Penile Implant Surgical Steps
1. No Touch and Pain Minimization:
We start the surgery by carefully washing and prepping the penis, scrotum, and surrounding areas with anti-bacterial (chlorhexidine) washes and anti-bacterial paint (chloroprene) to reduce your risk of post-surgical infection.
We use local anesthesia to dull the nerves of the penis and scrotum to minimize post-operative pain.
An anti-bacterial drape (Ioban) is placed. This prevents the prosthesis from contact with the underlying skin. This has been found to further reduce infection risk.
2. The Initial Cut:
- Through a 3 cm scrotal incision, dissection is carried out at the level of the erectile channels or corpora cavernosa. Care is taken to limit the size of the incision and any excess manipulation in order to minimize postoperative inflammation. This allows for faster post-operative recovery time. After these channels are identified, cavernosal sparing space is created where the prosthetic cylinders will eventually sit. This erectile body sparing approach allows us the maximum blood flow to the head of the penis (glans) improving sexual stimulation during arousal. The initial internal length of your erectile channels using a measuring tool called a furlough.
3. Bow and Arrow (eversion of the penis)
- Through the scrotal incision, the surrounding penile muscle (dartos), is carefully released along the overlying (ventral) surface of the penile shaft. The penis is brought out into the surgical field. This allows for full exposure to the erectile bodies.
4. Girth Enhancement vs Girth and Length Restoration:
For GIRTH enhancement, the overlying tissue layer over the corpora (buck’s fascia), which contains the sensory penile nerves, is mobilized laterally to the urethra to the 2 o’clock position along the length of the penis. Approximately 30-40 half centimeter vertical slits are created on the surface of the penis or tunica albuginea this is the restrictive tissue (fascia) that surrounds the erectile bodies. This maneuver creates a slinky life effect that will allow them to expand. The slits are staggered as they allow for better expansion of the tissue. Care is taken to avoid the nerves which run along the back of the penis as well as the urethra, along the front of the penis. Because these slits run in the direction of the nerves, the risk of nerve injury is rare.
For combined GIRTH AND LENGTH RESTORATION, using magnification glasses Buck’s fascia is elevated. Partial elevation of these nerves followed by the creation of slits typically will increase the penile length by about 1-2 cm while the complete elevation of the entire nerve bundle will increase the penile length by about 2-4 cm (~1.5inches) on average. Increased nerve dissection does however have a higher theoretical risk of nerve injury. After elevating these nerves, we now make staggered horizontal slits along the underlying penile shaft, allowing us to maximize the penile length. It is important to note that length enhancement slits allow the penis to stretch both vertically and horizontally, and thus have the added benefit of added girth enhancement with it.
5. Implant placement:
After completion of the enhancement slits, the penile bodies are once again measured to determine the change in length and determine the size of the prosthesis. Based on the new length measurement, the appropriately sized cylinders of the penile implant are placed into these erectile channels. The pump is placed in a pouch created in the scrotum between the testicles where it is not visible but can be easily felt
The reservoir of the penile prosthesis is ‘floated’ into the space of Retzius or in a space created under the muscle of the abdomen.
The implant is inflated to maximize the expansion of the slits.
The penis is then inspected and Buck’s fascia is returned to its normal anatomical position.
The previously made cuts are closed and a drain is oftentimes placed to keep any bleeding from storing within the scrotum. The scrotal incision is closed in multiple layers with an absorbable suture. These sutures dissolve over time and will not need to be removed. The penis and scrotum are wrapped with a mildly compressive wrap to reduce swelling. If a bladder catheter was placed during the case, it is typically removed at the end of the surgery.
If a drain was placed at the time of surgery, it will typically be taken out in the office within 48 hours of the surgery. The purpose of the drain is to evacuate any blood to prevent it from being stored in the scrotum.
You will have a compressive dressing that will be removed at the time of drain removal. 48 hours after drain removal you will be able to shower and use some gentle soap and water to clean around the surgery area. Use a wet towel to keep the area clean until you are cleared to shower.
We recommend using briefs to support the scrotum, but not compress the scrotum. When able, we recommend pulling the pump downward 2-3 times a day to prevent it from migrating into a less favorable position.
After about 2-4 weeks from the time of surgery, you will be directed to start inflating and deflating (cycling) the penile implant daily. We recommend inflating the prosthesis every morning before getting out of bed. Maintain the prosthesis inflated during the morning routine (10-20 min) and again inflate the prosthesis in the evening for at least 10 minutes. This is to allow for full expansion of the relaxing incisions and maximize the girth and length of your penis. As you continue to cycle it, you will see increases in girth. This is typically seen over the next 3-6 months as the erectile bodies continue to stretch over the penile implant.