Subcoronal IPP placement and length preservation

These videos illustrate state-of-the-art penile prosthesis placement. Achieving excellent outcomes in penile prosthetic surgery requires precisely defining anatomic planes, excellent sterile technique, and optimal wound closure to prevent infection. These are all elective procedures where patients have little tolerance for what can be devastating complications. All of these surgeons demonstrate novel ways to provide optimal outcomes for patients undergoing penile prosthesis placement.

Commentary on the videos is provided by Robert J. Valenzuela, MD, director of penile prosthesis surgery and assistant professor of urology, Icahn School of Medicine at Mount Sinai, New York, and 'Y'tube Section Editor James M. Hotaling, MD, MS, assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.

Continue to the next page to watch the videos.

Subcoronal IPP: Modified no-touch technique - Robert J. Valenzuela, MD

Surgical treatment for disorders of male sexual function requires specific exposure to safely and efficiently correct the underlying problem. Historically, subcoronal exposure was utilized for treatment of phimosis, Peyronie’s disease plaque, and semi-rigid penile prosthesis insertion. Infrapubic and scrotal incisions are used for inflatable penile prosthesis (IPP) placement. However, men who present with several disorders may require multiple procedures and surgical incisions. This video demonstrates the placement of a three-component IPP through a subcoronal incision with degloving of the penis-an approach that allows for access to the entire corporal shaft for multiple reconstructive procedures.

Dr. Hotaling: The subcoronal approach avoids the pain of the scrotal incision and eliminates an area that can have problematic wound healing in patients with multiple medical comorbidities. The ability to access nearly the entire corpora through the same incision used for prosthesis placement makes this an excellent choice for patients requiring adjuvant procedures such as plication or grafting.

Dr. Valenzuela is director of penile prosthesis surgery and assistant professor of urology, Icahn School of Medicine at Mount Sinai, New York. He is a consultant for Coloplast, Boston Scientific, and Teleflex (Neotract).

Subcoronal IPP: No-touch technique with ventral phalloplasty - Tariq S. Hakky, MD

In this video, we demonstrate placement of an IPP using a subcoronal approach with a no-touch technique with simultaneous ventral phalloplasty. As seen in the video, this novel approach allows the surgeon to take advantage of both the penoscrotal approach and the infrapubic approach.

Dr. Valenzuela: Dr. Hakky places his patient in a modified lithotomy. This position may assist in dropping the scrotal contents and facilitate corpora dilatation and insertion of the prosthesis. This is similar to a scrotal penile prosthesis insertion. His degloving technique focuses on ventral dissection with minimal dorsal dissection in order to preserve the dorsal vein and lymphatics. This may minimize postoperative penile edema. I typically perform circumferential dissection to the level of the suspensory ligament in order to maximize the elasticity and length of the corporal bodies. This has not shown any significant increase in post-op penile edema.

In this video, after completing the subcoronal IPP insertion, Dr. Hakky demonstrates the ventral phalloplasty. This is performed without entering or exposing the scrotal content. This simple excision of scrotal skin is less likely to break down and expose the prosthesis. This is an excellent adjunct procedure at the time of IPP, regardless of surgical approach.

Dr. Hotaling: This technique combines the subcoronal approach with a ventral phalloplasty. The major advantage of this approach is that the ventral phalloplasty incision is completely separate from the incision for placing the penile prosthesis. This reduces the chance that any wound issues with the phalloplasty could compromise the device. The limited dorsal dissection improves recovery and limits postoperative edema.

Dr. Hakky provides innovative treatments in sexual medicine and infertility at Advanced Urology and Men’s Health Georgia, Atlanta. He is a consultant for Coloplast.

Subcoronal IPP with modified Wilson's Deaver maneuver - Sean, Sung Hun, Park, MD

In this video, Dr. Park demonstrates IPP surgery through a subcoronal approach under local anesthesia with length preservation. The video outlines a stepwise approach to minimizing patient discomfort and surgical complications.

Dr. Valenzuela:In this video, Dr. Park demonstrates his subcoronal IPP under local anesthesia. I had the opportunity to assist Dr. Park in one of these cases. He also demonstrates the injection into the inguinal canal and above the transversalis fascia. The procedure is well tolerated. The use of intra-corpora Trimix with local anesthetic facilitates ventral proximal dissection to the level of the ischio-cavernosum. I typically use papaverine, 60 mg, with 3 cc of ropivacaine 0.5%. This helps with postoperative pain and also allows for placement of the retaining sutures for the corporotomy as proximal as possible. Once this is achieved, the remainder of the procedure is similar to a scrotal approach, including dropping the scrotal septum in order to facilitate pump placement.

Dr. Park is very meticulous and deliberate in his closure. By closing the dartos and the skin separately, he adds an extra layer of protection to the surgical site. As you can imagine, it is very challenging to perform this procedure under local anesthesia, yet Dr. Park is very experienced and makes it look easy.

Dr. Hotaling: Dr. Park’s skill with local and regional blocks is impressive. Once these blocks are achieved, he is able to proceed with an anatomic and efficient placement of an IPP in standard fashion. This video illustrates how the procedure can be done without the need for general anesthesia or even a spinal. This could be a significant benefit for patients whose inability to tolerate a general or spinal anesthesia prevent them from undergoing surgery for an IPP.We typically use 30 cc of 1% lidocaine to induce an artificial erection at the beginning of the case, which enables us to assess for penile curvature while providing significant postoperative pain control.

Dr. Park is clinical associate professor of urology, Ajou University, School of Medicine, Suwon, Korea.

'Y'tube Section Editor James M. Hotaling, MD, MS, is assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.