Rigi10™ Malleable Penile Prosthesis
Also Known As
Infrapubic approach, Minimally invasive infrapubic approach, Suprapubic incision
Definition
An infrapubic incision is a surgical cut made in the lower abdomen, specifically one fingerbreadth above the penopubic junction (the area where the penis meets the pubic bone), while the penis is gently pulled downwards.¹ This type of incision is a well-established surgical approach, particularly in urology, for procedures such as the implantation of inflatable penile prostheses (IPPs).¹
The primary purpose of the infrapubic incision is to provide the surgeon with access to the corpora cavernosa (the erectile tissues of the penis) and the space of Retzius (for reservoir placement in IPP surgery) through a single, relatively small incision, typically only as wide as the pump component of an IPP.¹ The technique involves carefully dissecting through skin and subcutaneous tissue, including Scarpa’s fascia, to expose the corpora cavernosa bilaterally.¹
Hydrodilatation, the injection of saline into the corpora, is often performed to facilitate identification of anatomical structures, such as the dorsal nerve, and to allow for easier placement of stay sutures.¹ These stay sutures are crucial for manipulating and stabilizing the corpora during the creation of corporotomies (incisions into the corpora) and the subsequent insertion of prosthetic cylinders.¹
One of the key advantages of the infrapubic approach is that it allows for the placement of the IPP reservoir under direct vision through the same incision, which can be more rapid and potentially safer compared to other approaches that might require a separate incision or blind passage of the reservoir.¹ Additionally, it avoids an incision directly on the scrotum, which some patients may prefer and which can be an obstacle to postoperative rehabilitation.¹
The infrapubic incision is considered a minimally invasive technique, with some surgeons utilizing incisions as small as 3 cm.² While historically there were concerns about potential damage to the dorsal nerves of the penis leading to sensory loss, this has not been documented in the literature when careful dissection is performed.¹ The approach is versatile and can be used for various penile prosthetic surgeries, including revisions, and is often preferred for its direct access and potentially reduced patient morbidity compared to other incisional approaches.¹
Clinical Context
The infrapubic incision is a primary surgical approach in urological surgery, most commonly used for implanting inflatable penile prostheses (IPPs) in patients with erectile dysfunction (ED) refractory to other treatments.¹ It is one of the main techniques for IPP placement, alongside penoscrotal and subcoronal incisions.⁸
Relevant Medical Conditions and Patient Selection
The infrapubic incision is primarily utilized for IPP implantation to treat erectile dysfunction (ED).¹ Candidates for this procedure are typically patients who have not responded to or cannot tolerate less invasive ED treatments, such as oral medications, vacuum erection devices, or intracavernosal injections.¹ Perito’s approach, as described by Vollstedt et al. (2017), considers any patient a candidate for the infrapubic approach, including those undergoing revision surgeries, as it allows reservoir retrieval without a secondary incision.¹ This technique is also suitable for patients who prefer an incision site outside the penis and scrotum or wish to avoid a Foley catheter, as reservoir placement can often be performed without one.¹ Obese patients, who may require a flat surface for instruments like the Furlow passer, can be accommodated with careful positioning.¹
Surgical Procedure
The infrapubic incision is integral to placing a three-piece inflatable penile prosthesis, as detailed in Dr. Perito’s technique (Vollstedt et al., 2017).¹ The procedure includes the following steps:
- Patient Positioning and Preparation: The patient is supine with the table hyperextended at the mons pubis. The groin is shaved, prepped, and a pudendal nerve block may be administered.¹
- Artificial Erection and Hydrodilatation: Saline induces an artificial erection to identify penile pathology and hydrodilate the corpora, reducing the need for serial dilation in diagnostic cases and aiding in dorsal nerve identification for safer stay suture placement.¹
- Incision: A transverse incision (1–2 cm or as wide as the pump) is made one fingerbreadth above the penopubic junction.¹
- Exposure and Stay Sutures: Scarpa’s fascia is incised, and dissection reaches the corpora cavernosa. Bilateral stay sutures (e.g., 2-0 absorbable suture) are placed on the tunica albuginea, moving the neurovascular bundle aside.¹
- Corporotomies: Bilateral incisions (approximately 1.5 cm) are made into the corpora at the widest part of the cylinder’s tubing exit site.¹
- Measurement and Dilation (Dilation): The corpora are measured proximally and distally using a Furlow introducer. Serial dilation is unnecessary if hydrodilatation is successful, though a Hegar #12 dilator may be used for calibration.¹
- Cylinder Placement: Appropriately sized IPP cylinders are inserted into the corpora using Keith needles for distal placement, ensuring correct positioning.¹
- Reservoir Placement: The reservoir (e.g., 125 cc) is placed in the space of Retzius or an ectopic location (e.g., submuscularly in the abdominal wall for compromised pelves) under direct vision through the same infrapubic incision, often using a nasal speculum to create space posterior to the transversalis fascia or between muscle layers.¹˒¹⁰
- Pump Placement: The pump is placed in a dependent scrotal position through the same infrapubic incision by developing a subcutaneous tunnel to the scrotum using a nasal speculum. The pump is positioned midline, posterior, and dependent.¹
- Connections and Closure: Tubing connections are made between the cylinders, reservoir, and pump. Corporotomies are closed with pre-placed stay sutures, Scarpa’s fascia is closed, and the skin is closed, often with staples. A surgical drain (e.g., #10 flat drain) may be placed.¹
Expected Outcomes
The primary goal of IPP implantation via the infrapubic incision is to restore erectile function, enabling erections suitable for sexual intercourse.¹ Patient satisfaction rates with IPPs are generally high.¹ The infrapubic approach, when performed proficiently, aims for safe and effective implantation with minimal complications. Studies comparing infrapubic and penoscrotal approaches show no significant differences in primary outcomes, such as incisional discomfort, scrotal pain/edema, hematoma, penile paresthesia, or infection rates. However, specific advantages and disadvantages are debated.⁸˒⁹ Post-operative recovery involves pain management (typically with NSAIDs), wound care, and gradual resumption of activities. Patients are instructed on device use, with implants normally cycled once tolerable, and sexual activity is often permitted after approximately 3 weeks, as advised by the surgeon.¹ Infection rates for IPP surgery, including the infrapubic approach, are low (routinely <1% yearly in experienced hands) when best practice infection prevention strategies are followed.¹˒¹¹