Abstract Introduction Reservoir placement remains among the most technically challenging steps of three-piece inflatable penile prosthesis (IPP) surgery. Traditionally, the reservoir is positioned in the retropubic space via an extraperitoneal approach. However, patients with a history of major abdominopelvic surgery, pelvic trauma, or vascular interventions often present with distorted anatomy where the conventional retropubic pathway is inaccessible or unsafe. In such scenarios, the risks of visceral or vascular injury are significantly elevated, necessitating alternative strategies for safe and effective reservoir placement. Objective This video abstract demonstrates the high sub-rectus space as a safe and reliable alternative site for reservoir placement during IPP implantation, particularly in patients with hostile pelvic anatomy. By showcasing a complex case, we aim to highlight technical nuances, perioperative outcomes, and the potential advantages of this approach. Methods The presented case involved a middle-aged man with a history of devastating pelvic trauma. His injuries included comminuted bilateral inferior pubic ramus fractures with pubic diastasis, bilateral internal iliac artery embolization, exploratory laparotomy with sigmoid colostomy, and complete posterior urethral rupture. Following staged urethral reconstruction and recovery, the patient sought definitive management of erectile dysfunction with a three-piece IPP. Given the obliterated and high-risk retropubic space, the reservoir was instead positioned in the high sub-rectus plane. This location, situated between the rectus abdominis muscle and the posterior rectus sheath, was accessed through a controlled dissection. The procedure was captured step-by-step on video, with emphasis on anatomical landmarks, technical refinements, and tips for avoiding complications. Results The operation was completed without intraoperative difficulties. The reservoir was seated securely in the high sub-rectus space, and the remainder of the prosthesis implantation proceeded in standard fashion. The patient was discharged on postoperative day one in good condition. During follow-up, he demonstrated excellent device function, with no complications related to reservoir positioning, such as herniation, palpable bulge, or functional impairment. Compared with conventional retropubic placement, the high sub-rectus approach yielded equivalent functional outcomes while minimizing risk in this high-complexity patient. Conclusions The high sub-rectus reservoir placement technique represents a valuable addition to the surgical armamentarium for penile prosthesis implantation. It offers a safe and effective option for patients with altered abdominopelvic anatomy where traditional retropubic placement is contraindicated. Adoption of this approach may reduce the likelihood of major intraoperative complications and broaden the applicability of IPP surgery in challenging patient populations. By sharing operative video, we aim to provide surgeons with practical guidance and confidence to apply this method when confronted with anatomically complex scenarios. Disclosure No
Canguven et al. (Mon,) studied this question.