© 2015 International Society for Sexual Medicine
Surgical Techniques Modified Sliding Technique (MoST) for Penile Lengthening with Insertion of Inflatable Penile Prosthesis Paulo Henrique Egydio, MD,* Franklin Emmanuel Kuehhas, MD,† and Robert J. Valenzuela, MD‡ *Penile Curvature Center, São Paulo, Brazil; †London Andrology Institute, London, UK; ‡Washington Heights Urology, New York, NY, USA
Indication Penile curvature caused by Peyronie’s disease (PD) and the subsequent difficulty with penetration and shortened stretched penile length are extremely distressing to men. Although plication may work for low magnitude simple curvature, plaque manipulation and grafting has been the preferred method for correcting large or complex deformities. Penile plication leads to “long side” penile shortening, whereas grafting may lead to erectile dysfunction. We describe the Modified Sliding Technique (MoST) for correcting PD combined with penile lengthening with neurovascular bundle (NVB) and urethral mobilization followed by inflatable penile implant placement, using a single sub-coronal incision. Figure 1 After de-gloving the penis through a circumcising incision, the Dartos layer is everted over the penile skin using 2-0 silk suture. An iodine-laden drape is then placed over the field, and the penis is brought out through a small opening in this drape. Buck’s fascia is longitudinally incised lateral to the urethra, and the neurovascular bundle is isolated circumferentially for the length of the penis (penopubic junction to coronal sulcus). After creating an artificial erection (while also instilling the corpora with lidocaine), the corpus spongiosum is mobilized off the corpora cavernosa from the corona to the proximal penis. The corpora are then marked for the proposed incisions. With the penis on stretch, a semi-circumferential line is marked on the ventral surface of the corpora 2 cm proximal to the coronal sulcus (ventral incision is distal). The line should extend from the 3 o’clock position to the 9 o’clock position on the corpora. A second semi-circumferential marking is created on the dorsal corpora, 1–2 cm distal to the penoscrotal junction (dorsal incision is proximal). The semi-circular lines are connected by longitudinal lines on the lateral aspects of both corpora cavernosa (3 o’clock and 9 o’clock positions). Figure 2 Prior to distraction of the corporal bodies, two separate small corporotomies (enough to allow passage of an implant cylinder) are created proximal to the dorsal semi-circumferential incision (3 and 9 o’clock positions). These corporotomies ensure a proximal point of exit of the implant cylinder tubing. The edges of the corporotomy are tagged with 0 Vicryl (Ethicon, Somerville, NJ, USA). For making the corporotomies, we use needle tip bovie set at 20 watts. Next, the proximal dorsal semicircular incision is created. The proximal and distal corpora are dilated (we use advancing Metzenbaum scissors) to the level of the mid glans distally and crura proximally. The remaining tunical incisions are then created, and the corporal bodies are fully distracted (this is limited by the ability of the NVB to stretch). Figure 3 The corpora are measured and the cylinders are passed through the proximalmost lateral corporotomies using the standard technique. Figure 4 The proximal corporotomies are closed using the stay sutures. The prosthesis cylinders are fully inflated. Note the ventral defect is covered by the exposed and compressed corpus cavernosum. While the prosthesis is exposed in the ventral defect, we do not place a graft. Bucks fascia is then re-approximated using 4-0 running monocryl suture. The reservoir is placed in the space of Retzius. The scrotal pump is placed in the midline at the most dependent portion of the scrotum. The tubing from the reservoir is connected to the scrotal pump. The tubing of the reservoir and pump is placed behind the ipsilateral spermatic cord for maximal cosmesis. The Dartos layer is re-approximated using 4-0 running monocryl suture in a relaxed running stich. The circumcision incision is re-approximated using 3-0 chromic catgut in an interrupted fashion. The wound is dressed with xeroform, and the penis/scrotum is wrapped with a gauze bandage for compression. Post-Operative Management Post-operatively, the implant is kept fully inflated for a period of 1–2 hours to assist in hematoma prevention. The prosthesis is then deflated to 50% (enough to keep the cylinders from collapsing). On post operative day (POD) #1, the prosthesis is cycled by the physician, based on patient pain tolerance. The dressing is replaced, and the implant is inflated to >50%. If possible, the patient is asked to cycle the implant (inflation/deflation) daily starting on POD #7. The patient is instructed to maintain the implant partially inflated with the glans pointed upward and to try to maximally inflate for 1 hour in morning and 1 hour in the evening.
1100
J Sex Med 2015;12:1100–1104
Surgical Techniques
Penile curvature caused by Peyronie’s disease
The corpora are marked for the proposed incisions
Circumcising incision
A semicircular incision is marked from 3 o'clock to 9 o’clock on the ventral corporal bodies 2-3 cm proximal to the coronal sulcus Corpus spongiosum is mobilized off of the corpora cavernosum from the corona to the proximal penis
Buck’s fascia is longitudinally incised lateral to the urethra
A second marking is created on the dorsal corpora 1.5 cm distal to the penoscrotal junction. These lines are connected by longitudinal lines at the 3 o'clock and 9 o'clock positions.
J Sex Med 2015;12:1100–1104
1101
Surgical Techniques
Full distraction (sliding) of the corporal bodies
Dorsal neurovascular bundle
Corpus spongiosum
The tunica albuginea is incised to the level of the corpus cavernosum, using needle tip bovie set at 20 watts. Initially the proximal dorsal semicircular incision is created.
1102
The remaining tunical incisions are then created for full distraction (sliding) of the corporal bodies.
J Sex Med 2015;12:1100–1104
Surgical Techniques
Distally the prosthesis is covered by the exposed and compressed corpus cavernosum on the ventral surface and exposed proximally at the level of the ventral corporal defect
Corpus spongiosum
Dorsal neurovascular bundle
The corpora are measured and the cylinder is passed through the proximal corporotomy incision
J Sex Med 2015;12:1100–1104
1103
Surgical Techniques
Preop
Erect penis with incision closed
Prosthesis is covered by the exposed and compressed corpus cavernosum on the ventral surface
Dorsal neurovascular bundle
Corpus spongiosum
Erect penis with xeroform
Lateral incisions are closed using 2-0 Maxon suture in an interrupted inverted (knots on inside) manner exposed Prosthesis
Erect penis with coban gauze
Proximal corporotomies are closed using the stay sutures
1104
J Sex Med 2015;12:1100–1104
Surgical Techniques Modified Sliding Technique (MoST) for Penile Lengthening with Insertion of Inflatable Penile Prosthesis Paulo Henrique Egydio, MD,* Franklin Emmanuel Kuehhas, MD,† and Robert J. Valenzuela, MD‡ *Penile Curvature Center, São Paulo, Brazil; †London Andrology Institute, London, UK; ‡Washington Heights Urology, New York, NY, USA
Indication Penile curvature caused by Peyronie’s disease (PD) and the subsequent difficulty with penetration and shortened stretched penile length are extremely distressing to men. Although plication may work for low magnitude simple curvature, plaque manipulation and grafting has been the preferred method for correcting large or complex deformities. Penile plication leads to “long side” penile shortening, whereas grafting may lead to erectile dysfunction. We describe the Modified Sliding Technique (MoST) for correcting PD combined with penile lengthening with neurovascular bundle (NVB) and urethral mobilization followed by inflatable penile implant placement, using a single sub-coronal incision. Figure 1 After de-gloving the penis through a circumcising incision, the Dartos layer is everted over the penile skin using 2-0 silk suture. An iodine-laden drape is then placed over the field, and the penis is brought out through a small opening in this drape. Buck’s fascia is longitudinally incised lateral to the urethra, and the neurovascular bundle is isolated circumferentially for the length of the penis (penopubic junction to coronal sulcus). After creating an artificial erection (while also instilling the corpora with lidocaine), the corpus spongiosum is mobilized off the corpora cavernosa from the corona to the proximal penis. The corpora are then marked for the proposed incisions. With the penis on stretch, a semi-circumferential line is marked on the ventral surface of the corpora 2 cm proximal to the coronal sulcus (ventral incision is distal). The line should extend from the 3 o’clock position to the 9 o’clock position on the corpora. A second semi-circumferential marking is created on the dorsal corpora, 1–2 cm distal to the penoscrotal junction (dorsal incision is proximal). The semi-circular lines are connected by longitudinal lines on the lateral aspects of both corpora cavernosa (3 o’clock and 9 o’clock positions). Figure 2 Prior to distraction of the corporal bodies, two separate small corporotomies (enough to allow passage of an implant cylinder) are created proximal to the dorsal semi-circumferential incision (3 and 9 o’clock positions). These corporotomies ensure a proximal point of exit of the implant cylinder tubing. The edges of the corporotomy are tagged with 0 Vicryl (Ethicon, Somerville, NJ, USA). For making the corporotomies, we use needle tip bovie set at 20 watts. Next, the proximal dorsal semicircular incision is created. The proximal and distal corpora are dilated (we use advancing Metzenbaum scissors) to the level of the mid glans distally and crura proximally. The remaining tunical incisions are then created, and the corporal bodies are fully distracted (this is limited by the ability of the NVB to stretch). Figure 3 The corpora are measured and the cylinders are passed through the proximalmost lateral corporotomies using the standard technique. Figure 4 The proximal corporotomies are closed using the stay sutures. The prosthesis cylinders are fully inflated. Note the ventral defect is covered by the exposed and compressed corpus cavernosum. While the prosthesis is exposed in the ventral defect, we do not place a graft. Bucks fascia is then re-approximated using 4-0 running monocryl suture. The reservoir is placed in the space of Retzius. The scrotal pump is placed in the midline at the most dependent portion of the scrotum. The tubing from the reservoir is connected to the scrotal pump. The tubing of the reservoir and pump is placed behind the ipsilateral spermatic cord for maximal cosmesis. The Dartos layer is re-approximated using 4-0 running monocryl suture in a relaxed running stich. The circumcision incision is re-approximated using 3-0 chromic catgut in an interrupted fashion. The wound is dressed with xeroform, and the penis/scrotum is wrapped with a gauze bandage for compression. Post-Operative Management Post-operatively, the implant is kept fully inflated for a period of 1–2 hours to assist in hematoma prevention. The prosthesis is then deflated to 50% (enough to keep the cylinders from collapsing). On post operative day (POD) #1, the prosthesis is cycled by the physician, based on patient pain tolerance. The dressing is replaced, and the implant is inflated to >50%. If possible, the patient is asked to cycle the implant (inflation/deflation) daily starting on POD #7. The patient is instructed to maintain the implant partially inflated with the glans pointed upward and to try to maximally inflate for 1 hour in morning and 1 hour in the evening.
1100
J Sex Med 2015;12:1100–1104
Surgical Techniques
Penile curvature caused by Peyronie’s disease
The corpora are marked for the proposed incisions
Circumcising incision
A semicircular incision is marked from 3 o'clock to 9 o’clock on the ventral corporal bodies 2-3 cm proximal to the coronal sulcus Corpus spongiosum is mobilized off of the corpora cavernosum from the corona to the proximal penis
Buck’s fascia is longitudinally incised lateral to the urethra
A second marking is created on the dorsal corpora 1.5 cm distal to the penoscrotal junction. These lines are connected by longitudinal lines at the 3 o'clock and 9 o'clock positions.
J Sex Med 2015;12:1100–1104
1101
Surgical Techniques
Full distraction (sliding) of the corporal bodies
Dorsal neurovascular bundle
Corpus spongiosum
The tunica albuginea is incised to the level of the corpus cavernosum, using needle tip bovie set at 20 watts. Initially the proximal dorsal semicircular incision is created.
1102
The remaining tunical incisions are then created for full distraction (sliding) of the corporal bodies.
J Sex Med 2015;12:1100–1104
Surgical Techniques
Distally the prosthesis is covered by the exposed and compressed corpus cavernosum on the ventral surface and exposed proximally at the level of the ventral corporal defect
Corpus spongiosum
Dorsal neurovascular bundle
The corpora are measured and the cylinder is passed through the proximal corporotomy incision
J Sex Med 2015;12:1100–1104
1103
Surgical Techniques
Preop
Erect penis with incision closed
Prosthesis is covered by the exposed and compressed corpus cavernosum on the ventral surface
Dorsal neurovascular bundle
Corpus spongiosum
Erect penis with xeroform
Lateral incisions are closed using 2-0 Maxon suture in an interrupted inverted (knots on inside) manner exposed Prosthesis
Erect penis with coban gauze
Proximal corporotomies are closed using the stay sutures
1104
J Sex Med 2015;12:1100–1104
