Heterotopic placement of prosthesis reservoir in penile prosthetic surgery: exception or rule
Traditional placement of tri-component penile prosthesis reservoirs into the space of Retzius may be difficult and dangerous in patient who have had previous pelvic surgery in particular kidney transplantation, inguinal hernia repair with alloplastic material, colectomy with ileostomy or colostomy, radical cistectomy with ortotopic bladder and transperitoneal robotic or laparoscopic radical prostatectomy1. To avoid the retropubic space in high-risk patients various maneuvers have been described for placing prosthesis reservoir in a location superficial to the transversalis fascia, including the infrapubic approach2. We show our preliminary experience in heterotopic implant of tri-component penile prosthesis reservoirs using a transscrotal approach.
Materials and Methods
From May 2012 to July 2014, sixty patient underwent penile prosthesis implantation with an AMS 700 3-piece inflatable penile prosthesis with a Conceal reservoir. Of these, twenty patient underwent heterotopic implant of reservoir in a submuscular location by bluntly tunneling through the external inguinal ring into a potential space between the transversalis fascia and the rectus abdominis muscle3. We used a thoracic surgery clamp. Average patient age was 65 years with an average BMI of 27.5 . The most common primary etiology of ED in the first 20 patients with sub-muscular Conceals was radical prostatectomy (45%). At 6th month all patient were given a standardized questionnaire (Morei questionnaire) during an andrological consultation. The surgeon also indicated on the questionnaire if he could palpate the reservoir at maximum volume. We use independent sample t-test and statistical significance was set at P<0.05.
Submuscular implantation was possible in all patients without important complications and without necessity of an abdominal counterincision or perforation into the space of Retzius. Mean surgery duration was superimposable: 65 minutes (σ=13) for Retzius implantation and 70 minutes (σ=13) for submuscular implantation (p=0,09). One patient with Retzius implantation and one patients with submuscular implantation had scrotal hematoma. At six month, 90% of the cases (18/20) had no palpable reservoir and no disconfort . One patient had palpable reservoir (too low implantation) but he refused re-implantation. One patient underwent reservoir re-implantation because of important abdominal swelling due to a surgical mistake (subcutaneous implantation). BMI was not associated with reservoir palpability (BMI mean 27.2 (σ=0.70) when palpable vs. 28.3 (σ=1.75) when not palpable, P=0,40).
We believe this technique represents a significant advance in prosthetic urology using a single incision transscrotal approach, in particular when traditional placement of reservoirs into the space is difficult and dangerous. We have found this technique to be simple and easy to teach and learn. Our study limitations include small number of patients sampled, short overall follow-up and use of a nonvalidated questionnaire. Nevertheless, this report represents a noteworthy initial experience at a high-volume prosthetic center. Although traditional placement of reservoir into the space of Retzius is widely utilized and have been safely employed for ten of thousand of patients, potential complications are described, including bladder perforation or erosion4 and vascular damages1-5. Our preliminary experience provides important clinical evidence that strongly supports the safety and continued expansion of the high submuscular alternative placement strategy, especially in high-risk patients. Sub-muscular placement avoids potential injury to bladder, bowel and blood vessels, especially in patients with previous pelvic surgery.
High submuscular placement of penile prosthesis reservoir using a single incision transscrotal approach, is a safe and reliable technique that avoids a laborious deep retropubic dissection in patient who have had previous pelvic surgery, in particular kidney transplantation, inguinal hernia repair with alloplastic material, colectomy with ileostomy or colostomy, radical cistectomy with ortotopic bladder and transperitoneal robotic or laparoscopic radical prostatectomy. Sub-muscular placement avoids severe intra-operative complications also in patients who have not had previous pelvic surgery. Our future target will be to increase our number of patients sampled. In the future, will this technique replace traditional technique in all patients?
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2-Perito PE et all., Traditional (retroperitoneal) and abdominal wall (ectopic) reservoir placement. J Sex Med. 2011 Mar;8(3):656-9.
3-Morey AF. et all., High submuscular placement of urologic prosthetic balloons and reservoirs via transscrotal approach. J Sex Med. 2013 Feb;10(2):603-10.
4-Fitch WP 3rd, Roddy T ,Erosion of inflatable penile prosthesis reservoir into bladder. J Urol. 1986 Nov;136(5):1080.
5-Brison D. et all., Reservoir repositioning and successful thrombectomy for deep venous thrombosis secondary to compression of pelvic veins by an inflatable penile prosthesis reservoir. J Sex Med. 2007 Jul;4(4 Pt 2):1185-7.