Skip to main content

Intraoperative Setup: Anesthesia, Positioning, No-Touch Protocol

The infection-prevention bundle discussed in the infection article is executed on the day of surgery through a sequence of small decisions (anesthesia type, positioning, skin preparation, draping protocol, glove choreography, and irrigation choice) that together determine the microbial burden the device will see. High-volume implanters commonly treat these choices as a protocol and deviate only for explicit reasons.[1][2]

Approach-specific technique is covered in surgical approaches.

Anesthesia​

General vs. regional vs. spinal​

All three modalities are used, and none is clearly superior. The choice is driven by patient factors (cardiopulmonary status, anticoagulation, anxiety), surgeon preference, and institutional practice.

ModalityAdvantagesDisadvantages
GeneralComplete immobility; no time pressure; airway control; usable for any approach; avoids neuraxial antithrombotic restrictions[25]Postoperative nausea; airway and systemic anesthetic risks; possible longer PACU time
SpinalAvoids GA; profound pelvic/perineal relaxation; excellent pump-pocket developmentPost-dural puncture headache risk; time-limited; challenging in ankylosing spondylitis or prior lumbar fusion
MAC + local / penile blockFastest throughput; outpatient-friendly; avoids GA morbidityRequires patient cooperation; selected primary subcoronal implants can be completed with local anesthesia, sometimes with conscious sedation[36]; complex revisions may need additional anesthesia

High-volume outpatient prosthetic practices increasingly use MAC plus dorsal penile block plus local infiltration, with general anesthesia reserved for complex revisions, concurrent procedures and patients who cannot tolerate conscious sedation. A 2024 review recommends multimodal analgesic regimens that include nerve blocks and narcotic-free pathways.[3]

Dorsal penile block​

A dorsal penile block placed before incision reduces early postoperative pain. In a randomized, placebo-controlled trial of 30 men (1% lidocaine plus 0.5% bupivacaine without epinephrine), pain scores were lower at 0 hours (VAS 2.5 vs 5.3) and 4 hours (2.8 vs 5.1), and narcotic use did not differ.[13] In a retrospective matched comparison, a multimodal regimen that included dorsal and pudendal nerve blocks was associated with lower pain scores and opioid use, and fewer patients needed narcotic refills (10.7% vs 28.0%).[4]

Technique: At the base of the penis, the dorsal nerves (terminal branches of the pudendal nerve) run beneath Buck's fascia at roughly the 10 o'clock and 2 o'clock positions. A 25-gauge needle is introduced through the dorsal skin lateral to the midline, advanced through Buck's fascia (a characteristic "pop"), and aspirated. For IPP placement, a randomized dorsal penile block trial used 1% lidocaine plus 0.5% bupivacaine without epinephrine.[13] The block described here uses local anesthetic without epinephrine. Epinephrine use in penile blocks remains debated: a 95-patient ring-block series reported no anesthetic complications but did record postoperative small-area skin necrosis in 13%, while a pediatric circumcision case reported ischemia without proving epinephrine as its cause.[30][31]

Liposomal bupivacaine (Exparel) delivers up to 3 days of local anesthetic. In a single-surgeon retrospective series of 37 patients it reduced inpatient narcotic use with similar pain scores, at a reported cost of about $285 per dose.[5]

Local infiltration​

For supplemental analgesia, 0.25% bupivacaine is a labeled option for local infiltration at the planned incision.[40] Epinephrine use in penile blocks remains debated; a penile ring-block series used it without anesthetic complications, while a case report described ischemia after use without establishing causation.[30][31] Scrotal and pump-pocket infiltration adds another layer. Sum local-anesthetic doses across block and infiltration sites, inject slowly with repeated aspiration, and have a local-anesthetic systemic-toxicity response plan available.[38]

Adjunct nerve blocks​

The pudendal nerve block (transperineal or transvaginal technique, guided by ultrasound or anatomic landmarks at the ischial spine) provides deeper perineal anesthesia, and is used in revision cases and in concurrent AUS and IPP placement.

The ilioinguinal / iliohypogastric block supplements an infrapubic incision, adding analgesia to the lower abdominal skin and superficial fascia.

Positioning​

Supine, arms tucked or on a board, legs flat. Lithotomy is not routine for primary IPP; it adds time, increases pressure-injury risk, and offers no meaningful advantage over flat supine for the penoscrotal or infrapubic approach. Selective use of lithotomy:

  • Subcoronal approach with anticipated concurrent glans work
  • Concurrent AUS placement requiring perineal access
  • Concurrent complex urethroplasty or vesicourethral work

A small pad under the hips can assist pump pocket development in shorter scrota, but routine hip extension is not required.

Foley placement: Standard practice is placement of a 14–16 Fr Foley catheter after prep and drape, under sterile technique, after antibiotic administration. Pre-prep placement is avoided; the catheter then becomes a conduit for skin flora into the prepared field.

Pressure-injury prevention​

IPP cases run 60–120 minutes; heels, sacrum, and elbows tolerate supine positioning well for this duration, but the genital prep itself carries unique exposure:

  • Shield the non-operative skin with sterile drapes; avoid direct pooling of chlorhexidine under skin folds
  • Avoid perineal adhesive drapes that peel back along the scrotum during pump placement

Skin Preparation​

The shift from povidone-iodine to chlorhexidine​

ChloraPrep (2% chlorhexidine gluconate in 70% isopropyl alcohol) was used for skin preparation in a cohort of 103 primary IPP cases.[6] In a randomized trial of 100 genitourinary prosthetic cases, post-preparation skin cultures were positive in 8% with chlorhexidine-alcohol and 32% with povidone-iodine.[7] A 2025 prospective cohort using ChloraPrep plus fibrin sealant plus no drains reported 0/103 infections at 12 months in primary cases versus 3.5% (4/115) at 12 months in historical controls prepped with povidone-iodine and drained.[6]

Application​

  • ChloraPrep application. Apply for approximately 30 seconds on dry skin and two minutes on moist skin, per the selected applicator label. Allow complete drying before draping or cautery (at least three minutes on hairless skin; hair may take up to one hour), prevent pooling, and remove wet materials.[26]
  • Cover the entire penis and scrotum, mons pubis, lower abdomen above the umbilicus, and medial thighs to mid-thigh with generous margins; use enough 3-mL ChloraPrep applicators to completely wet the field, with each covering at most about 130 cm².[26]
  • Do not pool under the scrotum; elevate and prep all scrotal surfaces individually
  • Hair is clipped, not razor-shaved, immediately before the prep

Povidone-iodine still has a role in specific revision or salvage circumstances and in patients with documented chlorhexidine hypersensitivity, but it is no longer the default for primary IPP.

Do not irrigate the wound with povidone-iodine​

In Manka's retrospective single-surgeon study, betadine wound irrigation was associated with a higher infection risk than vancomycin-gentamicin irrigation (adjusted OR 9.3), and a later report from the same institution gave a relative risk of 16.9.[14] Povidone-iodine has a legitimate role on skin before draping; it does not have a role in the wound once the incision is made. See the infection article for the full "what NOT to irrigate with" list.

Draping and the No-Touch Barrier​

The Eid no-touch protocol​

J. Francois Eid developed the no-touch technique.[1] In Eid's high-volume, single-surgeon series of 3,342 implants, a historical comparison found infection in in 11/2,506 implants (0.44%) after adding no-touch versus 14/704 (1.99%) with coated devices before its addition.[1] The central principle: the implant never touches the patient's skin, and the surgeon's gloves that touch skin never touch the implant.

The elements:

  1. After skin prep and standard drape, an adhesive barrier drape (Ioban or equivalent) is applied over the entire surgical field
  2. The barrier is fenestrated only over the planned incision site
  3. The incision is made through the Ioban, and all subsequent manipulations occur through the fenestration
  4. The skin-exposure step (incision, initial dissection through dartos) is performed with the first set of gloves
  5. Before the device is opened, the surgeon changes gloves; many surgeons double-glove and simply peel the outer layer
  6. The device is handled only by instrument tips or by the clean-gloved hand
  7. Frequent glove changes during handling of different components
  8. Strict minimization of OR traffic; door opens and out-of-room staff are the documented contamination vector

Adhesive barrier choice​

Eid used a loose 3M #1012 sterile drape as the no-touch barrier after initial incision and dissection; the underlying adhesive iodophor drape was not his implant–skin barrier.[1] A substitute barrier must isolate the implant from skin while permitting penile and scrotal manipulation; the cited Eid series did not evaluate chlorhexidine-impregnated substitutes.[1] The defining feature is a continuous barrier across the entire surgical field; partial draping or a drape with multiple fenestrations defeats the protocol.

Hair management​

Hair is clipped before prep and before draping so that clipped hair does not contaminate the prepped field. Razor shaving is avoided because it creates microabrasions that can act as infection reservoirs.

Antibiotic Regimen​

The full rationale is in the infection article. The intraoperative execution:

  • Vancomycin (15 mg/kg) started within 120 minutes before incision, with the infusion complete before incision (ASHP 2013). AUA Table V lists aminoglycoside plus vancomycin among prosthetic-surgery options, while its footnote advises against routine vancomycin prophylaxis; regimen selection reflects local resistance and patient risk.[15]
  • Gram-negative agent tailored to local antibiogram:
    • Gentamicin 5 mg/kg as a single prophylactic dose requires renal-risk assessment, appropriate dosing weight, and local susceptibility review. The AUA table permits aztreonam substitution for renal insufficiency; a small retrospective prosthetic-surgery cohort associated weight-based gentamicin with more AKI (9/57 versus 2/67), without a demonstrated infection benefit.[15][34]
    • Piperacillin-tazobactam 3.375 g: preferred at many high-volume centers
    • Ceftriaxone 2 g: where local gram-negative sensitivities support it
  • Fluconazole 400 mg IV, if selected by the local protocol: infuse at no more than approximately 200 mg/hour; start at least 2 hours before incision when the dose is to be completed before incision.[27]
  • Stop prophylaxis at wound closure. The 2020 AUA best-practice statement limits prophylaxis to the procedure, even with a drain; retrospective IPP cohorts found no protective association with postoperative oral antibiotics or IV prophylaxis longer than 24 hours.[15][2][8]

Redose short-half-life beta-lactams at the guideline interval during prolonged surgery or after excessive blood loss; vancomycin has no routine redosing interval, although unusually long cases may require another dose.[15]

Device Preparation​

Prior to opening the device​

  • Confirm device selection, size, accessories, and model-specific contraindications before opening; InhibiZone is contraindicated with rifampin, minocycline, or other tetracycline sensitivity and with systemic lupus erythematosus.[16]
  • Confirm expiration date
  • Confirm temperature-stable storage per manufacturer specification
  • Open the outer box; the sterile inner tray is opened only at the moment of implantation

AMS 700 (InhibiZone)​

  • Do not soak. The IFU states that InhibiZone components should not be soaked before implantation and may be briefly rinsed or dipped in a sterile solution immediately before implantation. Contact with alcohols or acetone can remove the antibiotics.[16][20]
  • Prepare cylinders and reservoir with sterile normal saline: fill to a rounded shape (about 20–30 mL per component), aspirate every air bubble, then aspirate flat and clamp the tubing one notch only, about an inch from the needle, with tubing-shod hemostats. Do not over-aspirate, because air can be drawn back through the semipermeable silicone. Squeezing the pump deflation button and the bulb together is warned against.[19][20]
  • Treated components stay dry once prepared, on an empty uncovered tray, basin or Mayo stand, not submerged in saline (soaking turns the solution orange as antibiotic leaves the device). Untreated components can wait in saline or antibiotic solution. Store treated devices at no more than 40 °C.[19][20]
  • With the MS Pump the manual has the first hard, quick bulb squeeze after a single press of the deflation button, then repeats squeeze and deflate until no bubbles appear; with the TENACIO Pump the button is fully depressed once before the first squeeze.[19][20]
  • Irrigation of the wound or pocket with antibiotic-fortified saline (vancomycin 1 g/L plus gentamicin 80 mg/L) or, where chosen, 0.05% chlorhexidine gluconate (Irrisept).[33][9] In a 14-center retrospective antibiotic-impregnated IPP cohort, 0.05% CHG use was associated with similar infection-related explantation (1.9% versus 2.0%), but median follow-up was shorter with CHG (4 versus 8 months).[9]

Coloplast Titan (hydrophilic)​

  • Submerge the hydrophilic Titan in a surgeon-selected compatible aqueous antimicrobial solution before placement, following current model-specific preparation instructions.[32]
  • In the Towe 2020 retrospective cohort of diabetic men receiving primary Coloplast Titan implants, vancomycin plus gentamicin dip was associated with a lower postoperative infection rate than all other dips combined (1.4% versus 6.4%)[10]
  • Antifungal addition (fluconazole or amphotericin B) in high-risk patients did not reduce antibacterial activity in vitro[11]
  • Use caution with 0.05% chlorhexidine gluconate (Irrisept) on hydrophilic surfaces. The 2026 Ivan J Urol cohort associated it with more explants for infection (4.6% versus 2.1%); among CHG-exposed revision cases, 12% underwent explantation for infection[12]
  • Keep the device submerged in its dip bath on the field until the moment of implantation

Malleable devices​

Preparation depends on the malleable model: Genesis and the Rigi10 Hydrophilic variant have hydrophilic surfaces that accept a surgeon-selected compatible dip; other models follow their own instructions.[28][29] In the protocol described here, irrigate the corporotomy and skin wound with antibiotic saline at closure.

Instruments to Have Ready​

Beyond the standard prosthetic tray, the following specific instruments commonly save operative time and reduce device contamination. See instruments section for device-specific pages.

  • Corporal dilators. Brooks, Rossello, or Pratt graduated sizes (8–14 mm typical range). The AMS instructions dilate the proximal corpus to at least 11 mm (more if the tubing lies inside the proximal corpus) and the distal corpus to at least 12 mm[19][20]
  • Cavernotomes. Mooreville, Ghanem, Uramix (for fibrotic corpora; do not routinely use for virgin corpora)
  • Furlow insertion tool. For cylinder placement with Keith needle
  • Keith needle. Carries the cylinder traction suture through the glans; leave the traction sutures in until the end of the case in case a cylinder must be repositioned, then cut one end about 2 cm from the glans and pull the suture out slowly[19][20]
  • Measuring forceps / corporal measuring device (Coloplast or Boston Scientific versions)
  • Rear-tip extenders (RTEs). Full size range on the field
  • Specialty retractors. Lone Star ring retractor for penoscrotal or subcoronal approaches; small Deaver or Army-Navy for infrapubic
  • Pump-pocket developer. Babcock forceps or Allis clamp to open dartos planes
  • Reservoir introducer. Coloplast or Boston Scientific proprietary, or nasal speculum or Yankauer for manual technique
  • Tubing connectors. Appropriate to the device

Closed-suction drain decision​

Many contemporary protocols omit closed-suction drains (Jackson-Pratt, Blake).[37] A prospective nonrandomized pilot of 345 first-time IPPs found day-10 sonographic hematoma in 1/117 (0.9%) with 72-hour drainage, 11/114 (9.6%) with 24-hour drainage, and 8/114 (7.0%) without drainage; infection differences were not statistically significant.[37] A retrospective comparison of 410 primary implants found no reduction in hematoma or infection with a 24-hour drain,[17] and an earlier three-institution series of 425 implants with 12–24 hour scrotal drainage reported a 3.3% infection rate.[18] That series used a 10 French round Blake drain (occasionally Jackson-Pratt) in every patient for less than 24 hours and reported hematoma in 0.7% (3 of 425) over an average 18-month follow-up; it had no undrained comparison arm of its own.[18] Some surgeons continue to favor routine brief closed-suction drainage with partial device inflation and a compressive wrap on the strength of this and older teaching.[21] Fibrin sealant (Tisseel, Evicel) is used in some protocols to reduce hematoma without a drain.[6]

The Time-Out Specific to Prosthetic Urology​

Beyond the standard universal protocol elements:

  • Confirm device type, model, and size range on the field
  • Confirm antibiotics administered, including antifungal
  • Confirm dip solution (if hydrophilic): drug, concentration, time submerged
  • Confirm no-touch protocol understood by all scrub staff
  • Confirm OR traffic is limited; door will remain closed
  • Confirm Foley status (pre-prep placement: replace after drape; after-drape placement is standard)

Closure and Postoperative Hand-Off​

  • Device left partially inflated in many protocols: reduces hematoma and promotes tissue molding around cylinders; typically kept inflated for 24 hours to 2 weeks per surgeon preference. The AMS labeling leaves some fluid in the cylinders at closure (the MS Pump manual by pressing the deflation button as the final act, the TENACIO IFU by squeezing the bulb), a dressing applied with the cylinders partly inflated, the penis supported on the abdomen, and an optional drain for 12 to 24 hours[19][20]
  • Supportive scrotal wrap / compressive dressing to limit swelling and hematoma without constricting the penile shaft or urethra. Leave the glans visible, check its color and sensation after dressing, and urgently assess discoloration or increasing pain; release compression and consider cylinder deflation while evaluating perfusion.[22][35] One described technique, the Henry Mummy Wrap, uses a 4-inch Kerlix roll wrapped loosely around the shaft with the glans left exposed, then passed around the genital base and beneath both testes to elevate the scrotum and support the pump, with additional circumferential turns to secure the cast; it is generally removed the next day, though the describing authors report leaving it up to 2 days in selected anticoagulated patients without establishing that uninterrupted therapeutic anticoagulation is safe.[22] In a 200-man retrospective sub-coronal series using a modified no-touch technique and this wrap, 3 infections (1.5%) occurred in a cohort that was 74% diabetic, with plaque plication in 24% and relaxing incisions in 22%; this combined, uncontrolled series cannot isolate an effect of the wrap or the approach.[23]
  • No drain in many modern protocols
  • Fibrin sealant applied to the pump pocket and corporotomy sites in some protocols[6]
  • Foley left overnight or removed at end of case per surgeon preference; early removal is increasingly standard
  • Postoperative orders. Scheduled NSAIDs and acetaminophen; narcotic as PRN rescue only; ambulation on postoperative day 0 if tolerated; discharge the same day or postoperative day 1. Document a patient-specific VTE risk assessment and prophylaxis plan; IPP evidence for perioperative heparin comes from one retrospective cohort with routine scrotal drainage.[39]

Continuing antithrombotic therapy​

For a patient whose thromboembolic risk favors continuing anticoagulation or antiplatelet therapy through surgery, one center describes a bundle after multispecialty assessment and shared decision-making: a penoscrotal approach; a watertight corporotomy closure with the cylinders left about 60% inflated for intracorporal tamponade; high-submuscular rather than retropubic reservoir placement (retropubic placement is avoided in this group); a 10-Fr Jackson-Pratt drain removed on postoperative day 1 if output is under 50 cc over the preceding 8-hour shift; a scrotal Mummy Wrap for 48 to 72 hours; and overnight observation, with caution against routine outpatient surgery in this population. Their practice included continuing clopidogrel or dual antiplatelet therapy, and selected lifelong warfarin or a factor Xa inhibitor, after specialist risk assessment; they report that hematomas in this group delayed activation but did not require drainage or exploration, without a stated denominator.[24]

See Also​

References​

1. Eid JF. Penile implant: review of a "no-touch" technique. Sex Med Rev. 2016;4(3):294–300. doi:10.1016/j.sxmr.2016.01.002

2. Abou Chawareb E, Hammad MAM, Azad B, et al. Perioperative antimicrobial strategies in inflatable penile prosthesis surgery. J Urol. 2025;214(6):642–653. doi:10.1097/JU.0000000000004716

3. Ancha N, Eldin M, Woodle T, et al. Current devices, outcomes, and pain management considerations in penile implant surgery: an updated review. Asian J Androl. 2024;26(4):335–343. doi:10.4103/aja202386

4. Lucas J, Gross M, Yafi F, et al. A multi-institutional assessment of multimodal analgesia in penile implant recipients demonstrates dramatic reduction in pain scores and narcotic usage. J Sex Med. 2020;17(3):518–525. doi:10.1016/j.jsxm.2019.11.267

5. Cotta BH, Welliver C, Brahmamdam A, et al. Long-acting liposomal bupivacaine decreases inpatient narcotic requirements in men undergoing penile prosthesis implantation. Turk J Urol. 2016;42(4):230–234. doi:10.5152/tud.2016.44442

6. Fathollahi A, Razdan S, Razdan S. Zero infection protocol in inflatable penile prosthesis surgery: a prospective cohort study using chlorhexidine-alcohol skin preparation and fibrin sealant hemostasis. Int J Impot Res. 2026;38(4):363–367. doi:10.1038/s41443-025-01174-8

7. Yeung LL, Grewal S, Bullock A, Lai HH, Brandes SB. A comparison of chlorhexidine-alcohol versus povidone-iodine for eliminating skin flora before genitourinary prosthetic surgery: a randomized controlled trial. J Urol. 2013;189(1):136–40. doi:10.1016/j.juro.2012.08.086

8. Dropkin BM, Chisholm LP, Dallmer JD, et al. Penile prosthesis insertion in the era of antibiotic stewardship — are postoperative antibiotics necessary? J Urol. 2020;203(3):611–614. doi:10.1097/JU.0000000000000578

9. Ivan SJ, Abou Chawareb E, Hammad M, et al. 0.05% chlorhexidine gluconate is not associated with infection in antibiotic impregnated inflatable penile prosthesis surgery. J Sex Med. 2026;23(1):qdaf368. doi:10.1093/jsxmed/qdaf368

10. Towe M, Huynh LM, Osman MM, et al. Impact of antimicrobial dipping solutions on postoperative infection rates in patients with diabetes undergoing primary insertion of a Coloplast Titan inflatable penile prosthesis. J Sex Med. 2020;17(10):2077–2083. doi:10.1016/j.jsxm.2020.07.009

11. Im B, Giordano A, Winslow A, et al. Addition of antifungal agents to antibiotic solutions does not diminish the antibacterial properties of penile prosthesis hydrophilic surface dips. J Sex Med. 2026;23(2). doi:10.1093/jsxmed/qdaf372

12. Ivan SJ, Abou Chawareb E, Hammad M, et al. Intraoperative 0.05% chlorhexidine gluconate utilization is associated with an increased incidence of infection in hydrophilic inflatable penile prosthesis surgery. J Urol. 2026;215(4):460–471. doi:10.1097/JU.0000000000004853

13. Raynor MC, Smith A, Vyas SN, et al. Dorsal penile nerve block prior to inflatable penile prosthesis placement: a randomized, placebo-controlled trial. J Sex Med. 2012;9(11):2975–2979. doi:10.1111/j.1743-6109.2012.02756.x

14. Manka MG, Yang D, Andrews J, et al. Intraoperative use of betadine irrigation is associated with a 9-fold increased likelihood of penile prosthesis infection: results from a retrospective case-control study. Sex Med. 2020;8(3):422–427. doi:10.1016/j.esxm.2020.05.010. Bole R, Habashy E, Yang D, et al. J Sex Med. 2023;20(1):107–112. doi:10.1093/jsxmed/qdac001

15. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195–283. doi:10.2146/ajhp120568. Lightner DJ, Wymer K, Sanchez J, Kavoussi L. Best practice statement on urologic procedures and antimicrobial prophylaxis. J Urol. 2020;203(2):351–356. doi:10.1097/JU.0000000000000509

16. Boston Scientific. AMS 700 with MS Pump Penile Prosthesis: Instructions for Use. Manufacturer IFU.

17. Ortaç M, Cetin B, Onuk O, et al. Does a 24-h closed-suction drain reduce infection and hematoma after inflatable penile prosthesis surgery? A comparative study. J Sex Med. 2026;23(6):qdag152. doi:10.1093/jsxmed/qdag152

18. Sadeghi-Nejad H, Ilbeigi P, Wilson SK, et al. Multi-institutional outcome study on the efficacy of closed-suction drainage of the scrotum in three-piece inflatable penile prosthesis surgery. Int J Impot Res. 2005;17(6):535–538. doi:10.1038/sj.ijir.3901354

19. Boston Scientific (American Medical Systems). AMS 700 with MS Pump Penile Prosthesis: Operating Room Manual. 92127382-01C, 2019.

20. Boston Scientific. AMS 700 Inflatable Penile Prosthesis with TENACIO Pump: Instructions for Use. 51558342-01A (US English); AMS 700 with MS Pump IFU (ectopic reservoir edition), 51873615-01A.

21. Köhler TS, Gupta NK, Wilson SK. The Pearls of This Text. In: Köhler TS, Gupta NK, Wilson SK, eds. Wilson's Pearls, Perils and Pitfalls of Penile Prosthesis Surgery. 2nd ed. Calvert McBride Publishers; 2018:9.

22. Henry GD. Surgical techniques: the Henry Mummy Wrap and the Henry Finger Sweep surgical techniques. J Sex Med. 2009;6(3):619-622. doi:10.1111/j.1743-6109.2008.01200.x

23. Weinberg AC, Pagano MJ, Deibert CM, Valenzuela RJ. Sub-Coronal Inflatable Penile Prosthesis Placement With Modified No-Touch Technique: A Step-by-Step Approach With Outcomes. J Sex Med. 2016;13(2):270-276. doi:10.1016/j.jsxm.2015.12.016

24. Hebert KJ, Yang DY, Köhler TS. Perioperative Management of Antithrombotic Therapy in Penile Implant Surgery. In: Miranda EP, Mulhall JP, eds. Penile Implant Surgery: Contemporary Challenges and Controversies. Springer; 2022:49-59.

25. Kopp SL, Vandermeulen E, McBane RD, Perlas A, Leffert L, Horlocker T. "Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition)." Reg Anesth Pain Med. 2025:rapm-2024-105766. doi:10.1136/rapm-2024-105766

26. CareFusion 213, LLC. BD ChloraPrep One-Step 3 mL Sterile Applicator: Drug Facts and Directions. DailyMed; updated November 2025. Product label.

27. Hospira, Inc. Fluconazole in Sodium Chloride Injection, USP: Prescribing Information. DailyMed; revised April 2023. Drug label.

28. Coloplast. Genesis Malleable Penile Prosthesis: Hydrophilic Coating and Product Information. Manufacturer product information.

29. Rigicon. Rigi10 Malleable Penile Prosthesis: HydroShield Coating and Product Information. Manufacturer product information.

30. Schnabl SM, Herrmann N, Wilder D, Breuninger H, Häfner HM. "Clinical results for use of local anesthesia with epinephrine in penile nerve block." J Dtsch Dermatol Ges. 2014;12(4):332–339. doi:10.1111/ddg.12287

31. Palinrungi MA, Palinrungi ALR, Christeven R, Faruk M. "Penile ischemia as a complication of epinephrine use in penile nerve block: Truth or myth?" Res Rep Urol. 2021;13:553–555. doi:10.2147/RRU.S308428

32. Coloplast. Titan Touch Inflatable Penile Prosthesis: Hydrophilic Coating and Product Information. Manufacturer product information.

33. Bole R, Habashy E, Yang D, et al. "Timing and causative organisms associated with modern inflatable penile prosthesis infection: an institutional retrospective." J Sex Med. 2023;20(1):107–112. doi:10.1093/jsxmed/qdac001

34. Moore RH, Anele UA, Krzastek SC, Klausner AP, Roseman JT. "Potential association of weight-based gentamicin with increased acute kidney injury in urologic prosthetic surgery." J Sex Med. 2019;16(1):137–144. doi:10.1016/j.jsxm.2018.10.016

35. Torremadé Barreda J, D'Anna M, Bonet Puntí X, Martínez Salamanca JI, Alcaraz Asensio A, Peri Cusí L. "Postoperative glans color changes following penile prosthesis implantation: not always glans ischemia." J Clin Med. 2026;15(3):1267. doi:10.3390/jcm15031267

36. Park SH, Wilson SK, Wen L. "Subcoronal incision for inflatable penile prosthesis does not risk glans necrosis." J Urol. 2023;210(4):678–687. doi:10.1097/JU.0000000000003619

37. Osmonov D, Ragheb AM, Petry T, et al. "Value of prolonged scrotal drainage after penile prosthesis implantation: a multicenter prospective nonrandomized pilot study." Int J Impot Res. 2025;37(1):87–91. doi:10.1038/s41443-023-00710-8

38. Park M, Lee SH, Sohn JT. "Local anesthetic systemic toxicity induced by penile nerve block: a systematic review." Medicine (Baltimore). 2025;104(37):e44582. doi:10.1097/MD.0000000000044582

39. Hebert KJ, Findlay BL, Yang DY, et al. "Incidence of venous thromboembolism and safety of perioperative subcutaneous heparin during inflatable penile prosthesis surgery." Urology. 2021;157:155–160. doi:10.1016/j.urology.2021.08.002

40. Meitheal Pharmaceuticals. Bupivacaine Hydrochloride Injection: Prescribing Information. Revised March 2026. DailyMed label.