Advancements in ectopic reservoir placement for inflatable penile prostheses.

INTRODUCTION: Traditional reservoir placement (RP) into the space of Retzius during three-piece inflatable penile prosthesis implantation has been associated with serious bladder, iliac vessel, and bowel complications, encouraging the development of "ectopic" RP methods. OBJECTIVES: In this study we sought to document an up-to-date, comprehensive analysis of ectopic RP techniques regarding both patient satisfaction and clinical complications. METHODS: A PubMed, Ovid MEDLINE, and Cochrane Library literature search of English language articles from 1966 to 2023 with keywords "inflatable," "penile prosthesis," "reservoir," and "placement" gave 179 publications, 70 of which were included in a comprehensive chronology and investigation after review. Overall, 12 retrospective studies detailing 9 ectopic RP techniques were compared for discussion. RESULTS: Sufficient data for comparison were found for 9 ectopic RP methods: posterior/anterior to transversalis fascia (PTF/ATF); high submuscular (HSM); HSM "Five-Step" technique (HSM-FST); lateral retroperitoneal (LR); sub-external oblique (SEO); direct vision, transfascial (DVT); low submuscular with transfascial fixation (LSM w/ TFF); and midline submuscular reservoir (MSMR). Although rare, serious complications have occurred with the use of ectopic RP techniques: 2 bladder perforations on implantation with PTF RP, a delayed bowel obstruction with HSM RP, and a colonic injury in a patient with a history of colon surgery with LR RP. Generally, herniation is the most relevant clinical complication in ectopic RP. At the time of this review there was no reported herniation with LR, SEO, LSM w/ TFF, or MSMR, likely due to fixation steps and/or reinforced spaces. Regarding patient satisfaction, HSM, HSM-FST, and LSM w/ TFF had similarly high rates of patient satisfaction while other techniques had no patient satisfaction data available. Importantly, reservoir palpability/visibility relates directly to patient satisfaction. Levels of palpability and/or visibility were reported in patients who underwent PTF/ATF, HSM, HSM-FST, SEO, and LSM w/ TFF, whereas no palpability was reported in patients who underwent LR, DVT, and MSMR. CONCLUSION: Proper comparison of ectopic methods is not possible without standardized patient surveys, consistent complication reporting, and larger sample sizes, indicating the need for a large, prospective, multisurgeon trial.

Penile prosthesis in the medically complex patient: a narrative review.

Background and Objective: Penile prosthesis surgery is considered a safe and effective treatment for patients with erectile dysfunction. Implantation in the medically complex patient can be a challenge. The benefits of treatment must outweigh the possible risks or complications. A description of possible problems and how to cope with them is given in this narrative review. Methods: Literature search was performed in January 2023 using different search prompts in PubMed. These articles, excluding non-English and non-full text articles, were listed by the two authors and afterwards, the most relevant ones were included. Key Content and Findings: This article is divided into five important topics. We evaluated different comorbidities such as spinal cord injury, diabetes mellitus and cardiovascular disease, in which preoperative work-up and counseling is of significant importance. A detailed description of these comorbidities and how to handle these can be found in each section. In addition to the preoperative aspect in organ transplant patients, problems during surgery can arise, e.g., with the reservoir placement. Similarly, in patients with previous pelvic surgery, an ectopic reservoir placement can prevent possible complications. Conclusions: Preoperative diagnostics are crucial and prosthetic surgery should be done by an experienced high-volume surgeon with a diverse range of surgical techniques at his disposal.

Inflatable penile prosthesis reservoir placement-Are we ready for a paradigm change?

In 2002, Steve Wilson pioneered new procedures for alternative placement of reservoirs for inflatable prostheses in patients who have suffered damage to the space of Retzius following pelvic surgery or obliteration of the transversalis fascia by mesh hernia repair. Since then, surgical techniques and tools for ectopic reservoir placement have gradually gained acceptance to minimize palpability, and the risk of visceral and vascular lesions for high risk patients has been all but eliminated. Lockout valves and high submuscular placement techniques are now recommended, and reports of vascular, bowel or bladder injuries are uncommonly rare. While surgeons continue their search for safer and more effective placement methods, new skills and instruments are constantly being introduced to make recommendations to minimize complications and provide safety and functionality. Additional studies and comparisons of techniques are needed to achieve a consensus of best practice for reservoir placement solutions.

A Modified Surgical Technique for Reservoir Placement During Inflatable Penile Prosthesis Implantation.

INTRODUCTION: At the moment, there is an ongoing debate regarding the controversial issue of the ideal reservoir placement (RP) surgical technique during implantation of a 3-piece inflatable penile prosthesis, but a definitive winner has not yet emerged. AIM: In this light, we herein describe our modified technique for RP into the space of Retzius through the external oblique muscle fascia and present its results. METHODS: In total, 253 inflatable penile prosthesis procedures (110 AMS 700 and 143 Coloplast Titan) via a single transverse penoscrotal incision were retrospectively reviewed. 2 Kocher-Langenbeck retractors were placed over the right side of the penoscrotal incision and were used to retract the incision superior to the pubic bone. Then, the external oblique muscle fascia was incised medially to the spermatic cord which was retracted laterally. Next, a "W", Vicryl 1, stay suture was placed to the incision, and under direct visualization, external oblique muscle fibers were dissected and fascia transversalis was perforated using a Metzenbaum scissor. A Foerster lung grasping clamp was then used to dissect further into the extraperitoneal space and create the reservoir space. The reservoir was placed into the created space and fascia incision was closed using the prepositioned stay suture. The procedure was then completed in a standard fashion. OUTCOMES: The main outcome measures were intraoperative or postoperative complications of our modified RP technique. RESULTS: All 253 patients were available for short-term follow-up (average 9.1 months, range 3-22 months). No intraoperative or postoperative complications were reported. Reservoir-related prolonged pain (1 month) was reported by 1 patient, resolving completely after treatment with non-steroidal analgesics. CONCLUSION: We are, surely, not proposing that our modified RP technique should supplant all other methods; rather, it should be considered another useful option for RP in the implanter's armamentarium. Mykoniatis I, Osmonov D, van Renterghem K. A Modified Surgical Technique for Reservoir Placement During Inatable Penile Prosthesis Implantation. Sex Med 2020;8:378-382.

Counter incision is a safe and effective method for alternative reservoir placement during inflatable penile prosthesis surgery.

BACKGROUND: Alternative reservoir placement is increasingly popular during inflatable penile prosthesis (IPP) surgery to prevent intraperitoneal positioning, bowel, bladder, or vascular injury in patients with prior pelvic surgeries. Counter incision (CI) can be used for submuscular reservoir placement in high risk patients, however series exploring the safety remain limited. METHODS: A database of IPP surgeries was queried for use of a CI during reservoir placement to compare 90-day clinical outcomes in a retrospective case-control study. Primary outcome was device infections, with secondary outcomes including reservoir herniation, hematoma, device malfunction rates, and operative times. Groups were compared using Kruskal-Wallis and Chi-Squared tests, with multivariate logistic regression models to identify predictors of infectious complications. RESULTS: A total of 534 cases met criteria, of which 51 (9.6%) used a CI for reservoir placement. The CI cohort included significantly more removal and replacements, 45.1% vs. 20.9% (P<0.001). Thirty-one CI patients (61.0%) had undergone prior prostatectomy compared to 134 (27.7%) non-CI patients (P=0.001). The most common reasons for CI were prior prostatectomy and inguinal hernia repair. Median operative time was 17 minutes longer in the CI group (74 vs. 57 minutes, P<0.001). Device infection rates were similar (2.0% vs. 4.1%, P=0.71), as were rates of hematoma (5.9% vs. 2.7%, P=0.19), and device malfunction (0.0% vs. 1.4% P=1.00). CONCLUSIONS: Complication rates were similar between CI and non-CI cohorts, even in a subset where approximately half the cases were removal and replacements. For physicians not comfortable with alternative placement through a penoscrotal or infrapubic incision, this offers a reasonable alternative and permits use of three-piece devices in patients with a hostile pelvis.

Penile Prosthesis Reservoir Removal: Surgical Description and Patient Outcomes.

BACKGROUND: Removal of the penile prosthesis reservoir can be technically challenging because of its difficult locations either deep in the pelvis or high in the abdominal wall. AIM: To describe a detailed surgical technique for reservoir removal through a penoscrotal approach. METHODS: We describe our preferred method for removal of prosthetic reservoir and present a retrospective review of patient outcomes after reservoir removal. MAIN OUTCOME MEASURE: Primary outcomes included immediate or late complications. Secondary outcomes included operative time. RESULTS: 34 patients underwent reservoir removal with the use of our described technique. 23 patients (67.6%) had reservoirs removed because of device malfunction and 11 (32.4%) because of infection. A total of 18 reservoirs (52.9%) were found in the space of Retzius (SOR), whereas the other 16 (47.1%) were in an alternative/ectopic space. 2 cases (5.9%) required a counterincision to remove the reservoir. Mean overall operative time was 96.2 minutes (range 35-175). There were no complications in this series. There was no statistical difference in operative time between reservoirs removed because of malfunction when compared with infection (P = .283). However, there was a difference in operative time between reservoirs removed from the SOR when compared with those removed from an ectopic space, with mean operating room times of 104.5 and 75.4 minutes, respectively (P = .001). CLINICAL IMPLICATIONS: Reservoir removal through a penoscrotal incision is feasible and safe. STRENGTH & LIMITATIONS: This is the first report, to our knowledge, describing surgical techniques and outcomes for reservoir removal. Limitations include its retrospective nature and lack of validated questionnaires to assess patient satisfaction. CONCLUSION: Although removal of a reservoir deep in the SOR or placed in alternate/ectopic locations can be challenging, the use of a lighted retractor, meticulous dissection, and a few technical maneuvers described allow for safe removal of the reservoir completely intact while avoiding complications. Our technique for a secondary incision in particularly difficult cases is also described. Clavell-Hernández J, Aly SG, Wang R, et al. Penile Prosthesis Reservoir Removal: Surgical Description and Patient Outcomes. J Sex Med 2019;16:146-152.

Modified Inflatable Penile Prosthesis Reservoir Placement Into Space of Retzius: Comparing Outcomes in Men With or Without Prior Pelvic Surgery.

BACKGROUND: Traditional inflatable penile prosthesis (IPP) reservoir placement has rare but potentially serious complications including damage to local structures, and Levine and Hoeh (J Sex Med 2012;9:2759-2769) described a modified technique designed to avoid these complications. AIM: To determine whether the modified Jorgenson scissors technique is safe and effective in patients who have had prior pelvic surgery. METHODS: A retrospective chart review was performed on all patients who had a three-piece IPP placed by a single urologist from 2011 to 2015. Complication rates between the prior pelvic surgery group and the virgin pelvis group were compared using χ2 test. Differences between the two groups were considered statistically significant at a P value less than .05. OUTCOMES: Reservoir-related complication rate and rate of converting to ectopic placement. RESULTS: A total of 246 procedures were included, with 174 having no prior pelvic surgery and 72 with prior pelvic surgery. The reservoir-related complication rates were 2.8% (2 of 72) in the prior pelvic surgery group and 3.4% (6 of 174) in the virgin pelvis group. This difference was not statistically significant (P = .79). The two complications from the prior pelvic surgery cohort were inguinal hernias requiring surgical repair, which occurred in the same patient. In the virgin pelvis cohort, there were five inguinal hernias and one autoinflation. There were 16 patients who required ectopic placement of the reservoir owing to difficulty in entering the space of Retzius (SOR), 14 of whom had prior pelvic surgery. CLINICAL IMPLICATIONS: We believe this modified technique for IPP reservoir placement into the SOR is a safe alternative because the Jorgenson scissors allow perforation into the SOR away from vital structures. STRENGTHS AND LIMITATIONS: The study is limited by the fact that it is a retrospective, single-center, chart review of a non-randomized surgical procedure with variable follow-up in a limited number of patients. Its strength is its applicability to provide surgeons a modified technique that can be used routinely for IPP reservoir placement that appears to be safe and effective, even in men who have had prior pelvic surgery. CONCLUSION: In our experience, the modified Jorgenson scissors technique allows for safe entry into the SOR through a transverse scrotal incision and is a viable alternative to the standard SOR placement and the ectopic approach. Capoccia EM, Phelps JN, Levine LA. Modified Inflatable Penile Prosthesis Reservoir Placement Into Space of Retzius: Comparing Outcomes in Men With or Without Prior Pelvic Surgery. J Sex Med 2017;14:968-973.