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Revision Scenarios in Penile Prosthesis Surgery

Revision surgery carries a different risk profile from primary implantation. Reoperation was associated with infection rates of 7% to 18% in older series, and revision was associated with higher infection in a 5,261-patient multicenter cohort (overall infection rate 1.9%, p < 0.001).[1][3] Complication rates across implant series vary widely, and mechanical failure remains a concern.[2] Prior IPP infection was an independent risk factor for later infection in the same cohort (OR 4.67).[3]

The scenarios that bring a patient back to the OR are: corporal scarring and fibrosis, crural crossover, corporal perforation, residual or curved erection, SST (supersonic transporter) deformity, pump complications, reservoir complications, and the modified-Mulcahy salvage washout. Infection-specific management is covered in detail in the infection article.

Corporal Scarring / Fibrosis​

Corporal fibrosis is scar that obliterates the intracorporal erectile-tissue planes. Cylinder insertion into a scarred corpus is difficult, and experienced implanters advise having cavernotomes and narrow-base cylinders available.[12]

Causes​

In a 42-patient multicenter series, corporal fibrosis followed prior device explantation for infection in 40.5% (and for erosion in 16.7%) and a history of priapism in 33.3%.[13] In a 49-patient series of narrow cylinders, the indications were prior explantation for infection (67.3%), ischemic priapism (16.3%) and idiopathic fibrosis (16.3%).[14] Other causes are prior shunt surgery, penile trauma or urethroplasty with corporal exposure, severe Peyronie's disease, and long-term injection therapy.

  • Prior device explantation for infection
  • Ischemic priapism >36 hours[47]
  • Prior penile shunt surgery (distal or proximal shunts)
  • Prior penile trauma, prior urethroplasty with corporal exposure
  • Severe Peyronie's with dense plaques spanning the entire corpus
  • Long-term intracavernosal injection therapy

Preoperative optimization — vacuum erection device protocol​

Levine's group (Tsambarlis 2017) described a preoperative VED protocol of 10–15 minutes at least twice daily for at least 3 months (mean 3.5 months) before surgery.[15] In a retrospective series of 13 men with severe fibrosis, all underwent three-piece IPP placement with standard-size cylinders without additional maneuvers, and stretched flaccid length increased a mean of 0.92 cm; one infection and one erosion occurred.[15] The authors recommend preoperative tissue rehabilitation.[15] A shorter, once-daily protocol was tested in a selected penile-prosthesis population: 51 men scheduled for prosthesis placement were randomized to 30 or more days of VED use (10–15 minutes daily; n = 25) or no intervention (n = 26). Mean stretched penile length increased 0.80 ± 0.38 cm within the VED arm (p = 0.020); the authors described a larger change than in controls, although absolute day-of-surgery lengths did not differ significantly between arms (p = 0.244). Blinded operating surgeons reported easier corporal dilation with VED use.[30] After device removal for infection, Wilson and colleagues describe a separate practice of VED without the constriction ring for at least 10 minutes twice daily, with reimplantation at 7 weeks (when they judge stretching to be maximal) and cylinders selected slightly oversized to allow for later tissue expansion; this post-explant protocol is described from experience rather than a comparative series.[31]

Stepwise intraoperative escalation​

Reviews find that no specific algorithm can be prescribed; the technique is escalated by the degree of fibrosis encountered.[16][17]

  1. Sequential Hegar dilation (8–12 mm). This is the first step, and standard dilators alone were used in 35.7% of fibrosis cases in a multicenter series.[13]
  2. Cutting cavernotomes. When standard dilators meet resistance, cavernotomes cut scar after a starter tract is established. The original Mooreville (Uramix) set makes controlled 1 mm cuts with oscillation and rotational shaving.[18][27] Clavijo et al. describe keeping a cavernotome cutting edge lateral, away from the urethra.[19] Carrión-Rossello rasps scar on withdrawal with its smooth surface toward the septum and urethra.[27] In a multicenter fibrosis cohort, 25 of 42 cases (59.5%) had cavernotome dilation and one further case had limited sharp excision plus cavernotomes.[13] The named designs:
CavernotomeDesignTechnique note
Mooreville (Uramix)Original 6–13 mm set; forward oscillating and rotational cuttingThe 1 mm blade stays within the dilator diameter; use sizes sequentially[18][27]
Carrión-RosselloBackward-cutting rasp; 8–12 mmResection on withdrawal; keep the smooth surface toward the septum and urethra[27]

Ghanem et al. described corporal counter incisions using Metzenbaum scissors, Hegar dilators and a Dilamezinsert instrument, a separate technique for severe fibrosis rather than a cavernotome design.[27]

Creating the starter channel. In a corpus with no developable plane, a cavernotome cannot simply be inserted; a channel must first be carved. The Wilson backward-cutting scissors (Freeman-Kaye / Gourney pattern, supplied by Uramix) are the dedicated tool: their outer blade edges are sharpened, so they cut not only on closing but when spread open inside scar, opening the initial space to seat a cavernotome. The cavernotomes then enlarge it: the Rossello-Carrión with a backward-cutting rasp that resects on withdrawal, the Mooreville with a 1 mm blade advanced by rotation.[18][27]

One described stay-suture and dilation sequence places a medial 2-0 polydioxanone stay suture 0.5 cm lateral to the urethra and a lateral stay suture 1 cm further lateral, with a minimum of three pairs per corpus and up to six or seven pairs as fibrosis requires; the corporotomy is made between the stay sutures and extended as needed. The starter channel is carved by inserting closed reverse-cutting scissors just deep to the tunica with a twisting motion, advancing about 1 cm, then opening and withdrawing repeatedly until the tract accepts the smallest cavernotome; Carrión-Rossello cavernotomes are then passed sequentially from 8 mm to 10 or 11 mm[27], with the corporotomy extended and further stay sutures added, rather than forcing the instrument, if it will not pass. Before cylinder placement, each corpus is filled with antibiotic irrigant through the corporotomy to confirm no fluid leaks from the meatus around the urethral catheter, checking for an occult urethral injury.[32]

Corporoscopic excavation. As an alternative to cavernotome dilation when a Hegar dilator cannot pass without force, corporoscopic excavation has been described: a corporotomy set with a 21 Fr sheath and a 0- or 30-degree lens is used to incise the fibrotic tissue laterally, away from the urethra, under vision (optical corporotomy), the tract is dilated to Hegar size 12–13, and a 26 Fr resectoscope loop then resects fibrotic tissue and removes chips before implantation proceeds. In the original series of 6 patients with diffuse corporal fibrosis, no complications were noted through 1 year of follow-up.[33] No comparative outcome data exist.[33]

  1. Corporal counter incisions. Distal or proximal incisions through the tunica albuginea add access and visualization when dilation from the corporotomy alone is insufficient.[16][17]
  2. Corporeal excavation (Montague–Angermeier). For severe diffuse fibrosis, an inverted-T penoscrotal incision exposes nearly the entire corpus bilaterally. Extended ventral corporotomies develop a plane between scar and inner tunica, allowing core removal of nearly all intracorporal scar; cylinders then lie in the empty corporal bed and the tunica is closed primarily, with no graft required. All 9 patients in the original series had successful outcomes, and a later critical appraisal noted the limited reporting of that series.[20]
  3. Corporal reconstruction with grafting. When scar excision leaves a tunical defect that will not close primarily, pericardium, dermis, or synthetic graft reconstructs the corporal body. Sansalone reported simultaneous total corporal reconstruction plus implantation in 18 patients; all received a prosthesis, four underwent further surgery during an average 26-month follow-up (three elective exchanges to an inflatable device and one upsizing), and the authors caution that complication rates exceed those in virgin cases.[21]

Extensive corporotomies with scar resection, with or without grafts, are the traditional approaches to severe fibrosis, and outcomes can be improved by combining scar-incision techniques with cavernotomes and downsized prostheses.[17]

Cylinder selection in the fibrotic corpus​

Narrow-base cylinders are the device option when full dilation cannot be achieved. Standard cylinders require dilation to 12 mm; narrow-base devices (AMS 700 CXR, Coloplast Titan Narrow Base) are designed for narrower corpora (manufacturer specification of about 10 mm). The AMS 700 IFU has CX and LGX cylinders dilated proximally to at least 11 mm and distally to at least 12 mm; the CXR is 9.5 mm deflated and 14.5 mm inflated in 10 to 18 cm lengths, and the IFU names re-implantation as a use.[19][22][29]

  • AMS 700 CXR accounted for 5.0% of IPPs (49 of 982) at one high-volume center. Discordant intraoperative corporal measurements were common (24.5%). Postoperative complications occurred in 16.3% (infection 6.1%, cylinder herniation 4.1%, mechanical failure 4.1%, glans necrosis 2.0%), and 73.5% of patients reported satisfaction with rigidity. Loss of length and girth were the main causes of dissatisfaction.[14]
  • Staged upsizing (Wilson 2006). Downsized cylinders act as tissue expanders: the patient inflates up to 3 h/day and, after 8–12 months, the corporal space has expanded enough to reoperate and replace with standard cylinders. All 37 patients in this retrospective series were upsized; mean corporal length increased 2.2 cm in post-infection patients, and priapism patients gained width but not length.[23]

Single (unilateral) cylinder placement​

Bilateral cylinders are the standard for axial rigidity; unilateral placement is a salvage decision.[24] A single cylinder may be placed when:

  • One corpus is completely obliterated (unilateral shunt, asymmetric infection, trauma) and cannot be dilated despite all techniques; a cylinder is placed on the functional side only.[12]
  • Unilateral urethral injury. Aborting implantation is the safer default after urethral injury.[25] An experienced implanter may rarely consider one contralateral cylinder after adequate repair of a unilateral defect, with tissue and infection risks assessed.[51]
  • Neophallus or phalloplasty anatomy. Some constructions create a single neocorporal channel that accepts only one device (often a malleable or semi-rigid implant).[26]

When to abort and place a malleable​

Fibrosis severe enough that the corpus cannot be safely dilated to accommodate an inflatable cylinder is an indication to place a malleable prosthesis instead. Boston Scientific Tactra, AMS Spectra and Rigicon Rigi10 are used in this scenario. Switching from an intended inflatable to a malleable device mid-case is a judgment call, and forcing an inflatable into a corpus too fibrotic to accept it is avoided.[26]

Length preservation​

Fibrosis after priapism reduces corporal length and makes dilation harder.[47] In a multicenter retrospective cohort of 124 men, the authors reported postoperative noninfectious complications in 40.5% of 47 men implanted more than 6 months after ischemic priapism, versus 0% of 15 implanted within 6 months and 0% of 62 matched controls without priapism.[5] A narrative review of 8 studies likewise found lower complication rates with early placement (3.37% vs 37.23%), while noting that early placement still carries risks of edema, infection and distal perforation and that consensus on timing is lacking.[4][47]

AUA/SMSNA permits considering a prosthesis for untreated acute ischemic priapism >36 hours or failure of shunting, with or without tunneling .[47] Its discussion describes early placement as within 2 weeks. Discuss the risks and benefits of early versus delayed placement .[47] The 2026 EAU guideline recommends delaying implantation after a shunt to reduce infection and erosion while oedema resolves and the wound heals .[52]

Technique selection at a glance​

TechniqueWhen to useKey detail
Preoperative VEDSelected planned severe-fibrosis casesA 13-man retrospective series used 10–15 min twice daily for at least 3 months; all received standard cylinders, without a comparison group.[15]
Sequential Hegar dilationFirst-line intraoperativeStandard dilators 8–12 mm[13]
Cutting cavernotomesDilators meet resistanceAim cutting edge laterally; 6–13 mm
Counter incisionsInadequate access from corporotomyDistal/proximal tunical incisions
Corporeal excavationSevere diffuse fibrosisInverted-T incision; core out scar; no graft
Reconstruction + graftingTunical defect after excisionPericardium, dermis, or synthetic graft
Narrow-base cylindersCannot dilate to 12 mmAMS 700 CXR requires 9 mm; Titan NB requires 10 mm[27]
Staged upsizingAfter downsized placementInflate 3 h/day × 8–12 mo, then reoperate
Malleable conversionCorpus too fibrotic for inflatableMid-case judgment call
Unilateral cylinderOne native corpus unsalvageable / unrepairable injurySalvage option in native corpora; assess stability and corporal integrity case by case

Crural Crossover​

Definition​

During corporal dilation, the dilator perforates the medial septum between the two corpora cavernosa and crosses into the contralateral corpus. A cylinder placed down this false tract sits in the wrong corpus and produces curvature, asymmetric inflation, and potential urethral injury.

Recognition​

  • The dilator feels "soft" and encounters less resistance than expected
  • Bilateral corporal measurements diverge despite apparently identical dilation
  • On test inflation, the penis deviates to one side or appears bowed
  • The cylinder tip position differs side to side on palpation

Management​

  • Recognize before cylinder placement. Always confirm the dilator track by palpating the corpus from outside during dilation
  • If crossover is identified, redirect the dilator laterally and reestablish the correct track; many surgeons use a narrower dilator to find the true plane before re-dilating
  • If a cylinder has already been placed down the wrong track and crossover is suspected postop, reoperation is required
  • The Mulcahy windsock technique, placement of a synthetic graft (Dacron sleeve or GoreTex windsock) around the proximal cylinder to prevent proximal migration, is used when crural perforation has occurred or is anticipated in a friable corpus

Corporal Perforation​

A national UK audit of 1,071 penile-prosthesis procedures across 22 centers recorded urethral injury in 7 cases (0.7%), corporal perforation in 12 (1.1%) and crossover in 6 (0.6%).[34] A separate Italian registry of 367 procedures (310 first implants, 43 prosthesis substitutions and 14 explants without substitution) recorded two intraoperative complications overall.[35]

Where it happens​

  • Distal perforation. Through the glans or subcoronal tunica into the subcutaneous tissue
  • Proximal perforation. Through the crural tunica into the perineum or ischioanal fossa
  • Urethral perforation. Through the medial tunica into the urethra; the most consequential perforation

Prevention of proximal perforation. Some authors advise avoiding narrow-calibre dilators (under 9 mm) in the proximal corpora to reduce crural perforation.[38] This is expert opinion without comparative data; a separate fibrosis series used standard 8–12 mm dilators, while the perforation-prevention chapter advises dilating the crura without force and stopping when a dilator meets abnormal resistance or passes without the expected resistance at the ischiopubic ramus.[13][38]

Recognition​

  • Hematuria. Immediate concern for urethral injury; confirmed with retrograde urethrogram or direct cystoscopy
  • Dilator or Keith needle entering a non-corporal space. Recognized by the feel of the tip
  • Bleeding out of proportion to the expected corporotomy bleeding
  • The field-goal (goal-post) sign for proximal perforation. Dilators placed simultaneously into both proximal corpora should reach equivalent depth; a significant discrepancy suggests a proximal perforation on the shallower side.[36]

Management​

  • Urethral perforation. Stop dilation and assess the injury location. After distal urethral injury, aborting implantation and deferring reimplantation for 2–3 months is a described pathway; Wilson’s group describes no repair and no Foley drainage beyond 3 days when the offending cylinder is removed, while a separate synchronous-repair practice maintains a Foley for 14 days. Selected injuries may instead undergo synchronous repair and device placement with suprapubic diversion in experienced hands, as detailed below.[36][39][40]
  • Tunica perforation (distal or proximal): if a synthetic-sleeve (Mulcahy windsock) can contain the cylinder within the intended plane, the case can often be completed. If not, abort and return.
  • Distal perforation into the glans. A known but rare complication; sometimes salvageable with careful distal cylinder tip repositioning and suture repair of the glans tunic; glans necrosis is a feared downstream complication.

Stabilizing the cylinder after proximal/crural perforation — the rear-tip-extender (RTE) sling. As an alternative to a windsock graft (graft material placed against an existing implant has been associated with increased infection risk), Wilson described a nonabsorbable-suture sling that holds the cylinder base out of the perforation while it scars over instead of formally closing the defect: the cylinder and RTE are sized to match the uninjured side, a nonabsorbable suture (2-0 Prolene in the original description) is passed from outside the corpus through the corporotomy, through the base of the RTE, and back through the corporotomy and corporal wall on the other side; the cylinder is then implanted and fully inflated, the guide strings are held under traction, and the sling is tied to lock the cylinder in position.[37] Textbook accounts of the same technique describe variants using 0 Prolene and a 2-0 polypropylene sling combined with the field-goal test described above, and advise avoiding intercourse for at least 12 weeks after the repair to allow the perforation to scar over; these are described operative variants without comparative outcome data.[38][36]

Urethral injury — location-dependent management. Aborting the implant, as above, remains the default when a urethral injury is recognized. Textbook accounts distinguish two mechanisms and describe a more selective approach in some centers. Injury during the initial penoscrotal dissection, evident from a visible Foley catheter in the field, is repairable with a watertight two-layer closure; some experienced implanters proceed with implantation in the same setting after a confirmed watertight repair, leaving a Foley for 3–7 days. Injury at the fossa navicularis during distal dilation is managed by abandoning further distal dilation on that side; if the cylinder is removed or the case aborted on that side, urethral repair is not required, prolonged drainage is avoided (a catheter beyond 3 days is discouraged because it can promote meatal stricture), and reimplantation is deferred 2–3 months.[39][36] A retrospective single-institution review of 1,508 mixed prosthetic cases (AUS, IPP, and sling) identified 7 patients (0.46%) who underwent synchronous urethral repair, including 4 after an intraoperative injury; 6 of 7 repairs were closed primarily and 6 of 7 patients received suprapubic-tube diversion for a mean 4.1 weeks.[40] At a mean 21.5-month follow-up all patients were continent with no device infections or urethral complications.[40]

See complications for the broader complication framework.

Residual / Curved Erection​

Persistent curvature after implantation in Peyronie's disease with ED is a revision scenario. Causes include:

  • Residual tunical plaque. Not addressed or incompletely addressed at implant
  • Asymmetric cylinder length
  • Asymmetric RTE selection mimicking length difference
  • Pump or reservoir positioning causing traction on one side

Management​

  • Intraoperative modeling. Gentle manual bending of the fully inflated cylinders against the concavity to mechanically stretch the tunical plaque; curvatures <30° usually respond
  • Plication. Addition of tunical-albuginea plication sutures on the convex side to correct residual curvature
  • Tunical incision and grafting. For severe residual curvature, formal tunica albuginea incision with graft (dermis, bovine pericardium, SIS, or synthetic) is indicated; this can be done at the primary implant (via subcoronal approach) or at revision

The subcoronal approach at revision​

When the original case was penoscrotal or infrapubic and severe residual curvature requires formal grafting, converting to subcoronal at revision provides the exposure needed. This is a more demanding operation than either primary and benefits from co-surgery with an experienced subcoronal implanter.

SST (Supersonic Transit) Deformity​

Definition​

SST or supersonic transporter deformity refers to a glans that droops or folds over the end of the inflated cylinders. The distal cylinder tip does not extend into the glans, and the glans hangs passively off the end of the shaft.[6]

Mechanism​

  • Cylinder too short for the distal corpus (the most common cause)
  • Underdilation of the distal corpus (the cylinder sits shy of the subcoronal recess)
  • Chronic distal corporal fibrosis preventing full expansion
  • Glans atrophy from prior surgery, aging, or hypogonadism

Distinguishing a short cylinder from true glans hypermobility​

Because undersized cylinders are the dominant cause, one described bedside maneuver helps sort the two before committing to revision: the shaft skin is shifted toward the penoscrotal junction; if the apparent SST deformity disappears, the cylinders are considered too short, while persistence of the droop suggests true glans hypermobility. In a described practice of observing through healing rather than performing immediate glans fixation, capsule formation around a correctly positioned cylinder tip often resolved early glans mobility on its own; one experienced implanter reports correcting only 6 true SST cases in more than 40 years and over 11,000 implant procedures, estimating that most presentations called SST were instead undersized cylinders.[41]

Management​

  • Upsize the cylinder if revision is planned, with a longer cylinder and appropriate RTE. Because of biofilm and infection risk with any revision, sterile new components are generally preferred over reusing components already in place, combined with a washout of the field.[41]
  • Redilate the distal corpus to the subcoronal recess
  • Glanular support plication. Suturing the glans to tissue overlying the distal corpora with permanent suture through the tunica albuginea pulls the glans forward over the cylinder.[48]
  • Tunica albuginea–to–glans suturing. The "glans fixation" technique for persistent SST. In a modified glanulopexy, a permanent suture is passed into the glans and secured to the tissue overlying the corpora through small incisions on the lateral aspects of the distal shaft, which can be done under local anesthesia. In a single-surgeon series of 12 men (2014–2017; 9 at the time of implantation and 3 delayed), all with the device still in place had appropriate glans position at a median of 12 months (range 1–33), none reported changed penile sensation, and 1 device was removed for infection; there was no comparison group.[48]

Prevention​

  • Adequate distal dilation at primary implant
  • Appropriate cylinder length (always re-measure before final selection)
  • Recognition that SST is more common in older patients, diabetic patients, and those with prior distal corporal surgery

Suspensory Ligament Laxity​

An infrequent cause of poor axial rigidity despite an appropriately sized and filled cylinder is laxity of the suspensory ligament, which normally anchors the crura to the symphysis pubis and ischiopubic rami and resists proximal migration of the penis during intercourse.[42] On examination, a palpable gap is felt between the crura and the pubic bone, and the penis can be moved side to side with the implant inflated.[43][44] Series of suspensory-ligament repair for the full range of causes (sexual trauma, congenital absence or laxity, Peyronie's disease, venogenic erectile dysfunction) report good surgical outcomes — correction of instability or curvature and a return to normal sexual function — in 85–91% of patients.[43][44] Repair has been described with two or three nonabsorbable interrupted sutures securing the tunica albuginea to the periosteum of the symphysis pubis and ischiopubic rami bilaterally.[42]

Pump Complications​

Malposition (high-riding pump, low-riding pump)​

High-riding pump. Pump retracts into the superficial inguinal region where the patient cannot reach it for cycling. Causes: inadequate scrotal pocket; scrotal retraction with age; tethering of pump tubing to overlying dartos.

Low-riding pump. Pump sits low against the testis, uncomfortable and occasionally visible. Causes: overly dependent pocket; loss of scrotal tone.

Management: revision with pump repositioning. Re-tunneling of the dartos pocket; consideration of tacking sutures to hold the pump in position (controversial; some surgeons argue tacking increases infection risk).

Pump erosion​

Erosion is uncommon in primary cases and is more likely with repeated revision, a thin scrotum, and diabetic or radiated scrotal tissue. Presents as skin tenting, focal erythema, or frank erosion through the scrotal skin.

Management: assess for infection and tissue compromise. For an infected or exposed system, remove all device components, wash out the field, and provide wound care; selected stable patients may undergo immediate replacement with a new device, while patients unsuitable for salvage need delayed reimplantation.[49]

Pump malfunction​

Mechanical failure of the pump mechanism (valve failure, deflation valve sticking). Mechanical failure becomes more frequent with device age; in a series of 2,384 first-time implants, mechanical-breakage-free survival was 79.4% at 10 years and 71.2% at 15 years.[28]

Management: isolated pump replacement (with intraoperative pressure testing of cylinders and reservoir to confirm they are intact), or complete device exchange.[53] In a systematic review of noninfected IPP revisions, infection was reported after 6.3% of partial exchanges versus 2.7% of complete exchanges.[53] A component that will be left in place can be checked by hydraulic distension with observation for fluid loss or, described as more accurate, with an ohmmeter: a 15-gauge blunt metal needle is inserted into the component's tubing, the part is filled with saline, and one ohmmeter lead contacts the needle while the other contacts a retractor elsewhere in the wound; a leak lets the saline's ions complete the circuit. This is a described troubleshooting method without reported sensitivity or specificity.[45]

Reservoir Complications​

Covered in detail in reservoir placement. Revision-specific scenarios:

  • Reservoir herniation into the scrotum. Revision with relocation to HSM
  • Reservoir autoinflation. Revision with pocket enlargement or relocation; modern lock-out valves have reduced this incidence
  • Reservoir bladder erosion. Reservoir explantation, cystorrhaphy, delayed reimplantation
  • Retained reservoir after prior infection explantation. Imaging (CT or MRI) to localize; open retrieval at time of reimplantation if accessible

Drain and Retain​

When a functioning revision requires a new reservoir but the old one has become densely adherent in the space of Retzius, formal explantation can be more morbid than the revision itself. The drain and retain maneuver sidesteps this: the existing reservoir is emptied and intentionally left in situ rather than dissected free, and a new reservoir is placed, typically on the contralateral side.[9][10] The current AMS 700 IFU describes the same option for non-infected revisions: drain, insert a tubing plug and leave the reservoir in place, or place a replacement pump or reservoir on the contralateral side, and document the choice in the record. It also asks the surgeon to account for every previously implanted component, including the number of rear tip extenders, particularly in infection, and notes that mechanical lavage of the implant site may mitigate later infection. The stainless-steel tubing plug contains nickel, which matters in nickel sensitivity.[29] The same principle applies to the AUS pressure-regulating balloon (see artificial urinary sphincter — PRB modification).

Technique: aspirate all fluid from the reservoir to defunctionalize it, place the tubing on traction, and transect the tubing proximally to disconnect it from the rest of the system. The collapsed reservoir is left behind as an inert foreign body; a new reservoir is sited fresh (HSM or contralateral space of Retzius).[9]

Rationale: an encapsulated reservoir in the space of Retzius can be densely adherent to the bladder, iliac vessels, obturator nerve, or bowel. Dissecting it out risks exactly those injuries; draining-and-retaining avoids the retropubic dissection while still allowing a functional new reservoir.[9][10]

Safety data:

  • Cefalu et al. (2013). Original single-surgeon series of 55 drain-and-retain cases over 5 years. In this mixed AUS/IPP series, infection occurred in 1 of 55 drain-and-retain cases (1.8%) versus 6 of 390 primary AUS/IPP procedures (1.5%; p = 0.88), with no complications attributed to the retained balloon/reservoir in the report.[9]
  • Pereira et al. (2026). Largest multi-institutional review to date: 233 revision cases across 7 high-volume centers (112 drain-and-retain versus 121 complete removal). At a mean 12.6-month follow-up there were no complications attributed to retained reservoirs and no significant differences in postoperative infection (p = 0.940), device malfunction (p = 0.674), or symptomatic migration of the new reservoir (p = 0.955).[10]

Caveats:

  • Avoid drain and retain when explanting a device for infection. Both cited safety series excluded infection explants, and infected-device salvage descriptions call for removal of the infected components. A retained reservoir could serve as a nidus for persistent or recurrent infection.[9][10][49]
  • Long-term outcomes are unknown. The largest series has a mean follow-up of only about 12.6 months, and the practice remains debated given the risk of retained foreign material.[10] Loloi et al. (2022) reported two cases of drained-and-retained reservoirs (one IPP, one AUS, the latter the first such AUS report) presenting later as small bowel obstruction, the migrated balloon acting as a lead point; the risk is greatest with intraperitoneal reservoir position. Confirm the retained reservoir is extraperitoneal, and counsel the patient that a retained reservoir can become symptomatic years later.[11]

The Modified-Mulcahy Salvage Washout​

For an infected IPP without extensive tissue erosion or systemic infection, immediate washout and replacement can be offered as an alternative to explantation and delayed reimplantation. Mulcahy's original salvage protocol used removal of all foreign material, irrigation with a series of antiseptic solutions and placement of a new prosthesis.[7] A modified washout, also used at noninfectious revision, is described below; Razdan and colleagues described a separate four-patient infected-IPP salvage technique using 0.05% chlorhexidine, new corporal channels and malleable replacement, with median 4.8-month follow-up.[1][8] Salvage is rarely an emergency; one described practice, in a patient without systemic toxicity, is admission with at least 48 hours of intravenous antibiotics before deciding between salvage and complete explantation, salvaging if the patient improves (with a described preference for malleable substitution) and proceeding to complete removal if the patient worsens.[46]

  1. Explant all components. Cylinders, pump, reservoir, tubing.
  2. Culture of capsule, pseudocapsule, and fluid, with next-generation sequencing where available.
  3. Sequential antiseptic washes. Vancomycin-gentamicin saline is used in many protocols; some surgeons avoid hydrogen peroxide (cytotoxic, air embolism risk) and excessive povidone-iodine (cytotoxic).
  4. Change all gloves and instruments after explantation and wash steps.
  5. Re-prep and re-drape the field with fresh Ioban.
  6. Place a new prosthesis. An antibiotic-coated inflatable or malleable replacement may be used according to the clinical circumstances.[49]
  7. Add antifungal coverage. Many protocols add it in salvage settings.
  8. Check the IFU before using 0.05% chlorhexidine irrigation if the replacement has a hydrophilic coating (for example, Coloplast Titan).[54] A bench study found no apparent coating damage[50], but a retrospective 14-center cohort of 2,150 hydrophilic IPPs associated 0.05% chlorhexidine irrigant or dip with more infection-related explants than antimicrobial solutions (4.6% vs 2.1%; adjusted OR 2.07).[54] The clinical result includes primary and revision surgery.[50][54]
  9. Close; postoperative antibiotic course per institutional protocol (though emerging data suggest shorter courses).

In Mulcahy's series, 45 of 55 patients with known status (82%) had no sign of infection at 6 to 93 months, 5 had recurrent infection and 5 had erosion.[7] In a separate study of revisions for noninfectious reasons, postoperative infection followed 2.9% (4 of 140) of washed-out revisions versus 11.6% (5 of 43) without washout over 6 to 33 months of follow-up.[1] Success is expected to be lower with tissue erosion, radiated tissue or severe systemic inflammation.

When to explant without replacement​

  • Extensive necrosis or erosion, including urethral or bladder involvement, that precludes safe immediate replacement
  • Sepsis or systemic illness that makes a longer operation unsafe
  • Acute metabolic derangement requiring correction before reimplantation
  • Patient instability precluding longer OR time

Diabetes or localized erosion alone does not automatically exclude immediate salvage in a stable, carefully selected patient; recent series include such patients, often with a malleable replacement.[49]

In these scenarios: explant, delayed reimplantation at 3–6 months after infection clearance.

Unique consent elements for revision patients:

  • Higher infection risk. Older reports cited infection rates of 7% to 18% after revision; a retrospective multicenter cohort of primary and revision IPP operations reported infection in 102 of 5,261 patients (1.9%) overall, with a higher rate in the revision subgroup (P < .001).[1][3]
  • Shorter penis after revision. Cumulative length loss with each operation
  • Higher mechanical complication rate for the revised device
  • Possibility of intraoperative conversion (3-piece to 2-piece to malleable) based on anatomic findings
  • Possibility of abort if corporal or urethral injury occurs

Documentation is especially important in revision patients.

See Also​

Videos​

Penile Implant in Corporal Fibrosis
Operative video (2019)
Unilateral Corporal Reconstruction With a Single Implant Cylinder
Omer Raheem, operative video (2022)
SST Correction by Proximal Extracapsular Tunnelling
Karpman E, et al. Urology Video Journal 2023 (CC BY-NC-ND 4.0)
Open source videoRead the article

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