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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 treat these choices as a protocol, not a preference list, and deviate only for explicit reasons.[1][2]

This article covers the intraoperative setup elements that are common across all approaches. 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 approachPostoperative nausea; deeper anticoagulation effects; 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; limited usefulness for subcoronal or complex revisions

The trend in high-volume outpatient prosthetic practices is toward MAC + dorsal penile block + local infiltration, with general anesthesia reserved for complex revisions, concurrent procedures, and patients who cannot tolerate conscious sedation.[3]

Dorsal penile block​

An effective dorsal penile block is the single most consequential analgesic decision in the case. Placed before incision, it reduces intraoperative narcotic requirement, allows lighter sedation, and provides up to 8–12 hours of postoperative analgesia — a significant contribution to the narcotic-free pathway that most modern prosthetic urology practices have adopted.[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. Approximately 5–10 mL of long-acting local anesthetic without epinephrine (bupivacaine 0.25–0.5% or ropivacaine 0.5%) is deposited on each side. Epinephrine is contraindicated in penile blocks due to risk of end-arterial ischemia.

Liposomal bupivacaine (Exparel) provides 72+ hour analgesia and has been adopted in many prosthetic urology ERAS pathways, though cost and volume limitations apply.[5]

Local infiltration​

Regardless of the block chosen, surgeons typically infiltrate the planned incision with 0.25% bupivacaine ± lidocaine for both hemostasis (with the field already dry from epinephrine if used in peri-incisional skin — never in the penis) and supplemental analgesia. Scrotal and pump-pocket infiltration adds another layer.

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 + 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) has replaced povidone-iodine as the skin prep of choice for IPP. Advantages are faster bactericidal onset, longer residual activity, and better tolerance of wet surgical fields. A 2025 prospective cohort using ChloraPrep + fibrin sealant + no drains reported zero infections in 103 primary cases vs. 3.5% in povidone-iodine controls.[6]

Application​

  • Two applications, each with full 3-minute dry time before draping
  • Cover the entire surgical field plus generous margins: entire penis and scrotum, mons pubis, lower abdomen above the umbilicus, medial thighs to mid-thigh
  • Do not pool under the scrotum; elevate and prep all scrotal surfaces individually
  • Hair is clipped in the OR, never razor-shaved, and never at home

Povidone-iodine still has a role in specific revision/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​

The Manka case-control data showed 9–17× higher infection risk when 5% betadine was used for wound irrigation compared with antibiotic-fortified saline.[7] 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​

Developed by J. Francois Eid and producing the lowest published infection rates in the field (0.46% in his reported series), the no-touch technique is now the standard of care in high-volume practice.[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 key 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​

Ioban (3M) is the original. Generic chlorhexidine-impregnated drapes are acceptable. The key feature is a continuous barrier across the entire surgical field — partial draping or a drape with multiple fenestrations defeats the protocol.

Hair management​

If hair is clipped in the OR rather than the preop area (which is preferred), clipping should occur before prep and before draping — otherwise clipped hair contaminates the prepped field. Razor shaving is never appropriate; it creates microabrasions that act as infection reservoirs.

Antibiotic Regimen​

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

  • Vancomycin (15 mg/kg, max 2 g) started 60–120 minutes before incision; a full infusion must be complete before incision to ensure adequate tissue levels
  • Gram-negative agent tailored to local antibiogram:
    • Gentamicin 5 mg/kg (single dose) — classic choice but increasing resistance
    • 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 — single dose, ≥30 minutes before incision
  • Stopped within 24 hours — no postoperative oral antibiotics[2][8]

Redosing of vancomycin or beta-lactams for cases extending beyond the established redose interval is routine.

Device Preparation​

Prior to opening the device​

  • Confirm device selection, size, and accessories match the surgeon's call and the booking sheet
  • Confirm expiration date (antibiotic coatings are not indefinite)
  • 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 dip — the rifampin-minocycline coating is covalent and dipping strips it
  • Inflate the cylinders fully before implantation to confirm integrity and to pre-stretch the material
  • Deflate, cap the cylinders if the manufacturer's caps are present
  • Keep the device in its tray on the field under sterile cover until ready
  • Irrigation of the wound / pocket with antibiotic-fortified saline (vancomycin 1 g/L + gentamicin 80 mg/L) or, where chosen, 0.05% chlorhexidine gluconate (Irrisept) is supported by the 2026 Ivan J Sex Med data for InhibiZone devices[9]

Coloplast Titan (hydrophilic)​

  • Must be dipped in antibiotic solution for at least 30 seconds immediately before placement
  • Most-evidenced dip: vancomycin 1 g/L + gentamicin 80–160 mg/L (Towe 2020 diabetic RCT data)[10]
  • Antifungal addition (fluconazole or amphotericin B) in high-risk patients — does not compromise antibacterial efficacy[11]
  • Avoid 0.05% chlorhexidine gluconate (Irrisept) on hydrophilic surfaces — 2026 Ivan J Urol data show increased infection rate (4.6% vs. 2.1%) and 12% infection rate in revisions[12]
  • Keep the device submerged in its dip bath on the field until the moment of implantation

Malleable devices​

No dip. Irrigation of 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)
  • 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 — for distal cylinder tip placement
  • 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 / Yankauer for manual technique
  • Tubing connectors — appropriate to the device

Do not use suction drains​

Placement of closed-suction drains (Jackson-Pratt, Blake) has been associated with higher infection rates and is omitted in modern protocols. 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
  • Tight scrotal wrap / compressive dressing to minimize scrotal hematoma
  • No drain — established as standard in 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 + acetaminophen; narcotic as PRN rescue only; ambulation postop day 0 if tolerated; discharge same day or POD 1

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/aja202412

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(12):2412–2418. doi:10.1016/j.jsxm.2020.09.007

5. Raynor MC, Smith A, Vyas S, et al. Dorsal penile nerve block prior to inflatable penile prosthesis placement: a randomized, placebo-controlled trial. J Sex Med. 2012;9(11):2975–9. doi:10.1111/j.1743-6109.2012.02850.x

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. 2025. 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