V09-10: External Iliac Vein Injury from Penile Implant Reservoir Removal - How to Manage and Avoid
Introduction Intraoperative catastrophic bleeding events are infrequent in prosthetic surgery for erectile dysfunction, however significant venous bleeding from the iliac veins during reservoir placement or removal during a 3 piece penile implant remains an infrequent but most feared intraoperative issue for penile implant surgeons. A stepwise surgeon’s guide to manage this complication during penile implant surgery has not been described. Objectives To use our experience with intraoperative external iliac vein bleeding and subsequent vascular management demonstrate to Urologists best practice “how to” guide to technically manage for those who encounter this during penile implant reservoir placement, removal, or remove/replace.
Methods High definition video of an actual case of external iliac vein bleeding intraoperatively during a routine remove/replace 3 piece penile implant for a young patient who required revision of his previously implanted device. The complex repair and management is closely analyzed and demonstrated. Then discussion of real time surgical thinking and actions taken that both succeed and fail are assessed, with video confirmation of which maneuvers gain control and which make the situation worse.
Results: The first step to successful hemostatic control is adequate visualization of origin of the bleed, in most cases this requires a counter incision or extension of incision. Adequate visualization should include view and access to the vein both above and below the laceration. With proper exposure with a counter incision of extension of original incision, proximal and distal pressure using sponge sticks, or similar instruments, should be applied. Alice or other clamping to couple and re-approximate the edges of the vein should be done while assistants are holding proximal/distal control. At this point with proper visualization and hemostatic control, a running prolene suture should be used. Immediate suturing of the venous laceration should not be done until appropriate vascular control is achieved.
Conclusion Repair of this complication in a controlled and efficient manner is a challenging vascular surgical procedure. Stepwise surgical steps will be successful, and these are described. Real time video makes a theoretical clinical scenario an easy to follow and instructive guide. The case presented offers individuals to view of the case in real-time as the surgeon would experience it.