Surgical Technique Steps

In Dr. Gheiler’s practice, after a thorough history and physical exam, a penile Doppler is performed to document irreversible, organic erectile dysfunction. This test is also a trial of injection therapy — it gives the patient a cause for their ED while showing them they can get erections again, and helps identify penile plaques or curvatures. Be careful with the patient who doesn’t get a full erection with injections, as they may have occult curvatures. A full set of labs helps identify poorly controlled diabetes or hypogonadism. Dr. Gheiler does not treat low testosterone alone as a reason to withhold an implant — in his experience, low-T therapy by itself does not resolve ED in a patient who otherwise needs one; individualized evaluation still applies.

In this practice, patients who have had a radical prostatectomy undergo cystoscopy to rule out bladder neck contractures, and implant patients have urine cultures obtained along with appropriate medical and cardiac clearances. Individual evaluation varies with each patient’s history and risk factors.

Patients cancel for several reasons — most commonly external family factors and misconceptions. Families often do not consider ED a significant illness. In Dr. Gheiler’s experience, implants reliably restore erectile function, can relieve much of the distress that accompanies ED, and can meaningfully improve relationships. It is up to us to properly educate the medical communities around us.

Fear of pain is natural. I reassure patients that extreme pain is unusual with implants: I use perioperative penile blocks with long-acting anesthetics, send pain medicine home, and use a JP drain to minimize swelling and hematoma. A good surgical coordinator is crucial for helping patients obtain timely medical clearance.

In Dr. Gheiler’s practice, patients wash with an antimicrobial soap starting three days before surgery and again the morning of. His standard preoperative regimen — absent allergies, culture results, or local resistance patterns dictating otherwise — is 1 gram of Vancomycin over one hour and Gentamycin 5 mg/kg, fully infused before any incision for high tissue levels. Antimicrobial selection should follow current guidelines, cultures, and each patient’s risks.

• Paper gowns and sheets to avoid contaminating the surgical theatre with lint bacteria.
• No jackets or blankets in the OR; restricted personnel access.
• Prep with Hibiclens, removed completely, then ChloraPrep over the field; alcohol on hands after scrubbing.
• Strict no-touch technique with frequent glove changes and copious antibiotic irrigation; antibiotic-coated implants only.
• No Foley catheter — prevents catheter contamination and makes the surgery more comfortable.
• Always change gloves when opening the implant for the first time.

Fast surgery decreases infection rates — strive for total surgical time under 20 minutes. Infection rates are never zero, and patients should be aware of this possibility; it is our responsibility to constantly evaluate technique and drive the rate as close to zero as possible.

I have modified the incision site to sit in the upper lateral part of the scrotum along the rugae, on the same side as reservoir placement. Reasons:

1. Avoids the penoscrotal junction — no postoperative pain or scarring at this sensitive area, and the incision is invisible once healed.
2. Far from the pump, allowing early manipulation of the pump.
3. Most dissection and implant placement is done on that side, decreasing postoperative swelling and hematoma.

The scrotal approach leaves a less visible scar, gives better access to the entire corpora, avoids pump migration issues, and keeps cylinder tubing from coming from above — less bother for thin patients.

1. Use a Scott retractor and a nasal speculum.
2. Place the table on flex with Trendelenburg to get more proximal on the corpora and level the field.
3. Place the penis on maximal stretch before the no-touch drape to help dissection and sizing; change gloves.
4. Elevate and traction scrotal skin during dissection, repositioning hooks frequently.
5. Preplace 2-0 Monocryl UR-6 sutures on the corpora as proximally as possible — two overlapping stay sutures per side — before opening.
6. Do not serial dilate if no fibrosis is present; only introduce the Furlow.
7. Point the Furlow laterally toward the bone when passing proximally to avoid proximal crossover.
8. Surgery is ballet, not karate — be gentle with the Furlow to prevent perforations.
9. Measure proximal and distal as many times as needed; avoid rear tips as much as possible.
10. Reservoir placement with finger dissection when possible — the path of least resistance.
11. Irrigate, irrigate, irrigate. Multi-layered closure.
12. Aim for a functional result, not a perfect one — avoid maneuvers driven by perfectionism that turn out disastrous.

• Ice packs 20 minutes on / 20 minutes off — never directly on the skin.
• Remove the JP drain on postoperative day 3.
• Penile implant activation at 5–6 weeks.
• Oral antibiotics for 5 days at home.

In the course I discuss when I consider an ectopic, submuscular (retropubic) reservoir space, and the pelvic anatomy I use to evaluate that approach.

• The submuscular / retropubic spaces and the anatomy relevant to assessing them.
• How the scrotal approach can reach these spaces without a separate counter-incision, including in complex or reoperative cases.
• Using CT to confirm reservoir position when it is in question.

Reservoir malposition is a common source of avoidable complications — the pitfalls below are the ones I teach urologists to recognize and prevent.

Placement of the pump is one of the most important aspects of the surgery, as it is the part the patient accesses most. The pump must sit in the posterior dependent portion of the scrotum — this allows concealment, ease of operation, and does not shorten effective penile length.

Pump placement failure occurs when:

• The scrotal dissection for the pump is inadequate.
• The tubing exiting the corpora is too short (wrong implant size, corporotomies too distal, rear tips not used when needed).
• An infra-pubic implant pump migrates up and the patient is not told to manipulate it early to bring it down.

Much of the course is complication avoidance. We review the pitfalls I most often see in revision and referral cases, and the techniques I discuss to reduce each:

• SST deformity — its clinical appearance, the mechanisms behind it (an implant that is too short or a posterior perforation), and the role of careful sizing.
• ‘Chevron’ tubing — how corporotomies placed too distal can produce it, and why I emphasize a proximal corporotomy.
• Distal or proximal crossover — how it is recognized, and the checks I discuss to reduce the risk (including a ‘goal-post’ check for proximal perforation).
• Rear tips — how measurement informs the number of rear tips used.
• Reservoir malposition — which has been associated with serious complications, including bowel obstruction, bladder erosion, or superficial (subcutaneous) malposition.
• Pump placement — how positioning affects how easily a patient can use the device.