Avoiding deep pelvic complications using a ‘Five‐Step’ technique for high submuscular placement of inflatable penile prosthesis reservoirs

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.

Long-term results of three-part penile prosthesis implantation with Ectopic reservoir placement in the treatment of erectile dysfunction: is supramuscular tubulation a reliable method?

BACKGROUND

Penile prosthesis implantation is the last resort for refractory erectile dysfunction. Reservoir placement is one of the biggest challenges in inflatable penile prosthesis implant surgery in several cases, especially in patients with abnormal pelvic anatomy. Ectopic reservoir placement with supramuscular approach has many advantages in these cases.

RESULTS

No complications were encountered except wound site infection in 2 patients which could be controlled with antibiotic treatment. EDITS scores were not statistically different between patients divided into 2-year groups according to follow-up time. Median values of EDITS scores were high in all groups, suggesting that couples had high sexual satisfaction both in the long term and in the short term.

CONCLUSIONS

We recommend placement of the supramuscular tube and reservoir through the incision described, especially in patients whose pelvic anatomy has been modified by lower abdominal surgery.

Complications and troubleshooting in primary penile prosthetic surgery-a review

Penile implant surgery is the gold standard to treat erectile dysfunction with success rates of over 90%. The first penile implants were developed in the early 1900s. Since then, several types of implants have been developed including malleable implants, two-piece inflatable implants, and three-piece inflatable implants. The three-piece inflatable penile prosthesis, which was introduced in 1973, is the most widely used type of penile implant in the United States. Penile implant surgery has undergone numerous advancements over the years, improving outcomes and patient satisfaction. However, as with any surgical procedure, there are risks and complications associated with penile implant surgery. It is important for surgeons to understand these potential complications and to have strategies in place to manage and prevent them to achieve the best possible outcomes for their patients.

Increasing role of counterincision for high submuscular penile prosthesis reservoir placement

Background

Inflatable penile prosthesis (IPP) reservoir placement into the high submuscular (HSM) space is safe and well tolerated. Recent studies have proposed that reservoirs placed via an abdominal counterincision (CI) may offer more precise and durable positioning as compared with a transinguinal (TI) approach.

Aim

Herein we compare the CI-HSM and TI-HSM techniques with respect to operative time, pain control, and postoperative complications.

Methods

We reviewed our penile prosthesis database at a large single-surgeon tertiary referral center from 2014 to 2021 to compare those who underwent virgin reservoir placement via the CI-HSM technique vs the TI-HSM technique. Statistical analysis was performed with the Mann-Whitney U test for continuous variables and the chi-square test and Fisher exact test for discrete variables.

Outcomes

Operative time, postoperative complications, morphine milligram equivalents prescribed, and postoperative correspondence were compared between patients undergoing the CI-HSM and TI-HSM techniques.

Results

Among 456 virgin IPP implants, the CI-HSM technique was used in 34 cases (7.5%) and the TI-HSM technique in 422 cases (92.5%). Of these 456 cases, 92 (20.2%) were combined with ancillary procedures such as artificial urinary sphincter, urethral sling, or penile plication (6/34, CI; 86/422, TI). Cases employing the CI-HSM technique had a 19.9% greater median operative time: 81.5 minutes (IQR, 69.3-106.5) vs 68 minutes (IQR, 57.8-80.3; P < .01). A similar proportion of patients in the CI-HSM group (2/34, 5.9%) were treated for infection as in the TI-HSM group (17/422, 4.0%; P = .64). Reservoir herniation was seen in 12 patients in the TI-HSM group (2.8%) and in none of the CI-HSM group, but this did not reach significance (P > .99). No differences were identified between patients in the TI-HSM and CI-HSM groups with regard to postoperative morphine milligram equivalents prescribed, narcotic medication refills, or postoperative correspondence.

Clinical Implications

CI-HSM reservoir placement was associated with similar surgical outcomes to TI-HSM without increased infection risk or need for narcotic pain management.

Strengths and Limitations

Although this study is a large contemporary series addressing a clinically important subject, it is limited by its retrospective preliminary nature and nonrandomized unmatched design. Patient pain regimens were assessed via discharge prescriptions, although data regarding narcotic consumption were not available in the medical record.

Conclusions

IPP reservoir placement via the CI-HSM technique is safe and well tolerated. Increased operative time of the CI-HSM technique as compared with the TI-HSM technique is clinically negligible given its potential safety benefits of direct visualization of reservoir placement.

Distance from Critical Pelvic Structures: Radiographic Comparison of High Submuscular and Space of Retzius IPP Reservoir Placement Techniques

OBJECTIVES

To evaluate the distance from critical pelvic structures (CPS, defined as bladder and iliac vessels) among inflatable penile prosthesis (IPP) reservoirs placed into the space of Retzius (SOR) and high submuscular (HSM) locations using cross-sectional imaging. IPP reservoir placement into the HSM location has been proposed as a strategy to prevent injury due to greater distance from CPS.

METHODS

Our institutional database was retrospectively reviewed to identify men who underwent IPP insertion between 2007 and 2020 and had available cross-sectional abdominopelvic imaging after the time of surgery. Patients were grouped based on reservoir placement technique (SOR vs. HSM). Staff radiologists blinded to placement technique evaluated reservoir position to determine the shortest distance between CPS and the reservoir and if a mass effect was present on CPS. Variables were analyzed using chi-squared, Fisher's exact, and student's T-tests as indicated.

RESULTS

Among 1,010 IPP cases performed during the study interval, 139 (13%) were imaged. Compared with SOR reservoirs (n = 32), HSM reservoirs (n =107) were significantly less likely to induce a mass effect on the bladder (72 vs. 9%, p = <0.01) or iliac vessels (34 vs. 4%, p = <0.01) and were located roughly five times further from the bladder (10 ± 22 vs. 49 ± 36 mm, p = <0.01) and iliac vessels (5 ± 9 vs. 23 ± 26 mm, p = <0.01).

CONCLUSIONS

This study radiographically confirms that IPP reservoirs are located significantly further away from CPS following HSM placement compared to SOR placement.

Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice

BACKGROUND

Inflatable penile prosthesis (IPP) reservoirs are typically placed into the Space of Retzius (SOR) or alternative locations including the High Submuscular (HSM) space via transinguinal (TI) or counter incision (CI) techniques. A cadaver study showed variability in reservoir location after TI-HSM placement.

AIM

To evaluate reservoir location using cross-sectional imaging following IPP insertion.

METHODS

We retrospectively reviewed our institutional database and identified men who underwent virgin penoscrotal IPP insertion between 2007 and 2019. We then identified those men who subsequently underwent cross-sectional imaging prior to October 2019. Radiologists evaluated cross-sectional imaging in a blinded manner and categorized reservoir locations as follows: 1) submuscular; 2) posterior to the external oblique fascia and lateral to the rectus abdominis musculature; 3) preperitoneal; 4) retroperitoneal; 5) intraperitoneal; 6) inguinal canal; 7) subcutaneous. Patients were stratified by reservoir placement technique, transinguinal space of Retzius (TI-SOR), transinguinal high submuscular (TI-HSM), or counterincision high submuscular (CI-HSM). Clinical characteristics and outcomes were reviewed and compared. Statistical analysis was performed using Chi-squared and Fisher's exact tests.

OUTCOMES

Variability exists in the TI placement of SOR and HSM reservoirs, CI-HSM reservoirs were associated with a low level of variability.

RESULTS

Among 561 men who underwent virgin IPP insertion during the 12-year study period, 114 had postoperative cross-sectional imaging (29 TI-SOR, 80 TI-HSM, and 5 CI-HSM). Among the 114 patients imaged, TI-HSM reservoirs were more likely than TI-SOR to be located anterior to the transversalis fascia (48 vs 14%, P < .01) and were less likely to be located in the preperitoneal space (18 vs 62%, P < .01). Rates of intraperitoneal reservoir location were similar between the TI-HSM and TI-SOR groups (5 vs 7%, P = .66). Among imaged CI-HSM reservoirs, 4 (80%) were anterior to the transversalis fascia and 1 (20%) was within the inguinal canal. Among all 536 transinguinal cases (131 TI-SOR and 405 TI-HSM), rates of reservoir-related complications requiring operative intervention were similar between groups (5 vs 2%, P = .24). No complications were noted among the 25 patients in the CI-HSM cohort.

CLINICAL IMPLICATIONS

The level of variability seen in this study did not seem to impact patient safety, complications were rare in all cohorts.

STRENGTHS AND LIMITATIONS

This study is the first and largest of its kind in evaluating reservoir positioning in live patients with long-term follow-up. This study is limited in its retrospective and nonrandomized nature.

CONCLUSIONS

Despite variability with both TI-HSM and TI-SOR techniques, reservoir related complications remain rare. Kavoussi M, Cook G, Nordeck S, et al. Radiographic Assessment of Inflatable Penile Prosthesis Reservoir Location Variability in Contemporary Practice. J Sex Med 2021;XX:XXX-XXX.

Practical Considerations in Inflatable Penile Implant Surgery

BACKGROUND

Penile prosthesis implantation remains an effective solution for men with medical-refractory erectile dysfunction (ED) following radical pelvic surgery. Despite the distortion of pelvic anatomy, a penile implant can be performed with excellent clinical outcomes provided strict patient selection, proper preoperative workup and safe surgical principles are adhered to.

AIM

To provide practical recommendations on inflatable penile prosthesis (IPP) implantation in patients with medical-refractory ED, with an emphasis on patient selection and counselling, preoperative workup as well as surgical considerations to minimize intraoperative complications.

METHODS

A Medline search on relevant English-only articles on penile prostheses and pelvic surgery was undertaken and the following terms were included in the search for articles of interest: "bladder cancer", "prostate cancer", "rectal cancer", "pelvic surgery" and "inflatable penile implant".

OUTCOMES

Clinical key recommendations on patient selection, preoperative workup and surgical principles.

RESULTS

Patients should be made aware of the mechanics of IPP and the informed consent process should outline the benefits and disadvantages of IPP surgery, alternative treatment options, cost, potential prosthetic complications and patient's expectations on clinical outcomes. Specialised diagnostic test for workup for ED is often not necessary although preoperative workup should include screening for active infection and optimising pre-existing medical comorbidities. Precautionary measures should be carried out to minimise infective complication. Corporal dilation and reservoir placement can be challenging in this group, and surgeons may require knowledge of advanced reconstructive surgical techniques when dealing with specific cases such as coexisting Peyronie's disease and continence issue.

CLINICAL TRANSLATION

Strict patient selection and counselling process coupled with safe surgical principles are important to achieve excellent linical outcomes and patient satisfaction rates.

STRENGTHS AND LIMITATIONS

This masterclass paper provides an overview of the practical considerations for men who are undergoing IPP surgery following radical pelvic surgery. Limitations include the lack of highquality data and detailed surgical description on each surgical troubleshooting steps for various prosthetic-related complications.

CONCLUSION

The IPP implantation can be performed efficiently and safely in patients following radical pelvic surgery. Chung E, Mulhall J. Practical Considerations in Inflatable Penile Implant Surgery. J Sex Med 2021;18:1320-1327.

A Case Report of Large Bowel Obstruction in a Patient With an Inflatable Penile Prosthesis

INTRODUCTION

Inflatable penile prostheses (IPP) consist of 2 cylinders implanted into the corpora cavernosa, a pump placed in the scrotum, and a saline-filled reservoir traditionally placed in the space of Retzius. IPPs are used to treat refractory erectile dysfunction with few rare, but serious, complications. Cases of reservoirs causing erosion into the bladder, small bowel obstructions, vascular compression, and inguinal herniation have been described.

AIM

We highlight the importance of keeping a broad differential diagnosis when assessing patients with bowel obstructions.

METHODS

A 68-year-old man with a previous IPP placement presented with left lower quadrant abdominal pain, constipation and obstipation for 5 days. On exam, he was afebrile, and noted to have a firm, distended, tympanic abdomen. CT scan showed a distended cecum at 11 cm, narrowing of the proximal sigmoid with adjacent inflammatory changes, and minimal peri-colonic air, suggestive of a localized perforation. The IPP reservoir was seen in the left iliac fossa, coinciding with the lead point of the obstruction, suggesting that the reservoir may have itself caused the obstruction. The patient was taken to the operating room for an emergent exploratory laparotomy, which revealed a mass in the colon abutting the IPP reservoir.

MAIN OUTCOME MEASURES

Considerations for IPP component explantation, factors considered for reintervention, and preservation of penile length with avoidance of penile fibrosis.

RESULTS

A left colectomy with transverse colostomy was successfully performed and the IPP reservoir was explanted. Intraoperative frozen section revealed adenocarcinoma. Upon initial review of the imaging, it was thought that the IPP reservoir may have caused the obstruction, but intraoperatively, the colonic tumor was found to be the culprit.

CONCLUSION

Although complications related to IPPs, including bowel obstructions, have been previously described in the literature, treatment for large bowel obstructions must take into account all possible etiologies, including malignancy. Atri E, Mallory C, Perez A, et al. A Case Report of Large Bowel Obstruction in a Patient With an Inflatable Penile Prosthesis. Sex Med 2021;9:100391.

Explantation of High Submuscular Reservoirs: Safety and Practical Considerations

BACKGROUND

Over the past decade, high submuscular (HSM) placement of inflatable penile prosthesis (IPP) reservoirs has emerged as a viable alternative to space of Retzius (SOR) placement; however, data comparing the feasibility and complications of HSM vs SOR reservoir removal do not presently exist.

AIM

To present a comparison of the safety, feasibility, and ease of removal of HSM vs SOR reservoirs in a tertiary care, university-based, high-volume prosthetic urology practice.

METHODS

Data were retrospectively collected on patients who underwent IPP reservoir removal between January 2011 and June 2020. Cases were separated into 2 cohorts based on reservoir location. Statistical analysis was performed using Fisher's exact and Chi-squared tests for categorical variables and Student's t-test for continuous variables. Timing from IPP insertion to explant was compared between the HSM and SOR groups using the Mann-Whitney U test.

OUTCOMES

Time from IPP insertion to explant, operative time, intraoperative and postoperative complications, and need for a counter incision were compared between the HSM and SOR groups.

RESULTS

Between January 2011 and June 2020, 106 (73 HSM, 33 SOR) patients underwent IPP removal or replacement by a single surgeon at our institution. Average time from IPP insertion to removal was 43.6 months (24.2 HSM, 52.7 SOR, P = .07)-reservoir removal occurred at the time of device explant in 70 of 106 (66%) cases. More HSM reservoirs were explanted at the time of IPP removal compared with the SOR cohort (54 of 73, 74% HSM vs 16 of 33, 48.5% SOR, P = .01). Similar rates of complications were noted between the HSM and SOR groups (1.9% vs 6.3%, P = .35). There was no significant difference in need for counter incision between the 2 groups (24 [42%] HSM vs 4 [25%] SOR, P = .16) or in average operative times (76.5 ± 38.3 minutes HSM vs 68.1 ± 34.3 minutes SOR, P = .52).

CLINICAL IMPLICATIONS

Our experience with explanting HSM reservoirs supports the safety and ease of their removal.

STRENGTHS AND LIMITATIONS

Although the absolute cohort size is relatively low, this study reflects one of the largest single-institution experiences examining penile implant reservoir removal. In addition, reservoir location was not randomized but was instead determined by which patients presented with complications necessitating reservoir removal during the study period.

CONCLUSIONS

HSM reservoir removal has comparable perioperative complication rates and operative times when compared with SOR reservoir removal. Kavoussi M, Bhanvadia RR, VanDyke ME, et al. Explantation of High Submuscular Reservoirs: Safety and Practical Considerations. J Sex Med 2020;17:2488-2494.