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Reservoir Placement for Three-Piece Inflatable Penile Prostheses

The reservoir is the component of the 3-piece IPP most often placed through altered anatomy (prostatectomy, cystectomy, transplant, hernia mesh, cesarean delivery). Reservoir placement is the step at which bladder injury, bowel injury, vascular injury and reservoir herniation can occur. These complications are rare in published series.[1] Cylinder and pump placement are more standardized.

Three reservoir locations are in contemporary use: the space of Retzius, the ectopic high submuscular (HSM) location, and other ectopic subfascial or preperitoneal locations. A review of 70 articles (9,565 patients) found that 6,413 reservoirs were placed ectopically. Fourteen studies directly compared ectopic with retropubic placement and found no statistically significant difference in reported safety or efficacy outcomes.[2] The AMS 700 instructions for use describe the same search (70 articles, 9,565 men, 6,413 with ectopic reservoirs), report similar satisfaction and adverse events across locations, and define ectopic as submuscular, either behind the rectus abdominis or lateral retroperitoneal. They list body mass index, prior pelvic surgery (prostatectomy, cystoprostatectomy), pelvic trauma, hernia repair and prior prosthesis surgery as reasons to choose a location other than the prevesical space, and advise a counter incision when clinically warranted.[7]

Anatomic Review​

The space of Retzius (prevesical space)​

The preperitoneal space anterior to the bladder, bounded by:

  • Anteriorly: pubic bone and posterior surface of the rectus abdominis with the transversalis fascia
  • Posteriorly: bladder and pelvic peritoneum
  • Laterally: obturator internus and the lateral umbilical ligaments
  • Inferiorly: endopelvic fascia and puboprostatic ligaments (in men)
  • Superiorly: open to the preperitoneal fat of the anterior abdominal wall

This is the native space for 3-piece reservoir placement. In virgin anatomy, the prevesical pocket may accommodate an AMS 700 65- or 100-mL reservoir; the IFU directs creation of a pocket large enough to avoid pressure on the reservoir.[7]

The transversalis fascia​

The entry point. Accessed from the penoscrotal approach by passing a finger or reservoir introducer through the external inguinal ring, along the iliopubic tract, and through the transversalis fascia into the space of Retzius. In an infrapubic approach, the transversalis fascia is entered directly under vision.

Why "altered anatomy" is the central problem​

  • Radical prostatectomy obliterates much of the inferior space of Retzius; the anterior-to-bladder plane is scarred
  • Radical cystectomy with ileal conduit or neobladder can disrupt or scar the space of Retzius, making conventional retropubic reservoir placement less reliable; consider an alternate reservoir site based on the operative anatomy.[31]
  • Renal transplant places a transplanted kidney with its vascular pedicle in the iliac fossa, creating a reservoir no-go zone
  • Prior pelvic radiation may alter pelvic tissue planes. In a matched database study, radiation history was not significantly associated with overall IPP complications; reservoir-specific complications were not separately assessed.[25]
  • Hernia mesh, particularly bilateral TAPP or TEP repairs, creates a mesh-anchored barrier across the space
  • Prior C-section (multiple). Less often problematic, but can alter the preperitoneal plane

Reservoir Location Options​

1. Space of Retzius (SoR) — the traditional location​

The classic location and the usual default in a virgin abdomen. The reservoir sits anterior to the bladder, behind the rectus abdominis, conforming to the space naturally.

Volume: Select by device: AMS 700 reservoirs are 65 or 100 mL[7]; Coloplast lists 75- and 125-mL Cloverleaf reservoirs.[32] Surgeons often underfill to lower the autoinflation risk, but the AMS labeling ties spontaneous inflation to improper reservoir placement or filling technique and does not endorse underfilling; overfilling risks reservoir-induced bladder compression.[7]

Access technique (penoscrotal approach — blind):

  1. Identify the external inguinal ring by palpation with an index finger from inside the scrotal wound (or through a counter-incision in some protocols).
  2. Advance the finger cephalad through the ring, along the inguinal canal.
  3. Perforate the transversalis fascia with controlled finger pressure or a Metzenbaum scissors tip; the transversalis gives way with a characteristic "pop."
  4. Sweep the space of Retzius bluntly to confirm a soft, empty space, with no adhesions, no firm tissue, and no pulsation. Vascular structures, mesh or bowel adhesions are reasons to stop and choose another location.
  5. Drain the bladder through the Foley so that it is empty for reservoir placement. A cadaveric study measured the distance from the external inguinal ring to nearby structures: the decompressed bladder averaged 6.45 cm away (range 5–8 cm) at an average 22.8° medial angle, the filled bladder averaged 2.61 cm away (range 2–4 cm), and the external iliac vein averaged 3.23 cm away (range 2.5–4 cm) at an average 36.4° lateral angle.[9] These illustrate anatomic variability across specimens and reinforce decompressing the bladder and avoiding deep dissection lateral to the ring.[9]
  6. Pass the reservoir introducer (Coloplast or Boston Scientific proprietary, or a nasal speculum / Yankauer for manual technique) and advance the reservoir into the space.
  7. Fill with the appropriate volume (per manufacturer and device).
  8. Confirm the reservoir sits dependently behind the pubic bone; no herniation, no abdominal wall contour abnormality, no compression of the Foley balloon.

Access technique (infrapubic approach — direct):

The transversalis fascia is incised under vision after exposure of the pubic symphysis and rectus insertion. The reservoir is placed directly into the space of Retzius under visual control.

Complications specific to SoR placement:

  • Bladder injury. Hematuria or failure to maintain reservoir fill prompts evaluation, usually with cystoscopy. Confirmed injury requires management according to site, repair integrity and contamination; a clean, promptly recognized injury may permit same-operation reservoir relocation, while significant contamination or erosion generally calls for staged management.[20][21][26]
  • Bowel injury. Prior pelvic surgery or adhesions can bring small bowel or sigmoid colon into the operative field. Suspected or missed injury requires urgent surgical assessment and source control; definitive repair may be laparoscopic or open according to contamination, anatomy and exposure.[26]
  • Vascular injury. The external iliac or inferior epigastric vessels are at risk. It is rare but can be fatal
  • Reservoir herniation. Into the scrotum or inguinal canal, particularly in patients with a patent processus vaginalis

2. High Submuscular (HSM) / Ectopic Submuscular — the modern workhorse for altered anatomy​

High submuscular placement was described by Morey, Cefalu and Hudak in 2013. The reservoir is placed beneath the rectus abdominis, in the potential space between the transversalis fascia and the muscle, reached by blunt tunneling through the external inguinal ring. This avoids deep retropubic dissection.[3] In the initial retrospective series, 120 balloons and reservoirs were placed in 107 patients, and two reservoirs required repositioning. A follow-up series in 146 patients included 93 IPP reservoirs and 65 AUS balloons. At a mean 3.2 months after surgery, patients reported that 126 of 158 high-submuscular IPP reservoirs and AUS balloons (80%) were not palpable; no bowel, bladder, ureteral or vascular injury was reported during mean 5.5-month clinical follow-up in this mixed-device series.[4]

A cadaver model of the HSM technique (20 reservoirs in 10 specimens) found variable anatomic location on dissection: 35% deep to the rectus muscle, 45% deep to the external oblique fascia and lateral to the rectus muscle belly, 10% retroperitoneal, 5% preperitoneal (deep to the transversalis fascia) and 5% intraperitoneal.[10] HSM placement does not guarantee the intended plane.[10]

A retrospective single-surgeon comparison of 142 men receiving a Coloplast Titan OTR with a Cloverleaf reservoir (70 HSM, 72 space-of-Retzius) reported satisfaction of 88% with HSM versus 81% with space-of-Retzius placement, with no grade IV or V Clavien-Dindo complications in either group.[11] Of the HSM group, 45 (64.3%; BMI range 18.5–28.8) could palpate the reservoir immediately after surgery; among those with BMI above 26.5, palpability had resolved in 80% by 3 months after capsule formation (that subgroup's denominator was not separately reported).[11] A 2020 ESSM position statement lists HSM as a reservoir location that may be considered an alternative (Level 2, Grade C) and states that palpability alone may not justify revision.[12]

The arcuate line (semicircular line of Douglas) helps orient the pocket. Below it, the posterior rectus sheath is absent, and the rectus lies directly on the transversalis fascia and peritoneum. Above it, the rectus has a defined posterior sheath. The arcuate line marks the end of the posterior rectus sheath, not the boundary between submuscular and preperitoneal planes. A subrectus reservoir stays anterior to transversalis fascia; passing deep to that fascia creates a preperitoneal pocket and may risk peritoneal entry.[10]

Technique:

  1. From the penoscrotal (or infrapubic) incision, identify the external inguinal ring.
  2. Advance the reservoir introducer through the ring, hug the abdominal wall, and pass the introducer cephalad above the inguinal ligament.
  3. Bluntly dissect cephalad, high above the pubic symphysis and above the arcuate line.
  4. The dissection plane is beneath the rectus muscle. The rectus can be felt to tent as it is lifted off the deeper layer.
  5. Place the reservoir in this high submuscular pocket.
  6. Inspect for herniation and a palpable bulge below the arcuate line; blind palpation cannot confirm that the reservoir remains in the intended submuscular plane.[10]

Advantages:

  • Avoids space of Retzius entirely. Ideal for post-prostatectomy, post-cystectomy, transplant, hernia mesh, multiple-C-section patients
  • Avoids intended retropubic dissection. HSM aims to keep the reservoir superficial to the transversalis fascia, but blind placement can miss the intended plane; 2 of 20 cadaver placements were preperitoneal or intraperitoneal.[10]
  • Autoinflation. In one series, none of 8 lock-out-valve reservoirs placed ectopically (beneath the abdominal musculature) auto-inflated[5]
  • Revision access. HSM can avoid a scarred retropubic plane, but ectopic reservoir removal may require a counterincision and risks inferior epigastric-vessel injury. Review imaging to locate the reservoir and adjacent structures before complex removal.[28]

Disadvantages:

  • Palpable or visible reservoir in thin patients. In the 158-device series (93 IPP reservoirs and 65 AUS balloons), 2 devices (1.3%) were revised for bothersome patient palpability[4]
  • More cephalad dissection. The reach can be difficult in obese patients with deep scrotal anatomy
  • Mesh. HSM can still be complicated by mesh extending above the inguinal ring

3. Subfascial / preperitoneal ectopic placement​

Other ectopic locations include the preperitoneal or retroperitoneal position, lateral to the bladder and away from the midline, and a sub-external oblique position, which has been described in a retrospective series of 50 patients with short follow-up.[6] These are used less often than HSM.[2]

Decision Framework: Which Reservoir Location?​

Anatomic scenarioPreferred location
Virgin abdomen, primary implantSpace of Retzius
Prior radical prostatectomyAssess operative anatomy; consider HSM, while selected space-of-Retzius placement can remain feasible after prostatectomy. Use a two-piece device if no safe reservoir site is available.[35]
Prior radical cystectomy / neobladderHSM (or 2-piece)
Renal transplantHSM (or 2-piece; contralateral side from graft)
Bilateral inguinal hernia meshHSM if a safe pocket is accessible; consider directly exposed midline submuscular placement for a three-piece device when both inguinal rings are inaccessible, or a two-piece device when no safe reservoir site is available.[29]
Prior pelvic radiationAssess the operative history and retropubic plane; consider HSM if the space of Retzius is scarred or uncertain
Obese patient, virgin abdomenSoR (HSM reach may be difficult from below)
Prior multiple C-sectionsSoR usually feasible; HSM as backup
Thin patient, cosmetic concernSoR (HSM reservoirs are occasionally palpable)
Unknown anatomy, aborted SoR attemptHSM as salvage

The 2-Piece Alternative​

When the abdominal anatomy is so altered that neither SoR nor HSM placement is safe, the 2-piece IPP eliminates the separate reservoir entirely:

  • AMS Ambicor. The fluid reservoir is integrated into the rear-tip of the cylinders
  • Rigicon Infla2P. The reservoir is integrated into the scrotal pump, unlike Ambicor's proximal-cylinder reservoirs. The manufacturer lists Infla2P as unavailable for sale in the United States.[36]

Advantages: No abdominal reservoir; entire device lives between penis and scrotum; avoids all reservoir-placement complications.

Disadvantages: Less rigidity than 3-piece; less complete flaccidity; shorter expansion range.

The 2-piece device is used when the anatomy cannot accept any abdominal reservoir: extensive mesh, pelvic exenteration, solid-organ transplant with complicated vascular anatomy, or prior reservoir complications in multiple locations. See implant models for device specifics.

Reservoir Fill Volume​

Some surgeons underfill selected reservoirs, but a reduction in autoinflation has not been established for that practice. Select volume by device and cylinder configuration and follow the applicable manufacturer instructions.[7][8] Typical fills are listed below; the manufacturer's instructions for use govern. For AMS 700 reservoirs those instructions say to fill to the labeled volume (65 or 100 mL), with the 100 mL Conceal filled up to 100 mL to suit every cylinder size, so the underfill figures below are surgeon practice rather than label guidance.[7] The AMS manual requires a 100 mL reservoir for 18 and 21 cm LGX cylinders; a 65 mL reservoir may be used with 12 and 15 cm LGX cylinders if the inflate-deflate test shows that 55 mL or less is needed.[8] During ectopic placement the AMS IFU has the pocket stay superficial to the transversalis fascia and behind the rectus, with the final position above the inguinal ring and the ring left intact to limit herniation.[7][8]

  • 65 mL AMS reservoir: fill generally to 65 mL per the IFU.[7]
  • 75 mL Coloplast Cloverleaf reservoir (manufacturer-listed capacity).[33] Select fill volume from the current device instructions and cylinder requirements.
  • 100 mL AMS reservoir: fill generally to 100 mL; for Conceal, use up to 100 mL according to cylinder requirements.[7]
  • Coloplast Titan Cloverleaf reservoir (manufacturer-described low-profile design for HSM) filled per manufacturer guidance

Cycling is checked after fill and before closure. A reservoir that does not deflate completely suggests a kink in the tubing, a reservoir in a cramped pocket, or a pump held against scar tissue.

Reservoir-Specific Complications​

Autoinflation​

Mechanism: Pocket is too tight or the reservoir is positioned against a rigid structure that compresses it during Valsalva, coughing, or lifting. Fluid is displaced into the cylinders without the patient activating the pump.

Prevention: Develop an uncompressed pocket, position the reservoir correctly, fill according to the device instructions and test cycling. For the AMS 700 MS Pump, the IFU instructs pressing the deflation button as the last action before closure.[7][8]

Treatment: Confirm device use and assess reservoir position before considering pocket enlargement or relocation. In a retrospective Mentor Alpha 1 comparison, initial autoinflation complaints occurred in 2/160 patients (1.3%) with a lock-out valve and resolved after instruction; 11% of 339 earlier non-valve recipients complained, and 2% required an operation.[5]

Reservoir herniation​

Mechanism: Reservoir migrates from SoR through the inguinal canal into the scrotum, creating a painful, cosmetically abnormal scrotal mass.

Prevention: Careful preoperative assessment for patent processus vaginalis; use of HSM in patients with large patulous external rings. A prophylactic purse-string suture at the inguinal ring has been suggested for selected high-risk HSM cases, such as a patulous ring, obesity or a disorder associated with vigorous coughing.[13]

Reported incidence: A single-author database reviewed alongside a surgeon survey reported traditional IPP reservoir herniation in 8/1,206 implants (0.7%).[14] A separate single-surgeon retrospective IPP series reported herniation in 6/447 (1.34%) anterior-to-transversalis-fascia placements versus 2/2,239 (0.09%) posterior-to-transversalis-fascia placements; the location groups differed by prior pelvic surgery.[16] A mixed IPP/artificial-urinary-sphincter series reported herniation in 3/161 (1.9%) space-of-Retzius balloons or reservoirs and 4/399 (1.0%) first-time high-submuscular implants.[14][16][17][15][13][3][6]

Treatment: Revision surgery to relocate reservoir, often to HSM, and repair of the internal ring. When the herniated reservoir is not bothersome, observation has been described as an alternative to early intervention: the surrounding capsule can flatten the hernia over time and, if repair is later needed, its anterior and posterior walls can be used as tissue for a capsule-based closure that opens the capsule, displaces the reservoir and closes the defect with the capsule walls.[18]

Bladder injury​

Presentation: Hematuria, inability to maintain reservoir fill volume (fluid drains into the bladder), failure of the device to cycle properly. May present immediately or after the reservoir erodes through a scarred bladder wall weeks to months postop.

Workup: Cystoscopy is the standard diagnostic test. CT cystogram is useful for suspected delayed erosion. When bladder injury is suspected during reservoir-space development, one described intraoperative option is to first check for gross hematuria after draining or irrigating the Foley, then pack the space of Retzius and instill saline with methylene blue into the bladder; dye on the packing confirms a leak, and cystoscopy or a separate suprapubic exploration then locates the defect.[19]

Treatment: Management described includes explantation of the reservoir, cystorrhaphy, a period of catheter drainage and delayed reimplantation. Intervals vary by surgeon. For an immediately recognized injury, one described approach uses an ipsilateral abdominal counter-incision, reservoir removal, a two-layer watertight bladder closure and washout; if no pre-existing infection is present, a clean reservoir may be replaced in a new contralateral space in the same operation, distinct from delayed intravesical erosion, for which complete explantation and delayed replacement is favored.[20]

A separate caution applies to mechanical revision: a reservoir emptied by mechanical failure may have a contracted capsule around it, and refilling it can split the capsule and injure the adjacent bladder; possible biofilm contamination is an additional concern. At noninfected revision, reservoir options include full replacement, drain-and-retain, or validated reuse. A single-surgeon series of 140 patients undergoing revision, each with at least one follow-up visit and complete reservoir-handling documentation, included 30 reservoir-recycling cases. Reservoir-related complications requiring surgery did not differ significantly across strategies, but median follow-up was only about 4.5 months.[27] The contracted-capsule warning applies to refilling a depleted reservoir without evaluating its integrity or surrounding anatomy; drain-and-retain leaves the old reservoir drained and disconnected.[21]

Vascular injury​

Vascular injury is rare but reported; iliac-vessel compression by a reservoir has also been reported after implantation, with unilateral leg edema, pain, venous thrombosis and absent distal pulses warranting urgent vascular assessment.[34] External iliac vessels, inferior epigastric vessels, and obturator vessels are at risk in blind SoR placement in altered anatomy. Recognition requires a high index of suspicion; immediate hemodynamic changes or an expanding abdominal hematoma warrant pressure or packing, resuscitation and early vascular-surgery involvement to secure definitive control.[26]

While help is mobilized, an initial response described by one author group is direct pressure for about five minutes, alerting anesthesia to possible bleeding, and calling vascular surgery early while a hemostatic agent is prepared; they report success with this approach in a few cases. This is their limited experience, not a substitute for definitive exposure, laparotomy or expert assistance when bleeding is uncontrolled or the patient is unstable.[22] For an inferior epigastric-vessel injury specifically, temporary manual compression followed by suture ligation through an inguinal counter-incision has been described; deep pelvic bleeding suggesting iliac injury should prompt anesthesia notification, pelvic packing and vascular-surgery involvement for proximal and distal control and repair.[20]

Bowel injury​

Bowel injury is a serious complication, described mainly after retropubic placement in patients with extensive prior abdominal surgery. Recognition may be delayed by days. Early postoperative sepsis, ileus or acute abdomen calls for CT and probably laparotomy. Avoiding the space of Retzius is the reason HSM is favored in altered abdominal anatomy.

No published studies define management of the rarer scenario of a fistula that drains along the reservoir tubing into the scrotum while remaining retroperitoneal rather than communicating with the free peritoneal cavity. One author group's personal experience favors immediate device removal and limited retroperitoneal exploration through an extended incision, cautioning that opening the peritoneum to run the bowel looking for the source risks spreading contamination; if the fistula cannot be found without entering the abdomen, they report that bowel rest and total parenteral nutrition closed three such fistulas within 30 days without the source being visualized at surgery, with two of those patients later receiving an ectopic-reservoir implant. This anatomy-specific author account does not replace acute-care surgical judgment in a patient with signs of a missed bowel injury or establish a general rule against laparotomy.[23]

Reservoir migration​

Reservoir migration is displacement into an adjacent space, such as the retroperitoneum, scrotum or paravesical region, and may follow an inadequately developed pocket or patulous entry defect. A 2025 review pooled a 0.2% migration rate (95% CI 0.0%–0.6%) across 5,783 patients in 15 observational series/cohorts; the estimate is limited by heterogeneous reporting.[30] Can present immediately or years later.

Specific Technical Points​

Foley management during placement​

Drain the bladder through the Foley before reservoir placement. A full bladder is easier to injure and changes the feel of the space on palpation. After reservoir placement, the Foley is often left overnight and removed the next morning.

Fill with saline, not water​

Sterile saline is standard. Contrast can be added when postoperative imaging of reservoir position is anticipated, which is unusual.

Confirm no communication with the bladder​

After fill, palpate the Foley (if in place). A reservoir compressing the bladder or adjacent to an injury can alter Foley feel, but palpation cannot exclude perforation; unexpected loss of resistance, clear wound fluid or gross hematuria should prompt cystoscopy or an on-table cystogram before closure.[26] Cycle the device 2–3 times to confirm full inflation and full deflation before closure.

The one-incision vs. two-incision question​

A one-incision approach places all three components through the single primary penoscrotal or infrapubic incision. A two-incision approach uses a separate low midline or inguinal counter-incision for direct reservoir placement under vision. This is used in many infrapubic protocols and in complex SoR cases.

Radical prostatectomy after a prior IPP with a reservoir in place​

For a man with an existing IPP who later needs radical prostatectomy, one author group describes identifying the reservoir before proceeding. For open retropubic surgery, they describe opening the reservoir's capsule, temporarily moving the still-connected reservoir out of the field in an antibiotic-soaked sponge, and then proceeding with the prostatectomy. For laparoscopic or robotic surgery, they advise identifying and moving the reservoir aside before the main dissection and reapproximating the peritoneum over its former location. They also advise fully deflating the IPP during postoperative urethral catheterization, with suprapubic drainage mentioned as an alternative when prolonged catheterization is expected.[24]

See Also​

Videos​

Should Occasional Implanters Learn Ectopic Reservoir Placement?
Steven K. Wilson, SMSNA (2024)
IPP Reservoir Fixation: THALIA and Low Transfascial
Kemble J, et al. Urology Video Journal 2023 (CC BY-NC-ND 4.0)
Open source videoRead the article

References​

1. Levine LA, Hoeh MP. Review of penile prosthetic reservoir: complications and presentation of a modified reservoir placement technique. J Sex Med. 2012;9(11):2759–69. doi:10.1111/j.1743-6109.2012.02807.x

2. Atwater B, Krug A, Gross MS, Marty-Roix R, Chapin L, Morey AF. A review of the safety and efficacy of inflatable penile prosthesis ectopic reservoir placement. Sex Med Rev. 2025;13(1):20–32. doi:10.1093/sxmrev/qeae067

3. Morey AF, Cefalu CA, Hudak SJ. High submuscular placement of urologic prosthetic balloons and reservoirs via transscrotal approach. J Sex Med. 2013;10(2):603–10. doi:10.1111/jsm.12000

4. Chung PH, Morey AF, Tausch TJ, Simhan J, Scott JF. High submuscular placement of urologic prosthetic balloons and reservoirs: 2-year experience and patient-reported outcomes. Urology. 2014;84(6):1535–40. doi:10.1016/j.urology.2014.08.029

5. Wilson SK, Henry GD, Delk JR Jr, Cleves MA. The Mentor Alpha 1 penile prosthesis with reservoir lock-out valve: effective prevention of auto-inflation with improved capability for ectopic reservoir placement. J Urol. 2002;168(4 Pt 1):1475–8. doi:10.1016/S0022-5347(05)64477-1

6. Garber BB, Gross MS, Stember D. Sub-external oblique placement of inflatable penile prosthesis reservoirs: initial experience. Int J Impot Res. 2019;31(6):400–3. doi:10.1038/s41443-018-0101-z

7. Boston Scientific. AMS 700 with MS Pump Inflatable Penile Prosthesis: Instructions for Use (ectopic reservoir edition). 51873615-01A (English). Reservoir placement clinical evidence, prevesical and ectopic technique, filling.

8. Boston Scientific (American Medical Systems). AMS 700 with MS Pump Penile Prosthesis: Operating Room Manual. 92127382-01C, 2019. Reservoir and product line matrix.

9. Henry G, Hsiao W, Karpman E, et al. A guide for inflatable penile prosthesis reservoir placement: pertinent anatomical measurements of the retropubic space. J Sex Med. 2014;11(1):273-278. doi:10.1111/jsm.12361

10. Ziegelmann MJ, Viers BR, Lomas DJ, Westerman ME, Trost LW. Ectopic Penile Prosthesis Reservoir Placement: An Anatomic Cadaver Model of the High Submuscular Technique. J Sex Med. 2016;13(9):1425-1431. doi:10.1016/j.jsxm.2016.06.012

11. Osmonov D, Chomicz A, Tropmann-Frick M, Arndt KM, Jünemann KP. High-submuscular vs. space of Retzius reservoir placement during implantation of inflatable penile implants. Int J Impot Res. 2020;32(1):18-23. doi:10.1038/s41443-019-0201-4

12. Osmonov D, Christopher AN, Blecher GA, et al. Clinical Recommendations From the European Society for Sexual Medicine Exploring Partner Expectations, Satisfaction in Male and Phalloplasty Cohorts, the Impact of Penile Length, Girth and Implant Type, Reservoir Placement, and the Influence of Comorbidities and Social Circumstances. J Sex Med. 2020;17(2):210-237. doi:10.1016/j.jsxm.2019.10.016

13. Karpman E, Brant WO, Kansas B, et al. Reservoir alternate surgical implantation technique: preliminary outcomes of initial PROPPER study of low profile or spherical reservoir implantation in submuscular location or traditional prevesical space. J Urol. 2015;193(1):239-244. doi:10.1016/j.juro.2014.07.082

14. Sadeghi-Nejad H, Sharma A, Irwin RJ, et al. Reservoir herniation as a complication of three-piece penile prosthesis insertion. Urology. 2001;57(1):142-145. doi:10.1016/s0090-4295(00)00864-5

15. Pagliara TJ, Smith DW, Viers BR, et al. Alternative Reservoir and Balloon Placement in Complex Patients Undergoing Urologic Prostheses. Curr Urol Rep. 2018;19(6):40. doi:10.1007/s11934-018-0789-9

16. Stember DS, Garber BB, Perito PE. Outcomes of abdominal wall reservoir placement in inflatable penile prosthesis implantation: a safe and efficacious alternative to the space of Retzius. J Sex Med. 2014;11(2):605-611. doi:10.1111/jsm.12408

17. Pagliara TJ, Viers BR, Scott J, et al. Extended Experience with High Submuscular Placement of Urological Prosthetic Balloons and Reservoirs: Refined Technique for Optimal Outcomes. Urol Pract. 2018;5(4):293-298. doi:10.1016/j.urpr.2017.06.006

18. Wilson SK, Terrell JD. New Advances in Penile Implant Surgery. In: Brandes SB, Morey AF, eds. Advanced Male Urethral and Genital Reconstructive Surgery. 2nd ed. Humana Press; 2014:675-696. doi:10.1007/978-1-4614-7708-2_47

19. Buscaino K, Fernandez-Crespo RE, Carrion R. Considerations in the Management of Visceral and Vascular Injury During Penile Implant Surgery. In: Miranda EP, Mulhall JP, eds. Penile Implant Surgery: Contemporary Challenges and Controversies. Springer; 2022:125-153. doi:10.1007/978-3-030-82363-4_8

20. Ivan S, Maffucci F, Simhan J. Surgical Management of Inflatable Penile Prosthesis Complications. In: Joshi PM, Aubé-Peterkin M, Kulkarni SB, Datar G, eds. Surgical Atlas of Urethroplasty. Springer; 2024:389-404. doi:10.1007/978-981-97-5196-9_39

21. Köhler TS, Gupta NK, Wilson SK. Bladder Injury. In: Köhler TS, Gupta NK, Wilson SK, eds. Wilson's Pearls, Perils and Pitfalls of Penile Prosthesis Surgery. 2nd ed. Calvert McBride Publishers; 2018:56.

22. Köhler TS, Gupta NK, Wilson SK. Injury to Pelvic Vessels. In: Köhler TS, Gupta NK, Wilson SK, eds. Wilson's Pearls, Perils and Pitfalls of Penile Prosthesis Surgery. 2nd ed. Calvert McBride Publishers; 2018:55.

23. Köhler TS, Gupta NK, Wilson SK. Postoperative Pearls, Perils and Pitfalls. In: Köhler TS, Gupta NK, Wilson SK, eds. Wilson's Pearls, Perils and Pitfalls of Penile Prosthesis Surgery. 2nd ed. Calvert McBride Publishers; 2018:111-136.

24. Köhler TS, Gupta NK, Wilson SK. Frequently Asked Questions and Miscellaneous Advice. In: Köhler TS, Gupta NK, Wilson SK, eds. Wilson's Pearls, Perils and Pitfalls of Penile Prosthesis Surgery. 2nd ed. Calvert McBride Publishers; 2018:151.

25. Foss HE, Prebay ZJ, Ebbott D, et al. "A global, propensity-score matched analysis of patients receiving inflatable penile prostheses and the risk of complications, infections, and re-interventions." Transl Androl Urol. 2024;13(8):1537–1545. doi:10.21037/tau-23-412

26. Michael S, Grice P, Oumeziane A, et al. "Recognition to repair: Managing reservoir complications in inflatable penile prosthesis surgery." BJUI Compass. 2026;7(7):e70246. doi:10.1002/bco2.70246

27. Amini AD, Nealon SW, Badkhshan S, et al. "Management of the inflatable penile prosthesis reservoir at time of revision surgery: remove, retain, or recycle?" J Sex Med. 2025;22(1):170–174. doi:10.1093/jsxmed/qdae155

28. Piraino J, Madison I, Supak D, et al. "Outcomes related to penile prosthesis reservoir removal: a 7-year multi-institutional experience." J Sex Med. 2024;21(11):1076–1080. doi:10.1093/jsxmed/qdae112

29. Zisman A, Razdan S, Siegal A, et al. "Midline submuscular penile prosthesis reservoir placement for patients with bilateral inaccessible inguinal rings: technique and outcomes." Ther Adv Urol. 2022;14:17562872221139109. doi:10.1177/17562872221139109

30. Curran E, Love C. "Reservoir migration in inflatable penile prostheses: a systematic review and development of a clinical decision algorithm." Int J Impot Res. 2025 Aug 1. doi:10.1038/s41443-025-01139-x

31. Sharma D, Smith RP. "Troubleshooting intraoperative complications of penile prosthesis placement." Transl Androl Urol. 2017;6(Suppl 5):S892–S897. doi:10.21037/tau.2017.07.13

32. Coloplast. Titan Inflatable Penile Prosthesis: Product Options. Manufacturer product listing.

33. Coloplast. Titan Inflatable Penile Prosthesis: Product Options. Manufacturer product listing.

34. Dehò F, Henry GD, Marone EM, et al. "Severe vascular complication after implantation of a three-piece inflatable penile prosthesis." J Sex Med. 2008;5(12):2956–2959. doi:10.1111/j.1743-6109.2008.01012.x

35. Lane BR, Abouassaly R, Angermeier KW, Montague DK. "Three-piece inflatable penile prostheses can be safely implanted after radical prostatectomy through a transverse scrotal incision." Urology. 2007;70(3):539–542. doi:10.1016/j.urology.2007.04.009

36. Rigicon. Infla2P Integrated-Reservoir Inflatable Penile Prosthesis. Manufacturer product information. Accessed October 8, 2026.