What is the recommended next step if a distal urethral perforation occurs during malleable penile prosthesis insertion before the contralateral cylinder is placed?

Management of Distal Urethral Perforation During Malleable Penile Prosthesis Insertion

In the case of a distal urethral perforation during malleable penile prosthesis insertion before the contralateral cylinder is placed, the recommended next step is to abort the procedure, place a urinary catheter for drainage, and plan for delayed repair and prosthesis placement.

Assessment and Initial Management

When a distal urethral perforation is identified during malleable penile prosthesis insertion:

1. Immediate steps:

   • Stop the procedure
   • Assess the extent of the urethral injury
   • Place a urethral catheter (if possible) or suprapubic catheter for urinary drainage

2. Antibiotic coverage:

   • Initiate broad-spectrum antibiotic therapy to prevent infection

Rationale for Aborting the Procedure

Continuing with prosthesis placement after urethral perforation carries significant risks:

• Increased infection risk: Urethral perforation creates a direct communication between the urethra and corpora cavernosa, introducing urinary contamination to the prosthesis site 1
• Risk of fistula formation: Urethrocavernous fistulas can develop, requiring complex repair 2
• Higher likelihood of prosthesis erosion: Patients with urethral injuries during implantation have higher rates of subsequent erosion 3
• Potential for recurrent perforation: Without adequate healing, the risk of repeat perforation increases 4

Risk Factors to Consider

Several factors increase the risk of urethral perforation and complications:

• Diabetes mellitus
• Corporal fibrosis
• Prior pelvic radiation
• Neurological impairment
• Revision surgery 2, 4

Management Algorithm

Immediate Phase:

1. Abort the procedure
2. Establish urinary drainage via urethral catheter or suprapubic tube
3. Administer prophylactic antibiotics
4. Document the location and extent of the perforation

Intermediate Phase:

1. Maintain urinary drainage for 2-4 weeks to allow healing
2. Monitor for signs of infection or abscess formation
3. Perform urethrography every two weeks to assess healing 5

Delayed Phase:

1. Once complete healing is confirmed (typically 6-12 weeks):
   • Consider reattempting prosthesis placement
   • Use caution during corporal dilation, particularly at the site of previous perforation
   • Consider reinforcement techniques at the site of previous injury if reimplantation is performed 4

Special Considerations

• Urethral catheter vs. suprapubic tube: While urethral catheterization is generally preferred when possible, suprapubic catheterization may be considered in cases with extensive urethral injury or associated perineal injuries 5

• Surgical repair options: If direct repair of the urethral injury is attempted, it should be performed by surgeons experienced in urethral reconstruction, with primary excision and anastomosis for small defects or grafting techniques for larger defects 5, 3

• Prevention of recurrence: During subsequent prosthesis placement, techniques such as double breasting or grafting at the site of previous perforation may provide reliable distal support and prevent reperforation 4

Pitfalls to Avoid

• Continuing with implantation: Although some surgeons report continuing implantation after urethral injury (45% in one survey), this approach carries significant risks and is not recommended as standard practice 1

• Inadequate drainage: Failure to establish proper urinary drainage can lead to urinary extravasation, infection, and abscess formation

• Premature reimplantation: Attempting reimplantation before complete healing of the urethral injury increases the risk of recurrent perforation and prosthesis erosion

By following this approach, you can minimize the risk of serious complications and optimize the chances for successful prosthesis placement in the future.