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Penile Enhancement
in Implant Patient
Patients
Some implant patients may be consistently unhappy
with the postoperative penile length or cold and small
glans penis which contract the body image they have
preoperatively.
Anesthesia
Same as the session of E, but the needle for injection
of local anesthetic is not allowed to penetrate through
the tunica albuginea.
Procedure
The surgery
is begun with a semi-circumsion where the retrocoronal
plexus in ligated one by one with a 6-0 nylon suture.
Then the medial longitudinal incision is made in order
to perform the first 90-degree Z-plasty, made in the
pubic region, is used for advancement of penopubic
skin, which then becomes the skin of the penile base.
The suspensory ligament is severed and the collagen
bundles are detached from the arcuate ligament and
released as much as possible, meanwhile the deep dorsal
vein, cavernosal vein and the para-arterial vein are
likewise ligated. The skin is repaired with a 6-0nylon
or 5-0 chromic suture. The second 90-degree
Z-plasty is made at the penoscrotal junction to elongate
the penile shaft.
Discussion
- After this procedure, the circulation of the
penis is altered, which the sinusoidal blood of the
glans is drained exclusively through the corpus spongiosum
via the bulbourethral vein. This can explain why
the glans penis becomes enlargement gradually after
operation. Not surprisingly the coldness sensation
of the glans is
no more.
- In penile implantation it is standard
for the surgeon to dilate the corpus cavernosum as
much as possible to house an implant of maximal size.
In contrast we recommend the smallest implant to
prevent the possibility of cavernosal artery from
being compressed lest the coital tumescence of the
sinusoid is compromised postoperatively.
- The drainage
veinlets at the level of the retrocoronal sulcus
may number as many as 29 in our study. Ligating these
will confine the glanular drainage pathway to the
corpus spongiosum. Meanwhile, with the deep dorsal
vein, cavernosal and para-arterial vein ligated at
the level of the penile hilum, the circulation of
the corpora cavernosa is switched to the corpus spongiosum
and lesser amount of the superficial dorsal vein.
Thus, blood flow, enhanced during coitus, is forced
into the corpulatory segment of the penis. This may
be responsible for the enhancement phenomenon in
implant patients.
- We apply two 90-drgree Z-plasties
which differ from the regular 75-degree Z-plasty.
Some may question us why a Z-plasty can be extended
to 90 degrees. As far as we know that the extensibility
of the exogenitalia is overwhelming, therefore the
design of 90 degrees is feasible.
SUGGESTED READINGS:
- 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
- Montorsi, F., Guazzoni, G., Bergamaschi, F. et
al: Patient-partner satisfaction with semirigid
penile prostheses for Peyronie's disease: a 5-year
followup study. J Urol, 150: 1819, 1993
- Hsu, G. L., Brock, G., Martinez-Pineiro, L. et
al: The three-dimensional structure of the tunica
albuginea: anatomical and ultrastructural levels. Int J
Impot Res, 4: 117, 1992
- Breza, J., Aboseif, S. R., Orvis, B. R. et
al: Detailed anatomy of penile neurovascular
structures: surgical significance. J Urol, 141: 437,
1989
- Hsu, G. L., Hsieh, C. H., Wen, H. S. et al: Penile
enhancement: an outpatient technique.Eur J Med
Sexology, 11: 7, 2002
Figure 16. Schematic illustration of the ligation
sites of these erection-related veins for implant patients
The deep dorsal vein, consistently in the median position,
receives blood of emissary veins from the corpora cavernosa
and of circumflex veins from the corpus spongiosum. It
is sandwiched by cavernosal veins, although these lie
in a deeper position. Bilaterally, the dorsal arteries
are sandwiched by a medial and a lateral para-arterial
vein respectively. They are ligated at the level of the
penile hilum. Likewise the veinlets of the retrocoronal
plexus are ligated with a 6-0 nylon suture. |
