- Email: [email protected]
Penile Prosthesis Implantation: Size Matters
european urology 51 (2007) 887–888
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Editorial –
referring to the article published on pp. 1128–1131 of this issue
Penile Prosthesis Implantation: Size Matters Drogo K. Montague * Head, Section of Prosthetic Surgery and Genitourethral Reconstruction, Glickman Urological Institute, A/100, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, United States
When the outcome of penile prosthesis implantation according to the surgeon is excellent and the patient is displeased, the reason in my experience is almost always that the patient’s expectations in terms of penile size have not been met. With today’s three-piece inflatable penile prostheses, penile girth is seldom an issue. Instead when prosthesis recipients are dissatisfied, it is usually because their expectations in terms of length with the prosthetic erection have not been met. This is based on the patient’s recall of his erect penile length. Many of these men with erectile dysfunction have not had a normal erection in many months or years. Some have become obese with added adipose tissue in the prepubic area. Others have acquired disorders (e.g., Peyronie’s disease) that produce penile shortening. Even in the absence of these factors, a patient’s recall of his former erections may sometimes err in the direction of exaggerated length. In this issue, Deveci and coworkers compare stretched penile length to penile length following three-piece or two-piece inflatable penile prosthesis implantation in 56 first- time penile prosthesis recipients [1]. Although they found no found no statistically significant difference in stretched penile length before implant surgery and penile length with the prosthesis after surgery, 72% of the recipients reported a decrease in their penile length after surgery. Perceived loss of penile length was more common in men who had undergone radical prostatectomy. Savoie et al. measured stretched penile length before and after radical prostatectomy
in 124 men [2]. There was a significant decrease in stretched penile length after prostatectomy and in 12 patients (19%) it was a 15% decrease. The findings of Deveci et al. in this regard therefore are not surprising. How does stretched penile length correlate with erect penile length? Wessells et al. measured flaccid and stretched penile length in 80 normal men and then compared that to penile length after pharmacologic erection [3]. Mean stretched penile length was 12.4 cm, and mean length with pharmacologic erection was 12.9 cm. Although stretched penile length correlated closely with erect penile length, in this study it was still somewhat shorter. It is likely that inflatable penile prosthesis implantation does not provide a prosthetic erection quite as long as a natural erection. In addition, a prosthetic erection does not include glans tumescence and this also contributes to decreased penile length. Intraurethral alprostadil has been used in conjunction with penile prostheses to produce increased blood flow into the glans [4]. Although a response was noted in 23 of 28 men, 12 discontinued its use because of pain. In our informed consent for penile prosthesis implantation we discuss the lack of glans tumescence following implantation and the likelihood that the erection might be shorter than the patient’s normal erection. In addition, we demonstrate to the patient, and sometimes to the partner as well, his stretched penile length telling him that this will approximate his length after prosthetic surgery.
DOI of original article: 10.1016/j.eururo.2006.10.026 * Tel. +1 216 444 5590; Fax: +1 216 445 2267. E-mail address: [email protected]. 0302-2838/$ – see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2006.10.027
888
european urology 51 (2007) 887–888
We have already discussed that radical prostatectomy often leads to a loss of penile length. Other conditions often associated with the need for penile prosthesis implantation that result in loss of penile length include Peyronie’s disease, erectile dysfunction following ischemic priapism, and penile prosthesis reimplantation following removal of an infected penile prosthesis. Stretched penile length in these individuals is often significantly reduced and their prosthetic erection will be significantly shorter than their normal erection. Proper discussion of this issue preoperatively should result in realistic expectations by the patient regarding postoperative size. The American Medical Systems (AMS) 700 Ultrex penile prosthesis produces not only girth expansion but also some length expansion. The initial Ultrex cylinder design released in 1990 permitted >20% length expansion. This cylinder was associated with a significantly greater rate of mechanical failure than other inflatable penile prostheses cylinders [5]. In 1993, the Ultrex cylinder design was changed to allow only a 15–17% increase in length. The Ultrex inflatable penile prosthesis with this cylinder modification now has mechanical reliability similar to other inflatable penile prostheses [6]. We implant the Ultrex penile prosthesis in men with straight penises and normal elasticity. This device is not useful in men with limited penile elasticity, and girth-only expanding cylinders have better straightening properties in men with erectile deformity (Peyronie’s disease). To avoid the S-shaped deformity with the Ultrex cylinders described by Wilson
[7], inserting a properly sized cylinder is necessary [8]. The use of the Ultrex prosthesis in properly selected patients produces 1–2 cm of additional length thus avoiding some of the disappointment of perceived penile shortening following prosthesis implantation.
References [1] Deveci S, Martin D, Parker M, Mulhall JP. Penile length alterations following penile prosthesis surgery. Eur Urol 2007;51:1128–31. [2] Savoie M, Kim SS, Soloway MS. A prospective study measuring penile length in men treated with radical prostatectomy for prostate cancer. J Urol 2003;169:1462–4. [3] Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol 1996;156:995–7. [4] Benevides MD, Carson CC. Intraurethral application of alprostadil in patients with failed inflatable penile prosthesis. J Urol 2000;163:785–7. [5] Daitch JA, Angermeier KW, Lakin MM, Ingleright BJ, Montague DK. Long-term mechanical reliability of AMS 700 series inflatable penile prostheses: comparison of CX/ CXM and Ultrex cylinders. J Urol 1997;158:1400–2. [6] Milbank AJ, Montague DK, Angermeier KW, et al. Mechanical failure of the American Medical Systems Ultrex inflatable penile prosthesis: before and after 1993 structural modification. J Urol 2002;167:2502–6. [7] Wilson SK, Cleves MA, Delk 2nd JR. Ultrex cylinders: problems with uncontrolled lengthening (the S-shaped deformity). J Urol 1996;155:135–7. [8] Montague DK, Angermeier KW. Cylinder sizing: less is more. Int J Impot Res 2003;15(Suppl 5):S132–3.
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Editorial –
referring to the article published on pp. 1128–1131 of this issue
Penile Prosthesis Implantation: Size Matters Drogo K. Montague * Head, Section of Prosthetic Surgery and Genitourethral Reconstruction, Glickman Urological Institute, A/100, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, United States
When the outcome of penile prosthesis implantation according to the surgeon is excellent and the patient is displeased, the reason in my experience is almost always that the patient’s expectations in terms of penile size have not been met. With today’s three-piece inflatable penile prostheses, penile girth is seldom an issue. Instead when prosthesis recipients are dissatisfied, it is usually because their expectations in terms of length with the prosthetic erection have not been met. This is based on the patient’s recall of his erect penile length. Many of these men with erectile dysfunction have not had a normal erection in many months or years. Some have become obese with added adipose tissue in the prepubic area. Others have acquired disorders (e.g., Peyronie’s disease) that produce penile shortening. Even in the absence of these factors, a patient’s recall of his former erections may sometimes err in the direction of exaggerated length. In this issue, Deveci and coworkers compare stretched penile length to penile length following three-piece or two-piece inflatable penile prosthesis implantation in 56 first- time penile prosthesis recipients [1]. Although they found no found no statistically significant difference in stretched penile length before implant surgery and penile length with the prosthesis after surgery, 72% of the recipients reported a decrease in their penile length after surgery. Perceived loss of penile length was more common in men who had undergone radical prostatectomy. Savoie et al. measured stretched penile length before and after radical prostatectomy
in 124 men [2]. There was a significant decrease in stretched penile length after prostatectomy and in 12 patients (19%) it was a 15% decrease. The findings of Deveci et al. in this regard therefore are not surprising. How does stretched penile length correlate with erect penile length? Wessells et al. measured flaccid and stretched penile length in 80 normal men and then compared that to penile length after pharmacologic erection [3]. Mean stretched penile length was 12.4 cm, and mean length with pharmacologic erection was 12.9 cm. Although stretched penile length correlated closely with erect penile length, in this study it was still somewhat shorter. It is likely that inflatable penile prosthesis implantation does not provide a prosthetic erection quite as long as a natural erection. In addition, a prosthetic erection does not include glans tumescence and this also contributes to decreased penile length. Intraurethral alprostadil has been used in conjunction with penile prostheses to produce increased blood flow into the glans [4]. Although a response was noted in 23 of 28 men, 12 discontinued its use because of pain. In our informed consent for penile prosthesis implantation we discuss the lack of glans tumescence following implantation and the likelihood that the erection might be shorter than the patient’s normal erection. In addition, we demonstrate to the patient, and sometimes to the partner as well, his stretched penile length telling him that this will approximate his length after prosthetic surgery.
DOI of original article: 10.1016/j.eururo.2006.10.026 * Tel. +1 216 444 5590; Fax: +1 216 445 2267. E-mail address: [email protected]. 0302-2838/$ – see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2006.10.027
888
european urology 51 (2007) 887–888
We have already discussed that radical prostatectomy often leads to a loss of penile length. Other conditions often associated with the need for penile prosthesis implantation that result in loss of penile length include Peyronie’s disease, erectile dysfunction following ischemic priapism, and penile prosthesis reimplantation following removal of an infected penile prosthesis. Stretched penile length in these individuals is often significantly reduced and their prosthetic erection will be significantly shorter than their normal erection. Proper discussion of this issue preoperatively should result in realistic expectations by the patient regarding postoperative size. The American Medical Systems (AMS) 700 Ultrex penile prosthesis produces not only girth expansion but also some length expansion. The initial Ultrex cylinder design released in 1990 permitted >20% length expansion. This cylinder was associated with a significantly greater rate of mechanical failure than other inflatable penile prostheses cylinders [5]. In 1993, the Ultrex cylinder design was changed to allow only a 15–17% increase in length. The Ultrex inflatable penile prosthesis with this cylinder modification now has mechanical reliability similar to other inflatable penile prostheses [6]. We implant the Ultrex penile prosthesis in men with straight penises and normal elasticity. This device is not useful in men with limited penile elasticity, and girth-only expanding cylinders have better straightening properties in men with erectile deformity (Peyronie’s disease). To avoid the S-shaped deformity with the Ultrex cylinders described by Wilson
[7], inserting a properly sized cylinder is necessary [8]. The use of the Ultrex prosthesis in properly selected patients produces 1–2 cm of additional length thus avoiding some of the disappointment of perceived penile shortening following prosthesis implantation.
References [1] Deveci S, Martin D, Parker M, Mulhall JP. Penile length alterations following penile prosthesis surgery. Eur Urol 2007;51:1128–31. [2] Savoie M, Kim SS, Soloway MS. A prospective study measuring penile length in men treated with radical prostatectomy for prostate cancer. J Urol 2003;169:1462–4. [3] Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol 1996;156:995–7. [4] Benevides MD, Carson CC. Intraurethral application of alprostadil in patients with failed inflatable penile prosthesis. J Urol 2000;163:785–7. [5] Daitch JA, Angermeier KW, Lakin MM, Ingleright BJ, Montague DK. Long-term mechanical reliability of AMS 700 series inflatable penile prostheses: comparison of CX/ CXM and Ultrex cylinders. J Urol 1997;158:1400–2. [6] Milbank AJ, Montague DK, Angermeier KW, et al. Mechanical failure of the American Medical Systems Ultrex inflatable penile prosthesis: before and after 1993 structural modification. J Urol 2002;167:2502–6. [7] Wilson SK, Cleves MA, Delk 2nd JR. Ultrex cylinders: problems with uncontrolled lengthening (the S-shaped deformity). J Urol 1996;155:135–7. [8] Montague DK, Angermeier KW. Cylinder sizing: less is more. Int J Impot Res 2003;15(Suppl 5):S132–3.