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Also known as
Intrathecal pump implantation, Implantable drug delivery system implantation, Pain pump implantation, Spinal pump placement, Drug infusion pump placement, Device Implantation (specific to pump type, e.g., Baclofen pump implantation, Morphine pump implantation).
Definition
Pump placement is the surgical step in which the hand-operated pump of an implanted urological device is positioned, usually in the scrotum. In a three-piece inflatable penile prosthesis, the pump connects two inflatable cylinders in the corpora cavernosa with a fluid reservoir in the abdomen.1 Squeezing the pump transfers fluid into the cylinders to produce an erection, and a deflation mechanism in the pump allows the fluid to return to the reservoir.2 Because the patient has to locate and operate the pump throughout the life of the device, it is typically placed in a subdartos pouch in a dependent, easily palpable scrotal position, with the deflation button lying anteriorly and inferiorly.3 Poor positioning or later displacement can make the pump difficult to use and is a recognized reason for reoperation to reposition it.2,4 The artificial urinary sphincter (AUS) uses a similar scrotal control pump, which is also placed superficially in a subdartos pouch so that the patient can operate it several times a day.5
Clinical Context
Pump placement is closely linked to the surgical approach. The penoscrotal approach is described as simplifying pump placement, whereas reported disadvantages of the infrapubic approach include difficulty with pump placement because of possible pump migration.6 Surgeons describing the penoscrotal technique also report that the incision helps prevent pump migration.7
During penoscrotal implantation, a subdartos pouch is created in the middle of the scrotum or in one hemiscrotum, and the pump tubing is preferably brought out through the posterior aspect of the pouch.3 Some surgeons secure the pump in its pocket with a “locking” stitch. In one series, two patients (1.7%) required revision because the pump had migrated into the perineum and was difficult to manipulate; the authors reported no further problems with pump position after adopting the locking stitch.7
Pump migration can result from inadequate closure of the scrotal space or from complications such as hematoma, and patients may present with difficulty using the pump.2 In a single-center review of 99 first-time penile prosthesis reoperations, the valve pump was the most frequently repositioned component among reoperations for technical causes (n = 11, 39.3%), and the authors concluded that more than a quarter of reoperations might have been preventable through changes in surgical technique, device positioning and postoperative care.4 Scrotal pump erosion is usually related to infection, although isolated erosion has been described; management may require removal of the entire implant, but salvage techniques that focus solely on revising the pump have also been reported.8
Patient anatomy also matters. Men with a large body habitus can struggle to manipulate a pump placed in the scrotum, and a small case series of three patients has described ectopic placement of the pump in a subcutaneous pocket in the mons fat pad as an alternative.9
In the AUS, the pump is generally placed on the side of the patient’s dominant hand, low in the scrotum in a subdartos pouch; postoperative swelling or hematoma can cause it to migrate upward and make manipulation more difficult.5 In a series of 1,082 primary AUS implantations, 29 patients underwent secondary surgery for pump malposition or tubing complications.10