Despite high patient satisfaction rates amongst men who undergo penile prosthesis placement for refractory erectile dysfunction (ED), perceived penile length and/or girth loss after prosthesis placement is associated with patient dissatisfaction [1,2,3]. It is therefore imperative to appropriately counsel patients pre-operatively regarding realistic post-operative penile length expectations, especially in the setting of Peyronie’s disease where patients may exhibit higher likelihood length or girth loss [4]. Nonetheless, techniques to preserve penile length and minimize girth loss in patients with Peyronie’s disease following prosthesis placement may play an important role in maximizing overall patient satisfaction.

In this article “Scrotal Approach for Tunica Expansion Procedure (TEP) for Penile Girth and Length Restoration in Patients with Penile Angulation due to Peyronie’s Disease and Erectile Dysfunction: Technique and Outcomes”, the authors nicely describe a single-surgeon’s experience with 32 patients with Peyronie’s disease and ED undergoing the modified tunica expansion procedure (TEP) through a scrotal approach at the time of penile prosthesis placement [1]. A thorough, step-by-step description of the modified TEP technique is provided by the authors with great clarity and appears easily replicable. The modified TEP procedure negates the need for a subcoronal incision and avoids the need for grafting. The author’s appropriately highlight their technique’s customizability, with recommendation for preferential tunical scorings at the point of maximal curvature and/or tunical plaque to both correct for angulation and maximize penile length and girth. In their cohort, all patients underwent bilateral modified TEP rather than preferential targeting of penile angulation. Mean degree of penile curvature improved from 20 degrees to 5 degrees. Mean increase in penile length as measured by Furlow dilator was 2.8 cm comparing pre and post penile degloving with modified TEP. Mean increase in girth, measured at midphallus prior to and after IPP insertion, was 1.6 cm. At one year follow up, the authors report no complications [1].

Other techniques used for length and girth preservation in patients with Peyronie’s disease and ED undergoing penile prosthesis implantation include those that combat perceived loss of length/girth and those that prevent actual loss of length/girth. Techniques that target perceived length loss include ventral phalloplasty and suprapubic lipectomy, however true length and girth are not affected [5]. Techniques that target true length and girth loss include grafting procedures and the modified sliding technique, however these procedures are more complex and inherently come with greater risk as they commonly involve neurovascular bundle dissection and subsequent risk of glans necrosis [5, 6].

The modified TEP procedure through a scrotal approach described by the authors appears to have a shorter learning curve and less overall peri and post-operative risk compared to the previously described techniques above. A key perceived benefit to this approach is avoidance of neurovascular bundle dissection and urethral mobilization, which undoubtedly decreases risk for iatrogenic injury to vital structures of the penis [7]. This technique can be similarly applied through both an infrapubic and subcoronal approach, despite possibly higher rates of sensory nerve injury and or glans necrosis, making it a viable option to all implanters with specific preferences for overall approach.

Overall, patient satisfaction outcomes and assessment of perceived penile length/girth loss using this technique remains to be fully understood. Similarly, as the authors point out, lack of overt complications seen at one year in a population of only 32 patients does not suggest that the technique is inherently low risk and warrants further study. Nonetheless, this technique paper nicely contributes to the growing body of literature on adjunctive procedures at time of penile prosthesis implantation to prevent penile length/girth loss while simultaneously combating penile angulation in men with ED secondary to Peyronie’s disease.