Suprapubic Lipectomy and Placement of a Three-piece Inflatable Penile Prosthesis

Abstract

Penile length loss is often observed in patients with erectile dysfunction and obesity. In patients with a prominent infrapubic fat pad, the excess fat can further reduce perceived penile length.1 As others have reported, concurrent suprapubic lipectomy and placement of a penile implant has been shown to be an effective way of exposing phallic length in this challenging patient population.2,3 OBJECTIVE: In this video, we present surgical technique and initial outcomes of concurrent suprapubic lipectomy and 3-piece inflatable penile prosthesis (IPP) placement in patients that have erectile dysfunction and lipodystrophy of the mons pubis. We retrospectively reviewed an institutional review board-approved prosthetic database of male patients that underwent placement of a 3-piece IPP and concurrent suprapubic lipectomy from 2020 to 2023. Intraoperative complications and postoperative outcomes were collated and analyzed. To perform this operation, an elliptical incision is made around the suprapubic fat pad that extends to the base of the penis inferiorly. Laterally the incision is carried just medial to the inferior margin of the iliac crest. Sharp dissection and electrocautery are used to dissect the fat pad free. A layer of areolar tissue is preserved above the layer of the fascia to prevent seroma formation. For larger blood vessels, vascular clips are used to ensure adequate hemostasis. After removal of the fat pad, placement of the penile prosthesis can proceed as one would through an infrapubic approach. After the device is placed, the tissue flaps based on the external pudendal vessels are inspected for adequate vascularity. Penetrating towel clamps are used to approximate the skin edges from lateral to medial so that the midline closure can be approximated accurately. 0-PDS is used to anchor the flap superiorly into the lower edge of the abdominal fold. The incision is then closed in multiple layers of absorbable suture from lateral to medial. A skin stapler or suture is then used to approximate the skin and the penis is wrapped with a compressive dressing. Nine patients underwent the combined surgery. There were no intraoperative complications. In follow-up, 1 patient developed an infection-related complication that required device removal and immediate replacement. The remaining 8 did well postoperatively with improved dorsal phallic length with no infection or device-related complications. Concurrent suprapubic lipectomy and placement of a 3-piece IPP is a safe and reproducible technique for the treatment of suprapubic lipodystrophy, buried penis, and refractory ED.