Comparison of “No-Touch” Peno-Scrotal Midline Penile Implant Technique vs. Infra-pubic (above the penis) Approach

It has been well established that infections occur when bacteria, most often from the patient’s own skin, is introduced into the incision during the procedure.  Studies have shown that it is impossible to sterilize skin completely, and that even under the best of circumstances, surgical cleansing of the skin only marginally reduces bacteria colony count. Any direct or indirect contact of the implant with skin will therefore expose the implant to bacteria; regardless of the surgical approach, the rapidity of the procedure, or the type of antibiotics used.  In the event of infection it is necessary that the penile prosthesis be completely removed and replaced; a painful and traumatic experience for the patient. Patients subsequently may require up to one month of intravenous antibiotic therapy to get rid of the infection or prevent infection of the second prosthesis. In addition, the outcome of a second penile implant procedure will not be as satisfactory as a successful original implant. This highlights the fact that an experienced surgeon specializing in techniques that reduce the risk of infection are essential to a proper penile implant procedure.

Dr. J. Francois Eid, a specialist in urological prosthetic reconstruction, has performed over 4,000 implant surgeries over the last 20 years. 

He has proven, unparalleled surgical results; the lowest infection rate in the world; and overwhelmingly positive patient satisfaction. 

The below analysis compares Dr. Eid's proprietary "No-Touch" implant surgery technique, which boasts an infection rate of less than half of one percent, with the Infra-pubic (above the penis) approach. In addition to providing patients with the lowest infection rate, there are several additional advantages of the scrotal “below the penis” incision method over the “above the penis” incision.

Comparison Criteria	The No-Touch Surgical Technique	Infra-pubic Minimally Invasive Approach
Post operative infection rates	Less than 0.5%	Historically 2 to 5%
Procedure sterility/operative/post operative bacterial contamination and infection risks	The “No-Touch” Technique provides complete isolation of skin from the implant, preventing bacterial contamination of the device. Any skin contact whatsoever will void the sterility of the device regardless of the location and cleanliness of the skin that is touched.	In the Infra-pubic approach, the implant cylinders, pump and reservoir all come into direct contact with the skin, thus allowing for possible bacterial contamination of the device during the procedure.  In addition, surgeons’ gloves and instruments touch the skin, providing an indirect way for bacteria to enter into the patient.
Surgical incision size and post operative scaring	The “No-Touch” Technique has a smaller incision.  Using the median raphe on the midline of the scrotum, the surgical scar becomes completely concealed. No scar is seen above the penis.	The scar from the Infra-pubic approach is more visible on the skin above the penis.  Hair must grow to conceal the incision, which may occur unevenly.  The incision is more likely to be noticed by the partner.
Placement of implant pump and tubing	The “No-Touch” Technique enables better positioning of the input tubing from the base of the penile prosthesis cylinder directly downwards to the pump. The pump and tubing are placed deep inside the scrotal sac to optimize cosmetic results and make the patient look and feel natural.	In the Infra-pubic approach, the tubing from the cylinders comes out from the back or top of the penis and is wrapped around the right side of the penis in order to place the pump in the scrotum. This results in the pump being placed higher in the scrotum, making it more visible in combination with the tubing, which remains palpable at the base of the penis.
Reservoir placement	Using the “No-Touch” Technique the reservoir is placed all the way next to the bladder, starting from an incision below the penis; a method requiring higher levels of skill and experience.  In patients who have had previous pelvic surgery this may not be possible, and a second small incision may be necessary.	Infra-pubic approach provides direct placement of the reservoir, which is advantageous in patients who have had previous pelvic surgery.  The reservoir is the only component that the patient never sees or feels, therefore the cosmetic benefit of this positioning is minimal.  However in patients who have had previous surgery this allows the entire implant to be performed through one incision.
Use of surgical drain sticking out of the skin after the surgery is complete	“No-Touch” patients have no drain placed through the skin.  This is unnecessary because the surgical openings in the penis are closed in a watertight fashion, eliminating bleeding and the “No-touch” decreases the need for irrigation.	Infra-pubic patients have a drain placed through skin because the openings in the penis are not closed completely and bleeding occurs. The drain must be removed the day after surgery. The drain sticks out through the skin can cause post-operative soreness, is painful to remove, and requires the patient to spend the night in the hospital.  Some believe that this also provides an additional route for bacterial contamination.
Procedure time	A “No-Touch” surgery is typically performed in 45-90+ minutes depending on the complexity of the case.  The surgical goals of the technique are to minimize the surgical impact on fragile penile tissue and reduce post-operative bleeding and infection risks.	Part of the procedure is completed in 15 minutes or more.  The openings in the base of the penis are not closed requiring placement of a drain to remove blood, which continues to drain from the penile shaft. Pre-operative skin preparation, closure of the incision, and placement of the drain requires additional surgical time.
Hospital discharge – home	Patients having the “No-Touch” Technique are discharged from the hospital or surgery center the same day.	Patients having the Infra-pubic approach must spend a minimum of one night in the hospital, possibly longer, before being discharged.

Results of “No-Touch Technique"

Number of cases:  2953
Infection rate as of 5/2/2013:  1%

Year	Implant #	Infection #	%
2002	132	7	5.3
2003	204	4	2.0
2004	218	3	1.4
2005	298	6	2.0
2006*	247	2	0.8
2007*	282	1	0.4
2008*	226	1	0.4
2009*	300	1	0.3
2010*	305	0	0
2011*	336	2	0.6
2012*	303	2	0.7
2013*	102	0	0

* No touch technique and saline irrigation only



Prior to 2006, Dr. Eid expertly used state-of-the-art infection prevention techniques, achieving low rates of infection comparable to other prominent penile prosthesis surgeons today.

In 2006, Dr. Eid further reduced his infection rate to well below most penile implant surgeons with his innovative No Touch Technique.

In 2008, Dr. Eid's infection rate dropped to almost 0% (fewer than 1 in 225 surgeries).