Pharmacologically induced erect penile length and stretched penile length are both good predictors of post-inflatable prosthesis penile length

Penile Erection Morphometry: The Need for a Novel Approach

For many males, sexual function holds significant value in determining their quality of life. Despite the importance of male erectile function, no quantitative method to measure it accurately is currently available. Standardized assessment methods such as RigiScan™, International Index of Erectile Function (IIEF-5), and the stamp test are used to evaluate sexual function, but those methods cannot repetitively and quantitatively measure erectile function. Only direct measurement can quantitatively assess the shape of an erect penis. This paper presents the essential requirements for developing an ideal measurement method for penile erection. It also introduces current approaches for diagnosing male sexual function and reviews ongoing research to quantitatively measure erectile function. The paper further summarizes and analyzes the advantages and disadvantages of each method with respect to the essential requirements. Finally, the paper discusses the future direction toward the development of Penile Erection Morphometry.

Patient selection, counseling and preparation for penile prosthesis

The penile prosthesis has revolutionized the management of erectile dysfunction and is a mainstay in the treatment of this clinical entity. The goal of proper patient selection and counseling is to achieve a satisfactory outcome for the patient. Most patients receiving a penile prosthesis are satisfied with their outcome, and while the penile prosthesis generally allows for high satisfaction rates, avenues for dissatisfaction can arise. Our aim is to aid the prosthetic urologist in identifying such avenues by discussing what factors can lead to a dissatisfied patient. Even a technically successful surgical outcome in the improperly counseled patient can have negative consequences for the patient and the patient-physician relationship. Satisfaction in the penile prosthesis arena can be variably defined and viewed from different perspectives. As such, establishing a personalized framework of expectation management, even in the patient who poses challenging factors, is paramount in preparation for penile prosthesis implantation.

Worldwide Temporal Trends in Penile Length: A Systematic Review and Meta-Analysis

PURPOSE

Normative male genital measurements are clinically useful and temporal changes would have important implications. The aim of the present study is to characterize the trend of worldwide penile length over time.

MATERIALS AND METHODS

A systematic review and meta-analysis using papers from PubMed, Embase, and Cochrane Library from inception to April 2022 was performed. PRISMA guidelines were used for abstracting data and assessing data quality and validity. Pooled means and standard deviations for flaccid, stretched, and erect length were obtained. Subgroup analyses were performed by looking at differences in the region of origin, population type, and the decade of publication. Metaregression analyses were to adjusted for potential confounders.

RESULTS

Seventy-five studies published between 1942 and 2021 were evaluated including data from 55,761 men. The pooled mean length estimates were flaccid length: 8.70 cm (95% CI, 8.16-9.23), stretched length: 12.93 cm (95% CI, 12.48-13.39), and erect length: 13.93 cm (95% CI, 13.20-14.65). All measurements showed variation by geographic region. Erect length increased significantly over time (QM=4.49, df=2, p=0.04) in several regions of the world and across all age groups, while no trends were identified in other penile size measurements. After adjusting for geographic region, subject age, and subject population; erect penile length increased 24% over the past 29 years.

CONCLUSIONS

The average erect penis length has increased over the past three decades across the world. Given the significant implications, attention to potential causes should be investigated.

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.

Does knowing pre-operative penile length influence patient satisfaction post penile prosthesis implantation?

Patients who undergo penile prosthesis implantation as treatment for erectile dysfunction commonly complain of penile shortening after implantation. We conducted a study to determine whether knowledge of pre-operative stretched penile length measurement influences patient satisfaction. This prospective study consisted of 149 patients undergoing inflatable penile prosthesis (IPP) implantation from August 2017 to December 2019. Study group participants underwent pre-operative stretched penile length measurement in clinic while the control group did not. Six months post-operatively, patients completed a modified 14-item Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire to assess overall satisfaction and penile length satisfaction. A total of 102 patients were eligible for final analysis (49 in study group, 53 in control). Mean scores for overall treatment satisfaction were 3.57 and 3.53 (scale from 0 to 4) in the study versus control group, respectively (p = 0.483). Mean scores for satisfaction with penile length were 4.08 and 4.11 (scale from 1 to 5) in the study vs. control group (p = 0.645). The study suggests that knowledge of pre-operative stretched penile length does not influence post-operative satisfaction after penile prosthesis implantation. Therefore, performing pre-operative measurements in clinic solely for informing the patient may be unnecessary. Current interventions aimed at conserving penile length may be effective at maintaining satisfaction with penile length.Trial Registration- This trial is registered and approved by the IRB committee at our institution, ID: HSC-MS-19-0320.

The Efficacy of Suspensory Ligament Release and Pubic Lipectomy Via Penopubic Z Plasty During Penile Prosthesis Implantation in Improving Sexual Satisfaction: A Prospective Randomized Controlled Trial

BACKGROUND

The utility of penile suspensory ligament release (SLR) in the setting of penile prosthesis implantation (PPI) has received limited attention in the literature.

AIM

To assess the efficacy and safety of penile SLR release, pubic lipectomy (PL), and the utility of penopubic Z-plasty (ZP) during malleable PPI in improving sexual satisfaction compared to that achieved with the conventional method.

METHODS

Between August 2018 and April 2020, 61 patients with refractory erectile dysfunction were prospectively randomized into 2 groups; group A included 31 patients who underwent PPI with SLR and PL via ZP, and group B included 30 patients who underwent conventional PPI via a penoscrotal incision.

OUTCOMES

Penile length was assessed at 3 months, and sexual satisfaction was assessed up to 1 year after PPI using both validated and non-validated tools.

RESULTS

The median operative time was higher in group A than in group B (170 min; interquartile range [IQR] [160-190] vs 97.5 min; IQR [90-110] P < .001).The median pre- to postoperative differences in functional and visible penile lengths for group A were 1.5 cm; IQR [0-2] and 2.5 cm; IQR [1-3.5], respectively, while those in group B were both 0 cm; IQR [-1 to 0] P < .001). Group A patients reported higher scores in the International Index of Erectile Function satisfaction domains than the group B patients did (13; IQR [12-14] and 9; IQR [8-10] vs 11; IQR [9.5-12] and 8; IQR [6.5-8.5], respectively, P < .001). Moreover, the postoperative Erectile Dysfunction Inventory of Treatment Satisfaction score was higher in group A than that in group B (95.40; IQR [91-97.7] vs 85.20; IQR [72.7-91], respectively, P < .001). Common complications in group A were penile edema (77.4%), penile instability (9.7%) and glans numbness (9.7%).

CLINICAL IMPLICATIONS

The benefit in patient satisfaction following SLR and PL via ZP during PPI may outweigh the incremental increase in complications.

STRENGTH & LIMITATIONS

To our knowledge, this is the first prospective randomized controlled study to evaluate the efficacy and safety of SLR, PL, and ZP during PPI. However, because an optimal tool for assessing sexual satisfaction after PPI is lacking at this time, we alternatively adopted the most used assessment tools. Further, our data applies only to malleable penile prosthesis.

CONCLUSION

SLR and PL via ZP during PPI resulted in a substantial improvement of the patients' sexual satisfaction without serious complications. Fotouh El Gharably MA, Ghoneima W, Lotfi MR, et al. The Efficacy of Suspensory Ligament Release and Pubic Lipectomy Via Penopubic Z Plasty During Penile Prosthesis Implantation in Improving Sexual Satisfaction: A Prospective Randomized Controlled Trial. J Sex Med 2022;19:852-863.

Optimizing Outcomes in Penile Implant Surgery

Since their initial release in the 1970s, modern penile prostheses have been subjected to continuous improvement with respect to both device engineering and surgical technique. Proper implantation begins with appropriate patient selection and counseling; these are essential elements to optimize results and set expectations postoperatively. An evidence-based protocol for the prevention of infections is essential. A pain management protocol should be initiated even before surgery. Strict adherence to recommended intraoperative techniques minimizes the risk complications; when complications occur, a step-by-step process for management improves odds of resolution. Safe techniques to increase the perceived or actual penile length postimplant can markedly improve patient satisfaction. Postoperatively, the surgeon and the patient should follow strict evidence-based instructions to optimize the overall outcomes of penile prosthesis surgery.

A Review on Penile Length and Girth Issues in Penile Prosthetic Surgery

PURPOSE OF REVIEW

The goal of this paper is to understand the reasons behind penile length and girth issues after penile prosthesis surgery and review the literature for current strategies employed to decrease these issues.

RECENT FINDINGS

Measurement inconsistencies triggering further studies have shown there is a real loss of penile length and girth after prosthesis surgery. There have been varying hypotheses of why this happens, and numerous approaches have been proposed to help combat this in the preoperative, intraoperative, and postoperative settings. Erectile dysfunction prevalence is expected to increase; therefore it is important for urologists to understand the treatment options, including prosthesis surgery. Numerous techniques have been hypothesized and studied in smaller settings in the preoperative, intraoperative, and postoperative settings with regard to prosthetics surgery. However, larger studies are still needed to confirm these findings in order to help to counsel and educate patients preoperatively in addition to employing tactics to help minimize penile shortening.

Expanding the Limits-Improving Penile Length With Inflatable Penile Prosthesis Implantation: A Review

INTRODUCTION

Erectile dysfunction is a multifactorial disorder that increases in prevalence as men age. When medical therapy fails or when men are unwilling to try it, surgical intervention becomes the urologist's next best tool. However, the loss of penile length is of great concern to many patients, and there have been a myriad of ways to try to combat this fear from both patients and the surgeons themselves. In this review, we evaluate the current literature of these various approaches to improve penile length in penile prosthesis surgery.

OBJECTIVES

To review novel techniques in penile prosthesis implantation surgery.

METHODS

A literature search using PubMed was conducted to identify relevant peer-reviewed studies to penile prosthesis surgery. Search terms included penile prosthesis, penile shortening, sliding technique, Peyronie's Disease, erectile dysfunction, nondegloving, penile length, and Multiple Slice Technique.

RESULTS

Novel techniques included preoperative techniques such as use of vacuum-assisted erection device, intraoperative techniques of aggressive dilatation and maximal sizing, ventral phalloplasty and/or scrotoplasty, suprapubic fat pad excision, relaxing tunica albuginea incisions, a sliding or slicing technique, or the postoperative use of penile rehabilitation. In addition, recognizing recall bias or inconsistencies in measurement techniques is important when evaluating men with possible penile shortening after penile prosthesis surgery.

CONCLUSIONS

Advancements in surgical techniques and managing patient expectations can be crucial in the success of penile prosthesis surgery. Panuganti S, Kannady C, Wang R, Expanding the Limits-Improving Penile Length With Inflatable Penile Prosthesis Implantation: A Review. Sex Med Rev 2021;9:498-506.

Analysis of preoperative and postoperative expectations of penile implant candidates

Penile prosthesis implantation is a good option for the treatment of refractory erectile dysfunction. However, the patient's expectations, among other factors, condition his satisfaction after surgery. This review article aims to present the scientific evidence available concerning patient satisfaction with penile prosthesis surgery.

Strategies and current practices for penile lengthening in severe Peyronie's disease cases: a systematic review

Several strategies to optimize penile length in the presence of Peyronie's Disease (PD) have been described so far. In case of severe curvature and preserved erectile function, plaque incision/excision (PIG/PEG) are advisable in order to maximize penile length, despite the risk of postoperative erectile dysfunction (ED), recurrent curvature, or penile shortening. For men with PD deformities associated to a certain degree of ED several lengthening techniques associated to penile prosthesis (PPI) implantation can be considered. Because of the potential postoperative complications, the indication must be balanced between patient's risk factors and surgeon's experience. Furthermore, adjuvant surgeries, such as prepubic V-Y plasty, suspensory ligament release, suprapubic lipectomy, and ventral phalloplasty, can be performed simultaneously or in a staged fashion to maximize the outcomes. Restoration a decent penile length in the case of a severe PD represents a real challenge for reconstructive surgeons. We present a systematic review of the literature on the current practices for penile lengthening in severe PD, providing the reader with a practical overview on the existing surgical strategies and their surgical and functional outcomes.

Postoperative vacuum therapy following AMS™ LGX 700® inflatable penile prosthesis placement: penile dimension outcomes and overall satisfaction

Penile shortening after inflatable penile prosthesis for erectile dysfunction is a common postoperative patient complaint and can reduce overall satisfaction with the procedure. In this prospective study we report our results regarding penile dimensions and patient satisfaction outcomes after 1 year of follow-up from AMS™LGX700® penile prosthesis implant with 6 months of vacuum erectile device therapy. Seventy-four selected patients with medically refractory erectile dysfunction underwent AMS™ LGX 700® IPP placement. Postoperatively, patients were assigned vacuum device therapy for 5 min twice daily. Follow-up continued for 1 year after surgery. Dimensional and functional results were assessed. Baseline median preoperative stretched penile length and girth were 14 cm (range 10-17) and 9 cm (range 7-12), respectively. At the end of the study penile median dimensional outcomes were 17 cm (range 13-23) for length and 11 cm (range 10-13) for girth while a median number of 24 pumps (range 18-29) to fully inflate the device was seen. Baseline median International Index of Erectile Function (IIEF-5) score was 9 (range 5-11), at 6 months 20 (range 18-26) and at 1 year was 25 (range 20-27) (p < 0.0001). Median Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) score at the end of the follow-up was 74 (range 66-78). Our postoperative rehabilitation program is feasible and should be recommended after prothesis surgery in order to increase overall satisfaction with the procedure. Penile postoperative dimensional outcomes were statistically significant improved and complications were negligible.

Penile Prosthesis Complications: Planning, Prevention, and Decision Making

INTRODUCTION

Inflatable penile prosthesis (IPP) is an established treatment option for men with erectile dysfunction (ED) refractory to medical therapy. Standardization of surgical technique and improvements in device construction have reduced all-cause complication rates to less than 5% in recent reports. Nonetheless, complications do exist, and can strongly impact morbidity and the quality of life of patients. Prosthetic urologists must be aware of the constellation of complications that can arise during or after IPP placement.

AIM

To provide a comprehensive review of penile prosthesis complications and discuss preventative strategies, as well as proper preoperative, intraoperative, and postoperative decision making.

METHODS

A review of the available literature from 1973 to 2018 was performed using PubMed with regard to IPP complications.

MAIN OUTCOME MEASURES

We reviewed publications that outlined preoperative planning strategies and the following IPP complications: hematoma, floppy glans, corporal fibrosis, corporal perforation and crossover, urethral injury, infection, impending erosion, and glandular ischemia.

RESULTS

Careful patient and device selection, setting realistic expectations of postsurgical outcomes, and adherence to a perioperative checklist is essential in the preoperative period. Intraoperatively, anticipate corporal fibrosis situations and always dilate laterally during corporal passage to reduce the risk of crossover and urethral injury. Limit perioperative antiplatelet therapy, apply compressive dressing, use a closed suction drain if indicated, and leave the device partially inflated postoperatively to reduce risk of hematoma. After surgery, monitor patients for potential complications that may warrant device explantation or salvage: IPP infection, glans ischemia, and impending erosion.

CONCLUSIONS

By using evidence and expert opinion-based decision-making strategies in the preoperative, intraoperative, and postoperative period of IPP placement, surgeons can reduce the risk of complications and dissatisfaction, even in ED patients with multiple comorbid conditions. Scherzer ND, Dick B, Gabrielson AT, et al. Penile Prosthesis Complications: Planning, Prevention, and Decision Making. Sex Med Rev 2019;7:349-359.

Penile Length: Measurement Technique and Applications

INTRODUCTION

Penile size has long been an important fixation in men's lives. On the one hand, a smaller penis has been associated with anxiety and apprehension; on the other hand, a larger penis has generally been related to virility and strength. These perceptions predominate during an erection, when penile size is representative of a man's masculinity.

AIM

To assess adult penile length and summarize average penile length assessments from the literature; analyze how various urologic diseases and therapies affect penile length and volume; and review how surgical treatments for Peyronie's disease, penile prosthesis implantation, and radical prostatectomy can affect penile size to appropriately counsel patients seeking such therapies and set realistic goals for patients.

METHODS

To achieve the aim of this review, we analyzed the literature on penile size and volume and how these can be affected by various urologic diagnoses and therapies. We summarize common diagnoses and therapies that can affect penile size.

MAIN OUTCOME MEASURE

We thoroughly discuss how the aforementioned diagnoses and therapies can negatively affect penile size. In doing so, we allow readers to understand the intricacies of penile size when faced with such diagnoses and therapies in their patients.

RESULTS

Surgical treatments for Peyronie's disease, penile prosthesis implantation for refractory erectile dysfunction, and radical prostatectomy for prostate cancer can lead to a decrease in penile size.

CONCLUSION

Urologists must recognize that the different therapies they offer can affect a man's penile size, often negatively. This in turn can lead to poorer satisfaction outcomes in patients. Davoudzadeh EP, Davoudzadeh NP, Margolin E, et al. Penile Length: Measurement Technique and Applications. Sex Med Rev 2018;6:261-271.

Inflatable penile prosthesis as tissue expander: what is the evidence?

OBJECTIVE

Many patients who undergo inflatable penile prosthesis (IPP) replacement are often upsized to larger cylinders, suggesting the IPP may serve as a tissue expander and increase internal penile length. The objective of this study is to evaluate whether cylinder length increases with subsequent IPP insertion.

MATERIALS AND METHODS

We queried American Medical Systems and Coloplast Patient Information Form databases to identify patients who underwent IPP placement and replacement between 2004-2013. Patients were grouped by device type and time to replacement (<2 or ≥2 years). We selected the 2-year mark for subgroup analysis to allow time for tissue expansion to occur and to exclude patients who underwent early explantation (e.g. erosion or infection).

RESULTS

Two thousand, seven hundred and forty nine patients (1,532 AMS 700 LGX, 717 AMS 700 CX, and 500 Coloplast Titan) met the inclusion criteria. Mean time between implants was earlier for LGX (29 months) than CX (39 months) and Titan (48 months) patients (p<0.001). Patients who underwent device replacement at <2 years did not experience an increase in mean cylinder length. On the contrary, patients who underwent device replacement at ≥2 years did experience significant increases in mean cylinder length (LGX 1.2 cm, CX 1.1 cm, and Titan 0.9 cm, p<0.001). The mean increases in length at ≥2 years were similar between the 3 devices (p=0.20). Sixty percent of patients demonstrated increases of >0.5 cm and 40% demonstrated increases of ≥1 cm.

CONCLUSIONS

As demonstrated, the IPP may provide tissue expansion over time. Further evaluation is needed to determine if increased cylinder length correlates to increased functional length and patient satisfaction.

Preoperative counseling and expectation management for inflatable penile prosthesis implantation

The inflatable penile prosthesis (IPP) is the gold standard surgical treatment for medical refractory erectile dysfunction (ED). While the modern IPP has enjoyed high satisfaction rates as a product of its continued innovation, reliability, and performance, patient dissatisfaction can still occur. IPP implantation restores physiologic function with cosmetic and psychological consequences, both of which place inherent emphasis on preoperative counseling and expectation management. This review aims to highlight the complex nature of such counseling and provide practitioners with a roadmap to navigate the landscape. Preoperative counseling begins with appropriate patient selection and identification of those patients who are at risk for dissatisfaction as a result of personality characteristics. The informed consent provides a natural framework to discuss the host of complications and risks that are associated with surgery, including infection, device malfunction, damage to nearby structures, and device erosion. Device selection is a nuanced process that merges patient preference with clinical factors and consideration. We address device selection through a description of cylinder construction, pump design, and reservoir placement in the context of preoperative counseling. Lastly, we draw attention to expectation management with a specific focus on possible post-operative changes to penile length and sensation as well as partner involvement. The modern IPP provides excellent results with high patient and partner satisfaction. Ultimately, satisfaction is dependent on multiple factors, but providing accurate, realistic counseling and expectation management prepares patients for the best possible outcomes.

A prospective evaluation of penile measures and glans penis sensory changes after penile prosthetic surgery

Background

With better designed devices and lower infection rates, satisfaction with inflatable penile prosthesis (IPP) placement is increasingly high. However, dissatisfaction is still present and there is disagreement regarding length and sensation changes after the IPP placement. The aim of this study was to evaluate changes in penile length, girth and sensitivity after IPP placement.

Methods

From August 2012 to January 2013 all patients undergoing “de novo” IPP surgery were invited to participate in this study. Eighty six patients met inclusion criteria while 62 agreed to participate in this observational study. A week before surgery, penile length and circumference, and glans/elbow biothesiometer readings were recorded 15 minutes after Trimix induced erection. Same measures were taken at postoperative week 6 and month 6.

Results

Amperage from Glans biothesiometer readings showed statistically significant shorter readings than elbow biothesiometer preoperatively, 6 weeks and 6 months after surgery (P<0.001 each). No significant sensory difference in the glans penis after IPP was noted. However, compared to preoperative Trimix induced erections, penile length and circumference were greater after IPP placement (P=0.04 and P=0.001, respectively).

Conclusions

We observed statistically significant increase in penile length and girth after IPP placement without significant changes in sensory conduction.

Penile Lengthening, Girth, and Size Preservation at the Time of Penile Prosthesis Insertion

INTRODUCTION

Penile prosthetic devices are the gold standard treatment of medication-refractory erectile dysfunction. Inflatable penile prosthetic (IPP) devices have been available and used for more than four decades. Oftentimes, medical conditions causing erectile dysfunction also cause penile shortening, causing decreased patient quality of life.

AIM

To identify and review all available penile lengthening procedures that can be performed at time of IPP insertion.

METHODS

An extensive, systematic literature review was performed using PubMed searching for key terms penile lengthening, inflatable penile prosthesis, penile girth, corporoplasty, glans augmentation, and penile enhancement; all articles with subjective and/or objective penile length outcomes were reviewed.

MAIN OUTCOME MEASURES

A review of various techniques for penile length and girth preservation and enhancement during penile prosthesis insertion.

RESULTS

Several advanced and novel techniques were found for penile length preservation and enhancement at time of IPP insertion, including the sub-coronal IPP insertion technique, and adjuvant maneuvers during insertion, such as the sliding technique, modified sliding technique, multiple slice technique, and circumferential incision and grafting. Other adjuvant techniques that can enhance perception of increased length include ventral phalloplasty, suprapubic lipectomy, and suspensory ligament release. Further enhancement can be obtained using augmentation corporoplasty and glans augmentation with hyaluronic acid and other fillers. The different techniques vary in complexity and could require specialized training and experience. Maximum length gain appears to be limited by the length of the neurovascular bundles.

CONCLUSION

Overall, surgical penile lengthening procedures at time of IPP insertion appear safe and effective for treatment of patients with penile shortening and severe erectile dysfunction. These therapies can significantly improve patient self-esteem and quality of life in properly selected patients. Tran H, Goldfarb R, Ackerman A, Valenxuela RJ. Penile Lengthening, Girth and Size Preservation at the Time of Penile Prosthesis Insertion. Sex Med Rev 2017;5:403-412.

Lengthening strategies for Peyronie's disease

Loss of penile length is a common complaint of men with Peyronie's disease (PD), both before and after corrective intervention, which has a significant negative effect on patient quality of life. We sought to identify and describe the methods by which penile length can be preserved or increased. We conducted an extensive, systematic literature review, based on a search of the PUBMED database for articles published between 1990 and 2015. Articles with the key words "Peyronie's disease", "penile length" and/or "penile lengthening" were reviewed if they contained subjective or objective penile length outcomes. Only English-language articles that were related to PD and penile size were included. We found no evidence in the literature that medical therapy alone increases penile length. Classic inflatable penile prosthesis (IPP) placement, plication procedures, and the Nesbit procedure appear likely to maintain or decrease penile length. Plaque incision (PI) and grafting appears likely to maintain or increase penile length, but is complicated by risk of post-operative erectile dysfunction (ED). There are several surgical procedures performed concomitantly with IPP placement that may be suitable treatment options for men with comorbid ED, and consistently increase penile length with otherwise good outcomes concerning sexual function. These include the subcoronal penile prosthesis (scIPP), Egydio circumferential technique, the sliding technique, the modified sliding technique (MoST), and the multiple slice technique (MuST). In addition, adjuvant therapies such as penile traction therapy (PTT), post-operative inflation protocols, suspensory ligament relaxation, lipectomy, and adjuvant medical therapy for glans engorgement appear to increase subjective and/or objective penile length for men at high risk of decreased penile length after PD surgery. Considering the psychological burden of length loss in men with PD, providers with adequate volume and expertise should attempt, if possible, to maintain or increase penile length for men undergoing surgical intervention. There are several evidence-based, safe, and effective ways to increase penile length for these men and multiple emerging adjuvant therapies that may help ensure adequate length.

A practical overview of considerations for penile prosthesis placement

Penile prostheses have remained the gold-standard therapy for medically refractory erectile dysfunction (ED) since their popularization. Advances in device design and surgical techniques have yielded improved rates of infection, satisfaction, and mechanical survival of devices. Operative techniques in penile prosthesis surgery include the use of adjunctive procedures (such as ventral phalloplasty and release of the suspensory ligament), management of penile fibrosis, and manoeuvres to correct Peyronie's-disease-related curvature. Complications include urethral and corporal perforation, crossover, infection, impending erosion, and/or supersonic transporter deformity. Long-term data regarding mechanical, overall, and infection-free survival demonstrate excellent results, and, given the consistently high satisfaction rates and limited alternatives for medically refractory ED, penile prostheses are likely to remain a relevant and important treatment strategy for the foreseeable future.