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Surgical Approaches to Penile Prosthesis Implantation

Penoscrotal (PS), infrapubic (IP) and subcoronal (SC) incisions are the three approaches used for inflatable penile prosthesis (IPP) placement in the published comparative literature, and some surgeons use a transverse scrotal (TS) variant. In a critical review, the available data did not show a difference between PS and IP in implant size, penile length, patient satisfaction, infection rate or urethral injury. The risk of dorsal nerve injury, although low, appeared greater with IP, and IP was associated with shorter operative time and earlier use of the device.[1] The 2020 critical review found limited comparative data for SC.[1] In a retrospective single-surgeon series of 898 SC implants with median follow-up of 41 months, transient incisional paresthesia was reported in 20.6%, distal penile skin necrosis in five patients, and no glans ischemia or necrosis was observed.[17]

Intraoperative setup (prep, drape, no-touch, antibiotics) is in intraoperative setup. Reservoir placement specifics (including ectopic or submuscular technique) are in reservoir placement.

Approach Comparison​

AxisPenoscrotal (PS)Infrapubic (IP)Subcoronal (SC)Transverse Scrotal (TS)
IncisionHorizontal, penoscrotal junctionHorizontal, suprapubicCircumferential behind coronaHorizontal upper scrotum
Reservoir placementBlind through external inguinal ringDirect visualization into space of RetziusBlind or via separate inguinal incisionBlind through external inguinal ring
Pump pocketDirect, excellent exposureSeparate scrotal counter-incision required (or delivered through tunnel)Through scrotal tunnelDirect
Dorsal nerve riskLowLow in reports; may exceed PS[1]Comparative risk uncertainNot separately quantified
Visualization of corporaExcellent proximal, limited distalExcellent proximal, limitedComplete (distal and proximal)Excellent proximal
Activation timingCommonly 4–6 weeksEarlier than PS in comparative data (as early as 14 days in one high-volume infrapubic practice)Limited data; possibly similar to IPCommonly 4–6 weeks
Operative timeReferenceShorter than PSLonger than PS (mean 73 min in one 200-patient series[4])Similar to PS
Best forMost primary casesExperienced surgeons; direct reservoir; fastComplex reconstruction (Peyronie's, fibrosis, concurrent glans work)Alternative to PS; selected anatomies
Selection considerationsVery long scrotum with pendulous dartosThin abdominal wall with scar; prior pelvic surgery (for SoR)Selected uncircumcised men underwent SC implantation without concurrent circumcision; a single-surgeon abstract reported transient distal skin edema in 96.2% of those declining it. For patients prioritizing glans sensation, the cited cohort did not compare sensory outcomes across incision approaches.[17][23]Morbid obesity with deep scrotum

Penoscrotal Approach (PS)​

PS is the most frequently used incision and the usual reference against which other approaches are compared.[1]

Incision​

  • Horizontal transverse incision at the penoscrotal junction
  • 3–4 cm length, extended as needed
  • Carried through dartos to expose the corpora
  • A Lone Star retractor ring with elastic stays is commonly used for exposure

Step-by-step​

  1. Prep, drape, Ioban barrier per no-touch protocol (see intraoperative setup).
  2. Foley placed after drape, 14–16 Fr, to identify urethra throughout the case.
  3. Horizontal penoscrotal incision, Lone Star retractor placed.
  4. Dartos divided to expose bilateral corpora cavernosa. Buck's fascia identified but not violated laterally.
  5. Stay sutures (2-0 Vicryl or PDS) placed at planned corporotomy sites bilaterally, proximal and distal to the corporotomy line, for traction and easier closure.
  6. Longitudinal corporotomies (1.5–2 cm) made on the ventrolateral aspect of each corpus, avoiding the midline (urethra) and dorsal neurovascular bundle. Cautery or scalpel; bleeding controlled with the stay sutures on tension.
  7. Corporal dilation sequentially:
    • Start with 8 mm Brooks or Pratt dilator distally and proximally
    • Progress only to the diameter needed for the selected cylinder; follow the device-specific targets below.[6]
    • Dilate proximally to the crus (pubic arch) and distally to the glans (stop at the subcoronal recess; do not perforate the glans)
    • Measure total corporal length (proximal and distal) with the Coloplast or Boston Scientific measuring device
    • For AMS 700 cylinders the instructions dilate the proximal corpus to at least 11 mm (more if the tubing will lie inside it) and the distal corpus to at least 12 mm, and measure both directions from a stay suture; for LGX cylinders some surgeons instead measure from the ends of a 2 cm corporotomy. Tactra is dilated about 1 mm beyond its diameter through a corporotomy of about 3 cm or more[6]
    • A paired-dilator visual check ("goalpost view") after dilation, comparing the position of dilators placed simultaneously in both corpora at the proximal and distal ends, has been described to help identify posterior crural perforation, crossover or under-dilation before cylinders are placed; it is a described verification technique, not a validated test with reported accuracy[7]
    • Before cylinder insertion, irrigate the distal corpora and check for leakage at the meatus that suggests urethral injury; assess suspected perforation before proceeding.[21]
  8. Sizing. Select cylinder length and rear-tip extenders (RTEs) to fully fill the corporal space. Undersizing can cause supersonic transporter (SST) deformity;[18] oversizing causes glans pain.
  9. Cylinder placement. Furlow tool with Keith needle. The Keith needle exits through the glans; seat the distal cylinder tip beneath the glans and the proximal end against the crus.[6] Confirm with inflation-deflation trial. Both distal guide strings are passed through the corpora and glans before either cylinder is inserted; placing one cylinder first risks the contralateral Keith needle puncturing it.[9] If a Furlow insertion tool is unavailable, distal counter-incisions and counter-corporotomies just proximal to the glans, with the guide strings delivered through them with a long tonsil clamp and the Keith needles passed by hand under direct vision, have been described as a fallback, with stay sutures placed around the counter-corporotomies before the cylinders are inserted to reduce the risk of needle puncture.[10]
  10. Corporotomy closure. Running 2-0 Vicryl or PDS over the stay sutures, taking care not to puncture the cylinder. A corporal bite with the Vicryl is not a cylinder hole if the needle passes superficial; confirm integrity with a partial inflation after each closure. A horizontal mattress closure, tying the upper and lower strands of each paired stay suture together instead of a running suture line, has also been described as a closure option.[8]
  11. Pump pocket. Dependent scrotal position created between the dartos layers, using blunt finger dissection or Babcock or Allis clamp spreading.
  12. Reservoir placement. Through the external inguinal ring or via ectopic approach (see reservoir placement).
  13. Tubing connections and cycling test. Inflate and deflate fully 2–3 times to confirm function before closure.
  14. Closure. Dartos with 3-0 Vicryl; skin with 4-0 Monocryl subcuticular. Device left partially inflated; compressive scrotal dressing.

Pearls​

  • The horizontal penoscrotal incision, properly placed, cosmetically disappears into the natural penoscrotal crease within 6 months.
  • The Lone Star ring improves exposure and removes the need for an assistant to hold retractors.
  • Stay sutures before corporotomy. The untraumatized tunica is much easier to grasp before bleeding begins.

Limitations​

  • Reservoir placement is blind through the external inguinal ring. This is why ectopic placement is used with PS in high-risk abdomens.
  • Distal corporal visualization is limited; severe Peyronie's curvature or complex fibrosis is harder to address than with a subcoronal.

Proximal exposure and minimal- or no-dilation alternatives​

For an inflatable implant, dividing the central tendon has been described to gain additional proximal exposure beyond routine dartos dissection.[7]

For difficult distal dilation through scarred or narrow corpora, using Hegar dilators rather than the more pointed Brooks dilators, keeping the trajectory lateral and away from the urethra, and compressing the fossa navicularis between the nondominant index finger and thumb have been described to reduce the risk of urethral injury. If the dilator still will not advance, a circumcoronal incision to deglove the penis with a second corporotomy made over the point of resistance, for controlled dilation under more direct access, has been described as a bailout.[11]

Graduated serial dilation is the standard step above, but a randomized trial in 100 men receiving AMS 700CX implants compared no corporal dilation (Furlow tool only, for both measurement and cylinder insertion) with standard serial dilation. The no-dilation group had significantly less postoperative pain and significantly higher IIEF scores at follow-up (12 versus 7) than the dilated group; postoperative complication rates were similar between groups, and the authors concluded dilation is not necessary for primary implantation.[12] A comparable minimal-dilation principle has randomized-trial support for malleable implants: 92 men were randomized to conventional dilation or an 8 Fr cavernous-tissue-sparing technique before malleable prosthesis placement; at 1 month, the sparing group had significantly greater residual cavernous tissue thickness on duplex ultrasound (5.2 ± 0.8 mm versus 2.2 ± 1.04 mm), more patient-reported spontaneous or arousal-induced penile tumescence (89% versus 15%), and greater penile girth (11.2 versus 10.1 cm, all p < .01–.001).[13] These are described alternatives to the standard graduated sequence above rather than a replacement for it; case selection and single-surgeon or single-center experience limit generalization.

Infrapubic Approach (IP)​

IP is used by a smaller group of implanters, and technique has been described by Perito and colleagues.[2][3] Its central feature is direct visualization of the space of Retzius for reservoir placement. Perito's practice omits the indwelling Foley and postoperative inflation and uses hydrodistension of the corpora in place of dilation, so details differ from the steps below.[2] In this technique, a butterfly needle and 60 mL of saline are used for combined artificial erection and corporal hydrodilatation: the first 30 mL, with manual pressure at the penile base, assesses for curvature such as Peyronie's disease, and the remaining 30 mL distends the corpora, allowing serial dilation to be omitted when the penis has no pathology.[14][19]

Incision​

  • Horizontal transverse incision 3–5 cm immediately above the pubic bone, at the penopubic angle
  • Carried through subcutaneous fat to the suprapubic fascia / linea alba
  • Puboscrotal ligament identified and preserved where possible

Step-by-step​

  1. Prep, drape, no-touch protocol.
  2. Horizontal infrapubic incision; dissect through fat to the pubic symphysis.
  3. Identify and protect the dorsal neurovascular bundle, which runs dorsally deep to Buck's fascia. The dorsal nerves are at risk in this approach; blunt dissection and lateral retraction of the bundle are used to protect it.
  4. Expose the proximal corpora by ventrolateral dissection, keeping the dorsal bundle cranial or lateral.
  5. Stay sutures placed; corporotomies made on the dorsolateral aspect.
  6. Dilation and sizing: same as PS. Distal dilation feels "further" because the working incision is more proximal.
  7. Reservoir placement. Enter the transversalis fascia under vision and develop the space of Retzius bluntly when anatomy permits; direct access is a principal advantage of IP. Fill the selected reservoir according to its model-specific instructions (AMS 700 spherical 65 or 100 mL; Conceal up to 100 mL), then confirm device cycling.[1][6]
  8. Pump placement. Via a subdartos tunnel created from the incision, or via a separate scrotal counter-incision. The pump is passed distally through the tunnel into the dependent scrotum.
  9. Cycling test; closure in layers.

Advantages​

  • Direct access to the space of Retzius. Allows controlled placement when the retropubic plane is suitable. Prior pelvic surgery may favor an ectopic reservoir instead.[16]
  • No scrotal incision in many protocols. Cosmetic advantage
  • Earlier activation. Some infrapubic surgeons activate at 2–3 weeks postoperatively (versus 4–6 for PS)
  • Shorter operative time than PS in a critical review[1]

Disadvantages and caveats​

  • Dorsal nerve injury is the main risk. Its rate is low but appeared greater than with PS in a critical review[1]
  • Concealed pump. The tunnel must be well developed to avoid a high-riding pump that is hard to cycle
  • Combination with subcoronal glans work is difficult

Pearls​

  • The dorsal neurovascular bundle runs between Buck's fascia and the tunica albuginea; stay external to Buck's for retraction, and don't dissect through it
  • The corporotomy is slightly more dorsal than in PS; respect the neurovascular bundle with every stitch
  • With difficult pubic anatomy, convert to PS instead of forcing the IP approach

Subcoronal Approach (SC)​

The SC approach exposes the entire corpora for complex reconstructive cases. Weinberg and colleagues described it with a modified no-touch technique in a prospective series of 200 men, of whom 92 had Peyronie's plaque treated through the same incision and 53% consented to circumcision.[4] It is generally considered the most demanding approach.

Indications​

  • Severe Peyronie's disease requiring tunica albuginea plication or grafting at time of implant
  • Severe corporal fibrosis from prior priapism, infection, or revision requiring aggressive cavernotomy
  • Concurrent glans or shaft cosmetic work
  • Neophallus after phalloplasty. This requires a separate operative pathway rather than the native-corporal SC steps below. Published techniques use infrapubic or parascrotal incisions and usually proximal pubic anchoring, with protection of the urethra and flap vascular pedicle.[20]
  • Shortened penis with distal fibrosis where modeling alone is inadequate

Incision​

  • Circumferential subcoronal incision (as in circumcision), with the shaft degloved to the penoscrotal junction
  • Circumcision is usually performed with the approach in uncircumcised men; the everted dartos is used to exclude scrotal and penile skin from the field[4]
  • Buck's fascia and the dorsal neurovascular bundle are identified and preserved throughout the degloving

Step-by-step​

  1. Prep, drape, no-touch protocol.
  2. Subcoronal circumferential incision; degloving of the penis down to the penoscrotal junction with careful preservation of the dorsal neurovascular bundle.
  3. Entire corporal surface exposed. Proximal, distal, dorsal, ventral. Any fibrosis, plaque, or deformity is directly visible.
  4. Perform an artificial erection to assess the plaque and deformity; defer straightening maneuvers until after cylinder placement.[4]
  5. Corporotomies made on the most suitable surface (often ventrolateral, adjusted for Peyronie's anatomy).
  6. Dilate, size and place the cylinders as in PS; after placement and inflation, correct residual deformity by modeling, plication, tunical incision or grafting as indicated.[4]
  7. Reservoir placement. Either through a separate low midline or inguinal counter-incision for direct Retzius access, or blind through the external ring similar to PS.
  8. Pump placement. Through a subdartos tunnel from the subcoronal wound into the scrotum. Pump placement is technically demanding with this approach.
  9. Closure in layers; redraping of the penile skin is meticulous to avoid redundancy or devascularization.

Advantages​

  • Best visualization for complex pathology, such as severe Peyronie's disease or distal fibrosis
  • Distal tip positioning is controlled under direct vision
  • Straightforward tunical work. Plication, incision, or grafting all done under direct vision

Disadvantages​

  • Longer operative time than PS in a critical review; the mean was 73 minutes (range 39–161) in the 200-patient series[1][4]
  • Sensory symptoms. Comparative risk of glans sensory loss with SC versus PS has not been established.[1]
  • Skin complications. Skin-flap necrosis, wound dehiscence and unsatisfactory cosmetic outcome are potential problems; comparative rates are not established

When to refer out​

Expert opinion suggests that a surgeon who does not perform subcoronal IPP regularly refers a patient with severe Peyronie's disease and ED to a high-volume center.

Transverse Scrotal Approach (TS)​

The TS approach is used by some implanters. It is not compared with the other approaches in the published review cited above.

Incision​

  • Horizontal transverse incision in the upper scrotum, below the penoscrotal junction; in Wilson's technique, retractor hooks move the incision onto the junction for corporal access.[22]
  • 3–4 cm, centered between the penoscrotal junction and the scrotal raphe

Rationale​

  • Preserves the penoscrotal junction skin (relevant for some concurrent urethroplasty or perineal reconstruction)
  • Provides direct pump placement
  • Allows simultaneous bilateral corporal access

Technique​

The technique substantially mirrors the penoscrotal approach in terms of corporotomy, dilation, sizing, and reservoir placement through the external ring. The main difference is the starting incision location. For this reason most surgeons treat TS as a variant of PS rather than a distinct approach.

Selected indications​

  • Concurrent perineal / urethral reconstruction where penoscrotal skin integrity matters
  • Surgeon preference for a fully scrotal approach with no dartos disruption at the penoscrotal junction
  • Alternative when PS would cross a prior scar

Implant Placement After Posterior Urethroplasty for Pelvic Fracture Urethral Injury (PFUI)​

Patients with a prior posterior urethroplasty for pelvic fracture urethral injury present altered anatomy that affects approach and technique. A lateral-incision approach has been described for this population: lateral skin incisions are made with care to avoid the corpus spongiosum, followed by three corporal stay sutures, corporotomy, and progressive proximal and distal Hegar dilation to 11 mm with separate length measurements for each side. Because the urethra was typically already mobilized to the penoscrotal junction during the prior anastomotic urethroplasty, aggressive spongiosal dissection is avoided. After the crural separation performed during PFUI repair, the proximal corpora may angle more laterally than usual, which should be anticipated during proximal dilation and cylinder seating.[15]

Prior operative records should be reviewed for the side of any supracrural urethral rerouting, because the rerouted urethra can lie between a corpus cavernosum and the pubis; a cylinder on that side risks compressing the urethra against the pubis. For a semirigid device, omitting the cylinder on the rerouted side has been described as an option, while an inflatable device has been placed bilaterally. Directing dissection scissors away from the urethra during initial corporal dissection and avoiding cylinder oversizing that could kink or compress the urethra are both advised, as is attention to dartos-flap laterality in a patient with a prior preputial-tube urethroplasty.[15] These are chapter-described operative practices without a comparative outcome series; co-surgery or referral to a center experienced in both reconstructive urethroplasty and implant surgery is reasonable in complex cases.

Choosing an Approach for the First 50 Cases​

A commonly suggested sequence of approach adoption for a new prosthetic urologist is:

  1. Penoscrotal first. Learn it as the default. The exposure is forgiving and reservoir placement is standardized, although blind.
  2. Infrapubic second. After about 25–50 PS cases, consider adding IP when direct reservoir visualization is useful and the retropubic plane is suitable. After prostatectomy or other pelvic surgery, choose the reservoir site using the reservoir-placement framework.
  3. Subcoronal selectively. Reserved for complex Peyronie's and ED cases; consider referral or co-surgery with an experienced subcoronal implanter for the first 5–10 cases if this direction is taken.
  4. Transverse scrotal as needed. As a variant on PS; no independent curve.

In a single-practice comparison, iatrogenic failures requiring removal occurred in 0/57 implants placed by one surgeon and 8/57 placed by ten surgeons. After excluding cases with additional procedures, median placement time was 34 minutes (n = 37) versus 94 minutes (n = 11); cylinders were longer in the single-surgeon group. The study did not compare incision approaches.[5]

See Also​

Videos​

Three-Piece Penile Prosthesis: Tips and Tricks for Successful Implantation
Dr. Pankaj Joshi (2022)
Penoscrotal Inflatable Penile Prosthesis: Tips and Tricks
UNC Department of Urology (2021)

References​

1. Otero JR, Manfredi C, Wilson SK. The good, the bad, and the ugly about surgical approaches for inflatable penile prosthesis implantation. Int J Impot Res. 2022;34(2):128–137. doi:10.1038/s41443-020-0319-4

2. Perito P, Mulcahy J, Wen L, Wilson SK. Nuances of infrapubic incision for inflatable penile prosthesis. Int J Impot Res. 2022;34(6):524–533. doi:10.1038/s41443-020-00370-y

3. Perito PE. Minimally invasive infrapubic inflatable penile implant. J Sex Med. 2008;5(1):27–30. doi:10.1111/j.1743-6109.2007.00682.x

4. 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

5. Henry GD, Kansal NS, Callaway M, et al. Centers of excellence concept and penile prostheses: an outcome analysis. J Urol. 2009;181(3):1264–8. doi:10.1016/j.juro.2008.10.157

6. Boston Scientific. AMS 700 with MS Pump Penile Prosthesis: Operating Room Manual. 92127382-01C, 2019; AMS 700 with TENACIO Pump IFU, 51558342-01A; Tactra Malleable Penile Prosthesis IFU, 51519609-01A.

7. Alzahrani A, Aleid M, Carrier S. Standard Technique for Semi-rigid and Inflatable Penile Implants. In: Joshi PM, Aubé-Peterkin M, Kulkarni SB, Datar G, eds. Surgical Atlas of Urethroplasty. Springer; 2024:369–381. doi:10.1007/978-981-97-5196-9_37

8. Köhler TS, Gupta NK, Wilson SK. Cylinder Placement. In: Köhler TS, Gupta NK, Wilson SK, eds. Wilson's Pearls, Perils and Pitfalls of Penile Prosthesis Surgery. 2nd ed. Calvert McBride Publishers; 2018:81.

9. Köhler TS, Gupta NK, Wilson SK. Cylinder Placement. In: Köhler TS, Gupta NK, Wilson SK, eds. Wilson's Pearls, Perils and Pitfalls of Penile Prosthesis Surgery. 2nd ed. Calvert McBride Publishers; 2018:81.

10. Köhler TS, Gupta NK, Wilson SK. Dr. Gupta Insertion Method When Missing a Furlow Insertion Tool. In: Wilson's Pearls, Perils and Pitfalls of Penile Prosthesis Surgery. 2nd ed. Calvert McBride Publishers; 2018:148.

11. Alnajjar HM, Muneer A. Intraoperative Complications of Penile Prosthesis Surgery. In: Miranda EP, Mulhall JP, eds. Penile Implant Surgery: Contemporary Challenges and Controversies. Springer; 2022:238–239.

12. Moncada I, Martínez-Salamanca JI, Jara J, Cabello R, Moralejo M, Hernández C. Inflatable penile prosthesis implantation without corporeal dilation: a cavernous tissue sparing technique. J Urol. 2010;183(3):1123–1126. doi:10.1016/j.juro.2009.11.048

13. Zaazaa A, Mostafa T. Spontaneous penile tumescence by sparing cavernous tissue in the course of malleable penile prosthesis implantation. J Sex Med. 2019;16(3):474–478. doi:10.1016/j.jsxm.2019.01.012

14. Köhler TS, Gupta NK, Wilson SK. Infrapubic Approach (Perito Technique). In: Köhler TS, Gupta NK, Wilson SK, eds. Wilson's Pearls, Perils and Pitfalls of Penile Prosthesis Surgery. 2nd ed. Calvert McBride Publishers; 2018:85-92.

15. Joshi PM, Navarro J, Kulkarni SB, Aubé-Peterkin M. Penile Prosthesis Insertion After Urethroplasty. In: Joshi PM, Aubé-Peterkin M, Kulkarni SB, Datar G, eds. Surgical Atlas of Urethroplasty. Springer; 2024:383–388. doi:10.1007/978-981-97-5196-9_38

16. Atwater B, Krug A, Gross MS, Marty-Roix R, Chapin L, Morey AF. "A review of the safety and efficacy of inflatable penile prosthesis ectopic reservoir placement." Sex Med Rev. 2025;13(1):20–32. doi:10.1093/sxmrev/qeae067

17. 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

18. Ziegelmann MJ, Alom M, Bole R, Kohler T, Trost L. "Modified glanulopexy technique for supersonic transporter deformity and glanular hypermobility in men with penile prostheses." J Sex Med. 2018;15(6):914–919. doi:10.1016/j.jsxm.2018.04.633

19. Vollstedt A, Gross MS, Antonini G, Perito PE. "The infrapubic surgical approach for inflatable penile prosthesis placement." Transl Androl Urol. 2017;6(4):620–627. doi:10.21037/tau.2017.07.14

20. Pang KH, Christopher N, Ralph DJ, Lee WG. "Insertion of inflatable penile prosthesis in the neophallus of assigned female at birth individuals: a systematic review of surgical techniques, complications and outcomes." Ther Adv Urol. 2023;15:17562872231199584. doi:10.1177/17562872231199584

21. Osmonov D, Wilson SK, Heinze T, et al. "Anatomic considerations of inflatable penile prosthetics: lessons gleaned from surgical body donor workshops." Int J Impot Res. 2023;35(7):672–678. doi:10.1038/s41443-023-00715-3

22. Wilson SK, Perito P, Park SSH, Mulcahy J. "Unexpected nuances of the penoscrotal inflatable penile prosthesis." Int J Impot Res. 2022;34(5):416–423. doi:10.1038/s41443-020-0341-6

23. Park SH, Wilson SK. "(452) Glans necrosis is not a risk for simple inflatable penile prosthesis insertion performed via subcoronal incision." J Sex Med. 2023;20(Suppl 1):qdad060.425. doi:10.1093/jsxmed/qdad060.425