Alternative Reservoir Placement Research Articles

Outcomes of Alternative Reservoir Placement in the Lateral Retroperitoneum During Inflatable Penile Prosthesis Placement

To describe outcomes of reservoir placement, exchange, and extraction from the lateral retroperitoneum (LR) in complex patients with a three-piece inflatable penile prosthesis (IPP). A retrospective chart review was performed on all patients that underwent placement of an IPP from 2009 to 2019. Patients with placement of the reservoir in the LR were identified. Intraoperative complications during reservoir placement, exchange, or removal, reservoir-related outcomes, and secondary device-related outcomes were collated and compared to patients who underwent traditional Space of Retzius reservoir placement. A total of 587 men underwent primary IPP placement with 321 patients undergoing reservoir placement in the SOR and 266 in the LR. No significant differences were found in intra-operative reservoir-related outcomes (P=.272) between the 2 groups during placement, replacement, or extraction. Bowel injury occurred in 1 patient in the LR group during placement. No significant differences were found in postoperative reservoir complications (P= .534). Both groups each had one instance of patient reported bulge and pain at reservoir site (P= .6777). Two (0.6%) patients in the SOR group and 3 (1.1%) patients in the LR group had a reservoir failure or leak. There was a trend towards a lower rate of device infections in the LR group (1.9%) compared to the SOR group (4.7%) (P= .063). There were no significant differences in overall device mechanical failure rates between both groups (P= .919). Reservoir placement in the LR is safe in patients with complex pelvic anatomy with equivalent device durability and no difference in surgical outcomes compared to standard retropubic reservoir placement.

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

BackgroundAlternative 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.MethodsA 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.ResultsA 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).ConclusionsComplication 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.

336 Reservoir Induced Bladder Rupture: A Rare Complication of Inflatable Penile Prosthesis Revision Surgery

Bladder rupture is a rare complication following prosthesis component replacement for malfunction. Current practice for a deflated reservoir involves overdistention of the reservoir during revision surgery, which can increase the risk of this complication. There is limited literature describing this complication or providing recommendations regarding intraoperative or postoperative management. Our objective is to describe our experiences with this rare complication and propose ways to manage and possibly avoid this complication. We retrospectively reviewed the charts of two patients who underwent inflatable penile prosthesis (IPP) revision surgery complicated by bladder rupture. Intraoperatively, the existing reservoirs had been left in situ and overdistended to break the surrounding fibrous capsule according to common practice prior to being placed in circuit with new cylinders and pump. Gross hematuria was noted in each case following this technique. Delayed identification of the complication occurred in the first case, while the complication was immediately recognized in the second case. The first patient returned to the OR for complete penile prosthesis removal and replacement of component parts including placement of an ectopic reservoir and foley catheter. He subsequently underwent bladder closure for a persistent bladder leak. The second patient underwent immediate removal of three-piece penile prosthesis and placement of a malleable prosthesis and foley catheter. Follow-up cystogram demonstrated the bladder had completely healed with conservative management alone. On follow-up, both patients were satisfied with their penile prostheses and able to engage in penetrative intercourse. Immediate intervention following identification of this complication was crucial to the successful outcomes. In retrospect, this complication may have been minimized if the reservoirs were refilled, but not overdistended. Any back pressure may signify the fibrous capsule has become too thickened and may perforate the bladder if broken. Alternative reservoir placement or placement of a malleable prosthesis may be safer options in this scenario.

Re: Sub-External Oblique Placement of Inflatable Penile Prosthesis Reservoirs-Initial Experience.

No AccessJournal of UrologyUrological Survey1 Jul 2019Re: Sub-External Oblique Placement of Inflatable Penile Prosthesis Reservoirs—Initial Experience Allen D. SeftelMD Allen D. SeftelAllen D. Seftel More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000557720.63487.51AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Re: Sub-External Oblique Placement of Inflatable Penile Prosthesis Reservoirs—Initial Experience." The Journal of Urology, 202(1), p. 14 Suggested Reading : Emerging complications following alternative reservoir placement during inflatable penile prosthesis placement: a 5-year multi-institutional experience. J Urol 2019; 201: 581. Link, Google Scholar © 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 202Issue 1July 2019Page: 14-14 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Allen D. Seftel More articles by this author Expand All Advertisement Loading ...

Non-Infectious Reservoir-Related Complications During and After Penile Prosthesis Placement.

Inflatable penile prosthesis (IPP) surgery offers a high satisfaction rate and low rate of complications when performed by experienced surgeons. 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. To review the prevalence and management options for non-infectious intraoperative and postoperative complications related to prosthetic reservoirs. A Medline PubMed search was used to identify articles related to IPP reservoir-related complications including bladder and bowel injury, vascular injury, autoinflation, herniation, palpability, leakage, and tubing torsion. Rates and types of reservoir-related complications during and after IPP surgery. 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. Patients undergoing alternative reservoir placement (ARP) may complain of reservoir palpability and premature mechanical failure secondary to reservoir leakage or tubing torsion. Although most surgeons continue to use the SOR as the main location for reservoir placement, ARP has gained popularity owing to its low risk of bother, minimal loss of functionality, and safety advantages in patients with history of pelvic surgery. Both reservoir placement in the SOR and ARP carry a low rate of complications while maintaining a high satisfaction rate. Clavell-Hernández J, Shah A, Wang R. Non-Infectious Reservoir-Related Complications During and After Penile Prosthesis Placement. Sex Med Rev 2019;7:521-529.

Emerging complications following alternative reservoir placement during inflatable penile prosthesis placement: a 5-year multi-institutional experience.

PurposeAlternative, or ectopic, reservoir placement (ARP) has recently gained popularity among prosthetic surgeons in order to avoid injury to pelvic structures during inflatable penile prosthesis (IPP) implantation. However, the true incidence of complications associated with these new techniques remain understudied. We carried out a 5-year multi-center retrospective study with the aim to evaluate complications related to alternative reservoir placement. Materials and MethodsWe retrospectively reviewed databases of IPP surgeries in three institutions from February 2011 to December 2016. The mechanism of failure and complications related to reservoir placement were analyzed. ResultsA total of 974 IPPs were placed in the 5-year period by three surgeons, of which 612 underwent ARP. Mean follow-up to emergence of reservoir-related complications was 20.4 months. There was no significant difference in complication rates between primary and revision cases (p=0.72). A total of 12 cases (2.0%) required revision for reservoir-related complications in the ARP group vs 1.3% in the SOR group (p=0.44). The most common complication in the ARP group was reservoir leakage (N=5). There were three cases that required revision due to abdominal muscular pain. Three Conceal™ reservoir tubing torsions were found that caused blockage of fluid transportation. One reservoir was incidentally found to be intraperitoneal via unrelated imaging. ConclusionsAlternative reservoir placement is a safe and mechanically reliable approach, including among men with prior pelvic surgery. However, there are associated risks which include reservoir leakage, tubing torsion, muscle discomfort and unintended reservoir malposition that may require surgical revision.

A retrospective analysis of risk factors for IPP reservoir entry into the peritoneum after abdominal wall placement.

Placement of an inflatable penile prosthesis (IPP) is the most effective treatment modality for men with ED refractory to medical management. We have previously demonstrated a protocol for IPP reservoir placement within the abdominal wall musculature, which was shown to be a safer location than traditional placement in the retropubic space of Retzius. The aim of this study was to review our complications with IPP reservoir entry into the peritoneum after abdominal wall placement of the reservoir. We retrospectively reviewed our two patients with peritoneal entry of the reservoir after posterior to transversalis fascia and anterior to transversalis fascia placement during virgin and compromised IPP cases, respectively. Our goal was to assess common inherent patient and surgical factors that resulted in this complication in order to develop a management algorithm to prevent future occurrence during alternative reservoir placement. Peritoneal reservoir entry was identified in two patients. These patients were both noted to be thin (mean body mass index (BMI) 18.5 kg/m2), current or former smokers. Peritoneal entry was identified early after reservoir placement. Neither of the patients suffered bowel injury and both subsequently underwent successful reservoir removal and IPP replacement. Both are currently doing well with functional IPPs on follow-up. Peritoneal entry of the reservoir occurs very rarely and, in our series, occurred in a cohort of patients with low BMI and tobacco use history. We recommend early identification of similar patients and subsequent reservoir placement anterior to transversalis fascia with caution to prevent peritoneal entry.

Author Reply

We would like to thank the reviewers for their thoughtful comments. 1 Wilson S.K. Subcutaneous placement of inflatable penile prosthesis reservoirs [Editorial Comment]. Urology. 2015; (in press) PubMed Google Scholar On April 13, 2015, Coloplast Corp. received U.S. FDA approval for ectopic reservoir placement. This approval was based on FDA review of 9 published references. 2 Smaldone MC Cannon GM Benoit RM Subcutaneous reservoir placement during penile prosthesis implantation. Can J Urol. 2006; 13: 3351-3352 PubMed Google Scholar , 3 Perito PE Ectopic reservoir placement–no longer in the space of Retzius. J Sex Med. 2011; 8: 2395-2398 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar , 4 Perito PE Wilson SK Traditional (retroperitoneal) and abdominal wall (ectopic) reservoir placement. J Sex Med. 2011; 8: 656-659 Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar , 5 Hartman RJ Jr., Helfand BT McVary KM Outcomes of lateral retroperitoneal reservoir placement of three-piece penile prosthesis in patients following radical prostatectomy. Int J Impot Res. 2010; 22: 279-283 Crossref PubMed Scopus (26) Google Scholar , 6 Chung PH Morey AF Tausch TJ et al. High submuscular placement of urologic prosthetic balloons and reservoirs: 2-year experience and patient-reported outcomes. Urology. 2014; 84: 1540-1545 Google Scholar , 7 Stember DS Garber BB Perito PE Outcomes of abdominal wall reservoir placement in inflatable penile prosthesis implantation: a safe and efficacious alternative to the space of Retzius. J Sex Med. 2014; 11: 605-612 Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar , 8 Karpman E Brant WO Kansas B et al. Reservoir alternate surgical implantation technique: preliminary outcomes of initial PROPPER study patients consecutively implanted with low profile or spherical reservoir in submuscular location or traditional prevesical space. J Urol. 2014; https://doi.org/10.1016/j.juro.2014.007.082 Crossref PubMed Google Scholar , 9 Karpman E et al. Current opinions on alternative reservoir placement for inflatable penile prosthesis among members of the Sexual Medicine Society of North America. J Sex Med. 2013; 10: 2115-2120 Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar , 10 Tausch TJ et al. High submuscular versus space of Retzius placement of inflatable penile prosthesis reservoirs: results of a surgeon survey. Can J Urol. 2014; 21: 7465-7469 PubMed Google Scholar In our series, we have expanded the published literature on ectopic reservoirs, specifically involving subcutaneous reservoir placement (SRP). We used this technique on <1% of patients, specifically those with a thick subcutaneous fat layer, which would be capable of concealing the reservoir. However, we do not yet feel that ectopic placement should be considered a paradigm shift. There is a large amount of literature reporting on traditional space of Retzius (SOR) placement, and a much smaller amount concerning ectopic placement. Ectopic placement does not conceal the reservoir as well as SOR placement in thin individuals. We believe that more patients, more authors, and longer follow-up are required before we come to any final conclusions about these issues. We continue to prefer SOR reservoir placement in uncomplicated cases, and have published recommendations on how to avoid visceral injury. 11 Garber BB Morris A Intravesical penile implant reservoir: case report, literature review, and strategies for prevention. Int J Imp Res. 2012; 25: 41-44 Crossref PubMed Scopus (17) Google Scholar However, for those patients with anatomic issues (eg, hernia repair with mesh, prior pelvic surgery, morbid obesity, etc.) we freely use ectopic placement. Ectopic sites we have safely used include the space immediately subjacent to: the rectus muscle, the anterior rectus fascia, the external oblique muscle, the external oblique fascia, and Scarpa's fascia. Rather than considering ectopic placement as a paradigm shift, we prefer to consider these techniques as additional reservoir placement options that implanting urologists now have at their disposal.

Reservoir Alternate Surgical Implantation Technique: Preliminary Outcomes of Initial PROPPER Study of Low Profile or Spherical Reservoir Implantation in Submuscular Location or Traditional Prevesical Space

Alternative reservoir site placement has become an accepted technique for patients who require an inflatable penile prosthesis. To our knowledge there has been no prospective evaluation of this technique, which is currently off label. We performed a prospective, multicenter, multinational, internal review board approved study to evaluate the effectiveness and safety of alternative reservoir site placement. PROPPER initiated in June 2011, is a database containing patient outcomes of inflatable penile prosthesis implantation. Patients with AMS® penile prostheses continue to be enrolled at 13 North American sites. We examined PROPPER study data to determine surgical implantation use patterns for the AMS 700™ series. We evaluated reservoir implantation site and complications by implantation site. A total of 759 patients had been implanted with an AMS 700 series implant by the time of evaluation. Mean patient followup was 17.8 months (range 0 to 36). There was no reported case of revision surgery for a palpable reservoir and no report of vascular or hollow viscous injury associated with alternative reservoir site placement. Two cases of reservoir herniation in the alternative reservoir site placement group and 2 in the space of Retzius group were treated with reservoir reimplantation. Patients with 1-year assessment available were satisfied or very satisfied with the device and reported a frequency of use of more than once per month. Alternative reservoir placement in the submuscular location is an option in patients who undergo inflatable penile prosthesis surgery. Implant surgeons should consider alternative reservoir site placement a safe, effective alternative to reservoir placement in the space of Retzius.

Current Opinions on Alternative Reservoir Placement for Inflatable Penile Prosthesis among Members of the Sexual Medicine Society of North America

The Sexual Medicine Society of North America (SMSNA) includes as its members the most experienced prosthetic surgeons in North America who implant inflatable penile prostheses (IPPs). Obliteration of the space of Retzius (SOR) resulting from robotic-assisted laparoscopic prostatectomy (RALP) is a growing concern that has prompted many surgeons to look for alternative locations for reservoir placement during IPP implantation. The aim of this article is to educate the community of prosthetic urologists about potential complications and alternative locations for IPP reservoir placement. A panel of high-volume experienced prosthetic surgeons discussed their views on alternative IPP reservoir implantation during a symposium focused on this topic. After reviewing reservoir complications, physician members of the SMSNA in attendance were surveyed using an audience response system (ARS) to facilitate sharing of knowledge, opinions, and recommendations related to reservoir implantation. Six ARS questions were used to identify the percentages of SMSNA member physicians with concerns about traditional IPP reservoir placement and utilizing alternative reservoir placement (ARP), and the impact of changing practice patterns on patient safety. A majority (81%) of experienced implant surgeons surveyed think that RALP sometimes or frequently makes traditional IPP reservoir placement more difficult. Placement of the reservoir in an alternative location is sometimes or frequently advantageous for patient safety. A vast majority (97%) of the 95 respondents indicated that ARP techniques should be included in physician training courses. Physicians have concerns about reservoir placement in the SOR in RALP patients, which may explain why ARP is popular among SMSNA members. Device manufacturers should support physician training that provides for ARP. Clinical outcomes in RALP patients are needed to better understand the risks and benefits, and define the ideal location of reservoir placement in this population.