Advancements in penile lengthening techniques concurrent with penile prosthesis placement: a narrative review

Abstract

Penile prosthetic devices stand as the foremost solution for medication-resistant erectile dysfunction. Frequently, medical conditions triggering erectile dysfunction also led to penile shortening, detrimentally impacting patients' quality of life. This narrative review aims to explore and evaluate the various techniques available for penile lengthening that can be performed concurrently with inflatable penile prosthesis (IPP) insertion. We conducted a comprehensive examination of the literature, utilizing PubMed focusing on key terms such as "penile prosthesis corporal length", "inflatable penile prosthesis and short penis", and "buried penis". The review identified several advanced methodologies for preserving and enhancing penile length during IPP insertion. These techniques include subcoronal IPP insertion, sliding technique, modified sliding technique, multiple slice technique, and circumferential incision with grafting. Supplementary procedures aimed at improving the perception of increased length involve ventral phalloplasty and suprapubic lipectomy. It is worth noting that the maximum length gain seems to be constrained by the length of the neurovascular bundles. In summary, the evidence available in the literature is limited due to the short of case series reported, lack of randomized controlled trials, and heterogeneity of the studies. The literature suggests that for carefully selected patients, surgical penile lengthening procedures performed concurrently with IPP insertion emerge as effective treatments for individuals grappling with penile shortening and severe erectile dysfunction. Well-designed, larger studies are needed to establish the safety and efficacy of these procedures.

Keywords: buried penis; inflatable penile prosthesis; penile fibrosis; short penis.

Figure 1

(a) Once Buck’s fascia and urethra have been completely dissected off the corpora, the point of maximum curvature is identified after induction of an artificial erection. (b) A circumferential incision is carried out at the level of maximum curvature, and the dimension of the defect is measured with the penis in traction. (c) The graft presents a trapezoidal shape with large width at the level of maximum curvature. (d) The tunical defect is covered with the graft that is sutured with graft.

Figure 2

(a) Sliding technique. The stretching (in the direction of the arrow) is arrested when the neurovascular bundle reached the maximum length. (b) The two losses of substance are covered with two rectangular grafts. (c) Insertion of the prosthesis in modified sliding technique. (d) Proximal corporotomies are closed using the stay sutures.

Figure 3

(a) Sliding approached used for the MUST technique; multiple small tunical defects are created instead of one large incision, then the penis is stretched in the direction of the arrow. (b) These defects will be covered with Buck’s fascia instead of using a conventional graft. MUST: multiple slice technique.

Figure 4

(a) Complete isolation of the neurovascular bundle is performed and then urethra is dissected from the cavernosa. (b) In order to counteract a narrowing phenomenon, multiple small relaxing tunical incisions/slits are performed in a rhomb-like configuration, in order to distend the corpora in the direction of the arrow. (c) This will lead to penile girth restoration.

Figure 5

Lipectomy. (a) Preoperative marking before incision. (b) Suprapubic fat pad is removed (as showed from the arrow). (c) Final aspect after the defect is sutured.