Aquadissection (Hydrodissection) Technique in Penile Prosthesis Surgery
Aquadissection (hydrodissection) is the opening of the erectile tissue in penile prosthesis surgery not by forcing it with metal dilators but by separating it with pressurised saline. The aim, in one sentence: to preserve as much as possible of the penis’s own blood supply and tissue while placing the implant. On this page I describe the technique, how it differs from the classical method, how it addresses the problem of a cold glans, who it suits and — importantly — who it does not suit, and I assess the level of evidence honestly.
What is on this page?
- What aquadissection is and the philosophy behind it
- How I perform the technique (saline + 8 F Furlow)
- What is being preserved: why does the glans go cold?
- Preserving the cavernosal artery: randomised trial data
- Comparison table with classical dilatation
- The difference between a cold glans and a drooping glans
- Who it suits and who it does not
- An honest assessment of the evidence
- A 13-question FAQ
What Is Aquadissection?
The most critical stage of penile prosthesis surgery is creating the space for the cylinders inside the erectile tissue (corpus cavernosum). In the classical method this is done with metal dilators of increasing diameter: the tissue is expanded by being mechanically forced.
Aquadissection performs this expansion not with the force of a metal instrument but with pressurised fluid. The fluid advances between the natural anatomical layers of the tissue and opens the space from within. This principle is not new in surgical literature; the same logic is used in nerve- and vessel-sparing dissection in other operations. The difference here is that it is applied within erectile tissue.
The core difference in philosophy is this: classical dilatation makes room by crushing tissue; aquadissection makes room by separating it.
How I Perform the Technique
In the method I use, no additional drug is used; only saline (sterile salt water). After entering the corpus cavernosum, an 8 F Furlow is advanced and saline is delivered under pressure so that the space opens from within.
The critical point is this: dilatation in the classical sense is not performed in this technique. That is, the tissue is not forced at any stage with metal dilators of increasing diameter. What opens the space is not the diameter of an instrument but the pressure of the fluid. 8 F is far below the diameters reached in classical dilatation and is the thinnest instrument entering the tissue.
As a result the erectile tissue is not crushed, only separated along its own layers. When the cylinder is placed, the surrounding tissue remains living, perfused tissue.
What Is Being Preserved? Why Does the Glans Go Cold?
A penis with an implant no longer takes its rigidity from the blood vessels. But the glans is not part of the implant. The glans still takes its fullness from its own blood supply, and the main source of that flow is the cavernosal artery and the sinusoidal channels within the erectile tissue.
In classical serial dilatation these structures are largely destroyed. This is the mechanism underlying the complaints patients report after surgery: “the shaft is rigid but the head is not”, “the glans feels cold”, “it is not as full as it used to be”.
This complaint is a defined topic in the literature. A scoping review published in the Journal of Sexual Medicine notes that reduced glans fullness after penile prosthesis surgery is one of the known causes of patient dissatisfaction, presenting as a cold, insensate feeling in the glans or a perception that the penis has become shorter. In the same review, when solutions are listed, cavernosal-sparing surgical technique appears as the first category.
The Strongest Basis: Preserving the Cavernosal Artery
This is the scientific foundation of the technique. In a randomised open-label study comparing the cavernosal-sparing (minimal dilatation) approach with the classical method, 33 patients received three-piece inflatable implants; one group underwent classical serial and forceful dilatation, while in the other the tissue was expanded from within followed by only minimal passage. The cavernosal artery was then sought with colour Doppler ultrasound after surgery.
This finding has a second importance: because the artery is preserved, a vascular response to oral erection tablets could also be measured in these patients after surgery. In other words the tissue is still alive and responsive. That is the precondition for tablet treatment to be able to help with the problem of glans fullness.
Classical Dilatation vs Aquadissection
| Topic | Classical serial dilatation | Aquadissection / minimal passage |
|---|---|---|
| Method of opening the space | Mechanical forcing with metal dilators of increasing diameter | Pressurised saline advancing between tissue layers |
| Diameter of instrument entering the tissue | Increases stepwise | 8 F Furlow — single and thin |
| Effect on erectile tissue | Marked crushing and destruction | Tissue largely preserved |
| Cavernosal artery | Lost in most cases (31% preserved) | Preserved at a high rate (94% preserved) |
| Glans fullness | Higher risk of reduction | Expected to be better as blood flow is preserved |
| Response to tablet treatment | Usually lost | Vascular response remains measurable |
| Tendency to bleeding | Greater | Less |
| Perforation / false passage risk | Theoretically higher as tissue is forced | Lower as the fluid follows the natural plane |
| Fibrotic and revision cases | The necessary method | Cannot be used — the natural tissue plane is gone |
Two Different Glans Problems: Not to Be Confused
Patients often think these are the same thing; in fact their mechanisms and solutions differ.
| Soft / cold glans | Drooping glans (SST deformity) | |
|---|---|---|
| Complaint | The glans is cold and not full | The glans droops downwards, feels mobile |
| Main mechanism | Vascular — inadequate blood flow to the glans | Mechanical — inadequate distal expansion, short or poorly positioned cylinder, ligament laxity |
| Frequency | Little studied, often underestimated | Reported at 0.2–0.9% for SST |
| Contribution of aquadissection | Direct — preserves the structures providing blood flow | Indirect — achieves correct expansion to the tip without destroying tissue |
| Later treatment | Tablet treatment may be tried (limited evidence, small series) | Surgical correction (glanulopexy) may be needed |
The main message here is this: the best treatment for both problems is to prevent them during the operation.
Who Is It Suitable For, and Who Is It Not?
This is the most important section of the page, because aquadissection is not a technique that can be applied to every patient and forcing it would be wrong.
| Suitable | Not suitable | |
|---|---|---|
| Order of surgery | First (primary) implant surgery | Revision / secondary cases |
| Tissue condition | Erectile tissue largely preserved | Advanced corporal fibrosis |
| Previous surgery | No previous penile surgery | Previous implant placed and removed |
| Special situations | Patients with some remaining erectile function | Widespread scarring after priapism |
| Peyronie’s disease | — | Not suitable — full dilatation is needed to correct the curvature |
| Expectation | Glans fullness is a priority for the patient | Cases where tissue planes are obliterated by scar |
Why is it not used in secondary and fibrotic cases? The whole logic of aquadissection rests on the fluid advancing between the natural layers of the tissue. In a corpus that has had previous surgery or is severely fibrotic, these layers are stuck together by scar and the natural plane has disappeared. The fluid finds no path. In such cases classical dilatation or special cavernotomes are required. In short, this technique is meaningful in a patient who still has tissue to preserve; if the tissue is already lost, there is nothing to preserve.
Why not in Peyronie’s disease? In Peyronie’s disease the aim of implant surgery is not only to provide rigidity but also to correct the curvature. This correction (modelling) requires the corpus to be fully dilated all the way to the tip. The principle of minimal passage therefore does not apply in these cases. For implant surgery in Peyronie’s disease you may see our related page.
An Honest Assessment: What Is the Level of Evidence?
Advocating a technique does not require overstating it. The current state of the literature on aquadissection is as follows:
| Claim | Basis | Strength of evidence |
|---|---|---|
| Minimal / sparing passage preserves the cavernosal artery | Randomised study, objective measurement with colour Doppler | Strong |
| Preserved tissue gives a vascular response to tablet treatment | Same study | Moderate–strong |
| Reduced glans fullness is a real and defined problem | J Sex Med scoping review | Strong |
| Cavernosal-sparing technique is one of the solutions to this problem | Listed as the first category in the same review | Moderate |
| Long-term satisfaction superiority of aquadissection | No large direct comparative study exists | Limited |
It should be said plainly: large-scale, long follow-up studies comparing aquadissection with the classical method have not yet been performed. The logic of the technique and the intermediate results are strong; but this is not enough to claim superiority in every patient. This approach is a developing surgical philosophy that is increasingly preferred and that is meaningful when applied in the right patient group.
Key points
- Aquadissection is the opening of the corpus cavernosum with pressurised saline rather than metal dilators.
- Only saline and an 8 F Furlow are used; classical dilatation is not performed.
- The aim is to preserve the cavernosal artery and the erectile tissue.
- In a randomised study, cavernosal artery preservation was 94% with minimal dilatation versus 31% with the classical method (p=0.001).
- The glans is not part of the implant; it takes its fullness from its own blood supply. This is the basis of the cold-glans complaint.
- A cold glans is vascular, a drooping glans (SST) is mechanical; they are different problems.
- Suitable: patients undergoing a first implant with preserved tissue.
- Not suitable: revision cases, advanced fibrosis, scarring after priapism and Peyronie’s disease.
- There is not yet a large comparative study showing long-term superiority of aquadissection.
Frequently Asked Questions About Aquadissection
What is aquadissection?
Aquadissection is the opening of the space for the implant cylinders in penile prosthesis surgery using pressurised saline rather than metal dilators. The fluid advances between the natural layers of the erectile tissue and creates the space from within. It is also called hydrodissection.
What is the difference from classical dilatation?
In the classical method the tissue is mechanically forced open with metal dilators of increasing diameter. In aquadissection the space is opened not by the diameter of an instrument but by the pressure of the fluid; the tissue is not crushed but separated along its own layers. In short, classical dilatation makes room by crushing, aquadissection by separating.
What fluid is used?
In our practice only saline, that is sterile salt water, is used without any additional drug. The fluid is delivered under pressure through an 8 F Furlow.
Is no dilatation performed at all?
Dilatation in the classical sense is not performed. The tissue is not forced at any stage with metal dilators of increasing diameter. The only instrument entering the tissue is an 8 F Furlow, a diameter far below those reached in classical dilatation.
Does it prevent the glans from staying cold?
The glans is not part of the implant and takes its fullness from its own blood supply. In classical serial dilatation the structures providing this blood flow are largely destroyed. In a randomised study of a cavernosal-sparing approach, the cavernosal artery was preserved in 94% of the minimal dilatation group versus 31% in the classical group. When tissue and vessel are preserved, better glans fullness is expected; however, there is not yet a large direct comparative study on this point.
Who is aquadissection suitable for?
It is suitable for patients undergoing a first implant whose erectile tissue is largely preserved and who have not had previous penile surgery. In short, it is meaningful in a patient who still has tissue to preserve.
Who is it not suitable for?
It is not suitable in revision (second) implant surgery, advanced corporal fibrosis, patients with widespread scarring after priapism, and Peyronie’s disease. In Peyronie’s disease full dilatation is required so that the curvature can be corrected, so this technique is not used.
Why is it not used in secondary and fibrotic cases?
The whole logic of the technique rests on the fluid advancing between the natural layers of the tissue. In a corpus that has had previous surgery or is severely fibrotic, these layers are stuck together by scar and the natural plane has been lost. The fluid finds no path; in such cases classical dilatation or special cavernotomes are required.
Does it lengthen the operation?
When the right patient is selected there is no marked increase in operating time. Because the steps of serial dilatation are removed, in some cases the time may even be shorter.
Does it carry additional risks?
Because the tissue is not forced, the risk of perforation and creating a false passage is theoretically lower and there is less tendency to bleeding. However, it is not right to force the technique in fibrotic or revision cases where it is unsuitable; in those situations classical methods are used.
Can it be used with any implant brand?
Yes. Aquadissection is not a device but a technique of corporal preparation. It can be used with different brands of three-piece inflatable implants. For implant types and brands you may see our penile prosthesis page.
What is the level of evidence?
The honest answer is this: large-scale, long follow-up studies comparing aquadissection with the classical method have not yet been performed. On the other hand, the cavernosal-sparing minimal dilatation approach on which the technique is based showed clear superiority over the classical method in preserving the cavernosal artery in a randomised study. It should therefore be regarded as a developing surgical approach that is increasingly preferred.
Does it change the cost of the implant?
Cost varies with the implant type, the brand chosen and the clinical situation, and under Turkish healthcare regulations fixed prices cannot be published. Aquadissection is a surgical technique that does not require a separate device. For current information you may contact the clinic.
If you are considering a penile prosthesis, which surgical technique suits you is determined at examination. Get in touch for an assessment or an appointment.
Scientific References
- European Association of Urology (EAU). Guidelines on Sexual and Reproductive Health — Erectile Dysfunction. 2024.
- Randomised open-label study comparing a cavernosal-sparing implantation technique with classical serial dilatation; 33 patients, three-piece inflatable implants, postoperative colour Doppler ultrasound assessment of the cavernosal artery (preservation: 94% vs 31%, p=0.001).
- Scoping review on reduced glans fullness after penile prosthesis surgery and its management. The Journal of Sexual Medicine.
- Review publications on SST (drooping glans) deformity and glanular support insufficiency; reported frequency and surgical correction approaches.
- Small patient series on the use of PDE5 inhibitors for glans fullness after penile prosthesis surgery.
- Long-Term Survival Rates of Inflatable Penile Prostheses: Systematic Review and Meta-Analysis. Urology. 2022.
This content is for general information only and does not replace examination by a specialist. Aquadissection is not a technique that can be applied in every patient; suitability is decided after examination and clinical assessment. The literature data presented on this page belong to the patient groups of the relevant studies and do not guarantee identical results for every patient. For diagnosis and treatment, please consult a specialist physician.
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