Case Report Venous Thromboembolism Secondary to Penile Prosthesis Timothy Shiraev,1 and Antony Graham,2,3 Kogarah and Darlinghurst, Australia
We report the case of a 65-year-old male who presented with an extensive iliofemoral venous thrombosis, which computed tomography demonstrated was secondary to compression of the right common and external iliac veins by a 5-cm diameter penile prosthesis reservoir. A similar occurrence has only been reported a handful of times previously, and only in urological journals, never in vascular literature. It is a potentially serious complication of penile prosthesis surgery, the risk of which can be minimized by ready awareness of this postoperative event.
CASE REPORT A 65-year-old male with a background of chronic lymphoblastic leukemia and erectile dysfunction presented with a painful, swollen right leg shortly after driving for 10 hours. On examination the right leg was edematous to the groin. Venous Doppler revealed an extensive iliofemoral venous thrombosis (Fig. 1), which computed tomography (CT) demonstrated was secondary to compression of the right common and external iliac veins by a 5-cm diameter penile prosthesis reservoir (Fig. 2). The patient denied symptoms consistent with a pulmonary embolism. An urologist was consulted, and the patient taken to theater. An incision was made over the deep ring, the reservoir tubing identified and mobilized, and the reservoir was deflated. The patient was then commenced on heparin and warfarin until the international normalised ratio was therapeutic. The reservoir had been inserted into
1 Department of Surgery, St George Hospital, Kogarah, New South Wales, Australia. 2 Division of Surgery, St Vincent’s Hospital, Darlinghurst, New South Wales, Australia. 3 St Vincent’s Clinic Vascular Laboratory, Darlinghurst, New South Wales, Australia.
Correspondence to: Timothy Shiraev, BSc (Hons), MBBS (Hons), St George Hospital, Gray Street, Kogarah, New South Wales 2217, Australia; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–2 http://dx.doi.org/10.1016/j.avsg.2014.06.076 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 18, 2014; manuscript accepted: June 20, 2014; published online: ---.
the preperitoneal space via the deep ring and had migrated to the right side of the pelvis. The urologist and vascular surgeon recommended repositioning the reservoir, or placing a new reservoir in the midline with fixation to local tissue to prevent migration. Lower limb venous thromboembolism (VTE) secondary to compression of pelvic veins by the reservoir component of a penile prosthesis is extremely rare,1 with only a handful of cases previously reported.2e4 Time from prosthesis implantation to presentation ranged from 12 to 96 hr in the previously described cases,2e4 although the patient described presented over 2 years after surgical intervention. Management involves removing the causative foreign body, and then as for any venous thrombosis, namely heparin and warfarin.4 Adhesion formation secondary to previous radiotherapy or surgical intervention has been reported to predispose to reservoir migration, causing compression of local vasculature.2,4 Penile prosthesis reservoirs range in size from 65 to 100 mL and are placed blindly into the retropubic space through a penoscrotal incision, via the external inguinal ring.4 A separate suprapubic incision can be made to reduce the risk of vascular compression, which should be considered in patients at high risk of migration.2 Complication rates differ between the available types of prosthesis,5 but incidence of venous thrombosis secondary to these devices is so rare that differences in VTE risk is not known. In conclusion, lower limb VTE secondary to penile prosthesis reservoir compression of pelvic veins is a rare but serious complication of penile prosthesis surgery, the risk of which can be minimized by careful placement of prosthesis components4 and ready awareness of this postoperative adverse event.
1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Ultrasound with compression demonstrates incompressible (A) right common femoral and (B) right external iliac veins.
REFERENCES 1. Sadeghi-Nejad H. Penile prosthesis surgery: a review of prosthetic devices and associated complications. J Sex Med 2007; 4:296e309. 2. Brison D, Ilbeigi P, Sadeghi-Nejad H. Reservoir repositioning and successful thrombectomy for deep venous thrombosis secondary to compression of pelvic veins by an inflatable penile prosthesis reservoir. J Sex Med 2007;4(4 Pt 2): 1185e7. 3. da Justa DG, Bianco FJ Jr, Ogle A, Dhabuwala CB. Deep venous thrombosis due to compression of external iliac vein by the penile prosthesis reservoir. Urology 2003;61:462.
Fig. 2. CT reveals penile prosthesis reservoir compressing the neurovascular bundle in both (A) axial and (B) coronal views. 4. Deho F, Henry GD, Marone EM, et al. Severe vascular complication after implantation of a three-piece inflatable penile prosthesis. J Sex Med 2008;5:2956e9. 5. Wilson S, Delk J, Salem E, Cleves M. Long term survival of inflatable penile prostheses: single surgical group experience with 2,384 first-time implants spanning two decades. J Sex Med 2007;4:1074e9.
We report the case of a 65-year-old male who presented with an extensive iliofemoral venous thrombosis, which computed tomography demonstrated was secondary to compression of the right common and external iliac veins by a 5-cm diameter penile prosthesis reservoir. A similar occurrence has only been reported a handful of times previously, and only in urological journals, never in vascular literature. It is a potentially serious complication of penile prosthesis surgery, the risk of which can be minimized by ready awareness of this postoperative event.
CASE REPORT A 65-year-old male with a background of chronic lymphoblastic leukemia and erectile dysfunction presented with a painful, swollen right leg shortly after driving for 10 hours. On examination the right leg was edematous to the groin. Venous Doppler revealed an extensive iliofemoral venous thrombosis (Fig. 1), which computed tomography (CT) demonstrated was secondary to compression of the right common and external iliac veins by a 5-cm diameter penile prosthesis reservoir (Fig. 2). The patient denied symptoms consistent with a pulmonary embolism. An urologist was consulted, and the patient taken to theater. An incision was made over the deep ring, the reservoir tubing identified and mobilized, and the reservoir was deflated. The patient was then commenced on heparin and warfarin until the international normalised ratio was therapeutic. The reservoir had been inserted into
1 Department of Surgery, St George Hospital, Kogarah, New South Wales, Australia. 2 Division of Surgery, St Vincent’s Hospital, Darlinghurst, New South Wales, Australia. 3 St Vincent’s Clinic Vascular Laboratory, Darlinghurst, New South Wales, Australia.
Correspondence to: Timothy Shiraev, BSc (Hons), MBBS (Hons), St George Hospital, Gray Street, Kogarah, New South Wales 2217, Australia; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–2 http://dx.doi.org/10.1016/j.avsg.2014.06.076 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 18, 2014; manuscript accepted: June 20, 2014; published online: ---.
the preperitoneal space via the deep ring and had migrated to the right side of the pelvis. The urologist and vascular surgeon recommended repositioning the reservoir, or placing a new reservoir in the midline with fixation to local tissue to prevent migration. Lower limb venous thromboembolism (VTE) secondary to compression of pelvic veins by the reservoir component of a penile prosthesis is extremely rare,1 with only a handful of cases previously reported.2e4 Time from prosthesis implantation to presentation ranged from 12 to 96 hr in the previously described cases,2e4 although the patient described presented over 2 years after surgical intervention. Management involves removing the causative foreign body, and then as for any venous thrombosis, namely heparin and warfarin.4 Adhesion formation secondary to previous radiotherapy or surgical intervention has been reported to predispose to reservoir migration, causing compression of local vasculature.2,4 Penile prosthesis reservoirs range in size from 65 to 100 mL and are placed blindly into the retropubic space through a penoscrotal incision, via the external inguinal ring.4 A separate suprapubic incision can be made to reduce the risk of vascular compression, which should be considered in patients at high risk of migration.2 Complication rates differ between the available types of prosthesis,5 but incidence of venous thrombosis secondary to these devices is so rare that differences in VTE risk is not known. In conclusion, lower limb VTE secondary to penile prosthesis reservoir compression of pelvic veins is a rare but serious complication of penile prosthesis surgery, the risk of which can be minimized by careful placement of prosthesis components4 and ready awareness of this postoperative adverse event.
1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Ultrasound with compression demonstrates incompressible (A) right common femoral and (B) right external iliac veins.
REFERENCES 1. Sadeghi-Nejad H. Penile prosthesis surgery: a review of prosthetic devices and associated complications. J Sex Med 2007; 4:296e309. 2. Brison D, Ilbeigi P, Sadeghi-Nejad H. Reservoir repositioning and successful thrombectomy for deep venous thrombosis secondary to compression of pelvic veins by an inflatable penile prosthesis reservoir. J Sex Med 2007;4(4 Pt 2): 1185e7. 3. da Justa DG, Bianco FJ Jr, Ogle A, Dhabuwala CB. Deep venous thrombosis due to compression of external iliac vein by the penile prosthesis reservoir. Urology 2003;61:462.
Fig. 2. CT reveals penile prosthesis reservoir compressing the neurovascular bundle in both (A) axial and (B) coronal views. 4. Deho F, Henry GD, Marone EM, et al. Severe vascular complication after implantation of a three-piece inflatable penile prosthesis. J Sex Med 2008;5:2956e9. 5. Wilson S, Delk J, Salem E, Cleves M. Long term survival of inflatable penile prostheses: single surgical group experience with 2,384 first-time implants spanning two decades. J Sex Med 2007;4:1074e9.
