Placement of a 3-piece inflatable penile prosthesis (IPP) serves as a definitive treatment for erectile dysfunction (ED) and has proven to provide superior efficacy in patients with medically refractory ED [1–3]. Definitive surgical management for ED with the use of an IPP continues to increase. Furthermore, patient satisfaction is dependent on the ability to manipulate the pump and inflate the cylinders to obtain an erection that is adequate for penetrative sex [4]. The third component of the IPP, the reservoir, should never contribute to the patient experience once it is placed. The goal is for it to remain dormant throughout the lifetime of the implant.
Implanters have focused their efforts on ensuring that IPP reservoirs can be safely placed in the virgin and compromised pelvices, as well as being both non-palpable nor visible to the patient [5]. Several modifications to both reservoir technology and surgical technique have been introduced to accomplish these goals in a reproducible manner [6–9]. The original IPP design utilized a fluid-filled reservoir that lacked a lockout valve mechanism, consequently causing “auto inflation” which resulted in spontaneous, undesired erections. To prevent this, implanters sought to place the IPP reservoir in low-pressure environments and the introduction of the Intraperitoneal and Space of Retzius (SOR) placement gained popularity amongst implanters [7, 10–12]. For decades, SOR reservoir placement was favored amongst prosthetic surgeons as the gold standard. This potential space posterior to the pubic bone and anterior to the bladder is familiar to all urologists [8]. It can be accessed bluntly through either an inguinal canal or directly via a counter incision. This landmark also served as a seemingly convenient landmark for reservoir retrieval during IPP revision or explant. However, in those who have undergone previous pelvic or inguinal surgery, the SOR may present the implanter with adverse anatomy as demonstrated by reports of catastrophic injuries to bowel, bladder, ureter, and vascular structures. Therefore, access to the SOR is not without serious risk [13]. Henry and colleagues utilized an anatomic model to depict the proximity of the reservoir to these vital structures. Their report described the bladder within 2.61 cm and the external iliac vein as 3.23 cm [14]. In men who present with compromised anatomy (abdominal, pelvic, or inguinal) because of previous radical prostatectomy, radical cystectomy, urinary diversion, bowel resection, colonic diversion, and inguinal hernia repair procedures (with or without mesh), implanters will be faced with distorted anatomy and obliteration of the usual planes [15]. The resultant changes may create challenging and even dangerous reservoir placement if performed in the standard fashion using the SOR.
These challenges were initially addressed in 2001 when Wilson, et al, introduced the concept of “ectopic” [16] or alternative reservoir placement (ARP) to optimize reservoir placement in patients with compromised anatomy. Their technique employed submuscular reservoir placement. This lower groin location led to some implanters encountering device herniation and problems with palpable reservoirs. Since then, there have been multiple iterations of ARP. Perito and colleagues introduced the concept of placing the reservoir anterior to transversalis fascia to avoid distorted anatomy in patients with previous pelvic or inguinal surgery [13, 17]. Their use of a nasal speculum and pediatric Yankauer allowed for placement above the inguinal ring. This prevented herniation and maintained a position allowing for reservoir retrieval in the future. [18] Morey, et al, elaborated on this approach with the introduction of high submuscular (HSM) reservoir placement [19]. This modification calls for greater cephalad trajectory to minimize the risk of reservoir herniation and device palpability.
It is our intent to now describe reservoir placement during IPP for three specific and often problematic clinical scenarios not yet described in the literature: patients with history of bilateral inguinal hernia repair, unilateral hernia repair, or bilateral “compromised” abdominal wall. We will evaluate the safety and efficacy of this novel midline approach to reservoir placement in these unique clinical scenarios.
Description Of Technique
We utilize a minimally invasive infrapubic approach for our penile implant placement (20, 21). Patients are required to void to completion just prior to entering the operative suite and a foley catheter is typically not used. A 2.5cm incision is made horizontally at the midline and 2 fingerbreadths above the base of the penis. The landmarks of the superior crest of the pubic bone and pubic tubercles are easily palpated without the need for additional dissection. The surgeon’s index finger is used to bluntly dissect along the linea alba just above the pubic tubercles. A tonsil clamp gated by the surgeon’s index finger is used to pierce the Rectus fascia at the midline (Fig. 1). This dissection is below the arcuate line, the next deepest layer is the transversalis fascia. Like other abdominal wall techniques, the surgeon has the option to place the reservoir either anterior or posterior to the transversalis fascia (Fig. 2). The fascial defect needs to be just wide enough to accommodate a nasal speculum that is guided cephalad and then opened with impunity. The surgeon’s finger will assess the space and determine if a 9/10 Hagar Dilator is needed to further develop the avascular space by sweeping the dilator in a parallel fashion to the fascia. The dilator is removed, and the 70 mm nasal speculum remains with the blades parallel and along the axis of the fascia and handles pointed superiorly. A metal pediatric Yankauer is then used to deploy the prepared reservoir through the open blades of the nasal speculum (Fig. 3). At this point, the reservoir is safely deployed cephalad to the pubic bone (not posterior to) avoiding the bladder.