Tuesday, October 23, 2007

Complications of penile lengthening and augmentation seen at one referral centre.

Glossary:

Scrotalization: One possible result of a penile lengthening operation, in which the skin that had once been just behind the penis advances down the shaft. This pubic hair-bearing skin is bunched up around the shaft, resembling a scrotum that extends above as well as below the base of the penis. It is useless for intercourse, and comparatively devoid of sensation.

Peyronie's disease: A disease of unknown cause in which the corpus cavernosum is surrounded by dense fibrous tissue, causing deformity and painful erection.

Epispadias: A malformation in which the urethra's opening is located on the dorsal (upper) side of the penis.

Penile lengthening is widely accepted as a necessary treatment for men with very short penises who suffer from Peyronie's disease, epispadias, or penile retraction following spinal injury. Only recently has it been adopted as a cosmetic technique for healthy men. The normal approach is to cut the suspensory ligament, which connects the base of the upper side of the penis to the pubic area. With this released, the penis can theoretically hang lower when flaccid. The operation is known as inverted V-Y plasty, after the shape of the incisions made. All 12 of the patients looked at here had undergone V-Y plasty.

Penile girth augmentation, which involves injecting fat from other parts of the body, is a purely cosmetic treatment. If the experiences of the 10 Californian patients who tried it are any guide, it can only be described as a remarkably unsuccessful procedure. In fact, it is practically guaranteed to fail in the long term, because such fat transplants lose 55% to 90% of their volume after one year. Moreover, such deposits as there are tend to be very unevenly spread, giving the penis a bulbous and misshapen look. Two of these patients had attempted to have this problem rectified with further injections into the narrow areas, but without success. In another patient the fat had migrated immediately after the operation to the underside of the penis, giving it an appearance quite different from that desired. Such fat deposits can be removed by resection, but there is a risk of losing erectile function by cutting the blood flow to the overlying skin.

Scarring, scrotalization and wound infection were common results of V-Y plasty in these patients. Four of the 12 patients required hospitalization for infections. Two suffered skin breakdown which required scar revision -- unfortunately these repair attempts failed. Six of the 12 had already undergone secondary operations in an effort to correct cosmetic deficiencies before they turned to the authors for help. Two patients had raised scarring at the base of the penis bad enough to cause pain during sex, one to such an extent that he no longer had intercourse. Four patients suffered scrotalization, a deformity that was fortunately reparable by reversal of the V-Y plasty. One patient was afflicted with severe ventral penile deflection -- in other words, his penis pointed straight down even when erect -- as a result of the severing of his suspensory ligament. He had to be warned that he would be unlikely to maintain penetration.

Four other patients exhibited sexual dysfunction of one sort or another. One had already been impotent due to diabetes; another had reduced libido, a third had poor erections, and one found penetration difficult because of excess fat deposits on the shaft. Several patients showed signs of neurological injury to the penis. All patients reported feelings of guilt, shame, and intense embarrassment, which could contribute psychosomatically to sexual dysfunction.

All of these problems were compounded by the very poor cosmetic results, and the failure of the V-Y plasty operations to achieve their main aim -- lengthening of the penis. Only one of the twelve patients said his penis was longer than before the operation, while nine reported no change and two said their penises were actually shorter.

This was not a planned survey of success rates in penis augmentation. There are no figures telling what proportion of these operations end in failure, either in this paper or anywhere else. Obviously, satisfied customers are unlikely to present themselves at a urological unit, so there were no controls. Two patients were found in the university's sexual dysfunction clinic who had undergone augmentation and declared themselves not dissatisfied with the result. One had been impotent already, while the other had Peyronie's disease. In both cases, the doctors who had performed the augmentation had failed to treat their primary condition.

The Society for the Study of Impotence has decreed that in view of the total lack of reliable evidence for the efficacy of augmentation, it should be regarded as an unproven experimental procedure. The authors of this paper, it seems, are strongly inclined to agree.

Questions for Dr. Wessells:

1. Could V-Y plasty theoretically lengthen the erect penis as well as the flaccid one?

Release of the suspensory ligament of the penis theoretically increases penile length. V-Y plasty changes the configuration of the skin which would otherwise prevent the penis from assuming a lower position in relation to the pubic bone. No published data exists regarding the effectiveness of penile lengthening in normal men. In a study of cadaver dissections, division of the suspensory ligament and V-Y plasty resulted in only a 1.6 cm increase in flaccid length and a 1.6 cm increase in erect length. Honest surgeons performing penile lengthening have suggested that a man can expect to gain one inch in flaccid length from the procedure, with minimal change in erect length.

2. Did you see any cases of urinary incontinence or similar problems?

We didn't see any urinary problems due to penile augmentation. The nerves which supply the bladder are far from the surgical site of penile augmentation. Problems with penetration can occur due to ventral deflection or excessive fat placed around the shaft of the penis.

3. What reasons did your patients give for attempting augmentation, especially those who were already impotent?

The impotent men were led to believe that the penile lengthening would solve all their sexual problems. It is unlikely that any preoperative evaluation of their sexual dysfunction was carried out.

Most of the other men responded to advertisements touting the procedure. Many were told that the procedure could be performed without complications and that their penises would be larger. The logic was: "Who wouldn't want a larger penis if there were no drawbacks?" Several of the men faced mid-life concerns about their masculinity and saw the procedure as a way to rejuvenate their lives. Popular culture is filled with jokes and references to penile size, and penile augmentation plays on fears of having a small penis.

4. What sort of doctor is carrying out this surgery? Is there any redress for disfigured patients?

Urologists and plastic surgeons perform most penile augmentations. No sanctioned training exists in this field in America, and no national organisation or board certification process can monitor the procedure. An article in the Wall Street Journal on June 6th of this year suggested that penile augmentation was a new source of income for doctors feeling the pressures of managed care. A few surgeons performed the majority of operations on the patients we saw, and other more scrupulous doctors continue to carry out penile enlargements.

Disfigured patients can write to their state medical board to obtain the necessary papers to lodge a formal complaint against their surgeon. There are also reports in the lay press regarding patients who have brought suit against their surgeon.

Very few patients actually have penises small enough to warrant augmentation. Since the procedure has not been proven to increase penile size, normal men should be very wary of penile augmentation, and demand objective documentation of their surgeon's previous results with this technique.

Complications of penile lengthening and augmentation seen at one referral centre.

Hunter Wessells, Tom F. Lue and Jack W. McAninch.

Purpose: Complications of the recent cosmetic technique of penile lengthening and girth enhancement are reviewed.

Materials and methods: During a 16-month period 12 men presented with complications of penile augmentation performed elsewhere. All 12 patients had undergone release of the suspensory ligament and 10 had received autologous fat injection.

Results: The chief complaint was poor cosmetic appearance (irregular residual fat nodules in seven men, skin deformity and scarring in four and scrotalization in four). Reoperation was necessary in six patients, wound complications occurred in six and sexual dysfunction was reported by four. Only one patient reported a subjective increase in penile length.

Conclusions: Although a verifiable complication rate may never be available, the morbidity of elective penile lengthening and girth enhancement is noteworthy. These cosmetic techniques should be regarded as experimental.

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