Introduction

Closing the corporotomies over the inflatable penile prosthesis (iPP) can be either with the classic technique of suturing the corporotomies closed in a running suture line, or by tying the stay sutures over the iPP cylinders [1]. Suturing the corporotomies closed yields water-tight closure, therefore -theoretically speaking- reducing the risk of hematoma and subsequent infection [2, 3], though no comparative studies exist to examine this assumption. However, caution should be exercised to avoid needle puncture of the iPP cylinders, which is reported to be responsible for approximately 8% of device failures [3]. This meticulous closure while avoiding damage of the cylinders increases operative complexity and duration. A shorter operative time lends to better infection control and lower infection rates [4]. Tying the pre-placed stay sutures is needle-free closure, avoiding the risk of puncturing the cylinders and is perceived as easier and with shorter operative time. However, this is at the expense of non-watertight sealing of the corporotomies, possibly increasing the risk for hematoma formation. Therefore, many implanters adopt measures to prevent hematoma formation such as suction drainage [5], the mummy-wrap [6], or leaving the cylinders semi-inflated to act as an internal tamponade [7], particularly when closing the corporotomies by tying the pre-placed stay sutures in an interrupted fashion [3]. Yet, surgeons with preference for tying the stay sutures may find themselves forced to suture, using the needle with the implant in situ, in case the stay sutures get cut or if there is a bleeding gap in the corporotomy.

In this study, we present Shaeer’s Corporotomy Closure Technique (SCCT); a surgical technique to enhance the ease and safety of suturing the corporotomies closed, with a lower risk of puncturing the cylinders. To achieve that purpose, the corporotomy edges are everted away from the iPP cylinders by placing stay sutures in a horizontal mattress fashion, on either side of the corporotomy. After suturing the corporotomies closed, the mattress stays can be removed.

Subjects and methods

This is a prospective randomized controlled study performed in a single center, between 2022 and 2025, in Cairo, Egypt. Ethical approval #N-159-2025 was obtained from the Research Ethics Board, Kasr El Aini Faculty of Medicine, Cairo University, Egypt. All methods were performed in accordance with the relevant guidelines and regulations. Thorough patient counseling was performed, explaining the nature of surgery and its possible outcomes. Surgical steps were illustrated, particularly the different methods of corporotomy closure including SCCT, with the pros and cons of each. The advantages of SCCT were explained, as well as the possible disadvantage, namely the use of needle suturing with risk of device failure – though mitigated- and the longer operative time. Written informed consent was obtained from all participants.

iPP implantation was performed for 32 patients with erectile dysfunction refractory to medical treatment. Patients had full history taking including demographic data (age, relationship status, fertility status, ethnicity, contact information), general medical history and sexual history including types and outcome of previously-tried treatment modalities for ED, general and local examination, review of previously done investigations for ED, pre-operative investigations and anesthesia review. Exclusion criteria included patients who had previous penile surgery, Peyronie’s disease, history of priapism, corporal fibrosis or radical prostatectomy, patients with a requirement for ancillary procedures, or those receiving anticoagulant therapy.

Patients were randomized into two groups, using a computerized randomization generator, with allocation blinded to the surgical team. Control Group had the corporotomies closed by tying the pre-placed stay sutures. SCCT Group had the corporotomy edges everted with pre-placed horizontal mattress sutures, then sutured closed.

Operative details

Surgery was performed through the peno-scrotal incision. Dartos and Buck’s layers were dissected down to the corpora cavernosa. For the Control Group, four stay sutures were pre-placed using 2/0 Polyglactin suture material, one on each side of the intended corporotomy sites. Each stay suture was placed in a W-shape, ending in four suture limbs on each side of the intended corporotomies. Corporotomies were cut open. The corpora were dilated, measured, and cylinders were implanted. Corporotomies were closed by tying-over the stay sutures, over the iPP cylinders.

For SCCT Group the following steps were performed: A stay suture was placed at the upper angle of the intended corporotomy (Fig. 1-A). This was pulled upon to pull the tunica albuginea of the crura out, for a proximally-placed corporotomy. It would serve other purposes as will be demonstrated further on.

Fig. 1: Laying-in the stay sutures.
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A Upper angle stay suture. B First arm of the everting suture, perpendicular to and towards the intended corporotomy (C) Secomd arm of the everting suture, parallel to and along the line of the intended corporotomy. D Third arm of the everting suture, perpendicular to and away from the intended corporotomy.

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Four horizontal mattress sutures were placed on each side of the intended corporotomy, two on each corpus cavernosum. This was performed as follows: Starting with the medial mattress suture, a 2/0 Polyglactin suture line was passed into the tunica albuginea close to the spongiosum, from medial to lateral, in then out (Fig. 1-B). The suture was then passed parallel to and along the line of the intended corporotomy, half a centimeter laterally, in then out (Fig. 1-C). This was completed by passing the suture line back, from lateral to medial, in and out of the tunica, along the line of the first entry point (Fig. 1-D). This was repeated as a mirror image on the other side of the intended corporotomy on the same side. Then a similar pair was placed on the contralateral corpus cavernosum.

The corporotomies were cut. The horizontal mattress stay sutures were then tied on either sides of the corporotomies, everting the edges. For each knot, one of the two suture ends was cut, and the other kept to pull on the corporotomy edge (Fig. 2).

Fig. 2
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Everting sutures tied, corporotomy cut and everted.

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The corpora were dilated, measured, and cylinders were implanted. Upon implantation, the stay suture at the upper angle was pulled upwards to lift-up that angle, allowing easier insertion of the distal tip of the cylinder, however short the corporotomy was. The everted corporotomy edges were then sutured closed in a running fashion (Figs. 3, 4), starting from the proximal end adjacent to the tubes, proceeding distally towards the stay suture at the upper angle. We mostly ran the suture line loose, and pulled it taught once the upper angle was reached. The running suture line was tied to the upper angle suture. Once the corporotomies were closed, the stay sutures were cut, and the stump pulled out unless deemed difficult. Video of the technique can be viewed at the Video Journal of Sexual Medicine [8].

Fig. 3
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Suturing the everted corporotomy edges.

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Fig. 4
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Corporotomy closed by a running suture line, before the everting stay sutures are removed.

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For both groups, the reservoir was inserted in a high submuscular position, and the pump was inserted in an anterior position. Submuscular reservoir placement was the surgeon’s and patient’s choice rather than a part of the technique at hand. The implant tubes were connected and cycling was performed. Suction drain was inserted. Buck’s fascia, Dartos and skin were closed. Mummy wrap was applied. Cylinders were left semi-inflated for one week. The drain was removed once drain output was less than 20 cc’s, and the drain tube was empty, not before 24 h, and no later than three days in any case. Cycling started by the third week.

Operative time, drain output, complications and device malfunction were recorded and compared across the two groups. We applied out regular follow up protocol to this patient cohort: Patients were followed up at the hospital on days 1, 2 and 6, then by clinic visits at day 7, 21 and day 40, then at 3 and 6 months post-operative, and by phone interviews every 6 months for the first 2 years, and an annual phone call every year thereafter. Phone interviews included a general question on satisfaction with rigidity on a 5-point scale, any change in ability to inflate and deflate the implant, and de-novo pain or deformity.

Statistical analysis was performed using Microsoft Excel 365. Results were represented as range, mean and standard deviation. Statistical significance was calculated using Student T-Test. P-Value of 0.05 or lower was considered statistically significant.

Results

There was no statistically significant difference in demographic data between the two groups. Mean age for Control Group was 62.3 years ± 7, and for SCCT Group; 62.6 ± 8.2, p = 0.93. Prevalence of controlled diabetes mellitus was 37.5% in Control Group and 31.25% in SCCT Group, p = 1.

Operative time was 9.5% (5 min) shorter in the Control Group (47.7 ± 5.3 mins vs. 52.7 ± 4.4 mins, p = 0.009). Drain output at 24 h was 78.8% (59.4 cc’s) higher for Control Group (75.4 ± 32.8 cc’s vs. 16 ± 8.6 cc’s, p < 0.001). Total drain output was 81.5% (77.5 cc’s) higher in Control Group (95.1 ± 64.8 cc’s vs. 17.6 ± 12 cc’s, p < 0.001) (Table 1, Fig. 5). For the Control Group, the drain was removed at Day 2 in 12/16 cases, and Day 3 in 4/16 cases. For the SCCT Group, all drains were removed at Day 2.

Table 1 Results.
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Fig. 5
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Results.

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For both groups, no intra-operative complications, infections or device mechanical failures were recorded through the follow up period; 14 months ± 4.4. One case in Control Group developed a scrotal hematoma that was detected at day 8, measuring 8 × 5.4 × 3.8 cm by ultrasonography. It resolved spontaneously over 3 months, delaying cycling until then. Another two cases in Control Group developed scrotal tissue induration surrounding the pump, though without a sonographically definable collection. This delayed deflation and cycling until the fifth week in one case, and 8th week in another. No hematoma or similar induration was recorded in SCCT Group, where cycling was successfully started by the third week post-operative.

As a subjective observation, everting the edges with SCCT rendered suturing the corporotomies significantly easier, compared to our past experience with suturing. Picking up the edges of the corporotomies was relatively easy, and with less risk for puncturing the iPP cylinders.

Discussion

The results at hand indicate a lower drain output upon suturing the everted corporotomies compared to tying the stay sutures, though at the expense of somewhat longer operative time.

To our knowledge, closing the corporotomies by tying the stay sutures was first proposed in 1993 by Montague [1], avoiding damage to the iPP with the surgical needle. This soon became popular amongst many high-volume implanters, though not all. Some still adopt suturing the corporotomies closed to avoid hematoma formation. The corporotomies required for iPP surgery can be a source of significant bleeding [2]. The overall incidence of hematoma formation following iPP surgery ranges from 0.2– 3.6% [2], up to 9.6% in complex cases [9]. With the less water-tight closure offered by tying the stay sutures, every effort should be exerted to guard against hematoma formation, hence the common practices of inserting a suction drain [5, 10], using the mummy-wrap [6], and/or leaving the cylinders semi-inflated [7]. Several other measures have been proposed to protect against hematoma formation. Those include the use of hemostatic agents over the corporotomies such as oxidized regenerated cellulose [11, 12], and tying a pre-placed suture over the tube at the proximal angle of the corporotomy [13]. On the other hand, with suturing the corporotomies closed, every effort should be exerted to avoid damage to the iPP with the surgical needle, however long this may require.

We have now operated on 16 cases with SCCT, and have found suturing the everted corporotomies to be relatively easy and safe, compared to the classic suturing technique. The everted edges pop out, away from the cylinders, lowering the risk of needle puncture. Water-tight closure with suturing is -theoretically speaking- more effective in preventing hematoma formation, compared to the interrupted closure offered by tying the stay sutures. This is demonstrated in this study by the lower drain output and lower incidence of hematoma and induration in SCCT Group compared to tying the stay sutures in Control Group. Bleeding through the corporotomies in Control Group could have been higher, if not for the drain, the mummy wrap and leaving the cylinders semi-inflated.

A full-blown hematoma may be uncommon, but can result in implant infection and explantation. Nevertheless, it is our observation that milder forms of hematoma are more prevalent. They result in scrotal induration and therefore difficulty and delay in cycling the implant. This was encountered in Control Group where the stay sutures were tied.

On the other hand, there is the longer operative time with water-tight suturing does not pass unnoticed. Although we have not noticed a difference in infection rates between the two groups, it should be acknowledged that a shorter operative time is a factor that reduces infection rates [4, 14]. Tying the stays is safe and efficient. This speed factor would have been even more obvious if the stays are laid in a single pass (the U-shaped stay suture) rather than two passes (the W-shaped stay suture). Cylinder safety is also a clear advantage with tying the stay sutures. However, tying the stay sutures is not 100% cylinder safe. It happens occasionally that after tying the stay sutures, there is need to suture a bleeding gap in the corporotomy line. This would add time and difficulty to the procedure, with the potential risk of puncturing the cylinder, defying the purpose of tying the stay sutures.

So, it appears that every one of those techniques has its unique point of strength: water-tight closure for suturing, versus speed and cylinder safety for tying the stays. With everting the edges in SCCT, suturing can now be performed with higher cylinder-safety, possibly bringing suturing back.

With tying the stay sutures, it is our habit to leave the cylinders semi-inflated, and to drain and wrap. We take all possible measures to avoid hematoma. With SCCT, we are now encouraged to give up one or more of the fore mentioned hematoma-preventing measures, starting with deflating the cylinders earlier if the patient expresses the need for it. We know that this bodes well with most patients, lending to a more satisfactory post-operative experience. However, the main aim is not to give up on protective measures, but to lower the risk of hematoma formation that is more liable to occur with tying the stay sutures, even with adopting all guarding measures. An avid supporter of tying the stays may still consider suturing in particular cases. An example being a case with a bleeding disorder. In such situations, everting the corporotomy edges will possibly help.

Limitations of the current study include lack of prior power analysis, this being a pilot study, the primary investigator (main surgeon) not being blinded to the operative time and drain output, and lack of external validation by other centers. A multi-center study is always preferred before reaching a verdict. The limited follow up period meant lack of reporting on long-term revision rates, mechanical failures and couple satisfaction. Lack of comparison to a third group where the corporotomies are sutured without eversion is another limitation.

In conclusion, suturing the corporotomies closed may lower the risk of hematoma formation, though with the risk of needle-puncture of the iPP cylinders. SCCT protects the cylinders by everting the corporotomy edges. Further multi-center studies with larger sample numbers are needed for a more solid conclusion. While running sutures are more hemostatic, further measures to minimize the risk for hematoma are always recommended.