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Revision Scenarios in Penile Prosthesis Surgery

Revision surgery accounts for roughly 10–20% of prosthetic urology volume at high-volume centers and carries a materially different risk profile than primary implantation: higher infection rates (3–13%), higher mechanical complication rates, longer operative times, and steeper outcomes gradient with surgeon volume.[1][2] Prior IPP infection is the single largest patient-level risk factor for subsequent infection (OR ~4.7).[3]

This article covers the anatomic and mechanical scenarios that bring a patient back to the OR: corporal scarring and fibrosis, crural crossover, corporal perforation, residual / curved erection, SST (supersonic transit) 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​

Causes​

  • Prior device explantation for infection — the most severe fibrosis
  • Ischemic priapism >36 hours — progressive fibrosis begins within days
  • Prior penile trauma, prior urethroplasty with corporal exposure
  • Severe Peyronie's with dense plaques spanning the entire corpus
  • Long-term intracavernosal injection therapy

Technical implications​

The scarred corpus resists routine blunt dilation. Cavernotomes — the key specialty instrument for this scenario — are designed to cut through fibrosis while staying in the corporal plane. Several cavernotome families exist:

CavernotomeDesignBest for
MoorevilleBlunt-tipped, sharpened lateral edgesModerate fibrosis; the workhorse cavernotome
GhanemTapered cutting tip with graduated sizesSevere fibrosis; full corporal length
UramixRetractable cutting elementSelective cutting; user-controlled
Carrión-RosselloOpen-tipped with progressive sharpeningVariant of Mooreville concept

Carter-Trost technique​

For the densely fibrotic corpus, the Carter-Trost approach opens the corpus by making a longitudinal ventral corporotomy extending from proximal to distal, then dilating the corpus under direct vision. The corporotomy is closed over the cylinder at the end. This converts a blind dilation problem into an open-dissection problem and is particularly useful after prior infection explantation.[4]

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. Coloplast Tactra, AMS Spectra, or Rigicon Rigi10 are routinely used in this scenario. Switching from an intended inflatable to a malleable mid-case is a judgment call that experienced prosthetic urologists make without hesitation — forcing an inflatable into a corpus too fibrotic for the expansion produces poor outcomes.

Length preservation​

Fibrosis and time from priapism both reduce corporal length. In the priapism patient, the 2019 Yafi consensus recommends early implantation (within 4–6 weeks of the priapism event) to preserve length — with the recognition that infection risk is higher on a recently inflamed corpus.[5] The alternative — delaying for months while fibrosis consolidates — progressively shortens the achievable cylinder length.

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​

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

Recognition​

  • Hematuria — immediate concern for urethral injury; confirms 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

Management​

  • Urethral perforation: abort the implant. The device cannot be placed over an open urethral injury. Repair the urethra primarily, leave a Foley 10–14 days, and delay reimplantation by at least 6 weeks (many prefer 3 months).
  • 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.

See complications for the broader complication framework.

Residual / Curved Erection​

Persistent curvature after a Peyronie's-with-ED implant is a common 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; most curvatures <30° 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 transit" deformity refers to a drooping, floppy glans that sits forward of the inflated cylinders when the device is erect. The distal cylinder tip fails to 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

Management​

  • Upsize the cylinder if revision is planned — longer cylinder + appropriate RTE
  • Redilate the distal corpus to the subcoronal recess
  • Glanular support plication — suturing the glans to the cylinder tips with permanent suture through the tunica albuginea to pull the glans forward and onto the cylinder
  • Tunica albuginea–to–glans suturing — the "glans fixation" technique for persistent SST

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

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​

Rare in primary cases but increases with revision frequency, thin-scrotum patients, and in diabetic/radiated scrotal tissue. Presents as skin tenting, focal erythema, or frank erosion through the scrotal skin.

Management: explantation of the pump and associated tubing, wound care, and delayed reimplantation.

Pump malfunction​

Mechanical failure of the pump mechanism (valve failure, deflation valve sticking). The 3-piece IPP has a long mechanical life, but pump failure rates rise after 10–15 years.

Management: isolated pump replacement (with intraoperative pressure testing of cylinders and reservoir to confirm they are intact), or complete device exchange.

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

The Modified-Mulcahy Salvage Washout​

For infected IPP — when the surgeon judges the infection is not extensive tissue erosion or systemic and the patient is a salvage candidate — immediate washout and replacement is offered as an alternative to explantation + delayed reimplantation. The modified protocol:[7][8]

  1. Explant all components — cylinders, pump, reservoir, tubing.
  2. Culture — capsule, pseudocapsule, fluid — with next-generation sequencing where available.
  3. Sequential antiseptic washes — vancomycin-gentamicin saline; avoid hydrogen peroxide (cytotoxic, air embolism risk) and avoid excessive betadine (cytotoxic, infection-promoting).
  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 antibiotic-coated device — typically the same manufacturer as explanted, or the contralateral manufacturer per surgeon preference.
  7. Add antifungal coverage — routine in salvage settings.
  8. Avoid 0.05% CHG if the new device is hydrophilic Titan.
  9. Close; postoperative antibiotic course per institutional protocol (though emerging data suggest shorter courses).

Salvage success rates in experienced hands: approximately 80–90% at 1 year. Lower in radiated tissue, in patients with severe systemic inflammation, and in those with tissue erosion.

When to explant without replacement​

  • Tissue erosion (cylinder through glans or urethra; pump through scrotum; reservoir through bladder)
  • Sepsis or SIRS physiology
  • Uncontrolled diabetes or acute metabolic derangement
  • Patient instability precluding longer OR time

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

Unique consent elements for revision patients:

  • Baseline higher infection risk — 3–13% in revision vs. 1–3% in primary
  • Shorter penis after revision — cumulative length loss with each operation
  • Higher mechanical complication rate for the revised device
  • Possibility of intraoperative conversion (3-piece → 2-piece → malleable) based on anatomic findings
  • Possibility of abort if corporal or urethral injury occurs

Documentation is especially important here — medicolegal exposure on revision patients is materially higher than on primaries.

See Also​

References​

1. Henry GD, Wilson SK, Delk JR 2nd, et al. Revision washout decreases penile prosthesis infection in revision surgery: a multicenter study. J Urol. 2005;173(1):89–92. doi:10.1097/01.ju.0000146717.62215.6f

2. Cocci A, Capogrosso P, Minhas S, et al. Penile prosthesis implantation: a systematic review of intraoperative and postoperative complications. Int J Impot Res. 2025. doi:10.1038/s41443-025-01108-4

3. 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

4. Carrion H, Martinez D, Parker J, et al. A history of the penile prosthesis. J Sex Med. 2016;13(10):1522–1527. doi:10.1016/j.jsxm.2016.07.002

5. Yafi FA, Hatzichristodoulou G, April Y, et al. Review of management options for patients with atypical priapism. Sex Med Rev. 2015;3(2):103–118. doi:10.1002/smrj.44

6. Ball TP Jr. Surgical repair of penile "SST" deformity. Urology. 1980;15(6):603–4. doi:10.1016/0090-4295(80)90381-x

7. Mulcahy JJ. Long-term experience with salvage of infected penile implants. J Urol. 2000;163(2):481–2. doi:10.1016/s0022-5347(05)67906-2

8. Razdan S, Siegal AR, Celtik KE, Carrion R, Valenzuela RJ. Three-piece penile prosthesis salvage with chlorhexidine gluconate and length preservation: our technique and outcomes. Asian J Androl. 2026;28(1):9–15.