Robot-assisted reservoir capsulotomy and mobilization to treat auto-inflation of an inflatable penile prosthesis

Introduction: Auto-inflation of inflatable penile prostheses (IPPs) is an uncommon but bothersome complication for patients who encounter the issue, with pump cycling difficulties often causing pain and embarrassment. Incidence is estimated to be between 3-5% over the past decade.
Case presentation: We present our experience with a 67-year-old male who noted auto-inflation of his IPP four weeks after placement, and who was managed with a novel, robot-assisted laparoscopic approach to mobilize the reservoir. His prior operations included a robotic prostatectomy, as well as his IPP placement (Coloplast Titan Touch, Coloplast, Minneapolis, MN).
Protocol: Trocars were placed in an inverted U-shaped configuration similar to a robotic prostatectomy setup. Pre-operative CT imaging revealed that the reservoir was in close proximity to the iliac vessels in the space of Retzius on the left side. Intraoperative ultrasonography with Doppler was used to identify the reservoir and distinguish it from surrounding vessels. The preperitoneal space was carefully entered and the reservoir was visualized. A thin encapsulation around the reservoir was skeletonized. The reservoir was noted to remain tethered in place by the left inferior epigastric vessels, which were ligated to fully mobilize it. The patient’s device was cycled on the field and the prosthesis was noted to remain appropriately deflated.
Outcome: Total operative time was 90 minutes; EBL was 20 mL. At follow-up in two and four weeks, the patient reported excellent pump cycling quality, resolution of his pain and discomfort, and no further episodes of auto inflation.
Discussion: Common causes of IPP auto-inflation include insufficient space created at the time of reservoir placement, with post-prostatectomy patients being at higher risk due to an obliterated space of Retzius. Although there exists a prior report of laparoscopic capsulotomy for autoinflation, our case represents a novel approach of reservoir revision that affords advantages in ergonomics and fine dissection offered by the robot-assisted modality.