The following shows the technique of placing an inflatable penile prosthesis.
Penile Prosthesis Prep
We use a soap prep called Chlorhexidine-Alcohol, which was recently reported in the New England Journal of Medicine to be a better choice than iodine based solution in preventing wound infections. We then cover the skin with an adhesive drape to reduce the amount of exposed skin as the source of penile implant infections is often skin bacteria.
Penile Implant Incision
There are 2 incision options. One option is to make an incision just above the penis and this is called an infrapubic approach to penile implant placement. Our preference is an incision just below the base of the undersurface of the penis, and this is called a penoscrotal incision. We prefer to enter enter the corpora (the structures that contain the cylinders) along the undersurface of the penis because the nerves that provide sensation to the head of the penis are mostly on the opposite side, away from our incision.
The metal retractor used to facilitate exposure during penile implant surgery is called the Jordan Retractor, and this instrument was developed by Dr. Gelman’s mentor (Dr. Gelman is Fellowship trained in penile-urethral reconstructive surgery). Here you can see excellent exposure of the urethra in the middle and the corpora cavernosa (the structures that will contain the 2 cylinders of the penile prosthesis) on each side of the urethra.
Implant Cylinder Marking
The urethra is identified, and the corpora cavernosa where the penile implant cylinders will be places is marked. An incision is then made, exposing the space where the penile prosthesis cylinders will be placed after the space is dilated and then the length within the space is measured.
Penile Prosthesis Dilation
During penile implant surgery, after an incision is made into the corpora cavernosa that will contain the cylinders, the space is dilated. Since the incision into the corpora is along the middle of the penis, dilation is performed distally (towards the tip of the penis) and proximally (deep into the body). In this photo, there is a dilator on the right side and another on the left side placed proximally. Note that the dilators advance to the same extent, indicating both sides are equally dilated.
Penile implant cylinders inserted
The penile prosthesis cylinders are in place and connected to the penile implant pump. The incisions into the corpora are then closed.
Implant Reservoir Incision
After the penile implant cylinders are placed, scissors are used to create an opening in the tissue covering the space where the reservoir is placed.
Prosthesis Reservoir Space
After scissors are used to incise the tissue covering the area where the penile implant reservoir will be placed, a finger is used to develop this space, called the retropubic space. This space is deep to the abdominal wall and to the side of the bladder. When a penile prosthesis reservoir is placed in this area, it cannot be felt.
Penile Implant Tubing
After the penile implant cylinders and prosthesis reservoir are placed, the tubing connected to the reservoir must be connected to the tubing to the pump. In this photo, the connection is completed.
Implant Cylinders Inflated
After the penile implant cylinders and reservoir is inserted, and the pump tubing is connected to the reservoir tubing, the cylinders are inflated with the use of the pump. In this picture, it can be seen that the cylinders are nicely inflated, and this confirms proper cylinder position and penile implant function. Then, the pump is placed in the scrotum and the skin incision is closed.
Penile Implant Healed
After the incision has healed, the penile implant pump can be easily identified in the scrotum as shown. When the penile prosthsis pump is squeezed slowly several times, fluid is then transferred from the reservoir into the cylinders causing the penis to become rigid. There is another area of the pump that contains a button. When this button is depressed, the fluid moves back from the cylinders to the reservoir and the penis becomes soft again.
Our penile implant surgery patients who suffer from erectile dysfunction are given intravenous antibiotics before surgery (this is continued after surgery. It is our preference to perform penile implant surgery under general anesthesia. There are 2 common approaches. One approach is called infrapubic, where the incision is made at the base of the top of the penis. The other approach is peno-scrotal, where the incision is made at the base of the undersurface of the penis just below where the skin of the penis and scrotum join. Our preference is the peno-scrotal approach because we prefer to enter the corpora of the penis along the ventral aspect (the area just lateral or to the side of the urethra). The dorsal or top portion of the penis is the location of the neurovascular bundle, which are nerves and blood vessels that provide blood and sensation to the head of the penis, and we believe that an infrapubic approach can be associated with an increased risk of damage to these structures. Most penile implants are accomplished with a single small transverse incision along the base of the penis that is barely noticeable when healed.
At the time of penile implant surgery, potential complications include perforation of the proximal tip of the crura (the tip of the penis inside the body where it joins the pelvis) and cross over, a situation where the implant is on the left side at one end and then crosses over to the right side on the other end. Both of these complications, which occur with increased frequency by inexperienced implanters, can be easily corrected at the time of surgery without consequence. A more troublesome complication is urethral perforation. This generally is best managed with aborting the implant to prevent subsequent penile implant infection. One patient referred to our center with urethral stricture disease after an aborted attempt at a penile implant due to a urethral injury was found to have an 8 cm total obliteration of his urethra. We have never had this particular complication.
Our patients are usually admitted to the hospital for a “23 hour stay.” They given additional antibiotics and are discharged the morning following surgery. Antibiotics are given at the time of discharge. A very devastating potential complication of penile implant surgery is wound and penile implant infection. When this happens, antibiotics alone are generally ineffective and the required treatment is implant removal or in some cases, a salvage replacement surgery. Therefore, we make every effort to take every precaution to prevent infection and this includes special care when shaving and prepping the penis and scrotum at the time of surgery, certain technical details during surgery to maintain sterility such as the use of a clear adhesive drape to cover the skin, and the liberal use of antibiotics. Patients are instructed to remain sedentary during the first week after surgery. A follow-up appointment is scheduled the week following surgery. Penile implant surgery patients return 6 weeks after penile implant surgery to be counseled in the use of the device and can then resume sexual relations.
There are three different types of implants a patient may receive during penile implant surgery. A Malleable Penile Implant, AMS Penile Prosthesis, Ambicor and an inflatable penile prosthesis 3-piece. Each of the penile implants our discussed in further detail on our penile implant types page.