Maximizing penile size, quality of erection and cosmetic appearance of a penis with a penile implant.

Patient’s need to be aware of key issues that determine the penile length, feel of the cylinders, quality of erection and cosmetic appearance of the penis after the penile implant procedure. First a penile implant has limitations and although satisfaction rates are extremely high, an inflatable penile implant will not function exactly like a “normal” penis. The flaccid penis with an implant cannot retract like a “normal” penis. The flaccid penis therefore will always be longer than before the implant was inserted.

Second, when the cylinders are deflated, the flesh of the penis will no longer be under tension and will retract causing the deflated cylinders to bend and fold inside the shaft of the penis like an accordion. The folds will be more prominent and palpable with the Coloplast Titan than with the AMS cylinders. In a beefy overweight patient with the metabolic syndrome for example, this will not be an issue, but in a very thin frail elderly patient this may be uncomfortable and unsightly. In general the deflated AMS cylinders are more comfortable and softer than the deflated Coloplast cylinders. Third, to date nothing exists in the world to make the erect penis longer (including vacuum devices, traction or surgery). And neither the Coloplast nor the AMS LGX will increase the length of the erect penis. At best the length of the erect penis with the implant will be the same as the length of the erect penis measured before the implant procedure in the standing position after a penile injection test. Finally the health of the tunica albuginea (the thick layer that surrounds the erectile muscle) also will impact the size of the implanted penis, as does the postoperative care, which I will discuss later. In a patient with vascular disease or diabetes the tunica may be thickened and loses its elasticity limiting its ability to stretch. This may decrease the overall length of the pre-implanted erect penis. So does Peyronie’s disease, which in a patient with ED may not be revealed until the patient is in the OR.

It is vital that the stretched penile length is measured preoperatively with and without a penile injection test preferably in the standing position in order to provide the patient with realistic postoperative expectations regarding size.

Several surgical techniques will allow the surgeon to maximize the postoperative length including surgical approach peno-scrotal (below the penis) vs. infra-pubic (above the penis), use of the “No-Touch” technique, positioning of the patient on the OR table, advanced knowledge of the size of the stretched penis and type of anesthesia.

Type of anesthesia

Spinal anesthesia, as opposed to general anesthesia, will make the body numb from the waist down and blood will pool into a relaxed penis. The penis will stretch by itself allowing the surgeon to place the longest possible cylinders that will fit. The surgeon can also immediately see the size and measure the stretched penis before the start of the surgery. General anesthesia does not have the same relaxing effect on penile tissue and the surgeon will have to manually stretch the penis to estimate the length of the penis. This is the equivalent of comparing the length of the manually stretched penis when not sexually aroused with the length when sexually active.

No-Touch technique and preoperative measurement of the penis

As previously mentioned, knowledge of the pre-implantation length is very useful in maximizing post-operative length. After the cylinders are inserted in the penis and before the corporotomies are closed, the cylinders are inflated and the erect penis measured. This measurement can be compared with the pre-implantation measurement. If the length of the cylinders needs to be adjusted, the “No-Touch” technique enables the surgeon to remove and reposition the cylinders and adjust their length without contaminating the cylinders with skin bacteria. Urologists not using the “No-Touch” technique, fearing infection, may not perform a size adjustment just to gain a centimeter or less. This will result in an undersized penis. Also if the penis was not measured before the implant operation, the surgeon may not be aware of the discrepancy in size. Most urologists do not measure and document the length of the stretched penis before the implant is performed. More information on the “No-Touch” technique including ten year data in over 3000 consecutive patients is available on my website.

Surgical approach

Performing the surgery through a midline scrotal incision will not only result in a better cosmetic outcome (scar will be concealed by the natural raphe) but also will maximize length. Making a transverse incision above the penis or below the penis will result in a more distal (closer to the glans penis) incision onto the shaft of the penis often beyond the body plane or bodyline. Input cylinder tubes that exit the penis and connect the cylinders to the pump are more likely to be visible and palpable by the patient and partner. Scar tissue will also form on the part of the penis that is supposed to stretch with an erection decreasing the overall length of the erect penis. Regarding the “above the penis” surgical approach, tubing from the cylinders will exit the base of the shaft at the 12 o’clock position and make a 180 degree turn to reach the scrotal pump. This tubing will therefore be palpable at the base of the lateral aspect of the shaft of the penis on the right, may rub and be painful during intercourse and even limit the depth of penetration. This can be particularly annoying for the thin patient.

Patient’s operative position

Flexing the OR table at the pubis, positioning the patient’s head and feet down with pelvis up and with the head of the table tilted downward will enable the surgeon to access the proximal crus (towards the body) or base of the penis. Positioning the legs with the knees bent outward and feet touching will also enable more proximal access of the crus of the penis. With this approach tubing exiting the shaft of the penis is oriented straight down towards the pump, resulting in buried, non-palpable or visible input tubing. This will result in a better cosmetic outcome and the tubing will not interfere with deeper penetration during intercourse. Also scar tissue will form deep in the scrotum on the fixed portion of the shaft of the penis and is less likely to decrease the stretched length. Optimal scrotal pump positioning is facilitated with this approach as well. The pump needs to be accessible far away from the shaft at the base of the penis yet concealed slightly behind the testicles. This is more difficult to perform through other surgical approaches. Most urologists perform the penile implant with the patient supine and flat on the operating table.

Choice of implant cylinder

The AMS cylinders are tunical independent and will only expand to 18mm girth (a mesh prevents further expansion). This is more than adequate for many patients. For patients requiring cylinder length of 20cm or more this lateral expansion may not be enough and better rigidity will occur with the wider Coloplast cylinders (the longer cylinders expand to 21mm plus). The Coloplast cylinders are tunical dependent and if the tunica is not healthy or thin, the rigidity will not be as good as with the AMS cylinders.The Coloplast cylinders expand fully against the tunica and overtime this can cause thinning and atrophy the tunica albuginea which will cause the penis to become very wide and less rigid. On the other hand, use of the AMS cylinders in the larger and wider penises will cause inadequate rigidity of the penis as well as a flat appearance of the shaft of the erect penis. The urethra, which is usually at the bottom of the shaft, will instead nestle between the narrower AMS cylinders. It’s important to have all types, makes and sizes of cylinders for every case, because often the surgeon may not have pre-operative knowledge of all the variables necessary to select the best cylinder option for that particular individual. For practical reasons, most urologists will use the same brand of penile implant for every patient.

The issue of rear tips extenders

The inflatable cylinder is made of a non-inflatable rear portion that measures 4.5cm (AMS) and 5 cm (Coloplast) and an inflatable anterior portion of variable length. So for example a 20cm Coloplast cylinder will only have 15cm of inflatable distal portion. The fixed proximal portion also has a thinner diameter. For the AMS cylinders that diameter is only 9mm. Often surgeons will increase the length of the proximal portion with rear tip extenders to adjust the size of the cylinders, rather than choosing a cylinder of the correct length. For example if a patient measures 20cm and the doctor is committed in using an AMS device he will have to use an 18cm with 2cm rear tip extenders. Therefore only 13.5cm out of the total 20cm inflates; the rear, which now measures 6.5cm, is thin and non-inflatable. The unstable junction where the inflatable portion connects with the fixed rear portion will now be located in a more distal position in the penile shaft and the erection will have a hinge effect, wobble and point downward when the cylinders are inflated. This may not affect the overall length of the penis but will decrease the quality of the erection. Instead a better choice would have been to use a 20cm Coloplast (AMS does not make a 20cm). Most urologists, including yours truly, were trained believing that the crus of the penis does not play a significant role on the quality of the erection and that placing a thin non-inflatable implant would not affect the outcome. Use of rear tip extenders decreases the quality of the erection.

Post-operative care

During the first three months after the surgery the cylinders must be kept fully deflated in order to maintain the reservoir fully inflated. This will allow scar tissue to form on a full reservoir and prevent auto-inflation later on. This means that the penis will heal over deflated cylinders and scar tissue will form over cylinder folds and curvatures. A long wide penis with deflated cylinders may retract by as much as two inches. If the implant is not inflated early in the immediate two weeks after the surgery, it may heal in this foreshortened dimension, causing permanent deformity and reduced inflated length. In order to be able to inflate early one must be able to feel all of the components of the pump, inflating bulb and deflation footprint. The more experienced the surgeon and the more precise the surgical technique the less swelling and pain will occur after the surgery. Incisions and dissection must be kept at a minimum and meticulous surgical hemostasis must be achieved so that the patient’s postoperative risk of hematoma and swelling is reduced. This will enable the patient to feel the components of the pump early after the procedure and inflate and deflate as soon as possible. Think of it as rehab after an orthopedic procedure. If the shoulder is kept in a sling for several postoperative weeks, the shoulder will freeze in that position. Post-op bed rest for 48 hours with ice followed by daily hot baths will minimize swelling and accelerate healing. Unfortunately in most general urology practices post-operative care is often relegated to ancillary staff with little knowledge of these issues.

It is vital, especially for the larger stretchy penises that inflation and deflation of the cylinders is started as soon as possible in order to prevent healing in a retracted foreshortened state.

Maximizing length and quality of the erection as well as cosmetic appearance depends on many factors perhaps the most important being the practice implant volume and surgeon’s experience.