Ectopic Reservoir Placement—No Longer in the Space of Retzius

© 2011 International Society for Sexual Medicine

Ectopic Reservoir Placement—No Longer in the Space of Retzius Paul E. Perito, MD Perito Urology, Coral Gables Hospital, Miami, FL, USA

Finger palpates medial aspect of external inguinal ring

Finger perforates bladder

External inguinal ring Bladder

Transversalis fascia

Extravasation of urine

Bladder

Bladder perforation with urine extravasation

Foley catheter

FIGURE 1 Traditionally, the inflatable penile prosthesis reservoir has been placed blindly within the space of Retzius. Technically, the index finger/blunt instrument entered the external inguinal ring, perforated the transversalis fascia inguinal canal floor, allowing the reservoir to be placed within the fat of the space of Retzius. Space of Retzius reservoir placement has been difficult after hernia and mesh surgery, and pelvic surgery (robotic prostatectomy, cystectomy, and kidney transplantation). Complications of space of Retzius reservoir placement have included bladder, vascular, and bowel injuries.

J Sex Med 2011;8:2395–2398

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Surgical Techniques Muscle and fascia layers

Blade is above transversalis fascia and below transversus abdominus muscle

Peritoneum Transversalis fascia Transversus abdominus muscle Anterior rectus fascia Scarpa’s fascia Skin Nasal speculum

Proper blade direction toward ipsilateral shoulder

Stay sutures

Improper oblique blade direction

Bladder

Improper anterior/posterior blade direction

Foley catheter

FIGURE 2 The inflatable penile prosthesis reservoir can be safely placed above the transversalis fascia and below the transversus abdominus muscle. This is especially made feasible by new reservoir design—cloverleaf for Coloplast and conceal flat reservoir for AMS (American Medical Systems). These new reservoirs can be placed in the abdominal wall without bulging and will avoid bladder, vascular, and bowel injuries. The external inguinal ring is palpated. Nasal speculum blades are placed at the external inguinal ring above the transversalis fascia and below the transversus abdominus muscle. The nasal speculum is driven directly cephalad toward the ipsilateral shoulder.

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J Sex Med 2011;8:2395–2398

Surgical Techniques

FIGURE 3 To place the newly designed inflatable penile prosthesis reservoir above the transversalis fascia and below the transversus abdominus muscle, a space is developed. Turn the blades of the nasal speculum in the anterior–posterior orientation and spread. Drive the reservoir cephalad, not posterior or lateral or obliquely, as it wants to do. The fascia thins out laterally, and the reservoir tends to be very superficial. Roll the new reservoir design around your finger and insert the new reservoir in the space above the transversalis fascia and below the transversus abdominus muscle.

J Sex Med 2011;8:2395–2398

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Surgical Techniques Bulge of reservoir under skin

Two weeks postop

Reservoir placed between transversus abdominus muscle and transversalis fascia

Anterior rectus fascia Transversus abdominis Rectus abdominis

Peritoneum

Transversalis fascia Transversalis fascia Peritoneum Reservoir Reservoir

Anterior rectus fascia

External oblique Internal oblique Transversus abdominus

FIGURE 4 The newly designed high volume inflatable penile prosthesis reservoir can be safely placed above the transversalis fascia and below the transversus abdominus muscle without bladder, bowel, or vascular injury and without bulging of the abdominal wall postoperatively.

The Surgical Techniques Section is sponsored in part by Coloplast

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J Sex Med 2011;8:2395–2398