in the CI-HSM cohort, however one (2.2%) patient in the TI-HSM matched control cohort required revision secondary to herniation. No differences were identified between TI-HSM and CI-HSM patients with regards to outpatient medications, narcotic medication refills, or postoperative phone calls. Conclusions IPP reservoir placement via CI-HSM technique is safe and well tolerated. Operative times were similar as compared to reservoirs placed via TI-HSM technique. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast.

(403) Artificial Urinary Sphincter Implantation for Severe Post-Prostatectomy Incontinence in Setting of Salvage Radiotherapy and Prior Inflatable Penile Prosthesis

Abstract Introduction Artificial urinary sphincter (AUS) implantation is one of the most common treatment options for individuals with severe stress urinary incontinence (SUI), which is a common complication after radical prostatectomy (RP). The modern AUS consists of a urethral cuff, pump, and reservoir, which serves as a replacement for the native incompetent sphincter. There are various surgical approaches for AUS insertion, including transperineal, transscrotal, and abdominal approaches. Objective This video covers the surgical technique for the implantation of an AUS for management of SUI. Notably, this patient underwent RP followed by salvage radiotherapy (XRT) for biochemical recurrence of prostate cancer and had prior inflatable penile prosthesis (IPP) placement. Methods A standard step-by-step surgical technique for placement of an AUS through a perineal incision and additional counter incision to allow for high submuscular placement of the pressure-regulating balloon is demonstrated in this unique case of a patient with prior IPP placement and salvage XRT. Results We highlight a meticulous dissection around the urethra in a case that had a challenging urethral dissection secondary to prior radiotherapy and a prior IPP in the proximal corpora. The AUS pump was successfully placed in the subdartos pouch of the scrotum on the contralateral side to avoid the patient’s prior IPP pump. At the conclusion, a flexible cystourethroscopy showed adequate AUS cuff coaptation and cycling. Conclusions This video covers the step-by-step technique for insertion of an AUS with a transperineal approach in the unique context of a patient with prior IPP placement and XRT. Preoperative counseling, evaluation, and careful intraoperative dissection of key parts of the procedure are critical for successful placement of the AUS, especially in patients who are at high-risk for complications, such as in this case. Disclosure No

PD42-07 OUTCOMES RELATED TO INFLATABLE PENILE PROSTHESIS (IPP) RESERVOIR REMOVAL: A 7-YEAR MULTI-CENTER EXPERIENCE

You have accessJournal of UrologyCME1 Apr 2023PD42-07 OUTCOMES RELATED TO INFLATABLE PENILE PROSTHESIS (IPP) RESERVOIR REMOVAL: A 7-YEAR MULTI-CENTER EXPERIENCE Javier Piraino, Ian Madison, Matthew Ziegelmann, Run Wang, Tobias Kohler, Aram Loeb, Gerard Henry, Robert Cornell, Dylan Supak, Landon Trost, and Jonathan Clavell Javier PirainoJavier Piraino More articles by this author , Ian MadisonIan Madison More articles by this author , Matthew ZiegelmannMatthew Ziegelmann More articles by this author , Run WangRun Wang More articles by this author , Tobias KohlerTobias Kohler More articles by this author , Aram LoebAram Loeb More articles by this author , Gerard HenryGerard Henry More articles by this author , Robert CornellRobert Cornell More articles by this author , Dylan SupakDylan Supak More articles by this author , Landon TrostLandon Trost More articles by this author , and Jonathan ClavellJonathan Clavell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003352.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The 3-piece IPP is the most widely used device for erectile dysfunction refractory to medications, containing a reservoir inserted into the Space of Retzius (SOR) or an alternative/ectopic space (AES). Indications for removal of the reservoir include malfunction, malposition or infection. In revision cases without infection, reservoir removal is sometimes optional. We review outcomes and complications specifically related to reservoir removal from a large multi-institutional series. METHODS: We retrospectively reviewed databases at 6 institutions over 7 years. Patients with artificial urethral sphincter, urethral sling or Mini-jupette were excluded. Outcomes and complications related to IPP reservoir removal were analyzed. Data were collected but only reservoir-related complications at surgery were included. Data were compared between SOR and AES cohorts to evaluate differences with χ2, with significance at p<0.05. RESULTS: Of 215 cases, there were 172 SOR (80%) and 43 AES (20%) reservoirs. Mean patient age was 65.3 years old. 131 (60.9%) procedures were due to malfunction, 49 (22.8%) were due to malposition of an IPP component, and 35 (16.3%) were secondary to infection. Among those retained (N=44, 20.5%), reasons included reuse, avoiding surrounding structure damage, unspecified, and difficult dissection. Among those removed (N=171), 15 (8.8%) required a counter-incision (6 in SOR and 9 in AES). χ2 to determine statistical difference between those removed from SOR and AES found a p=0.00059, indicating significant difference in the need for a counter-incision those groups. Complications included bladder perforation (N=1) in the SOR group, and an avulsion of the epigastric vessels requiring abdominal exploration (N=1) in the AES group. χ2 to determine statistical difference when comparing SOR and AES complications was p=0.365, indicating no significant difference between groups. CONCLUSIONS: Removal of an IPP reservoir remains safe with few complications. Surgeons should be aware of the inferior epigastric vessels during removal in an AES or be willing to perform a counter incision to avoid injury to surrounding structures. Surgeons should obtain preoperative imaging to identify the specific location of the reservoir and adjacent anatomy. This is the first and largest multi-institutional study reviewing outcomes related to reservoir removal during IPP revision or removal surgery. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1113 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Javier Piraino More articles by this author Ian Madison More articles by this author Matthew Ziegelmann More articles by this author Run Wang More articles by this author Tobias Kohler More articles by this author Aram Loeb More articles by this author Gerard Henry More articles by this author Robert Cornell More articles by this author Dylan Supak More articles by this author Landon Trost More articles by this author Jonathan Clavell More articles by this author Expand All Advertisement PDF downloadLoading ...

Endoscope-Assisted Greater Occipital Nerve Decompression for Migraines, Occipital Neuralgia, and New Daily Persistent Headaches.

In the occipital trigger site for migraine, the greater occipital nerve (GON) is thought to be irritated by surrounding structures, including the semispinalis capitis muscle and occipital artery (OA), producing headaches in the back of the neck. Thus, standard decompression involves removal of surrounding tissue and dissection away from the vessel. The authors noticed a consistent pattern between the GON and OA more distally: the OA approaching laterally and diving under the GON, the OA looping back over the GON and intertwining with the medial branch of the GON, and lastly the OA traveling parallel to the GON. The technique described uses a modified endoscopic approach with a counter incision, endoscopic assistance, and radical artery lysis to address distal sites in addition to the standard release. At the counter incision, distal intertwining between vessel and nerve was released. A high-definition endoscope was used to address dynamic compression points more proximally, including hidden areas where the vessel dives under the GON, as well as to facilitate cautery and removal of the vessel. Without the use of an endoscope and counterincision, it is difficult to achieve complete decompression of the nerve distally without injury to the proximal body of the nerve.

Increasing role of counterincision for high submuscular penile prosthesis reservoir placement

AbstractBackgroundInflatable penile prosthesis (IPP) reservoir placement into the high submuscular (HSM) space is safe and well tolerated. Recent studies have proposed that reservoirs placed via an abdominal counterincision (CI) may offer more precise and durable positioning as compared with a transinguinal (TI) approach.AimHerein we compare the CI-HSM and TI-HSM techniques with respect to operative time, pain control, and postoperative complications.MethodsWe reviewed our penile prosthesis database at a large single-surgeon tertiary referral center from 2014 to 2021 to compare those who underwent virgin reservoir placement via the CI-HSM technique vs the TI-HSM technique. Statistical analysis was performed with the Mann-Whitney U test for continuous variables and the chi-square test and Fisher exact test for discrete variables.OutcomesOperative time, postoperative complications, morphine milligram equivalents prescribed, and postoperative correspondence were compared between patients undergoing the CI-HSM and TI-HSM techniques.ResultsAmong 456 virgin IPP implants, the CI-HSM technique was used in 34 cases (7.5%) and the TI-HSM technique in 422 cases (92.5%). Of these 456 cases, 92 (20.2%) were combined with ancillary procedures such as artificial urinary sphincter, urethral sling, or penile plication (6/34, CI; 86/422, TI). Cases employing the CI-HSM technique had a 19.9% greater median operative time: 81.5 minutes (IQR, 69.3-106.5) vs 68 minutes (IQR, 57.8-80.3; P &amp;lt; .01). A similar proportion of patients in the CI-HSM group (2/34, 5.9%) were treated for infection as in the TI-HSM group (17/422, 4.0%; P = .64). Reservoir herniation was seen in 12 patients in the TI-HSM group (2.8%) and in none of the CI-HSM group, but this did not reach significance (P &amp;gt; .99). No differences were identified between patients in the TI-HSM and CI-HSM groups with regard to postoperative morphine milligram equivalents prescribed, narcotic medication refills, or postoperative correspondence.Clinical ImplicationsCI-HSM reservoir placement was associated with similar surgical outcomes to TI-HSM without increased infection risk or need for narcotic pain management.Strengths and LimitationsAlthough this study is a large contemporary series addressing a clinically important subject, it is limited by its retrospective preliminary nature and nonrandomized unmatched design. Patient pain regimens were assessed via discharge prescriptions, although data regarding narcotic consumption were not available in the medical record.ConclusionsIPP reservoir placement via the CI-HSM technique is safe and well tolerated. Increased operative time of the CI-HSM technique as compared with the TI-HSM technique is clinically negligible given its potential safety benefits of direct visualization of reservoir placement.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.

Subcutaneous Emphysema of Dental Origin – Two Case Reports with a Comprehensive Review of Literature from 1965 to 2020, with an Emphasis on Timely Management

Subcutaneous emphysema (SE) is a rare but possible complication of dental treatment resulting from the usage of high-speed air-driven instruments and introduction of irrigating solutions like hydrogen peroxide into soft tissues. Two case reports are described here, namely (a) drying of root canals using a three-way syringe by “Venturi” technique and (b) accidental injection of hydrogen peroxide instead of local anesthesia in an infiltration technique. A review of the literature is done wherein a search for terms such as pneumomediastinum, mediastinitis, embolism, or extensive SE (ESC) from 1965 to 2020 using the PubMed search engine was done and the results were tabulated. Since the number of cases and complications reported are on the rise, data regarding diagnosis, investigations, and a management protocol with an emphasis on prevention have been elaborated. Methods such as reductive manipulation or “counter incision,” as incited from medical literature, have been suggested to reduce morbidity and mortality. In both of the case reports, subcutaneous cervicofacial emphysema resolved briefly due to the effectual reduction maneuver implemented promptly.

VACUUM-ASSISTED CLOSURE AND MUSCLE FLAP AS AN ALTERNATIVE MODALITY FOR INFECTED WOUND AFTER ORIF OF TIBIAL FRACTURE: CASE REPORT

Background: The blood supply of a bone can be decreased due to the use of an implant, leading to wound-bed bacterial colonization and the development of the SSI. The principle of vacuum-assisted closure (VAC) is to use a negative pressure environment in the wound to promote increased wound healing. The case shows that VAC application and muscle flap therapy provide the definitive healing of infected wounds after ORIF. Case Report: A 45 years-old male presented with a close comminuted proximal third right tibia fracture and tense skin. The fracture was openly reduced and internally fixated with plate fixation and a skin flap on the fracture area. Still, the wound could not be closed due to difficulty covering the wound, so a counter incision was made. After four days, the patient developed necrosis in the post-operation wound and subsequently underwent debridement and muscle flap with VAC application. Discussion: SSI can be treated by applicating of appropriate antibiotic and surgical procedures. In this case, the infection was treated using third-generation cephalosporin antibiotic, debridement, dissection, and re-elevation of gastrocnemius muscle flap covering the exposed plate area in inferior, split skin graft above the muscle flap and VAC above skin graft with 75 mmHg pressure. Conclusion: Debridement with muscle flap and application of VAC in the deep infected wound of open reduction and internal fixation was found to be successful methods in minimizing complications and obtaining an optimal outcome. This finding was associated with accompanying morbidities or a good wound healing process.

Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice

ABSTRACT Introduction Inflatable penile prosthesis (IPP) reservoirs are typically placed into the Space of Retzius (SOR), High Submuscular Space (HSM), or alternative locations via a transinguinal (TI) approach or a lower abdominal counter incision (CI). A cadaver study showed variability in reservoir location after TI-HSM placement (JSM: 2016 Sep;13(9):1425-1431). Objective We sought to evaluate reservoir location using cross-sectional imaging following contemporary IPP insertion. Methods We retrospectively reviewed our institutional database and identified men who underwent virgin penoscrotal IPP insertion from 2007 to 2019. We then identified those men who subsequently underwent cross-sectional imaging prior to October 2019. Radiologists blinded to reservoir placement technique evaluated cross-sectional imaging and categorized each reservoir location in relation to the abdominal wall musculature, transversalis fascia, and peritoneum. Statistical analysis was performed using Chi-squared and Fisher's exact tests. Results Among 561 men who underwent virgin IPP insertion during the 12 year study period, 114 had cross-sectional imaging subsequently obtained: 29 TI-SOR, 80 TI-HSM, and 5 CI-HSM (Table). TI-HSM reservoirs were more likely than TI-SOR to be located anterior to the transversalis fascia (14 vs. 48%, p=0.001). TI-HSM reservoirs were less likely than TI-SOR to be located in the preperitoneal space (62 vs. 18%, p&amp;lt;0.001). Rates of retroperitoneal reservoir location were similar between the TI-HSM and TI-SOR groups. Among all 561 patients (131 TI-SOR, 405 TI-HSM, and 25 CI-HSM), rates of reservoir-related complications requiring operative intervention were similar between groups (5 vs. 2 vs. 0%, p = 0.24). Conclusions Roughly half of the TI-HSM reservoirs in this series appeared to be located posterior to the transversalis fascia on cross-sectional imaging. Although preperitoneal and retroperitoneal locations were common in both groups, reservoir related complications were rare. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast

Preventing driveline infection during left ventricular assist device support by the HeartMate 3: A survey-based study.

Driveline infection (DLI) is a significant source of morbidity and mortality during left ventricular assist device (LVAD) support yet limited studies are available to describe the center-level prevalence, preventive practices, and their potential effectiveness. We surveyed LVAD centers in the United States to determine program burden and preventive practices for DLI during HeartMate (HM) 3 support. An online, anonymous, question-based survey was sent to expert providers at implanting centers. Only a single respondent completed the survey for each center. As an exploratory analysis, we compared specific DLI preventive practices between centers with low (≤10%) and high (>10%) reported prevalence of DLI. Seventy-eight centers responded to the survey (response rate: 50%). Respondents were comprised of 37 (47%) heart failure cardiologists, 27 (35%) LVAD coordinators, and 14 (18%) cardiothoracic surgeons. The prevalence of DLI during HM3 was reported as ≤10% by 27 (35%), 11%-25% by 36 (46%), and >25% by 16 (19%) centers. Thirteen (17%) centers had a body mass index threshold for device placement, 29 (37%) utilized a counter incision, 66 (81%) placed an anchor stitch, and 69 (88%) used an external device to stabilize the DL. Proportionally, more centers with a low DLI prevalence used a wound vacuum 6 (22%) versus 3 (6%, p=0.03) than those with high DLI. Variation exists in reported prevalence and practices of preventing and managing driveline infections across centers during HM3 support. Further studies are warranted to develop and assess the effectiveness of standardized preventive strategies.

Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice

Inflatable penile prosthesis (IPP) reservoirs are typically placed into the Space of Retzius (SOR) or alternative locations including the High Submuscular (HSM) space via transinguinal (TI) or counter incision (CI) techniques. A cadaver study showed variability in reservoir location after TI-HSM placement. To evaluate reservoir location using cross-sectional imaging following IPP insertion. We retrospectively reviewed our institutional database and identified men who underwent virgin penoscrotal IPP insertion between 2007 and 2019. We then identified those men who subsequently underwent cross-sectional imaging prior to October 2019. Radiologists evaluated cross-sectional imaging in a blinded manner and categorized reservoir locations as follows: 1) submuscular; 2) posterior to the external oblique fascia and lateral to the rectus abdominis musculature; 3) preperitoneal; 4) retroperitoneal; 5) intraperitoneal; 6) inguinal canal; 7) subcutaneous. Patients were stratified by reservoir placement technique, transinguinal space of Retzius (TI-SOR), transinguinal high submuscular (TI-HSM), or counterincision high submuscular (CI-HSM). Clinical characteristics and outcomes were reviewed and compared. Statistical analysis was performed using Chi-squared and Fisher's exact tests. Variability exists in the TI placement of SOR and HSM reservoirs, CI-HSM reservoirs were associated with a low level of variability. Among 561 men who underwent virgin IPP insertion during the 12-year study period, 114 had postoperative cross-sectional imaging (29 TI-SOR, 80 TI-HSM, and 5 CI-HSM). Among the 114 patients imaged, TI-HSM reservoirs were more likely than TI-SOR to be located anterior to the transversalis fascia (48 vs 14%, P < .01) and were less likely to be located in the preperitoneal space (18 vs 62%, P < .01). Rates of intraperitoneal reservoir location were similar between the TI-HSM and TI-SOR groups (5 vs 7%, P = .66). Among imaged CI-HSM reservoirs, 4 (80%) were anterior to the transversalis fascia and 1 (20%) was within the inguinal canal. Among all 536 transinguinal cases (131 TI-SOR and 405 TI-HSM), rates of reservoir-related complications requiring operative intervention were similar between groups (5 vs 2%, P = .24). No complications were noted among the 25 patients in the CI-HSM cohort. The level of variability seen in this study did not seem to impact patient safety, complications were rare in all cohorts. This study is the first and largest of its kind in evaluating reservoir positioning in live patients with long-term follow-up. This study is limited in its retrospective and nonrandomized nature. Despite variability with both TI-HSM and TI-SOR techniques, reservoir related complications remain rare. Kavoussi M, Cook G, Nordeck S, et al. Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice. J Sex Med 2021;18:2039-2044.

Counter incision is a safe and effective method for alternative reservoir placement during inflatable penile prosthesis surgery.

BackgroundAlternative reservoir placement is increasingly popular during inflatable penile prosthesis (IPP) surgery to prevent intraperitoneal positioning, bowel, bladder, or vascular injury in patients with prior pelvic surgeries. Counter incision (CI) can be used for submuscular reservoir placement in high risk patients, however series exploring the safety remain limited.MethodsA database of IPP surgeries was queried for use of a CI during reservoir placement to compare 90-day clinical outcomes in a retrospective case-control study. Primary outcome was device infections, with secondary outcomes including reservoir herniation, hematoma, device malfunction rates, and operative times. Groups were compared using Kruskal-Wallis and Chi-Squared tests, with multivariate logistic regression models to identify predictors of infectious complications.ResultsA total of 534 cases met criteria, of which 51 (9.6%) used a CI for reservoir placement. The CI cohort included significantly more removal and replacements, 45.1% vs. 20.9% (P<0.001). Thirty-one CI patients (61.0%) had undergone prior prostatectomy compared to 134 (27.7%) non-CI patients (P=0.001). The most common reasons for CI were prior prostatectomy and inguinal hernia repair. Median operative time was 17 minutes longer in the CI group (74 vs. 57 minutes, P<0.001). Device infection rates were similar (2.0% vs. 4.1%, P=0.71), as were rates of hematoma (5.9% vs. 2.7%, P=0.19), and device malfunction (0.0% vs. 1.4% P=1.00).ConclusionsComplication rates were similar between CI and non-CI cohorts, even in a subset where approximately half the cases were removal and replacements. For physicians not comfortable with alternative placement through a penoscrotal or infrapubic incision, this offers a reasonable alternative and permits use of three-piece devices in patients with a hostile pelvis.

Évaluation de la forme et du résultat esthétique d’ombilics transposés selon quatre techniques chirurgicales

In abdominal plastic surgery, umbilicus is frequently transposed, generating scars and shapes variating with the techniques used. Various umbilical transposition techniques have been described, all of them attempt to reproduce the "ideal" umbilicus. This study aimed to define the shape and the aesthetic results obtained with four different surgical procedures, in order to choose an "ideal" umbilical transposition technique. This retrospective study analyzed the characteristics of transposed umbilicus, in 50 patients who had undergone abdominal dermolipectomy for aesthetic reason, after a loss of weight or in breast reconstruction by Deep-Inferior-Epigastric-Perforator. Four surgical procedures were chosen, which differed by their counter-incision shape in the abdominal flap (Y, inverted Y, de-epidermized round with horizontal incision or U), and the deep points position of umbilical docking (along a horizontal or vertical axis). Shape and depth were evaluated by a panel of experts. The global assessment was based on a double evaluation, by the surgical jury and the patients themselves. The counter-incision type determined the umbilicus shape: triangular for the Y (60%) or inverted-Y (41%), round for the U (52%) and vertical oval (67%) or round (32%) for the de-epidermized circle. The deep points position influenced the umbilicus axis. Regarding the appreciation, the de-epidermized circle had the best results for surgeons in a significant way, and for patients (respectively 72% and 100% satisfied), followed by the inverted-Y (57% and 92%) and Y techniques (55% and 89%) and at last the U (50 and 75%). Horizontal counter incision in a de-epidermized round, with two anchoring points on a vertical axis, generates vertical oval or round shaped umbilicus, considered attractive in the literature, and giving the highest aesthetic satisfaction for both surgeons and patients.

Explantation of High Submuscular Reservoirs: Safety and Practical Considerations

BackgroundOver the past decade, high submuscular (HSM) placement of inflatable penile prosthesis (IPP) reservoirs has emerged as a viable alternative to space of Retzius (SOR) placement; however, data comparing the feasibility and complications of HSM vs SOR reservoir removal do not presently exist. AimTo present a comparison of the safety, feasibility, and ease of removal of HSM vs SOR reservoirs in a tertiary care, university-based, high-volume prosthetic urology practice. MethodsData were retrospectively collected on patients who underwent IPP reservoir removal between January 2011 and June 2020. Cases were separated into 2 cohorts based on reservoir location. Statistical analysis was performed using Fisher's exact and Chi-squared tests for categorical variables and Student's t-test for continuous variables. Timing from IPP insertion to explant was compared between the HSM and SOR groups using the Mann-Whitney U test. OutcomesTime from IPP insertion to explant, operative time, intraoperative and postoperative complications, and need for a counter incision were compared between the HSM and SOR groups. ResultsBetween January 2011 and June 2020, 106 (73 HSM, 33 SOR) patients underwent IPP removal or replacement by a single surgeon at our institution. Average time from IPP insertion to removal was 43.6 months (24.2 HSM, 52.7 SOR, P = .07)—reservoir removal occurred at the time of device explant in 70 of 106 (66%) cases. More HSM reservoirs were explanted at the time of IPP removal compared with the SOR cohort (54 of 73, 74% HSM vs 16 of 33, 48.5% SOR, P = .01). Similar rates of complications were noted between the HSM and SOR groups (1.9% vs 6.3%, P = .35). There was no significant difference in need for counter incision between the 2 groups (24 [42%] HSM vs 4 [25%] SOR, P = .16) or in average operative times (76.5 ± 38.3 minutes HSM vs 68.1 ± 34.3 minutes SOR, P = .52). Clinical ImplicationsOur experience with explanting HSM reservoirs supports the safety and ease of their removal. Strengths and LimitationsAlthough the absolute cohort size is relatively low, this study reflects one of the largest single-institution experiences examining penile implant reservoir removal. In addition, reservoir location was not randomized but was instead determined by which patients presented with complications necessitating reservoir removal during the study period. ConclusionsHSM reservoir removal has comparable perioperative complication rates and operative times when compared with SOR reservoir removal.Kavoussi M, Bhanvadia RR, VanDyke ME, et al. Explantation of High Submuscular Reservoirs: Safety and Practical Considerations. J Sex Med 2020;17:2488–2494.

PD20-12 SAFETY PROFILE OF COUNTER INCISION FOR RESERVOIR PLACEMENT DURING INFLATABLE PENILE PROSTHESIS SURGERY

INTRODUCTION AND OBJECTIVE: Non-traditional reservoir placement is increasingly popular during penile prosthesis (PP) surgery to prevent intraperitoneal positioning and bowel, bladder, or vascular injury. A variety of locations have been described including submuscular, high-submuscular, and subcutaneous. In this study we present our experiences using a counter incision for submuscular reservoir placement and compare these to patients who underwent traditional reservoir placement. METHODS: A single institution database of PP surgeries was queried for use of a counter incision (CI) during reservoir placement from July 2011 to 2019. Demographic, medical, and surgical histories as well as 90-day outcome data were extracted. Primary outcome was device infections, with secondary outcomes including cellulitis, reservoir herniation, hematoma, device malfunction rates, and operative times. Additionally, a descriptive analysis of the reasons for CI was performed. Groups were compared using Kruskal Wallis and Fisher’s exact tests for continuous and categorical variables respectively. RESULTS: A total of 432 cases met inclusion criteria of which 46 (10.6%) used a CI for reservoir placement. Twenty-six CI patients (56.5%) had undergone a prior prostatectomy compared to 108 (28.0%) non-CI patients (p<0.001). The CI cohort included significantly more removal and replacement procedures, 54.3% vs. 26.4% (p<0.001). Most common reasons for CI were prior prostatectomy and inguinal hernia repair. Device infection rates were similar between groups (CI 2.2 vs. non CI 3.6%), as were rates of hematoma (2.2 vs 3.6%), cellulitis (4.3 vs 0.5%), and device malfunction (0.0 vs 0.7%). An internal iliac artery injury, one intravesical reservoir placement, and one reservoir herniation were seen in the non-CI cohort, but no similar complications occurred in the CI group. Of wound complications, only one was of the CI with a total CI wound complication rate of 1/46 (2.2%). Median operative time was 15 minutes longer in the CI cohort (69.6 vs 84.0 minutes, p = 0.007). CONCLUSIONS: Use of a CI is a safe and effective means of reservoir placement in patients with a compromised space of Retzius, albeit with a slightly higher operative time. Complication rates were similar between groups, even in a subset where approximately half the cases were removal and replacements. Of wound complications, the vast majority did not occur at the CI, rather at the penoscrotal or infrapubic incisions. Source of Funding: None