A Single-Surgeon Retrospective and Preliminary Evaluation of the Safety and Effectiveness of the Penuma Silicone Sleeve Implant for Elective Cosmetic Correction of the Flaccid Penis

Cosmetic penile enhancement procedures: an SMSNA position statement

BACKGROUND

Penile cosmetic enhancement procedures have been performed for many years with varying success. However, they have historically been relegated to niche areas of sexual medicine, with limited data, and have not achieved mainstream adoption. More recently, the topic has been increasingly discussed within academic congresses due to availability of novel techniques, therapies, and procedures. Given their distinctive nature, the Sexual Medicine Society of North America (SMSNA) felt that it was pertinent to develop formal position statements to help guide both patients and sexual medicine providers on the current state of the scientific literature and to give recommendations for future research.

AIM

The study sought to provide an evidence-based set of recommendations for injection and surgical procedures designed to lengthen, augment, or otherwise cosmetically enhance the penis.

METHODS

A review was performed of all scientific literature listed in PubMed from inception through December 2023 relating to penile cosmetic enhancement procedures. Only invasive (injection/surgery) therapies were included due to their distinct risk-benefit profile compared with more conservative treatments (eg, vacuum erection devices, penile traction devices). Similar therapies were categorized, with pertinent data summarized and used to help create relevant position statements. All statements were expert opinion only and were based on analyses of the potential risks and benefits of the specific therapies.

OUTCOMES

A total of 6 position statements were issued relating to 5 distinct sexual medicine cosmetic enhancement procedures.

RESULTS

A consensus opinion was reached by SMSNA leadership on the state of injection/surgical penile cosmetic enhancement procedures as of 2024. Key topic areas addressed included injectable soft tissue fillers, suspensory ligament division, graft-and-flap procedures, silicone sleeve implants, and sliding/slicing techniques. Distinct recommendations were tailored to each therapy and were based solely on the current state of the literature. It is anticipated that future studies will further inform position statements and will lead to ongoing modifications.

CLINICAL IMPLICATIONS

The current position statements provide both patients and clinicians evidence-based, expert recommendations on best practices relating to penile cosmetic enhancement procedures.

STRENGTHS AND LIMITATIONS

Strengths include the use of an expert panel of sexual medicine clinicians, consensus design, and summary of existing literature. Limitations include expert opinion and limited research on the topic.

CONCLUSION

The current SMSNA position statements provide evidence-based, consensus opinions on the appropriate role for penile augmentation and cosmetic procedures in 2024.

Techniques for Penile Augmentation Surgery: A Systematic Review of Surgical Outcomes, Complications, and Quality of Life

The increase in practices related to enhancing penile size can be attributed to the belief that an improved genital appearance contributes to a man's virility, coupled with an altered self-perception of his body. It is crucial to tailor interventions to meet the genuine needs of patients by thoroughly assessing their history, psychological state, and potential surgical benefits, all while considering the associated risks of complications. This systematic review aims to summarize the available evidence on outcomes, complications, and quality of life after penile augmentation surgery, examining both minimally invasive and more radical techniques. A search of the PubMed and Scopus databases, focusing on English-language papers published in the last 15 years, was performed in December 2023. Papers discussing surgery in animal models and case reports were excluded from the present study unless further evaluated in a follow-up case series. The primary outcomes were changes in penile dimensions, specifically in terms of length and girth, as well as the incidence of surgical complications and the impact on quality of life. A total of 1670 articles were retrieved from the search and 46 were included for analysis. Procedures for penile length perceived enhancements include lipoplasty, skin reconstruction plasty, V-Y and Z plasty, flap reconstruction, scrotoplasty, ventral phalloplasty, and suspensory ligament release; techniques for increasing corporal penile length include penile disassembly, total phalloplasty, and sliding elongation. Finally, penile girth enhancement may be performed using soft tissue fillers, grafting procedures, biodegradable scaffolds, and Penuma®. In conclusion, while penile augmentation surgeries offer potential solutions for individuals concerned about genital size, the risks and complexities need to be accounted for.

Use of Himplant® for correction of residual deformity following prior treatment of peyronie's disease: a case series

Over the years, numerous non-surgical and surgical treatment options have been explored for Peyronie's disease. Current options may result in incomplete correction of the deformity, which can be bothersome to the patient. This is a two-center case series of three patients who had previously undergone treatment for Peyronie's disease. Patient 1 underwent plication with extratunical grafting. Patient 2 underwent a series of Xiaflex® injections and then subsequent surgical plication for residual curvature. Patient 3 underwent a series of Xiaflex® injections. The Himplant® subcutaneous silicone penile prosthesis was placed in a standardized manner through a scrotal incision in all cases to mask residual penile deformities and enhance penile girth after Peyronie's disease treatment. Patients were contacted and asked 18 questions regarding satisfaction and erectile function with the responses recorded. This pilot study presents findings of high patient satisfaction, increases in flaccid penile length and girth, and an acceptable profile of adverse events following Himplant® placement. Based on our limited experience, we would consider offering Himplant® implantation when residual curvature is <40° and the penile indentation does not cause instability/buckling during penetrative sexual activity. Further research and larger studies are warranted to validate these findings and assess long-term outcomes and patient-reported satisfaction.

A multi-institutional update on surgical outcomes after penile silicone sleeve implantation

Background

The increasing popularity of the silicone sleeve penile implant has been accompanied by concerns over potential risks and adverse events.

Objectives

To provide multi-institutional data on safety outcomes in patients undergoing silicone sleeve penile implant surgery across high-volume implant surgeons. In addition, we discuss preventative techniques to minimize postoperative complications and the management of these events.

Design and methods

We performed a retrospective analysis of men undergoing penile silicone sleeve implants between November 2020 and November 2022 with four surgeons, each from a separate institution. Perioperative and postoperative adverse events, including unsatisfactory cosmetic outcomes requiring revision, were determined by physician follow-up. Flaccid penile length and girth were measured preoperatively and postoperatively.

Results

A total of 299 male patients underwent silicone sleeve implant surgery, with an average age of 42.5 ± 10.5 years and an average body mass index of 28.5 ± 4.0. The patient cohort exhibited minimal comorbidities, with 5% having hyperlipidemia, 2% being smokers, 2% having cardiovascular disease, and 1% having diabetes. Patients experienced an average increase of 4.1 ± 1.5 cm in their flaccid penile length (a 50% increase) and an average increase of 3.4 ± 1.5 cm in their flaccid girth (a 37% increase) (p < 0.01). Complication rates included new-onset postoperative erectile dysfunction (0%), infection (1.3%), seroma (2.0%), and erosion (5.0%). The average follow-up time was 11.6 months. Notably, our rates of infection and seroma were lower than those reported in a previous single-center review, while erosion rates were higher.

Conclusion

This is the largest study to characterize the safety of the penile silicone sleeve implant across multiple institutions. In men who desire cosmetic size augmentation, silicone sleeve implant surgery is associated with significantly increased flaccid penile length and girth. Complications are mainly cosmetic and may be corrected; however, patients should be appropriately counseled on the risk of erosion, which appears to be higher than previously reported.

European Association of Urology Guidelines on Penile Size Abnormalities and Dysmorphophobia: Summary of the 2023 Guidelines

CONTEXT

Recommendations regarding the management of penile size abnormalities and dysmorphophobia are important in guiding evidence-based clinical practice.

OBJECTIVE

To present a summary of the 2023 European Association of Urology sexual and reproductive health evidence-based recommendations for the management of penile size abnormalities and dysmorphophobia.

EVIDENCE ACQUISITION

A broad and comprehensive scoping exercise covering all areas of the guidelines was performed. Databases searched included Medline, EMBASE, and the Cochrane Libraries. A level of evidence and a strength of recommendation were assigned for each recommendation according to the evidence identified. The evidence cutoff date for the 2023 guidelines is June 1, 2022.

EVIDENCE SYNTHESIS

Well-structured studies reporting high level of evidence, with standardized PROMS were deficient on penile size abnormalities and dysmorphohobia. A shared definition for short penis/micropenis was also lacking. Categorisation of penile abnormalities according to congenital, acquired, and dysmorphophobic aetiology is deemed compulsory. A detailed medical and psychosexual history and precise measurements of penile size are essential in the diagnostic pathway. Patients with normal penile size who are seeking penile augmentation should be referred for psychological evaluation for potential dysmorphophobic disorders. Penile length and girth enhancements can be achieved via a multitude of treatments, but a personalised management plan is crucial for satisfactory results. Endocrinological therapies, when indicated, are effective in the prepubertal setting only. Vacuum therapy has a limited evidence base in treatment protocols, although acceptable outcomes have been reported for penile traction therapy. Surgical techniques to enhance penile length and girth have limited evidence and should only be proposed after extensive patient counselling.

CONCLUSIONS

Management of penile abnormalities and dysmorphophobia is a complex issue with considerable ethical concerns. The adoption of a structured diagnostic and therapeutic pathway is crucial, as recommended in the guidelines.

PATIENT SUMMARY

Requests for medical/surgical treatments to increase penis size have increased dramatically worldwide. Several conservative and surgical treatments are available. However, few patients receive clear information on the benefits and possible harms of these treatments. These guidelines aim to provide a structured path to guide both physicians and patients in the selection of appropriate treatment(s) to increase penis size.

Outcomes of a Single Center's Initial Experience With the Penuma® Penile Implant

OBJECTIVE

To provide new data, techniques, and safety and efficacy outcomes in patients undergoing Penuma penile implant surgery at a large tertiary care center.

METHODS

We performed a retrospective analysis of men undergoing Penuma implants between November 2020 and January 2022 with a single surgeon at a tertiary hospital. Measurements of penile length were made both pre- and postoperatively. Adverse events including infection and unsatisfactory cosmetic outcomes requiring revision were recorded. We also provide detailed technique descriptions of Penuma implantation and revision. Outcomes include measurements of incidents of peri and post-operative adverse events and penile length and girth pre- and post-operatively.

RESULTS

49 male patients underwent Penuma implant surgery. Mean age was 40.2 ± 8.9 years. Mean BMI was 28.2 ± 4.5. All but 2 patients were nonsmokers and only 2 had comorbidities (diabetes). Preoperative mean flaccid length was 8.1 ± 1.9 cm. Postoperative mean length was 12.3 ± 1.9 cm. Patients added an average of 4.9 ± 2.9 cm to their penile length, a 52% increase (P < .01). Average follow up time was 6 months. Among the complications were 1 case of infection and 2 cases of erosion. There were 4 cases of persistent flaring of the Penuma; 3 required revision surgery, all with a good cosmetic outcome.

CONCLUSION

The Penuma implant can be used to safely enhance flaccid penile length and girth in patients with retractile penis or other cosmetic deformities. Should complications occur, they are mainly cosmetic and can be easily corrected with low risk.

The International Penile Prosthesis Implant Consensus Forum: clinical recommendations and surgical principles on the inflatable 3-piece penile prosthesis implant

Despite significant scientific advances in the modern three-piece inflatable penile prosthesis implant surgery, it is not without surgical risks and can carry additional cosmetic and psychosocial consequences in poorly selected and consented individuals. To address this problem, an international group of key opinion leaders and high-volume prosthetic surgeons reviewed the current guidelines and clinical evidence, discussed their experiences, and formed a consensus regarding inflatable penile prosthesis surgery. The findings of this consensus panel were presented at the 17th biennial Asia Pacific Society of Sexual Medicine scientific meeting. The experts concluded that proper patient selection, informed consent and strict adherence to safe surgical principles are important to optimize clinical outcomes. Furthermore, most intraoperative complications, if recognized, can be addressed intraoperatively to enable placement of the device at the time of initial surgery. Men with significant corporal fibrosis due to Peyronie's disease, prior prosthesis explantation and priapism, and men who have undergone construction of a neophallus, as well as men who receive concurrent continence surgery, are complex cases requiring additional care and advanced techniques to obtain optimal surgical outcomes. Variability in patient care - in terms of postoperative antibiotic use, pain management, scrotal care, and cycling of the penile prosthesis implant - must be reduced to enable optimization and assessment of outcomes across patient groups.

Multidisciplinary approach and management of patients who seek medical advice for penile size concerns: a narrative review

We aimed to provide an overview of the strategies available to manage patients concerned about their penile size and to provide useful surgical hints regarding the most common penile enlargement approaches, based on our surgical expertise in this field. A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning penile enlargement issues. The search strategy included a range of keywords; e.g. penis, penile, enlargement, augmentation, lengthening, girth. Management of penile size-related concerns represents a real challenge for the urologist, especially when dealing with patients suffering from penile dysmorphophobic disorder (PDD). A multidisciplinary preoperative assessment, including a psychiatric/psychological evaluation, may help in discerning those patients who would benefit the most from counselling/conservative management from those who would benefit from surgery instead. Conservative approaches include the use of vacuum-based and penile-stretching devices, which have shown encouraging levels of efficacy and safety. Over the last decades, different surgical strategies have been developed, aimed at either increasing flaccid penile length or improving penile girth. Penile lengthening procedures are more established, and satisfactory results can be achieved by experienced, large referrals' volume, surgeons. To date, there is lack of consensus regarding the penile girth enhancing techniques, and therefore these should be regarded as experimental. A multidisciplinary approach is necessary to identify patients with PDD, who should not be offered surgical intervention and should be referred for psychiatric/psychological counselling instead. The surgical approach should be tailored to the subject's unique anatomy and underlying conditions.

History and future perspectives of male aesthetic genital surgery

Since ancient times, men have tried to change the size and shape of their genitals. Bites from insects or poisonous snakes and weights were among the first methods used for this purpose. In the first half of the 1900s, the scientific push regarding male genital aesthetic surgery began. Scrotoplasty, penile suspensory ligament release, injection of hyaluronic acid as filler, use of several types of grafts, lipofilling, and liposuction are techniques currently used. The Penuma® implant has recently been described with promising results. We are living in the era of tailored surgery and regenerative medicine. Shortly the surgeons will have to know several surgical techniques and adapt them to the patient. New fillers with ideal characteristics, innovative prosthetic devices, and stem cells will probably be the protagonists of future aesthetic surgery. The main effort of the scientific community should be directed towards the design of new randomized controlled trials to increase the evidence on the efficacy and safety of the topic, with the ultimate aim of allowing clear recommendations from scientific societies.

Male esthetic genital surgery: recommendations and gaps to be filled

The reason behind the spread of penis enlargement practices over time is rooted in the virility that the appearance of the genitals can give a man, as well as an altered perception of his own body. The approach should be to modulate the interventions on the real needs of patients, carefully evaluating the history, the psychological picture, and possible surgical advantages. The aim of this study was to shed light on cosmetic surgery of male genitalia through minimally invasive and more radical techniques, with the purpose of laying the foundation for possible indications and recommendations for the future. A non-systematic literature review using the PubMed and Scopus databases was conducted to retrieve papers written in English on cosmetic surgery of the penis published over the past 15 years. Papers discussing cosmetic surgery in patients with concomitant pathologies associated with sexual dysfunction were excluded. The main outcomes recorded were change in penile dimensions in term of length and girth and surgical complications.

Update on the Penuma® an FDA-cleared penile implant for aesthetic enhancement of the flaccid penis

The Penuma® implant is a medical-grade silicone implant surgically inserted subcutaneously to provide cosmetic improvement of the penile aesthetic. The principal author was invited to provide an update on the usage of the Penuma® implant for penile aesthetics. He collected as yet unpublished data, which is undergoing synchronous submission to Urologic meetings and peer-reviewed publications by a variety of authors for this communication. The objective of this article is to provide updated information regarding the Penuma® aesthetic penile implant. A new scrotal method of implantation named "concealed" is emerging. Through physician comparison of various factors prior to and after the scrotal method intervention, early findings suggest this approach seems to have less visible scar, is quicker and is followed by less seroma formation. As the device is now surgically implanted by surgeons other than its inventor, new developments have appeared authenticating the original published paper in 2018. Patients were contacted via phone and were asked five questions regarding satisfaction with the responses recorded. This new multicenter study shows findings of high patient and partner satisfaction coupled with acceptable adverse outcomes similar to the single-surgeon study. A new penile rehabilitation program has been developed with the aim for the penis appearance to be restored to its pre-operative state if the Penuma® is removed. 12 patients who underwent penile implant removal were followed for 6 months while participating in the penile rehabilitation program. The discipline worked in patients who desired removal for dissatisfaction and is currently under evaluation in patients who require device removal for medical reasons, e.g., infection or suture-related issues. Through new developments, the acceptance of Penuma® in the prosthetic community seems to be further solidified.

Revelations on Men Who Seek Penile Augmentation Surgery: A Review

INTRODUCTION

Men with normal penis size sometimes mistakenly believe they have below average penile dimensions and often seek out treatment. Many men suffer from significant anxiety regarding this perceived defect. In this review, we evaluate the current literature of psychological, medical, and surgical treatment options for men with a complaint of a small penis.

OBJECTIVE

To review the current practice for treatment of men presenting for penile augmentation surgery.

METHODS

A literature review was conducted, using PubMed to identify current studies regarding penile enhancement. Search terms included "penile enhancement," "small penis anxiety," "small penis syndrome," "body dysmorphic disorder," and "penile augmentation."

RESULTS

The literature consistently reveals that men who seek out penile augmentation surgery usually have normal penile dimensions. There are limited published data on the practice of penile lengthening surgery or procedures to increase penile girth. New techniques have expanded on suspensory ligament release, such as tissue grafting and flaps. Structured psychological counseling continues to be the recommended initial standard of care for these men.

CONCLUSION

Many social forces have increased the perception among men that their penis size is inadequate. This increases anxiety and can lead to psychological disorders such as Penile Dysmorphic Disorder and Small Penis Syndrome. Men who undergo penile enhancement are often not satisfied with the results and may develop complications. Soubra A, Natale C, Brimley S, et al. Revelations on Men Who Seek Penile Augmentation Surgery: A Review. Sex Med Rev 2021;XX:XXX-XXX.

The Augmenta Implant: A Cadaver Model of a Novel Anatomic Subdermal Implant for Cosmetic Penile Enhancement

INTRODUCTION

There are limited options for cosmetic penile enhancement and the correction of structural penile deformities.

AIM

We present the Augmenta, an innovative, technologically advanced subcutaneous elastomer-silicone cosmetic penile implant (CPI), as evaluated by objective structural changes in a cadaveric model.

METHODS

Five fresh male cadaver pelves were utilized in this preclinical setting. Placement of a subcutaneous elastomer-silicone CPI was performed via a penoscrotal approach. Penile circumference was measured at the base and distal shaft before and after implant placement. Penile length was measured from the pubic bone to the tip of the glans penis before and after implantation of Augmenta.

MAIN OUTCOME MEASURE

Objective outcomes included changes in penile circumference and shaft length in both the flaccid and erect state, both before and after CPI placement.

RESULTS

In 5 cadaver models, implantation of the Augmenta CPI increased flaccid penile shaft base circumference from an average of 8.7 cm to 12.0 cm after implantation (39.1% increase, P < .001). Flaccid distal circumference increased from 7.3 cm to 10.3 cm (41.8% increase, P = .020). During the erect state, penile base circumference increased from an average of 12.5 cm to 13.7 cm (6.3% increase, P = .273), while distal erect circumference changed from an average of 11.3 cm to 12.4 cm (9.7% increase, P = .298). Nonstretched flaccid shaft length increased from an average of 12.1 cm to 14 cm (15.2% increase, P = .073).

CLINICAL IMPLICATIONS

The Augmenta CPI could serve as alternative option for men seeking cosmetic penile enhancement.

STRENGTHS AND LIMITATIONS

Limitations include a small number of cadavers which do not completely reproduce living physiologic function and the use of a single technical approach. However, a consistent and standardized surgical approach reduces operator-dependent outcomes. Another strength is the use of fresh human cadavers that most closely represent live models.

CONCLUSION

In a cadaveric model, the Augmenta CPI demonstrates enhancements in penile girth in both the flaccid and erect state. The unique honeycomb technology, the embedded polyester mesh, and the antimicrobial hydrophilic coating of the Augmenta CPI may provide an advantage to currently available CPIs. Clinical trials will be needed to demonstrate both the safety and feasibility. Clavell-Hernández J, Tatem AJ, Lipshultz LI, et al. The Augmenta Implant: A Cadaver Model of a Novel Anatomic Subdermal Implant for Cosmetic Penile Enhancement. Sex Med 2021;XX:XXXXXX.

Infection of the Penuma penile implant and associated post-operative complications: A case report

The Penuma penile implant is the only FDA approved device for cosmetic correction of the penis. We present a case of an infected Penuma implant that presented similarly to penile prosthesis infection. Explantation is recommended, similar to the management of infected penile prosthesis, via an infrapubic approach, which differs from explantation of a penile prosthesis. Post-operatively, the patient developed penile shortening and dorsolateral curve, which is important to discuss when counseling patients.

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Penuma penile implant is used for cosmetic correction of the penis.

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Infections of Penuma penile implant present similarly to infection of penile prosthesis.

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Recommended management is explantation of the penile implant and antibiotics.

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Post-operative side effects include penile shortening and penile curvature.

Penile girth enhancement procedures for aesthetic purposes

The present study aimed to describe and critically discuss the current evidence regarding the penile girth enhancement procedures for aesthetic purposes. We designed a narrative review of the literature. A comprehensive search in the MEDLINE database was performed. Original articles in English-language, published until March 2021, were selected. A total of 29 studies were included (3 reporting non-invasive approaches, 11 injection therapies, and 15 surgical procedures). The vast majority of articles (26, 89.7%) were not randomized controlled trials, with overall low quality and limited level of evidence. Only 1 (33.3%) paper regarding non-invasive approaches reported a minimal (+0.03 cm) but a significant increase of penile girth (p = 0.034). A low rate (11.2-14.4%) of mild, temporary adverse events and poor-to-moderate patient satisfaction were found. Eight (72.7%) articles concerning injection therapies showed a significant increase in penile girth (p < 0.05). A low rate of mild complications, generally at the injection site, and a high patient satisfaction rate (75-100%) were highlighted. Nine (60%) papers on surgical treatments found a significant increase in penile girth (p < 0.05), while the other 6 (40%) studies reported a generic improvement in penile circumference. Skin necrosis or ulcers, wound infections, or need for reoperation were reported in 8 (53.3%) studies. A high patient satisfaction rate (60-100%) was reported. Our review highlighted the overall positive results of injection procedures, the poor outcomes associated with non-invasive techniques, and the good efficacy and satisfaction with a non-negligible risk of complications in patients undergoing surgical treatments. However, the adverse events are probably largely under-reported and these procedures should still be considered under investigation due to the limited evidence available and the lack of guidelines.

Future considerations in prosthetic urology

Since their popularization, genitourinary prosthetics have remained a gold-standard therapy for the treatment of erectile dysfunction and stress urinary incontinence and in cases of testicular loss or dysfunction. They have also represented an area of significant innovation, which has contributed to excellent long-term outcomes. Given this history, the objective of the current review was to provide a 5–10-year outlook on anticipated trends and developments in the field of genitourinary prosthetics. To accomplish this objective, a PubMed and patent search was performed of topics relating to penile and testicular prostheses and urinary sphincters. In regard to penile prostheses, findings demonstrated several new concepts including temperature-sensitive alloys, automated pumps, devices designed specifically for neophalluses, and improved malleable designs. With artificial urinary sphincters, new concepts include the ability to add or remove fluid from an existing system, two-piece systems, and new mechanisms to occlude the urethra. For testicular prosthetics, future implementations may not only better replicate the feel of a biological testicle but also add endocrinological functions. Beyond device innovation, the future of prosthetics is also one of expanding geographic boundaries, which necessitates variable cost modeling and regulatory considerations. Surgical trends are also changing, with a greater emphasis on nonnarcotic, postoperative pain control, outpatient surgeries, and adjunctive techniques to lengthen the penis and address concomitant stress incontinence, among others. Concomitant with device and surgical changes, future considerations also include a greater need for education and training, particularly given the rapid expansion of sexual medicine into developing nations.

Non-invasive and surgical penile enhancement interventions for aesthetic or therapeutic purposes: a systematic review

OBJECTIVE

To systematically review the literature in order to investigate the efficacy and safety of surgical and non-invasive penile enhancement procedures for aesthetic and therapeutic purposes.

METHODS

A systematic search for papers investigating penile enhancement procedures was performed using the MEDLINE database. Articles published from January 2010 to December 2019, written in English, including >10 cases, and reporting objective length and/or girth outcomes, were included. Studies without primary data and conference abstracts were excluded. The main outcome measure was objective length and/or girth improvement. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

Out of 220 unique records, a total of 57 were reviewed. Eighteen studies assessed interventions for penile enhancement in 1764 healthy men complaining of small penis. Thirty-nine studies investigated 2587 men with concomitant pathologies consisting mostly of Peyronie's disease and erectile dysfunction. Twenty-five studies evaluated non-invasive interventions and 32 studies assessed surgical interventions, for a total of 2192 and 2159 men, respectively. Non-invasive interventions, including traction therapies and injection of fillers, were safe and mostly efficacious, whereas surgical interventions were associated with minor complications and mostly increased penile dimensions and/or corrected penile curvature. Overall, the quality of studies was low, and standardized criteria to evaluate and report efficacy and safety of procedures, as well as patient satisfaction, were missing.

CONCLUSION

The quality of the studies on penile enhancement procedures published in the last decade is still low. This prevents us from establishing recommendations based on scientific evidence regarding the efficacy and safety of interventions that are performed to increase the penis size for aesthetic or therapeutic indications.

Correction of retractile penis with subcutaneous soft silicone penile implant

We report a novel solution for patients suffering from adult acquired retractile penis. Three patients complained of retractile penis (when standing) and/or prepubic recession. Physical examination confirmed the shaft of the penis was buried with only the glans visible. All three patients reported lower levels of self-confidence, self-esteem, and sexual confidence prior to their procedure. The three patients received surgical treatment with the insertion of a subcutaneous soft silicone penile implant and two of the three also received removal of the suprapubic fat pad. Over one year post operatively, the penile shaft and glans was visible and appeared natural. All patients reported an increase in self-confidence and self-esteem. The insertion of a subcutaneous soft silicone penile implant may prove to be a viable solution to reverse retractile penis and to increase patient quality of life when compared to more invasive current surgical treatments.

MRI of the Penis: Indications, Anatomy, and Pathology

The purpose of this review is to discuss the role of magnetic resonance imaging (MRI) in the evaluation of penile pathology. Normal penile anatomy as well as the appearance of neoplastic and non-neoplastic entities on MRI will be reviewed. While ultrasound remains the first line imaging modality in evaluating most penile pathology, MR imaging has specific advantages owing to improved soft tissue resolution, ability to evaluate less accessible or complex anatomy (such as at the base of the penis), and the ability to detect subtle enhancement. Therefore, MRI is useful for when ultrasound and/or clinical findings are equivocal or incongruent. In addition, MR imaging is essential for preoperative surgical planning and is the imaging modality of choice in evaluating penile prostheses. The added value of MRI in these settings makes it an integral component to the management of many pathological entities affecting the penis.

Additional procedures performed at time of penile prosthesis implantation: a review of current literature

Penile prosthesis implantation for treatment of medical refractory erectile dysfunction remains the gold standard. However, some men have additional pathology present such as Peyronie's Disease, penile shortening, penoscrotal webbing, buried penis or other penoscrotal anatomical abnormalities that may be addressed at the time of prosthesis implantation. Although several techniques are described, there remains a lack of data regarding the outcomes. We sought to identify the results of available literature regarding the additional procedures performed at the time of penile prosthesis implantation that provide defined surgical outcomes rather than merely describe surgical techniques. Surgical outcomes to procedures provide more realistic clinical outcome for readers than simply the description of novel techniques or expert opinions. We performed a review of the MEDLINE database to identify additional procedures performed in conjunction with penile prosthesis placement. Many procedures are described in review articles, however, with limited data regarding their outcomes. The included articles must describe additional procedures performed in conjunction with penile prosthesis placement. Perioperative office techniques and management were included if it changed the surgical technique. All abstracts obtained through search criteria were reviewed. Only articles written in English, on human subjects with documented surgical results and relevant articles were included in this study. After a thorough literature search, a total of 24 articles were identified. Penile lengthening procedures at the time of penile prosthesis comprise most of the literature on this subject. Lengthening procedures are as simple as Peyronie's plaque excision and grafting to complex sliding and lengthening procedures requiring complete neurovascular bundle and partial urethral mobilization. Additionally, aggressive cylinder sizing and prolonged postoperative cycling at home are also described. Glanulopexy may be necessary when malpositioning of the glans is present. Other options such as scrotoplasty are also available options for those patients with scrotal webs. Notably there is a paucity of published literature regarding girth enhancement, buried penis repair, hernia repair, and vasectomy at time of penile prosthesis placement. There are numerous procedures that can be performed in the same operative setting as penile prosthesis. Although the procedures do have a common goal to provide optimal postoperative natural appearance, length, straightness, girth and function, the techniques employed must be tailored to each patient as there is not a one-procedure fits all in this patient population.