Hydraulic penile prosthesis: infrapubic or penoscrotal approach – what are the differences?

Two surgical approaches, one goal

When a hydraulic penile implant is being considered, a question often arises: is it better to make an incision above the base of the penis or at its junction with the scrotum? These two approaches, known as the infrapubic and penoscrotal approaches, are used to insert a device designed to provide the rigidity necessary for sexual intercourse. This article focuses primarily on three-piece hydraulic implants.

The answer cannot be based on the size of the scar or the promise of a quick recovery. The recommendations of the European Association of Urology do not indicate that one approach is generally superior to the other in terms of patient satisfaction and complications. They emphasise the importance of being familiar with both techniques in order to adapt the approach to complex cases. [1]

Understanding the components of the implant

A three-piece hydraulic system comprises two cylinders placed within the corpora cavernosa of the penis, a pump located in the scrotum and a reservoir containing fluid. Tubing connects these components. The patient activates the pump to achieve rigidity, then the deflation mechanism to return the cylinders to their resting state.

The incision is the access point used to insert these components. It does not denote a specific brand nor, on its own, a category of performance. In both approaches compared here, the pump is designed to remain in the scrotum. The infrapubic approach therefore does not mean that the patient will have to operate a pump above the penis. [2]

Infrapubic approach: access and points to note

The incision is made above the base of the penis, in the area below the pubis. This approach may facilitate visualisation during certain steps involved in placing the reservoir. The pump must then be guided into a scrotal pocket via this approach.

The difficulties described relate in particular to preserving the dorsal neurovascular bundle, a working space that is sometimes limited, and the positioning of the pump. A technical academic article published in October 2026 also emphasises the learning curve. It brings together surgical advice and the experience of experts: this is not a trial demonstrating superiority over the penoscrotal approach. [3]

For the patient, the key considerations relate to the final position of the pump, its accessibility and the team’s experience with this approach, rather than solely the stated length of the incision.

Penoscrotal approach: access and points to note

The incision is made at the junction of the penis and scrotum, or in the upper part of the scrotum, depending on the variant. This approach provides access to the corpora cavernosa and the pocket intended for the pump. The technical literature describes the possibility of positioning and securing the pump under direct visual control.

Placement of the reservoir requires a distinct strategy: the penoscrotal approach does not guarantee direct visualisation of its entire trajectory. Swelling or bruising of the scrotum may also temporarily affect post-operative recovery. These characteristics explain the practical advantages and limitations; they do not allow us to conclude that this approach is safer in all situations. [2,4]

Technical data sheets and accessories: how does the chosen route make a difference?

Surgical descriptions distinguish between the cylinders, any extenders, the pump, the reservoir, the connectors and the instruments used to fit them. The tubing must follow a suitable path, without tension or excessive kinking. Exposure and insertion tools do not serve the same purpose as the components that will remain in the body. [3,4,5]

It is therefore necessary to distinguish between three decisions: the device selected, its configuration and the route of access. The length of a tubing or a pre-connected assembly may depend on the exact model. It cannot be stated that all prostheses have a universal kit that is interchangeable between the two routes.

A technical data sheet describes the possibilities and conditions of use. It does not prove that a particular configuration yields better clinical results. Ask for the compatibility of the equipment to be verified in its instructions for use and for the surgical report to specify exactly what was actually implanted.

What do comparative studies say?

A study published in 2018 compared 42 patients, divided into two matched groups of 21: the penoscrotal approach and the minimally invasive infrapubic approach. The average duration of surgery was 128 minutes in the first group compared with 91 minutes in the second. Satisfaction and quality-of-life scores were comparable; no statistically significant difference in complications was found. [6]

Four patients in the infrapubic group had resumed sexual activity within four weeks, compared with none in the penoscrotal group. This observation does not constitute a recommendation for early resumption: the sample size is small, the study was conducted at a single centre, and the timing must remain individualised. [6]

A systematic review of 26 publications, published online in 2023, also found no significant overall difference in complications. It reports certain advantages regarding operative time for the infrapubic approach and more frequent use of the penoscrotal approach, particularly due to the surgical exposure it provides. The studies included are heterogeneous. The absence of a demonstrated difference does not prove perfect equivalence. [7]

Pain, rehabilitation and resumption of sexual intercourse

These three criteria must be considered separately. A shorter operation does not guarantee less pain. Early use of a vacuum pump does not mean that the scar allows for sexual intercourse. Rehabilitation protocols, pain management, wound healing and the centre’s practices all influence the timeframe.

A hospital information sheet on the suprapubic approach provides for training and approval from the team before sexual activity, often around four to six weeks into the patient’s own recovery process. This guideline should not be taken as a promise applicable to all patients or all teams. [8]

To compare two proposals, ask what exactly is meant by ‘recovery’: walking, returning to office work, operating the pump, taking part in sport or resuming sexual intercourse.

Glans sensitivity: an issue to be addressed without either downplaying or exaggerating it

A French study published in 2026 retrospectively examined 116 patients who underwent infrapubic surgery at two centres between 2010 and 2022. With a median follow-up of 81.5 months, 31 patients, or 26.7 per cent, reported a reduction in glans sensitivity. [9]

This finding warrants discussion. It does not mean that one in four patients will necessarily suffer nerve damage as a result of this approach. The study does not include a penoscrotal control group and does not demonstrate a causal link between the surgical approach and the symptom. The authors call for prospective comparative studies to clarify this issue. [9]

The pre-operative assessment must document sensation prior to the procedure and address any changes following it. Claims such as ‘no risk to sensation’ or ‘inevitable loss of sensation’ are not supported by these data.

Reservoir and history of pelvic surgery

Following a prostatectomy, bladder surgery or certain hernia operations, the anatomy and tissues may be altered. The surgeon must therefore explain where they intend to place the reservoir and whether they are considering an alternative site or an additional incision.

The skin approach and the final location of the reservoir are two related but distinct factors. A hospital information sheet describes, for example, the possibility of an additional approach to ensure secure placement in certain patients who have previously undergone surgery. [8]

An international consensus also emphasises the importance of adapting the strategy to the patient’s anatomy, medical history and associated procedures. It would be simplistic to choose a particular approach solely on the basis that the reservoir is ‘easier’ to insert via that route. [2]

Infection, device failure and reoperation: comparing comparable situations

Both approaches remain prosthetic surgical procedures: infection, haematoma, tissue damage, component displacement or mechanical problems must be considered. Device failure and a complication arising from the surgical approach are not synonymous. [1,2]

In the French cohort of 116 patients, four infections were reported. Procedures performed by high-volume surgeons were associated with a lower risk of reoperation, although this association is not sufficient to establish causality. [9]

An isolated rate from a single centre is insufficient to rank two techniques. It is necessary to know the duration of follow-up, whether the procedures were initial placements or revisions, the presence of complex cases, patients lost to follow-up, and the definition of complications. These factors are just as important as the percentage reported.

How should you make a decision with your surgeon?

Publications do not identify a single best approach for all patients. The choice must be explained on the basis of your medical history and the team’s experience. The desired scar may be part of the discussion, but it does not sum up the procedure.

Prepare these questions:

- Why are you recommending this approach in my case? - Which aspects of my medical history influence this choice? - Where will the reservoir and pump be placed? - What experience do you have with this approach and with cases similar to mine? - What outcomes and complications do you monitor, and over what period? - How will you ensure that I am able to locate and operate the pump? - When will the training, follow-up checks and clearance to resume sexual activity take place? - Who will provide follow-up care and emergency treatment after my return if I have the operation abroad?

A good comparison explains the trade-offs and uncertainties. It allows us to discuss a suitable strategy, rather than choosing a technique based on a catchphrase.

This content provides general information and is not a substitute for a medical consultation.

References

[1] European Association of Urology. Guidelines on Sexual and Reproductive Health, Management of Erectile Dysfunction, section on penile prostheses. Online version accessed on 10 November 2026. https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/management-of-erectile-dysfunction

[2] Chung E et al. The International Penile Prosthesis Implant Consensus Forum: clinical recommendations and surgical principles on the inflatable 3-piece penile prosthesis implant. Nature Reviews Urology. 2022. DOI: 10.1038/s41585-022-00607-z. https://doi.org/10.1038/s41585-022-00607-z

[3] Pozzi E et al. Top ten surgical tricks: infrapubic inflatable penile prosthesis implantation. International Journal of Impotence Research. Published online 13 October 2026. DOI: 10.1038/s41443-026-01370-0. Abstract consulted; technical advice and expert opinions. https://pubmed.ncbi.nlm.nih.gov/42869942/

[4] Gupta NK et al. The penoscrotal surgical approach for inflatable penile prosthesis placement. Translational Andrology and Urology. 2017;6(4):628–638. DOI: 10.21037/tau.2017.07.32. https://pmc.ncbi.nlm.nih.gov/articles/PMC5583046/

[5] Karpman E. Streamlined Approach for Infrapubic Placement of an Inflatable Penile Prosthesis. Advances in Urology. 2012:520180. DOI: 10.1155/2012/520180. https://pmc.ncbi.nlm.nih.gov/articles/PMC3368174/

[6] Grande P et al. Penoscrotal versus minimally invasive infrapubic approach for inflatable penile prosthesis placement: a single-centre matched-pair analysis. World Journal of Urology. 2018;36:1167–1174. DOI: 10.1007/s00345-018-2249-z. Abstract consulted. https://pubmed.ncbi.nlm.nih.gov/29492584/

[7] Penoscrotal approach for inflatable penile prosthesis implantation: why it should be preferred. Minerva Urology and Nephrology. Published online in 2023, PMID: 38126284. Systematic review of 26 publications; abstract consulted. https://pubmed.ncbi.nlm.nih.gov/38126284/

[8] The Christie NHS Foundation Trust. Infrapubic inflatable penile prosthesis. Patient information sheet, April 2020, scheduled for review in April 2023. Used to illustrate a hospital pathway, without implying that its protocol is current or universal. https://www.christie.nhs.uk/media/wswjrqtc/1387-infrapubic-inflatable-penile-prosthesis-uro-april-2020.pdf

[9] El Akri M et al. Infrapubic approach for inflatable penile prosthesis: Perioperative and long-term outcomes. French Journal of Urology. 2026;36(4):103087. DOI: 10.1016/j.fjurol.2026.103087. Abstract consulted; retrospective study, level of evidence 4. https://pubmed.ncbi.nlm.nih.gov/41653989/