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Also known as
Reoperation, repeat surgery, secondary surgery, redo surgery, follow-up surgery, additional surgery, subsequent surgery, surgical procedure again.
Definition
Revision surgery is a repeat operation on a previously implanted prosthesis to repair, reposition, replace or remove one or more of its components. For the inflatable penile prosthesis, the two main complications are mechanical failure and infection, and a meta-analysis cited in the EAU Guidelines reported implant survival rates of 87.2% at 5 years and 76.8% at 10 years.1 In a multicenter analysis of over 200 inflatable penile prosthesis revisions, 65% were performed for mechanical failure and 19% for erosion or infection, while 16% involved functioning, uninfected devices revised for patient dissatisfaction, SST deformity, scrotal hematoma or upsizing because of corporal fibrosis.2 The term also covers reoperations on the artificial urinary sphincter (AUS), for which urethral tissue atrophy is probably the most common cause of revision and mechanical failure is another frequent reason.3
Clinical Context
Reoperations have been estimated to be necessary in approximately 30% of penile prostheses over 15 years after the original implantation.4 Indications include mechanical failure such as tubing, cylinder or reservoir leaks and pump malfunction; non-mechanical problems such as component herniation, malposition, erosion or cylinder crossover; chronic postoperative pain; SST deformity; and patient dissatisfaction.2,4,5 Impending erosion involving the distal corpora, urethra or glans can occur in 1-6% of cases after surgery.1
An infected prosthesis requires removal and antibiotic treatment.1 Alternatively, the infected device can be removed and immediately replaced with a new prosthesis using a wash-out protocol, with successful salvage described in more than 80% of cases; the EAU Guidelines state that no absolute recommendation can be given and that the decision should follow full consultation with the patient.1 In a long-term salvage series, 45 of the 55 patients whose status was known (82%) showed no sign of infection.6
Infection rates have been reported to be higher in revision surgery than in primary implantation; one series cited in a review recorded infection in 3% of primary and 10% of revision procedures.7 A more recent review cites infection rates of 1-3% for virgin prostheses and up to 7-18% for revision cases, with risk rising with the number of previous revisions.8 Bacteria are often present on devices that appear uninfected: in a multicenter study, 66% of revised prostheses had positive swab cultures of the fluid around the pump or of visible biofilm, and an antiseptic revision washout reduced positive capsule tissue cultures from 43% to 25%.9 In revisions using antibiotic-coated implants, infection occurred in 10% of cases without washout and in 3% with an antiseptic washout.10 With component exchange followed by revision washout, Henry et al. reported that 93% of cases were successfully revised to a functioning prosthesis, and that 5.7% of clinically uninfected, non-eroded prostheses were complicated by infection or impending extrusion/erosion.2
For the AUS, a series of 1,082 primary implantations reported secondary surgery in 31.2% of patients, for device infection and/or erosion, device malfunction, urethral atrophy, and pump malposition or tubing complications; secondary surgery-free survival was 74% at 5 years and 57% at 10 years.11 Surgical options for revision because of urethral atrophy include relocating or downsizing the urethral cuff, adding a second (tandem) cuff, transcorporal cuff placement, or revising the pressure-regulating balloon to a higher pressure.3