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Which of these approaches is best and why one over the other.

The jury is out on this one. My surgery was infrapubic and I had absolutely no problems. The thought of getting my "nut sack" terrified me.
Donnie

From what I have read, scrotal incisions are preferred with the high volume surgeons. I remember Kramer stating a number of reasons why he does scrotal. These include avoiding nerve damage (penis nerves run down pubic area where pubic incisions are made), easier pump placement, and easier cylinder sizing. This isn't to say you cant get a good result with infra-pubic, its just Kramer and Eid do it scrotal because they think it gives their patient a better result.

Personally, I would insist on scrotal. Kramer / Eid will absolutely do that.

I have experienced both. First and third penoscrotal, and second infra public. Aside from what was mentioned before, technically, the infra pubic procedure allows faster healing due to less scrotal swelling.

My first surgeon left me with a grapefruit sac for 5-6 weeks. But if you use a pro like Kramer, the scrotal swelling is not an issue. There will be discomfort, which is managed by ibuprofen.

I was told that "the most difficult and unpredictable " part of the implant operation involves placing the pump in the proper place in the scrotum. The peno-scrotal approach allows for better control of how and where the pump will "lie" in the scrotum; and , I am told, it also allows for more effective hiding and placing of the tubes (sometimes , I am told, the tubes can be felt during lovemaking in infrapubic installs.)

I just did a quick search on this and there is a paper discussing this topic. the key excerpt is:

".. The advantages of the penoscrotal access reported in this paper are:

– The penoscrotal approach provides an excellent exposure.
– It affords proximal crural exposure if necessary.
– Avoids dorsal nerve injury.
– Permits direct visualization of pump placement.

The disadvantage highlighted for the penoscrotal approach is that the reservoir is blindly placed into the retropubic space, which can be a problem in patients with a history of major pelvic surgery (mainly radical cystectomy). Furthermore this document reinforces the idea that revision surgery is associated with decreased outcomes and may be more challenging with the infrapubic approach.

The ISSM Consensus in Chapter 18 (8), dedicated to penile implants reports that there is no clear advantage of one type of access or other, and the choice depends on the surgeon's preference and that the literature data showed that the incidence of infection is similar between the penoscrotal and infrapubic access. ...."

There is also a statement that:

"...A very interesting study comparing penile prosthesis implant surgery before and after Expert Training with Standardized Operative Technique for residents demonstrated that after the training, penoscrotal access increased from 52.2% to 97.8% ..."

To contradict the above, there apparently was a survey of 42 patients that concluded that both groups were happy, and there was no statistical difference: "....Candela & Hellstrom presented retrospective study comparing satisfaction of the patients submitted to implantation of 3 volume inflatable penile prosthesis with penoscrotal and infrapubic access through a questionnaire sent to 86 patients. Analysis of the 42 questionnaires returned demonstrated no statistical differences in the replies of the two groups in either the factual or perceptual data (9)....."


REFERNECE:
Gromatzky C. Opinion: Why I prefer the penoscrotal access. International Brazilian Journal of Urology : official journal of the Brazilian Society of Urology. 2015;41(3):410-411. doi:10.1590/S1677-5538.IBJU.2015.03.04

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4752132/

Mine said he uses infrapubic because of the risk in reservoir placement. It is the most dangerous part of the procedure.
Because of my RP, even with infrapubic, it was difficult to place my reservoir because of that previous surgery. Thus mine is next to my bladder instead of ectopically in the muscle.

Really depends on the patient and surgeon. Go with a high volume surgeon and ask them what their complication and redo rates are if not going with Dr Kramer or Eid. I had zero problems with mine and began inflating gently in about two weeks and intercourse at the same time. Sore first few days and then swelling and pain rapidly improved with peno scrotal. I honestly think it is the surgeon not the approach and some luck to be sure if they only have a 1% problem rate that you are not the 1%. A surgeon mentor of mine told me back in med school that complication rates for an individual patient are 0% or 100%. Younger and healthier less chance of issues. High volume doc less chance of issues. Follow instructions less chance of issues. Etc. Good luck.

I too have had both. First was scrotal but I chose my surgeon poorly. Among my many problems was reservoir migration that Dr Perito said was actually dangerous. My second two were infra public. My current issues are relatively minor, the worst being "cold head".

I believe choice of surgeon is at least and probably more important than insertion method.....

Good luck!