ESSM Newsletter # 33

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6 ESSMToday
According to current guidelines on erectile
dysfunction (ED), the implantation of a penile
prosthesis is the ultimo ratio for the treat-
ment of therapy resistant ED. In a significant
subset of patients with ED penile length loss
is already an issue preoperatively. Patients
with Peyronie’s disease report in up to 80%
of cases subjective penile length loss due to
their underlying condition (1). The treatment
of prostate cancer with radical prostatectomy
(2) or androgen suppression (3) with or without
radiation therapy (4) is also associated with
penile length loss. A Nesbit procedure (5) as
well as fibrotic changes due to recurrent pria-
pism (6) have also been reported to result in
reduced penile length.
Since a simple implantation of a penile pros-
thesis will result in additional penile length loss
(7), the question arises what should be done
with patients who suffer from therapy resist-
ant ED and complain about significant loss of
penile length. It is well known that reduced
penile length and girth as well as the inability
to participate in sexual intercourse may lead
to severe emotional challenges, dissatisfac-
tion, and decreased quality of life in a high
percentage of men (8).
Therefore, patients with severe ED and signifi-
cant penile shortening could be candidates for
more aggressive surgical procedures, beyond
the routine insertion of a penile prosthesis in
order to restore their original penile length
and girth.
Publications on circular and longitudinal tunica
albuginea incisions with grafting to restore
penile length and girth and concomitant penile
prosthesis insertion have shown promising
results (9,10). Rolle et al (11) published the so-
called “sliding technique” which is also a safe
and valid therapeutic option for this subset of
patients. The length gain with either of the two
procedures ranges between 2 – 5 cm. However
these approaches have one problem in com-
mon they are time-consuming procedures.
Extended operative time is a potential risk
factor for penile prosthesis infection. There-
fore extended procedures should be avoided
to reduce the risk of infection of the implant.
We recently published our experience with a
modification of the “sliding technique” (11),
which aims to reduce operative times, infec-
tion risk and costs associated with this type of
surgery (12). The “modified sliding technique
(MOST)” consists of three key elements: 1) the
sliding manoeuvre for the restoration of penile
length, 2) potential complementary longitudinal
ventral and/or dorsal tunical incisions for the
restoration of penile girth, and 3) the closure of
the newly created tunical defects using Buck’s
fascia, rather than a graft.
143 patients underwent the MOST procedure.
Malleable penile prostheses were used in 133
patients and inflatable penile prostheses were
inserted in 10 patients. The median follow-up
was 9.7 months (range, 6 – 18 months). Mean
penile length gain was 3.1 cm (range, 2 – 7 cm).
No penile prosthesis infection caused device
explantation. The average IIEF score increased
from 24 points at baseline to 60 points at
the six-month follow-up. The average opera-
tive time for restoring penile length and girth
with concomitant prosthesis implantation was
93 min for malleable prostheses (range,
64 – 22 min) and 121 min for inflatable pros-
theses (range, 100 – 164 min), which is a
marked improvement compared with other
series dealing with the treatment of ED and
penile length and girth restoration (9 – 11).
The MOST technique is a safe and effective
procedure to restore penile length and girth, as
the elimination of grafting reduces the opera-
tive time, consequently decreasing the cost of
surgery and potentially also the risk of infec-
tion. Therefore, any patient with severe ED who
is a candidate for penile prosthesis implanta-
tion should be evaluated for subjective penile
length reduction before the surgery, as penile
prosthesis implantation with concomitant pe-
nile length and girth restoration is associated
with higher patient satisfaction.
References
1. Kueronya, V., et al., International mul-
ticenter psychometric evaluation of
patient reported outcome data for
the treatment of Peyronie’s disease.
BJU Int, 2014.
2. Vasconcelos, J.S., et al., The natural
history of penile length after radi-
cal prostatectomy: a long-term pro-
spective study. Urology, 2012. 80(6):
p. 1293-6.
3. Park, K.K., S.H. Lee, and B.H. Chung,
The effects of long-term andro-
gen deprivation therapy on penile
length in patients with prostate
cancer: a single-center, prospec-
tive, open-label, observational study.
J Sex Med, 2011. 8(11): p. 3214-9.
4. Haliloglu, A., S. Baltaci, and O. Yaman,
Penile length changes in men treated
with androgen suppression plus radia-
tion therapy for local or locally ad-
vanced prostate cancer. J Urol, 2007.
177(1): p. 128-30.
5. Ralph, D., et al., The management of
Peyronie’s disease: evidence-based
2010 guidelines. J Sex Med, 2010. 7(7):
p. 2359-74.
Key from Kols: The Modified Sliding Technique (MOST) for
penile length and girth restoration in patients with severe
erectile dysfunction by Paulo H. Egydio and Franklin E. Kuehas
Paulo h. Egydio
Centre for Peyronie’s Disease
Reconstruction, Rua Joaquim
Floriano, 533 – cj. 902, Bairro Itaim
Bibi, Sao Paulo 04534-011, Brazil
franklin E. Kuehas
nternational Andrology London
Suite 7 Exhibition House, Addison
Bridge Place, London W14 8XP,
United Kingdom