456
SUPPLEMENT ARTICLE Management of Perforation Injuries During and Following Penile Prosthesis Surgery Doron S. Stember, MD,* Tobias S. Kohler, MD, MPH,† and Allen F. Morey, MD‡ *Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; †Urology, Southern Illinois University School of Medicine, Springfield, IL, USA; ‡Urology, UT Southwestern Medical Center, Dallas, TX, USA DOI: 10.1111/jsm.12997
ABSTRACT
Introduction. Distal extrusion of penile prosthesis cylinders is a challenging problem that is associated with pain and imminent erosion through penile skin. Distal extrusion and other perforation injuries, including crural and urethral, are other manifestations of tunica albuginea injuries that result in poor clinical outcomes and patient satisfaction. Aim. A description of Dr. John Mulcahy’s landmark article for management of lateral extrusion is presented along with discussion of techniques for managing other types of perforation injuries associated with penile implants. Methods. Dr. Mulcahy’s original article is reviewed and critiqued. Surgical methods to manage perforation injuries are discussed. Main Outcomes Measures. The main outcome measures used were the review of original article, subsequent articles, and commentary by Dr. Mulcahy. Results. Knowledge of techniques for management intraoperative and postoperative complications related to tunical perforation is necessary for implant surgeons. Conclusions. Perforation injuries are challenging noninfectious complications of penile prosthesis surgery. Familiarity with techniques to manage these problems is essential for ensuring good outcomes and patient satisfaction. Stember DS, Kohler TS, Morey AF. Management of perforation injuries during and following penile prosthesis surgery. J Sex Med 2015;12(suppl 7):456–461. Key Words. Penile Prosthesis; Lateral Extrusion; Distal Extrusion; Erectile Dysfunction; Crural Perforation; Surgical Complication
Introduction
D
istal or lateral extrusion of penile prosthesis cylinders is a well-recognized and challenging complication following implant surgery for erectile dysfunction (ED) or Peyronie’s disease [1]. Extrusion occurs when the distal tunica albuginea is weakened by one or more of the following factors: aggressive dilation, placement of a cylinder in too narrow a corporal cavity, or mechanical pressure from the cylinder [2]. Cylinder ends that have worn through the tunica albuginea are easily palpated immediately under the skin, most commonly in the lateral or ventral aspect of the
J Sex Med 2015;12(suppl 7):456–461
penis. Patients often complain of pain and express concern about imminent erosion. Dr. John Mulcahy published his technique for surgical repair of lateral extrusion in 1999 [3]. His method has been adopted as an elegant and effective approach that avoids the use of foreign material. Technique modifications have been developed since the original description (Table 1). In addition to lateral extrusion, penile implant surgery is associated with other types of injuries related to perforation of the tunica albuginea. Proximal and urethral perforations are significant noninfectious complications that require surgical repair. Erosion of device component parts into © 2015 International Society for Sexual Medicine
457
Lateral Extrusion JSM Supplement Article Table 1
Techniques for Managing Lateral Extrusion
Author
Ref #
Year
n
Technique
Outcomes
Seftel et al. Levine et al. Jordan et al. Alter et al. Knoll et al.
[14] [13] [12] [5] [11]
1992 1993 1994 1995 1995
1 4 7 2 20
Synthetic graft material Synthetic graft material Synthetic graft material Prefabricated tunica vaginalis flap Synthetic graft material
Smith et al. Mulcahy
[10] [3]
1998 1999
5 14
PTFE distal windsock graft Distal corporoplasty
Carson and Noh
[8]
2000
28
Distal corporoplasty (18/28); Gore-tex windsock (10/28)
Shindel et al.
[16]
2010
6
0% infection rare 0% infection rate 43% infection rate 2 stage surgery required 30% infection rate with IPP + graft compared with 5% for IPP alone 0% infection rate; mean operative time 111 minutes 50% required additional fixation of hypermobile glans; 29% infection rate (successfully treated with salvage washout IPP exchange) Corporoplasty: mean operative time 53 minutes, 0% infection rate. Windsock repair: mean operative time 90 minutes, 10% infection rate, 20% extrusion recurrence. Cylinder tip eyehole used to permanently fix device away from impending erosion side; small working space and brisk glanular bleeding presented challenge
Transglanular repair
IPP = inflatable penile prostheses; PTFE = polytetrafluorethylene.
adjacent organs or through skin also necessitates operative interventions. The ability to promptly recognize these problems, and familiarity with techniques to manage them appropriately, is critical to providing successful outcomes. Management of Lateral Extrusion
Lateral extrusion describes the relatively rare phenomenon of distal cylinder tips wearing through the tunica albuginea of the corpus cavernosum. Hsu and Brock have reported that the distal corporal tunica albugineal layer is thinner than the penile shaft tunica, particularly on the ventral aspect where most prostheses tend to extrude, suggesting an anatomic basis for this process [4]. Other possible causes of extrusion include oversizing the cylinders and overly vigorous distal dilation, especially with small caliber dilators [5]. Although semi-rigid rods have been associated with erosion because of the constant pressure they exert [6], comparative series have not found that rods have a higher complication rate compared with inflatable penile prostheses (IPP) [7,8]. Rates of extrusion and erosion have been reported at 1.2–8.0% [7,8]. The patient often complains of distal pain and erosion of the tip through the skin seems imminent on palpation. Patients’ partners may complain of discomfort during receptive intercourse from the lack of tissue padding over the cylinder tip. Erosion of distal implant is a disastrous result since it requires the entire device to be removed. Exposed implant material renders the device infected by definition, even in the absence of clinical symptoms characteristic of infection.
Mulcahy described a technique for salvage of an infected implant by removing all device components, thoroughly washing out the component spaces with a series of antiseptic solutions, and then placing a new implant in the same setting [9]. Unlike other cases of infected implants that might be considered for salvage, salvage replacement is not a feasible option following erosion since a closed system that can be adequately irrigated is not present. Following erosion and explantation alone leads to significant scarring and fibrosis of the penile tissue. This process renders subsequent implantation extremely difficult and fraught with the possibility of complication, particularly since the distal tunica was abnormally perforated even before the erosion. For these reasons, it is critically important for implant surgeons to be familiar with maneuvers to manage lateral extrusion before erosion occurs. In 1998, Smith et al. described a method for management of men with impending distal erosion [10] with polytetrafluorethylene distal windsock graft, a strategy which subsequently has raised concern regarding infectious complications. Knoll et al. reviewed 20 patients with cavernosal fibrosis who underwent prosthesis surgery and reported an infection rate of 30% in men who received a prosthesis along with synthetic graft material, compared with 5% in men who received a prosthesis alone [11]. In a much smaller series, Jordan et al. reported that three out of seven patients who underwent penile implant for phallic reconstruction with synthetic graft material had postoperative infection [12]. Although other series with grafting did not have any infections [13,14], the concern related to increased infection rates gave J Sex Med 2015;12(suppl 7):456–461
458 rise to efforts to manage impending erosion without the use of foreign material. Alter et al. described a technique of using a prefabricated tunica vaginalis flap to reconstruct the distal tunica albuginea after prosthesis extrusion [5]. The method involved two stages and was described based on their successful experience in two patients. In the first stage, rectus fascia was grafted onto the testis external tunica vaginalis. In the second stage, 2 weeks later, the prefabricated tunica vaginalis fascial flap was transposed to the distal corpora, thereby replacing a portion of the weakened tunica albuginea and also serving as tissue padding between the cylinder and urethra (for medial tunica extrusion) or lateral wall (for lateral tunica extrusion). The staged nature of the procedure is an obvious drawback, and the authors acknowledged that the repair may best be used as “a final resort in a patient with multiple previous urethral extrusions or a thin distal tunica albuginea.” In 1999, Mulcahy described a landmark technique for repair of lateral extrusion that obviates the need for graft material [3]. Although a hemicircumcising incision the affected cylinders are exposed. A lateral corporotomy incision is made about 4 cm proximal to the cylinder tip. IPP cylinders are retracted laterally through the corporotomy by a suture that is placed through the eye hole at the tip. With the distal cylinder retracted laterally, an incision is made medial to the cylinder in the pseudocapsule layer about 3 cm proximal to the glans. A plane of dissection medial to the pseudocapsule is then developed toward the glans with Metzenbaum scissors. The new space is then appropriately dilated to match the caliber of the in situ cylinder. Using a Keith needle and Furlow introducer, the cylinder is redirected and seated into the new cavity. In this manner, the pseudocapsule back wall that formerly comprised the medial wall of the capsule becomes the lateral aspect of the capsule. The initial corporotomy is closed with long-term absorbable suture in order to reinforce the repair. Of 14 patients who underwent this distal corporoplasty technique in the original report, seven also required fixation to secure a hypermobile glans [15]. Infection was present in four patients and these infections were successfully treated in the same setting using the salvage washout procedure [9]. Mulcahy’s article represented an importance advance in the management of a relatively rare, but distinctly challenging, complication that can occur following IPP surgery. The crucial innovation is J Sex Med 2015;12(suppl 7):456–461
Stember et al. that Mulcahy found a way to use native tissue to provide padding over the threatening cylinder tip. Prior to the publication of this technique, synthetic graft inlay was the most commonly used procedure. Although success rates varied between authors, a number of reports using graft material resulted in high infection rates as noted earlier. In addition to removing concern about infection rates associated with graft material, the largest subsequent series comparing distal corporoplasty to windsock utilization showed a marked decrease in operative time for the former (mean 53 and 90 minutes, respectively) [8]. Avoiding graft material has an added advantage of decreasing financial costs (as does decreasing operating time). Finally, in our opinion, the Mulcahy technique is remarkable for its relative simplicity compared with other methods for addressing lateral extrusion. Carson and Noh compared the techniques based on their experience with 28 patients (mean age 56 years old) who presented with impending extrusion [8]. Distal corporoplasty using the Mulcahy technique was performed in 18/28 men, with the remaining 10/28 undergoing repair with Gore-tex windsock. Of these men, 8/18 who underwent corporoplasty and 6/10 who underwent windsock repair also required glans fixation for hypermobile glans after the cylinders were relocated. The authors reported that the operative time was shorter for corporoplasty (mean 53 minutes, range 36–81 minutes) than for windsock repair (mean 90 minutes, range 64–142 minutes). There were no infections or recurrences among men who received distal corporoplasty. One patient who had a windsock repair had a postoperative infection and two had recurrences of extrusion (6 and 18 months after windsock repair, respectively). Functional results were otherwise similar and both groups, with the majority of all patients returning to normal coital activity within 34 months (range 6–85 months). The authors concluded that distal corporoplasty is an overall superior method because of fewer major complications and reduced surgical time. We too have found the Mulcahy distal corporoplasty to be safe, reliable, and elegant in its simplicity. We have found the pseudocapsule layer to be resilient enough to protect against impending erosions over time. We have applied this principle for both lateral and medial impending erosions, and in conjunction with repair of cylinder crossover deformities. Shindel et al. developed a transglanular repair method and reported on their experience with 6
Lateral Extrusion JSM Supplement Article men [16]. In Shindel’s approach, the prosthesis is inflated and the cylinder tip is manipulated to the middle part of the hemiglans. A 1-cm incision is made on the glans immediately above the cylinder tip using cutting electrocautery current. After spongy glans tissue is dissected free and the capsule is incised over the tip, the device is deflated to allow for easier manipulation. A nonabsorable suture is placed through the eyehole at the cylinder tip. The suture is then tied to the underside of the fibrotic capsule contralateral to the area of weakened tunica albuginea and impending erosion. The wound is copiously irrigated with antibiotic solution and the glans is closed in three layers. The authors identified a visual challenge of the transglanular repair because of a small working space and brisk bleeding of the glans, their approach takes advantage of the eyehole at the cylinder tip to permanently fix the device away from the side of impending erosion. Management of Crural Perforation Injuries
Another well-known tunical perforation injury associated with penile prosthesis surgery occurs during proximal dilation. During dilation of the crural bodies, the scissors or dilating instrument should be passed in a manner that corresponds to the lateral flaring of the proximal crural bodies. When the bodies are scarred, there is a tendency to dilate aggressively downwards, and this may lead to proximal perforation of the crus. If an implant cylinder is placed without steps taken to limit its movement, it will eventually migrate through the hole and the distal end of the cylinder will be palpated in the midshaft. Although the input tubing from the proximally migrated cylinder to the pump will limit the distance it can go, an unanchored semi-rigid rod can migrate all the way to the buttocks. In either case, proximal migration is an extremely undesirable result that will require revision surgery unless recognized and dealt with intraoperatively. Narrow caliber dilators (i.e.,
SUPPLEMENT ARTICLE Management of Perforation Injuries During and Following Penile Prosthesis Surgery Doron S. Stember, MD,* Tobias S. Kohler, MD, MPH,† and Allen F. Morey, MD‡ *Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; †Urology, Southern Illinois University School of Medicine, Springfield, IL, USA; ‡Urology, UT Southwestern Medical Center, Dallas, TX, USA DOI: 10.1111/jsm.12997
ABSTRACT
Introduction. Distal extrusion of penile prosthesis cylinders is a challenging problem that is associated with pain and imminent erosion through penile skin. Distal extrusion and other perforation injuries, including crural and urethral, are other manifestations of tunica albuginea injuries that result in poor clinical outcomes and patient satisfaction. Aim. A description of Dr. John Mulcahy’s landmark article for management of lateral extrusion is presented along with discussion of techniques for managing other types of perforation injuries associated with penile implants. Methods. Dr. Mulcahy’s original article is reviewed and critiqued. Surgical methods to manage perforation injuries are discussed. Main Outcomes Measures. The main outcome measures used were the review of original article, subsequent articles, and commentary by Dr. Mulcahy. Results. Knowledge of techniques for management intraoperative and postoperative complications related to tunical perforation is necessary for implant surgeons. Conclusions. Perforation injuries are challenging noninfectious complications of penile prosthesis surgery. Familiarity with techniques to manage these problems is essential for ensuring good outcomes and patient satisfaction. Stember DS, Kohler TS, Morey AF. Management of perforation injuries during and following penile prosthesis surgery. J Sex Med 2015;12(suppl 7):456–461. Key Words. Penile Prosthesis; Lateral Extrusion; Distal Extrusion; Erectile Dysfunction; Crural Perforation; Surgical Complication
Introduction
D
istal or lateral extrusion of penile prosthesis cylinders is a well-recognized and challenging complication following implant surgery for erectile dysfunction (ED) or Peyronie’s disease [1]. Extrusion occurs when the distal tunica albuginea is weakened by one or more of the following factors: aggressive dilation, placement of a cylinder in too narrow a corporal cavity, or mechanical pressure from the cylinder [2]. Cylinder ends that have worn through the tunica albuginea are easily palpated immediately under the skin, most commonly in the lateral or ventral aspect of the
J Sex Med 2015;12(suppl 7):456–461
penis. Patients often complain of pain and express concern about imminent erosion. Dr. John Mulcahy published his technique for surgical repair of lateral extrusion in 1999 [3]. His method has been adopted as an elegant and effective approach that avoids the use of foreign material. Technique modifications have been developed since the original description (Table 1). In addition to lateral extrusion, penile implant surgery is associated with other types of injuries related to perforation of the tunica albuginea. Proximal and urethral perforations are significant noninfectious complications that require surgical repair. Erosion of device component parts into © 2015 International Society for Sexual Medicine
457
Lateral Extrusion JSM Supplement Article Table 1
Techniques for Managing Lateral Extrusion
Author
Ref #
Year
n
Technique
Outcomes
Seftel et al. Levine et al. Jordan et al. Alter et al. Knoll et al.
[14] [13] [12] [5] [11]
1992 1993 1994 1995 1995
1 4 7 2 20
Synthetic graft material Synthetic graft material Synthetic graft material Prefabricated tunica vaginalis flap Synthetic graft material
Smith et al. Mulcahy
[10] [3]
1998 1999
5 14
PTFE distal windsock graft Distal corporoplasty
Carson and Noh
[8]
2000
28
Distal corporoplasty (18/28); Gore-tex windsock (10/28)
Shindel et al.
[16]
2010
6
0% infection rare 0% infection rate 43% infection rate 2 stage surgery required 30% infection rate with IPP + graft compared with 5% for IPP alone 0% infection rate; mean operative time 111 minutes 50% required additional fixation of hypermobile glans; 29% infection rate (successfully treated with salvage washout IPP exchange) Corporoplasty: mean operative time 53 minutes, 0% infection rate. Windsock repair: mean operative time 90 minutes, 10% infection rate, 20% extrusion recurrence. Cylinder tip eyehole used to permanently fix device away from impending erosion side; small working space and brisk glanular bleeding presented challenge
Transglanular repair
IPP = inflatable penile prostheses; PTFE = polytetrafluorethylene.
adjacent organs or through skin also necessitates operative interventions. The ability to promptly recognize these problems, and familiarity with techniques to manage them appropriately, is critical to providing successful outcomes. Management of Lateral Extrusion
Lateral extrusion describes the relatively rare phenomenon of distal cylinder tips wearing through the tunica albuginea of the corpus cavernosum. Hsu and Brock have reported that the distal corporal tunica albugineal layer is thinner than the penile shaft tunica, particularly on the ventral aspect where most prostheses tend to extrude, suggesting an anatomic basis for this process [4]. Other possible causes of extrusion include oversizing the cylinders and overly vigorous distal dilation, especially with small caliber dilators [5]. Although semi-rigid rods have been associated with erosion because of the constant pressure they exert [6], comparative series have not found that rods have a higher complication rate compared with inflatable penile prostheses (IPP) [7,8]. Rates of extrusion and erosion have been reported at 1.2–8.0% [7,8]. The patient often complains of distal pain and erosion of the tip through the skin seems imminent on palpation. Patients’ partners may complain of discomfort during receptive intercourse from the lack of tissue padding over the cylinder tip. Erosion of distal implant is a disastrous result since it requires the entire device to be removed. Exposed implant material renders the device infected by definition, even in the absence of clinical symptoms characteristic of infection.
Mulcahy described a technique for salvage of an infected implant by removing all device components, thoroughly washing out the component spaces with a series of antiseptic solutions, and then placing a new implant in the same setting [9]. Unlike other cases of infected implants that might be considered for salvage, salvage replacement is not a feasible option following erosion since a closed system that can be adequately irrigated is not present. Following erosion and explantation alone leads to significant scarring and fibrosis of the penile tissue. This process renders subsequent implantation extremely difficult and fraught with the possibility of complication, particularly since the distal tunica was abnormally perforated even before the erosion. For these reasons, it is critically important for implant surgeons to be familiar with maneuvers to manage lateral extrusion before erosion occurs. In 1998, Smith et al. described a method for management of men with impending distal erosion [10] with polytetrafluorethylene distal windsock graft, a strategy which subsequently has raised concern regarding infectious complications. Knoll et al. reviewed 20 patients with cavernosal fibrosis who underwent prosthesis surgery and reported an infection rate of 30% in men who received a prosthesis along with synthetic graft material, compared with 5% in men who received a prosthesis alone [11]. In a much smaller series, Jordan et al. reported that three out of seven patients who underwent penile implant for phallic reconstruction with synthetic graft material had postoperative infection [12]. Although other series with grafting did not have any infections [13,14], the concern related to increased infection rates gave J Sex Med 2015;12(suppl 7):456–461
458 rise to efforts to manage impending erosion without the use of foreign material. Alter et al. described a technique of using a prefabricated tunica vaginalis flap to reconstruct the distal tunica albuginea after prosthesis extrusion [5]. The method involved two stages and was described based on their successful experience in two patients. In the first stage, rectus fascia was grafted onto the testis external tunica vaginalis. In the second stage, 2 weeks later, the prefabricated tunica vaginalis fascial flap was transposed to the distal corpora, thereby replacing a portion of the weakened tunica albuginea and also serving as tissue padding between the cylinder and urethra (for medial tunica extrusion) or lateral wall (for lateral tunica extrusion). The staged nature of the procedure is an obvious drawback, and the authors acknowledged that the repair may best be used as “a final resort in a patient with multiple previous urethral extrusions or a thin distal tunica albuginea.” In 1999, Mulcahy described a landmark technique for repair of lateral extrusion that obviates the need for graft material [3]. Although a hemicircumcising incision the affected cylinders are exposed. A lateral corporotomy incision is made about 4 cm proximal to the cylinder tip. IPP cylinders are retracted laterally through the corporotomy by a suture that is placed through the eye hole at the tip. With the distal cylinder retracted laterally, an incision is made medial to the cylinder in the pseudocapsule layer about 3 cm proximal to the glans. A plane of dissection medial to the pseudocapsule is then developed toward the glans with Metzenbaum scissors. The new space is then appropriately dilated to match the caliber of the in situ cylinder. Using a Keith needle and Furlow introducer, the cylinder is redirected and seated into the new cavity. In this manner, the pseudocapsule back wall that formerly comprised the medial wall of the capsule becomes the lateral aspect of the capsule. The initial corporotomy is closed with long-term absorbable suture in order to reinforce the repair. Of 14 patients who underwent this distal corporoplasty technique in the original report, seven also required fixation to secure a hypermobile glans [15]. Infection was present in four patients and these infections were successfully treated in the same setting using the salvage washout procedure [9]. Mulcahy’s article represented an importance advance in the management of a relatively rare, but distinctly challenging, complication that can occur following IPP surgery. The crucial innovation is J Sex Med 2015;12(suppl 7):456–461
Stember et al. that Mulcahy found a way to use native tissue to provide padding over the threatening cylinder tip. Prior to the publication of this technique, synthetic graft inlay was the most commonly used procedure. Although success rates varied between authors, a number of reports using graft material resulted in high infection rates as noted earlier. In addition to removing concern about infection rates associated with graft material, the largest subsequent series comparing distal corporoplasty to windsock utilization showed a marked decrease in operative time for the former (mean 53 and 90 minutes, respectively) [8]. Avoiding graft material has an added advantage of decreasing financial costs (as does decreasing operating time). Finally, in our opinion, the Mulcahy technique is remarkable for its relative simplicity compared with other methods for addressing lateral extrusion. Carson and Noh compared the techniques based on their experience with 28 patients (mean age 56 years old) who presented with impending extrusion [8]. Distal corporoplasty using the Mulcahy technique was performed in 18/28 men, with the remaining 10/28 undergoing repair with Gore-tex windsock. Of these men, 8/18 who underwent corporoplasty and 6/10 who underwent windsock repair also required glans fixation for hypermobile glans after the cylinders were relocated. The authors reported that the operative time was shorter for corporoplasty (mean 53 minutes, range 36–81 minutes) than for windsock repair (mean 90 minutes, range 64–142 minutes). There were no infections or recurrences among men who received distal corporoplasty. One patient who had a windsock repair had a postoperative infection and two had recurrences of extrusion (6 and 18 months after windsock repair, respectively). Functional results were otherwise similar and both groups, with the majority of all patients returning to normal coital activity within 34 months (range 6–85 months). The authors concluded that distal corporoplasty is an overall superior method because of fewer major complications and reduced surgical time. We too have found the Mulcahy distal corporoplasty to be safe, reliable, and elegant in its simplicity. We have found the pseudocapsule layer to be resilient enough to protect against impending erosions over time. We have applied this principle for both lateral and medial impending erosions, and in conjunction with repair of cylinder crossover deformities. Shindel et al. developed a transglanular repair method and reported on their experience with 6
Lateral Extrusion JSM Supplement Article men [16]. In Shindel’s approach, the prosthesis is inflated and the cylinder tip is manipulated to the middle part of the hemiglans. A 1-cm incision is made on the glans immediately above the cylinder tip using cutting electrocautery current. After spongy glans tissue is dissected free and the capsule is incised over the tip, the device is deflated to allow for easier manipulation. A nonabsorable suture is placed through the eyehole at the cylinder tip. The suture is then tied to the underside of the fibrotic capsule contralateral to the area of weakened tunica albuginea and impending erosion. The wound is copiously irrigated with antibiotic solution and the glans is closed in three layers. The authors identified a visual challenge of the transglanular repair because of a small working space and brisk bleeding of the glans, their approach takes advantage of the eyehole at the cylinder tip to permanently fix the device away from the side of impending erosion. Management of Crural Perforation Injuries
Another well-known tunical perforation injury associated with penile prosthesis surgery occurs during proximal dilation. During dilation of the crural bodies, the scissors or dilating instrument should be passed in a manner that corresponds to the lateral flaring of the proximal crural bodies. When the bodies are scarred, there is a tendency to dilate aggressively downwards, and this may lead to proximal perforation of the crus. If an implant cylinder is placed without steps taken to limit its movement, it will eventually migrate through the hole and the distal end of the cylinder will be palpated in the midshaft. Although the input tubing from the proximally migrated cylinder to the pump will limit the distance it can go, an unanchored semi-rigid rod can migrate all the way to the buttocks. In either case, proximal migration is an extremely undesirable result that will require revision surgery unless recognized and dealt with intraoperatively. Narrow caliber dilators (i.e.,
