Outpatient Surgery of Penile Enhancement

patients

This type of surgery is controversial both in its subjective responsiveness and postoperative result. It shall not be in routine use because it is uncommon for a male who is absolutely indicated. It may be necessary in patients whose penis with erectile length less than 9cm or erectile girth less than 7cm.

As a penile reconstructive surgeon, we had used the prototype of penile enhancement (Figure 1) in which the tissue enhanced was superficial to the Bucks’ fascia, no touch with the tunica albuginea, from 1998 to 2006. In tandem with the advances in our understanding of the penile tunical, venous and related anatomy, A true method of penile enhancement has been developed (Figure 2). It entails a tunical incision followed by autologous graft with deep dorsal and cavernosal veins which is then enforced by an artificial derma. Albeit it always results a true penile enhancement, limited surgery benefit and painstaking operation are problematic.

Anesthesia

Lidocaine solution (0.8%, 50 ml) is prepared in an aseptic steel bowl prerinsed with epinephrine. A 23G needle with the bevel parallel to the longitudinal body axis is inserted into the periosteum along the pubic angle. The penile shaft is pulled away from the body axis, while the dominant hand ensures proper positioning. The solution is injected via a 10-ml syringe in three directions: the penile hilum and the proximal dorsal nerve bilaterally. Scrotal and topical infiltration is then achieved with finger-guided manipulation. The anesthetic effect can be confirmed by pinching the glans and local skin with toothed forceps. The dosage of lidocaine should not exceed 400 mg.

Procedure (Figure 1)

The first circumferential incision is carefully performed and deepened to Buck’s fascia. All the veins of the retrocoronal plexus penis are ligated with a 6-0 nylon (A). The second circumferential incision is made at the midpoint of the penile shaft with preservation of the vascular pedicle. The circumferential prepuce is detublarized along the ventral raphe (B). A longitudinal incision is carried from the midpoint of the dorsal penile shaft to 6 cm proximal to the midpoint of the penopubic fold, about 10 cm below the umbilicus. In impotent patients, stripping surgery of the deep dorsal, circumflex, para-arterial, and cavernosal veins which are possible to be stripped, albeit difficult, with 6-0 nylon is then performed. The suspensory ligament is dissected and released (C). The preputial flap is then transferred 90 degrees and sutured 2-3cm above the penopubic fold, where its subcutaneous tissue is anchored to a stump of the suspensory ligament with 6-0 nylon suture. The flap is fashioned with 5-0 chromic suture (D). The first 90-degree Z-plasty, made in the pubic region, is used for advancement of penopubic skin, which then becomes the skin of the penile base (E and F). The second 90-degree Z-plasty is made at the penoscrotal junction to elongate the penile shaft (G and H).

Figure 1. Schematic representation of procedure
  1. The first circumferential incision is made and deepened to Buck’s fascia. Care is taken to preserve thevascular pedicle. A tiny lymphatic vessel could be readily seen if squeezed. The glanular veins are all freed and ligated with 6-0 nylon.
  2. The second circumferential wound is made at the midpoint of the penile shaft as superficially as possible.
  3. The preputial flap is created after an incision is made along the median raphe. A longitudinal incision is carried out from the midpoint of the dorsal prepuce to 6-7 cm caudal to thepenopubic fold. Venous stripping surgery is performed if necessary. The suspensory ligament is dissectedand released. The preputial flap is then transferred 90 degrees and sutured 2-3 cm above the penopubic fold.
  4. It is then fashioned with 5-0 chromic suture.
  5. The first 90-degree Z-plasty is performed at the pubic region, finished with 5-0 chromic approximation (F).
  6. The second 90-degree Z-plasty is performed at the penoscrotal junction, likewise sutured with 5-0chromic (H).

Figure 2: Cavernosography of a 33 year-year-old male
  1. This cavernosogram was undertaken while Omnipaque solution profuse the corpora cavernosa (asterisk) via a #19 scalp needle (white arrow). This film shows the deep dorsal vein (black arrow) as well as the cavernosal vein (masked).
  2. After the intracavernous injection of 20μg prostaglandin E1 (test), a pharmacocavernosogram demonstrates veno-occlusive dysfunction (VOD) because the leaky veins (black arrows) still present. The ventral curvature is remarked.
  3. This film was obtained after surgery with the similar condition as that in panel A. Note the sinusoids (asterisk) was obviously improved in fluid retention.
  4. Likely it is for comparison with panel B. Note that no more leaky veins (autologous graft) and favorable penile morphology. Implying a gratifying penile shape in addition to an enhanced girdle? Note that this film is free from intracavernous injection of prostaglandin E1.

Discussion

  1. We use silk suture to affix the penis between glans and prepuce to prevent the glans from retracting behind the dressing. Sutures should be taken in small bites, drawing up superficial amounts of material; otherwise, ischemia of the underlying skin may ensue.
  2. Firm penile dressing with gauze casting is recommended for the first postoperative week, and patients are instructed to return for a dressing change in 3 days. At that time, the glans is stretched and released back into position to prevent tissue adhesion, which would otherwise be irreversible.
  3. In our experience of 85 patients, followed from 3 months to 4 years (mean 2 years and 3 months), penile girth increased in each (Figure 4) from 1.5 to 2.5 cm (mean 2.1 cm). Penile length increased by 1.1 to 2.5 cm (mean 1.6 cm) in 66; 18 experienced no length increase and 1, a 71-year-old man, sustained penile shortening resulting from wound contraction attributed to chronic inflammation of the foreskin preoperatively. Thus, although the improvement rate was 98.8% (84/85), the rate of satisfaction was 77.6% (66/85). Statistical significance was inferred from paired t-test in both penile length and girth (p< 0.01 and 0.000 respectively). Two patients experienced prolonged penile edema (6 and 9 months), managed with penile dressing and elevation only. In the 57 patients who underwent venous stripping, erectile dysfunction persists in 1. Hematoma developed in 1 patient; otherwise, significant complications such as infection, reduced penile sensation and painful erection have not occurred.
  4. No standardized method of penile measurement has been agreed upon; thus, estimates of flaccid length vary and may not be related to erectile length. Regardless, length and girth, measured with as much objective accuracy as possible, sometimes bear no relation to subjective body image in patients who perceive themselves to be inadequate. Wessells et al. have reported their guidelines for penile augmentation: flaccid length less than 4 cm or erect length less than 7 cm. In our series, patients with penile girth no more than 7 cm or erectile length less than 9 cm were included because they were highly motivated. Psychological evaluation was undertaken before this procedure, and the sole problem uncovered was their strong expression of perceived penile inadequacy. Although operative success was anticipated, each was informed of possible complications.
  5. This kind of operation was first described in the early 1970s. Surgery for cosmetic reasons, albeit   controversial, has since become popular. The traditional technique involves release of the suspensory ligament and an inverted VY-plasty. Autologous fat tissue and an abdominal flap were used for penile augmentation. In our series we used an autologous preputial flap instead of fat tissue to prevent lumpiness and resorption. The increment in girth depends on the amount of transferred prepuce.  Augmentation was successful in all 85 (mean of 2.1 cm), but length was increased in only 66 (mean 1.9 cm). One patient reported postoperative displeasure because, in his view, the augmented girth resulted in a disproportionately small appearance of the glans. This may be further improved by glanular augmentation using injectable hyaluronic acid gel recommended by Kim JJ et al., further research is absolutely mandatory. We did not use VY-plasty because the outcome cannot always be predicted with accuracy. The two 90-degree Z-plasty procedures elongate the penile base, where the diameter is larger and the area is rich with hair. This was viewed as a bonus by many patients.
  6. Despite careful lymphatic preservation (clearly visible by compression during surgery), prolonged edema developed in two patients. However, dressing and elevation provided sufficient management. Given the anatomically dependent penile position, complete resolution of edema can take as long as 10 months.
  7. We give careful attention to nerve-sparing throughout the procedure; indeed, a good command of scrupulous microsurgical technique is a prerequisite. Because this procedure preserves pudendal nerve innervation, preservation of sensation should be anticipated. No alteration was reported in our 85 patients.
  8. We developed this modified procedure under local anesthesia (0.8% lidocaine prerinsed with epinephrine) to keep the expense within the patients’ capacity and to ensure their privacy. Although epinephrine is contraindicated as an addition to local anesthetics, only one case of postoperative bleeding has developed with this prerinsing practice in 4433 applications. We use neither a Bovie nor suction apparatus, but tie tiny vessels with a 6-0 nylon when necessary.
  9. Tissue necrosis developed at the corner of the preputial flap in one patient.  This was attributed to a heavy smoking habit, prohibited postoperatively.  Because of the 90-degree Z-plasty, tissue tension must be borne in mind. Strong suture material may be advocated, but we use at least 300 cm 5-0 chromic for skin approximation and 6-0 nylon suture for vessel ligation.
  10. The number of veinlets at the retrocoronal sulcus can total as many as 29. All are meticulously freed and fixed with a 6-0 nylon, and the glanular drainge is then confined to the corpus spongiosum and its sinusoids. Thereafter, the glans penis enlarges progressively. This phenomenon requires confirmation, but we feel this operation may promote glanular enlargement insidiously although further research is mandatory.
  11. A dog-ear formation may be encountered with preputial transfer, but this can be addressed by denuding the prepuce of all redundant skin. The patient in whom hematoma developed took aspirin regularly. Therefore, despite the outpatient nature of this operative, PT, PTT, platelet count and medication should be documented. In addition smoking has to be quitted until complete healing.
  12. We do not recommend this type of operation recently as we realize that erectile function is overwhelmingly more important than penile size per se. Particularly the necessity of penile elongation and augmentation surgery remains controversial, in carefully selected patients we use this technique of autologous preputial transfer, which prevents tissue absorption and preserves sensation. Performed on an outpatient basis, it offers an alternative to other surgical methods and has the advantages of privacy and cost-effectiveness. In addition to physical criteria for patient selection, psychological evaluation is mandatory and scheduled long-term follow-up appropriate. Both physician and patient shall take much attention before this operation is undergone.
  13. Anatomy: See above

Suggested Readings

  1. Kelley, J. H. and Eraklis, A. J.: A procedure for lengthening the phallus in boys with extrophy of the bladder.  J Pediatr Surg, 6: 645, 1971
  2. Hinman, F.:  Microphallus:  characteristics and choice of treatment from a study of 20 cases. J Urol, 107: 499,1972
  3. Johnston, J. H.:  Lengthening of the congenital or acquired small penis.  Br J Urol, 46: 685, 1974
  4. Van Driel, M. F., Schultz, W. C., Van de Wiel, H. B. et al:  Surgical lengthening of the penis.  Br J Urol, 82: 81, 1998
  5. Wessells, H., Lue, T. F. and McAninch, J. W.:  Penile length in the flaccid and erect states:  guidelines for penile augmentation. J Urol, 156: 995, 1996.
  6. Roos, H., Constantivides, C. and Lissoos, I.: Penis lengthening. Int J Impot Res, 7: 33, 1995
  7. Wessells, H., Lue, T. F. and McAninch, J. W.: Complications of penile lengthening and augmentation seen at one referral center.  J Urol, 156: 1617, 1996
  8. Foerster, D. W.: Penile enhancement: another wrong way to go. Plast Reconst Surg, 101: 244, 1998
  9. Hsu, GL., Hsieh, C. H., Wen, H. S. et al: Penile enhancement: an outpatient technique. Eur J Med Sexology, 11: 7, 2002
  10. Kim, J. J., Kwak, T. I., Jeon, B. G. et al: Human glans penis augumentation using injectable hyaluronic acid gel. Int J Impot Res, 15:439, 2003
  11. Hsu GL, Hill JW, Hsieh CH, Liu SP and Hsu CY: Venous ligation: A novel strategy for glans enhancement in penile prosthesis implantation. BioMed Research International Volume 2014 Article ID 923171, 7 pages, 2014.  http://dx.doi.org/10.1155/2014/923171 (Principal author)