What are the different ways of performing a penile implant?

There are several surgical approaches/incisions to placement of a multicomponent (three piece) inflatable penile implant. The incision can be made above the penis on top of the pubic bone and is most often transverse and is referred to as (minimally invasive) infra-pubic approach. The incision below the penis on the anterior aspect of the scrotum is often called peno-scrotal and can also be made transverse or vertical. And lastly the incision can be made near the glans or head of the penis similar to a circumcision. This approach is rarely used as it results in extensive dissection of the entire skin of the penile shaft and prevents the surgeon from obtaining good concealment of input tubing and precise scrotal placement of the pump.

The best approach for the patient is the vertical penoscrotal incision (below the penis) for the following reasons:

It allows the surgeons to insert the cylinders through an opening very deep in the shaft of the penile corpora in an area called the crus. The crura (plural of crus) are fixed to the pelvis and do not lengthen or stretch with an erection. Furthermore the crura are located below the body plane of the abdomen. This avoids making any cuts on the part of the tunica, which lengthens when the penis becomes erect and results in my opinion in longer penises after the implant. When performing the implant through an infra-pubic skin incision the openings in the shaft of the penis are above the body plane of the lower abdomen and on the shaft of the penis (pendulous part) that lengthens with an erection. When this approach is used scar tissue forms in this area above the penis and results in decreased mobility of the infra-pubic region decreasing the functional length of the penis. The flesh above the penis is fixed, indurated and in some cases tethered to the penis preventing deep penetration during intercourse.

In addition, the peno-scrotal incision has the distinct advantage of achieving better concealment of input tubing that connects the cylinders to the pump. With the infra-pubic approach the input tubing exists from the right and left corpora of the shaft of the penis at the 12 o’clock position and needs to make 180 degrees turn, around the base of the penile shaft, in order to connect with the scrotal pump. This results in palpable and often visible input tubing located at the base of the penis and groin. In addition the tubing can be tethered to the shaft of the penis, which will rub and become painful during intercourse thrusting.

The peno-scrotal incision results in more precise and dependent scrotal pump placement. The pump is placed in the most dependent portion of the scrotum, away from the shaft of the penis and slightly behind the testicles. The goal is to achieve concealment without compromising manual access to the device. A pocket is fashioned in the scrotal cavity under vision in order to secure the pump and prevent post-operative migration. This maneuver is not feasible when performing the implant through an infra-pubic approach, which can result in a high riding pump. The pump can also become attached to and visible at the base of the penile shaft on the anterior aspect of the scrotum. In addition of being uncomfortable during sexual activity, this can makes it more difficult to manipulate the pump and is cosmetically unsightly.

The vertical peno-scrotal approach results in better concealment of the incision scar. The scar is completely invisible and concealed by the natural midline crease of the scrotum called the raphe. On the other hand, the scar of the transverse incision of the infra-pubic approach will always be very visible, especially if pubic hair is shaved.

The only advantage of the infra-pubic approach is easier reservoir placement, which explains why it is preferred by the less experienced penile implanters. This is advantageous for the surgeon and not necessarily for the patient.

In summary the peno-scrotal approach is superior for the patient because it results in better-input tubing and pump concealment, more precise and predictable scrotal pump placement, complete concealment of scar and longer erect penis.