If erectile dysfunction medication and all non-surgical options prove ineffective in helping a patient achieve and maintain an erection, he should consider penile implant surgery as a treatment option. This surgical procedure involves the placement of a internal device that restores the patient’s ability to have sexual intercourse. Some call this device a “penis pump” with a more medically correct term being “penile prosthesis”. The components are all placed inside the body
Below is a slideshow that illustrates each stage of inflatable penile implant surgery.
The following images show the technique of placing an inflatable penile prosthesis.
Penile Prosthesis Surgery Prep
We use a soap called Chlorhexidine-Alcohol to prepare the patient for surgery, as Chlorhexidine-Alcohol has been recently reported in the New England Journal of Medicine to be a better choice in preventing wound infections than an iodine-based solution. We then reduce the amount of skin exposed with an adhesive drape. The most common source of penile implant infection is skin bacteria, and the drape aims to protect the patient from these types of infections.
Penile Implant Incision
There are two incision options. One option is an infrapubic approach to penile implant placement, which is to make an incision at the base of the top of the penis. However, our preference is penoscrotal incision, which is an incision just below the base of the undersurface of the penis.
The Jordan Retractor Is Used to Facilitate Exposure
Once the incision is made, a retractor is used to facilitate exposure of the urethra and corpora cavernosa. The metal retractor used to facilitate exposure, called the Jordan Retractor, was developed by Dr. Gelman’s mentor, Dr. Gerald Jordan (Dr. Gelman is Fellowship trained in penile-urethral reconstructive surgery). In the photo above, you can see excellent exposure of the urethra in the middle and the corpora cavernosa (the structures that will contain the two cylinders of the penile prosthesis) on each side of the urethra.
Marking and Making an Incision Where the Penile Implant Will Be Placed
Once the urethra is identified, the corpora cavernosa are marked where the silicone penile implant cylinders will be placed. An incision is then made at the marking, exposing the space where the penile prosthesis cylinders will be placed.
Dilating the Corpora Cavernosa
After an incision is made into the corpora cavernosa, the space is dilated. Since the incision is made along the middle of the penis, dilation is performed distally (towards the tip of the penis) and proximally (deep into the body). In the above penile implant surgery photo, there is one dilator on the right side and another on the left side. The dilators advance to the same extent, indicating both sides are equally dilated.
Silicone Penile Implant Surgery Cylinders Inserted
In the above photo, the penile prosthesis cylinders are in place and connected to the penile implant pump. Once the penile implant cylinders are successfully placed, the incisions into the corpora are closed, a reservoir is then placed where it can't be feldt (near the bladder) and the penile implant pump is placed in the scrotum.
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.
At the Center for Reconstructive Urology, penile implant surgery patients who suffer from erectile dysfunction are given intravenous antibiotics to help prevent infection, with the antibiotics administered both before and after surgery. It is our preference to perform the surgery under general anesthesia to eliminate any patient discomfort during the procedure.
There are two common approaches to penile implant surgery: the infrapubic approach and the peno-scrotal approach. The infrapubic approach is 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. There is a less common third approach that involves a circumcising incision called a “subcoronal approach”.
We typically opt for the peno-scrotal approach because it poses less of a potential risk of damage to the neurovascular bundles, which are nerves and blood vessels that provide blood and sensation to the head of the penis. The neurovascular bundle is located in the dorsal or top portion of the penis, dangerously close to where the infrapubic incision is made. Conversely, the peno-scrotal approach enters the corpora of the penis along the ventral aspect, which is the area just lateral or to the side of the urethra. Most penile implants are accomplished with a single small transverse incision along the base of the penis, resulting in a small scar that is barely noticeable when healed.
Two potential complications can occur during penile implant surgery. One is perforation of the proximal tip of the crura, which is the tip of the penis inside the body where it joins the pelvis. The other is cross over, which is when 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 is generally best managed by aborting the implant to prevent any subsequent 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 or crossover or perforation.
Penile implant surgery patients are usually admitted to the hospital for a “23-hour stay.” They are given additional antibiotics to prevent infection and are typically discharged the morning following surgery. Antibiotics may also be given at the time of discharge, but even with antibiotics, there is the possibility of wound and penile implant infection. This is a devastating complication, as antibiotics alone are generally ineffective when this occurs. The required treatment is implant removal or, in some cases, a salvage replacement surgery. Therefore, we make a concentrated effort to take every precaution to prevent infection. Precautions include special care when shaving and prepping the penis and scrotum prior to surgery, paying special attention to 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. Six weeks after penile implant surgery, patients return to be counseled in the use of the penile implant pump. Following this appointment, patients can then resume sexual relations.
There are three different types of penile mplants. These are Malleable Penile Implant, the 2-piece Ambicor Penile Implant, and an inflatable penile prosthesis 3-piece (the most common penile implant used). Each of these options are discussed in further detail on our penile implant types page.
If you have questions about the different types of penile implants, penile implant surgery cost, or any further inquiries regarding the procedure, ask Dr. Gelman today.