Surgical Approaches to Penile Prosthesis Implantation

Four incisions are in contemporary use for inflatable penile prosthesis (IPP) placement: penoscrotal, infrapubic, subcoronal, and transverse scrotal. Each has a defined role, trade-off profile, and surgeon community. There is no single "best" approach — high-volume outcomes have been reported with all four, and the most important variable is consistency: picking an approach, drilling it to reflex-level fluency, and modifying only for specific anatomic reasons.^[1][2]

This article covers the decision framework and the step-by-step for each approach. Intraoperative setup (prep, drape, no-touch, antibiotics) is in intraoperative setup. Reservoir placement specifics — including ectopic / submuscular technique — are in reservoir placement.

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Approach Comparison

Axis	Penoscrotal (PS)	Infrapubic (IP)	Subcoronal (SC)	Transverse Scrotal (TS)
Incision	Horizontal, penoscrotal junction	Horizontal, suprapubic	Circumferential behind corona	Horizontal mid-scrotum
Reservoir placement	Blind through external inguinal ring	Direct visualization into space of Retzius	Blind or via separate inguinal incision	Blind through external inguinal ring
Pump pocket	Direct, excellent exposure	Separate scrotal counter-incision required (or delivered through tunnel)	Through scrotal tunnel	Direct
Dorsal nerve risk	Very low	Moderate to elevated	Moderate (subcoronal sensory)	Very low
Visualization of corpora	Excellent proximal, limited distal	Excellent proximal, limited	Complete (distal and proximal)	Excellent proximal
Activation timing	4–6 weeks	4 weeks (some surgeons 2–3 weeks)	6 weeks	4–6 weeks
Operative time	60–90 min	45–75 min	75–120 min	60–90 min
Best for	Most primary cases; workhorse	Experienced surgeons; direct reservoir; fast	Complex reconstruction (Peyronie's, fibrosis, concurrent glans work)	Alternative to PS; selected anatomies
Relative contraindication	Very long scrotum with pendulous dartos	Thin abdominal wall with scar; prior pelvic surgery (for SoR)	Uncircumcised patient (requires circumcision); neurologically intact sensation critical	Morbid obesity with deep scrotum

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Penoscrotal Approach (PS)

The most common approach worldwide, taught as the default in most fellowships, and the 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 nearly universal 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 to 10, 12, then 14 mm
   • 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 + distal) with the Coloplast or Boston Scientific measuring device
8. Sizing — select cylinder length + rear-tip extenders (RTEs) to fully fill the corporal space. Undersizing causes supersonic transit (SST) deformity; oversizing causes glans pain and potential aneurysm.
9. Cylinder placement — Furlow tool with Keith needle. Distal tip exits at the glans; proximal end seated against the crus. Confirm with inflation-deflation trial.
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.
11. Pump pocket — dependent scrotal position created between the dartos layers, using blunt finger dissection or Babcock/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 is worth its weight — exposure quality substantially improves and retractor-holding personnel needs drop to zero.
• Stay sutures before corporotomy — not after. The untraumatized tunica is much easier to grasp before bleeding begins.

Limitations

• Reservoir placement is blind through the external inguinal ring — this is the approach's single largest weakness, and the reason ectopic placement has become popular for PS cases in high-risk abdomens.
• Distal corporal visualization is limited — severe Peyronie's curvature or complex fibrosis is harder to address than with a subcoronal.

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Infrapubic Approach (IP)

Favored by a smaller but experienced community, best exemplified by the Perito and Wilson publications.^[2][3] The central feature: direct visualization of the space of Retzius for reservoir placement.

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 — running in the midline deep to Buck's fascia. The dorsal nerves enter the penis at roughly the 11 and 1 o'clock positions and are at meaningful risk in this approach; sharp blunt dissection and lateral retraction of the bundle are critical.
4. Expose the proximal corpora by ventrolateral dissection, keeping the dorsal bundle cranial/lateral.
5. Stay sutures placed; corporotomies made on the dorsolateral aspect.
6. Dilation and sizing — same as PS. Distal dilation feels "further" because you are working from a more proximal incision.
7. Reservoir placement — direct. Transversalis fascia entered under vision; space of Retzius developed bluntly; reservoir placed with controlled volume (usually ~60–75 mL). This is the approach's major advantage.
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 visualization of the space of Retzius — essential in patients with complex abdominal anatomy or prior surgery
• No scrotal incision in many protocols — cosmetic advantage
• Faster activation — some infrapubic surgeons activate at 2–3 weeks postop (vs. 4–6 for PS)
• Shorter operative time on average

Disadvantages and caveats

• Dorsal nerve injury is the defining risk — sensory changes have been reported in up to 10% of IP cases in some series, though the experienced-surgeon rate is much lower
• Concealed pump — requires more experience; the tunnel must be well-developed to avoid a high-riding pump that is hard to cycle
• Cannot combine easily with subcoronal glans work

Pearls

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

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Subcoronal Approach (SC)

The most demanding approach, developed by Weinberg, Pagano, Deibert, Valenzuela and others for complex reconstructive cases where the entire corpora must be exposed.^[4]

Indications (why you would choose SC)

• 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 / phalloplasty implant placement
• Shortened penis with distal fibrosis where modeling alone is inadequate

Incision

• Circumferential subcoronal incision (as in circumcision) — the penis is essentially circumcised if not already, and the entire shaft is degloved to the penoscrotal junction
• Requires circumcision at the same operation if not already circumcised
• 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. Peyronie's plication, tunical incision/grafting, or modeling performed as indicated.
5. Corporotomies made on the most suitable surface (often ventrolateral, adjusted for Peyronie's anatomy).
6. Dilation, sizing, cylinder placement as in PS.
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. This is the most technically demanding pump placement of any approach.
9. Closure in layers; redraping of the penile skin is meticulous to avoid redundancy or devascularization.

Advantages

• Best visualization for complex pathology — irreplaceable for severe Peyronie's or distal fibrosis
• Best distal tip positioning control — the glans is right there
• Straightforward tunical work — plication, incision, or grafting all done under direct vision

Disadvantages

• Longest operative time — 90–120 minutes routinely
• Glans sensory changes — the subcoronal sensory nerves are at higher risk than in PS
• Requires circumcision as part of the operation for uncircumcised patients
• Skin complications — skin-flap necrosis, wound dehiscence, unsatisfactory cosmetic outcome — all more common than PS
• Steep learning curve — generally not the approach taught first in fellowship

When to refer out

If you do not perform subcoronal IPP regularly (<5–10 cases/year), a patient with severe Peyronie's + ED is appropriately referred to a high-volume center. Subcoronal is the approach where surgeon-volume effects are most pronounced.

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Transverse Scrotal Approach (TS)

A less commonly discussed approach but used by some high-volume implanters and worth knowing.

Incision

• Horizontal transverse incision in the mid-scrotum (not at the penoscrotal junction)
• 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 excellent 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

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Choosing an Approach for the First 50 Cases

For a new prosthetic urologist, the sequence of approach adoption that most high-volume practices recommend:

1. Penoscrotal first — master as your default. The exposure is forgiving, the reservoir placement is standardized (if blind), and the pump placement is excellent.
2. Infrapubic second — after ~25–50 cases of PS, consider adding IP for patients where direct reservoir visualization matters (post-prostatectomy, prior pelvic surgery).
3. Subcoronal selectively — reserved for complex Peyronie's + ED cases; consider referral or co-surgery with an experienced subcoronal implanter for your first 5–10 cases if you go this direction.
4. Transverse scrotal as needed — as a variant on PS; no independent curve.

The data supporting "do whatever you do well" are consistent across comparative series — outcomes are more closely correlated with surgeon volume than with approach choice.^[5]

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See Also

• Penile implants — overview
• Preoperative evaluation
• Intraoperative setup
• Reservoir placement
• Revision scenarios

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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/s41443-021-00423-w

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/s41443-021-00443-6

3. Perito PE. Minimally invasive infrapubic inflatable penile prosthesis. J Sex Med. 2008;5(1):27–30. doi:10.1111/j.1743-6109.2007.00712.x

4. Weinberg AC, Pagano MJ, Deibert CM, Valenzuela RJ. Sub-coronal inflatable penile prosthesis placement with modified no-touch technique. J Sex Med. 2016;13(2):270–276. doi:10.1016/j.jsxm.2015.12.018

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