IJIR: Your Sexual Medicine Journal

https://doi.org/10.1038/s41443-020-00370-y

REVIEW ARTICLE

Nuances of infrapubic incision for inflatable penile prosthesis

1
Paul Perito ●
John Mulcahy2 Lexiaochuan Wen
●
3 ●
Steven K. Wilson4

Received: 3 August 2020 / Revised: 30 August 2020 / Accepted: 27 October 2020

© The Author(s) 2020. This article is published with open access

Abstract
This workshop completes the trilogy of nuances of the various incisions used to place an inflatable penile prosthesis (IPP).
Infrapubic placement was the original technique employed 50 years ago for the very first IPP surgeries. The historical
perspective of the development of implantation incisions and the original Scott prosthesis highlighted in this work should be
fascinating to today’s younger prosthetic urologists. The developing surgeon should also find some surprising maneuvers
considered important technique nuances from the highest volume infrapubic implanter in the world. Among the wonders of
the infrapubic approach covered are: The surgery is conducted without the aid of an in-dwelling Foley catheter or post-
operative inflation. Hydrodistension of the corpora substitutes for corporal dilatation. The “chicken choke” protects the
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urethra from damage. Closed suction drainage is employed despite minimal scrotal dissection. Motivated patients may use
their new device as early as 14 days after implantation.

Introduction subcoronal approaches, respectively. The first author who

This is the third of a series of Wilson’s Workshops pro-
viding critical insights from the unique perspective of the
highest volume 3-piece inflatable penile prosthesis (IPP)
implanters in the world. These experts endow wisdoms that
indubitably will improve surgical outcomes for seasoned
and first-time implanters alike. The authors would like to
make it perfectly clear that a well-done implant is a well-
done implant regardless of your surgical approach six
months down the road. Nevertheless, Perito, the primary
author of this article, just as Wilson and Park writing on
penoscrotal and subcoronal in the previous workshops,
believe that his infrapubic approach to penile implantation
offers significant advantages to both the doctor and the
patient while performing the surgery and during the first
few months. In the preceding two workshops, Wilson and
Park highlighted the allure of the penoscrotal and
* Lexiaochuan Wen
Wen.Lexiaochuan@mayo.edu
1
Department of Urology, Perito Urology, Coral Gables, FL, USA
2
Department of Urology, University of Alabama, Birmingham, AL,
USA
3
Department of Urology, Mayo Clinic, Rochester, MN, USA
4
Department of Urology, Institute for Urologic Excellence,
La Quinta, CA, USA
penned the paragraphs to follow, Dr. Paul Perito, will now
share the ways in which his infrapubic approach to penile
implantation offers distinct advantages simply not obtain-
able with alternative techniques.
Historical perspective
We are approaching the 50th anniversary of the introduction
of the 3-piece IPP by Dr. Brantley Scott and his colleagues
[1]. Many of the original luminaries including Dr. Scott
have passed while others (SKW, JJM) are getting a bit long
in the tooth. Thus, more so than ever it is necessary to
record the history of the AMS 700 device and its methods
of installation that has been existent for 5 decades.
The original incision was a long vertical suprapubic
incision from pubis to umbilicus (Fig. 1a). When making
corporotomies (Fig. 1b), care was taken to avoid injury to
the dorsal neurovascular bundle (NVB) which coursed
between 11 o’clock and 1 o’clock position (Fig. 1c). The
reservoir was placed in the prevesical space in the midline.
Next, the tubing was routed through one inguinal canal
across the midline and out the other (Fig. 1d) using a special
instrument conceived by Dr. Scott called a “curved tubing
passer” (Fig. 2c).
Two years after publication of the Scott prosthesis, Dr.
William Furlow at the Mayo Clinic began to focus his
practice on prosthetic urology. Our author, JJ Mulcahy,

Fig. 1 Historical pictures of infrapubic implantation. a JJM mod-
ification of Scott suprapubic incision. Scott’s incision was much
longer. b Corporotomies at 10:00 and 2:00. Note Addison forceps
Fig. 2 Drs William Furlow & Brantley Scott IPP tool inventions. a Furlow curved IPP connection. b Furlow insertion tool. c Scott curved
tubing passer. d Scott IPP reservoir insertion device.
worked with Furlow as a resident during the 1960’s. Furlow
believed scrotal rugae were harbors of infection and all his
scrotal content surgery was performed through an inguinal
incision. He also believed in making incisions parallel to the
skin lines when possible. For this reason, he altered Dr.
Scott’s original vertical incision to transverse resembling a
Pfannensteil incision in order to parallel pelvic skin lines.
At the same time, in the late 1970’s, Dr. Scott was dis-
covering a penoscrotal approach. A young patient impotent
after pelvic trauma (a professional bull rider) was vocal
about avoiding an abdominal scar. Scott noted success with
using a penoscrotal approach in this patient and it even-
tually became his preferred surgical approach [2] particu-
larly because of a litigation following a dorsal nerve injury
on a multiple revision patient. To help with the blind pla-
cement of the reservoir with this new approach, he invented
a specialized insertion device—a hollow tube placed
through the inguinal ring into the space of Retzius. Next, an
obturator is used to manipulate the reservoir into the proper
position behind the pubic bone (Fig. 2d). Both the senior
authors (JJM & SKW) of this paper purchased the tool, but
P. Perito et al.
holding fundiform ligament. c Cross section of penis showing NVB
between 11:00 and 1:00. d Tubing route through both inguinal canals
to avoid kinking.
soon found that it was a bit dangerous (Wilson was slow to
learn, as it took two bladder injuries to convince him). We
have come to appreciate that a long nasal speculum or the
finger was safer and frankly worked better for reservoir
placement. Dr. Scott’s special reservoir insertion tool is no
longer commercially available.
Dr. Furlow, for the reasons mentioned above, continued
to implant through his transverse infrapubic incision his
entire career and his many disciples (e.g., Mulcahy, Knoll)
still use his approach today. Oblivious to the penoscrotal
movement, Furlow continued to enhance the infrapubic
technique with inventions. The early models of IPP did not
have kink resistant tubing; the choice of routing the tubing
through the inguinal canals was to avoid crimping the
tubing on account of the straight connections. Furlow sug-
gested the curved connection (Fig. 2a) which obviated the
need for cumbersome inguinal canal tubing passage
(Fig. 1d) and allowed shortening of the incision necessary
to implant (Fig. 1a). He also patented his cylinder intro-
ducer, titled the Furlow Insertion Tool (Fig. 2b). This was a
measuring rod with a hollow center through which an
Nuances of infrapubic incision for inflatable penile prosthesis
obturator drives a needle through the end of the penis to
properly seat the implant cylinders. Available in 1980, the
Furlow inserter eliminated the time-consuming freezing of
cylinders filled with saline creating basically a popsicle to
quickly jam into the dilated corporal body before the frozen
saline melted. Wilson remembers dispensing the circulating
nurse down to the nearby ice cream factory to obtain the dry
ice at the beginning of the surgery. The circulator would
then be tasked with placing cylinders maximally distended
with saline (they were not preconnected to the pump in
those days) into a sterile bowel bag and plunging the
package into the dry ice freeze bath until the popsicles were
created. Dr. Furlow truly changed the paradigm of IPP with
his Furlow inserter decreasing the hassle factor of IPP and
diminishing the surgical time by 30 min.
We would be remiss if we did not delineate the historical
development of the first Scott IPP cylinders. The original
cylinders were supplied in 1 cm. increments and whatever
the corporal length measured, that size cylinder was inser-
ted. The input tube frequently ran intracorporeally, abutting
against the inflatable part of the cylinder for a short dis-
tance. By the early 1980’s the vendor of the Scott 3-piece
IPP, American Medical Systems (AMS) realized this cre-
ated a wear area in the single silicone layer cylinder which
resulted in fluid loss (Fig. 3a, b). To avoid this, AMS added
rear tip extenders (RTE) to the proximal end of the cylinder
(Fig. 3c). They later added a polytetrafluorethylene (PTFE)
sleeve (surgeons called it a “boot”) to minimize friction
between the silicone tubing and silicone cylinder if tubing
remained intracorporeal (Fig. 3d). The current model of
AMS cylinders is triple layered and coated with an addi-
tional protectant called parylene® and this wear would not
occur today. Nevertheless the “boot” remains by FDA
mandate, but it can be stripped from the tubing (Fig. 3d).
This is recommended to avoid tissue ingrowth into the
Fig. 3 Development of AMS 700 IPP cylinders. a Crease in cylinder
caused by friction of input tubing. b Eventual rupture of cylinder wall.
PTFE material resulting in difficult removal of the cylinder
during revision surgery.
Coincident with the development of the inflatable pros-
thesis in the early 1970’s, semirigid and malleable implants
also were invented. Success with semirigid rods in reversing
impotence was first published by Drs. Michael Small and
Hernan Carrion in the same time frame as Dr. Scott’s initial
paper introducing the IPP [3]. Dr. Carrion went on to become
one of the legends in prosthetic urology and his son, Rafael,
continues to carry on his legacy. The Small Carrion pros-
thesis quickly gained popularity over Scott’s 3-piece because
of superior freedom from revision. Dr. John Barry at the
University of Oregon first reported success using the new
penoscrotal incision for semirigid rod implantation almost
simultaneous with the incision’s employment for IPP [4].
Previous to this, rods had been implanted via a perineal
incision [3]. Despite a slow start for the Scott prosthesis
because of frequent mechanical malfunction, inflatable
implants finally surpassed semirigid rod implants for the first
time in popularity in 1990. That year 80% of IPP were done
through a penoscrotal incision and 20% via infrapubic. In the
early 90’s, Perito conceived his minimally invasive infra-
pubic penile implantation and began to teach it extensively in
instructional courses. He single handedly created a rebirth of
enthusiasm for a variation of Dr. Scott’s original method of
implant placement from 50 years ago. The pendulum has
swung again—today the two IPP manufacturers report yearly
increases in the percentage of infrapubic models implanted.
Preparation of the patient: catheters,
positioning, and hydrodistention
In the holding area the patient is asked to void to comple-
tion. If the patient does not empty his bladder, he is
c Rear tip extender added to mitigate cylinder wear from intracorporal
tubing. d PTFE sleeve or boot stripped from input tubing.

catheterized, his bladder drained, and the catheter removed.
This simple in and out catheterization is performed prior to
the procedure and before the skin prep. One must remember
that patients dislike intensely the indwelling catheter; in our
opinion, there is absolutely no reason intraoperatively or
postoperatively for a patient to maintain a Foley catheter
when using the infrapubic approach. Unlike the subcoronal
and penoscrotal techniques, our approach cannot encroach
upon the urethra, except perhaps at the level of the meatus
and presence of a Foley will not affect that risk one iota.
Most importantly, in our opinion, you will never see a
patient with glans necrosis sans Foley catheter!
It is absolutely essential that the table be hyperextended
before you begin the case. This promotes a flat surface on
which to work. The Furlow Insertion Tool, being the
longest lever in our armamentarium, can be difficult to
negotiate in obese patients if the table is not broken. The
surgeon can gain further improvement in positioning by
supplementing the flexed table with Trendelenburg to
encourage the prepubic fat pad to retract cephalad.
Once prepped and covered with water repellant paper
drapes, we begin the case with an artificial erection created
by injecting 60 ccs of normal saline into the corpora using a
21-gauge butterfly needle (Fig. 4a). It is not necessary to
fully inflate the penis, but it is essential to hydro distend the
corpora enough to identify pathology when present. With
the artificial erection we are able to address any curvature,
notch, hour-glass defect, or plaque prior to inserting cylin-
ders. Physicians who do not perform an artificial erection
occasionally have to remove a cylinder to deal with an
unexpected surprise of penile deformity upon erection of the
IPP nearing the completion of the case. Every time the
surgeon is forced to remove a cylinder, we believe (but not
scientifically proven) you must be increasing your risk of
infection. The artificial erection also provides you with the
hydrodistention necessary to easily visualize and avoid the
Fig. 4 IPP through an infrapubic incision. a Hydrodilation of penis
with 60cc of saline. b Small transverse infrapubic incision one finger
P. Perito et al.
NVB and safely perform your corporotomies. Finally, if
you add lidocaine to the saline, one may perform a 3-piece
penile prosthesis under local anesthetic with employment of
concomitant pudendal, dorsal nerve and inguinal fan blocks.
The incision and dilatation (or lack of it)
{learning surgery from prose and pictures is difficult.
The reader is referred to www.vjpu-issm.info for videos
on the infrapubic incision: Perito P. The minimally
invasive infrapubic approach for placement of a 3-piece
inflatable penile prosthesis. VJPU 2018; 2: 141.}
The incision is created approximately one finger breadth
above the peno-pubic junction and only needs to be as wide
as the pump diameter (Fig. 4b). Some decry the minimally
invasive approach as unwise because of the difficulty of
troubleshooting if adversity appears. Perito answers, it is
always an option to simply extend the incision. In Perito’s
experience, however, the longer the incision the more penile
edema will be encountered postoperatively. Even with our
tiny incision, adequate exposure is gained by digitally
sweeping tissue on either side of the penis down and away
from the pubic bone (Fig. 4c). The only instruments
necessary to provide exposure to the corporal bodies are an
appendiceal retractor and a pediatric Yankaur suction tip
(Fig. 5a) which allows you to roll the neuro-vascular bundle
out of your way when placing the stay stitches in the cor-
pora (Fig. 5b). The stay sutures are placed conveniently as
the corpora starts to dive proximally toward the ischial
tuberosity. We use Ethicon 00 Monocryl suture on a UR6
needle (Fig. 6a); this needle is robust enough to reach down
and grab Tunica on a patient with a deep pannus. Before
creating your corporotomies, ensure that your stay sutures
breath above penopubic junction. c The sweep of tissue away from
corporal body with the finger.
Nuances of infrapubic incision for inflatable penile prosthesis
Fig. 5 Instrumentation to facilitate infrapubic IPP. a Pediatric
Yankaur suction tip (top) and Appendiceal retractor (bottom). b
Fig. 6 Stay sutures facilitate corporotomy. a 00 Monocryl on UR6 needle. b 1.7 mm corporotomy.
are at the 10 and 2 o’clock position on the penis (Figs. 1b,
6b). The artificial erection will allow plenty of topography
to work with on the corpora. The corporotomies should be
≤2 cm. This allows the widest part of the cylinder (17 mm)
which is where the tubing joins the base of the cylinder to
be inserted easily.
The described hydrodistention precludes the need for any
serial dilation. The Furlow is simply passed proximally and
distally to obtain the corporal measurements. Mulcahy and
Wilson also do not serially dilate but prefer to pass a single
#11 or 12 Brooks dilator prior to Furlow passage. This may
be unnecessary, but it is suggested during surgical proc-
toring to assure the Furlow has a proper path to follow. The
Furlow’s small diameter (9 mm) makes it difficult for the
inexperienced surgeon to follow the insertion tool’s journey
within the corporal body [5]. Perito believes every time a
dilator is passed up and down the corpora, we increase the
risk of complications such as crossover, perforation, and
possibly infection. Perito’s group has also shown through
biothesiometry that patients who are serially dilated are less
sensate when compared to those who are not [6].
For the non-pathologic penis, the only task that needs to
be completed at this point in the case is measurement of the
Rolling Neurovascular bundle (NVB) out of the way with Yankaur.
Stay sutures on either side of NGB.
corpora because there is no need for serial dilation. There is
no reason to go up and down the corpora with anything
sharp, e.g., scissors! The surgeon should be able to gain
access proximally and distally with the Furlow as long as
you WORK ALONG THE AXIS OF THE PENIS (Fig. 7a).
This is done proximally with aggressive counter-traction on
the penis and distally by keeping the penis on a stretch and
gently scything the Furlow laterally (Fig. 7b). This is one
point in the case where “QBM’s” (quick birdlike move-
ments) may actually serve you well.
While passing the Furlow Insertion Tool distally, one
must remember to squeeze the junction of the penis and
glans on the ventral surface. At this location the tunica
albuginea is at its weakest as anatomical dissection shows a
reduction of layers from three to one layer at the fossa
(Fig. 8a); this anatomical variant makes it the most likely
location to perforate the tunica and lacerate the urethra.
Perito calls this protective maneuver “like choking a
chicken” (Fig. 8b). Perito’s exposition of the effectiveness
of this “chicken choke” maneuver was a paradigm change:
the application of this defense has also proved very useful in
protecting the urethra from damage during modeling for
Peyronie’s disease [7] A recent study of modeling for
 P. Perito et al.

Fig. 7 Work along axis of

penis when dilating/
measuring. a Passing Furlow
distal, remaining lateral with
penis on stretch. Note digital
pressure on fossa navicularis to
prevent urethral damage. b
Passing Furlow proximal with
aggressive counter traction on
penis. Furlow passed with short,
gentle movements.

Fig. 8 Fossa navicularis has

weakest tunica albuginea
anatomy. a Note narrowing in
thickness of tunica at fossa
navicularis making dilation
dangerous. b Protecting urethra
with Perito “chicken choke”.

Peyronie’s disease showed reduction of urethral damage by
the “chicken choke” from the historic figure of 4–0% [8].
Once the penile measurements are obtained, we select
our cylinder with minimal to no addition of RTE. Infrapubic
implanters are spared the agony of calculating cylinder and
RTE sizes as the tubing length of 16 cm between pump and
cylinder on the infrapubic devices and the proximal location
of our corporotomy obviates this worry even on patients
with long penises. Upon hearing our measurements, the
back table gets to work on preparing our implant. They have
already prepared the largest capacity reservoir available
from the implant manufacturer whose product we have
selected. This time saving maneuver is efficacious because
there is no reason to use a smaller reservoir which could
only contribute to auto inflation due to intrinsic pressures.
The large reservoir also allows us to underfill diminishing
the chance of a palpable or visible reservoir when placed in
nontraditional locations. All implanters should reference the
maximum capacity of each cylinder length and fill the
reservoir with enough saline to have redundancy in the
system for the cylinders to grow over time. This is parti-
cularly important with the Coloplast devices whose Bio-
flex® cylinders expand over time to completely fill the
corporal space. Patients receiving Coloplast devices com-
monly report cylinders with more capacity 1 year later [9].
Reservoir and cylinder placement
{Perito P, Gross M, Vollstedt A. Alternative reservoir
placement in prosthetic urology. VJPU 2016; 2: 093}
While our back-table team is removing the air from the
cylinders/pump, the surgeon’s attention is turned to reser-
voir placement. Our reservoir placement is either going to
be beneath or on top of the transversalis fascia with the
reservoir being deployed cephalad—thus our terminology
of posterior to transversalis fascia (PTF) or anterior to
transversalis fascia (ATF) (Fig. 9a, b) [10]. Both techniques
are performed with a long (80 mm) nasal speculum whose
rounded shape and blunt jaws make it an atraumatic
instrument. In a virgin pelvis the nasal speculum is passed
through transversalis fascia and immediately driven cepha-
lad in order to deploy the reservoir behind transversalis
fascia but well away from the bladder’s surface. If the
patient has a surgically compromised retroperitoneum, we
Nuances of infrapubic incision for inflatable penile prosthesis
Fig. 9 Reservoir placements through infrapubic incision: PTF &
ATF. a Reservoir placed posterior to transversalis fascia (PTF). b
Fig. 10 Placement of reservoir
facilitated by nasal Speculum
& Yankaur. a Exposure for
both ATF and PTF reservoir
insertion. b In both ATF and
PTF reservoir placement nasal
speculum & Yankaur tip are
useful.
do not perforate transversalis fascia but simply break the
roof of the external inguinal ring with the nasal speculum
and drive the nasal speculum cephalad. This allows the
surgeon to create a space between the transversalis and
rectus muscles. This is not a true anatomical space thus a
Hager dilator is necessary to facilitate this opening between
the blades of the nasal speculum. In both the PTF and ATF
approach, the pediatric Yankaur suction tip (Fig. 10a) is
used to deploy the reservoir.
The authors of this paper participated in the discovery
and enhancement of ectopic placement of reservoirs
[10, 11]. While impressed with the safety and lack of
postoperative visibility of ATF reservoirs [12], the ATF
approach is no longer utilized on every patient. When fol-
lowing abdominal wall placed reservoir patients (presented
at meetings but as yet unpublished), Perito’s team has noted
Reservoir placed anterior to transversalis fascia (PTF). Also known as
ectopic or high submuscular placement.
increased post-operative pain associated with the ATF dis-
section when compared to the PTF approach. Thus, in
uncomplicated cases, Perito has returned to placing the
reservoir behind the transversalis fascia but cephalad to the
traditional retroperitoneal space (space of Retzius).
Every implanter has their own opinion on where the
Keith needle should exit the glans, but we do not stress over
the position of the puncture; we believe the only necessity is
to bring the Keith needle out on the correct side of the glans
and avoid sticking the urethra. Because the implant mounts
considerable pressure when inflated in the corpora, we
allow the cylinder to do the work of finding the end of the
corpora [13]. As during measurement with the insertion
tool, when passing the Furlow to position the cylinder, the
surgeon must again WORK ALONG THE AXIS OF THE
PENIS (Fig. 7a). Cylinders should be installed proximally

before the distal tip is pulled toward the glans. We find the
nasal speculum keeps you in the appropriate space and
prevents crossover during placement of the base of the
cylinder (Fig. 11a). While removing the nasal speculum, the
surgeon’s assistant can use the Furlow to keep the cylinder
base in the proximal tip of the corporal body (Fig. 11b).
You may then easily pull the guide string to deploy the
cylinders distally.
At this point in the procedure one should always perform
a surrogate reservoir test before closing the corporotomies.
This is a rapid fill of the implant with saline to check your
functional and cosmetic result (Fig. 12a). Any modeling for
curvature may be performed at this time. If modeling for
penile curvature is performed, always remember to protect
the urethra by applying pressure on the underside of where
the glans meets the distal corpora (Figs. 8b, 12b) [7, 8].
When using an infrapubic approach, the stay sutures are
almost always tied distal to the tubing exit site rather than
trapping the tubing as is sometimes performed in other
Fig. 11 Deployment of cylinders. a Deployment of proximal cylinder base through nasal speculum with tip of Yankaur. b Stabilizing base of
cylinder in corpora while removing the nasal speculum.
Fig. 12 Surrogate reservoir test for penile deformity & proper pump positioning. a Proper pump positioning. b Protecting the urethra during
modeling. c Repositioning pump after connections made.
P. Perito et al.
incisions. Because our corporal incision is so small, we
frequently tie the stays together rather than using the indi-
vidual legs of the stay sutures to create a horizontal mattress
closure as is recommended in the penoscrotal and sub-
coronal incisions for IPP. Any secondary sutures placed at
this time need only be for hemostasis and not integrity.
Pump placement, the drain and wound
closure
● Every pump should be mid-line—so you do not worry
about handedness.
● Every pump should be posterior—so you do not see it.
● Every pump should be dependent—so an obese man can
reach it.
The pump is deployed using the nasal speculum. It is
necessary to be assertive with the instrument. When driving
Nuances of infrapubic incision for inflatable penile prosthesis
the nasal speculum deep into the scrotum posteriorly, one
will encounter Colles fascia and feel the “pop” as you enter
into the most dependent portion of the scrotum (Fig. 12a, c).
Your assistant will then catch the pump and pull directly
caudad feeling Dartos fascia release the entire way. You
will know your pump is in the correct position if you dis-
place the penis toward the head and the pump does not
move (Fig. 12c). If pump movement is detected, the pump
is either too high or too anterior; these malpositions will not
be appreciated by the patient and or his partner. Before
making any connection pull the pump 2–3 cm toward the
infrapubic incision to allow you to make an easy quick
connection). Then displace the pump back into the depen-
dent scrotum and reduce the chance of any redundant tubing
that could be noticed by the patient (Fig. 12c).
Even though scrotal dissection is minimal with our
infrapubic incision, we firmly believe all patients should be
drained just as in the subcoronal and penoscrotal incisions.
In thousands of implants we have noted the minimum
amount of drainage ever reported is always at least 40 ml.
This is an amount equivalent to two extra testes resident in
the scrotum. Why allow any blood to accumulate in the
scrotum? Closed suction drainage has been proven to pre-
vent hematoma and not increase the risk of device infection
[14]. We favor a #10 Jackson Pratt drain. The drain runs
adjacent to the pump tubing and is brought out cephalad to
the infra-pubic incision. The wound is closed in 2 layers: 3-
0 Monocryl for Scarpa’s fascia and staples for the skin. The
reader may question the use of staples. We have found that
the staples keep patients from playing with their incisions
causing wound separation and superficial infections. Our
infrapubic placed Implants do not require inflation for
hemostasis in the immediate post-operative period because
we have placed a drain. The only thing accomplished by
leaving an implant inflated postoperatively is rendering the
patient with pain from his priapism for the duration of
inflation and then annoy him again the next morning with
the agonizing post-operative deflation.
We generally keep our patients hospitalized overnight for
our own convenience (drain & dressing removal the next
morning) and to keep the patient with minimal activity (less
scrotal swelling). A sandbag is placed directly on the inci-
sion for infrapubic pressure to discourage bleeders and, if
possible, left overnight. The patient is told to pull down on
his pump every time he goes to void or at least six times a
day. This maintains the pump in the position created by the
surgeon; patient compliance with this request assures the
correct pump position every single time. We encourage
bringing patients back during the first week to confirm that
they are pulling down on their pump. This will be the only
opportunity for the surgeon to pull it down for them if they
are not. The drain is usually removed the morning after
surgery, but it can be left in for 2–5 days without
consequence. The staples can be removed in 10–14 days at
which time the patient is taught how to cycle the implant.
Because there is no incision on the scrotum, patients are
instructed to learn the architecture of the pump and the
deflate tab from day one. Motivated patients should then be
able to use their penile implant 14–21 days from the date of
implantation without discomfort—a major distinction
between the infrapubic and Wilson’s penoscrotal technique
implant patients who must wait twice as long for activation
because of more scrotal discomfort!
Compliance with ethical standards
Conflict of interest Perito: Consultant Boston Scientific, Coloplast.
Mulcahy: Consultant Boston Scientific, Coloplast. Wen: None.
Wilson: Consultant AMT, Coloplast, International Medical Devices,
Lecturer Boston Scientific. Stockholder NeoTract.
Publisher’s note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
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