Matz, E.L., Franzen, B, Hudak, S, Morey, A, VanDyke, M

Priapism, surgical management, erectile function

The mainstay of surgical management for refractory erectile dysfunction is insertion of an inflatable penile prosthesis (IPP). This device comprises a pair of cylinders for the corpora, a pump concealed in the scrotum, and a reservoir, the placement of which varies by surgeon preference. Traditional placement in the retropubic space is now joined by other options including the submuscular space below the rectus muscles. Concerns over migration and herniation of the reservoir in this location have lead some surgeons to perform adjunctive maneuvers to aid in anchoring the device (to avoid herniation) and refinement of the tubing exit angle (to reduce mechanical stress on the tubing).1

Reservoir placement into a standard high submuscular position is carried out utilizing a counter incision. This is made in the lower abdomen just lateral to midline, and may preferentially be hidden in the natural crease that forms when a pannus is present. Dissection is carried out through Scarpa’s to the anterior rectus fascia. An 2cm incision is made in the fascia and stay sutures are placed. Local anesthesia is instilled. The muscle belly is bluntly split using a nasal speculum until the yellow of the transversalis fascia is seen. The reservoir is placed below the level of the arcuate line and therefore sits between the rectus muscle belly and transversalis fascia. A space is made for the reservoir superior to the fascial incision using blunt digital dissection and the device is placed. Rather than allow the tubing to exit the fascial incision, it is passed through a new opening approximately 2 centimeters caudal using a right angle, taking care to maintain a closed system. The tubing is then passed into the penoscrotal incision and connected to the remainder of the previously placed device.

Placing the reservoir in this manner allows direct visualization of the space anterior to the transversalis fascia, while also fixing the reservoir in place to obviate the risk of migration and herniation.

Ethan Matz MD and Lauren Beeder MD, operative surgeons

Steven Hudak is a consultant for Boston Scientific.

1. Khoei A, Racik N, Bansal U, Flores F, Khera M. The Low Submuscular Reservoir Placement With Transfascial Fixation for Inflatable Penile Prostheses. J Sex Med. 2022 Aug;19(8):1309-1312. doi: 10.1016/j.jsxm.2022.05.143. Epub 2022 Jun 17. PMID: 35718740.