Surgical techniques and devices for IPP implant have evolved, improving patient safety and satisfaction [5], since Scott et al. described the first inflatable penile prosthesis (IPP) implantation in 1973 [6]. Complications occur most frequently in patients with diabetes, spinal cord injury or immunosuppression [7]. Revision procedures after IPP implantation are most frequently due to cosmetic or erosive etiologies as opposed to mechanical issues [8]. As increasing numbers of patients with erectile dysfunction undergo penile prosthetic implantation, unusual complications are being reported. This highlights the need for new, simpler and safer revision techniques [9].
Accessing the corpora through direct scrotal incision may be beneficial as it avoids the prior penoscrotal or high scrotal incisions and surgical difficulties due to adhesions and fibrosis from the prior intervention. However, the risk of iatrogenic injury due to the direct scrotal approach is non-negligible. The scrotal pump or tubing may be threatened. The biofilm capsule may be violated during dissection, possibly leading to post-operative infection. Scrotal edema or hematoma may prolong the post-operative recovery period and delay sexual activity resumption.
The direct crural approach may be an alternative surgical method useful to treat penile prosthetic cylinder complication and manage existing abnormalities. Prosthetic cylinder revision using our technique may be safe and efficient; the single crural incision provides a more superficial access to the corpora with less tissue manipulation as compared to the traditional scrotal approach. Our novel direct crural approach facilitates surgical repair and provides better surgical field exposure and thus a better anatomical perspective. The technique can be used for both inflatable and semirigid (malleable) penile prostheses. It is useful in revising proximal penile prosthetic cylindrical complications such as oversized cylinders causing S-shaped deformities, undersized cylinders causing incompletely dilated corpora and Glans Bowing (Penile supersonic transporter [SST] deformities), and proximal cylinder erosions beneath the skin and proximal cylinder crossovers. Both iatrogenic injury and post-operative recovery time may be reduced as the approach avoids adhesions below the original incision, without jeopardizing the already implanted materials or the urethra. To note that it is widely demonstrated that revision procedures of penile prosthesis are at higher risk of complications. This is due first to corporal fibrosis or infection. In this context, studies indicate a complications rate (especially infectious ones) ranging from 8 to 12% [10,11,12,13].
The reduction of surgical time is possibly one of the main reasons for success of our technique, with the consequent reduction of the risk of infection. The prosthetic surgeon will always prefer the simple, fast and clean procedure.
This direct crural approach has several limitations. First, it is not appropriate for numerous penile prosthetic cylinder complications including distal corporal erosions beneath the skin or glans deformities that need plication. Thus it could not be a good option in case of cylinder crossing due to the difficulty in controlling the rest of the corpus cavernosum It almost invariably requires bilateral access, regardless of the type of prosthesis, being a problem of incorrect implant size. Second, this approach allows only a limited exploration of the distal corpora, an essential step in achieving successful outcomes. It is not adapted to patients requiring implantation of a new device and it should be further explored in patients presenting prosthetic cylinder complications requiring a bilateral approach. Finally, we would highlight that here, we are only considering a very small series from a non-comparative study which preclude conclusions on a large scale.
