Penile prosthesis surgery for erectile dysfunction has the highest satisfaction rates among all treatment options but is often associated with subjective and objective loss of penile length and girth following surgery. To present a novel technique using a subcutaneous soft silicone implant for reversal of penile shortening and narrowing after prosthesis surgery, with additional gains in overall penile length and girth. Nine patients were treated with the insertion of a subcutaneous soft silicone penile implant. All patients had previously reported a loss in penile length (0.5–2 cm), and seven of nine patients also reported a loss in penile girth (0.5–2.6 cm) after penile prosthesis surgery. During a follow-up period of 4–24 months, penile length and girth measurements showed a mean increase in length of 2.4 cm (±0.75 cm) and a mean increase in girth of 3.4 cm (±0.94 cm). The additional insertion of a subcutaneous soft silicone implant in patients with decreased penile length and girth after penile prosthesis surgery is an effective treatment option that provides reversal of lost penile length and girth.
Erectile dysfunction involves more than half of the male population between 40 and 70 years of age.1 Treatment options consist of oral medication, local pharmacotherapy, and penile prosthesis.2 Penile prosthesis (malleable and inflatable) is considered as the third-line solution, with one of the highest satisfaction rates (70–87%) among all treatment options.3
Design and technical advancements have contributed to patient satisfaction because of decreased device failure, erosion, and infection rates,4 but penile length shortening and narrowing post surgery remain major patient complaints and causes of frustration.5 Current studies report a subjective penile length decrease of up to 72%6 and a 100% objective and measurable loss of length (from 0.2–3.0 cm) regardless of the type of penile prosthesis.7
We present a novel technique using a subcutaneous soft silicone implant for reversal of penile shortening and narrowing following prosthesis surgery, with additional gains in overall penile length and girth.
Materials and methods
The subcutaneous soft silicone implant10 was developed and patented in the United States in 2002 and approved by the US Food and Drug Administration in 2004 for cosmetic correction of soft tissue deformities. It consists of a soft silicone ¾ tube (Figure 1) that is inserted subdermally through a suprapubic incision. It is presented in three different sizes to accommodate various baseline penile measurements. The very first patient was operated in 2004 and is still satisfied and without any complaints regarding his penile implant, as observed during his most recent follow-up in January 2013.
We report on nine patients (38–77 years old) who complained about significant decrease in penile length and girth following insertion of penile prosthesis, using malleable (AMS 650 Series, American Medical Systems, Minnesota, MN, USA) and inflatable (AMS 700 LGX, AMS 700 CX, and Mentor/Coloplast, Coloplast A/S, Humlebaek, Denmark) prostheses. All nine patients (100%) suffered from erectile dysfunction nonresponsive to oral or nonsurgical treatment; six patients were diabetic, two of whom were additionally diagnosed with hypertension, and three had no comorbidities. All patients (100%) reported a loss in penile length in flaccid and erect states (0.5–2.0 cm), and seven of nine patients (78%) also reported a loss in penile girth (0.5–2.6 cm) after penile prosthesis surgery (Table 1).
None of the patients were candidates for a traction device technique or weights because of the possible risk of damage to the prosthesis. All possible risks, benefits, complications, and alternatives, including no surgery, were discussed with all patients in full detail. Written and verbal consents regarding the insertion of the subcutaneous soft silicone implant were obtained.
The preoperative questionnaire (Table 2) consisted of the following questions (prosthesis refers to malleable or inflatable penile prosthesis):
How satisfied are you with your penile length after prosthesis surgery?
How satisfied are you with your penile girth after prosthesis implant surgery?
How much has the prosthesis surgery improved your self-esteem?
How much has the prosthesis surgery improved your sexual relationships?
How satisfied is your partner with your prosthesis surgery results?
How would you rate your overall improvement after prosthesis surgery?
Patients rated their satisfaction on a scale from 0–5, with 0 being absolutely dissatisfied and 5 being absolutely satisfied.
The surgical procedure was performed with completely deflated penile prosthesis and with full attention to preserve prosthesis integrity. After appropriate preparation and draping of the skin with antimicrobial drape (Ioban 2; 3M Healthcare, St Paul, MN, USA), an 8-cm horizontal incision is made in the suprapubic area. A pocket is prepared bluntly between the Buck and dartos fascia (Figure 2a). At this point, the penis is everted and the pocket is carefully extended towards its distal end by undermining the glans as far as possible (approximately 5 mm) (Figure 2b). The distal end of the silicone implant is then covered with a 1-cm-wide polyester mesh (Parietex; Covidien, Dublin, Ireland) and fixed with 6–8 nonabsorbable braided sutures to the distal aspect of the corpora cavernosa beneath the glans (Figure 2c).
The proximal end of the implant is placed adjacent to the pubic bone and symphysis, leaving the suspensory ligament partially intact as a resistor. The maximal possible length of the implant is now determined by pushing its end beneath the pubic bone (Figure 2d). If necessary, the implant’s end is trimmed and rounded to avoid friction and consequent serum formation (Figure 2e). The proximal end of the implant is not fixed and stays free to move during erection and intercourse. Throughout the procedure, the complete surgical area is irrigated with triple antibiotic solution.
Before skin closure, to prevent bacterial biofilm formation, a combination of antibiotic solution consisting of rifampicin and minocycline is instilled directly over the mesh and the implant (Figure 2f). After the placement of a small Jackson–Pratt drain, the proximal implant pocket is tightly closed with nonabsorbable sutures to prevent implant dislocation.
Because all surgical wounds are contaminated by skin bacteria,11 the drain remains closed for 3–6 h, keeping the antibiotic solution in place. Daily drainage assessment and rifampicin instillation is followed by drain removal after 2–3 days.
Postoperative swelling and inflammation resolved within a few weeks in all cases. The initial mild elevation of the distal end of the implant behind the glans, because of the presence of the mesh, gradually disappeared over subsequent months, when the mesh was integrated in the Buck’s fascia. None of the patients’ sexual partners expressed any concern or discomfort with this initial ‘soft’ step. Due to its design, the implant does not cover the urethral part of the corpus spongiosum, preventing urinary complaints. None of the patients reported any lower urinary tract symptoms after this procedure. All patients reported in Table 1 were followed for 4–24 months (8.7±5.1 months). Penile length and girth measurements during follow-up showed a mean increase in length of 2.4 cm (±0.75 cm) and a mean increase in girth of 3.4 cm (±0.94 cm).
The results for patient 1 (the first patient to have a penile prosthesis and to receive a subcutaneous implant in 2011) are shown in Figure 3. His current measurements after a follow-up period of 2 years are 20 cm in flaccid penile length and 15 cm in penile girth, with an additional increase of 1.0 cm in length and 0.5 cm in girth.
Patient 4 has had an AMS 700 LGX prosthesis, with the least loss of penile length, but was very interested to gain more length and girth. One patient suffered an Escherichia coli implant infection due to noncompliance with the need for removal of the subcutaneous soft silicone implant and replacement of the subcutaneous implant after 6 weeks of recovery. Since the penile prosthesis has no connection to the subcutaneous soft silicone implant, it remained unaffected by the infection and did not require a removal.
The results for patient 9 are shown in Figures 4 and 5. His current measurements after a follow-up period of 2 weeks are 15 cm and 15.5 cm in flaccid and erect penile length, respectively, and 14.5 cm and 17 cm, respectively, in flaccid and erect penile girth. The patient is a 38-year-old male diagnosed with diabetes and penile vascular disease who had been suffering from treatment-refractory erectile dysfunction since his early 30s. Loss of erectile functioning and associated penile shrinkage had been negatively affecting his body image, self-esteem and relationship status; according to him, these issues had been addressed only partially with the implantation of a penile prosthesis at age 36. During follow-up and as reflected in the questionnaire, the patient reported that the subcutaneous implant surgery had a great positive impact on his self-esteem, body image and psychosocial status. Further follow-up is required to verify his initial subjective improvements.
Satisfaction questionnaires were obtained from all patients following insertion of the subcutaneous soft silicone implant (Table 3).
The postoperative questionnaire consisted of the following questions (implant refers to the subcutaneous soft silicone implant):
How satisfied are you with your penile length after implant surgery?
How satisfied are you with your penile girth after implant surgery?
How much has the implant surgery improved your self-esteem?
How much has the implant surgery improved your sexual relationships?
How satisfied is your partner with your implant surgery results?
How would you rate your overall improvement after implant surgery?
All nine patients rated their objective and subjective satisfaction after insertion of the subcutaneous penile implant as very satisfactory (Table 3).
Penile prostheses are an effective method for treatment of erectile dysfunction if phosphodiesterase type 5 inhibitors and intracavernosal injections do not work or are inapplicable.3
The most common reason for postimplantation shrinkage of the penis, which is claimed by 72% of patients after inflatable penile prostheses,6 may be related to natural shrinkage of the fibrous capsule, formed around the prosthesis, during the rather long time of deflation compared with inflation or with inaccurate measurement of corporal length during surgery.7 The additional insertion of the subcutaneous soft silicone implant in patients with decreased penile length and girth after penile prosthesis surgery is an effective treatment option. It provides patients with reversal of the lost penile length and girth with additional possible increases in penile length. The implant is measured and inserted during maximal stretching of the deflated prosthesis. Because the difference between flaccid and erect penile lengths after insertion of the penile prosthesis is not significantly measurable, the initial gain in length after the insertion of the subcutaneous implant in a flaccid state is consistent with increased length in an erect state; additional possible gains in inflated length may be due to stretching of the corpus cavernosum and penile skin. The optimal timing of subcutaneous soft silicone implant (SSSI) insertion after the placement of penile prosthesis is 6 weeks postoperatively in order to guarantee full healing and prevent fibrosis after the initial surgery, or at any time when the patient experiences penile shortening after the placement of a penile prosthesis.
The genital skin is one of the areas, which is most densely populated with several strains of bacteria. Even if classified as nonpathogenic, these bacteria can cause chronic infections when they enter a wound pocket containing a smooth-walled implant. E. coli, as observed in our patient, is another possible cause of infection due to the proximity of the anal and genital areas. Most of the bacteria are able to produce a biofilm on smooth surfaces to protect them against disinfectants and antibiotics.
As in silicone breast implants, where bacterial infection leads to capsule formation and skin perforation, infection of a penile implant may lead to the need for removal and reinsertion. The main concern in this operation must be the prevention of intraoperative entry of bacteria into the pocket of the implant. Rigorous irrigation with minocycline and rifampicin and keeping both around the implant has reduced penile implant infection and subsequent shrinkage to a minimum. Since 2004, a total of more than 1000 cases of penile dysmorphia, penile soft tissue deformities and small penis syndrome have been successfully treated internationally with the insertion of the subcutaneous soft silicone implant by the authors. In a newer series since 2011 with the improved technique (mesh protecting the tip and local broad-band antibiotics), 206 patients have been operated for one of the above included pathologies, with infection and removal in only 13 (6.3%).
The additional insertion of the subcutaneous soft silicone implant in patients with decreased penile length and girth after penile prosthesis surgery is an effective treatment option that provides reversal of lost penile length and girth. Additional increases in penile length and girth over time have been observed. Further prospective studies are required to validate our initial experience.
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James J Elist, MD, FACS, is a patent holder and uses the implant in his private practice. The other authors do not have any conflicts of interest and ethical adherence.
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Cite this article
Shirvanian, V., Lemperle, G., Araujo Pinto, C. et al. Shortened penis post penile prosthesis implantation treated with subcutaneous soft silicone penile implant: case report. Int J Impot Res 26, 100–104 (2014). https://doi.org/10.1038/ijir.2013.44
- erectile dysfunction
- penile augmentation
- penile enlargement
- penile length and girth
- penile prosthesis
- penile shortening
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