Penile lengthening original technique using a pubo-cavernous spacer

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madman

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Penile lengthening original technique using a pubo-cavernous spacer. Long-term results from a series of over 200 patients (2022)
Antonio Rossi, Giovanni Alei, Marco Frisenda, Antonio Tufano, Pietro Viscuso, Guglielmo Mantica, Pierluigi Bove, Rosario Leonardi, Alessandro Calarco


Summary

Introduction:
We report our long experience in the surgical treatment of patients requesting penile lengthening by suspensory ligament release and placement of a custom-made soft silicone pubo-cavernous spacer. The aim was to show that with this surgical technique the results obtained are maintained over time. It is crucial to achieving postoperative satisfaction for these patients who show fragility and self-esteem problems.

Methods: From 1999 to 2020, we treated 245 patients with congenital or acquired penile brevity. We carefully analyzed the preoperative and postoperative (at 6, 12, 24, and 48 months) penile size of the patients to evaluate whether this technique could allow the long-term maintenance of aesthetic results. We also assessed preoperative erectile function and we focused on the psychological aspects to avoid surgery in patients with dysmorphophobia. This original technique involves the section of the suspensory ligament and the implantation of a silicone spacer between the pubic symphysis and the corpora cavernosa. This spacer is conformed to the patient's anatomy and maintains the relationship between the anatomical structures unchanged over time. Sexual self-esteem and patient satisfaction were assessed with the APPSSI questionnaire.

Results: The mean increase in penile length was about 2.5 cm in a flaccid state and 1.9 cm in a stretched state. There were no injuries to the neurovascular bundle or urethra, and no erectile dysfunction was noted. These results persisted at 6, 12, 24, and 48 months without significant differences. Over 80% of patients stated that they were completely satisfied with the results obtained. This satisfaction remained stable during the follow-up.

Conclusion: The section of the suspensory ligament and the implant of the soft silicone spacer provide real penis elongation with satisfactory results that persist over time. This technique avoids the frequent complication of short-term shortening due to the scar adhesions of the edges of the dissected ligament. The high aesthetic satisfaction of patients is stable at controls at 6, 12, 24, and 48 months.




INTRODUCTION

Men have always been worried about penis size, which can seriously affect their self-esteem. They have the tendency to seek their identity in the penis with the belief that ‘‘bigger is better’’. The stigmas of a small penis, as well as the increasing media influence on sexual issues, have created an increased demand for penile enhancement (1). The term microphallus or micropenis is referred to a penis that is formed normally but is of small size (less than 7-8 cm during erection or stretched state) and it is probably associated with abnormal production, or reduced activity, of LH hormone (2). On the other hand, the altered perception of the organ size is called “dysmorphophobia”. These patients present with a normal-sized penis but are dissatisfied both in a flaccid state and during erection (3, 4). It is mandatory for these patients to undergo psychosexual counseling and try to avoid surgery.

The demand for penile lengthening had tremendous increase in recent years.

According to the published data, the majority of men who request penile enhancement surgery usually have a normal-sized and normally functioning penis (5). In our experience, the most common request for penile lengthening comes from patients that suffer from the so-called ‘‘locker room syndrome”, i.e. anxiety and embarrassment arising from changing in front of others. At present, no current consensus guidelines are available for the treatment of patients with a normal-sized penis (6). The short penis can be congenital or acquired. The congenital small penis is defined as measurements of < 7-8 cm upon erection. The acquired disorders are caused by Peyronie’s disease or outcomes of partial penectomy for penile carcinoma. Finally, there are cases of the relatively short penis due to excess pubic fat.

The reported normal length of an adult flaccid penis ranges between 7.6 cm and 10.7 cm, and between 11.4 cm and 14.8 cm in erection (7). The increase in length following surgery that is required to satisfy the patient is not well established and is not adequately emphasized in the medical literature.

The gold standard of the penile lengthening technique consists of the dissection of the suspensory ligament followed by cutaneous “V to Y” or “Z” plasties (8-10). In cases where the penile shortening is associated with abundant pubic fat, the dissection of the suspensory ligament is performed along with a suprapubic lipectomy or pubic liposuction (11). This cosmetic surgery is commonly performed by experienced plastic surgeons and results in an aesthetic visual lengthening effect. In the last years, new surgical techniques for penile lengthening have been developed to improve the aesthetic appearance and functional state of the penis, giving rise to much controversy regarding their safety, and efficacy (12-18)

We report our approach to penile lengthening using a soft silicone pubo-cavernous spacer after suspensory ligament release.




Surgical technique


A skin incision is made with the V-Y technique in order to allow simultaneous skin lengthening at the time of suturing. The incision is performed about 2-3 cm at the midpoint of the pubo-penile arch (Figure 1)

After the incision of the subcutaneous tissue, the Scarpa fascia is reached. This is exposed in order to reveal the fundiform ligament, which is then resected. Below it, the suspensory ligament (Figure 2) is dissected by scissors along the anterior side of the pubic symphysis in an area which is usually avascular (Figure 3).

This step is performed while the assistant keeps the patient's penis fully stretched in order to feel the release of the corpora cavernosa.

At this point a block of soft silicone (Allied Biomedical carving blocks) is cut to fit the angle created by the cavernous bodies and the pubic symphysis, taking care to conform with the measurements of the newly formed cavity; the spacer is shaped to come into contact anteriorly with the surface of the corpora cavernosa which is convex, while posteriorly with the anterior wall of the pubic symphysis which is concave (Figure 4).

Four 0 Prolene stitches are passed through the spacer, two stitches in the deep part, one on the left and one on the right side, and two stitches in the superficial part. Holding back the spacer, the stitches are passed through the periosteum of the pubic symphysis into the deep part. The silicon spacer is inserted into the cavity and the first two stitches, previously placed in the deep part, are tied. The other two stitches are secured to the periosteum in the uppermost part of the newly formed cavity, taking care not to exert pressure upon the penile structures (Figures 4, 5).

A drain is placed in the deeper part of the formed cavity, which is usually removed 12 to 24 hours after surgery.

The subcutaneous part, in the deep tract, is closed with polyglycolic acid, then the Scarpa fascia is sutured using interrupted sutures in polyglycolic acid. A Y suture, in polyglycolic acid or silk, is then performed to guarantee to lowering of the pubo-penile arch (Figure 6).

This latter surgical step is of utmost importance in order to avoid impairment of the lengthening procedure. According to the surgeon’s opinion, this can also be integrated with further cutaneous plasty with Z elongation. The placement of a bladder catheter at the end of surgery depends on the type of anesthesia used. In case a catheter is placed, this must be removed within 12 hours.

In our case series, the mean operative time was 78 minutes, ranging from 58 to 116 minutes. Postoperative antibiotic therapy consists of combined therapy with rifampicin 300 mg/die, minocycline 50 mg/die, and moxifloxacin 400 mg/die for one week. Patients are instructed to refrain from sexual intercourse for 30 days after surgery. No traction or vacuum device was used postoperatively.





Discussion

M plasty, which became popular in China, is frequently responsible for hypertrophic scars and even necrosis of tissue at the outer edge of the flaps. The V-Y advancement is the most commonly used technique; however, several concerns have been risen about the site and extent of the incision (22). The advantages of a Y suture, in our opinion are to guarantee lowering of the pubo-penile arch (Figure 5) and to avoid impairment of the lengthening performed.

Postoperative penile traction was not used, as per our experience, the positioning of the penile extender or vacuum device caused discomfort for the patients, was complicated and risky to manage, and has given poor results. Our technique on the other hand, which includes inserting the space-maintainer of soft silicone into the new cavity, showed a very low incidence of penile retraction. Finally, it is extremely important that the urologist evaluates very carefully the patient’s reasons for requesting this kind of treatment, what does the patient expect from it, and, in general terms, his psychological situation.

We personally insist that our patients have two or more sessions with an andro-sexologist and we stress that counseling cannot be conducted either by a “psychologist” or by a “sexologist” who does not have proven specific competence in andrological problems. At the end of the counseling, the andro-sexologist will prepare a signed report, which in turn will be signed by the patient as his approval.


It is also mandatory that the surgeon is particularly careful in case of patients looking only for cosmetic results, partly because their expectations may be far beyond reality and partly because the best surgical result involves a “normal” organ. Patients with a dysmorphic disorder, profoundly depressed, psychotic patients, or patients with not realistic expectations should not be submitted to this surgical procedure (1)




CONCLUSIONS


Suspensor ligament release alone does not guarantee definitive results. Moreover, in some cases worsen the clinical situation due to scarring of the tissue along the edges of the resection of the ligament itself. The placement of a silicon spacer between the penis and the pubis seems to give the best results, as it prevents reattachment and a possible reshortening.

The definitive separation between the two anatomical structures is simple to carry out thanks to this small device. The soft silicone makes it easy to shape the spacer and adapt it to the newly formed anatomical cavity of each patient. It is also easy to fix to the pubis and remains stable over time (unlike the fibrosis resulting from the use of other materials such as dermal matrix).

In our opinion, this technique should finally guarantee excellent long-term aesthetic results and a high satisfaction rate preventing local recurrence and the loss of the good initial results obtained.
 

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madman

Super Moderator
Figure 1. Skin incision with V-Y technique. Each branch is about 2 cm
Screenshot (17726).png


Figure 2. Exposure of the penis suspensory ligament.
Screenshot (17727).png


Figure 3. Suspensory ligament release by scissors along the anterior side of the pubic symphysis.
Screenshot (17728).png


Figure 4. Conformation of the spacer and its relations with the anatomical structures. Passage of the points of 0 Prolene.
Screenshot (17729).png


Figure 5. 3D reconstruction of the relationships between the spacer and the surrounding anatomical structures.
Screenshot (17730).png


Figure 6. Final Y suture in order to stretch the pubic skin.
Screenshot (17731).png





 

Seth

Active Member
In a couple of the pre vs post pictures, there didn't appear to be much of a change. Heck of a surgery to undergo.
 
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