Intra-Abdominal Reservoir Placement and RALP

“Intra-Abdominal Reservoir Placement During Penile Prosthesis Surgery in Post-Robotically Assisted Laparoscopic Radical Prostatectomy Patients: A Case Report and Practical Considerations”

Hossein Sadeghi-Nejad, MD, Ricardo Munarriz, MD, and Neel Shah, MD

May 2011 – The Journal of Sexual Medicine


Introduction

Radical prostatectomy is an effective treatment option for many men with prostate cancer.   Over time, laparoscopic prostatectomy (LAP) and robot-assisted laparoscopic prostatectomy (RALP) have become more popular procedures.  The authors note that magnification is better with RALP and that patients undergoing this surgery tend to have decreased blood loss and fewer blood transfusions along with shorter hospital stays and faster recovery times.

Many men who undergo RALP need treatment to restore erectile function.  Many choose to have a 3-piece inflatable penile prosthesis (IPP), which includes a reservoir. 

However, the RALP procedure involves anatomic changes that are different from traditional retropubic radical prostatectomy.  Because of this, placement of the reservoir be challenging in some cases. 

In this article, the authors discuss these anatomical changes and suggest alternative reservoir placement techniques when needed.

Methods and Results

The case study involved a 68-year-old man with vasculogenic erectile dysfunction.  He had had a RALP procedure and pharmacologic strategies for ED were not an option for him.  Therefore, he had surgery to implant a 3-piece penile prosthesis.  Immediately following the implant, he underwent abdominal hernia repair. 

Laparoscopy showed “an intraperitoneal reservoir that was overlying the sigmoid colon with multiple diverticula.”  The surgeon repositioned the reservoir in the dependent pelvis, away from the diverticula and the pelvic vessels.

The patient did not have any post-surgery complications.  At a two-year follow up, the prosthesis was still fully functional.

Discussion

Surgeons have used extraperitoneal and transperitoneal approaches with RALP.  Both approaches have their pros and cons, but both change the anatomy of the space of Retzius.  Because of this change, it becomes more likely that the IPP reservoir will have intraperitoneal placement after RALP. 

While intraperitoneal placement has been used fairly successfully in the past, the authors believe that such placement could potentially become a cause of immediate or future adverse events in some cases.

In rare cases, it may be difficult to avoid “inadvertent bowel injury to segments adherent to the pubic bone.”

The authors suggest the following alternatives to surgeons if a clinical  and or anatomical finding is encountered such that they believe paravesical retroperitoneal reservoir placement will be difficult:

  • Use a semi-rigid penile prosthesis or 2-piece inflatable prosthesis instead of the 3-piece device.  This eliminates the need for a reservoir altogether.  (Some surgeons and patients do prefer the 3-piece prosthesis.)
  • Place the reservoir in a high, lateral retroperitoneal location or an epigastric location.  (This option involves two incisions and it may be more difficult to retrieve the reservoir later on.)
  • Ectopic placement in the intrafascial abdominal wall.  This can be done with one incision and prevents intraperitoneal placement.  With this placement, the reservoir may be noticeable in thinner patients. However, flat reservoirs and low-profile reservoirs currently available help with this issue.
  • Subcutaneous reservoir placement can be used with flat or low-profile reservoirs, but there is a risk of reservoir herniation into the inguinal or scrotal space.


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