What are the steps involved in a 3-piece penile implant surgery?

Three-Piece Inflatable Penile Prosthesis Surgical Technique

Preoperative Preparation

The patient must be infection-free (urinary tract, systemic, and cutaneous lesions) and receive broad-spectrum antibiotics covering both Gram-positive and Gram-negative organisms before incision. 1

• Administer aminoglycosides, vancomycin, cephalosporins, or fluoroquinolones preoperatively 1
• Shave the operative area immediately before surgery, not earlier, to prevent infected skin cuts 1
• Perform thorough skin preparation after shaving 1

Surgical Approach Selection

Two primary incisions are available, each with distinct advantages 2:

• Penoscrotal (PS) approach: Most commonly used, provides excellent exposure 2
• Infrapubic (IP) approach: Faster procedure, no reported cases of glans hypoesthesia 2

The surgeon should select based on patient anatomy, surgical history, and personal experience 2. Both approaches yield patient satisfaction rates exceeding 80% and infection rates of 3.3% or less 2.

Step-by-Step Surgical Technique

1. Incision and Corporal Exposure

• Make either a penoscrotal or infrapubic incision based on the selected approach 2
• Expose the corpora cavernosa bilaterally 3

2. Corporal Dilation

• Create corporotomies in both corpora cavernosa 3
• Dilate the corpora proximally and distally to accommodate the cylinders 3
• Measure corporal length carefully to select appropriate cylinder size 4

3. Cylinder Placement

• Insert paired inflatable cylinders into the corpora cavernosa 5
• Modern cylinders expand in both girth and length to minimize perceived penile shortening 4
• Ensure proper positioning without kinking or malposition 3

4. Reservoir Placement

• Standard anatomy: Place the fluid reservoir in the retropubic space (space of Retzius) 5
• Altered anatomy (post-cystoprostatectomy/urinary diversion): Use lateral retroperitoneal placement through a counterincision medial to the anterior superior iliac spine 6
• This lateral approach avoids injury to urinary diversions and has shown no increased infection or erosion risk 6

5. Pump Placement

• Position the scrotal pump in the dependent portion of the scrotum 5
• Ensure the pump is easily accessible for patient activation 7
• Connect all components with tubing 5

6. System Connection and Testing

• Connect cylinders, pump, and reservoir with appropriate tubing 3
• Fill the system with sterile saline 7
• Test inflation and deflation cycles intraoperatively to confirm proper function 3
• Check for leaks at all connection points 3

7. Closure

• Close corporotomies if needed 3
• Close the incision in layers 3
• Apply sterile dressing 1

Special Considerations for Complex Cases

Peyronie's Disease with Concurrent ED

When implanting in patients with Peyronie's disease, the three-piece inflatable prosthesis is preferred because it allows for modeling 8, 5:

• Insert cylinders first 8
• Mild-to-moderate curvature (<30°) often resolves with cylinder insertion alone 8
• For curvature >30°, perform manual modeling as first-line intervention 8
• If significant curvature persists after modeling, proceed with incision with/without collagen fleece coverage or plaque incision and grafting 8

Post-Cystoprostatectomy Patients

• Use lateral retroperitoneal reservoir placement to avoid urinary diversion structures 6
• This technique has been successfully performed in patients with orthotopic neobladders, ileal conduits, and continent cutaneous diversions without increased complications 6

Infection Prevention Strategies

Modern devices incorporate infection-inhibiting technologies that have dramatically reduced infection rates 5:

• Antibiotic-coated devices (rifampin and minocycline): Reduced infection rates from 1.61% to 0.68% 5
• Hydrophilic-coated devices: Can be immersed in antibiotics preoperatively, reducing infection rates from 2.07% to 1.06% 5
• Current infection rates with coated devices are 1-2% 1, 5

Critical Surgical Pitfalls to Avoid

• Urethral injury: Exercise extreme caution during corporotomy and dilation 1
• Corporal perforation: Avoid aggressive dilation that could breach the tunica albuginea 3
• Reservoir malposition: Ensure proper placement to prevent erosion into adjacent structures 6
• Inadequate cylinder sizing: Undersizing leads to patient dissatisfaction; oversizing risks erosion 4
• Component disconnection: Secure all tubing connections to prevent mechanical failure 3

Postoperative Management

• Monitor for penile edema, hematoma, and acute urinary retention 1
• Infection typically occurs within the first three months if it develops 1
• Mechanical failure rates with modern devices are 6-16% at 5 years 5
• Lockout valves in modern designs have reduced auto-inflation rates from 11% to 1.3% 5

Patient Counseling Points

Patients must understand before surgery 1, 9:

• The procedure is essentially irreversible 5
• Penile shortening compared to natural erections is common 5, 4
• The prosthesis will likely reduce efficacy of subsequent therapies if removal is needed 1, 9
• Satisfaction rates exceed 80% in most series 2, 7
• In Peyronie's disease patients, satisfaction rates are lower than general ED cases, primarily due to length concerns 8