Penile Prosthesis

Inflatable Penile Prosthesis

Penoscrotal approach

  1. Position in supine position, shave with razor if available (preferred over clippers)
  2. Prep and drape, use iodine sticky drape to decrease infectious risk - large half over superior portion of drape, smaller half as X shape to close hole between legs posterior to scrotum
  3. Give vancomycin + gentamicin (5mg/kg ideal body weight)
  4. Place 14Fr catheter into urethra, minimize lubrication
  5. Place Lone Star retractor with small loop inferiorly and white connector across behind infrapubic region, place hook into urethra to retract superiorly
  6. Perform ~2-3cm penoscrotal transverse incision, dissect through dartos, place 6 hooks for retraction
  7. Identify urethra and bluntly dissect laterally to identify corpora
  8. Protecting urethra, place 2-0 PDS stitch ~5mm lateral to urethra in corpora in proximal-to-distal fashion, snap/cut, then repeat ~1cm further lateral (repeat more proximally to create 4 stitches total)
  9. With #15 scalpel on finger, incise between stitches longitudinally, going 5mm proximal to stitch all the way to distal point of stitch
  10. Use #11 dilator distally and #13 proximally, aim laterally to avoid urethral injury, measure corpora and perform goal-post test (dilators in proximal corpora should not cross), irrigate to confirm no urethral injury
  11. Prepare appropriate size device
  12. Thread Keith needle and load urethrotome, pass distally and pass needle through glans (grab w/ hemostat), feed distal portion of prosthesis into corpus and secure stitch to retractor
  13. Place proximal end into corpus and use placement tool to secure and seat device
  14. Once device seated, tie proximal ends of stitch over a finger x8, then tie distal ends securely under tension to avoid prosthesis herniation or incisional bleeding
  15. Once prosthesis secured bilaterally, test inflate to ensure adequate placement and length
  16. Identify external inguinal ring, place plastic retractor, pop through with finger to enter retropubic space of Retzius, place retractor further interior, then place reservoir and inflate (waist should fill inguinal ring without herniating
  17. Grasping lateral and inferior incisional edges, create subdartos pouch and dilate with nasal speculum, then place pump into pouch
  18. Cut excess tubing length, fill ends with water, and secure connector
  19. Close inferior dartos hole vertically then close incisional dartos hole horizontally (both with 3-0 vicryl)
  20. Close skin with 4-0 monocryl interrupted fashion
  21. Place bacitracin ointment then provide mummy wrap

5-step high submuscular technique for reservoir placement

  1. Place patient in trendelenberg position
  2. Palpate external inguinal ring and place pediatric Deaver retractor
  3. Create submuscular tunnel above transversalis using finger blunt dissection, avoid widening neck (will prevent balloon prolapse)
  4. Place sponge stick, aim medial (towards ipsilateral nipple, keeps pocket deep to rectus)
  5. Ensure pocket is ≥ 10cm
  6. Insert reservoir via clamp, overfill to 120mL, then compress
  7. Palpate to ensure device is not too deep or too lateral