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- Clinical Experience -
Jorge Caso, Michael Keating, Alejandro Miranda-Sousa, Rafael Carrion
Division of Urology, Department of Interdisciplinary Oncology, University of South Florida, Tampa, FL 33612, USA
Aim: To present a simple technique during penile prosthesis implantation that promotes the perception of increased
phallic length. Methods: The penoscrotal web is defined. A "check mark" incision is made with excision of scrotal
tissue. Excellent exposure is provided for implantation of the cylinders, pump and reservoir. Wound closure is
performed longitudinally. Results: This technique is a modified extension of surgeries described in the pediatric
literature for webbed penis. Loss of penile length following penile implantation surgery is worrisome for patients
suffering from erectile dysfunction (ED). This technique helps with patient satisfaction, cosmetic results, and
improves perception of penile length. Conclusion:
Ventral phalloplasty is a safe, technically simple procedure that may
be performed in concert with penile prosthesis implantation or as a stand alone procedure under certain circumstances.
(Asian J Androl 2008 Jan; 10: 155_157)
Keywords: penile implantation; impotence; phalloplasty; genital lengthening
Correspondence to: Prof. Rafael Carrion, Moffitt Cancer Center & Research Institute, GU Program, MCC 4035, 12092 USF Magnolia Dr,
Tampa, FL 33612, USA.
Tel: +1-813-745-8200 Fax: +1-813-745-8494
Penile prosthesis surgery is a well-established, safe, and effective treatment option for impotence
from varied etiologies. Patient satisfaction has been reported to be high and durable . Concerns exist, however, about post-surgical
shortening of the penis , in addition to well documented loss of length from the causes of impotence . Various techniques
to increase apparent phallic length have been described [4, 5]. At our institution, placement of the prosthesis is
performed by an incision carried through the pensocrotal web. The excision of this tissue has been associated with excellent
results and patient satisfaction, together with a perceived increase in length . Herein, we discuss our technique in
Intravenous preoperative antibiotics are administered within two hours of incision. The exposed skin on the lower
abdomen, genitalia, and perineum receives a thorough cleansing. Drapes are applied in standard fashion. The head of
the penis is grasped and upward traction applied to its full stretched length. Holding the scrotum along the median
raphe and stretching it caudally defines the extent of the penoscrotal web (Figure 1A). In our experience there is great
variability in the insertion of the scrotum; some webs are very generous while others are less appreciable,
commencing near the base of the penis.
Subsequently, the boundaries of the incision are marked. This may be facilitated by placing a light behind the web,
thereby silhouetting the penile shaft and upper curve of the testicles. The incision line on the y-axis begins at a
fingerbreadth's clearance from the shaft (Figure 1B), thereby ensuring sufficient skin for later closure. It is carried
down near the penoscrotal angle, then upward in a soft convex curve to resemble a "check-mark" (Figure 1C). In our
original series, the upward stroke was straight, and this "V" shape led to a small bulge or "dog ear" in the inferior
portion of the wound after it was closed. Although this irregularity became less noticeable with time, the current
modification has produced a more immediately aesthetically pleasing result.
An added benefit of this incision is the resulting ample workspace with good exposure of the proximal ventral
corporal bodies and easy access to the inguinal canal and
scrotum (Figure 1D). This allows for the cylinders,
pump, and reservoir to be implanted in standard fashion.
A foley catheter is inserted and the bladder drained prior
to dissecting the space for the reservoir. On occasion
we will leave the catheter in place until the morning of
the first postoperative day. Optionally, a drain may also
be placed and left overnight. Interrupted 3-0 monocryl
sutures are used to close a deep layer of tissue over the
prosthetic device. The skin is then re-approximated
along the axis of the shaft with another layer of
interrupted 3-0 monocryl sutures (Figure 1E). This has
prevented wound breakdown, specifically in the portion over the penoscrotal angle where the most wound
tension is expected.
Historically, our technique has evolved from the
treatment of the webbed variant of inconspicuous penis as
described in the pediatric literature. Several methods have
been described to release the penis. An early, simple
technique involved vertically excising the redundant, high
insertion scrotal skin along the dorsum of the shaft
including a portion of the scrotum. This produced a
diamond-shaped defect with the penoscrotal angle as the
midpoint. The wound could be approximated in varying
ways, most often longitudinally [7_9].
We have found that applying this technique of
ventral phalloplasty to adults is a safe, simple procedure with
excellent cosmetic results. It works well with inflatable
penile prosthetic implantation, but is also useful in
patients undergoing surgery for Peyronie's disease. The
excellent exposure provided is a key added benefit to
both operations. We have also performed ventral phalloplasty as a stand alone procedure in select cases,
such as a means of securing an external drainage device
in spinal cord injury patients.
Phallic shortening is a well described phenomenon
that occurs after radical prostatectomy, which is a
common indication for prosthetic surgery. The most
significant decrease in penile length appears to occur at one
week after removal of the prostate, continuing at a lesser
rate over the next year . Early changes (first 3_6
months) have been postulated to be from sympathetic
overdrive following cavernosal nerve injury; later changes
are likely due to irreversible fibrosis and structural changes.
Similar etiologies may be present with other diseases that
cause nerve damage and impotence, such as diabetes
To counteract this effect, release of the suspensory
ligament during implantation has been described. While
this method is effective and also associated with high
patient satisfaction, it risks damage to the cavernosal
nerves and may require a more extensive dissection .
Others have explored using cylinders as tissue
expanders in corporal bodies scarred from a prior infected
prosthesis or a history of priapism. In one series utilizing this
technique, the scrotal skin was incised horizontally then
closed vertically without excision of tissue .
Our data comparing the technique of ventral
phalloplasty with a standard longitudinal penoscrotal incision
during penile implantation has recently been reported .
We demonstrated excellent patient satisfaction (98%) and
perception of increased penile length (84%) with release
of the penoscrotal web, while a majority of patients in
whom the standard approach was used felt there was a
decrease in length (84%). The perception of decreased
length following implantation agrees with other recently
published data , although, interestingly, no significant
difference between actual stretched penile length
measured preoperatively and the length at one and six months
post-implantation was found.
Ventral phalloplasty is a safe and technically simple
technique. Patient satisfaction is high, and it may aid
with perceived and real fears of phallic shortening. The
technique facilitates placement of a penile prosthetic. It
is also useful in the surgical correction of Peyronie's
disease and in spinal cord injury patients who need an
external drainage device.
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