Subcoronal Approach

The subcoronal approach is clinically indicated in several urological scenarios, primarily when surgical access to the penile shaft is required for implantation or reconstructive procedures.¹˒² It is a preferred method for the implantation of inflatable penile prostheses (IPP) and semi-rigid penile prostheses in patients with erectile dysfunction, particularly when concomitant procedures are anticipated.¹˒² For instance, patients with severe Peyronie’s disease, characterized by significant penile curvature (e.g., >60 degrees), indentations, or calcified plaques, often benefit from this approach because it allows the surgeon to perform plaque incision/excision and grafting, or penile modeling, simultaneously with IPP placement through the same incision.¹˒²

Patient selection criteria often include men who require complex penile reconstruction, those who might benefit from avoiding a scrotal incision (due to factors like previous scrotal surgery, hydrocele, or risk of poor wound healing in that area), or those undergoing revision surgeries where previous incisions might be compromised.³ The subcoronal approach provides excellent exposure of the corpora cavernosa, facilitating precise cylinder placement for IPPs and allowing for ancillary procedures such as corporotomy, dilation, and closure.¹˒² Some surgeons also utilize this approach for patients who desire a concurrent circumcision, as it can be performed through the same incision.²

The surgical procedure typically involves a circumferential incision made just proximal to the coronal sulcus. The penile skin and Dartos fascia are then dissected and retracted (degloved) to expose the Buck’s fascia and the tunica albuginea of the corpora cavernosa.¹˒² For IPP placement, corporotomies are made, the corpora are dilated, and the prosthesis cylinders are inserted. The pump and reservoir are placed according to standard techniques, which may involve a separate small counter-incision or ectopic placement for the reservoir depending on patient anatomy and surgeon preference.² If Peyronie’s reconstruction is needed, this is performed after penile degloving and before or after cylinder placement, depending on the specific reconstructive technique used.¹

Expected outcomes are generally good, with studies reporting low complication rates for the subcoronal approach in IPP surgery.¹˒² Complications can include wound issues (e.g., infection, dehiscence, edema), device malfunction, or, rarely, glans necrosis, though the latter is not consistently reported as a higher risk with this specific approach when performed correctly.¹˒² Revision rates for mechanical failure or cosmetic issues are also generally low.¹ The ability to perform multiple procedures through one incision is a key advantage, potentially reducing overall surgical trauma and recovery time compared to multiple separate incisions.³ Post-operative recovery involves managing pain and swelling, with a return to sexual activity typically guided by the healing process and device type, often within 4-6 weeks.