Abstract Introduction Penile prosthesis implantation is guideline-supported for drug-refractory erectile dysfunction (ED). In transplant recipients or hostile abdomen, a two-piece inflatable penile prosthesis (IPP) avoids an intra-abdominal reservoir while providing on-demand rigidity and simplified implantation. We present a standardized penoscrotal technique with practical pearls and a structured early recovery pathway. Objective To demonstrate a reproducible reservoir-free IPP implantation with emphasis on safe dilation, accurate sizing, pump-pocket optimization, intraoperative cycling and troubleshooting. Methods Video case of a 58-year-old renal-transplant recipient with complete, PDE5i-refractory ED who declined injections. Key steps shown in real time: midline penoscrotal incision; transverse dissection through Dartos and the superficial fascial plane; protection of the urethra and separation from proximal corpora; Lone Star retractor for circumferential exposure; four stay sutures on the tunica (3-0 Vicryl); left corporotomy (1.5–2 cm); sequential distal and proximal dilation with the Furlow introducer maintaining a lateral trajectory; distal/proximal measurements for sizing; antibiotic irrigation (gentamicin, rifampicin, fluconazole) per protocol; mirrored preparation on the right; creation of a dependent sub-Dartos pump pocket (lateralized to the dominant hand); proximal/distal cylinder insertion; pressurized cycling to confirm symmetry, alignment and hemostasis; deflation test; bilateral corporotomy closure (proximal then distal knots, buried); two-layer fascial closure leaving the device partially inflated; skin closure and compression dressing. Early pathway: Foley removal day 1; discharge day 2; gentle pump mobilization weeks 2–3; full activation at week 8 with home cycling. Results Uneventful course with on-schedule milestones (catheter removal at day 1 and discharge at day 2). Education enabled early familiarity and comfortable activation at week 8. Conclusions In carefully selected patients where an abdominal reservoir is undesirable - such as post-transplant - two-piece IPP offers a pragmatic, efficient solution. A standardized penoscrotal workflow with attention to lateral dilation, precise sizing, optimized pump pocket and intraoperative cycling helps avoid common pitfalls and supports early recovery, consistent with contemporary guidance and reviews. Disclosure No
Chambino et al. (Mon,) studied this question.