Reservoir Placement Research Articles

A Modified Surgical Technique for Reservoir Placement During Inflatable Penile Prosthesis Implantation.

IntroductionAt the moment, there is an ongoing debate regarding the controversial issue of the ideal reservoir placement (RP) surgical technique during implantation of a 3-piece inflatable penile prosthesis, but a definitive winner has not yet emerged.AimIn this light, we herein describe our modified technique for RP into the space of Retzius through the external oblique muscle fascia and present its results.MethodsIn total, 253 inflatable penile prosthesis procedures (110 AMS 700 and 143 Coloplast Titan) via a single transverse penoscrotal incision were retrospectively reviewed. 2 Kocher-Langenbeck retractors were placed over the right side of the penoscrotal incision and were used to retract the incision superior to the pubic bone. Then, the external oblique muscle fascia was incised medially to the spermatic cord which was retracted laterally. Next, a “W”, Vicryl 1, stay suture was placed to the incision, and under direct visualization, external oblique muscle fibers were dissected and fascia transversalis was perforated using a Metzenbaum scissor. A Foerster lung grasping clamp was then used to dissect further into the extraperitoneal space and create the reservoir space. The reservoir was placed into the created space and fascia incision was closed using the prepositioned stay suture. The procedure was then completed in a standard fashion.OutcomesThe main outcome measures were intraoperative or postoperative complications of our modified RP technique.ResultsAll 253 patients were available for short-term follow-up (average 9.1 months, range 3–22 months). No intraoperative or postoperative complications were reported. Reservoir-related prolonged pain (1 month) was reported by 1 patient, resolving completely after treatment with non-steroidal analgesics.ConclusionWe are, surely, not proposing that our modified RP technique should supplant all other methods; rather, it should be considered another useful option for RP in the implanter’s armamentarium.Mykoniatis I, Osmonov D, van Renterghem K. A Modified Surgical Technique for Reservoir Placement During Inatable Penile Prosthesis Implantation. Sex Med 2020;8:378–382.

Should occasional implanters learn ectopic placement of IPP reservoirs?

Should occasional implanters learn ectopic placement of IPP reservoirs?

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

V07-12 DEVELOPMENT OF A HIGH FIDELITY 3-PIECE INFLATABLE PENILE PROSTHETIC (IPP) MODEL USING 3D-PRINTING AND HYDROGEL MOLDING

You have accessJournal of UrologyLower-Tract Reconstruction II: ED/Infertility & Transgender Surgery (V07)1 Apr 2020V07-12 DEVELOPMENT OF A HIGH FIDELITY 3-PIECE INFLATABLE PENILE PROSTHETIC (IPP) MODEL USING 3D-PRINTING AND HYDROGEL MOLDING Patrick Saba, Rachel Melnyk, Michael Witthaus*, Gareth Warren, Divya Ajay, Alexander Cranwell, Ricardo Munarriz, and Ahmed Ghazi Patrick SabaPatrick Saba More articles by this author , Rachel MelnykRachel Melnyk More articles by this author , Michael Witthaus*Michael Witthaus* More articles by this author , Gareth WarrenGareth Warren More articles by this author , Divya AjayDivya Ajay More articles by this author , Alexander CranwellAlexander Cranwell More articles by this author , Ricardo MunarrizRicardo Munarriz More articles by this author , and Ahmed GhaziAhmed Ghazi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000897.012AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This video demonstrates a high-fidelity, anatomical, full procedural simulation for placement of a 3-piece IPP. METHODS: Anatomical penile models consisting of a male pelvis, penis, urethra, corporal bodies, inguinal canals, iliac vessels and relevant adjacent structures were created using 3D-printed injection molds. The molds are filled with a poly-vinyl alcohol, a hydrogel that can be modified to replicate realistic tissue consistency. Relevant procedural steps: corporal exposure, dilation, measurement, scrotal pump placement, reservoir placement, prosthesis assembly and closure can be simulated using both an infrapubic or penoscrotal approach. The model has the ability to detect surgical errors including perforation of corpora during dilation, damage to iliac vessels or urethra and improper prosthesis placement. Twelve surgeons: three experts (>250 caseload), three low volume faculty (>50 caseload) and six novices (residents), completed an IPP insertion on the model under operating room conditions, after which a survey assessing realism and usefulness as a training tool was completed. RESULTS: When compared to live surgery, over 83.3% of the participants agreed that the model realistically replicated the skin retraction, placement of corporal stay sutures, corporotomy, distal dilation, prosthesis measurement, and IPP placement (Figure 1). Skin incision, proximal dilation, reservoir placement, corporal closure and skin closure was found to be realistic in above 66.7% of participants. On average experts agreed that the model could function as a training tool, assessment tool, prerequisite for IPP accreditation, and a requirement prior to live surgery. Experts stated ideally, they would have their trainees complete an average of 3.33 models before live surgical training. CONCLUSIONS: This video presents a high-fidelity, anatomical, hydrogel simulation platform for 3 piece IPP placement. With the ability to replicate surgical errors, its educational effectiveness as a training tool is further supported. This platform requires no specialized facilities and offers the basis for future male genital reconstruction simulations such as correction of Peyronie’s disease and artificial urinary sphincter insertions. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e646-e646 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Patrick Saba More articles by this author Rachel Melnyk More articles by this author Michael Witthaus* More articles by this author Gareth Warren More articles by this author Divya Ajay More articles by this author Alexander Cranwell More articles by this author Ricardo Munarriz More articles by this author Ahmed Ghazi More articles by this author Expand All Advertisement PDF downloadLoading ...

PD20-01 VALIDATION OF A PENILE PROSTHETICS PLACEMENT SIMULATION PLATFORM FOR SURGICAL TRAINING: A COMPARATIVE STUDY WITH CADAVERS

You have accessJournal of UrologySexual Function/Dysfunction: Surgical Therapy I (PD20)1 Apr 2020PD20-01 VALIDATION OF A PENILE PROSTHETICS PLACEMENT SIMULATION PLATFORM FOR SURGICAL TRAINING: A COMPARATIVE STUDY WITH CADAVERS Rachel Melnyk, Patrick Saba, Michael Witthaus*, Gareth Warren, Divya Ajay, Timothy Campbell, Alexander Cranwell, Ahmed Ghazi, and Ricardo Munarriz Rachel MelnykRachel Melnyk More articles by this author , Patrick SabaPatrick Saba More articles by this author , Michael Witthaus*Michael Witthaus* More articles by this author , Gareth WarrenGareth Warren More articles by this author , Divya AjayDivya Ajay More articles by this author , Timothy CampbellTimothy Campbell More articles by this author , Alexander CranwellAlexander Cranwell More articles by this author , Ahmed GhaziAhmed Ghazi More articles by this author , and Ricardo MunarrizRicardo Munarriz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000870.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Simulation training is particularly relevant in prosthetic urology because of limited training during residency, low prosthetic surgical experience and decreased availability of cadavers. To overcome these limitations, a high-fidelity, non-biohazardous, procedural simulation was developed and validated for inflatable penile prosthetic (IPP) placement to supplement surgical training. METHODS: Using a combination of 3D printing and hydrogel molding, an anatomical male genital model was created and approved by experts. The model was constructed to replicate the appropriate steps of IPP placement: corporal exposure, dilation, measurement, reservoir and pump placement, and closure (Figure 1). Three expert level surgeons (>250 cases), 3 low volume faculty (<50 cases) and 6 residents performed IPP simulations on a cadaver followed by the hydrogel model via an infrapubic and penoscrotal approach. Questionnaires compared the simulations in regards to their realism and value as a training tool. RESULTS: Overall, 66.7% of the participants found the hydrogel models to be an equivalent training platform to cadavers. In terms of tissue texture, physical appearance and safety, the model was rated as similar or superior by 25%, 58.3%, and 92.7% of participants, respectively. Experts rated corporal dilation as the most beneficial step of the procedure, followed by corporal exposure then reservoir placement. Similar results were found in low volume faculty and residents, combined. All participants believed an operative checklist would be an ideal assessment tool. Experts recommended that trainees should complete an average of 3.3 simulations as a prerequisite to live surgical training. Participants believed the model's biggest advantage was its non-biohazardous nature (83.3%), and could potentially replace cadavers without the need for specialized facilities (66.7%). The most requested modifications included improvement of tissue texture (25%) and the addition of bleeding (25%). CONCLUSIONS: This procedural penile prosthesis simulation offers the opportunity to practice each step of IPP placement, obviating the need for specialized facilities. The non-biohazardous nature of this model provides a safe and accessible supplement for penile prosthesis surgical training. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e447-e447 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rachel Melnyk More articles by this author Patrick Saba More articles by this author Michael Witthaus* More articles by this author Gareth Warren More articles by this author Divya Ajay More articles by this author Timothy Campbell More articles by this author Alexander Cranwell More articles by this author Ahmed Ghazi More articles by this author Ricardo Munarriz More articles by this author Expand All Advertisement PDF downloadLoading ...

MP39-08 DRAIN, RETAIN, CAP &amp; ENTRAP: A NOVEL APPROACH TO FIXATE THE PENILE IMPLANT RESERVOIR

You have accessJournal of UrologySexual Function/Dysfunction: Surgical Therapy II (MP39)1 Apr 2020MP39-08 DRAIN, RETAIN, CAP & ENTRAP: A NOVEL APPROACH TO FIXATE THE PENILE IMPLANT RESERVOIR Daniel Heslop*, Matthew Houlihan, Matthew Ziegelmann, Sevann Helo, Jonathan Clavell, and Tobias Köhler Daniel Heslop*Daniel Heslop* More articles by this author , Matthew HoulihanMatthew Houlihan More articles by this author , Matthew ZiegelmannMatthew Ziegelmann More articles by this author , Sevann HeloSevann Helo More articles by this author , Jonathan ClavellJonathan Clavell More articles by this author , and Tobias KöhlerTobias Köhler More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000888.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) reservoir herniation or migration may occur with standard or sub-muscular placement. Reservoirs that are “drained & retained” may develop subsequent infection in accumulated reservoir fluid or more disturbingly, migrate to astonishing locations (near spleen, intertwined in bowel, etc.). Herein, we describe a novel technique to fixate IPP reservoirs into the preferred position. METHODS: We performed a total of 9 cases in between January 2019 and October 2019 in which we fixed the reservoir into position using our new technique. Four cases were required for an overly generous fascial defect for standard Retzius reservoir placement, two were performed to anchor non-Retzius reservoirs thought to be high risk for migration, and three were performed in non-infected retained reservoir scenarios where a reasonable attempt at removal either failed or was considered high risk. Technique: With no vulnerable implant material in the field, a 2-0 ethibond stitch is used to take a strong bite of tissue overlying the pubic bone. One portion of this stitch is then passed through the center of an extra connecter cap from the accessory kit. Next, the tubing of the reservoir is passed through the center of the extra connecter immediately adjacent to the suture. Finally, after the reservoir is ideally positioned, the ethibond is tied down pulling the extra connecter toward the pubis. In cases were reservoir herniation or migration is feared, the additional connecter acts as a backstop for the neck or lock out valve of the reservoir preventing migration down into the scrotum. In drain and retain scenarios, the reservoir is emptied, then capped (theoretically avoiding accumulation of fluid that can get infected) and the additional connecter acts as a backstop for the connecter used to cap the device preventing reservoir migration away from the scrotum. RESULTS: To date, all nine patients have done well with no post-procedural infections, reservoir migrations or complications. Mean follow up is 4.0 months. The technique extended the case time by a mean of 7.5 minutes. CONCLUSIONS: Our novel technique is feasible, and although further follow up and power is needed, may reduce reservoir complications. Source of Funding: None. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e579-e580 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Heslop* More articles by this author Matthew Houlihan More articles by this author Matthew Ziegelmann More articles by this author Sevann Helo More articles by this author Jonathan Clavell More articles by this author Tobias Köhler More articles by this author Expand All Advertisement PDF downloadLoading ...

MP40-13 ECTOPIC RESERVOIR PLACEMENT IN THE LATERAL RETROPERITONEUM DURING ARTIFICIAL URINARY SPHINCTER PLACEMENT: A REVIEW OF 729 CASES

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy I (MP40)1 Apr 2020MP40-13 ECTOPIC RESERVOIR PLACEMENT IN THE LATERAL RETROPERITONEUM DURING ARTIFICIAL URINARY SPHINCTER PLACEMENT: A REVIEW OF 729 CASES Jeffrey Loh-Doyle*, Azadeh Nazemi, Akbar Ashrafi, Eli Thompson, Mukul Patil, David Ginsberg, and Stuart Boyd Jeffrey Loh-Doyle*Jeffrey Loh-Doyle* More articles by this author , Azadeh NazemiAzadeh Nazemi More articles by this author , Akbar AshrafiAkbar Ashrafi More articles by this author , Eli ThompsonEli Thompson More articles by this author , Mukul PatilMukul Patil More articles by this author , David GinsbergDavid Ginsberg More articles by this author , and Stuart BoydStuart Boyd More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000889.013AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The artificial urinary sphincter (AUS) remains the gold standard treatment for male stress urinary incontinence (SUI).Conventionally, the pressure regulating balloon (PRB) is placed in the retropubic space. After extirpative pelvic surgery or radiotherapy, this space can be scarred and placing the reservoir in this space can lead to complications during initial placement and subsequent extraction, including significant vascular injury. To prevent this, several strategies for placing prosthetic reservoirs in alternate locations have been devised. We describe our technique that facilitates safe placement, simplifies subsequent interrogation and exchange, and avoids the reservoir-related complications associated with other locations. METHODS: We retrospectively reviewed an institutional review board approved prosthetic database of male patients that underwent placement of an AUS (AMS 800TM, Boston Scientific, Marlborough, MA) from 2005 to 2019. Patients with follow-up duration less than 6 months were excluded. All patients underwent ectopic placement of the PRB in the lateral retroperitoneum. The medical record of each patient was then specifically queried for reservoir-related complications including bladder and bowel injury, erosion into adjacent structures, vascular injury, herniation, palpability, leak, and tubing torsion during initial implantation and subsequent follow-up. RESULTS: From 2005-2019, 729 male patients with stress incontinence underwent implantation of an AUS. A total of 11 (1.5%) PRB-related complications were identified. No injuries to bowel or major vasculature occurred during placement or removal of the reservoir during subsequent revision. There were no instances of erosion into adjacent structures. Two patients had herniation of the reservoir into the subcutaneous space. 3 other patients were noted to have a palpable reservoir. There were no cases of mechanical failure attributed to torsion or twisting of tubing. 7 patients experienced failure of the device due to an identified leak that in the PRB. All patients underwent successful reservoir replacement without complication. One patient developed an infection of the PRB. The patient underwent immediate salvage removal and replacement of the entire device. CONCLUSIONS: Ectopic placement of the PRB in the lateral retroperitoneum during AUS placement is quick, safe, and avoids reservoir-related complications during implantation and future exchange. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e591-e591 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeffrey Loh-Doyle* More articles by this author Azadeh Nazemi More articles by this author Akbar Ashrafi More articles by this author Eli Thompson More articles by this author Mukul Patil More articles by this author David Ginsberg More articles by this author Stuart Boyd More articles by this author Expand All Advertisement PDF downloadLoading ...

Reservoir placement

Reservoir placement

Reusing of condensate water harvesting from spilt units for domestic and irrigation purposes: residential complex in Al-Mussiab Technical Institute and College, Iraq, as a case study

The research deals with the sustainable development of water resources. It considers with the possibility to benefit from condensate water harvesting from split units for domestic and irrigation purposes in residential complex of Al–Mussiab Technical Institute and College located in the Babylon Government of Iraq, which is selected as a case study. Ten samples of the water are collected in the scaled containers distributed in selected houses and apartments during six months of test in summer and winter seasons. The required physical and chemical parameters of water quality that is suitable for domestic and irrigation purposes requirements are tested. The results of the tests showed that the physical parameters are within Iraqi Standards while only Sulfates for heating condensate water are out of Iraqi Standards of chemical parameters. The results are also showed that the condensate water from cooling is soft in terms of suitability for washing clothes; while the condensate water from heating spilt units is very hard and the soap does not soak in the water; but they could be used to wash the floors and toilet as well as in the air coolers because there is no salt in them. On the other hand, the results demonstrate the validity of condensate water for drinking animals; especially the Poultry. The amount of condensate water harvesting from the split units that is collected from the residential complex forms 11% from the total consumption of water and this quantity of water could be added to the available water in the residential complex. It is concluded from the research, the condensate water from the cooling spilt units is within the limits, while the heating water exceeded the specified specifications for irrigation water and household water pumps. The research recommends to consider the placement of pipes and reservoirs for condensation water when designing residential complex, and to conduct studies about the effect of reusing the condensate water in agriculture on soil.

Evaluation of chlorine dioxide gas release rates from dry precursors intended for applied technologies under disparate conditions and their effects on Salmonella enterica, Escherichia coli O157:H7, and Listeria monocytogenes

The diverse food safety issues facing developed countries require innovations to current food safety intervention technologies and chemistries. Several innovations have been made to highly efficacious treatments, such as chlorine dioxide (ClO2). However, many of the innovations stop short of evaluating actual yield, practical feasibility, or basic chemistry of the technology. In this study, our aim was to evaluate ClO2 precursors, sodium chlorite and citric acid, under disparate but applicable conditions. First, we modeled production of ClO2 from the powdered precursors with three different masses, sample ID 1, 2, and 3, at room (18 °C) and refrigeration (2 °C) temperatures. Second, we investigated the effects of a water reservoir on ClO2 production. Third, we assessed collection method issues that may impact reported ClO2 values. Finally, we evaluated the precursor's efficacy against three common foodborne pathogens: Salmonella spp., Escherichia coli O157:H7, and Listeria monocytogenes on a glass surface between 15- to 60-min treatment times. Over 25 h the precursors produced between 1.87- to 37.76- and 0.87- to 4.19-mg ClO2 under 18 and 2 °C, respectively, demonstrating that low temperatures reduced ClO2 reported yield. Peak rates of production at 18 °C were estimated to be 3.51 mg/h, 3.83 mg/h, and 4.78 mg/h for sample ID 1, 2, and 3, respectively. Modeling the rate of production indicated that sample IDs had significantly (p < 0.0065) different rates of production, with sample ID 1 having the quickest production rate. Under 2 °C, these rates were <1 mg/h of all masses tested and did not follow the same production pattern observed at 18 °C. Under controlled conditions, availability of a water reservoir significantly increased ClO2 production by >15 fold. We also determined that the reservoir placement could affect reported ClO2 concentrations. At the same time, ClO2 was able to reduce all three pathogens in <45 min by >6-log10 CFU/carrier and performed significantly better at refrigeration temperature compared to room temperature.

Cyst fenestration and Ommaya reservoir placement in endoscopic transcortical transventricular approach for recurrent suprasellar cystic craniopharyngioma without ventriculomegaly

The efficacy of the endoscopic transcortical transventricular approach (ETTA) for craniopharyngioma in the third ventricle with hydrocephalus has been reported focusing on its reduced invasiveness. On the other hand, suprasellar craniopharyngioma without ventriculomegaly is generally surgically managed by craniotomy or the endoscopic endonasal approach (EEA). Here, we report an elderly patient who received cyst fenestration and Ommaya reservoir placement in ETTA for recurrent suprasellar cystic craniopharyngioma without ventriculomegaly. The ETTA as a less invasive procedure is feasible in patients not only with intraventricular craniopharyngioma but also with suprasellar craniopharyngioma without hydrocephalus provided a navigational system is applied and the surgeon has ample experience with transcranial endoscopic procedures.

Hydrocephalus – Focus Session

Dear Reader, You are receiving the second volume of Archives of Pediatric Neurosurgery. This is an electronic journal from the Brazilian Society of Pediatric Neurosurgery, which is published quarterly. We are dedicating this volume to hydrocephalus-related topics. Hydrocephalus is one of the most important topics in pediatric neurosurgery and is related to up to 40% of the activities performed in many specialized services. With its multiple etiologies and variety of proposed treatment modalities, this disease presents a huge challenge, and many questions have not been answered. When focusing on fetal hydrocephalus, we still cannot determine which fetuses will benefit from treatment during the fetal period. The answers are also unclear as to why surgery for myelomeningocele correction performed under 27 weeks of gestation decreases the prevalence of hydrocephalus. What is the best treatment for intraventricular hemorrhage in premature infants: Brain Washing, external ventricular drainage, ventriculosubgaleal shunt, reservoir placement and repeated punctures or lumbar punctures? Furthermore, what is the best treatment for hydrocephalus in cases of posterior fossa tumor: Placing an external ventricular drain and resecting the tumor, performing a third ventriculostomy or placing a ventriculoperitoneal shunt, considering that in cases of giant tumors in each of these situations, ascending herniations can occur? Of course, the procedure selected will be related to the dynamics, volume and expertise of the treatment center. Regarding valves, we know that the number of shunts implanted annually is enormous and that the market for valves is divided among several companies that manufacture these prostheses. Which valve is the best? An anti-gravitational one, a programmable one, one with an anti-siphon mechanism? Fixed-pressure valves, valves that produce fewer MRI artifacts, those that do not experience pressure changes due to MRI, or those impregnated with antibiotics? How can a simple valve work as well as a valve with a complex system? Why does a valve system cost $1,000 in one country but costs ten times more in another country? Why are some types of valves sold only in underdeveloped countries? How can we avoid or minimize biological and mechanical complications after valve placement? Even neuroendoscopic procedures that have been performed for more than 25 years in Brazil are not free of complications such as bleeding, infection and technical incapacity of the professional. Nevertheless, we believe that all services that treat children with hydrocephalus should be able to provide neuroendoscopic procedures, thus decreasing the number of shunts placed. We hope that this volume can answer some of these questions. I invite you to participate in Archives of Pediatric Neurosurgery by contributing scientific articles focusing on pediatric neurosurgery. This volume was compiled during the coronavirus (COVID-19) pandemic. We hope that this disease will be controlled quickly, allowing us to return to our normal activities. We also hope that pregnant women will not transmit the disease to their fetuses, causing hydrocephalus, as was observed in the last Zika virus epidemic. Sincerely, Sergio Cavalheiro Editor-in-chief, Archives of Pediatric Neurosurgery

336 Reservoir Induced Bladder Rupture: A Rare Complication of Inflatable Penile Prosthesis Revision Surgery

Bladder rupture is a rare complication following prosthesis component replacement for malfunction. Current practice for a deflated reservoir involves overdistention of the reservoir during revision surgery, which can increase the risk of this complication. There is limited literature describing this complication or providing recommendations regarding intraoperative or postoperative management. Our objective is to describe our experiences with this rare complication and propose ways to manage and possibly avoid this complication. We retrospectively reviewed the charts of two patients who underwent inflatable penile prosthesis (IPP) revision surgery complicated by bladder rupture. Intraoperatively, the existing reservoirs had been left in situ and overdistended to break the surrounding fibrous capsule according to common practice prior to being placed in circuit with new cylinders and pump. Gross hematuria was noted in each case following this technique. Delayed identification of the complication occurred in the first case, while the complication was immediately recognized in the second case. The first patient returned to the OR for complete penile prosthesis removal and replacement of component parts including placement of an ectopic reservoir and foley catheter. He subsequently underwent bladder closure for a persistent bladder leak. The second patient underwent immediate removal of three-piece penile prosthesis and placement of a malleable prosthesis and foley catheter. Follow-up cystogram demonstrated the bladder had completely healed with conservative management alone. On follow-up, both patients were satisfied with their penile prostheses and able to engage in penetrative intercourse. Immediate intervention following identification of this complication was crucial to the successful outcomes. In retrospect, this complication may have been minimized if the reservoirs were refilled, but not overdistended. Any back pressure may signify the fibrous capsule has become too thickened and may perforate the bladder if broken. Alternative reservoir placement or placement of a malleable prosthesis may be safer options in this scenario.

333 Extended Experience with High Submuscular Placement of Inflatable Penile Prosthesis Reservoirs

333 Extended Experience with High Submuscular Placement of Inflatable Penile Prosthesis Reservoirs

Intraventricular metastases from rectal carcinoma: case report and literature review.

Intraventricular metastases are a rare occurrence, particularly from a primary colorectal malignancy. To our knowledge, this is the first report of intraventricular metastasis from rectal cancer. A 72-year-old male presented with a new diagnosis of multiple intraventricular lesions, an anterior mediastinal mass and a rectal mass. His workup revealed rectal adenocarcinoma with intraventricular metastases and an incidental thymoma. Ommaya reservoir placement was performed via an awake procedure rather than under general anesthesia due to airway concerns. Cerebrospinal fluid (CSF) cytology was positive for malignancy and consistent with adenocarcinoma. Two weeks postoperatively, the patient underwent whole brain radiation. Although rare, this diagnosis should always be considered in the differential for solitary or multiple intraventricular lesions. CSF sampling is a useful alternative to intraventricular biopsy for diagnosis of intraventricular metastases. Awake placement of Ommaya reservoir is a safe option in the management of patients with intraventricular metastases, especially those who cannot undergo general anesthesia.

Surgery in the Neonatal Intensive Care Unit in Indian Scenario: Should It be "The New State of the Art" or Just "The Need of the Hour"?

Introduction:Critically ill surgical neonates are physiologically challenged and delicately poised on ventilator and inotropic support systems. They experience significant stress in the event of surgery. Shifting them poise further addition to this stress. We here share our experience of operating such surgical neonates for certain conditions in the neonatal intensive care unit (NICU).Methods:We retrospectively analyzed the data of operated patients in the NICU. We collected the demographic data, diagnosis, and preoperative stability of the patient, ventilator and inotropic requirements, need for extra anesthetic drugs, procedures performed, complications, and outcome. Operations were performed at bedside in the NICU in critically ill, unstable neonates who needed emergency surgery, neonates of very low birth weight (<1000 g), and neonates on special equipment such as high-frequency ventilators. We excluded minor routine procedures such as drain placement, central line placement, ventricular taps, incision and drainage, and intercostal drainage procedures.Results:We performed seven surgical procedures in the NICU. These included bowel resections and stoma creation, fistula ligation, lung biopsies, and ventricular reservoir placement. Gestational age ranged between 24 and 34 weeks (mean, 28 weeks). Birth weights ranged between 800 and 2500 g (mean, 1357 g). Age at surgery was between 2 and 18 days (mean, 10.2 days). All our patients were on inotropic support and were intubated and mechanically ventilated.Conclusion:Doing surgery for critically ill neonates in the NICU definitely has a place. It was the need of the hour based on the condition of the neonates; however, we feel that neonatal surgery in the NICU should be the norm as it can improve survival. Surgery in the NICU can give a fighting chance to these patients; however, operation theaters in the NICU would be an ideal setting.

ML-14 LOW INVASIVE APPROACH FOR PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA TREATMENT INVOLVING RITUXIMAB–METHOTREXATE + PROCARBAZINE + VINCRISTINE AND TRIPLE INTRATHECAL INJECTION

INTRODUCTIONAlthough the treatment outcomes of primary central nervous system lymphoma (PCNSL) with multiple treatment regimens involving high–dose methotrexate (MTX)–based multiagent chemotherapy have improved compared with the outcomes with high–dose methotrexate therapy in recent years, its regimen has not been established. Additionally, it is controversial whether intrathecal (IT) MTX injection can be included in a regimen. Our facilities treat PCNSL with R–MPV (rituximab–methotrexate + procarbazine + vincristine) and triple IT injection (methotrexate + Ara C + prednisolone). Here we report a low invasive approach for PCNSL treatment involving R–MPV therapy and triple IT injection.CASE DESCRIPTIONA 58–year–old woman complained of prolonged headache and had undergone a medical checkup at our department. Head computed tomography revealed a mass lesion with edema near the right anterior horn of the lateral ventricle. After being hospitalized, biopsy was performed via a small craniotomy for the mass lesion near the right anterior horn of the lateral ventricle, which was suspected to be PCNSL. Multipurpose Head Frame 2 (Mizuho Co., Ltd.) was used for four points of head fixation. Vertek Biopsy Kit (Medtronic Co., Ltd.) was attached to it, and needle biopsy guided by neuronavigation was performed. Finally, biopsy samples were obtained from the lesion. Changes in the entry and target points could be easily made through the operative procedure, which was performed uneventfully. The diagnosis was B–cell–related lymphoma. Subsequently, an Ommaya reservoir was placed via lumbar puncture on postoperative day 7. Finally, the patient was successfully treated with R–MPV therapy and triple IT injection, thereby avoiding repeated lumbar puncture and reduced pain associated with IT injection.CONCLUSIONWe have reported the diagnosis of PCNSL with needle biopsy guided by neuronavigation and its treatment with R–MPV therapy and triple IT injection after lumbar Ommaya reservoir placement. This approach was associated with reduced invasion and pain in the patient.

The Prevalence and Treatment of Erectile Dysfunction in Male Solid Organ Transplant Recipients.

Erectile dysfunction (ED) is a prevalent and under-recognized complaint among male solid organ transplant recipients. Most research on this topic has focused on kidney transplant recipients alone. In this review, we integrate current research on ED across all types of solid organ transplant recipients and assess the success of current methods of ED treatment in transplant populations. To review the current literature addressing the prevalence and treatment of ED in the male solid organ transplant population. A literature search was conducted using PubMed to identify relevant studies. Search terms included "organ transplant" and "erectile dysfunction." Titles and abstracts were reviewed for relevance. References from identified articles were also searched and included, if appropriate. Review of peer-reviewed literature. The prevalence of ED among transplant recipients is higher than that in the general population: 39.8-86.2% in liver transplant recipients, 54-66% in renal transplant recipients, 71-78% in heart transplant recipients, and 79% in simultaneous pancreas-kidney transplant recipients. Phosphodiesterase-5 inhibitors have up to 80% efficacy in treating ED in kidney transplant recipients. Intracavernosal injections have been used with success rates of 60-70% in cardiac and renal transplant recipients. Penile prostheses have also been shown to be safe and effective across transplant types. A low incidence of infection has been reported in several case series, although there is concern for an increased rate of mechanical complications in pelvic organ transplant recipients. Accordingly, placement of a two-piece or malleable prosthesis or ectopic reservoir placement with a three-piece inflatable prosthesis is suggested in this population. ED is highly prevalent among male solid organ transplant recipients and should be routinely screened in this population. Current modalities of ED treatment used in the general population are safe and effective in solid organ transplant recipients, although success rates are often lower than those in the general population. Payne K, Popat S, Lipshultz LI, etal. The Prevalence and Treatment of Erectile Dysfunction in Male Solid Organ Transplant Recipients. Sex Med Rev 2021;9:331-339.

Re: High-Submuscular vs. Space of Retzius Reservoir Placement during Implantation of Inflatable Penile Implants.

Re: High-Submuscular vs. Space of Retzius Reservoir Placement during Implantation of Inflatable Penile Implants.

HOUT-09. DEVELOPING OMMAYA CLINICS FOR LEPTOMENINGEAL CARCINOMATOSIS (LMC): STANDARDIZED TREATMENT, IMPACT ON SURVIVAL/NEUROLOGIC DISABILITY AND ROLE FOR ADVANCED PRACTITIONERS

Abstract Leptomeningeal carcinomatosis (LMC), first described in 1870, involves leptomeningeal and CSF invasion by neoplastic cells and portends poor survival. Among solid tumor LMC, breast cancer is the most common followed by lung and melanoma. With an estimated 100,000+ new cases yearly, the dual-edged sword of systemic treatment drives the increasing incidence as cancer patients live longer and on non-CNS penetrating therapies. Addition of immuno-oncotherapies has impacted LMC survival. At time of diagnosis, most patients have multiple neurologic disabilities. Multiple reports on the topic have not yielded consistent treatment standards to extend patient survival. Most agree that local CNS control coupled with systemic therapy offers the best survival. Still, there are few established Ommaya clinics (OC). Importantly, LMC is a common exclusionary criterion for clinical trials. A single institutional evaluation of 147 patients (2012–2019) with a diagnosis of LMC was completed. 69 of 147 were excluded, leaving 48 pre-OC and 30 OC patients. The mOS (weeks) of those treated with intrathecal chemotherapy (ITC) versus no ITC was compared between cohorts: pre-OC and OC (3.36, 15.29****). Average KPS at time of diagnosis in pre-OC and OC was 70–80 (ECOG 2–3). The mOS was compared between breast (5, 28*), lung (3, 3) and melanoma (5,10*) in the pre-OC and OC respectively. The treatment standardized for the OC includes whole-brain radiation, Ommaya reservoir placement, systemic treatment, treatment with ITC (2x weekly – q other month) and MR imaging every 3 months. Breast cancer patients fared the best followed by melanoma and lung patients in the OC. With use of advanced practitioners (APs), standardization of treatment and surveillance is achievable. Patients treated according to a standardized OC regimen experienced longer overall survival along with a 10% improvement in KPS after two months of treatment. Development of institutional OCs reduces treatment variability and increases clinical surveillance.