Abstract
Pump erosion is a rare complication of penile prosthesis implantation that often requires explantation. We present a 43-year-old diabetic male who developed impending pump erosion with scrotal skin thinning over a functional prosthesis pump. Salvage was performed by excision of the fibrotic pseudo-capsule and relocation of the pump into the median raphe, combined with antibiotic and antifungal irrigation. The patient recovered uneventfully with excellent cosmetic and functional outcomes. This case highlights pseudo-capsule excision and median raphe repositioning as a safe, effective salvage option in selected patients without infection.
Keywords: Inflatable penile prosthesis, Pump erosion, Salvage surgery, Pseudo-capsule, Penile implant complications
1. Introduction
Inflatable penile prostheses (IPPs) provide effective treatment for medication-refractory erectile dysfunction, with high patient satisfaction. Despite advances, complications such as infection, mechanical failure, and erosion may occur. Pump erosion usually necessitates explantation, leading to fibrosis, penile shortening, and reimplantation difficulties.1,2 Conventional management involves device removal with immediate reimplantation of a malleable prosthesis.3 Alternative strategies such as extracapsular relocation and capsule excision have been explored.4
2. Case presentation
A 43-year-old man with insulin-dependent diabetes, peripheral neuropathy, and bilateral foot ulcers (Fig. 1) presented with localized scrotal skin thinning overlying the pump six weeks after three-piece IPP (AMS LGX) implantation. The device was fully functional, and there were no systemic symptoms or signs of infection. Examination showed attenuated scrotal skin with concern for impending erosion (Fig. 2).
Fig. 1.
Bilateral foot ulcers in a 43-year-old patient with insulin-dependent diabetes mellitus.
Fig. 2.
Localized thinning of scrotal skin overlying the prosthesis pump, showing impending erosion.
The pump was not intentionally placed in a lateral position at the time of initial implantation. A standard sub-dartos pouch was created, and the pump was positioned in the usual fashion without deliberate lateralization.
After informed consent, salvage surgery was performed. The pump was exposed via a scrotal incision. A fibrotic pseudo-capsule was excised, cultures were obtained, and no purulent material was seen. The pump was irrigated and relocated into a new pocket within the median raphe. Washout was performed using a modified Mulcahy protocol with antibiotics and antifungal agents, given recent evidence highlighting fungal infections as important pathogens in prosthesis complications.5 The wound was closed primarily. Postoperatively, the patient received seven days of IV meropenem and fluconazole after consultation of the infectious disease service, followed by 10 days of oral levofloxacin.
3. Outcome and follow-up
The patient had an uneventful recovery. At 1, 3, and 4 months follow-up, there was no recurrence of skin thinning or signs of infection (Fig. 3). The prosthesis functioned normally, and the patient was satisfied with both cosmetic and functional outcomes.
Fig. 3.
Postoperative follow-up at 3 months showing intact scrotal skin without recurrence of thinning or erosion.
4. Discussion
Pump erosion is a rare but significant complication. Standard management involves prosthesis explantation, but this increases morbidity and complicates future reimplantation.1,2 Malleable prostheses have been used as temporary measures,1 while more recent reports describe salvage with extracapsular relocation.4
Our technique preserved the inflatable prosthesis by excising the pseudo-capsule and relocating the pump into healthy median raphe tissue. This minimized operative time, preserved corporal integrity, and avoided the subdartos pouch technique, which may carry a higher risk of re-erosion in diabetic patients with vasculopathy.6 Although older literature discouraged isolated salvage,1 our findings support emerging evidence that selected patients without systemic infection may benefit from conservative salvage.3,7
5. Conclusion
In selected patients with impending pump erosion but no systemic infection, pseudo-capsule excision with pump relocation into the median raphe may offer a safe and effective salvage strategy, preserving device function and reducing surgical morbidity.
Patient consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Funding
No funding was received for this work.
Conflict of interest
The authors declare no conflicts of interest.
References
- 1.Köhler T.S., Modder J.K., Dupree J.M., Bush N.C., McVary K.T. Malleable implant substitution for the management of penile prosthesis pump erosion: a pilot study. J Sex Med. 2009 May;6(5):1474–1478. doi: 10.1111/j.1743-6109.2009.01236.x. PMID: 19453933. [DOI] [PubMed] [Google Scholar]
- 2.Wilson S.K., Delk J.R.I.I. Inflatable penile implant infection: predisposing factors and treatment suggestions. J Urol. 1995 Mar;153(3 Pt 1):659–661. doi: 10.1016/S0022-5347(01)67678-2. PMID: 3599246. [DOI] [PubMed] [Google Scholar]
- 3.Furlow W.L., Goldwasser B. Salvage of the eroded inflatable penile prosthesis: a new concept. J Urol. 1987 Aug;138(2):312–314. doi: 10.1016/s0022-5347(17)43131-4. PMID: 3599246. [DOI] [PubMed] [Google Scholar]
- 4.Shaeer O., Shaeer K., AbdelRahman I.F.S. Salvage and extracapsular implantation for penile prosthesis infection or extrusion. J Sex Med. 2019 May;16(5):755–759. doi: 10.1016/j.jsxm.2019.02.005. PMID: 30898492. [DOI] [PubMed] [Google Scholar]
- 5.Natsos A., Tatanis V., Lekkou A., et al. Unveiling the hidden perils: a comprehensive review of fungal infections in inflatable penile prosthesis surgery. J Personalized Med. 2024 Jun 16;14(6):644. doi: 10.3390/jpm14060644. PMID: 38929865. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Talib R.A., Shamsodini A., Salem E.A., et al. Isolated pump erosion of an inflatble penile prosthesis through the scrotum in a diabetic patient. Arch Ital Urol Androl. 2013 Apr 19;85(1):53–55. doi: 10.4081/aiua.2013.1.53. PMID: 23695409. [DOI] [PubMed] [Google Scholar]
- 7.Basiri A., Zahir M. Successful re-implantation of eroded penile prostheses: report of two cases and review of the literature. Clin Case Rep. 2023 Dec 22;11(12) doi: 10.1002/ccr3.8365. PMID: 38144262. [DOI] [PMC free article] [PubMed] [Google Scholar]