(003) Graft-on-Graft Reconstruction with Proximal Extracapsular Tunneling for the repair of Large Aneurysmal Defect After Penile Prosthesis Surgery in Peyronie’s Disease

Abstract Introduction Penile prosthesis implantation (PPI) with plaque incision and grafting is a standard option for men with concomitant erectile dysfunction and Peyronie’s disease, but rare complications such as corporal/cylinder “aneurysm” can occur-particularly when tunical strength is compromised or cylinders migrate. Evidence to guide management of aneurysms arising at prior graft sites is scarce. We report a case of a large aneurysmal defect with cylinder migration after PPI and grafting, managed with a combined proximal extracapsular tunneling and graft-on-graft reinforcement strategy Objective To describe the intraoperative findings and stepwise reconstructive approach for a post-PPI aneurysmal defect after plaque grafting, and to document feasibility and early outcomes of combining proximal extracapsular tunneling with graft-on-graft reinforcement. Methods Case report. A 66-year-old man with ED, 40° rightward curvature, and severe hourglass deformity underwent inflatable PPI via the multiple-slit (MuST) technique with pericardium grafting at another institution. After resuming intercourse at 2 months, he noted progressive deformity by month 3. At referral 2.5 years later, exam and exploration revealed a large left corporal aneurysm with cylinder protrusion through a thinned tunica; the prior pericardial graft was incorporated, but its medial edge had dislodged from the tunica, permitting distal cylinder migration. Through the prior midline-ventral approach, the device was explanted and standard corporotomies performed. Bilateral measurements showed a 2-cm proximal discrepancy (right 20 cm; left 18 cm) due to narrowing of the left proximal pseudocapsule from migration. We performed left proximal extracapsular tunneling to redilate and equalize lengths to 20 cm bilaterally. At the distal defect, healthy tunica was present proximally/distally/medially; laterally, the old graft formed the wall. To prevent recurrence, we folded the lateral edge of the old graft to create a double layer, then placed and secured a new double-layer Tutoplast graft with absorbable running sutures, adding non-absorbable anchoring sutures at the graft-to-graft interface to compensate for limited tissue ingrowth. A new inflatable prosthesis was implanted in standard fashion Results Proximal extracapsular tunneling restored symmetric corporal length (20 cm/20 cm); distal graft-on-graft reinforcement corrected the aneurysmal segment. Intraoperative assessment demonstrated satisfactory cylinder seating and correction of deformity. The new prosthesis provided adequate functional and cosmetic results without immediate complications reported. Conclusions This case illustrates a practical solution for complex post-PPI deformity at a prior graft site: combine proximal extracapsular tunneling (to correct proximal pseudocapsule narrowing from migration) with graft-on-graft reinforcement (to buttress a weakened lateral wall). To our knowledge, this is the first contemporary description of using proximal extracapsular tunneling for a proximal corporal defect in conjunction with graft-on-graft repair after PPI with grafting. Surgeons should maintain a high index of suspicion for cylinder migration/aneurysm after plaque grafting and be prepared to deploy adjunctive reconstructive techniques during revision. Larger series are needed to define durability and outcomes. Disclosure No