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No-Touch vs. Infra-pubic Technique

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 Transverse Scrotal and Minimally Invasive Infra-pubic "above the penis" approach. In addition to providing patients with the lowest infection rate, there are several additional advantages of the mid-line scrotal “below the penis” incision method over all others skin incisions. This include better concealment of device components, better placement of scrotal pump, less swelling post-operatively, smaller skin incision and nearly invisible skin scar.

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Comparison Criteria The No-Touch Surgical Technique Infra-pubic Minimally Invasive & Transverse Scrotal Approach
Post operative infection rates Less than 0.5% (Registry) Historically 2 to 5% (No Registry)
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 & other approach, the implant cylinders, pump and reservoir all come into direct contact with the skin, thus allowing for bacterial contamination of the device during the procedure. In addition, surgeons’ gloves and instruments also 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 & Transverse Scrotal approach is more visible on the skin above and below the penis. Hair must grow to conceal the incision, which may heal 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. The partner is more likely to feel the pump during sexual activity.
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 completed 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 approach decreases the need for irrigation. This also results in much less post-operative swelling. Infra-pubic & Trans Scrotal patients have a drain placed through skin because the openings in the penis are not closed completely and bleeding occurs. This results in more post-operative swelling and need for pressure dressing. 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 as well as maximize outcome. Minimizing surgical time is not the priority.  Part of the procedure is completed in 30 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 & Transverse Scrotal approach must spend a minimum of one night in the hospital, possibly longer, before being discharged.

Patient Concerns

Question: Do you use the infra-pubic procedure, incision above the penis or the scrotal incision below the shaft of the penis?  What are the advantages and disadvantages of these two methods?

Answer: I prefer the peno-scrotal (midline on the scrotum) incision because I believe that it offers several advantages for the patient and provides a much better cosmetic outcome. It is easier to accurately size the penis and therefore to give the patient the longest possible implant. It also facilitates a more accurate and better placement of the penile implant pump in the scrotum, which will make it easier for the patient to inflate and deflate the device after, it heals. It enables the surgeon to place the implant with smaller incisions and enables the use of the "no-touch " technique thus reducing the risk of infection.

The incisions in the shaft of the penis are closed completely to prevent bleeding and no drains sticking out through the skin are needs after the surgery. These drains would have to be removed the next day requiring patients to stay in the hospital. Much better concealment of tubing connecting the pump to the cylinders is also obtained with the peno-scrotal incision, the input tubing exits from below the penile shaft instead of above, and therefore tubing is not wrapped around the base of the penis and is not palpable by the patient and sexual partner. No one needs to know! Input tubing from the cylinders in the shaft of the penis exits further back into scrotum. Less cutting is needed to get to the penis especially in an overweight patient, which means less swelling, less bleeding, no need for drains and less risk of infection. The only advantage of the above the penis incision approach is that it is easier for the surgeon to place the reservoir. This last step is not a problem for an experienced surgeon however.