A Guide for Inflatable Penile Prosthesis Reservoir Placement: Pertinent Anatomical Measurements of the Retropubic Space

Abstract

Introduction The primary concern for many prosthetic urologic surgeons in placing the three-piece inflatable penile prosthesis (IPP) is the concept of “blind reservoir placement.” Extensive reports permeate the literature regarding bladder, bowel, vascular, and various hernial complications occurring while attempting to place the reservoir into the retropubic space. However, despite these widely documented complications, there is a paucity of published literature on surgically pertinent anatomical measurements of the retropubic space relating to reservoir placement. The focus of this project was to evaluate the special relationships and anatomical measurements of the retropubic space to better aid the surgeon in the safe placement of the reservoir. Aim Analyses of the spatial measurements of reservoir placement into the retropubic space with a focus on utilizing a penoscrotal approach were conducted. In addition, we reviewed and evaluated the published literature for important contributions surrounding the various surgical techniques during placement of a penile prosthesis reservoir. Methods Cadaveric pelvic specimens were dissected to determine the distance and angulation (in degrees) from the inguinal ring to several critical anatomic structures in the pelvis. This format was utilized to simulate the basic features of reservoir placement into the classic retropubic space. We also reviewed and evaluated the published literature for important contributions describing the various surgical techniques in the placement of penile prosthesis reservoirs into the retropubic space. Main Outcome Measures Anatomic measurements were obtained from the inguinal ring to the bladder, external iliac vein, and superior origin of the dorsal suspensory ligament at the anterior apex of the pendulous penis. The angle was measured from the inguinal ring to these structures and recorded. We also reviewed the published literature for various penoscrotal IPP surgical techniques involving placement of the reservoir into the retropubic space to further supplement the pertinent spatial relationships data acquired in this study. Results Of the 28 cadavers, 3 were excluded because of signs of major pelvic surgery, and an additional 6 sides were excluded because of unilateral fibrosis/surgery or difficulty in exposure. Distance to the decompressed bladder was 5–8 cm (average 6.45 cm) at a 15–30 (22.8) degrees medial measurement from the inguinal ring. The filled bladder was 2–4 cm (average 2.61 cm) from the inguinal ring. The external iliac vein distance from the inguinal ring was 2.5–4 cm (average 3.23 cm) at a 20–60 (36.4) degrees lateral measurement from the inguinal ring. Heretofore, the published literature does not appear to have detailed measurements that are provided in this study. Conclusions These anatomical measurements of the retropubic space demonstrate the importance of decompressing the bladder and avoiding deep dissection lateral to the inguinal ring, as the external iliac vein is much closer than currently espoused. We feel that these data are significant to the surgeon proceeding with reservoir placement during IPP surgery.

Troubleshooting intraoperative complications of penile prosthesis placement

“…While rare, there have been several reports of complications related to this approach including bladder perforation, avulsion of a branch of the external iliac vein, postoperative venous compression syndrome, herniation of the reservoir, and direct inguinal herniation of intra-abdominal contents ( 11 ). Cadaveric studies have shown the bladder and external iliac vessels can be as close as two centimeters from the inguinal ring, which is closer than previously appreciated ( 12 ). Certain patient factors such as prior robotic-assisted laparoscopic prostatectomy or radical cystectomy can further complicate the anatomy by violating the space of Retzius.…”

The Prevention and Management of Noninfectious Complications of Penile Implants

“…Previous surgery in the area, pelvic radiation therapy, and an anastomotic leak with perivesical urinoma following radical prostatectomy are situations where excessive scar may be encountered. The iliac artery and vein are about 1 inch lateral to the pocket where the reservoir is placed [16]. Injury to either of these vessels is catastrophic [17].…”

Surgical Techniques in Penoscrotal Implantation of an Inflatable Penile Prosthesis: A Guide to Increasing Patient Satisfaction and Surgeon Ease

“…In fact, if the IPP was left inflated at the end of surgery (to minimize corporal bleeding with compression), the doctor still had to deflate the prosthesis, resulting in additional patient discomfort. Interestingly, a patient satisfaction study found that for many patients, the most negative experience of the surgery was the dressing removal/deflation of the IPP [40].…”