Placement of the Reservoir
The reservoir is to be placed in the space of Retzius, next to the bladder. To avoid perforating the bladder, the Foley catheter is uncapped and the urine drained. Using a blunt curved Mayo scissors, a small defect is made in the floor of the inguinal canal between the base of the penis and the medial aspect of the inguinal cord. Blunt use of the finger to perform this maneuver will create a very large defect in the floor of the canal thus predisposing for reservoir herniation. The hole in the floor of the canal is best made by tilting the scissors at a 90o angle with the plane of the abdominal wall and by positioning the tip of the scissors just over the pubic ramus. A common mistake here is not going deep enough with the scissors for fear of bladder puncture. Incomplete perforation of the floor of the inguinal canal prior to substituting the scissors with the operator’s index finger will result in separation of the transversalis fascia from the undersurface of the internal oblique muscle, rather then dilation of the space of Retzius. This also causes loss of counter-traction of the transversalis fascia, making puncture of the fascia and access to the space of Retzius very difficult. Finally, positioning of the reservoir above the transversalis fascia leads to auto-inflation and also predisposes to reservoir herniation.
Once the space of Retzius is entered, the tip of the scissors is replaced by the surgeon’s index finger mostly to confirm that the prevesical space was entered. A closed, long nasal speculum is placed through the opening prior to removal of the operator’s finger and an empty reservoir placed next to the bladder. The operator’s finger is used to help in this dilation. Again, there is no need to overdilate, and care must be taken not to split the floor of the inguinal canal during dilation of the space of Retzius as this may cause reservoir herniation.
(See pictures #183, 192, 194, 195 of the Inflatable Penile Prosthesis Procedure)
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