Opinion: Why I prefer the infrapubic access

Keywords:
Penile Prosthesis; Erectile Dysfunction

Penile prosthesis placement is the third line therapy to treat erectile dysfunction. It is gold standard on those who do not respond to more conservative options (¹). Placement of the penile prosthesis, specially the three piece inflatable, has been reported from various different approaches, including penoscrotal, infrapubic, suprapubic and perineal locations (²). Each approach has its own advantage and disadvantages, however every implanter should be able to perform a few of these techniques depending on specific anatomy or revision cases. The penoscrotal approach is the most widely used and according to manufacturer data, reaches 80% of all implants in the United States of the America. Historically, the suprapubic approach was the first used to implant prosthesis (³). However, the incisions were too big and there was some concern to bury the tubing underneath the fascia as it was not kink-resistant as today. Many physicians were afraid of injuring the dorsal nerve as well.

The infrapubic incision used today is a variation of the old one. The new technique utilizes smaller incision and corporotomies, minimal corporal dilatation and decreases tissue dissection allowing for a rapid recovery and possibility of engaging in sexual activity on a shorter time. We have adopted this approach to implant 3-piece inflatables prosthesis since visiting Dr. Paul Perito from Miami, USA (⁴). I do not recommend this approach for semi rigid ones, as I believe a penile midline ventral incision is perfectly adequate.

Regarding the infrapubic technique there are several advantages:

Incision - a 3 cm length incision is made on the inferior border of the pubic bone. The penis should always be stretched and the surgeon positioned on the left side of the patient.

Exposure of the corpora - the exposure of both corporal bodies are carried out with blunt digital dissection. Artificial erection before the incision helps on the identification of these structures. The neurovascular bundle is maintained intact on the center of both corpora. One or two hand-held retractors give the adequate exposure. Two stay sutures using a 2-0 monofilament is placed on each side on a parallel fashion. The corporotomy is made with a 12 blade knife.

Size of corporotomy - there is no need to open more than 1.5 cm of each corpora, unless a semi-rigid prostheses is taking place.

Minimal dilatation - The Furlow instrument is passed once proximally and once distally with simultaneous measurement. There is no need to progressive dilatation on first case implants. However, in some difficult cases such as post priapism and revisions after infections, this may be necessary.

Ease on positioning the reservoir - this is another advantage of this technique as the external inguinal ring is easily identified from this incision. Using a 6 or 8 cm nasal speculum the reservoir can be placed on Retzius space or ectopic, depending on the surgeons preference.

Ease on positioning the pump - This is the major advantage of this approach over the penoscrotal in my opinion, as there is not a scrotal scar. From the infrapubic incision is possible to create a space between the testicles through the introduction of a nasal speculum just parallel to the corpora. With the jaws opened, it is possible to create an adequate space.

Not redundant tubing on the scrotum - Here is another advantage. The redundant tubing is trimmed and the connection is made through the infrapubic incision. The connection is buried underneath the fascia. No tubing is visible on the scrotum.

Early recovery and prompt training - After 2 or 3 weeks, the patient is able to initiate his train managing the pump. When the surgeon keeps the prosthesis semi inflated after the procedure it is possible to deflate it after a few days without any harm. This is not possible after a penoscrotal approach as the area of the pump is too painful.

Conclusions

Prosthetic implanters should be aware of other techniques and, the infrapubic one is strongly recommended for 3-piece inflatables.

REFERENCES

• ¹
  Hatzimouratidis K, Amar E, Eardley I, Giuliano F, Hatzichristou D, Montorsi F, et al. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Eur Urol. 2010;57:804-14.
• ²
  Mobley DF. Early history of inflatable penile prosthesis surgery: a view from someone who was there. Asian J Androl. 2015;17:225-9.
• ³
  Karpman E. Streamlined approach for infrapubic placement of an inflatable penile prosthesis. Adv Urol. 2012;2012:520180.
• ⁴
  Perito PE. Minimally invasive infrapubic inflatable penile implant. J Sex Med. 2008;5:27-30.

Publication Dates

• Publication in this collection
  May-Jun 2015