Surgical techniques for penile implant
The penile implant surgery is minimally invasive and a relatively simple operation, performed on a day care basis. The operation usually takes between 1 and 2 hours and is performed as outpatient day surgery with no overnight stay required in the hospital. The surgeon’s skill and experience and the surgical technique employed are of paramount importance to achieve an excellent result. This section discusses the different surgical techniques and our preferred method.
Irrespective of the technique employed, an experienced surgeon would aim to achieve the following:
• Minimize the chance of infection of the implant
• Ensure the perfect fitting of the implant so as to prevent penile length loss or other issues associated with a poor fitting such as post-operative pain
• Minimize the aesthetic impact of the operation in terms of visible scarring.
The basic steps of penile implant surgery
Penile implant surgery is performed under sterile conditions in the operating room with the patient under general or spinal anaesthesia. The surgery involves the following steps:
• An incision is made across the top of the scrotum at the base of the penis.
• Special instruments are inserted through the incision to stretch the spongy tissues inside the hollow chambers of the penis (corpora cavernosa).
• Surgeon then flushes the chambers with antibiotic fluid to minimise the risk of infection postoperatively.
• The implant rods or cylinders are then inserted into position inside the penis.
• If an inflatable prosthesis is utilised a pump and valve is inserted into the scrotum and a fluid reservoir is implanted under the abdominal wall through an incision made internally by the surgeon.
• When the prosthesis is in place and functioning, the incisions are sutured by the surgeon.
In order to understand the surgical technique in more detail, please watch the following video animation:
Modifications to the basic penile implant surgery that we use
- Minimizing the risk of infection – the No-touch Technique
Studies have revealed that the main cause of any surgical infection is bacteria remaining present on the skin even after extremely cleaning and preparation. This does occur rarely even with the very best skin antiseptics such as alcohol and chlorhexidine.
Additionally, an overwhelming body of data became available in the late 90’s documenting that penile implant infections had been caused by contamination of the implant at the time of the surgery with the type of bacteria that was
present on a patient’s skin.
This led to the development of antibiotic-coated implants such as the AMS Inhibizone (Rifampin/ Minocycline) and the hydrophilic Coloplast implants. Clinical trials with these devices in the hands of experienced implanters showed a marked decrease in infection rates to less than 2%. The No-touch Technique developed allows the surgeon to completely insert a penile prosthesis in a patient without touching the skin at all to reduce the incidence of infection. This involves covering the penis completely with a sterilized surgical drape after making the incision and before inserting the prosthesis. Our own experience and clinical studies suggest that the No-touch Technique reduces the risk of infection below 1% and hence we commonly utilise it.
- Ensuring a good implant fit and no visible scarring – Scrotal vs Infra-pubic Incision
Some clinics and surgeons are promoting the so-called infra-pubic procedure, in which the incision to insert a prosthesis is created above the penis rather than below the scrotum. In our experience this technique offers no real advantage except a slightly reduced operating time. If the surgeon operating is not experienced, it can be easier to place the reservoir internally.
We prefer the penoscrotal (midline on the scrotum) incision because 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 makes 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 requires no unsightly drains in the penile area after surgery. These drains have to be removed the next day requiring patients to stay in the hospital. A much better concealment of tubing, connecting the pump to the cylinders, is also created with the penoscrotal 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 which may not be comfortable for our patients and their sexual partner. Input tubing from the cylinders in the shaft of the penis exits further back into the 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.
- Preserving or Restoring Penile Length – The Sub-coronal Incision and Modified Sliding Techniques
There are some new techniques for implant insertion that may allow for greater length preservation or restoration for patients that have lost significant length (such as patients suffering from Peyronie’s disease). Our doctors have been involved actively in the development or modification of these techniques and we can offer them to patients that are appropriate candidates.
The Sub-coronal Incision Technique
This technique is very similar to the standard implant surgery but instead of the incision in the scrotum, the penis is de-gloved and the implant is inserted through two incisions on the basis of the de-gloved penile shaft. Patients on average gain around 0.6cm (instead of losing some length) through this technique, especially in men with longstanding ED and fibrosis of the corporal tissues.
The surgical time is a little longer but other than that it does not increase the risk of infection or complications compared to the standard approach. In order to understand the surgical technique in more detail please see the following video animation:
The Modified Sliding technique (MoST)
This technique is a complex and invasive procedure that involves reconstructing and elongating the corpora cavernosa simultaneously with the implant insertion and should only be performed by very experienced surgeons. For this reason, we do not offer it routinely to all patients. However in cases where the technique is appropriate, it is a possible technique and based on our published results to date, patients may gain on average 3cm but we have had cases (in patients that had lost significant length due to Peyronie’s) where postoperative penile length gain was around 5cm.
In order to understand the surgical technique in more detail please watch the following video animation:
I am considering a Penile Prosthesis option. What should I do next?
If you are considering having a penile prosthesis operation, we advise you to book a consultation with one of our highly experienced doctors. Our clinic is one of the few high volume penile prosthesis centres in the country and we are confident that we can assist you in choosing the best treatment option.
During the consultation, the doctor will carry out a thorough evaluation of your erectile dysfunction issues, assess whether you are a viable candidate for penile implant surgery, discuss the different options for the penile implant operation and answer any questions that you may have.