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Article of the Week: Penile lengthening and widening without grafting according to a modified ‘sliding’ technique

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Franklin Kuehhas, discussing his paper. 

If you only have time to read one article this week, it should be this one.

Penile lengthening and widening without grafting according to a modified ‘sliding’ technique

Paulo H. Egydio and Franklin E. Kuehhas*

 

Centre for Peyronies Disease Reconstruction, Sao Paulo, Brazil, and *London Andrology Institute, Suite 7 Exhibition House, Addison Bridge Place, London, UK

 

OBJECTIVE

To present the feasibility and safety of penile length and girth restoration based on a modified ‘sliding’ technique for patients with severe erectile dysfunction (ED) and significant penile shortening, with or without Peyronie’s disease (PD).

PATIENTS AND METHODS

Between January 2013 and January 2014, 143 patients underwent our modified ‘sliding’ technique for penile length and girth restoration and concomitant penile prosthesis implantation. It is based on three key elements: (i) the sliding manoeuvre for penile length restoration; (ii) potential complementary longitudinal ventral and/or dorsal tunical incisions for girth restoration; and (iii) closure of the newly created rectangular bow-shaped tunical defects with Buck’s fascia only.

RESULTS

In all, 143 patients underwent the procedure. The causes of penile shortening and narrowing were: PD in 53.8%; severe ED with unsuccessful intracavernosal injection therapy in 21%; post-radical prostatectomy 14.7%; androgen-deprivation therapy, with or without brachytherapy or external radiotherapy, for prostate cancer in 7%; post-penile fracture in 2.1%; post-redo-hypospadias repair in 0.7%; and post-priapism in 0.7%. In patients with ED and PD, the mean (range) deviation of the penile axis was 45 (0‒100)°. The mean (range) subjective penile shortening reported by patients was 3.4 (1‒7) cm and shaft constriction was present in 53.8%. Malleable penile prostheses were used in 133 patients and inflatable penile prostheses were inserted in 10 patients. The median (range) follow-up was 9.7 (6‒18) months. The mean (range) penile length gain was 3.1 (2‒7) cm. No penile prosthesis infection caused device explantation. The average International Index of Erectile Function (IIEF) score increased from 24 points at baseline to 60 points at the 6-month follow-up.

CONCLUSION

Penile length and girth restoration based on our modified sliding technique is a safe and effective procedure. The elimination of grafting saves operative time and, consequently, decreases the infection risk and costs associated with surgery.

Editorial: Is the modified sliding technique the way forward in Peyronie’s surgery?

The old goal of prosthetic surgery, which aimed to guarantee a hard and straight penis good enough for penetrative intercourse, is likely to have now become obsolete. Various authors have reported that patients with Peyronie’s disease (PD) and severe corporal fibrosis who undergo penile prosthesis implantation tend to report the lowest satisfaction rates, mainly because of significant penile length loss [1, 2]. In particular, according to Kueronya et al. [3], ~80% of patients affected by PD perceive a degree of penile shortening before surgery, and any further loss of length attributable to the surgical correction leads to bother among all the affected patients. All attempts at penile length restoration during prosthetic surgery should therefore be welcomed in order to achieve higher patient satisfaction.

Initial attempts at penile length restoration involved a full disassembly of the penis and the use of a circumferential graft [4]. Then, in 2012, Rolle et al. [5] described the sliding technique, a modification of the circumferential graft that consists of a double dorsal-ventral patch and should therefore provide more stability to the corpora cavernosa than a circumferential graft.

The present series by Egydio et al. [6] describes a modified sliding technique without grafting the defect of the tunica albuginea. This reduces the operating time and theoretically infection rates should therefore be reduced.

Although leaving a defect in the tunica albuginea should, in theory, lead to a haematoma formation and potentially infection of the device, in the present series, no penile prosthesis infections were reported.

Although we believe that cutting corners in surgery is not the way forward, the authors of the present paper should be congratulated because the postoperative results in their series are very encouraging. In fact, the mean penile length gain in their series was 3.1 cm, with no reported infections requiring the explantation of the penile prosthesis and with an average increase in International Index of Erectile Function score of 36.

Certainly, if the results of the present series can be confirmed in the future, this technique will revolutionize the concept that any tunical defect >1 cm in size needs to be grafted to prevent aneurysmal dilatation of the cylinders of an inflatable penile prosthesis [7], as none of the inflatable cylinders in the series developed aneurysms.

Giulio Garaffa, and David J. Ralph
St Peters Andrology and the Institute of Urology, University College London Hospitals, London, UK

 

References

 

1 Akin-Olugbade O, Parker M, Guhring P, Mulhall J. Determinants of patients satisfaction following penile prosthesis surgery. J Sex Med 2006; 3: 7438

 

2 Zacharakis E, Garaffa G, Raheem AA, Christopher AN, Muneer ARalph DJ. Penile prosthesis insertion in patients with refractory ischemic priapism: early versus delayed insertion. BJU Int 2014; 114: 57681

 

 

 

 

 

7 Ralph D, Gonzalez-Cadavid N, Mirone V et al. The management of Peyronies Disease: 2010 guidelines. J Sex Med 2010; 7: 235974

 

 

Video: Penile lengthening and widening without grafting according to a modified ‘sliding’ technique

Penile lengthening and widening without grafting according to a modified ‘sliding’ technique

Paulo H. Egydio and Franklin E. Kuehhas*

 

Centre for Peyronies Disease Reconstruction, Sao Paulo, Brazil, and *London Andrology Institute, Suite 7 Exhibition House, Addison Bridge Place, London, UK

 

OBJECTIVE

To present the feasibility and safety of penile length and girth restoration based on a modified ‘sliding’ technique for patients with severe erectile dysfunction (ED) and significant penile shortening, with or without Peyronie’s disease (PD).

PATIENTS AND METHODS

Between January 2013 and January 2014, 143 patients underwent our modified ‘sliding’ technique for penile length and girth restoration and concomitant penile prosthesis implantation. It is based on three key elements: (i) the sliding manoeuvre for penile length restoration; (ii) potential complementary longitudinal ventral and/or dorsal tunical incisions for girth restoration; and (iii) closure of the newly created rectangular bow-shaped tunical defects with Buck’s fascia only.

RESULTS

In all, 143 patients underwent the procedure. The causes of penile shortening and narrowing were: PD in 53.8%; severe ED with unsuccessful intracavernosal injection therapy in 21%; post-radical prostatectomy 14.7%; androgen-deprivation therapy, with or without brachytherapy or external radiotherapy, for prostate cancer in 7%; post-penile fracture in 2.1%; post-redo-hypospadias repair in 0.7%; and post-priapism in 0.7%. In patients with ED and PD, the mean (range) deviation of the penile axis was 45 (0‒100)°. The mean (range) subjective penile shortening reported by patients was 3.4 (1‒7) cm and shaft constriction was present in 53.8%. Malleable penile prostheses were used in 133 patients and inflatable penile prostheses were inserted in 10 patients. The median (range) follow-up was 9.7 (6‒18) months. The mean (range) penile length gain was 3.1 (2‒7) cm. No penile prosthesis infection caused device explantation. The average International Index of Erectile Function (IIEF) score increased from 24 points at baseline to 60 points at the 6-month follow-up.

CONCLUSION

Penile length and girth restoration based on our modified sliding technique is a safe and effective procedure. The elimination of grafting saves operative time and, consequently, decreases the infection risk and costs associated with surgery.

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