[Perioperative nursing for patients undergoing autologous dermis grafting for penile girth augmentation and penile lengthening].

OBJECTIVE: To explore the perioperative nursing methods of autologous dermal transplantation for penile girth enhancement combined with penile lengthening surgery. METHODS: Summarize the perioperative nursing data of 5 patients with small penis who underwent autologous groin dermal transplantation for penile girth enhancement combined with penile lengthening surgery. RESULTS: After comprehensive perioperative nursing, all 5 patients recovered well after the surgery. The preoperative APPSSI scores of the patients were 4.60±0.48, which were all less than 6 points. The postoperative APPSSI scores at 2 months, 6 months, and 12 months were 9－12 (10.6±1.02), 10－12 (11.2±0.98), and 10－12 (11.2±0.98) respectively, showing satisfaction with the surgical outcomes. There was a statistically significant difference compared to the preoperative APPSSI scores (ï¼°<0.05). The preoperative SAS scores were 45－58 (52.2±4.35), and the SAS scores at 2 months, 6 months, and 12 months postoperatively were 31－40 (34.2±3.31), 30-41 (35.8±3.65), and 33－40 (35.6±2.33) respectively, indicating a reduction in anxiety levels after the surgery, with a statistically significant difference compared to the preoperative SAS scores (P<0.05). The preoperative IIEF-5 scores were 7－15 (10.4±2.87), and the IIEF-5 scores at 2 months, 6 months, and 1 year postoperatively were 16－24 (19.8±2.71), 18－25 (21.2±2.48), and 18－24 (20.8±2.39) respectively, showing a significant improvement postoperatively, with statistical significance (P<0.05). The preoperative NPTR examination showed a sustained erection time of 18－25 (21.2±2.59) minutes, and the NPTR examination at 2 months, 6 months, and 1 year postoperatively showed sustained erection times of 18－24 (21.8±2.28), 20-25 (23.4±2.30), and 24－27 (25.4±1.14) minutes respectively. There was no statistically significant difference in the sustained erection time at 2 months and 6 months postoperatively compared to preoperative NPTR examination, but there was a statistically significant difference at 12 months postoperatively (P<0.01). CONCLUSION: Comprehensive perioperative nursing is an important factor in achieving high satisfaction with the surgery, promoting postoperative recovery, and improving the quality of sexual life for patients undergoing autologous groin dermal transplantation for penile girth enhancement combined with penile lengthening surgery.

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

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Penile reconstruction after complete bladder exstrophy repair.

INTRODUCTION: 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. OBJECTIVE: 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. STUDY DESIGN: 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. RESULTS: 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. DISCUSSION: 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. CONCLUSIONS: 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.

Background: 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. Objectives: To evaluate the benefits and risks of different penile length preservation techniques during PP implantation. Design: A systematic review of the available literature on the use of penile length preservation maneuvers in conjunction with PP implantation was conducted. Data sources and methods: 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. Results: 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). Conclusion: 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. Trial registration: PROSPERO database registration CRD42022360758.

[Treatment of adult-acquired buried penis with suprapubic liposuction combined with modified Devine operation].

OBJECTIVE: To evaluate the safety and efficacy of suprapubic liposuction combined with modified Devine surgery in adult patients with concealed penis caused by obesity. METHODS: The clinical data of 26 adult patients with buried penis admitted to the Department of Urology of Peking University People' s Hospital and the Department of Surgery of Beijing Eden Hospital from September 2017 to June 2020 were analyzed retrospectively. The average age of the patients was (33.0 ± 5.7) years, the average body mass index (BMI) was (29.0±5.4) kg/m2, and the penis length in the supine position was (2.9±1.3) cm. All the patients were treated with suprapubic liposuction combined with modified Devine operation. The improvement of penis length and complications were statistically analyzed after operation, and the satisfaction of the patients was followed up, 1 = dissatisfied; 2 = basically satisfied; 3 = satisfied; 4 = very satisfied. The measurement data were expressed in (mean±SD), nonparametric Friedman tests and multiplex analysis methods were used for data comparison. RESULTS: The average liposuction volume of the 26 patients was (450.0±90.2) mL. Immediately after operation: the penis length was (7.4±2.1) cm, increased by (4.5±1.6) cm compared with that before operation; three months after operation: the penis length was (5.3±1.8) cm, increased by (2.4±0.7) cm compared with that before operation. There was significant difference in penis length before operation, immediately after operation and three months after operation (P < 0.01). All the patients had no sexual intercourse disorder or dysuria. Postoperative edema occurred in 11 cases (42.3%), ecchymosis in 7 cases (26.9%), poor healing of prepuce wound in 2 cases (7.8%), hematoma in 1 case (3.8%), 5 cases (19.2%) without postoperative complications, and no patient had wound infection. Seventeen patients (65.4%) were very satisfied with the appearance and function of the penis, 6 patients (23.1%) were satisfied, 3 patients (11.5%) were basically satisfied, and no patients were dissatisfied. The average score of all the patients' satisfaction with postoperative penis appearance and function was (3.5±0.7). CONCLUSION: Suprapubic liposuction combined with modified Devine operation is safe and effective in the treatment of adult-acquired buried penis.

Sexual health outcomes after penile reconstruction in the exstrophy-epispadias complex.

INTRODUCTION: The penis in exstrophy-epispadias complex (EEC) males is diminutive and patients are often dissatisfied with appearance and length. Due to an increased risk of psychosexual dysfunction, patients desire penile reconstruction. Surgical options include penile lengthening with a full thickness skin graft (SG) or tissue expansion (TE) used for cutaneous coverage or neophalloplasty using a radial forearm free flap or pedicled antero-lateral thigh flap. OBJECTIVE: The aim of this study was to assess sexual health outcomes before and after SG or TE assisted lengthening and neophalloplasty. STUDY DESIGN: Patients aged 18 years or older, who underwent penile reconstruction were identified using an institutionally approved database of EEC patients. Patient perception of penile appearance, sexual function, their frequency of sexual intercourse and overall satisfaction with reconstruction were assessed using a survey consisting of validated and non-validated questions. RESULTS: Eighty-three patients underwent penile reconstruction, 57 met the inclusion criteria and 28 responded to the survey (49.1%). Fourteen were reconstructed using a SG, 6 with TE and 8 underwent neophalloplasty. Median time from reconstruction to survey completion was 4.4 years (range 1.2-13.2) Four patients had a diagnosis of epispadias, 1 cloacal exstrophy, 23 classic bladder exstrophy (CBE). Before reconstruction patients were dissatisfied with their penile appearance with a median penile perception score of 4.5 compared to 7.5 after surgery (p = 0.0034, Fig. 1). Twenty-three patients were dissatisfied with penile length, with 18 reporting an improvement following reconstruction (p = 0.0002). There was no correlation in time after reconstruction with PPS or satisfaction with penile length (p = 0.86 and p = 0.55, respectively). Overall, the median Sexual Health Inventory for Men (SHIM) score was 19, with no difference between the surgical groups (p = 0.33). Nine patients engaged in sexual intercourse before reconstruction which increased to 17 afterwards. CONCLUSION: All three surgical methods improved patient perception of penile appearance and length. Patients who previously never engaged in intercourse were able to and those who had were doing so more frequently, of which a greater proportion were in a relationship. The results are encouraging though must be interpreted with caution due to the small number of responders and possible risk of bias. These findings provide vital information for future patients and routine psychological assessment will help manage patient expectations to improve satisfaction.

Penile shortening complaints in males with erectile dysfunction: a narrative review on penile lengthening procedures during penile prosthesis surgery.

Patients complaining of short penile length pose a challenge in urology practice. Those men who present seeking penile lengthening surgery usually overestimate 'normal' penile length, and may in often cases relate their penile length with the degree of masculinity and self-esteem. Penile prosthetic devices are the gold standard treatment of erectile dysfunction (ED) after failure of conservative options. Penile shortening is the most prevalent long-term complaint after successful inflatable penile prosthesis (IPP) placement. This has a significant impact on patient's overall satisfaction and quality of life. Using PubMed, we performed a thorough literature review of the current procedures of preservation or enhancement of penile length as well as reported perioperative protocols in patients undergoing penile prosthesis (PP) insertion. Keywords used were "penile lengthening", "penile enhancement", "penile girth", "inflatable penile prosthesis" and "glans augmentation". Several surgical techniques can be offered in the setting of penile shortening concurrently with PP insertion, e.g., sub-coronal approach of PP placement, sliding technique, modified sliding technique (MoST), multiple-slide technique (MuST), and tunica mesh expansion procedure (TMEP). Adjuvant techniques can also improve subjective penile length include, ventral phalloplasty, suprapubic lipectomy, suspensory ligament release and use of expanding penile implants. Preoperative protocols including use of a vacuum erectile device, traction therapy also seem to improve postoperative outcomes, minimizing postoperative pain, and encouraging the early device use. Currently, there is no consensus among experts on a particular lengthening procedure or when they can be performed to optimize outcomes. Furthermore, it is imperative to set proper expectations before surgery, with extensive patient and partner counseling. When used in the properly selected patient, penile lengthening procedures show promising results with minimal complication rates.

Outcome of penile lengthening of adolescents and young adults born with bladder exstrophy and epispadias.

BACKGROUND: The decreased penile length in patients born with BE results partly from pubic symphysis diastasis and the separation of the corporal bodies, which causes a shortened penis as the corporal length is lost in traversing the distance between the pubic rami. However, in some cases there is an intrinsic penile abnormality and dorsal chordee. Furthermore, multiple surgeries has in some cases, resulted in cutaneous and subcutaneous scarring, which contributed to the problem of the short phallus and dorsal tethering to the abdominal wall (figure). OBJECTIVE: Herein we evaluated the outcome of penile lengthening, repair of penile upward tethering to the abdominal wall and dorsal curvature in males born with bladder exstrophy and epispadias (BEE). STUDY DESIGN: We reviewed the records of 34 patients (11-29 years old) born with BE (31pts.) and epispadias (3 pts.). The parents and/or the young men were referred because of their dissatisfaction with and complains of short penile length, and upward tethering/chordee. The penile lengthening was achieved by detaching the corporal bodies from the pubic rami and suturing the corporal bodies as reported by Johnston (figure) However, in 11 patients who had had multiple surgeries the periosteum was incised and the corporal dissection was performed subperiosteally to protect the erectile tissues. In 16 pts dermal grafts of the dorsal corporal wall was performed to correct the dorsal curvature. 13 patients underwent single stage augmentation urethroplasty. RESULTS: Surgical complications were encountered in 4 pts (11.7%). Subjective evaluation by the patient and/or parents reported satisfactory and/or very satisfactory results in 31/34 (91%). 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. CONCLUSIONS: As children born with BEE transition to adolescence and adulthood, the external genitalia acquire greater importance. The short phallus and/or dorsal chordee and/or upwards tethering can be corrected successfully in the majority of patients.

Advanced Penile Length Restoration Techniques to Optimize Penile Prosthesis Placement Outcomes.

INTRODUCTION: The most common cause of patient dissatisfaction after penile prosthesis placement is penile shortening compared with one's memory of a natural erection. Surgical techniques as well as preoperative and postoperative protocols have been reported to preserve and possibly enhance penile length in someone undergoing penile prosthesis surgery. OBJECTIVES: This article presents a description of as well as the authors' experience with presurgical protocols, intraoperative techniques, and postsurgical protocols that allow for preservation or enhancement of penile length for patients who undergo inflatable penile prosthesis insertion. METHODS: An extensive, systematic literature review was performed using PubMed searching for key terms including penile lengthening, inflatablepenile prosthesis, penile girth, buried penis, and penile enhancement. All articles with subjective and/or objective penile length outcomes were reviewed. RESULTS: Several preoperative treatment protocols were found for penile length preservation and enhancement, which included use of a vacuum erection device as well as traction therapy. Intraoperative techniques included cavernosal sparing, channeling without dilatation, circumferential penile degloving, ventral phalloplasty, suprapubic lipectomy, liposuction, suspensory ligament release, sliding technique, modified sliding technique, multislice technique, and aggressive implant sizing. Postoperative protocols included early device inflation and cycling. Table 1 summarizes and compares the various preoperative, intraoperative, and postoperative strategies identified during literature review with their corresponding reported length gain. CONCLUSIONS: Many preoperative, intraoperative, and postoperative surgical techniques can be performed by high-volume implanters to improve one's perceived or true penile length. In the hands of experienced, high-volume implanters, these techniques can be very meaningful for patients undergoing penile prosthesis insertion, particularly those who are concerned with penile length. Shah B, Kent M, Valenzuela R. Advanced Penile Length Restoration Techniques to Optimize Penile Prosthesis Placement Outcomes. Sex Med Rev 2021;9:641-649.

Non-invasive and surgical penile enhancement interventions for aesthetic or therapeutic purposes: a systematic review.

OBJECTIVE: To systematically review the literature in order to investigate the efficacy and safety of surgical and non-invasive penile enhancement procedures for aesthetic and therapeutic purposes. METHODS: A systematic search for papers investigating penile enhancement procedures was performed using the MEDLINE database. Articles published from January 2010 to December 2019, written in English, including >10 cases, and reporting objective length and/or girth outcomes, were included. Studies without primary data and conference abstracts were excluded. The main outcome measure was objective length and/or girth improvement. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS: Out of 220 unique records, a total of 57 were reviewed. Eighteen studies assessed interventions for penile enhancement in 1764 healthy men complaining of small penis. Thirty-nine studies investigated 2587 men with concomitant pathologies consisting mostly of Peyronie's disease and erectile dysfunction. Twenty-five studies evaluated non-invasive interventions and 32 studies assessed surgical interventions, for a total of 2192 and 2159 men, respectively. Non-invasive interventions, including traction therapies and injection of fillers, were safe and mostly efficacious, whereas surgical interventions were associated with minor complications and mostly increased penile dimensions and/or corrected penile curvature. Overall, the quality of studies was low, and standardized criteria to evaluate and report efficacy and safety of procedures, as well as patient satisfaction, were missing. CONCLUSION: The quality of the studies on penile enhancement procedures published in the last decade is still low. This prevents us from establishing recommendations based on scientific evidence regarding the efficacy and safety of interventions that are performed to increase the penis size for aesthetic or therapeutic indications.

Suprapubic Liposuction With a Modified Devine's Technique for Buried Penis Release in Adults.

BACKGROUND: With the increasing prevalence of overweight and obesity, adult-acquired buried penis is more common in recent years. Many surgical techniques have been reported. However, none is the gold standard. OBJECTIVE: To evaluate the safety and efficacy of combining suprapubic liposuction and modified Devine's technique for penile lengthening in adult patients with buried penis due to obesity. METHODS: From September 2015 to June 2018, 26 consecutive suitable patients (mean age: 33 ± 5.7 years, mean body mass index: 29 ± 5.4 kg/m2) with a buried penis received suprapubic liposuction and modified Devine's technique for penis release in our medical centre. A retrospective study was conducted. Their penile length from tip to the skin (flaccid) was measured pre- and post-operatively. The amount of liposuction was also recorded accordingly. RESULTS: The mean length of the follow-up on the 26 patients is 18 ± 7.1 months (range 3-33 months). The average amount of liposuction is 450 ± 90.2 mL. The average penile length measured preoperatively, post-operatively (on table), and 3 months after the operation is 2.9 ± 1.3, 7.4 ± 2.1, and 5.3 ± 1.8 cm, respectively. The post-operative penile length had significantly increased by 4.5 ± 1.6 cm (on table) and 2.4 ± 0.7 cm (3 months post-operation) with a P value <.05. No patient had difficulties in sexual intercourse or urination post-operatively. None of the patients were dissatisfied with their surgical outcomes. CONCLUSIONS: The combination of suprapubic liposuction and modified Devine's technique is a safe and effective method for releasing the buried penis of adults with satisfying outcomes.

CONTEXTE: Avec la prédominance croissante du surpoids et de l'obésité, le pénis enterré adulte-acquis est plus commun ces dernières années. Beaucoup de techniques chirurgicales ont été rapportées. Cependant, aucun n'est l'étalon-or. OBJECTIF: Évaluer l'innocuité et l'efficacité de la combinaison de la liposuccion suprapubique et de la technique modifiée de Devine pour l'allongement du pénis chez les patients adultes avec un pénis enterré en raison de l'obésité. MÉTHODES: De septembre 2015 à juin 2018, 26 patients appropriés consécutifs (âge moyen : 33 ± 5.7 ans, indice de masse corporelle moyen : 29 ± 5.4 kg/m2) avec un pénis enterré ont reçu une liposuccion suprapubique et modifié la technique de Devine pour la libération du pénis dans notre centre médical. Une étude rétrospective a été menée. Leur longueur pénienne de la pointe à la peau (flasque) a été mesurée avant et postopératoirement. La quantité de liposuccion a également été enregistrée en conséquence. RÉSULTATS: La durée moyenne du suivi sur les 26 patients est de 18 ± 7.1 mois (gamme 3-33 mois). La quantité moyenne de liposuccion est de 450 ± 90.2 ml. La longueur pénitenelle moyenne mesurée de façon préopératoire, postopératoire (sur la table) et de 3 mois après l'opération est de 2.9 ± 1.3, 7.4 ± 2.1 et 5.3 ± 1.8 cm, respectivement. La longueur du pénis postopératoire avait considérablement augmenté de 4.5 ± 1.6 cm (sur la table) et de 2.4 ± 0.7 cm (3 mois après l'opération) avec une valeur P < 0.05. Aucun patient n'a eu des difficultés dans les rapports sexuels ou la miction postopératoire. Aucun des patients n'était insatisfait de leurs résultats chirurgicaux. CONCLUSIONS: La combinaison de la liposuccion suprapubienne et de la technique modifiée de Devine est une méthode sûre et efficace pour libérer le pénis enterré des adultes avec des résultats satisfaisants.

Characteristics of penile growth in pubertal rats and a non-invasive method to lengthen the penis.

BACKGROUND: Males with short penises may suffer from sexual dysfunction and psychological problems. However, currently, managing short penis is a huge challenge. OBJECTIVES: To explore whether inhibition of lysyl oxidase (LOX) activity (anti-LOX) combined with a vacuum device could lengthen the penis of pubertal rat. MATERIALS AND METHODS: Male rats of different ages were purchased, their exposed penile lengths and weights were measured, and protein expression and lysyl oxidase activity in the corpus cavernosum were analyzed. Fifteen-day-old rats were then purchased and divided into six groups: control, Anti-lysyl oxidase, -200 mm Hg (vacuum device under -200 mm Hg value), -200 mm Hg + Anti-lysyl oxidase, -300 mm Hg, and -300 mm Hg + Anti-lysyl oxidase groups. After the intervention duration of 7 weeks, rats' penile length was measured and erectile function was assessed. The corpus cavernosum was harvested for histopathology and molecular assessments. RESULTS: Exposed penile length and weight significantly increased with age, especially between 4 and 8 weeks. Both the protein expression and lysyl oxidase activity in corpus cavernosum were the highest at 2 weeks; however, they quickly decreased with age and slowly declined after 8 weeks. Anti-lysyl oxidase significantly increased the penile length by 10.79% over controlled rats, -200 mm Hg + Anti-lysyl oxidase lengthened it by 14.05%, and -300 mm Hg + Anti-lysyl oxidase increased it by 19.84%. Anti-lysyl oxidase significantly reduced lysyl oxidase activity to decrease pyridinoline concentration; however, it did not change desmosine (P = .28), hydroxyproline (P = .14), and total elastin (P = .06) levels. Anti-lysyl oxidase with or without a vacuum device did not diminish erectile function or impair the normal microstructure of corpus cavernosum. DISCUSSION AND CONCLUSION: The rats' penile growth peaks occurred between 4 and 8 weeks. Anti-lysyl oxidase with a vacuum device promoted penile lengthening by inhibiting pyridinoline production to induce tunica albuginea remodeling. The penile lengthening effect was more obvious in pubertal rats than the adult rats. None of the procedures decreased erectile function.

Anti-lysyl oxidase combined with a vacuum device induces penile lengthening by remodeling the tunica albuginea.

This study aimed to explore whether and how anti-lysyl oxidase (anti-LOX) combined with a vacuum device (VD) could promote penile lengthening and to evaluate the effect on erectile function. This study was performed on four groups of adult rats: control, anti-LOX, VD (negative pressure value of -300 mmHg), and anti-LOX + VD. Penile length was measured by a modified VD method and verified on exposed length data. Intracavernous pressure (ICP) and maximum ICP/mean arterial pressure (MAP) ratio were recorded to assess erectile function. For corpus cavernosum, LOX activity and concentrations of pyridinoline, desmosine, hydroxyproline, and elastin were analyzed; transmission electron microscope and Hart's elastin staining were performed to monitor microstructural changes. Anti-LOX and VD significantly lengthened the penis by 10.8% (3.75 mm) and 8.2% (2.48 mm) compared with the control group, respectively, while anti-LOX + VD achieved the longest penile size (40.58 ± 0.40 mm) which was 17.4% longer than the control group (34.58 ± 0.54 mm). After 1-week washout, no penile retraction was observed. Meanwhile, exposed penile length data confirmed that the penis in the anti-LOX + VD group was also significantly longer. Anti-LOX inhibited LOX activity to reduce pyridinoline level, which led the penile tunica albuginea remodeling. However, it had no effect on hydroxyproline, desmosine, and elastin levels. Moreover, anti-LOX had no impact on erectile function, which was determined by ICP and ICP/MAP ratio. These results suggest that anti-LOX elongates the penis by reducing pyridinoline, which induces tunica albuginea remodeling. This lengthening effect was more obvious when combined with a VD. All procedures had no impact on erectile function.

Augmentation Phalloplasty for Acquired Penile Shortening: A Systematic Review of Techniques, Outcomes, Patient Satisfaction, and Limitations.

INTRODUCTION: Although an infrequent cause of small penile size in adult men, acquired penile shortening represents a particular reconstructive challenge due to preexisting penile anatomic deformities. AIM: With numerous techniques being performed, the purpose of our study is to assess available literature on length enhancement procedures used for acquired penile shortening deformities. METHODS: A systematic review was performed using the guidelines outlined in the Preferred Reporting Items for Systematic reviews and Meta-analyses. Medline/PubMed, Scopus, and Cochrane Databases were used to identify papers on augmentation Phalloplasty in non-transgender males with acquired penile shortening from 1990 to 2018. MAIN OUTCOME MEASURE: Outcomes, complications, and patient-reported satisfaction were analyzed. RESULTS: 12 articles, involving 931 patients and 8 primary procedures, met our inclusion criteria. The majority of articles had level of evidence of 4 (83%) and Newcastle Ottawa Scale score of 6 (92%, moderate risk of bias). All studies reported mean penile length gain; however, inconsistent methodology was used when measuring penile dimensions. Mean length gain ranged from 0.6 to 6.4 cm. Overall, the mean complication rate for all techniques ranged from 0% to 50%. Post-operative satisfaction was reported in 10 (83%) studies, 7 of which used a validated scale. Patients were generally satisfied, with reported satisfaction rates ranging from 77% to 100%. CLINICAL IMPLICATIONS: While numerous procedures have been described, the significant limitations in the available data preclude identifying a single superior procedure. STRENGTHS & LIMITATIONS: The significant heterogeneity in the reported literature is a limitation of this study and highlights the need for standardized reporting. However, this study is the first to analyze augmentation phalloplasty literature in the setting of acquired penile shortening. CONCLUSION: Augmentation phalloplasty techniques for acquired penile shortening are evolving and are continuously being modified; best-practice guidelines are crucial to achieve safe and satisfactory outcomes in this population. Abu-Ghname A, Banuelos J, Davis MJ, et al. Augmentation Phalloplasty for Acquired Penile Shortening: A Systematic Review of Techniques, Outcomes, Patient Satisfaction, and Limitations. J Sex Med 2020;17:331-341.

Anti-lysyl oxidase combined with a vacuum device induces penile lengthening by remodeling the tunica albuginea / 亚洲男科学杂志(英文版)

This study aimed to explore whether and how anti-lysyl oxidase (anti-LOX) combined with a vacuum device (VD) could promote penile lengthening and to evaluate the effect on erectile function. This study was performed on four groups of adult rats: control, anti-LOX, VD (negative pressure value of -300 mmHg), and anti-LOX + VD. Penile length was measured by a modified VD method and verified on exposed length data. Intracavernous pressure (ICP) and maximum ICP/mean arterial pressure (MAP) ratio were recorded to assess erectile function. For corpus cavernosum, LOX activity and concentrations of pyridinoline, desmosine, hydroxyproline, and elastin were analyzed; transmission electron microscope and Hart's elastin staining were performed to monitor microstructural changes. Anti-LOX and VD significantly lengthened the penis by 10.8% (3.75 mm) and 8.2% (2.48 mm) compared with the control group, respectively, while anti-LOX + VD achieved the longest penile size (40.58 ± 0.40 mm) which was 17.4% longer than the control group (34.58 ± 0.54 mm). After 1-week washout, no penile retraction was observed. Meanwhile, exposed penile length data confirmed that the penis in the anti-LOX + VD group was also significantly longer. Anti-LOX inhibited LOX activity to reduce pyridinoline level, which led the penile tunica albuginea remodeling. However, it had no effect on hydroxyproline, desmosine, and elastin levels. Moreover, anti-LOX had no impact on erectile function, which was determined by ICP and ICP/MAP ratio. These results suggest that anti-LOX elongates the penis by reducing pyridinoline, which induces tunica albuginea remodeling. This lengthening effect was more obvious when combined with a VD. All procedures had no impact on erectile function.

Penile lengthening with porcine small intestinal submucosa grafting in Peyronie's disease treatment: long-term surgical outcomes, patients' satisfaction and dissatisfaction predictors.

BACKGROUND: Peyronie's Disease (PD) is an acquired connective tissue disorder that often leads to penile curvature (PC) and sexual dysfunction. Penile lengthening procedures (PLP) with four-layered porcine small intestinal submucosa graft (Surgisis® ES; Cook) have been widely used in patients with severe PC when erectile function is preserved. However, complications such as erectile dysfunction (ED) may limit treatment satisfaction. OBJECTIVES: Focusing on patients perspective, our study aims to evaluate longterm patient-reported outcomes, satisfaction, and dissatisfaction predictors after PLP. MATERIAL AND METHODS: This prospective study included 32 patients affected by PD with severe PC submitted to PLP with Surgisis® ES between 2011 and 2014. All patients were submitted to a standardized protocol with regular clinical evaluation at 3, 6 and 12 months, and yearly thereafter. After the third year follow-up, IIEF-5, modified EDITS and an additional non-validated questionnaire were completed. RESULTS: Concerning the surgical procedure, the mean tunical defect area (TDA) was 15.9 ± 6.9 cm2 . The mean follow-up time were 49.6 ± 12.7 months and there was a significant increase in stretched penile length (p = 0.01). Postoperative erectile function as assessed by IIEF-5 was positively correlated with overall treatment satisfaction evaluated through EDITS (p = 0.01). TDA was negatively correlated with postoperative IIEF-5 (R = -0.56, p < 0.001). TDA ≥ 14.375 cm2 can predict ED with 76.9% sensibility and 58.3% specificity. Moreover, TDA ≥ 21.875 cm2 can predict clinically significant ED (IIEF-5 score ≤17) with 80% sensibility and 95.2% specificity. Patient-reported longterm complications were 65.6% decreased penile length, 56.5% diminished rigidity and 25% curvature recurrence. CONCLUSION: PLP using a Surgisis® ES is a valuable surgical option for the treatment of PD with severe PC. Although it results in high rates of long-term patient-reported overall satisfaction, possible outcomes such as postoperative ED must be acknowledged. TDA is a strong predictor for postoperative ED and should be considered in clinical practice to classify patients in low- or high-risk for postoperative ED.

The Multiple-Slit Technique (MUST) for Penile Length and Girth Restoration.

BACKGROUND: Patients with severe erectile dysfunction (ED) and penile size issues, especially seen in Peyronie's disease (PD), are candidates for more invasive penile prosthesis insertion techniques that aim for penile length and girth reconstruction. AIM: To present the feasibility and safety of penile length and girth restoration based on the so-called multiple-slit technique (MUST) for patients with severe ED and significant penile shortening with or without PD. METHODS: From July 2013 through January 2016, 138 patients underwent the MUST. The International Index of Erectile Function (IIEF) and the Erectile Dysfunction Inventory of Treatment Satisfaction were completed. OUTCOMES: Outcome analysis was focused on penile length restoration, penile curvature correction, intra- and postoperative complications, and patient satisfaction. RESULTS: 138 patients underwent the procedure (103 malleable and 35 inflatable devices). Etiologies of penile shortening and narrowing were PD, severe ED, post-radical prostatectomy, and androgen-deprivation therapy with or without brachytherapy or external radiotherapy for prostate cancer, and post-penile fracture in 60.1%, 24.6%, 10.1%, 3.6%, and 2.2%, respectively. In PD cases, the mean deviation of the penile axis was 55° (range = 0-90°). Mean subjective penile length loss reported was 3.2 cm (range = 1-5 cm), and shaft constriction was present in 44.9%. Median follow-up was 15.2 months (range = 6-36 months). Mean penile length gain was 3.1 cm (range = 2-5 cm). No penile prosthesis infection caused device explantation. One glans necrosis was encountered. The average IIEF score increased from 22 points at baseline to 66 points at 6-month follow-up. CLINICAL IMPLICATIONS: The MUST helps address penile size issues in cases of severe ED with concomitant conditions that impair penile length or girth. STRENGTHS AND LIMITATIONS: The strength of the study is its applicability to provide surgeons with a solution for cases in which patients have severe ED and penile size impairment owing to underlying conditions such as PD. The study is limited by the relatively short follow-up. CONCLUSIONS: The MUST is an effective, safe, and viable treatment option for a selected patient cohort. Because of the potential complications, proper counseling should take place and only experienced surgeons should perform this type of surgery. Egydio PH, Kuehhas FE. The Multiple-Slit Technique (MUST) for Penile Length and Girth Restoration. J Sex Med 2018;15:261-269.

Infrapubic Liposuction for Penile Length Augmentation in Patients with Infrapubic Adiposities.

INTRODUCTION: Hidden penis, inconspicuous and concealed penis are synonyms for the same entity "buried penis" where the penile shaft is hidden below the surface of the prepubic fat to an extent that gives an impression of a short penis, despite corporeal length being normal. AIM: The aim of our work is the reduction in the amount of the suprapubic fat by liposuction to reveal the buried penis and assess the results, patient satisfaction and possible complications. METHODS: The procedure of suprapubic liposuction was carried out on ten men who were attending the outpatient clinic of Andrology complaining of small-sized penis. MAIN OUTCOME MEASURES: Pre-, immediate (on table) postoperative and 3 months postoperative skin to tip flaccid and stretched penile lengths were measured. Patient satisfaction was assessed using the five-point Likert scale. RESULTS: There was a statistically significant increase between the pre- and postoperative flaccid and stretched penile lengths in our patients with a p value <0.001 in both. CONCLUSION: An acquired adult buried penis is a correctable problem. Simple buried penis due to excess fat at the mons pubis should be differentiated from other complex cases that may require combined techniques to achieve good results with minor complications. Suprapubic liposuction is a very safe and successful procedure with minor or no complications if performed meticulously. It could improve self-esteem along with the associated physical and esthetic concerns. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. 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 Lengthening, Girth, and Size Preservation at the Time of Penile Prosthesis Insertion.

INTRODUCTION: Penile prosthetic devices are the gold standard treatment of medication-refractory erectile dysfunction. Inflatable penile prosthetic (IPP) devices have been available and used for more than four decades. Oftentimes, medical conditions causing erectile dysfunction also cause penile shortening, causing decreased patient quality of life. AIM: To identify and review all available penile lengthening procedures that can be performed at time of IPP insertion. METHODS: An extensive, systematic literature review was performed using PubMed searching for key terms penile lengthening, inflatable penile prosthesis, penile girth, corporoplasty, glans augmentation, and penile enhancement; all articles with subjective and/or objective penile length outcomes were reviewed. MAIN OUTCOME MEASURES: A review of various techniques for penile length and girth preservation and enhancement during penile prosthesis insertion. RESULTS: Several advanced and novel techniques were found for penile length preservation and enhancement at time of IPP insertion, including the sub-coronal IPP insertion technique, and adjuvant maneuvers during insertion, such as the sliding technique, modified sliding technique, multiple slice technique, and circumferential incision and grafting. Other adjuvant techniques that can enhance perception of increased length include ventral phalloplasty, suprapubic lipectomy, and suspensory ligament release. Further enhancement can be obtained using augmentation corporoplasty and glans augmentation with hyaluronic acid and other fillers. The different techniques vary in complexity and could require specialized training and experience. Maximum length gain appears to be limited by the length of the neurovascular bundles. CONCLUSION: Overall, surgical penile lengthening procedures at time of IPP insertion appear safe and effective for treatment of patients with penile shortening and severe erectile dysfunction. These therapies can significantly improve patient self-esteem and quality of life in properly selected patients. Tran H, Goldfarb R, Ackerman A, Valenxuela RJ. Penile Lengthening, Girth and Size Preservation at the Time of Penile Prosthesis Insertion. Sex Med Rev 2017;5:403-412.