Maximizing Three Piece Penile Prosthesis Length: Our Technique and Outcomes

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Celtik, Alexandra R. Siegal, Robert Valenzuela, Shirin Razdan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2987370/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Three-piece inflatable penile prosthesis (IPP) is considered the gold standard surgical treatment for erectile dysfunction (ED). The most common cause of patient regret after penile prosthesis surgery is penile shortening. We sought to query a national database on average prosthesis length and describe our techniques to maximize cylinder sizes. We performed a retrospective review of the Coloplast database of 3-piece penile prosthesis cases performed over the span of 1 year nationally and by a single high volume surgeon and compared average cylinder lengths. Our review did not investigate whether adjunct tunical lengthening or girth enhancing procedures were performed. Between July 1, 2021 and June 27, 2022, 145 three piece penile prosthesis surgeries were performed at our institution. All were performed via a scrotal incision. Nationally, 32.8% were performed infrapubic while 58.1% were performed scrotal. The most prevalent cylinder length in our series was 22cm, compared to the most prevalent nationally of 20cm. Our technique to maximize cylinder length involves circumferential mobilization of the corporal bodies and corporal tissue sparing. Corporal tissue sparing is carried out by employing 9” Metzenbaum scissors rather than sequential dilators for corporal tunneling. The benefit of this approach is the ability to create a dorsal compartment to the level of the triangular ligament of the glans, thereby extending the space to the level of the midglans. This maneuver minimizes placement of the prosthesis anteriorly at the level of the fossa navicularis and prevents floppy glans that would otherwise compromise maximum cylinder length. Three piece penile prosthesis cylinder size can be maximized by circumferential mobilization of the corporal bodies, corporal sparing maneuvers, and the utilization of long Metzenbaum scissors for precise corporal tunneling. Figures Figure 1 Figure 2 Figure 3 Introduction Three-piece inflatable penile prosthesis (IPP) is considered the gold standard surgical treatment for erectile dysfunction (ED). The most common cause of patient regret after penile prosthesis surgery is perceived penile shortening. 1 – 3 Penile shortening in the absence of IPP insertion can be caused by conditions such as Peyronie’s disease (PD), priapism with corporal fibrosis, and prostate cancer treated with radical prostatectomy, radiation, and or/androgen deprivation therapy. 4 Studies have shown that actual penile length after IPP is not different than stretched flaccid penile length, but rather perceived impression of penile shortening is more significant after IPP insertion in men with a prior history of radical prostatectomy. 5 Loss in length may be in part due to the inherently inelastic skin and fibrosis associated with these pathologies, which may be difficult to overcome with prosthetic surgery. 6 In men undergoing IPP insertion with multiple risk factors and underlying pathology for loss of penile length, techniques to optimize penile length and girth are crucial to ensure ultimate patient and partner satisfaction with their prostheses. Historically, these techniques include: sliding technique, multislice technique, tunica expansion procedure, ventral phalloplasty, suprapubic lipectomy, suspensory ligament release, and augmentation corporoplasty. 4 The majority of these techniques are adjunct procedures and not commonly performed at the time of virgin IPPs. There is scant literature describing techniques to maximize cylinder length without the need for these adjunct procedures. 4 , 7 We sought to query a national database on average prosthesis length and describe our standardized techniques to maximize cylinder sizes at the time of virgin IPP placement. Methods We performed a retrospective review of the Coloplast database for three-piece penile prosthesis cases performed nationally over the span of 1 year. We also isolated Coloplast IPP cases completed by a single high volume prosthetic surgeon at an academic practice over this same period. Average cylinder lengths utilized between the two groups were compared. Cases with adjunct procedures such as suspensory ligament release, suprapubic lipectomy, augmentation corporoplasty, or any other adjunct tunical lengthening or girth enhancing procedures at the time of prosthetic placement were excluded. Institutional Review Board (IRB) approval for patient chart review (IRB-20-01505) was previously obtained to query our surgeon’s database. Results Between July 1, 2021 and June 27, 2022, 145 three-piece penile prosthesis surgeries were performed by our single prosthetic surgeon. All were performed via a midline scrotal incision. Nationally, 32.8% were performed infrapubic while 58.1% were performed by scrotal approach. The most prevalent cylinder length in our series was 22cm, compared to the most prevalent nationally of 20cm. (Table 1 ). Our technique to maximize cylinder length begins during the preparation of the surgical field. After a mechanical scrub and anesthetic block, a mixture of 60mg papaverine in 3mL of ropivacaine is injected into the proximal corpora. The base of the penis is held and the mixture is distributed throughout the penis. Manual massage of the solution facilitates maximum distribution distally. Papaverine is a nonspecific phosphodiesterase inhibitor and potentiates erectile function by increasing availability of cGMP and cAMP. Studies have also shown that papaverine has a significant inhibitory effect on venous outflow. 8 , 9 This property is exploited with preoperative injection to allow full dilation of the corporal bodies and increased tissue pliability. Given the dual mechanism of action on erectile function, papaverine can cause priapismic pain, and, as such, we co-administer with ropivacaine to minimize this side effect. The cumulative effect of this anesthetic block is to augment blood flow, and therefore maximal dilation, of the corporal bodies. After initial scrotal incision and dissection to the level of the penile compartment, circumferential mobilization of the corporal bodies is carried out. This technique entails a combination of blunt dissection and sharp dissection with Metzenbaum scissors to free the anterior, lateral, and posterior attachments of the corporal bodies from the surrounding tissue for greater mobility and distal cylinder length. Care is taken to stay between the dartos and Buck’s layers as to avoid any potential nerve and vascular damage. The close adherence of these superficial and deep fascial layers to the underlying tunica limits the full radial expansion of the corpora. As such, circumferential mobilization technique allows for up to 1cm extra cylinder length due to freeing of the corporal bodies from their tethered positions within the perineum as well as improved girth. (Image 1). Furthermore, after bluntly dissecting the lateral layers of fascia off the corporal bodies, attention is turned to the base of the surgical field at the penoscrotal junction. The surgeon positions their index and middle fingers in an inverted V formation over the urethra and precisely cuts down on the urethral-scrotal septum using Metzenbaum scissors. Care is taken not to violate the scrotal compartment. A surgical sponge is then used to methodically sweep fascial attachments off each corporal body deep into the perineum, with subsequent packing of the scrotum to better display the full length of the corporal bodies proximally. This allows greater mobilization of the corporal bodies and a more proximal placement of the prosthesis and exit site of the tubing. Complete detethering of the corporal bodies from surrounding structures allows for maximal expansion of the corporal bodies. At this point, stay sutures are placed and corporotomies are made proximal to the penoscrotal junction to optimize distal cylinder length and to ensure dependent and concealed positioning of device tubing. Corporal tissue sparing is then carried out by employing 9” Metzenbaum scissors rather than sequential dilators for corporal tunneling. (Image 2). Corporal sparing preserves the cavernosal artery and cavernosal spongy tissue, which improves glans engorgement and hemodynamic responsiveness of the tissue and thus its natural elasticity. 10 Likewise, the benefit of this approach is the ability to displace and spare spongy cavernosal tissue ventrally while creating a channel in the dorsal compartment of the corpora up to the triangular ligament of the glans, limiting compression of the cavernosum distally which can otherwise lead to shorter cylinder placement. (Image 3). Indeed, our technique ensures the full length of the corpora is tunneled, thereby maximizing the size of implant cylinders and minimizing the risk of hypermobile glans. Care is taken to tunnel beyond the fossa navicularis to prevent placing the prosthesis in the ventral compartment of the corpora, where the tunica is thinner, thus reducing the risk of erosion. We estimate that placing the distal end of the prosthesis beyond the fossa navicularis and to the level of the triangular ligament of the glans increases the length of the prosthesis, and thus penile length, up to 0.5 to 1 cm. Discussion Penile prosthesis surgery is not solely meant for restoration of erectile functionality. It presents an opportunity to preserve or restore penile length that has been lost due to comorbid conditions. While adjunct procedures represent attractive tools in the arsenal of the prosthetic urologist to help maximize cylinder length, these are often very rigorous and challenging for the occasional prosthetic surgeon. Taking care to abide by anatomic principles and understanding the restrictive factors that may impact post prosthesis penile length may allow for fine-tuning of their surgical technique to ensure maximum outcomes. These principles are highlighted using preoperative papaverine injection, circumferential mobilization of the corpora, corporal sparing techniques, and manipulation of the triangular ligament to maximize corporal tunneling, which are employed in every IPP surgery performed at our institution. This standardization is the key to optimizing prosthesis length. Perceived loss of length, as compared with a patient's preoperative natural erection penile length, is the most common complaint after IPP placement. 11 As such, it behooves the prosthetic urologist to have an intimate understanding of the anatomy of the phallus, including cross sectional anatomy of the corpora cavernosa. Studies of human cadavers have shown that implants seated dorsally in the corpora and in the dorsal mid glans distally provided additional tissue coverage over weak ventral areas of the tunica albuginea, while ventrolateral dilation appeared to result in ventral seating, hypermobile glans, and susceptibility to perforation at the level of the fossa navicularis. 12 By using the Metzenbaum scissors to precisely create a dorsal channel for placement of the prosthesis rather than serial dilation, we strive to maximize corporal sparing and preserve or restore penile length. The triangular ligament of the glans is located approximately 5 mm distal and dorsal to the fossa navicularis, as described by Shafik et al., and anchors the glans to the distal tip of the corporal bodies, inherently limiting glans mobility at time of erection. 13 By placing the prosthesis to the level of this ligament during corporal sparing, greater distal stretch is provided for cylinders while at the same time ensuring improved seating in the dorsal compartment. This understanding of cross-sectional anatomy has not only been used at the time of virgin IPP insertion, but has also been utilized in salvage or revision surgeries to better seat malpositioned devices. 14 , 15 The purpose of this paper was to describe our standardized techniques of maximizing penile length at the time of penile prosthesis placement. Comparative outcomes were only available for the past year at the time of this writing. Anecdotally we report stable average prosthetic size of 22cm due to the described maneuvers. Limitations of the study include single surgeon, small sample size, its retrospective nature, and lack of comparison arm. Strengths include the understanding of restrictive factors that can affect cylinder length at the time of inflatable penile prosthesis insertion as well as detailed description of easy to perform techniques via standard midline scrotal incision without need for advanced reconstructive surgical training. Conclusion Three piece penile prosthesis cylinder size can be maximized by preoperative papaverine injection to dilate the corporal bodies, circumferential mobilization of the corporal bodies, corporal sparing maneuvers, and precise corporal tunneling to the level of the triangular ligament of the glans with the utilization of long Metzenbaum scissors, ensuring the distal cylinder tips are seated within the tip of the glans rather than at the coronal sulcus. These techniques may be employed by any prosthetic urologist without advanced training to ensure satisfactory IPP length and decrease patient regret after surgery. Table 1 NATIONAL Size 11cm 14cm 16cm 18cm 20cm 22cm 24cm 26cm 28cm Total % of Cases 0.05% 0.9% 8.0% 24.0% 32.7% 25.3% 6.6% 2.2% 0.3% 100% SURGEON Size 11cm 14cm 16cm 18cm 20cm 22cm 24cm 26cm 28cm Total % of Cases 0.0% 0.0% 1.4% 4.1% 29.0% 47.6% 14.5% 3.4% 0.0% 100% # Cases 0 0 2 6 42 69 21 5 0 145 Image 1 Image 2 Image 3 Declarations Disclosure Statements: • Acknowledgments – the authors have no acknowledgements • Funding – the authors have no funding to report • Competing interests – the authors have no competing interests References Akakpo, W., Pineda, M. A., Burnett, A. L.: Critical Analysis of Satisfaction Assessment After Penile Prosthesis Surgery. Sex Med Rev, 5: 244, 2017 Shah, T., Wang, R.: A Review of Factors Affecting Patient Satisfaction With Inflatable Penile Prosthesis. Sex Med Rev, 9: 350, 2021 Montorsi, F., Rigatti, P., Carmignani, G. et al.: AMS three-piece inflatable implants for erectile dysfunction: a long-term multi-institutional study in 200 consecutive patients. Eur Urol, 37: 50, 2000 Tran, H., Goldfarb, R., Ackerman, A. et al.: Penile Lengthening, Girth, and Size Preservation at the Time of Penile Prosthesis Insertion. Sex Med Rev, 5: 403, 2017 Deveci, S., Martin, D., Parker, M. et al.: Penile length alterations following penile prosthesis surgery. Eur Urol, 51: 1128, 2007 Jordan, G. H., Gilbert, D. A.: Male genital trauma. Clin Plast Surg, 15: 431, 1988 Borges, F., Hakim, L., Kline, C.: ORIGINAL RESEARCH—SURGERY: Surgical Technique to Maintain Penile Length After Insertion of an Inflatable Penile Prosthesis via Infrapubic Approach. The Journal of Sexual Medicine, 3: 550, 2006 Delcour, C., Wespes, E., Vandenbosch, G. et al.: The effect of papaverine on arterial and venous hemodynamics of erection. J Urol, 138: 187, 1987 Puyau, F. A., Lewis, R. W., Balkin, P. et al.: Dynamic corpus cavernosography: effect of papaverine injection. Radiology, 164: 179, 1987 Zaazaa, A., Bayerle-Eder, M., Elnabarawy, R. et al.: Penile Hemodynamic Response to Phosphodiesterase Type V Inhibitors after Cavernosal Sparing Inflatable Penile Prosthesis Implantation: A Prospective Randomized Open-Blinded End-Point (PROBE) Study. Adv Urol, 2021: 5548494, 2021 Shah, B. B., Kent, M., Valenzuela, R.: Advanced Penile Length Restoration Techniques to Optimize Penile Prosthesis Placement Outcomes. Sex Med Rev, 2020 Pagano, M. J., Weinberg, A. C., Deibert, C. M. et al.: Penile intracavernosal pillars: lessons from anatomy and potential implications for penile prosthesis placement. Int J Impot Res, 28: 114, 2016 Shafik, A., Shafik, A. A., Asaad, S. et al.: The corporo-glans ligament: description and functional significance of a ligament connecting the corpora cavernosa to the glans penis. Int J Impot Res, 16: 220, 2004 Clavell-Hernández, J.: Proximal Extracapsular Tunneling: A Simple Technique for the Management of Impending Cylinder Erosion and Complications Related to Corporal Dilation. Sex Med, 9: 100379, 2021 Rebez, G., Runti, O., Marco, L. D. et al.: Penile prosthesis impending erosion: Surgical technique for extracapsular re-implantation reconstruction. Urologia : 3915603221119165, 2022 Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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The most common cause of patient regret after penile prosthesis surgery is perceived penile shortening.\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Penile shortening in the absence of IPP insertion can be caused by conditions such as Peyronie\u0026rsquo;s disease (PD), priapism with corporal fibrosis, and prostate cancer treated with radical prostatectomy, radiation, and or/androgen deprivation therapy.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Studies have shown that actual penile length after IPP is not different than stretched flaccid penile length, but rather perceived impression of penile shortening is more significant after IPP insertion in men with a prior history of radical prostatectomy.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Loss in length may be in part due to the inherently inelastic skin and fibrosis associated with these pathologies, which may be difficult to overcome with prosthetic surgery.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn men undergoing IPP insertion with multiple risk factors and underlying pathology for loss of penile length, techniques to optimize penile length and girth are crucial to ensure ultimate patient and partner satisfaction with their prostheses. Historically, these techniques include: sliding technique, multislice technique, tunica expansion procedure, ventral phalloplasty, suprapubic lipectomy, suspensory ligament release, and augmentation corporoplasty.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e The majority of these techniques are adjunct procedures and not commonly performed at the time of virgin IPPs. There is scant literature describing techniques to maximize cylinder length without the need for these adjunct procedures.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e We sought to query a national database on average prosthesis length and describe our standardized techniques to maximize cylinder sizes at the time of virgin IPP placement.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e We performed a retrospective review of the Coloplast database for three-piece penile prosthesis cases performed nationally over the span of 1 year. We also isolated Coloplast IPP cases completed by a single high volume prosthetic surgeon at an academic practice over this same period. Average cylinder lengths utilized between the two groups were compared. Cases with adjunct procedures such as suspensory ligament release, suprapubic lipectomy, augmentation corporoplasty, or any other adjunct tunical lengthening or girth enhancing procedures at the time of prosthetic placement were excluded. Institutional Review Board (IRB) approval for patient chart review (IRB-20-01505) was previously obtained to query our surgeon\u0026rsquo;s database.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween July 1, 2021 and June 27, 2022, 145 three-piece penile prosthesis surgeries were performed by our single prosthetic surgeon. All were performed via a midline scrotal incision. Nationally, 32.8% were performed infrapubic while 58.1% were performed by scrotal approach. The most prevalent cylinder length in our series was 22cm, compared to the most prevalent nationally of 20cm. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur technique to maximize cylinder length begins during the preparation of the surgical field. After a mechanical scrub and anesthetic block, a mixture of 60mg papaverine in 3mL of ropivacaine is injected into the proximal corpora. The base of the penis is held and the mixture is distributed throughout the penis. Manual massage of the solution facilitates maximum distribution distally. Papaverine is a nonspecific phosphodiesterase inhibitor and potentiates erectile function by increasing availability of cGMP and cAMP. Studies have also shown that papaverine has a significant inhibitory effect on venous outflow.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e This property is exploited with preoperative injection to allow full dilation of the corporal bodies and increased tissue pliability. Given the dual mechanism of action on erectile function, papaverine can cause priapismic pain, and, as such, we co-administer with ropivacaine to minimize this side effect. The cumulative effect of this anesthetic block is to augment blood flow, and therefore maximal dilation, of the corporal bodies.\u003c/p\u003e \u003cp\u003eAfter initial scrotal incision and dissection to the level of the penile compartment, circumferential mobilization of the corporal bodies is carried out. This technique entails a combination of blunt dissection and sharp dissection with Metzenbaum scissors to free the anterior, lateral, and posterior attachments of the corporal bodies from the surrounding tissue for greater mobility and distal cylinder length. Care is taken to stay between the dartos and Buck\u0026rsquo;s layers as to avoid any potential nerve and vascular damage. The close adherence of these superficial and deep fascial layers to the underlying tunica limits the full radial expansion of the corpora. As such, circumferential mobilization technique allows for up to 1cm extra cylinder length due to freeing of the corporal bodies from their tethered positions within the perineum as well as improved girth. (Image 1).\u003c/p\u003e \u003cp\u003eFurthermore, after bluntly dissecting the lateral layers of fascia off the corporal bodies, attention is turned to the base of the surgical field at the penoscrotal junction. The surgeon positions their index and middle fingers in an inverted V formation over the urethra and precisely cuts down on the urethral-scrotal septum using Metzenbaum scissors. Care is taken not to violate the scrotal compartment. A surgical sponge is then used to methodically sweep fascial attachments off each corporal body deep into the perineum, with subsequent packing of the scrotum to better display the full length of the corporal bodies proximally. This allows greater mobilization of the corporal bodies and a more proximal placement of the prosthesis and exit site of the tubing. Complete detethering of the corporal bodies from surrounding structures allows for maximal expansion of the corporal bodies.\u003c/p\u003e \u003cp\u003eAt this point, stay sutures are placed and corporotomies are made proximal to the penoscrotal junction to optimize distal cylinder length and to ensure dependent and concealed positioning of device tubing. Corporal tissue sparing is then carried out by employing 9\u0026rdquo; Metzenbaum scissors rather than sequential dilators for corporal tunneling. (Image 2). Corporal sparing preserves the cavernosal artery and cavernosal spongy tissue, which improves glans engorgement and hemodynamic responsiveness of the tissue and thus its natural elasticity.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Likewise, the benefit of this approach is the ability to displace and spare spongy cavernosal tissue ventrally while creating a channel in the dorsal compartment of the corpora up to the triangular ligament of the glans, limiting compression of the cavernosum distally which can otherwise lead to shorter cylinder placement. (Image 3). Indeed, our technique ensures the full length of the corpora is tunneled, thereby maximizing the size of implant cylinders and minimizing the risk of hypermobile glans. Care is taken to tunnel beyond the fossa navicularis to prevent placing the prosthesis in the ventral compartment of the corpora, where the tunica is thinner, thus reducing the risk of erosion. We estimate that placing the distal end of the prosthesis beyond the fossa navicularis and to the level of the triangular ligament of the glans increases the length of the prosthesis, and thus penile length, up to 0.5 to 1 cm.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePenile prosthesis surgery is not solely meant for restoration of erectile functionality. It presents an opportunity to preserve or restore penile length that has been lost due to comorbid conditions. While adjunct procedures represent attractive tools in the arsenal of the prosthetic urologist to help maximize cylinder length, these are often very rigorous and challenging for the occasional prosthetic surgeon. Taking care to abide by anatomic principles and understanding the restrictive factors that may impact post prosthesis penile length may allow for fine-tuning of their surgical technique to ensure maximum outcomes. These principles are highlighted using preoperative papaverine injection, circumferential mobilization of the corpora, corporal sparing techniques, and manipulation of the triangular ligament to maximize corporal tunneling, which are employed in every IPP surgery performed at our institution. This standardization is the key to optimizing prosthesis length.\u003c/p\u003e \u003cp\u003ePerceived loss of length, as compared with a patient's preoperative natural erection penile length, is the most common complaint after IPP placement.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e As such, it behooves the prosthetic urologist to have an intimate understanding of the anatomy of the phallus, including cross sectional anatomy of the corpora cavernosa. Studies of human cadavers have shown that implants seated dorsally in the corpora and in the dorsal mid glans distally provided additional tissue coverage over weak ventral areas of the tunica albuginea, while ventrolateral dilation appeared to result in ventral seating, hypermobile glans, and susceptibility to perforation at the level of the fossa navicularis.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e By using the Metzenbaum scissors to precisely create a dorsal channel for placement of the prosthesis rather than serial dilation, we strive to maximize corporal sparing and preserve or restore penile length. The triangular ligament of the glans is located approximately 5 mm distal and dorsal to the fossa navicularis, as described by Shafik et al., and anchors the glans to the distal tip of the corporal bodies, inherently limiting glans mobility at time of erection.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e By placing the prosthesis to the level of this ligament during corporal sparing, greater distal stretch is provided for cylinders while at the same time ensuring improved seating in the dorsal compartment. This understanding of cross-sectional anatomy has not only been used at the time of virgin IPP insertion, but has also been utilized in salvage or revision surgeries to better seat malpositioned devices.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe purpose of this paper was to describe our standardized techniques of maximizing penile length at the time of penile prosthesis placement. Comparative outcomes were only available for the past year at the time of this writing. Anecdotally we report stable average prosthetic size of 22cm due to the described maneuvers. Limitations of the study include single surgeon, small sample size, its retrospective nature, and lack of comparison arm. Strengths include the understanding of restrictive factors that can affect cylinder length at the time of inflatable penile prosthesis insertion as well as detailed description of easy to perform techniques via standard midline scrotal incision without need for advanced reconstructive surgical training.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThree piece penile prosthesis cylinder size can be maximized by preoperative papaverine injection to dilate the corporal bodies, circumferential mobilization of the corporal bodies, corporal sparing maneuvers, and precise corporal tunneling to the level of the triangular ligament of the glans with the utilization of long Metzenbaum scissors, ensuring the distal cylinder tips are seated within the tip of the glans rather than at the coronal sulcus. These techniques may be employed by any prosthetic urologist without advanced training to ensure satisfactory IPP length and decrease patient regret after surgery.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eDisclosure Statements:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Acknowledgments \u0026ndash; the authors have no acknowledgements\u003c/p\u003e\n\u003cp\u003e\u0026bull;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Funding \u0026ndash; the authors have no funding to report\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Competing interests \u0026ndash; the authors have no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAkakpo, W., Pineda, M. A., Burnett, A. L.: Critical Analysis of Satisfaction Assessment After Penile Prosthesis Surgery. Sex Med Rev, \u003cstrong\u003e5:\u003c/strong\u003e 244, 2017\u003c/li\u003e\n\u003cli\u003eShah, T., Wang, R.: A Review of Factors Affecting Patient Satisfaction With Inflatable Penile Prosthesis. Sex Med Rev, \u003cstrong\u003e9:\u003c/strong\u003e 350, 2021\u003c/li\u003e\n\u003cli\u003eMontorsi, F., Rigatti, P., Carmignani, G. et al.: AMS three-piece inflatable implants for erectile dysfunction: a long-term multi-institutional study in 200 consecutive patients. Eur Urol, \u003cstrong\u003e37:\u003c/strong\u003e 50, 2000\u003c/li\u003e\n\u003cli\u003eTran, H., Goldfarb, R., Ackerman, A. et al.: Penile Lengthening, Girth, and Size Preservation at the Time of Penile Prosthesis Insertion. Sex Med Rev, \u003cstrong\u003e5:\u003c/strong\u003e 403, 2017\u003c/li\u003e\n\u003cli\u003eDeveci, S., Martin, D., Parker, M. et al.: Penile length alterations following penile prosthesis surgery. Eur Urol, \u003cstrong\u003e51:\u003c/strong\u003e 1128, 2007\u003c/li\u003e\n\u003cli\u003eJordan, G. H., Gilbert, D. A.: Male genital trauma. Clin Plast Surg, \u003cstrong\u003e15:\u003c/strong\u003e 431, 1988\u003c/li\u003e\n\u003cli\u003eBorges, F., Hakim, L., Kline, C.: ORIGINAL RESEARCH\u0026mdash;SURGERY: Surgical Technique to Maintain Penile Length After Insertion of an Inflatable Penile Prosthesis via Infrapubic Approach. The Journal of Sexual Medicine, \u003cstrong\u003e3:\u003c/strong\u003e 550, 2006\u003c/li\u003e\n\u003cli\u003eDelcour, C., Wespes, E., Vandenbosch, G. et al.: The effect of papaverine on arterial and venous hemodynamics of erection. J Urol, \u003cstrong\u003e138:\u003c/strong\u003e 187, 1987\u003c/li\u003e\n\u003cli\u003ePuyau, F. A., Lewis, R. W., Balkin, P. et al.: Dynamic corpus cavernosography: effect of papaverine injection. Radiology, \u003cstrong\u003e164:\u003c/strong\u003e 179, 1987\u003c/li\u003e\n\u003cli\u003eZaazaa, A., Bayerle-Eder, M., Elnabarawy, R. et al.: Penile Hemodynamic Response to Phosphodiesterase Type V Inhibitors after Cavernosal Sparing Inflatable Penile Prosthesis Implantation: A Prospective Randomized Open-Blinded End-Point (PROBE) Study. Adv Urol, \u003cstrong\u003e2021:\u003c/strong\u003e 5548494, 2021\u003c/li\u003e\n\u003cli\u003eShah, B. B., Kent, M., Valenzuela, R.: Advanced Penile Length Restoration Techniques to Optimize Penile Prosthesis Placement Outcomes. Sex Med Rev, 2020\u003c/li\u003e\n\u003cli\u003ePagano, M. J., Weinberg, A. C., Deibert, C. M. et al.: Penile intracavernosal pillars: lessons from anatomy and potential implications for penile prosthesis placement. Int J Impot Res, \u003cstrong\u003e28:\u003c/strong\u003e 114, 2016\u003c/li\u003e\n\u003cli\u003eShafik, A., Shafik, A. A., Asaad, S. et al.: The corporo-glans ligament: description and functional significance of a ligament connecting the corpora cavernosa to the glans penis. Int J Impot Res, \u003cstrong\u003e16:\u003c/strong\u003e 220, 2004\u003c/li\u003e\n\u003cli\u003eClavell-Hern\u0026aacute;ndez, J.: Proximal Extracapsular Tunneling: A Simple Technique for the Management of Impending Cylinder Erosion and Complications Related to Corporal Dilation. Sex Med, \u003cstrong\u003e9:\u003c/strong\u003e 100379, 2021\u003c/li\u003e\n\u003cli\u003eRebez, G., Runti, O., Marco, L. D. et al.: Penile prosthesis impending erosion: Surgical technique for extracapsular re-implantation reconstruction. Urologia\u003cstrong\u003e:\u003c/strong\u003e 3915603221119165, 2022\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-2987370/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2987370/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThree-piece inflatable penile prosthesis (IPP) is considered the gold standard surgical treatment for erectile dysfunction (ED). The most common cause of patient regret after penile prosthesis surgery is penile shortening. We sought to query a national database on average prosthesis length and describe our techniques to maximize cylinder sizes. We performed a retrospective review of the Coloplast database of 3-piece penile prosthesis cases performed over the span of 1 year nationally and by a single high volume surgeon and compared average cylinder lengths. Our review did not investigate whether adjunct tunical lengthening or girth enhancing procedures were performed. Between July 1, 2021 and June 27, 2022, 145 three piece penile prosthesis surgeries were performed at our institution. All were performed via a scrotal incision. Nationally, 32.8% were performed infrapubic while 58.1% were performed scrotal. The most prevalent cylinder length in our series was 22cm, compared to the most prevalent nationally of 20cm. Our technique to maximize cylinder length involves circumferential mobilization of the corporal bodies and corporal tissue sparing. Corporal tissue sparing is carried out by employing 9\u0026rdquo; Metzenbaum scissors rather than sequential dilators for corporal tunneling. The benefit of this approach is the ability to create a dorsal compartment to the level of the triangular ligament of the glans, thereby extending the space to the level of the midglans. This maneuver minimizes placement of the prosthesis anteriorly at the level of the fossa navicularis and prevents floppy glans that would otherwise compromise maximum cylinder length. Three piece penile prosthesis cylinder size can be maximized by circumferential mobilization of the corporal bodies, corporal sparing maneuvers, and the utilization of long Metzenbaum scissors for precise corporal tunneling.\u003c/p\u003e","manuscriptTitle":"Maximizing Three Piece Penile Prosthesis Length: Our Technique and Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-06 17:34:54","doi":"10.21203/rs.3.rs-2987370/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3edc585b-efa1-48f9-9b1a-c5521a28b189","owner":[],"postedDate":"June 6th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-06-19T08:41:17+00:00","versionOfRecord":[],"versionCreatedAt":"2023-06-06 17:34:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2987370","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2987370","identity":"rs-2987370","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}