Penile Prosthesis

Penile prosthesis implantation is the definitive, third-line surgical treatment for erectile dysfunction that has failed oral PDE5 inhibitors, intracavernosal injection, and the vacuum erection device (VED). Two device families exist: the inflatable (multicomponent) prosthesis, which best reproduces natural erection and flaccidity, and the semirigid (malleable) rod, which is simpler and suits men who lack the manual dexterity to operate a pump or who need to hold a condom catheter. Because implantation permanently destroys the native erectile tissue and carries a meaningful infection risk, patient selection, expectation-setting, and antimicrobial discipline matter as much as the operation itself. Erectile dysfunction itself is covered in the Andrology topic; this page is the operative reference.

Device	Share of implants	Function and best candidate
Three-piece inflatable (IPP)	~70% (gold standard)	Paired cylinders + scrotal pump + abdominal reservoir; most natural rigidity and flaccidity; first choice for most men
Two-piece inflatable (Ambicor)	~20%	Inflatable without a separate retropubic reservoir; used when reservoir placement is to be avoided
Semirigid / malleable rod	~10%	Permanently rigid bendable rod; for poor manual dexterity, condom-catheter use, or complex reconstruction

Note: the source chapters give the Ambicor's two-piece classification and ~20% share but do not detail its design; the combined pump–reservoir is the defining feature of the two-piece type.

Indications and Patient Selection

Prostheses are reserved for men who have failed or cannot use less invasive ED therapy. Device choice blends surgeon preference with patient factors — abdominal girth, Peyronie disease, corporal fibrosis, spinal cord injury, and manual dexterity all steer the decision.

Counseling

• Irreversible — implantation destroys the native corpora, so the man can never return to other erectile aids. The device works alongside a VED but not with other ED treatments.
• Satisfaction is high — 92–100% for patients and 91–95% for partners, often still improving 9–12 months after surgery; device-specific figures run ~86–98% for inflatable and ~66–89% for malleable.
• Set length expectations — the commonest complaint afterwards is that the penis feels shorter or smaller than before. The device will not lengthen the penis, engorge the glans, or change libido or sensation, and men are at particular risk of perceived shortening after radical prostatectomy.
• "CURSED Penis" predicts dissatisfaction — Compulsive, Unrealistic, Revision, Surgeon-shopping, Entitled, Denial, and Psychiatric traits flag the man likely to be unhappy whatever the technical result.
• Malleable-specific — suits men without the dexterity to work a pump and those who must keep a condom catheter in place (e.g. spinal cord injury), but erosion risk is higher when penile sensation is poor or absent.

Device Choice for Special Cases

• Post-prostatectomy — the length-expanding LGX cylinder is preferred (also for men with good penile elasticity); aggressive cylinder sizing plus intermittent inflate/deflate "stretching" over the first 6 months (rehabilitation continuing up to ~12 months) maximises perceived length.
• Peyronie disease — the non-expanding CX (AMS) or the high-tensile Coloplast Titan straightens the penis. Implant alone corrects curvature to within ~15° when curvature does not exceed 45°, with intraoperative manual modelling (forcible bending against the curve) for any residual deformity.

Preoperative Preparation

• History and examination — document prior abdominal/pelvic surgery (bilateral inguinal herniorrhaphy, prostatectomy, cystectomy, proctocolectomy); each complicates reservoir placement and may push it ectopic (high submuscular).
• Glycemic control and infection screen — exclude UTI and any systemic or remote infection, and correct an elevated HbA1c before booking (a common elective cutoff is below 8.0; some use < 7.5–8.5%).
• Anticoagulation — scrotal hematoma is a near-universal consequence, so stop new oral anticoagulants ~3–5 days preoperatively and remain off them 10–14 days postoperatively. A man who cannot stop anticoagulation should return to conservative therapy (high-dose intracavernosal Trimix or a VED).
• Voiding — assess obstructive/irritative symptoms (uroflow and post-void residual) first, and complete any BPH surgery well in advance so voiding has normalised before implantation.

Infection Prevention

Prosthetic infection is the most feared complication, so the entire operative routine is built around preventing it. Gram-positive skin organisms (Staphylococcus epidermidis, S. aureus) predominate.

• Antibiotics — broad-spectrum cover for gram-positives and gram-negatives; the standard is IV vancomycin + gentamicin (~5 mg/kg ideal body weight) given ~1 hour before incision.
• Skin prep — the surgeon shaves the genitalia with a razor at the time of surgery (less skin trauma than clippers), then a mechanical betadine scrub followed by a chlorhexidine–alcohol paint, allowed to dry 3 minutes before draping to avoid a Bovie-ignited fire.
• Device coatings — the AMS 700 carries an InhibiZone rifampin–minocycline coating; the Coloplast Titan is hydrophilic and is dipped in antibiotic (e.g. rifampin–gentamicin) immediately before implantation. Coated devices bring novel-case infection to ~1–2% (≤ 1% in recent series); the broader reported range is 2–5%, usually within 3 months.
• No-touch technique — prepare the prosthesis on a separate plastic-covered Mayo stand (never on cloth or paper drapes) and cleanse gloves in antibiotic solution before handling hardware.

Inflatable Penile Prosthesis

The three-piece IPP — paired intracorporeal cylinders, a scrotal pump, and a retropubic/abdominal reservoir — is the gold standard. It can be placed through a penoscrotal incision (favoured ~80%; greater proximal crural exposure, avoids the dorsal nerve, direct pump placement, but the reservoir is placed blindly) or an infrapubic incision (reservoir placed under direct vision, no scrotal dissection, faster, but risks the dorsal neurovascular bundle).

Device Selection

• AMS 700 — CX and CXR expand in girth only (CX for concomitant Peyronie disease; CXR for revision or small corpora), while LGX adds up to 20% length. Features include preconnected cylinders/pump, Snap-Fit rear-tip extenders, the Conceal low-profile reservoir, and a Momentary-Squeeze one-touch pump.
• Coloplast Titan — built from Bioflex polyurethane (higher tensile strength and abrasion resistance than silicone), making it ideal for complex Peyronie disease; uses the CloverLeaf reservoir and a lock-out valve that prevents autoinflation, in Titan Touch and Narrow Body cylinder widths.

Penoscrotal Approach

1. Position and prep — supine or low lithotomy in Allen stirrups; razor shave, betadine then chlorhexidine–alcohol, Ioban drape; vancomycin + gentamicin. Place a 16-Fr Foley for novel cases (14-Fr for revisions) with minimal lubricant and clean the exposed catheter with a chlorhexidine stick.
2. Retraction — a Lone Star retractor on the urethral meatus places the penis on stretch (avoid the sharp urethral hook in revisions).
3. Incision — a ~2–3 cm transverse incision at the penoscrotal junction; develop through dartos to the tunica albuginea and place ~6 blunt hooks for exposure.
4. Stay sutures and corporotomy — place two pairs of 2-0 Vicryl stay sutures in each corpus (for later closure); make a longitudinal corporotomy 1–1.5 cm lateral to the corpus spongiosum, palpating the urethra to avoid it. Keep the corporotomy short in novel cases; extend it (1.5–3.5 cm) for fibrotic revisions.
5. Dilate and measure — dilate with Hegar, Brooks, or Uramix dilators (a common scheme is #11 distally and #13 proximally), aiming laterally to spare the urethra; distal dilation can be skipped in virgin corpora. Record corporal length and choose cylinder size plus rear-tip extenders (RTEs).
6. Goal-post / A-frame check — two dilators (or Furlow tools) in the proximal corpora must not cross and should form an "A"; a metallic "clank" or a crossed configuration signals proximal crossover. Irrigate to confirm there is no urethral injury.
7. Prepare hardware — on the separate Mayo stand, charge the reservoir (saline in, air out) by no-touch technique and prepare the cylinders. AMS RTEs snap on with a "click" (smallest 0.5 cm; build up from 1.5 cm); Titan RTEs twist on counter-clockwise.
8. Place the cylinders — load each cylinder suture on a Keith needle in the Furlow inserter, pass distally (lateral and slightly dorsal to the meatus), deploy the obturator through the glans, and pull the cylinder into place; seat the proximal end in the crus and trim the AMS reinforcing sleeve at the tubing exit.
9. Place the reservoir — in Trendelenburg with the bladder empty, sweep the cord laterally, identify the external inguinal ring just superolateral to the pubic tubercle, pierce the transversalis fascia medial to the cord, and deliver the reservoir into the space of Retzius (the space feels silky, with no bowel or Foley balloon palpable). Fill and confirm there is no autoinflation.
10. Place the pump — develop a dependent subdartos pouch and seat the pump.
11. Connect and test — trim and saline-rinse the tubing, make the connections, then inflate and deflate several times to confirm rigidity and symmetric distal glans support.
12. Close — close the corporotomies over the preplaced stay sutures, leave a closed-suction drain exiting contralateral to the reservoir tubing, and close in two layers (3-0 chromic deep, 2-0 Monocryl vertical-mattress skin).

High Submuscular (Ectopic) Reservoir Placement

For men with prior inguinal, pelvic, or abdominal surgery, place the reservoir submuscular — in the plane between the rectus muscle and the transversalis fascia — rather than in the space of Retzius, using the high submuscular technique described by Morey.

1. Trendelenburg — palpate the external ring and place a pediatric Deaver retractor.
2. Develop the submuscular tunnel in the plane deep to rectus and above the transversalis fascia by blunt finger dissection, keeping the neck narrow to prevent balloon prolapse.
3. Aim cephalad (toward the ipsilateral nipple) with a sponge-stick or Foerster lung clamp, keeping the pocket deep to rectus; the space should be ≥ 10 cm.
4. Insert the reservoir via clamp, overfill to ~120 mL then compress, and confirm it is neither too deep nor too lateral.

Postoperative Care

• A closed-suction bulb drain ~24 hours and an indwelling Foley ~24 hours; an oversized athletic supporter packed with fluffs holds the penis upward (the "periscope" dressing), with ice for 48 hours.
• Shower from 48–72 hours; wound check at 10–14 days; device activation and counselling at 6–8 weeks.
• Instruct the man to pull the pump toward the bottom of the scrotum three times daily so it seats dependently.

Semirigid (Malleable) Penile Prosthesis

A single bendable rod is placed in each corpus. It is implanted less often than the IPP because most men prefer a device that inflates and deflates, but it is preferred for poor manual dexterity, condom-catheter use, or complex reconstruction. The penoscrotal incision is the workhorse; subcoronal, infrapubic (pubic), perineal, and dorsal approaches also exist. Avoid the perineal approach if a future incontinence procedure is possible (preserve virgin planes), and avoid the dorsal shaft approach in general (it risks penile edema from dorsal lymphatic obstruction).

Technique

1. Position, prep, antibiotics, catheter — as for the IPP (supine; razor shave; vancomycin + gentamicin; urethral catheter; Lone Star or ring retractor).
2. Expose and open the corpus — penoscrotal incision through dartos and Buck fascia; choose an insertion site to one side of the urethra, place stay sutures, and make a ~3 cm corporotomy beginning 0.5 cm from the distal end.
3. Dilate proximally and distally — develop the subtunical plane to the crural tip and toward the glans; dilate with a 10-mm Hegar/Brooks dilator beneath the glans, progressing to 12–14 mm with the curve pointed laterally, and an 8–10-mm dilator proximally to the ischial tuberosity — avoiding perforation. For obliterated corpora (priapism, infection, scarring) use an Otis urethrotome or Rosillo cavernotome.
4. Measure and size — measure corporal length and add rear-tip extenders if short; it is safer to oversize and trim than to undersize and open a second device.
5. Insert the rod — seat the proximal end first, then bend the distal end into a loop and shoehorn it under the glans with a vein retractor (the corporotomy must be at least as long as the fold). Confirm the glans is well supported.
6. Close — running 3-0 absorbable suture to the tunica over the stay sutures, then subcutaneous and subcuticular closure.

Sizing Pitfalls

• Too short → poor glanular support (SST deformity).
• Too long → glans erosion and chronic pain.

Complications

Intraoperative

• Urethral perforation (~1–3%) — abort placement on that side, repair, leave a Foley ~10 days, and reattempt at ~6 weeks; an already-dilated contralateral cylinder may be left in to avoid shortening.
• Crural (proximal) perforation (~1–3%) — does not mandate aborting, but needs a buttress (absorbable mesh or a vascular-graft sleeve, sometimes sutured to the pubic rami) to stop proximal migration.
• Crossover — proximal (dilators clank or cross) or distal (asymmetric glans tips); recognise it with the A-frame check, then re-dilate the correct channel — usually fixable intraoperatively.
• Bladder or bowel injury during reservoir placement — abandon the prosthesis to avoid seeding infection.

Early

• Hematoma / edema — scrotal ecchymosis is expected; penile edema/hematoma occur in ~3% and urinary retention in ~2%.
• Infection — ~1–2% for coated-device novel cases (broader range 2–5%), usually within 3 months. Remove all components, or attempt salvage with sequential betadine/peroxide/antibiotic irrigation (successful in up to ~80%); a synthetic high-purity calcium sulfate (CaSO4) antibiotic corporal cast can preserve the corporal space between explant and reimplant.

Late

• Mechanical failure — fluid loss from tubing fracture, cylinder or reservoir leak, aneurysm, or connector disruption; < 5% at 5 years, approaching 30% at 15 years (up to ~40% by 10–15 years in some series).
• Erosion / extrusion (~2%) — higher in insensate patients; remove, repair, place a spacer cylinder, and reimplant at ~5–6 months.
• SST (concorde) deformity — the glans droops because the cylinders are too short or distal dilation was inadequate; redilate and place a longer cylinder ± glanulopexy.
• S-shaped / buckling deformity — oversized cylinders buckle (a "lightning-bolt" configuration on imaging); replace with the correct length.
• Autoinflation — abdominal pressure on the reservoir, commoner without a lock-out valve; use a low-pressure cavity or replace the reservoir.
• Cold glans — the glans is not engorged by the device; a PDE5 inhibitor or MUSE can help.
• Rare — reservoir erosion into bowel or bladder, penile necrosis (compromised distal flow — remove the device), and paraphimosis in a short foreskin (preputial dorsal slit).

Tips & Pitfalls

• Protect the urethra at every step — aim dilators laterally, palpate the urethra before corporotomy, and irrigate to detect an unrecognised injury; meatal bleeding or hematuria signal an occult urethral or bladder injury.
• The A-frame / goal-post test is the crossover safeguard — two proximal dilators should form an "A" and never clank; a crossed or clanking pair means crossover.
• Size to the corpus, not to a wish — undersizing causes SST/concorde droop, oversizing causes buckling and erosion; oversize-and-trim a malleable rod rather than open a second device.
• Plan the reservoir around prior surgery — go high submuscular (ectopic) when the retropubic space is hostile, keeping the pocket neck narrow and ≥ 10 cm deep.
• Separate the wounds when combining devices — when implanting alongside an artificial urinary sphincter or sling, use separate incisions so one device infection need not condemn the other, and review old notes for a transcorporeal cuff before making the corporotomy.