A homosexual 42-year-old man presented with a 12-month history of Peyronie’s disease (PD) and erectile dysfunction (ED). His comorbidity profile included long-standing type I insulin-dependent diabetes mellitus with reasonably poor glycemic control (hemoglobin A1c [HbA1c] 8.8%) at presentation. He complained of progressive dorsal curvature associated with severe penile length loss, stable for at least 8 months. He had preexisting ED partially controlled with tadalafil 20 mg on demand.

Physical examination revealed poor penile elasticity and a robust dorsal plaque diffusely palpable throughout the dorsal septum. Stretched flaccid penile length measured from pubic bone to urethral meatus was 11.2 cm. In-office curvature assessment coupled with duplex Doppler ultrasound examination revealed a 92^o dorsal curvature, severe axial instability and normal penile hemodynamic parameters after a rigid erection was obtained with intracavernosal injection of 0.2 ml solution of papaverine 30 mg/ml, phentolamine 1 mg/ml and alprostadil 10 mcg/ml (fig. 1). Available therapeutic options and potential complications were fully explained to the patient. He then opted for the implantation of a malleable penile prosthesis in combination with an expansion procedure to restore penile dimensions.

Figure 1. In-office curvature assessment.

The procedure was performed after glycemic control (HbA1c <8.5%) through a penoscrotal approach, and degloving was performed to allow neurovascular bundle elevation (fig. 2). Multiple incisions were performed in the dorsolateral aspect of the tunica albuginea prior to cavernosal dilation, and 19.5 cm rods were placed bilaterally, which provided a 1.8 cm length gain (fig. 3). Figure 4 displays an image taken at the most recent followup visit 5 months after the procedure. The patient was satisfied with the functional and cosmetic aspects of his penis, and reported normal penile sensation.

Figure 2. Neurovascular bundle elevation through penoscrotal degloving approach.

Figure 3. Multiple tunica mesh incisions and immediate postoperative aspect with 1.8 cm length gain.

Figure 4. Postoperative followup visit after 5 months.

According to the AUA guideline for PD, clinicians may offer penile prosthesis surgery to patients with PD with ED and/or severe penile deformity sufficient to prevent coitus.¹ During the shared decision making process, the patient was reluctant about the possibility of worsening erectile function and was greatly concerned about his penile dimensions. Therefore, he underwent implantation of a malleable penile prosthesis associated with adjunct maneuvers to restore penile length. The operative decision to place a malleable, 2-piece or 3-piece inflatable penile prosthesis (IPP) is usually based on several factors, but in this case was mainly due to financial/coverage issues. Although studies have shown that IPPs might be associated with higher satisfaction rates, especially in patients with PD, these devices are much less accessible to most of the patients in many countries.

PD is a common cause of penile length loss, as up to 80% of individuals will report subjective loss of penile length, which might affect overall satisfaction with sexual activity.² The management of loss of penile length in the setting of PD is of increasing interest, since patient satisfaction following implant surgery is strongly related to the extent of perceived penile length loss. Therefore, lengthening maneuvers at the time of implant surgery represent an option to a selected patient population. Although maneuvers such as modeling or scratch technique may correct penile curvature in the majority of patients undergoing penile implants, they may not restore penile dimensions, mainly because the corporeal measurements are carried out when the contracture is still present.

Several procedures reporting tunica incisions and concomitant penile prosthesis have been described with favorable functional outcomes. Such techniques would provide reasonable length gain ranging from 0.8 to 5 cm and high satisfaction rates.^3-6 However, most of the traditional techniques would require grafting. Tunica mesh expansion procedure (TMEP) is a nongrafting technique that is proposed to achieve penile lengthening without the resultant large tunica defects.⁷ It consists of multiple, staggered, small tunical incisions in alternate rows, perpendicular to the desired direction of expansion according to the mesh expansion theory.⁸ By increasing the number of incisions, the procedure allows restoration of length and girth through smaller defects, thus promoting a better expansion without the need for grafting.

It is important to highlight that TMEP is associated with higher postoperative complication rates, which might reach up to 30% and include penile hematoma glans sensitivity impairment, device infection and glans necrosis. Reported infection rates are around 7%.⁹ Fortunately, glans necrosis is rare, but it is a devastating complication and should always be included as a potential complication during patient discussion. Although this procedure is usually carried out through a subcoronal incision to allow for good exposure of the corpora cavernosa and even some gain in length, we prefer a penoscrotal degloving technique. We believe that preservation of vascularization to the glans decreases the risk of glans necrosis and other ischemic complications, despite the more technically challenging exposure of the surgical site.

In summary, lengthening procedures and concomitant penile prosthesis implantation are valid options for cases of severe penile length loss. However, they might be associated with high complication rates, and patients should be adequately counseled about realistic expectations and the risks and benefits associated with these procedures. Careful patient selection is warranted, as many authors advocate that patients with known peripheral vascular disease, diabetes and previous radiation therapy should not be offered lengthening procedures.