Abstract Introduction Inflatable penile prosthesis (IPP) implantation is the gold-standard treatment for refractory erectile dysfunction. Traditional reservoir placement in the space of Retzius is associated with potential risks of visceral and vascular injury, particularly in patients with prior pelvic surgery or radiation. Alternative ectopic techniques, including inguinal canal or submuscular approaches, each carry distinct drawbacks such as risk of nerve injury, spermatic cord compression, misplacement, or the need for additional incisions. These limitations highlight the need for a safer, universally applicable technique. Objective To demonstrate the Hamdan Extrainguinal Sub-Oblique (HESO) technique for inflatable penile prosthesis reservoir placement and present its safety, reproducibility, and clinical outcomes. Methods A video demonstration of the HESO technique is provided. The procedure begins with a single transverse scrotal incision for cylinder placement. Through the same incision, a superficial tunnel is created parallel to the corpora toward the ipsilateral shoulder, avoiding the inguinal canal. A small incision in the external oblique aponeurosis permits blunt dissection into the submuscular plane between the external and internal oblique muscles, where the reservoir is placed under direct visualization. Clinical data from over 2,378 cases were reviewed, focusing on operative time, intraoperative safety, complications, and patient-reported outcomes. Results The HESO technique was successfully performed in all cases, with a mean operative time of 40 ± 15 minutes. No intraoperative visceral or vascular complications occurred. Reservoir migration or herniation was not observed. Transient postoperative discomfort was noted in some patients but typically resolved within one week. Reservoir palpability decreased within six weeks postoperatively. Long-term follow-up demonstrated consistently high patient satisfaction rates. Conclusions The HESO technique provides a safe, reliable, and efficient alternative for IPP reservoir placement. By avoiding the space of Retzius and inguinal canal, it minimizes complications while maintaining reproducibility and stability. Its applicability across diverse patient populations, including those with prior pelvic surgery, establishes HESO as a valuable advancement in prosthetic urology. Disclosure No
Hamdan et al. (Mon,) studied this question.