Suprapubic Fat Research Articles

(110) Evaluation of Penile Anatomy with MRI

Abstract Introduction Penile enlargement interventions have become increasingly popular in recent years. The common lengthening procedure involves dividing the fundiform and suspensory ligaments to enable the outward movement of the concealed part of the penis. Nevertheless, the outcomes of these surgeries can vary, and clear patient selection criteria have yet to be established. Objective In this study, our objective was to assess penile anatomy using MRI and to identify penile anatomical variations that can aid in the selection of patients for penile enlargement surgeries. Methods We conducted a retrospective study to assess penile anatomy in the context of lengthening surgery. Pelvic MRIs taken for various reasons were evaluated, and the angle between the penile shaft and the symphysis pubis (a), as well as the distance from the pubis to the skin (b), were measured. Patients were categorized into three groups (I, II, III) based on the highest point of the penis relative to the symphysis pubis in the sagittal plane (Figure 1). Results A total of 519 pelvic MRIs were initially reviewed, and 344 met the protocol's eligibility criteria. The participants had a median age of 53 years (IQR 38-65) and a median body mass index of 26 (IQR 24-29). The median angle between the penile shaft and pubis was 23 degrees, with a pubis-skin distance of 38 mm. Age was significantly correlated with the angle between the penile shaft and pubis (r=0.61, p<0.01). Patient distribution across the groups based on penis highest point and pubis location was as follows: 36.1% in Group I, 47.4% in Group II, and 16.5% in Group III. Additionally, a significant positive correlation existed between BMI and suprapubic fat thickness (r=0.65, p<0.01). The analysis unveiled noteworthy variations in penile anatomy, suprapubic fat distribution, peno-pubic angle, and the anchoring point of the fundiform ligament to the penis. Some penises also displayed an S-shaped anatomy. Figure 2 visually illustrates the range of observed penile anatomical variations. Conclusions Our study revealed a significant variability in penile anatomy. The distinctions among patients should be carefully considered when planning any penile enhancement intervention. Disclosure No.

Minimally invasive monsplasty

In this video, we present our technique for a minimally invasive monsplasty using a sling. This is a variation of Shaeer's technique, previously published on by Dr Shaeer. He has demonstrated excellent success with this and we have adapted it with a commercial sling and a midline incision.Buried penis repair can be a very difficult surgery with significant morbidity. In patients with a relatively soft suprapubic fat pad, we attempt to unbury the penis with a relatively simple and minimally invasive surgery.While this technique does not provide as robust a repair as a traditional buried penis repair, it is significantly less morbid and can produce good functional results with much shorter operative time and quicker recovery. Most patients are discharged same day and experience minimal pain. We believe this technique is best suited for patients with a soft, small to moderate fat pad, and who may be poor candidates for a larger surgery.

(407) Buried Penis in Morbidly Obese Patient: Surgical Technique of Fat Pad Excision, Malleable Penile Prosthesis Insertion and Penile Split Skin Graft

Abstract Introduction Buried penis has a significant impact on quality of life affecting voiding and sexual function. Central and suprapubic deposition of adipose tissue related to obesity is a common cause. Objective This video shows the surgical approach of a complex case of buried penis managed with a suprapubic fat pad excision and simultaneous malleable penile prosthesis insertion. Methods We present a case of buried penis in a morbidly obese patient (BMI:43) with a history of two previous gastric bypass surgery and an apronectomy. affecting micturition and sexual function. A skin incision is made with a transverse incision at the level of the anterior superior iliac spine and a curvilinear inferior border. The apex of the inferior border should be approximately 2 finger breadth above the level of the penopubic junction. The incision is extended down to the rectus sheath and the spermatic cords at the lateral boundaries and the penile shaft at the midline are exposed. A malleable implant is inserted using the infrapubic approach and a split skin graft harvested to replace the unhealthy penile shaft skin. The dermis of the skin edges are secured to the rectus sheath with 0/0 vicryl sutures and the wound is closed in layers. Results Post-operative recovery was complicated by partial necrosis of the skin graft. At 3 months, the patient was able to stand to void and engage in sexual intercourse at 6 months. Conclusions The prevalence of obesity is increasing and in men, the presence of a suprapubic fat bad can result in a buried penis and affect voiding and sexual function. Although weight loss should be advised in the first instance, this may often not be enough. A combination of a suprapubic fat pad excision with malleable penile implantation and spit skin graft is a treatment option that can be considered. Disclosure No

(538) Penile Enlargement for Patient with Buried Penis: Pubic Dermolipectomy, Scrotoplasty and Mons Pubis Reconstruction

Abstract Introduction Acquired buried penis is a common condition in obese patients. Abnormal excess fat accumulation under the pubic skin leads to the partially or completely disappearance of the penis. This condition is related to voiding difficulties and sexual dysfunction. The goal of surgical treatment is to expose full penile lengthy by excising the adipose pubic tissue and part of excess pubic skin. Objective The aim of this kind of surgery is to make possible to have a normal sexual life to obese patients with buried penis. Methods We performed this technique for buried penis in 25 patients aged from 18 to 72 y (mean 48). Preoperatively, the patient is marked for the procedure in the standing position. Two transversal incisions are made on the pubis and joined laterally on both sides towards anterior iliac spines with the care taken to avoid the formation of "dog ears". The suprapubic fat is removed. Following the inner surface of the Scarpas fascia, the fat is also removed from the penoscrotal angle and from the scrotum as much as possible leaving exposed funiculus and testis on both sides. Suspensory ligament of the penis was incised. Penile skin redistribution leads to a better organ exposure. Postoperative vacuum erectile device was used in order to prevent penile retraction. Results Follow up was at 6 months. Early postoperative complications were hematoma (7pts), penile skin edema (5pts), seroma (5pts), wound infection (5pts), penile shaft retraction (3pts). Majority of pts (22pts) were satisfied good aesthetical and functional outcome. Conclusions Pubic dermolipectomy is a safe procedure with satisfactory results to treat men with buried penis. Surgical exposition of the penile shaft was accomplished in all patients. Disclosure No

(344) The Surgical Outcome of Buried Penis Surgery

Abstract Introduction Buried penis is a condition where the penis retracts and becomes hidden beneath the skin. It has a significant impact on quality of life of the patient and can present with a variety of symptom including lower urinary tract symptoms and erectile dysfunction. Whilst there are several causes, obesity is the most common in adults. Objective The aim of this study is to assess the variety of different operations performed with patient and surgeon satisfaction rates. Methods This is a retrospective study on patients with a buried penis operated on between 2010 and 2020. Data retrieved included presenting complaints, previous surgery, co-morbidities, surgical details and patient and surgeon satisfaction rates with cosmesis. Results A total of 141 patients were recruited with buried penis (median age 54, range 20-80). The presenting complaints were inability to void standing n = 30, erectile dysfunction n = 18, small penis n = 94. Aetiological factors included diabetes n=47, vascular disease n=62, penile cancer surgery n= 3 and BXO n= 13. The BMI was recorded in 44 patients (range 23-52) with 7 being morbidly obese (BMI >40). 47 patients had only a weight was recoded with a median of 114kg (range 68-169kgs). A total of 96 (68%) patients had had previous surgery prior to referral and in particular circumcision in 49 patients. The operations performed on the 141 patients were circumcision n=40, scrotoplasty n=35, V-Y plasty n=11, skin grafting n=34, suprapubic fat pad excision n=77, abdominoplasty n=25, malleable penile prosthesis n=7, inflatable prostheses n=7 and division of suspensory ligament n=24. The post-operative length of stay was median 3 days (range 0-52 days) but for abdominoplasty and grafting this was a median of 5 days (range 1-52 days). There were 27 complications (19%); infections (n=15), dehiscence (n=5), haematomas (n=2) The mean follow up was 506 days (range 0-4313 days) with a surgical satisfaction rate of 87% and patient satisfaction of 79%. Of note the highest dissatisfaction occurred in patients having circumcision or suprapubic fat pad removal. Conclusions Buried penis is a complex condition with patients likely requiring a combination of surgical techniques. Circumcision alone usually does not treat the problem and may make things worse. A prolonged hospital stay with significant wound complications may occur but the majority of patients are happy with the final outcome. Disclosure No

Patients with adult-acquired buried penis and their surgical management: a single-center study

Adult-acquired buried penis (AABP) is a condition in which the suprapubic fat (the escutcheon) conceals the penis. The etiologies of AABP include obesity, pelvic lymphedema, lichen sclerosis, and scar contraction following a circumcision. If untreated, AABP can lead to hygiene-related infections, urinary and sexual disorders, and psychological issues, such as depression, diminished self-esteem, and poor quality of life. When weight reduction fails to resolve this condition, surgical correction can successfully manage the patient’s AABP. The goal of surgical repair is to extract the telescoped penis from the escutcheon. In our experience, this has been successful with a urologist/plastic surgeon team. Cases of surgical repair for AABP performed at a single medical center from 2012 to 2022 were retrospectively reviewed. Fourteen patients, whose age ranged from 40 to 74 years old, were identified, and their characteristics as well as the surgical techniques performed on them were reviewed. All patients were obese, their body mass index ranging from 32.1 to 62.4; eight patients were severely obese. Five patients had a history of adult circumcision, 5 had a prior diagnosis of lichen sclerosis, and 3 had genital lymphedema. The initial procedures were routine but with some variation. The surgical techniques included performing a panniculectomy and/or an escutcheonectomy, degloving the penis, removing nonfunctional fibrotic tissue, incising the suspensory ligament, and using a meshed split-thickness skin graft (STSG) for penile coverage. The most common complication was wound dehiscence. Two patients with complications required a return to the operating room; one patient returned for closure of an infected wound and the other for penile reconstruction and the placement of a new STSG for lymphedema. All patients eventually recovered, with no further complications reported.

The outcomes of surgical management options for adult acquired buried penis.

Functional and surgical outcomes after surgical correction of adult acquired buried penis (AABP) are limited in the current literature. We retrospectively recruited patients underwent surgical treatment of AABP in a single institution from 2017 to 2021. Surgical repair was classified according to surgical complexity following Pariser-Santucci's classification. The primary endpoint of the study was the recurrence-free rate survival. The secondary endpoints were surgical, functional and patients' reported outcomes. Overall 28 patients were included in the study. Median follow-up was 27.5 (18.5-34.5). The most common complaints at presentation were sexual (53.6%) and voiding (39.3%) dysfunction. Surgical management steps ranged from circumcision to more complex procedures, such as suprapubic fat pad excision, abdominoplasty and/or penile shaft skin grafting. Overall postoperative complications were recorded in 32.1%. High-grade complications (Clavien≥3) occurred in 7.1%. One-year recurrence-free survival was 88.7%. Postoperatively IPSS and IIEF-15 questionnaires showed a significant improvement in urinary 8 (0-12) vs 2 (0-3), p = 0.03 and sexual function 37 (23-68) vs 68 (45-72), p = 0.001 respectively. Overall, patients reported functional improvement and 93.8% experienced a positive impact of QoL. AABP surgical repair, despite the high incidence of complications, seems to allow satisfactory outcomes and a significant improvement in patients' QoL.

The surgical outcome of buried penis surgery

Buried penis is a condition where the penis retracts. It has a significant impact on quality of life of the patient and can present with a variety of symptom. Whilst there are several causes, obesity is the most common in adults. A retrospective study on patients with buried penis operated on between 2010 and 2020. Data retrieved included presenting complaints, previous surgery, co-morbidities, surgical details and patient and surgeon satisfaction rates. A total of 141 patients were recruited with buried penis (median age 54). The presenting complaints were inability to void standing n=30, erectile dysfunction n=18, and small penis n=94. 96 patients had had previous surgery, 49 were circumcisions. The operations performed on the 141 patients were circumcision (n=40), scrotoplasty (n=35), V-Y plasty(n=11), skin grafting (n=34), suprapubic fat pad excision(n=77), abdominoplasty (n=25), penile prosthesis (n=14), and division of suspensory ligament (n=24). The post-operative length of stay was 0-52 days. There were 27 complications; infections (n=15), dehiscence (n=5), haematomas (n=2)The mean follow up was 506 days (range 0-4313 days) with a surgical satisfaction rate of 87% and patient satisfaction of 79% (p=0.021). Of note the highest dissatisfaction occurred in patients having circumcision and/or suprapubic fat pad removal. Buried penis is a complex condition with patients likely requiring a combination of surgical techniques. Circumcision alone usually does not treat the problem and may make things worse. A prolonged hospital stay with significant wound complications may occur but the majority of patients are happy with the final outcome. No conflict of interest to declare.

Increase apparent penile length by cryolipolysis in the reduction of male suprapubic fat.

The buried or hidden penis in adults is troublesome in males, whereas the length of the penile shaft is buried under the skin surface of the suprapubic fat to a degree that reveals the concept of a little penis. We aimed to assess a new modality of treatment to increase the apparent penile length by using the cryolipolysis in the reduction of male suprapubic fat as a noninvasive procedure. This prospective study was performed on 46 male patients complaining of buried short apparent small size penis. All patients were subjected to full medical history, body mass index and examination of penile (length, size and abnormalities). The measures of the apparent penile length from the skin to the tip of the glans penis and suprapubic skin fold thickness using (adipometer) were recorded before the three consecutive suprapubic cryolipolysis sessions. The mean apparent stretched penile length at session 1, 2 and 3 were 12.1±0.5cm, 12.66±0.48 and 12.88±0.72, respectively, with a statistically significant increase between three sessions (p<.001), whereas the mean skin fold suprapubic fat at session 1, 2 and 3 was 2.99±0.49cm, 2.37±0.48 and 2±0.37, respectively, with a statistically significant decrease (p<.001). The cryolipolysis of suprapubic fat is a safe, effective, noninvasive and applicable procedure that successfully decreases the suprapubic fat in males and increases the apparent length of the buried penises.

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

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. To review novel techniques in penile prosthesis implantation surgery. 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. 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. 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.

Uncovering the Hidden Penis: A Nomenclature and Classification System.

A hidden penis can interfere with normal hygiene, prevent effective voiding, restrict sexual activity, and cause great embarrassment to the patient. The terms "hidden," "buried," and "trapped" penis are used interchangeably. To date, there is no classification system that adequately characterizes the spectrum of this condition. In this study, we propose a simplified nomenclature and classification system for adult-acquired hidden penis. We performed a retrospective review of all adult patients treated surgically for hidden penis by the senior author from 2009 to 2019. Patients were classified into either "buried" or "trapped" categories. A "buried" penis was defined as a hidden penis concealed by suprapubic fat without fibrous tethering. These patients were managed with panniculectomy, monsplasty, or both. In contrast, those with a "trapped" penis presented with scarred or fibrous tissue, which required surgical lysis, phalloplasty, and penile skin resurfacing. Thirteen patients met the inclusion criteria. The cohort was aged 53 ± 15.7 years with a mean body mass index of 37.4 ± 4.3 kg/m2. Two patients required repeat operations, yielding a total of 15 operative encounters. Six were defined as buried, and 9 as trapped. Inability to achieve erection was the most common preoperative complaint in those with buried penis (67%), whereas difficulties in voiding were most common with trapped penis (78%). Patients with trapped penises had a significantly larger body habitus than those with a buried penis (39.8 vs 34.2 kg/m2, P = 0.0088). Operative duration and length of hospital stay were comparable between the trapped and buried penis groups (206 vs 161 minutes, P = 0.3664) (5 vs 1 day, P = 0.0836). One third experienced wound complications, but this was not significantly different between buried and trapped penises (17% vs 44%, P = 0.5804). Postoperatively, 5 patients experienced spontaneous erections, and 7 were able to void while standing. Patients with a trapped penis present with a different preoperative symptom profile and body type than those with a buried penis. Our nomenclature and classification system offer a simple and clear algorithm for the management of hidden penis. Large cohort studies are warranted to assess differences in clinical outcomes between trapped and buried penises.

A Review of Factors Affecting Patient Satisfaction With Inflatable Penile Prosthesis.

A variety of factors that can influence patient satisfaction after inflatable penile prosthesis (IPP) surgery, including patient expectations before surgery, intraoperative complications, and perceived penile shortening and partner satisfaction after surgery. While patient satisfaction rates with IPP are high, there are several reported methods to further improve patient satisfaction with IPP. Identifying factors responsible for patient satisfaction after IPP surgery from preoperative counseling, intraoperative techniques, and postoperative care and identifying ways to improve overall patient satisfaction. A PubMed search was performed of all articles available on the database relating to penile prosthesis and patient satisfaction. The main outcome measure is patient satisfaction after IPP surgery. Patient satisfaction has been reported to be as high as 90%. Factors affecting postoperative satisfaction include preoperative counseling and expectations, patient comorbidities, partner satisfaction, and postoperative complications. One of the most common complaints is decreased penile length postoperatively. It is critical to accurately measure penile length before surgical intervention. Preoperative strategies to improve penile length with IPP include the use of penile traction therapy and vacuum erection device (VED). Several adjuvant procedures have been described and shown to safely increase penile length with concomitant IPP surgery, including ventral phalloplasty, suprapubic fat pad excision, and modified sliding technique-multiple slice technique. Postoperative penile rehabilitation program has been shown to improve penile length. The use of phosphodiesterase type 5 inhibitors in the postoperative period leads to increased glans engorgement and improved patient satisfaction. Patient satisfaction with IPP is influenced by many factors, which can be categorized into 3 distinct patient care stages: preoperative, intraoperative, and postoperative. There are several techniques described in each patient care stage to improve perceived penile length including preoperative counseling and correct penile length measuring, preoperative penile stretching, the use of adjuvant surgical procedures, and postoperative penile rehabilitation. Shah T, Wang R, A Review of Factors Affecting Patient Satisfaction With Inflatable Penile Prosthesis. Sex Med 2021;9:350-357.

Correction of retractile penis with subcutaneous soft silicone penile implant.

We report a novel solution for patients suffering from adult acquired retractile penis. Three patients complained of retractile penis (when standing) and/or prepubic recession. Physical examination confirmed the shaft of the penis was buried with only the glans visible. All three patients reported lower levels of self-confidence, self-esteem, and sexual confidence prior to their procedure. The three patients received surgical treatment with the insertion of a subcutaneous soft silicone penile implant and two of the three also received removal of the suprapubic fat pad. Over one year post operatively, the penile shaft and glans was visible and appeared natural. All patients reported an increase in self-confidence and self-esteem. The insertion of a subcutaneous soft silicone penile implant may prove to be a viable solution to reverse retractile penis and to increase patient quality of life when compared to more invasive current surgical treatments.

Subjective and objective results in surgical correction of adult acquired buried penis: A single-centre observational study.

The purpose of this study was to provide a detailed analysis of surgical and functional outcomes after correction of acquired buried penis in the adult. From 2006 to 2016, we retrospectively reviewed 47 patients undergoing surgical treatment for the correction of buried penis. Functional and surgical outcomes, as well as patients' satisfaction were the main endpoints. The most common complains at presentation were recurrent uro-genital infections, sexual dysfunction, voiding dysfunction and Lichen Sclerosus (LS). Surgical management steps included: circumcision (27.66%), scrotoplasty (19.14%), V-Y skin plasty (4.25%), split thickness skin graft (STSG) 12.76%, full thickness skin graft (FTSG) 36.17%, suprapubic fat pad excision (57.44%), abdominoplasty (25.53%), division of the suspensory ligament (36.17%). Postoperative complications were recorded in 15% of patients. Vaginal penetration and erectile function ended up being more effective in 97.87% (46/47) and 42.55% (20/47) of patients. Improvement in penile erogenous sensation was in 6.38% (3/47). Aesthetic appearance of genitalia fully satisfied 36.17% of patients (17/47). Overall patients' satisfaction rate resulted 76.59% (36/47). Management of adult acquired buried penis still remains a challenging task to achieve, however excellent cosmetic results can be obtained by surgical reconstruction.

Mid- to long-term outcomes of the ‘anatomical approach’ to congenital megaprepuce repair

The understanding of the aetiopathogenesis and the long-term outcomes of correctional repair of congenital megaprepuce (CMP) remains unestablished. Different techniques have been described; however, optimum results have been difficult to achieve. The aim of our study was to review our experience of the 'anatomical approach' to the correction of CMP. This is a retrospective review of boys who underwent CMP repair between 2003 and 2014. All of them had the anatomical approach: A curved incision is made between the scrotal and penile skin. Circumferential dissection superficial to Buck's fascia frees the penis and allows the scrotum to assume a more caudal position. The dissection distally lifts the preputial sac that is opened ventrally. The redundant inner preputial skin is excised. After full degloving, the dorsal flap of skin is thinned. The base of the flap is anchored, and the rectangle of skin is wrapped around the shaft. The remaining diamond-shaped incision is closed in a vertical line. Postoperatively, foam dressings and urethral catheter are left in place. Symptomatology, hospital stay, postoperative complications, redosurgery, voiding and cosmesis were evaluated. Sixty-one patients had surgery at 5-151 months (median 17 months). Medianhospital stay was 24h (12-168h). Foam dressings and urethral catheter were used in 47 boys and removed in outpatient clinic after 3-7 days. There were two immediate postoperative complications requiring surgery. One due to severe oedema and constriction ring, and the other had wound infection with wound breakdown, both in patients with no dressings (P<0.05). Follow-up was available for 58 patients, with a median of 22 months (3-79 months). Two required redosurgery (3.5%), one with poor cosmetic result and one recurrence. In all patients, a normal circumcised appearance had been achieved and in 47, cosmetic result was excellent (81%). Five patients have residual suprapubic fat, and four, excess ventral skin. One with residual suprapubic fat has reached puberty and it has resolved. All declared good stream. The same technique was used for six patients with poor cosmetic result after surgery elsewhere. The outcome is excellent for all, with median follow-up of 20.5 months (5-31 months). The 'anatomical' repair provides the ability to create the appearance of a standard circumcision, which is generally accepted as normality. Apart from the penis itself, this technique facilitates correction of the penoscrotal transposition, giving the external genitalia the best appearance. It seems to provide good functional and cosmetic outcomes, and it holds true at mid- to long-term follow-up. Dressings and catheter can potentially prevent postoperative complications. However, a prospective study with standardised parameters is required to confirm these findings.

Secondary phimosis after circumcision.

Male circumcision is one of the most common surgical procedures worldwide. Although it is widely performed because of health issues, in Muslim-majority countries, the primary motivation yielding to male circumcision is religious. It is a relatively safe procedure with a low overall complication rate. We herein report an underrated complication of circumcision that can be termed as "secondary phimosis." The medical records of 25 boys with post-circumcision secondary phimosis were reviewed. Demographics of the patients, method of circumcision, type of provider, peroperative findings and comorbidities were recorded. Between January 2005 and December 2016, 25 boys with post-circumcision secondary phimosis were treated surgically. The median age of the patients was 3 (2-5) years. The majority of the patients were circumcised by the Gomco clamp or Plastibell method (n=16). Of the patients' circumcisions, six were performed by the freehand method, and three by the dorsal slit method. In 15 boys, circumcision was performed by a traditional provider. Of the boys, seven were circumcised by a physician, and three were circumcised by a pediatric surgeon. All the patients were re-circumcised. The common peroperative finding was the redundant mucosal inner layer of the prepucium. Excess suprapubic fat was present in 12 patients. Although circumcision is known as a minor surgical practice with low complication rate, it must be performed safely and especially by experienced physicians/surgeons. Secondary phimosis is a technical error that is caused by insufficient removal of the inner mucosal layer of the prepucium. Re-circumcision of the patient is inevitable, causing the patient second trauma.

Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis

IntroductionMany men suffering from erectile dysfunction are overweight with generous suprapubic fat pads, which often contribute to a decrease in visible exophytic phallic length. AimTo present a novel surgical concept of suprapubic fat pad excision with a concomitant placement of inflatable penile prosthesis. MethodsA transverse incision begins slightly medial to the anterior superior iliac spine, with the superior edge crossing transversely to the contralateral anterior superior iliac spine. The inferior border is incised in a curvilinear fashion, with the medial apex being approximately 1 cm above the base of the penis. Dissection is carried down to the lower abdominal anterior fascia, which leads to excision of the suprapubic fat pad. Using this same exposure, the inflatable penile prosthesis (IPP) is placed via an infrapubic approach. The wound is reapproximated in multiple layers, and 2 drains are placed, 1 subcutaneous in the area of the fat pad excision and the other in the scrotum around the pump. Main Outcome MeasuresPrimary outcomes included penile implant functionality, ability to engage in sexual activity, and cosmetic satisfaction. ResultsA total of 8 patients have undergone suprapubic fat pad excision with simultaneous placement of IPP at our institution. Average body mass index of our patient cohort was 36.6. 1 patient developed prosthetic infection after inadvertent removal of his drains in the immediate postoperative period. At last follow-up, all other patients have excellent cosmetic and functional outcomes. Clinical ImplicationsThis technique can lead to higher patient satisfaction with their penile implant, enhanced sexual performance, and improved quality of life for patients with concurrent erectile dysfunction and significant suprapubic fat pad. Strengths & LimitationsThis unique technique has never been previously described. It allows placement of IPP in the setting of fat pad excision without any additional incisions. Limitations include the small patient population and relatively short follow-up. ConclusionsSuprapubic fat pad excision is a safe and reproducible technique that can be performed simultaneously with the placement of an IPP in appropriately selected patients. Patients must be counseled appropriately on the expectations of surgeries and the theoretical increased risk of postoperative complications, such as infection.Baumgarten AS, Beilan JA, Shah BB, et al. Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis J Sex Med 2019;16:333–337.

Simultaneous Suprapubic Lipectomy and Penile Prosthesis Implantation

IntroductionA shorter penis is a frequent complaint following penile prosthesis implantation (PPI), and a large redundant suprapubic fat pad can conceal the penis and possibly compromise patient and partner satisfaction with length. AimTo evaluate feasibility and outcome of same-session, same-incision, PPI and suprapubic lipectomy (SPL). MethodsIn 22 patients, SPL was performed through an abdominal crease incision. Through the same incision, the superficial perineal pouch was opened to gain access to the base of the penis. Penile prosthesis was implanted (semirigid in 16 patients and girth-expanding 3-piece inflatable in 6). Scarpa’s fascia, subcutaneous fat, and the abdominal crease skin incision were closed. Main Outcome MeasureEvaluation was in terms of implant survival, preoperative vs postoperative patient and partner satisfaction with penile length on a 5-point rating scale, subjective opinion over penile length postoperatively, compared with recall of erect length before erectile dysfunction (ED) had set in (longer, same, or shorter), and penile length with the implant rigid, compared in the supine and standing positions postoperatively (pubic skin to tip, using a rigid ruler). ResultsNo infections or extrusions or mechanical failures were encountered. There was a 53.3% increase in patient satisfaction with length comparing preoperative (2.55 ± 0.67) to postoperative (4.77 ± 0.43) ratings, P < .0001. Partner satisfaction showed a 40.2% increase, from 1.77 ± 0.61 to 4.41 ± 0.50, P < .0001. 19 of 22 patients reported that postoperative length was longer than their recall of erect length before ED had set in, and 3 patients reported that length was the same. With the implant rigid, there was no statistically significant difference in visible length between the supine and standing positions (14.1 cm ± 2.3 and 13.9 cm ± 2.3, respectively, P = .38). Clinical ImplicationsPatients with refractory ED and a concealed penis can be counseled as to the option of simultaneous SPL and PPI (SPL-PPI), a modification that may help avoid patient and partner dissatisfaction with length. Strength & LimitationsStrengths include objective evaluation of the efficacy of the procedure by comparing supine and standing penile length. Limitations of the current study include inability to evaluate erect length preoperatively owing to refractory ED, and subjectivity of patient and partner opinion. ConclusionSame-incision SPL-PPI appears to be a safe and effective procedure, with high patient and partner satisfaction rates.Shaeer O, Shaeer K, Abdel Rahman IF. Simultaneous suprapubic lipectomy and penile prosthesis implantation. J Sex Med 2018;15:1818–1823.

Measurement of stretched penile length in prepubertal boys in Egypt

Early diagnosis of penile size abnormalities is both medically and psychologically important. It is important in the diagnosis of penile problems. Therefore, a current established reference for penile size in newborns and children is vital for diagnosis and early management of micropenis. The aim of the present study was to establish reference values for penile length in newborn and prepubertal boys at different ages in Minia Governorate, Egypt. The study was conducted on 1000 boys with ages ranging from 1 day to 13 years. Stretched penile length (SPL) was measured in mm by using a ruler with markings along the dorsum of the penis. The suprapubic fat tissue was pressed with one end of the ruler through the pubic ramus, and the penis was fully stretched and measured. The mean SPL increased with age from newborn to 5 years, with a rapid growth observed in the first 8 months of life. After 5 years, SPL showed a slower growth rate until the age of 10 years, where it started to increase significantly again. Comparison of the SPL in different age groups revealed significant statistical differences between most groups. It showed a noticeable and significant increase, especially from birth to the age of 5 years. Although there was a mild increase in SPL from 5 to 10 years, it showed a significant level in few age groups, indicating that the change is trivial. After that, high growth rate occurred again and statistical differences remained from age 10-13 years. An updated reference for normal SPL in Egyptian boys from birth to 13 years old was provided in this study.

Micropenis

Micropenis refers to a normally structured penis, which is abnormally small, with a stretched length of less than 2.5 standard deviations (SD) below the mean of age or stage of sexual development. Patients with true micropenis usually have a 46,XY karyotype, associated to normally located male gonads, without any sign of other penile malformations. Penile length is measured from the point where the penis meets the pubic bone to the distal tip of the glans on maximal stretch, compressing any fat over suprapubic area. Differential diagnosis include buried penis (inability to adequately expose the penis, due to a severe phymosis associated to a decreased length of penile skin, which retain the shaft inside the preputial cavity), and obesity with excess fat pad over supra pubic area. The causes of congenital or true micropenis can be divided into three major groups: hypogonadotropic hypogonadism (pituitary/hypothalamic failure), hypergonadotropic hypogonadism (primary testicular failure) and idiopathic (associated with a functional hypothalamus–pituitary–testicular axis). Clinical treatment is based on testosterone therapy. Surgical treatment options are used after failed penile enlargement with testosterone therapy and include penile elongation, suprapubic fat pad aspiration and eventually neophaloplasty.