Penile Lengthening Research Articles

Microphallus early management in infancy saves adulthood sensual life: A ‎‎comprehensive review.

Microphallus/Micropenis is a rare condition with significant physical and psychological implications for affected individuals. This article comprehensively reviews micropenis, its etiology, epidemiology, and various treatment options. We conducted a thorough literature review to collect relevant information on micropenis and microphallus, as well as related disorders. Our primary databases were PubMed, Medline, and Google Scholar. We searched for articles published in English between 2000 and 2023. Our analysis included 67 review articles, 56 research studies, 11 case reports, one guideline, and one editorial. Our search terms included "microphallus", "micropenis", "congenital hypogonadotropic hypogonadism", "androgen insensitivity syndrome", "pediatric management of micropenis", "testosterone therapy", and "psychosocial implications of micropenis". We focused on diagnosing micropenis and related conditions, including hormonal assessments, medical and surgical treatment options, psychosocial and psychological well-being, sexual development of adolescents, and sociocultural influences on men's perceptions of penile size. Additionally, we explored parenting and family dynamics in cases of micropenis and disorders of sex development, implications of hormonal treatment in neonates, and studies related to penile augmentation procedures and their effectiveness. The article highlights the importance of early diagnosis and intervention in addressing the physical and psychological well-being of individuals with micropenis. Surgical procedures, such as penile lengthening and girth enhancement, and non-surgical approaches like hormonal therapy are explored. The significance of psychological support, education, and lifestyle modifications is emphasized. Early management and comprehensive care are crucial for individuals with micropenis, from infancy to adolescence and beyond. A multidisciplinary approach involving urologists, endocrinologists, and mental health professionals is recommended. Regular assessment of treatment effectiveness and the need for updated guidelines are essential to provide the best possible care. Healthcare professionals should prioritize early diagnosis, and neonatologists should measure stretched penile length in neonates. A collaborative effort is needed among professionals, parents, and affected individuals to create a supportive environment that recognizes worth beyond physical differences. Continuous research and evidence-based updates are crucial for improving care standards.

A contemporary systematic review of penile lengthening procedures with penile prosthesis.

Penile prosthetic devices are the standard treatment for erectile dysfunction (ED) after failure of maximum medical therapy and conservative options. Several penile lengthening procedures (PLPs) can be performed concurrently with penile prosthesis (PP) insertion in patients with severe ED, penile shortening, and/or Peyronie's disease to help combat negative emotional and psychological concerns from penile length loss with penile prosthetic device placement. An extensive, systematic literature review of the various pre-, intra-, and post-operative techniques that can be applied to preserve, restore or enhance penile length at the time of penile prosthetic implantation. Numerous pre-operative and post-operative inflation protocols exists with vacuum erection devices and penile traction therapy. Intraoperative surgical techniques include cavernosal sparing and channeling without dilatation, subcoronal incision with circumferential penile degloving and grafting, the sliding technique, the modified sliding technique, the multiple-slit technique, the tunical expansion procedure (TEP), modified TEP, and the auxetic expansion procedure. These approaches can be meaningful to restore and/or preserve length for patients undergoing PP insertion. PLPs can be performed by surgeons who have extensive penile reconstruction experience and have been trained to do these procedures, as there is significant risk to the patient and limitations to what can be expected. Each patient must be counseled in detail about the risks and benefits of these procedures and have their expectations managed as the average postoperative penile length recovery is around 3 cm and can range from 0-4.0 cm. Future research is needed to identify the appropriate candidate for each approach, and how much length gain the patient can expect.

(219) Lengthening Phalloplasty: Combined Technique of a Urologist and a Plastic Surgeon

Abstract Introduction Lengthening phalloplasty is an operation that aims at increasing the length of the penile shaft. This procedure has been gaining popularity with different surgical techniques being described and possible suboptimal patient satisfaction rate that can be optimized. The most popular surgical method used for penile lengthening is release of the suspensory ligament. Our technique differs as it involves a combination of urological and plastic surgical steps to achieve the maximum length with the safest optimum outcome. Objective We are advocating the above unique modified surgical technique aiming to achieve the desired results with higher satisfaction rate. Methods A retrospective study including consecutive male patients presenting for penile lengthening over the last 6years. Patients underwent pre-operative andrology and psychological evaluation. All procedures were performed by the same urologist and plastic surgeon simultaneously. A successful surgical outcome is defined as: achieving a lengthening equal to or more than 2cm. Results A total of 82 married male patients were included. The age ranged from 26 to 40 years with a median of 33years. They had normal sexual activity with no psychiatric nor behavioural disturbance. The average pre-operative penile length was: 9.75 cm. the average additional penile lengthening achieved post-operatively was: 3.7 cm. with a range of 2.8 to 4.7 cm. There was no major complications or failure of the procedure observed. One patient suffered from partial wound dehiscence following return to sexual activity two week after surgery. Patients satisfaction with the outcome 6 months following surgery reached 31/32 with a single case of dissatisfaction owing to the residual scar (success rate of 97%). Conclusions We have concluded that using our multimodality technique that this type of phalloplasty is a safe procedure with 100% anatomical surgical success rate in achieving the desired length gain and overall patient satisfaction rate of 97% which has not been reported using the standard procedure. Disclosure No.

Morphometric Predictors of Penile Length Increase After Division of its Suspensory Ligament

IntroductionDivision of the suspensory ligament of the penis has emerged as a popular surgical approach for penile lengthening, but accurate preoperative predictions of lengthening outcomes remain elusive. This study aimed to identify readily measurable anatomical parameters associated with post-ligamentolysis penile length gain, facilitating more reliable preoperative estimations.MethodsAn experimental cross-sectional study was performed on 16 adult cadavers. Data collected before dissection included: age at death, ethnicity, height, length of the penis before dissection and width of the suspensory ligament of penis. Following the complete dissection of the suspensory ligament of penis, the depth of the pubic symphysis and the penile length after the procedure were measured. The absolute and relative length differences pre- and post-ligamentolysis were calculated. Correlation coefficients were used to study relations between these variables.ResultsPenile length increased uniformly after complete division of the suspensory ligament (average gain: 26.38 mm, SD = 14.83 mm; range 4–60 mm). Pearson correlation revealed a significant negative correlation between pre-ligamentolysis penile length and post-ligamentolysis increase (r = − 0.601; p = 0.014), suggesting greater gains in individuals with shorter pre-ligamentolysis lengths. Age, ligament width, and pubic arch depth showed no significant correlations. Ethnicity did not impact post-ligamentolysis length increase (t = − 0.135; p = 0.894).ConclusionsThis study highlights the potential to predict penile length gain post-ligamentolysis through measurable anatomical parameters. The ability to anticipate the outcome of this procedure could empower surgeons to provide informed counseling, potentially elevating patient satisfaction.An experimental cross-sectional study was performed to investigate the outcomes of penile lengthening surgeryPenile lengthening was achieved in all subjects via complete dissection of the suspensory ligament of the penisPenile length increase may be predicted preoperatively using easily measurable anatomical parametersNo Level AssignedThis journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266

Penile reconstruction after complete bladder exstrophy repair

The decreased penile length in patients born with bladder exstrophy (BE) results partly from pubic symphysis diastasis and the separation of the corporal bodies. Also, intrinsic shortening of anterior corporal compartment, residual penile dorsal curvature, and postsurgical scarred skin share in creation of short penile length. The goal of this study was to look at whether adult men who had bladder exstrophy (BE) surgery as babies needed and benefited from penile reconstruction, which included penile lengthening and repair of any redo penile pathology that was present at the same time. We reviewed the records of 31 repaired BE patients with mean age of 21.4±3.7 years. The patients complained of their dissatisfaction with short penile length, residual dorsal penile curvature, distal dorsal or hypospadiac urethral opening and scared penopubic skin. The penile lengthening was performed by sub-periosteal detachment of the corporal bodies from the pubic rami in all cases. In 8 patients full thickness dermal grafts were used to penile resurfacing after its lengthening. Twelve patients underwent coronal or glanular urethroplasty. Phalloplasty was performed in one patient using forearm free graft. Subjective evaluation by the patient reported satisfactory results in 25/31 (80.6%). The degree of penile lengthening measured at 6 months and one year postoperatively showed increased length which varied between 50% and 150% of the preoperative penile length. We hypothesize that congenital causes, such as short anterior corporeal compartment, wide pubic rami diastasis, and short penile urethra, as well as iatrogenic causes, such as post-surgical peno-pubic scars, could account for the coexisting multifactorial causes of penile shortening in male adults with BE. Penile lengthening is permitted, in our opinion, provided that the crura from the pubic rami is carefully and partially mobilized. The short phallus, residual dorsal chordee and distal urethroplasty can be corrected successfully in the majority of patients. Adult males with BE may have short penis that requires another reconstructive stage. The short phallus, residual chordee and distal urethroplasty can be corrected` successfully in the majority of patients.

Risk and benefits of penile length preservation techniques during penile prosthesis implantation: a systematic review by the young academic urologists sexual and reproductive health working group.

Penile shortening, frequently resulting from end-stage Peyronie's disease (PD), has a negative impact on patients' sexual activity and overall quality of life, especially when accompanied by Erectile dysfunction (ED). Various surgical techniques have been described to manage concomitant ED and penile shortening through penile prosthesis (PP) implantation. To evaluate the benefits and risks of different penile length preservation techniques during PP implantation. A systematic review of the available literature on the use of penile length preservation maneuvers in conjunction with PP implantation was conducted. For this systematic review, three databases (Medline, Embase and Cochrane) and clinical trial.gov were queried for relevant publications from 1 January 1990 to 1 September 2022. The review process followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The qualitative analysis included 15 relevant articles involving 1186 adult patients who underwent penile length preservation techniques during PP implantation. Penile lengthening of 1-7 cm was reported. Overall, postoperative complications were described in up to 21.7% of cases. Only five studies reported functional outcomes, showing a significant improvement in postoperative period based on the administered questionnaire (e.g. IIEF - International Index of Erectile Function, EDITS - Erectile Dysfunction Inventory of Treatment Satisfaction). Penile length preservation procedures appear to offer a viable option for managing acquired penile shortening, particularly in cases of PD. However, they are associated with a significant risk of complications. Proper patient selection, thorough discussion of risks and benefits, and referral to high-volume centers are mandatory to achieve optimal outcomes and minimizing complications. PROSPERO database registration CRD42022360758.

Evaluation of surgical and functional outcome of penile lengthening surgery with or without suspensory ligament release in adult buried penis

Evaluation of surgical and functional outcome of penile lengthening surgery with or without suspensory ligament release in adult buried penis

(347) Prediction of Post-operative Sexual Satisfaction after Penile Prosthesis Implantation (With and Without Penile Lengthening Procedures) Using Preoperative Penile Length Measurements

Abstract Introduction `- Penile prosthetic devices are the gold standard treatment of medication-resistant erectile dysfunction, however penile length reduction was reported as one of the main post operative disturbing complaints - Many lengthening procedures during penile prosthesis implantation (PPI) were described to increase postoperative sexual satisfaction. Objective `- To predict post-operative sexual satisfaction after PPI (with or without penile lengthening procedure) using preoperative penile length measurements. Methods `- This study was conducted in our urology department as prospective RCT, in the period between August 2018 till April 2020 - It included 61 male patients with organic ED who are candidates for PPI. - Patients were randomized to 2 groups; group A included 31 patients who underwent suspensory ligament release via penopubic Z-plasty, dorsal phalloplasty, suprapubic lipectomy, +/− ventral phalloplasty (in case of high scrotal insertion); group B included control patients who underwent PPI only via penoscrotal incision. - Measurement of preoperative and postoperative (after 3 months) penile lengths were done, including; the flaccid, visible stretched and functional stretched penile lengths. - Assessment of patients’ sexual satisfaction was done using the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) score adapted to penile prosthetic implant. - Patients with EDITS scores of 60-80 were considered satisfied, and those with EDITS scores of 80-100 were considered very satisfied. - Receiver operating curve (ROC) analysis was done to detect cutoff value for the preoperative stretched penile lengths (functional & visible) that are predicted to aid the patient to reach a postoperative satisfaction of EDITS ≥90 in each group. Results `- The mean preoperative measurements showed no statistically significant difference between the two groups. - However, the mean postoperative measurements after 3 months demonstrated a statistically significant difference between the two groups. - The mean values of both overall EDITS and the EDITS resting state and malleability scores were higher in group A (91.92 ± 7.22 and 7.38 ± 0.78) Vs. (79.55 ± 15.55 and 5.32 ± 1.12) in group B (p < 0.001) - For EDITS satisfaction level, the percentage of the very satisfied patients [≥ 80] in group A (89.7%) was significantly higher than in group B (64.3%) (p= 0.045) - Also, for the EDITS resting state and malleability satisfaction level, the percentage of the very satisfied patients in group A (55.2%) was significantly higher than in group B (0.0%) (p < 0.001) - ROC curve was done for both groups In group A: - Functional stretched penile length: AUC 0.815 with a cutoff value of 12.75 cm yielding a 81.8% sensitivity and 71.4% specificity (p value = 0.013) - Visible stretched penile length: AUC 0.795 with a cutoff value of 10.75 cm yielding a 81.8% sensitivity and 71.4% specificity (p value =0.020) In group B: - Functional stretched penile length: AUC 0.927 with a cutoff value of 14.50 cm yielding a 77.8% sensitivity and 94.7% specificity (p value < 0.001) - Visible stretched penile length: AUC 0.892 with a cutoff value of 12.50 cm yielding a 66.7% sensitivity and 94.7% specificity (p value <0.001). Conclusions `- Preoperative measurement of functional and visible penile lengths can be of value in predicting post-operative sexual satisfaction after PPI (with or without concurrent penile lengthening procedures). Disclosure No

From a Single Penile Suspensory Ligament to a Penile Suspensory Apparatus: Application to the Buried Penis Surgery

Abstract Goals/Purpose The ligamentous system supporting the penis is widely called « penile suspensory ligament ». It supports and attaches the penis to the abdominal wall and the pubic bone. However, the complexity of the anatomy of the penile suspensory system was underestimated. The aim of this anatomical study was to describe the different ligamentous (features, insertion sites, path) and their functions. Methods/Technique The first step consisted in a description of the different components of the penile suspensory apparatus on two cadavers embalmed by the Thiel method. The second part was an evaluation of the function of each ligament on freshly dead cadavers. In the third stage, we applied those findings to an exploratory cohort of patients undergoing a penile lengthening surgery for buried penis. Results/Complications The penile suspensory apparatus consisted in four ligaments from anterior to posterior : the fundiform ligament, the suspensory ligament, dense vertical ligament and the arcuate ligament. The first two were loose, non-stabilizing and the two posterior ones were dense and stabilizing. In our cohort, 12 patients were included. The mean BMI was 38. The mean pre-operative flaccid length was 4.1 cm [2.2 cm – 7 cm] and at 6 months 8.2 cm [5.2 cm - 11.5 cm] which represents a mean augmentation of 100%. The mean pre-operative circumference at a flaccid state was 8.2 cm [2 cm – 11.5 cm] and at 6 months post-operative was 12.6 cm [8.3 cm - 16 cm] which represents a mean augmentation of 85.7%. The most common complication was a phimosis. Conclusion We have described the detailed anatomy of the penile suspensory apparatus. It is the first time that the dense vertical ligament was brought to light. To avoid instability in penile lengthening, the posterior part of the dense vertical ligament and the arcuate ligament must be spared.

PD06-05 MANAGEMENT OF SERIOUS COMPLICATIONS AND TISSUE LOSS FOLLOWING HYPOSPADIAS SURGERY

You have accessJournal of UrologyCME1 Apr 2023PD06-05 MANAGEMENT OF SERIOUS COMPLICATIONS AND TISSUE LOSS FOLLOWING HYPOSPADIAS SURGERY Tenny Zhang, Peter Cai, Ashraf Gamal, Cairo Egypt, and Moneer Hanna Tenny ZhangTenny Zhang More articles by this author , Peter CaiPeter Cai More articles by this author , Ashraf GamalAshraf Gamal More articles by this author , Cairo EgyptCairo Egypt More articles by this author , and Moneer HannaMoneer Hanna More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003230.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Despite the high re-operation rates after proximal hypospadias repairs, surgeons have rarely reported disastrous complications of hypospadias surgery. Herein we report on 16 patients who sustained partial or total glandular or penile loss after hypospadias surgery and were referred to us for further management over the last 40 years (Figure 1). METHODS: Operative details of the primary surgery were not available in the majority of cases as six cases were from Egypt, one from Portugal, and one from Iraq. Forty-four percent (7/16) of the index operations utilized epinephrine mixed with local anesthetic. The surgical repairs we performed included Bevan-DeCastro phalloplasty (4), forearm flap phalloplasty (1), and penile lengthening by cutting the suspensory ligament (6) followed by resurfacing using either rotational scrotal flap (3) or staged Cecil-Culp repair (3) (Figure 2). Four patients underwent contouring of the glans penis. One patient declined treatment. RESULTS: Significant penile lengthening was achieved in all patients ranging from 5 to 8 cm (75-150% of the preoperative penile length). Phalloplasty was technically successful in all patients however we deferred urethroplasty in the four Bevan-DeCastro repairs to a later date during adolescence when forearm flap phalloplasty and penile prosthetic implant are practical. All five phalloplasty patients had acceptable cosmetic result in the absence of erectile function. CONCLUSIONS: Partial or total glandular or penile loss subsequent to hypospadias repair is a rare and disastrous complication. Subsequent surgical repair provides some value in improving outcomes. We discourage the use of epinephrine injections during hypospadias repairs and emphasize the importance of leaving the glans exposed to allow for postoperative visual examination and early recognition of vascular compromise. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e157 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tenny Zhang More articles by this author Peter Cai More articles by this author Ashraf Gamal More articles by this author Cairo Egypt More articles by this author Moneer Hanna More articles by this author Expand All Advertisement PDF downloadLoading ...

Clinical recommendations on penile reconstructive and prosthetic surgery: a consensus statement from the Asia-Pacific Society of Sexual Medicine.

Penile reconstructive and prosthetic surgery remains a highly specialized field where potential complications can be devastating, and unrealistic patient expectations can often be difficult to manage. Furthermore, surgical practice can vary depending on locoregional expertise and sociocultural factors. The Asia Pacific Society of Sexual Medicine (APSSM) panel of experts reviewed contemporary evidence regarding penile reconstructive and prosthetic surgery with an emphasis on key issues relevant to the Asia-Pacific (AP) region and developed a consensus statement and set of clinical practice recommendations on behalf of the APSSM. The Medline and EMBASE databases were searched using the following terms: "penile prosthesis implant," "Peyronie's disease," "penile lengthening," "penile augmentation," "penile enlargement," "buried penis," "penile disorders," "penile trauma," "transgender," and "penile reconstruction" between January 2001 and June 2022. A modified Delphi method was undertaken, and the panel evaluated, agreed, and provided consensus statements on clinically relevant penile reconstructive and prosthetic surgery, namely (1) penile prosthesis implantation, (2) Peyronie's disease, (3) penile trauma, (4) gender-affirming (phalloplasty) surgery, and (5) penile esthetic (length and/or girth enlargement) surgery. Outcomes were specific statements and clinical recommendations according to the Oxford Centre for Evidence-Based Medicine, and if clinical evidence is lacking, a consensus agreement is adopted. The panel provided statements on clinical aspects of surgical management in penile reconstructive and prosthetic surgery. There is a variation in surgical algorithms in patients based on sociocultural characteristics and the availability of local resources. Performing preoperative counseling and obtaining adequate informed consent are paramount and should be conducted to discuss various treatment options, including the pros and cons of each surgical intervention. Patients should be provided with information regarding potential complications related to surgery, and strict adherence to safe surgical principles, preoperative optimization of medical comorbidities and stringent postoperative care are important to improve patient satisfaction rates. For complex patients, surgical intervention should ideally be referred and performed by expert high-volume surgeons to maximize clinical outcomes. Due to the uneven distribution of surgical access and expertise across the AP region, development of relevant comprehensive surgical protocols and regular training programs is desirable. This consensus statement covers comprehensive penile reconstructive and prosthetic surgery topics and is endorsed by the APSSM. The variations in surgical algorithms and lack of sufficient high-level evidence in these areas could be stated as a limitation. This APSSM consensus statement provides clinical recommendations on the surgical management of various penile reconstructive and prosthetic surgeries. The APSSM advocates for surgeons in AP to individualize surgical options based on patient condition(s) and needs, surgeon expertise, and local resources.

Anatomical Study of the Penile Suspensory System: A Surgical Application to Micropenis.

This study is subdivided in two parts: an anatomical analysis and a clinical analysis. The anatomical part consists of a dissection of eight male cadavers to describe the anatomy and test the stability after sectioning successively the suspensory ligaments. The clinical part consists of an analysis of 30 patients with micropenis operated on for penile lengthening by a penile suspensory ligament release and lipofilling. The suspensory apparatus consists of four distinct ligamentous structures: fundiform, suspensory, dense vertical, and arcuate ligaments. These different structures are lax superficially but become firm and tense posteriorly. The section of the fundiform and suspensory ligaments did not destabilize the penis. Penile lengthening by way of cautious suspensory ligament release can be performed without erection instability.

NEW PERSPECTIVES IN PENILE CANCER MANAGEMENT: HOW TO RETAIN FUNCTIONAL OUTCOMES

Penile cancer is a rare malignancy and a debilitating condition in most industrialized nations that often requires aggressive surgical or multimodal treatment with significant anatomical, functional, and psychosocial impact on patients’ quality of life. Total or partial penile amputation has been considered the standard of treatment according to locoregional clinical staging and risk stratification. However, these surgical options are associated with significant negative functional and psychological outcomes in terms of body image, self-esteem, and manhood resulting in loss of sexual function and inability of upright voiding. Recently, a critical paradigm shift has taken place in the clinical management of penile malignancy, that is, the implementation of alternative, less-invasive surgical strategies to deal with the primary malignancy. These sparing approaches of penile anatomy aim to retain penile and urinary functions and overall quality of life and thus interfering as little as possible with functional anatomy. This paradigm shift has been made possible by advances in surgical and technological developments which have resulted in organ-preserving strategies with gratifying psychosocial and functional outcomes simultaneously without compromising final cancer control. This spectrum of novel surgical strategies includes local excision, glansectomy, and partial penectomy followed by surgical reconstructive procedures consisting of primary closure of the resulting defect, closure with skin flaps or split- thickness skin grafts, penile lengthening and/or enhancing procedures, neophalloplasty, and, more recently, penile transplantation fostered by limitations of conventional reconstruction. This review discusses the complexities of surgical reconstruction following penile cancer treatment including the burgeoning field of penile transplantation.

Surgical tips in difficult penile prosthetic surgery: a narrative review.

Penile prosthesis implantation continues to represent a reliable solution to address erectile dysfunction when oral medications fail, are not tolerated or are contraindicated, and most typically is associated with excellent satisfaction rates and durable results. Despite the dramatic improvements in the prostheses' design, in the surgical instruments and techniques over the years, certain categories of patients still pose a significant surgical challenge. The aim of the current review is to provide a quick and useful practical guidance based on our expertise in the identification and management of the difficult penile prosthesis implantation cases. A narrative review design was here preferred to fulfil our purpose. The search strategy included a range of terms, e.g. penile prosthesis, corporal fibrosis, infection, ischaemic priapism, Peyronie's disease, radical prostatectomy, pelvic surgery. Extensive corporal fibrosis after explantation of an infected device or after prolonged ischaemic priapism may represent the most difficult situations to deal with in penile prosthesis implantation surgery. Penile prosthesis implantation in patients with Peyronie's disease and in those who previously underwent radical prostatectomy also presents with an increased risk of complications. Experienced surgeons need to be able to recognise promptly and manage urethral perforation, cylinder crossover, tunical perforation and erosion, as these complications are more common when dealing with difficult penile prosthesis implantation cases. Applying penile lengthening techniques and principles can be useful in selected cases to ensure better postoperative satisfaction rates, especially in those patients who have experienced a more significant degree of loss of length preoperatively. High-volume-implanting surgeons should always be involved in complex cases to minimise the risk of complications. A thorough preoperative counselling can set realistic patients' expectations in this context, further contributing to postoperative satisfaction.

Recurrent ventral curvature after corporoplasty with tunica vaginalis flap

Optimal means to correct ventral curvature (VC) is debated. Our preferred technique for curvature greater than 45° is corporoplasty using tunica vaginalis flap (TVF). We describe our complications with TVF for ventral lengthening. Forty-four boys who underwent ventral lengthening with a corporoplasty with TVF were identified in a prospective database for proximal hypospadias repair by a single surgeon from 2008 to 2021. Corporotomy was performed by incising the tunica albuginea of the corpora cavernosa transversely at the point of maximum curvature. Harvested TVF was tailored to the size of the corporotomy and anastomosed to the edges of the tunica albuginea and on laid to the corporal defect with the mesothelial side of the TVF abutting the erectile tissue. Median age at surgery was 1.0 years (IQR 0.72-1.82). Median follow-up time was 4.9 years (IQR 2.6-8.0). Thirteen patients (27%) were older than 10 years of age at last follow up (median 13.3, range 10-20). Twenty-two boys (50%) received preoperative testosterone. The most common location of the meatus after degloving was penoscrotal (41%). Median VC after degloving was 90° (IQR 80-100). The urethral plate was transected in 43/44 (98%) of boys, improving median VC to 60° (IQR 40-60). After corporotomy, the median longitudinal distracted distance was 15mm (IQR 12-17). Urethral reconstruction was most commonly achieved with the transverse island preputial flap technique or its modifications (39/44; 89%). Erections were reported in 42 boys (95%). None developed corporal diverticula, and two patients (4.5%) had ascended testis associated with TVF harvest. Seven percent of boys had recurrent ventral curvature (RVC; 3/44). Median RVC was 30° (IQR 30-45). One patient had RVC at the penoscrotal junction (not at site of prior corporoplasty) identified 11 years post operatively at age 15, and underwent dorsal plication. The other 2 patients were diagnosed less than 1 year post operatively. Both patients received testosterone due to small glans size, had double-face tubularized transverse island preputial flap as urethral and ventral skin coverage, and had endocrine and genetic consultation. Both had scarring of the preputial flap and of the corporoplasty. Scar excision and superficial transverse incisions on the tunica albuginea corrected RVC. The five-year outcome of ventral penile lengthening using TVF for corporoplasty is favorable with 7% of boys with RVC, and 4.5% with ascended testes associated with TVF harvest. None developed corporal diverticula.

Penile lenghthening original technique using a pubo-cavernous spacer. Long term results from a series of over 200 patients.

We report our long experience in the surgical treatment of patients requesting penile lengthening by suspensory ligament release and placement of a custom-made soft silicone pubo-cavernous spacer. The aim was to show that with this surgical technique the results obtained are maintained over time. It is crucial to achieve postoperative satisfaction of these patients who show fragility and self-esteem problems. From 1999 to 2020, we treated 245 patients with congenital or acquired penile brevity. We carefully analysed the preoperative and postoperative (at 6, 12, 24 and 48 months) penile size of the patients to evaluate whether this technique could allow the long-term maintenance of aesthetic results. We also assessed preoperative erectile function and we focused on the psychological aspects to avoid surgery in patients with dysmorphophobia. This original technique involves the section of the suspensory ligament and the implantation of a silicone spacer between the pubic symphysis and the corpora cavernosa. This spacer is conformed to the patient anatomy and maintains the relationship between the anatomical structures unchanged over time. Sexual self-esteem and patient satisfaction were assessed with the APPSSI questionnaire. The mean increase in penile length was about 2.5 cm in flaccid state and 1.9 cm in stretched state. There were no injuries of the neurovascular bundle or urethra, and no erectile dysfunction was noted. These results persisted at 6, 12, 24 and 48 months without significant differences. Over 80% of patients stated that they were completely satisfied with the results obtained. This satisfaction remained stable along follow up. The section of the suspensory ligament and the implant of the soft silicone spacer provide real penis elongation with satisfactory results that persist over time. This technique avoids the frequent complication of short-term shortening due to the scar adhesions of the edges of the dissected ligament. The high aesthetic satisfaction of patients is stable at controls at 6, 12, 24 and 48 months.

Emerging Roles of Penile Traction Therapy and Vacuum Erectile Devices.

Penile traction therapy (PTT) and vacuum erection devices (VED) are nonsurgical conservative treatment options that have been used in the treatment of various urologic and sexual disorders such as Peyronie's Disease (PD) and Erectile Dysfunction (ED). Recently expanded uses for these therapies now include penile lengthening and with surgical interventions such as penile prosthesis surgery (PPS) and radical prostatectomy (RP). These devices can be used as both monotherapy or combination therapy. To review the indications and clinical studies for PTT and VED. A literature search was conducted using PubMed to identify relevant studies addressing PTT, VED, and their indications. Searched terms included penile traction therapy, penile traction device, vacuum erection device, Peyronie's disease, penile prosthesis, radical prostatectomy, subjectively small penis, penile lengthening, erectile dysfunction. PTT with dynamic traction devices has shown favorable benefits for PD in many studies. The benefits of VED for PD cannot be confirmed due to limited studies with poor quality. In posterior urethroplasty, VED shows promise postoperatively, with additional trials also needed. In PPS, both PTT and VED have had positive findings in pre- and postoperative treatment. In RP patients, VED use has had positive outcomes while new literature shows beneficial effects of dynamic PTT and provides a basis for future studies. VED use does not show great benefit in patients with small penis, however PTT does have some positive findings. In ED, VED has a history of successful use and PTT has promising new data available. PTT and VED have been utilized in urologic and sexual conditions with various success. Several promising areas utilizing both PTT and VED are being studied, however, more research needs to be done in these areas prior to becoming a standard treatment. Mehr J, Santarelli S, Green TP, et al. Emerging Roles of Penile Traction Therapy and Vacuum Erectile Devices. Sex Med Rev 2022;10:414-426.

Revelations on Men Who Seek Penile Augmentation Surgery: A Review.

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. To review the current practice for treatment of men presenting for penile augmentation surgery. 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." 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. 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 2022;10:453-460.

Commentary to “Sexual health outcomes after penile reconstruction in the exstrophy epispadias complex”

In this study, Harris et al. [1] assess the sexual health of 57 adult males with bladder exstrophy-epispadias complex (EEC) who had undergone penile reconstruction. 28/57 responded to the survey by validated and non-validated questions. They compared 3 surgical methods for penile lengthening using free skin grafts (SG), tissue expanders (TE) and neo phalloplasty, the overall the median SHIM score was 19 with no difference between the 3 groups.

Penis Enlargement by Penile Suspensory Ligament Division with Cross-Plasty of the Skin.

To demonstrate modified technique of penile lengthening. We have reviewed 30 patients who underwent surgery with the use of the proposed "cross-method" and also compared with 35 patients who had surgery with the division of the suspensory ligament performed with the use of V-Y plasty method. We have achieved better enlargement and SEAR (self-esteem and relationship) scores with the "cross-method" compared to V-Y plasty. The cross-method is a simple alternative technique for penile lengthening that can be performed safely in order to treat small penis syndrome and obtain better results.