Editing Penile Prosthesis (section)

== Surgical Technique ==

* Position: supine
* Step by step
**Incision and dissection down to corpora
*** The three-piece device can be inserted through a scrotal or infrapubic incision.
*** '''Narrower inflatable and semirigid devices should be available for all cases in the event that implanting a three-piece device becomes difficult'''.
** Cylinder placement
*** The tunica albuginea of each corpus cavernosum is identified on either side of the urethra
*** An incision is made in the tunica albuginea taking care to avoid the underlying cavernosal muscle
*** Blunt scissors are used to develop a space between the tunica albuginea and cavernosal muscle
*** Sequential dilation of the corpora is done using Hegar dilators.
**** The use of force is unnecessary and should be avoided to prevent perforation of the tunica albuginea and damage to the urethra at the meatus or the crus, which can occur during either distal or proximal dilation.
*** The corporeal lengths should be measured distally and proximally to select an optimally sized cylinder
*** The device is opened on the surgical field and prepared for implantation
*** The cylinders are implanted
*** A watertight closure of the corporotomy can be achieved with a running 3-0 PDS using a hemostatic stitch or by approximating the previously placed tagging 3-0 PDS
*** '''Poor support of the glans penis by cylinder or rod tips leads to a drooping appearance of the glans, in which it appears to "flop" over the prosthesis'''.
**** This deformity may result from inadequate distal dilation, too short cylinders, or in the case of minor deformity, variations in anatomy where the corpora cavernosum does not extend completely under the glans.
**** '''For a severe deformity, definitive correction involves removing both cylinders, perforating the distal corpora with scissors, resizing, and then inserting longer cylinders or the same cylinders with longer rear tip extenders.'''
**** '''For mild defects, dorsal plication of the glans back onto the shaft of the penis (glansplasty) is preferable when there are minor but otherwise bothersome degrees of poor glanular support.'''
** Pump placement
** '''<span style="color:#ff0000">Reservoir placement</span>'''
*** '''Before reservoir placement, it is important to ensure the bladder is empty to avoid bladder perforation.'''
*** '''<span style="color:#ff0000">The reservoir is typically placed in the space of Retzius.</span>'''
**** '''<span style="color:#ff0000">Submuscular reservoir placement with a flat reservoir or a separate incision should always be performed in all patients after previous surgery involving the space of Retzius (robotic prostatectomy, radical cystectomy, and abdominoperineal resection and in patients with history of pelvic fracture with bladder rupture and pelvic surgery)</span>'''
****See [https://www.nature.com/articles/nrurol.2015.270/figures/1 Figure] for submuscular reservoir placement
** '''Closure'''
*** '''A closed-suction drain should be used if the surgeon is not satisfied with hemostasis'''