7889, 1, 33 – MRN D001421186 Norman Moser Dr Christopher Koller dictating on behalf of Wayne Hellstrom, MD July 1 2019 Primary Surgeon: Wayne Hellstrom, MD Assistant(s): Peter Tsambarlis, MD Christopher Koller, MD Pre-procedure diagnosis: Erectile dysfunction IPP malfunction with impending distal erosion Post-procedure diagnosis: same as pre procedure dx Procedures performed: 1. Foley catheter placed by MD 2. Explanation of exisiting Coloplast IPP 26cm +2rte (right side with rte, no rte on left), reservoir and pump not explanted 3. Placement of IPP Coloplast Titan 22cm Specimens removed/altered: REMOVED: IPP coloplast cylinders NOT REMOVED: pump/tubing/reservoir Tube(s): none (16fr foley catheter) Implant(s): Coloplast Titan 23cm, no RTES, 90cc in existing retropubic reservoir Findings: -tubing and pump interrogated, no failure of reservoir tubing. -impending distal erosion of IPP bilaterally, with left proximal cyclinder misplacement -explanted existing IPP cylinders, old reservoir placed on left not explanted -evidence of thin corporal tissues distally R more than L, new cylinders placed slightly more proximal and seated in spaced away from thinning corporal tissue to allow for granulation -no obvious infection or purulence upon explanation Anesthesia: general anesthesia Estimated blood loss in ml: 50cc DISPOSITION: Admit to MED-SURG bed overnight for IV antibiotics and observation. INDICATIONS FOR PROCEDURE: Mr. Norman Moser is a pleasant and well informed 61yo M lives in Pensacola, FL with extensive PMHx here for consultation for IPP revision. PMHx notable for IgG deficiency, htn, diabetes, PTSD, leishmaniasis, recurrent UTIs, hypothyroidism. Surgical history is complex and notable for over 25 surgeries on penis, urethra, and prostate. Patient had first IPP placed in 2011 in San Diego and since then he reports he has had at least 10 revisions for various reasons including length discrepancy, infection, punctured tubing, “cold head syndrome”. Patient currently has a 3-piece Coloplast titan that is 26cm in length placed by Dr. Paul Perrito in Miami Florida. Patient was sense and evaluated in clinic prior to surgery to evaluation for IPP malfunction and concern for distal cylinder erosion bilaterally. Patient’s surgery had previously been scheduled and canceled given he was being treated actively for UTI with IV antibiotics and due to the fact that in consultation with patient it appeared his expectations about increased length and girth were unrealistic. Patient presented to clinic on the day of surgery with a change in baseline physical exam now with distal tips of device even more pronounce and it was decided that patient has impending erosion of the device and the safest course of action would be to revision versus explant the device in the operating room. Patient and wife were counseling extensively regarding expectation of the device, the likelihood that this surgery would almost invariably lead to the shortening of his overall penile length and that this procedure is to fix function not cosmetic outcome. He obtained appropriate clearance prior to the procedure as well consent for possible photography for educational purposes. The potential risks, benefits, and potential complications that might ensure from surgical procedure were discussed in detail with the patient as well as potential management for his IPP malfunction. Risks and benefits discussed including but not limited to pain, infection, bleeding, scar, need for further surgical revision, and injury to the surrounding structures likely urethra, penis, testicles, bladder, and bowel as well as the potential risk for altered cosmetic appearance of the penis and scrotum or altered sensation either temporary or lasting as well as potential future device failure and need for revision surgery. The patient understood these risks and still elected to proceed. PROCEDURE IN DETAIL: After repeat discussion of the indications for the procedure and potential complications as well as the risks and benefits, the patient's informed consent was subsequently obtained. He was taken to the operative suite and placed in the supine position. After confirmation that SCDs were on and working and induction of perioperative antibiotics had been given, the patient underwent general anesthesia. After induction of general anesthesia and confirmation of perioperative antibiotics had been given vancomycin and gentamicin, the patient was prepped and draped as per standard protocol and WHO approved time-out for which Dr. Hellstrom was present. We began by placing Ioban membrane followed by Scott's ring. Subsequently, we placed a 16-French Foley catheter, which passed with some resistance, likely due to known urethral stricture, and drained clear yellow urine. A 10 mL of normal saline was instilled into the balloon and then the bladder was drained. Subsequently, the catheter was capped. We began by making a transverse incision approximately 2 cm in the penoscrotal junction. Dissecting down to the skin, subcutaneous tissue, and dartos fascia down to the existing tubing pump located in the scrotum. We carefully dissected out the existing pump through a combination of sharp, blunt, and electrocautery dissection until it was free and mobilized. At this time, the pump and the surrounding tubings were freely mobilized and the tubing was inspected. At this time, we turned our attention to exposing the corporal tissue and addressed removing the IPP cylinders bilaterally. Both corporal bodies were then exposed approximately 3 cm at the level of the penoscrotal junction and 2 parallel rows of 2-0 Vicryl stitches were applied after corporotomies were made using a Bovie. We started on the left side and carefully removed the existing IPP cylinder using a right angle clamp withdrawing it from the right corporal body. This was removed in its entirety. A nasal speculum was used to inspect the proximal corporal space for any retained rear-tip extenders or foreign bodies. It was noted that the rear-tip extenders and IPP cylinders were removed in entirety and no foreign bodies were present. The same procedure was then performed on the contralateral side, again noting no fragments remaining in the proximal segment of the corporal tissue on inspection using the nasal speculum. Then a leak test was performed by flushing corpora with antibiotic solution, this test illustrate no leak distally and no leakage from urethra. The IPP was then passed off the field. We then turned our attention back to the scrotum and the pump and IPP tubings were then transected and removed. The existing reservoir tubing in then was transected as distally as possible. We interrogated the existing reservoir tubing and removed fluid from reservoir without difficulty. We then began by measuring the corporal bodies using serial dilation with Hegar dilators, starting on the left side and then repeating it on the right. We had a measured stretched corporal length of 12 cm distal, 11 cm proximal on the right and 12 cm distal, 11 cm proximal on the left for a total measurement of 23 cm right and 23 cm left. Decision was made to use a Titan 0-degree 22 cm device without any rear- tip extenders on either side. At this time, we placed a 120 mL reservoir in retropubic space with ease. The reservoir was inflated with approximately 120 mL of normal saline and tested for back pressure and that this was not noted. Approximately 90 mL were left in the reservoir. Shod was applied to the tubing. The IPP was then loaded on the Furlow device and then the left Furlow was passed through the mid glandular position first on the right side followed by the left. Cylinders were placed in a satisfactory position within the corporal bodies as long as there was pressure from glans toward the base of the penis. The cylinders had a tendency to migrate distally towards the area of weaker tissue where erosion is more likely. The device was then deflated and the corporal bodies were closed proximally and stay-stitched on both sides. Hemostasis was achieved. Tubing to the pump and reservoir was then connected in a free manner. The pump was then placed by blunt dissection on the posterior scrotum and the tubing to the pump and the reservoir were secured with a 3-0 Monocryl We then proceeded to close the incision transversely using a 3-0 Monocryl for the dartos layer and 4-0 Monocryl interrupted mattress for the suture for the skin. This concluded the procedure, which the patient tolerated well and Dr. Hellstrom was present for the entire duration of the case. His dressing consisted of collodium, Xeroform gauze, and a Coban wrap along the shaft of the penis. The plan is for him to be admitted for pain control and continue IV antibiotics after recovering in the PACU and he will return to clinic in 1-2 week for a post-operative evaluation.