Ten Year Experience with High Submuscular Placement of Inflatable Penile Prosthesis Reservoirs: Refined 5-Step Technique

INTRODUCTION: High submuscular (HSM) placement of inflatable penile prosthesis (IPP) reservoirs is a promising new FDA approved alternative to traditional space of Retzius (SOR) reservoir placement. Since 2011, we have performed HSM placement of IPP reservoirs almost exclusively at our tertiary center. In 2014, we proposed a refined, 5-step HSM reservoir placement technique. Herein, we present our extended experience with HSM reservoir placement. METHODS: Data was retrospectively collected on patients undergoing virgin IPP placement between January 2009 and June 2019. Reservoir related complications and revisions were compared between SOR and HSM reservoir groups (2012-2019). HSM patients were divided into two cohorts—Initial Era (2012-2014) and Current Era (2014-2019). Revision cases were excluded. Our refined 5-step technique was developed to optimize outcomes and includes: 1. Position and access 2. Develop lower HSM pocket 3. Develop upper HSM pocket 4. Reservoir Delivery (fill and fine-tune) 5. Confirm and connect. RESULTS: Between January 2009 and August 2019, 733 total IPP procedures (586 HSM, 147 SOR) were performed at our institution, 561 of which were virgin cases (430 HSM, 131 SOR) and included in this analysis. We noted a significant decrease in complications requiring surgical revision (p=0.01) in the Current compared to the Initial HSM Era. Among 133 virgin cases performed in the Initial Era, seven (5.3%) required surgical revision (1 bowel obstruction after inadvertent placement into peritoneal cavity, 6 herniation). Among 297 virgin cases performed during the Current Era, three (1.0%) required revision, all due to herniation. The rate of all HSM reservoir complications was similar to reservoirs placed by SOR technique. Overall, surgical revision was required in ten (2.3%) HSM cases. Six (4.6%) SOR cases presented with reservoir related complications that required revision (1 bladder erosion, 2 vascular injury, and 3 herniation). CONCLUSION: Our extended experience validates the HSM placement of IPP reservoirs as a safe alternative to traditional SOR placement. Major reservoir complications were minimized utilizing our current 5-step HSM technique.