IPP surgery offers a high satisfaction rate and low rate of complications when performed by experienced surgeons. Penile prosthesis reservoir complications are unusual, and mechanical failure or spontaneous rupture of the reservoir is almost unheard of in the modern era. The most serious and feared complication with IPP surgery is infection, with the reported incidence after primary placement 1–3% and after revision surgery 8–18% [3].

The original inflatable penile prosthesis (IPP) reservoir placement is below the transversalis fascia in the space of Retzius.

However, reservoir placement, either in the space of Retzius (SOR), or alternative/ectopic locations, may lead to an array of serious complications that may require revision surgery.

In 2002, Dr. Steve Wilson described ectopic reservoir placement, thereby providing a safe and effective alternative for implant surgeons. This approach tried to stop the need for a second incision and decreased operative times during surgery. Thirteen years after Dr. Wilson’s pivotal study, this technique should be in the armamentarium of all urologic prosthetic surgeons.

Accordingly, in certain subsets of patients, ectopic/ hight submuscular reservoir site placement should be considered a safe, effective alternative to standard reservoir placement in the space of Retzius. Placement of penile prosthetic reservoirs in the space of Retzius has historically been the standard of care but Ectopic placement of reservoirs could be performed also in all patients with a history of surgical procedures obliterating the space of Retzius( post RP, New bladders,mesh hernioplasthy..).

Alternative reservoir placement is safe and mechanically reilable approach including in men with prior pelvic surgery. However,there are also associated risk, including reservoir hernation, leakege, tubing torsion, muscle discomfort and unintended reservoir malposition which may require surgical revision [1]

Stember et al demostreted that ectopic reservoirs had higher complication sates (herniation 1.3% VS o.1%), revision for palpable reservoir 0.5 VS 0%, Auto-inflation 0.5 VS 0%) [2]

Non-infectious reservoir-related complications in the intraoperative setting include injury to pelvic structures such as bladder, bowel, and blood vessels.

In the postoperative setting, patients may experience autoinflation and reservoir herniation that might require revision surgery.

Reservoir extrusion through the inguinal canal is quite unusual. Direct inguinal herniation of the reservoir is another unusual complication. Management usually consisted of reservoir replacement or repositioning through an inguinal incision with repair of the defect and hernioplasthy by the implanter surgeon in order to avoid damaging the system. Alternatively, several surgeons used the existing scrotal incision if the patient presented in the immediate postoperative period. The incidence of reservoir herniation was 0.7% [4]

Reservoir erosion into the bladder or bowel is unusual. Vascular injury during or following placement of a reservoir is certainly possible during the digital or sharp dissection to enter the space of Retzius, as the external iliac system is in close proximity. Certain predisposing conditions are believed to increase the risk of reservoir erosion, including prior pelvic surgery or radiation and full bladder during the procedure. In this cases also intraperitoneal second incision is recommended for better device function, as the sphincter Implantaion.

Based on cadaveric measurements, the external inguinal ring was only 2.5– 4 cm from the external iliac vein, 5.3–8 cm from the decompressed bladder, and 2–4 cm from the filled bladder. Due to the proximity of the iliac vessels and the bladder to the space of retzius explains its occasional injury when the reservoir is placed in this location [5].

Also partial venous obstruction with subsequent lower extremity edema is reported as a result of pressure of the reservoir. [6] Pelvic vessel complications may be avoided by ensuring that an adequate space has been created both anterior and lateral to the bladder such that there is not compression of the adjacent venous structures. If inadequate space is encountered, alternate reservoir placement ( second incision / high submuscolar) outside the space of Retzius should be considered.

When a vascular tear occurs during IPP surgery, the vessel most commonly lacerated is a branch of the external iliac such as the inferior epigastric, external superficial pudendal, or cremasteric vessels.

To reduce the creation of inguinal floor weakness and to reduce the potential risk of visceral injury particularly after prior pelvic surgery, current practice is to enter the space of Retzius sharply. This technique typically makes a hole just large enough for the index finger to gain entry and complete the dissection. If the space of Retzius cannot be entered due to extensive scarring, then ectopic placement may be considered via a separate transverse hypogastric incision through the anterior rectus sheath with placement of reservoir deep to the rectus muscle but superficial to the posterior rectus sheath.

Ectopic high submuscular reservoir placement can be considered as an alternative method of reservoir placement during IPP implantation (Level2, Grade C). In very obese patiens, subcutaneous reservoir can be used with caution (level2, Grade C)

Ectopic reservoir surgery could be considered a confortable tecnique for the surgeon. The removal of the reservoir can be challenging even for a skilled surgeon. ( Sadeghi Nejad’s Tec)

In many cases, It is mandatory remember to do not hesitate to make a short second incision when it is needed and play safe, because single incision is better and faster but “In medio stat virtus”

Refrences

1. Emerging Complications Following Alternative Reservoir Placement during Inflatable Penile Prosthesis Placement: A 5-Year Multi-Institutional Experience. Hernández JC^1,2, Trost L³, Köhler T^3,4, Ring J⁴, Traweek R¹, Alom M³, Wang R^1,2. J Urol. 2019 Mar;201(3):581-586. doi: 10.1016/j.juro.2018.10.013.
2. Outcomes of abdominal wall reservoir placement in inflatable penile prosthesis implantation: a safe and efficacious alternative to the space of Retzius. StemberDS¹, Garber BB, Perito PE. J Sex Med. 2014Feb;11(2):605-12. doi: 10.1111/jsm.12408. Epub 2013 Nov 29.
3. Inflatable penile implant infection: Predisposing factors and treatment suggestions. Wilson SK, Delk JR 2nd. J Urol 1995;153:659–61
4. Reservoir herniation as a complication of three-piece penile prosthesis insertion. Sadeghi-Nejad H, Sharma A, Irwin RJ, Wilson SK, Delk JR.. Urology 2001;57:142–5.
5. Pertinent anatomical measurements of the ret- ropubic space: A guide for inflatable penile prosthesis reser- voirs shows that the external iliac vein is much closer than thought. Henry G, Jones L, Carrion R, Bella A, Karpman E, Christine B, Kramer A.. J Sex Med 2014;11:273–8.
6. Reservoir repositioning and successful thrombectomy for deep venous thrombosis sec- ondary to compression of pelvic veins by an inflatable penile prosthesis reservoir Brison D, Ilbeigi P, Sadeghi-Nejad H.. J Sex Med 2007;4:1185–7.