Penile implant reservoir placement methods: is there a gold standard?

Erectile dysfunction (ED), a condition affecting nearly 150 million men worldwide, is expected to impact over 300 million by 2025. Phosphodiesterase type 5 inhibitors (PDE5Is) remain the first-line treatment for ED, yet a subset of patients exhibit inadequate responses. For these individuals, the inflatable penile prosthesis (IPP) offers an effective alternative, with the three-piece IPP being particularly favored for its high satisfaction and low complication rates. However, the challenge of optimal reservoir placement, particularly in the extraperitoneal space of Retzius (SOR), has prompted investigations into alternative approaches. SOR placement is associated with complications, such as injury to iliac vessels, bladder puncture, and bowel perforation. Various alternative sites have been proposed, including epigastric extraperitoneal, intraperitoneal (IP), high submuscular (HSM), and lateral retroperitoneal (LRP) positions, each aiming to mitigate these risks while improving patient outcomes. Comparative studies have shown that methods such as IP and HSM reduce the risk of vessel compression and bladder injury, often yielding higher satisfaction rates compared with SOR. However, each technique carries unique drawbacks, including risks of palpability, improper placement, and longer operative times. This review synthesizes current evidence on reservoir placement strategies, evaluates their advantages and limitations, and highlights crucial considerations for patient selection, providing a comprehensive overview of IPP implantation techniques and their evolving roles in the management of ED.