Avoiding Deep Pelvic Complications Using "Five-Step" Technique for High Submuscular Placement of Inflatable Penile Prosthesis Reservoirs.

OBJECTIVES: To compare our extended experience with high submuscular (HSM) reservoir placement to traditional space of Retzius (SOR) placement and to present our current, refined "Five-Step" technique (FST) for HSM placement. MATERIALS AND METHODS: Data was retrospectively collected on patients undergoing inflatable penile prosthesis (IPP) placement between January 2009 and June 2019. Reoperative cases were excluded. Reservoir-related complications and subsequent revisions were compared between SOR (2009-2012) and HSM reservoir groups (2012-2019). HSM patients were subdivided into two cohorts-Initial Technique (2012-2014) and FST (2014-2019). The refined FST protocol was developed in 2014 to optimize outcomes and includes the following steps: 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 June 2019, 733 total IPP procedures (586 HSM, 147 SOR) were performed by a single surgeon at our institution, 561 of which were virgin cases (430 HSM, 131 SOR) and included in this analysis. Overall, surgical revision was required in 10/430 (2.3%) HSM cases (1 delayed bowel obstruction, 9 herniations) and 6/131 (4.6%) SOR cases (1 bladder erosion, 2 vascular injuries, and 3 herniations, p=0.22). When comparing the FST to the Initial Technique, we noted a significant decrease in complications requiring surgical revision (p=0.01). Among 133 cases performed with the Initial Technique, seven (5.3%) required surgical revision (one bowel obstruction after placement into the peritoneal cavity, six herniations). Among 297 FST cases, three (1.0%) required revision, all due to herniation. CONCLUSION: HSM placement of IPP reservoirs is a safe alternative to traditional SOR placement. Major deep pelvic reservoir complications were minimized utilizing our current, refined FST.