***Trost Commentary and Key Take-Home Points***
The current manuscript examines a modification to a technique that is performed at the time of penile prosthesis placement to achieve greater penile length. Basically, several years back, a technique was developed known as the ‘sliding’ technique, where the penis was basically nearly amputated, stretched, and placed over a penile prosthesis. This resulted in longer penises, however, there were some severe complications, including the loss of the head of the penis. Because of these severe complications, the technique was never adopted by mainstream penile prosthesis surgeons (after all, who would really consent to a procedure that is designed to improve penile curvature and erections if the complication is losing the penis). The reason the complication occurred was because too many of the penis’s blood supplies were disturbed with the original technique. This new description is a modification on how the procedure is approached in order to better preserve the penile blood supply.
Results from the technique indicate that it results in a longer post-operative penis without any permanent, long-term complications. This is an advancement on the sliding technique, but it will take a little more study before it can be routinely adopted by all prosthesis surgeons. It is notable that this technique is ONLY used during placement of a penile prosthesis. It should NEVER be done in someone who is not getting a prosthesis, as it will most certainly lead to erectile dysfunction that is not responsive to any conservative (non-surgical) therapy.
Introduction
Peyronie’s disease is a connective tissue disorder affecting 8.9% of men. It is commonly believed that microtrauma plays a role in increasing inflammation and fibrotic plaque growth, though its etiology is unknown. Peyronie’s disease causes penile curvature, deformity, penile shortening, and sometimes the inability for penetrative intercourse. These undesirable symptoms often cause emotional distress and have negative psychological effects leading to a decreased quality of life.
Because 58% of men with Peyronie’s disease also have erectile dysfunction (ED), common treatments include inflatable penile prosthesis (IPP), plication and plaque incision or excision with grafting. While these treatments have proven effective in treating many aspects of Peyronie’s disease, they are sometimes met with dissatisfaction due to the loss of penile length caused by these surgeries. In response, surgical penile lengthening techniques have been developed including the sliding technique (ST), modified ST and multiple-slice technique with the goal of restoring penile length, girth and function. The ST is often performed simultaneously with IPP surgery and includes subcoronal circumcision incision and complete degloving of the penile shaft. However, due to complications stemming from degloving, a non-degloving method of ST was developed in hopes of reducing complications.
Methods
ST in combination with IPP placement is not recommend for all men with peyronie’s disease, it is reserved for patients with severe penile atrophy whose ED did not respond to treatment with PDE-5 inhibitors or intracavernosal injections. After patients undergo routine assessment and examination, realistic expectations and limitations are discussed and they are informed about the increased risk of complications of ST combined with IPP surgery.
The surgical procedure includes incisions to reveal the urethra and corporal bodies, then the neurovascular bundle, Buck fascia, dartos fascia, urethra and skin are separated from the tunica albuginea. As the tunica relaxes, lengthening incisions can be made and the penis can be stretched and sutured together to gain maximum length. Grafts are placed where needed and the regular IPP surgery can be continued.
Outcomes
At this facility, 7 out of 43 patients who had IPP surgery chose to include the ST procedure as well. Their mean preoperative length was 13 cm versus 15.5 cm postoperatively. 5 of the 7 men chose to have the non-degloving ventral incision rather than the circumcision-degloving approach. A mean follow-up of 15.5 months revealed 6 of the 7 men had no residual curvature, while 1 had minimal (15 degrees). There were several adverse events including numbness, anorgasmia, fixed drug eruption, and neurpathic pain, all of which cleared up within months post operation. A mean 5.7-24.3 improvement was seen in IIEF-5 scores.
Discussion
Several studies have been done about the different ST techniques and all have shown high patient satisfaction rates with the majority of adverse events clearing up within months. Nearly all patients in these studies experienced penile curvature correction and gained 2-3 cm of length. ST and subcoronal incision bring a higher risk of potential glans ischemia; though the ST non-degloving approach at this facility has not yet resulted in glans ichemia, possibly due to ventral incision preserving blood flow to the glans penis. Larger studies are required to confirm this theory.
Conclusion
The complicated nature of ST brings increased risks to the IPP surgery procedure, which makes it critical to properly inform and consent the patient prior to operation. The non-degloving techniques is beneficial in its ability to maintain glans penis blood flow, which could theoretically reduce the risk of glans ischemia. Further studies are required to verify the pros and cons of this modified non-degloving ST technique.
Resources
Clavell-Hernández J, Wang R. Penile Size Restoration With Nondegloving Approach for Peyronie’s Disease: Initial Experience. J Sex Med 2018;15:1506-1513
https://www.jsm.jsexmed.org/action/showPdf?pii=S1743-6095%2818%2931063-4