A 73-year-old man presented with long-term history of severe and medication-refractory erectile dysfunction (ED). His comorbidity profile included hypertension, diabetes mellitus and benign prostatic hyperplasia (BPH). After failing multiple attempts of pharmacotherapy for ED, the patient underwent his first implantation of a 3-piece inflatable penile prosthesis (IPP) 15 years ago (AMS 700^™). The procedure was performed through a penoscrotal approach, and the reservoir was placed at the right space of Retzius (SOR). Five years later, the patient presented with impending distal cylinder erosion through the glans penis bilaterally. At the revision procedure, cylinders were resized and replaced; the distal corpora were reinforced with a bovine pericardium patch, and the connections were remade to the original reservoir at the right SOR. After a 5-year period, a second revision procedure was indicated as a result of device malfunction. At this time, a new 3-piece system was implanted with the placement of the reservoir at the left SOR, while the previous reservoir was drained and retained.

Following another 5-year interval, the patient had another mechanical malfunction and sought specialized consultation at our facility. He denied any signs of infection but admitted to his habit of traumatic sexual activity. Physical examination was unremarkable and magnetic resonance imaging revealed 2 reservoirs in the prevesical space with no abnormalities throughout the cylinders. The patient was asked to perform a supervised inflation of his IPP: after pressing the pump 3 times it would become flat. It was also noticed that the patient had a tendency to twist the tubing during the inflation procedure.

The patient underwent a third penoscrotal revision for his IPP. During inspection a tear in the tubing was found near the pump junction (fig. 1), and the implant was replaced successfully. After failure to access the drained reservoir located at the right SOR through the penoscrotal access, a transverse suprapubic incision was made. The rectus abdominis muscle was spread gently and the pseudocapsule was incised to allow for removal of both reservoirs (figs. 2 and 3). Connections were then made to a new reservoir placed at the left SOR.

Figure 1. Tubing tear at pump junction.

Figure 2. Incision to reservoir capsule through suprapubic counter incision.

Figure 3. Retained reservoir (1) at right SOR. Left SOR reservoir (2).

Figure 4. A, suprapubic incision after 4 weeks. B, scrotal incision at 4 weeks and partially inflated penile implant.

The patient was discharged on the first postoperative day and his recovery was uneventful. Images obtained at a followup visit after 4 weeks are shown in figure 4. The patient was able to cycle the device with no difficulties and was retrained to avoid excessive twisting of the tubing during inflation.

The 3-piece IPP provides the most natural balance between erection and flaccid state of the penis and is considered the preferred option available. However, mechanical malfunction remains an issue for some men with IPP. A recent study evaluating 546 patients with history of IPP procedures has demonstrated that 14% experienced mechanical malfunction after a mean time of 7.4 years after the primary procedure. The most common reason for mechanical problems was pump failure, in which cylinder tubing fracture at pump junction similar to the present case was found in 76% of patients.¹ Although replacement of isolated components is an acceptable alternative in such cases, many authors recommend utilizing a whole new device to avoid reduced implant survival rates following the revision procedure, especially if IPP duration is superior to 5 years.

IPP’s reservoirs have been traditionally placed in the SOR as it is easy to access and it does not become palpable. However, it might be challenging for patients with history of pelvic surgery, radiation therapy, inguinal hernia repair and renal transplant. In this scenario, high submuscular placement (HSM) has gained increasing popularity lately, and many high-volume prosthetic surgeons have migrated to HSM reservoir placement as their primary option. Although it might become visible or palpable in some patients and explantation might become more challenging, HSM can be safely performed in those with a history of pelvic surgery, and the risk of herniation is virtually eliminated.^2,3

There is some controversy regarding the routine removal of the original reservoir during revision surgery in the non-infective setting.⁴ A classic study evaluated the overall incidence of reservoir erosion in more than 2,000 patients and found the incidence of long-term reservoir erosion to be 0.4%,⁵ mainly as a result of fibrotic changes secondary to prior surgical manipulation. These findings suggest that the 3-piece implant reservoir does not increase the likelihood of erosion or infection under normal circumstances, as modern reservoirs are considered to be inert. However, other authors advocate that the only strategy to completely eradicate any risk associated with retained reservoirs is to remove them at the time of replacing a malfunctioning 3-piece implant.⁶

Although rare, possible complications of retained reservoirs include infection, herniation, erosion, inflammatory reaction and cyst formation. Therefore, reservoirs could be removed if access is easy and no excessive traction is required. A recent study has described a novel approach for removal of defunctionalized reservoirs using laparoscopic instruments through a single penoscrotal incision as a viable option.⁷ However, if the reservoir is firmly adherent or difficult to remove in the absence of clinical infection, the best strategy is to drain the reservoir and remove as much tubing as possible.⁸

It is important to mention that in the present case the patient’s will had a major influence on the intraoperative medical decision, as he was reluctant about the concept of leaving 2 defunctionalized reservoirs behind. He was bothered by the fact that the cystic images of both reservoirs would often lead to misinterpretation or concern during routine ultrasound evaluation of his prostate. Therefore, he considered the options of HSM placement of a third reservoir or inserting either a 2-piece inflatable implant or a semirigid rod as the last resources. Then our option was to perform a counter incision to safely remove the previous reservoirs while implanting the new 3-piece device. At the most recent followup visit, the patient was satisfied with both the functional outcome of the procedure and the cosmetic appearance of the incision. In fact, defunctionalized reservoirs will likely become an increasingly common issue to be dealt with, as life expectancy increases and patients with penile implants will probably require re-interventions more often.⁹