Shortened penis post penile prosthesis implantation treated with subcutaneous soft silicone penile implant: case report

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.

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.

Clinical Recommendations From the European Society for Sexual Medicine Exploring Partner Expectations, Satisfaction in Male and Phalloplasty Cohorts, the Impact of Penile Length, Girth and Implant Type, Reservoir Placement, and the Influence of Comorbidities and Social Circumstances

INTRODUCTION

To date, several aspects of inflatable penile prosthesis (IPP) surgical procedure have been poorly studied.

AIM

The aim of this study was to review the evidence associated with IPP implantation and provide clinical recommendations on behalf of the European Society for Sexual Medicine (ESSM). Overall, 130 peer-reviewed studies and systematic reviews, which were published from 2007-2018 in the English language, were included.

METHODS

MEDLINE and EMBASE were searched for randomized clinical trials, meta-analyses, and open-label prospective and retrospective studies.

MAIN OUTCOME MEASURE

The panel provided statements exploring patients and partner expectations, satisfaction in male and phalloplasty cohorts, the impact of penile length, girth and implant type, reservoir placement, the influence of comorbidities, and social circumstances. Levels of evidence were provided according to the Oxford 2011 criteria and graded as for the Oxford Centre for Evidence-Based Medicine recommendations.

RESULTS

In the preoperative setting, it is fundamental to identify and interact with difficult patients with the intention of enhancing the surgeon's ability to establish the surgeon-patient relationship, reduce physical and legal risk, as well as enhancing patient satisfaction. To address this need, the mnemonic Compulsive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial, and Psychiatric ("CURSED") has been suggested to identify patients who are at high risk of dissatisfaction. The current recommendations suggest improving glycemic control in patients with diabetes. Available evidence suggests evaluating transplant recipients with the criteria of Barry, consisting of stable graft function for >6 months, avoidance of intra-abdominal reservoir placement, and low-dose immunosuppression. HIV status does not represent a contraindication for surgery. Smoking, peripheral vascular disease, and hypertension may be associated with an increased risk of revision surgery. Patients with spinal cord injury may receive IPP. Patients aged ≥70 years, as well as obese patients, can be offered IPP. The IPP implantation can be performed in patients with stable Peyronie's disease. Ectopic high submuscular reservoir placement can be considered as an alternative method.

CLINICAL IMPLICATIONS

There is a relevant lack of high-level data and definite conclusions in certain areas remain difficult to draw.

STRENGTH & LIMITATIONS

All studies have been evaluated by a panel of experts providing recommendations for clinical practice. Because of lack of sufficient prospective data, some of the included studies are retrospective and this could be stated as a limitation.

CONCLUSION

This ESSM position statement provides recommendations on optimization of patient outcome by patient selection, and individualized peri- and intra-operative management. ESSM encourages centers to collaborate and to create prospective, multicenter registries in order to address this topic of increasing importance. Osmonov D, Christopher AN, Blecher GA, et al. Clinical Recommendations from the European Society for Sexual Medicine Exploring Partner Expectations, Satisfaction in Male and Phalloplasty Cohorts, the Impact of Penile Length, Girth and Implant Type, Reservoir Placement, and the Influence of Comorbidities and Social Circumstances. J Sex Med 2020;17:210-237.

Spontaneous Penile Tumescence by Sparing Cavernous Tissue in the Course of Malleable Penile Prosthesis Implantation

INTRODUCTION

Spontaneous penile tumescence after penile prosthesis implantation has been sporadically reported in the literature.

AIM

To preserve residual erectile function of patients' spontaneous penile tumescence by sparing cavernous tissue in the course of malleable penile prosthesis implantation.

METHODS

Overall, 92 patients were randomized into 2 equal arms; patients undergoing conventional malleable penile prosthesis implantation, and patients undergoing the cavernous tissue-sparing technique. 1 month after surgery, these patients underwent penile duplex examination to assess the maximal cavernous tissue thickness around the implant cylinders. Additionally, they were asked about the occurrence of any spontaneous or arousal-induced penile tumescence.

MAIN OUTCOME MEASURES

Postoperative changes were compared with the preoperative ones.

RESULTS

The mean maximal cavernous tissue thickness was shown to be significantly higher in the cavernous tissue-sparing group compared with the conventional surgery group (5.2 ± 0.8 mm vs 2.2 ± 1.04 mm, P < .01). In the cavernous tissue-sparing group, 41 of 46 patients (89.13%) reported having a significantly higher incidence of residual penile tumescence vs 7 of 46 patients (15.2%) in the conventional surgery group (P < .001). The postoperative penile girth was significantly higher in the cavernous tissue-sparing group than in the conventional surgery group (11.16 ± 1.1 cm vs 10.11 ± 1.15 cm, P < .001).

CLINICAL IMPLICATIONS

This study provides a step-by-step approach to maintaining post-implantation penile tumescence and preserving penile girth in a reproducible manner.

STRENGTHS & LIMITATIONS

This is the first study to demonstrate the benefits of implanting a penile prosthesis while the penis is in a pharmacologically induced tumescent state. It is also the first to make use of ultrasound imaging in assessing postoperative corporal tissue. The main limitations are the short postoperative follow-up period and the non-blinding of measurements.

CONCLUSION

It could be concluded that the cavernous tissue-sparing technique is a reproducible technique that has the added value of preserving residual erectile function in the form of retained postoperative penile tumescence and preserved penile girth. Zaazaa A, Mostafa T. Spontaneous Penile Tumescence by Sparing Cavernous Tissue in the Course of Malleable Penile Prosthesis Implantation. J Sex Med 2019;16:474-478.

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.

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.