Revision of Penile Prosthesis Surgery after Use of Penile Traction Therapy to Increase Erect Penile Length: Case Report and Review of the Literature

Revision of Penile Prosthesis Surgery after Use of Penile Traction Therapy to Increase Erect Penile Length: Case Report and Review of the Literature

607 Revision of Penile Prosthesis Surgery after Use of Penile Traction Therapy to Increase Erect Penile Length: Case Report and Review of the Literat...

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Revision of Penile Prosthesis Surgery after Use of Penile Traction Therapy to Increase Erect Penile Length: Case Report and Review of the Literature jsm_2121

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Daniel J. Moskovic, MA,*† Alexander W. Pastuszak, MD, PhD,* Larry I. Lipshultz, MD,* and Mohit Khera, MD, MBA, MPH* *Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA; †Columbia Business School, New York, NY, USA DOI: 10.1111/j.1743-6109.2010.02121.x

ABSTRACT

Introduction. Erectile dysfunction, a common consequence of radical prostatectomy (RP), can be managed with placement of a penile prosthesis. Patient satisfaction and functional outcomes have been related to penile length after prosthesis placement. Aim. We report a case demonstrating the impact of daily penile traction therapy in a patient with a previously placed penile prosthesis with the goal of enabling revision with a longer device. Methods. A post-RP patient who underwent inflatable penile prosthesis placement 6 years ago complained of inability to maintain partner penetration with his device. The patient underwent vacuum erection device therapy twice daily for 10 minutes per session for approximately 1 year as well as 8 hours of penile traction therapy daily for 8 months. A revision implant surgery was subsequently attempted. Main Outcome Measure. Patient reported functional outcome. Results. Stretched penile length increased 2.3 cm after 6 months of traction therapy. A revision surgery enabled the placement of a prosthesis that was 20% longer in length (15 cm to 18 cm), and erect penile length increased by 4.4 cm. The patient reported that the new prosthesis enabled satisfactory maintenance of partner penetration. Conclusions. This case suggests that the use of a penile traction device increases penile corporal length, and thus the length of a penile prosthesis that can be implanted in a patient with an unsatisfactory prosthesis already in place. Importantly, this patient experienced a substantial improvement in erect penile length after surgery. It is unknown whether these results are generalizable, either to all patients with a previously placed prosthesis or pre-prosthesis patients, representing an opportunity for further investigation. Moskovic DJ, Pastuszak AW, Lipshultz LI, and Khera M. Revision of penile prosthesis surgery after use of penile traction therapy to increase erect penile length: Case report and review of the literature. J Sex Med 2011;8:607–611. Key Words. Penile Traction Therapy; Penile Implant; Inflatable Penile Prosthesis; Management of Erectile Dysfunction; Post-Prostatectomy Erectile Dysfunction

Introduction

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rectile dysfunction (ED) after radical prostatectomy (RP) is a relatively common occurrence, impacting quality of life in approximately 40% of patients at 18 months after surgery [1]. Although numerous treatment options for post-RP ED exist, definitive intervention involving the

Support: None.

© 2010 International Society for Sexual Medicine

placement of an inflatable penile prosthesis (IPP) is appropriate for some patients with ED refractory to less aggressive interventions. Post-prosthesis satisfaction rates are high [2], although pre-prosthesis expectations have been shown to be inversely related to satisfaction [3]. Penile length after IPP placement is also inversely correlated with patient satisfaction [4]. This attribute of the penile implant can have cosmetic and functional impact on sexual health. J Sex Med 2011;8:607–611

608 Penile traction therapy has been successfully used in patients with short penis (dysmorphophobia, hypoplastic penis, and postoperatively shortened penis) and Peyronie’s Disease (PD) to increase length and reduce curvature [5–7]. However, there is no published account of penile traction therapy use in the setting of penile prosthesis placement to modulate corporal body length with the intent of achieving the ability to implant longer prosthetic cylinders. We report here the case of a post-RP patient who presented to our clinic 6 years after initial penile prosthesis placement complaining that, despite his IPP functioning normally, he was unable to maintain penetration of his female sexual partner using his existing prosthesis. The use of penile traction therapy was attempted to facilitate the placement of longer cylinders during prosthesis revision surgery such that the patient might subsequently be able to maintain vaginal penetration during intercourse with his partner.

Case Report

F.H. is a 70-year-old man (height = 5′ 8″, weight = 186 lbs, body mass index = 28.3) who underwent surgery for placement of an IPP using 15-cm cylinders bilaterally (American Medical Systems [AMS], Minnetonka, MN, USA) in 2003 for ED after RP in 2001 at an outside hospital. The patient presented to our clinic approximately 6 years after IPP placement complaining of difficulty maintaining vaginal penetration due to insufficient penile length using his IPP, a problem that had been present since his initial surgery. He reported having visited three other urologists since his surgery and was repeatedly told that there was no further treatment available to increase penile length. The patient had no sensory complaints and reported that the IPP functioned normally despite insufficient length. He also noted a progressively decreasing libido and energy level over the 3 to 4 years prior to presentation to our clinic. An initial physical exam revealed a flaccid penile length of 8.1 cm, stretched penile length of 10.0 cm. Stretched penile length was measured by stretching the penis from the glans with the patient lying down. The length recorded is the distance from the mons pubis (with the fat pad compressed) to the coronal sulcus. The patient’s IPP was noted to be functional and in good position, with both cylinder heads located at the mid-glans. With the IPP inflated, erect penile length was 9.4 cm. The J Sex Med 2011;8:607–611

Moskovic et al. measured dimensions were the same as previously described. At his initial visit, it was recommended that the patient begin using a vacuum erection device (VED) twice daily for 10 minutes each session. At a follow-up visit 4 months later, physical exam revealed an approximately half-centimeter increase in stretched penile length with no other changes from the initial physical exam. Of note, all penile length measurements throughout this patient’s care were performed by the same examiner (M.K.). Laboratory evaluation revealed a testosterone level of 179 ng/dL and the patient was started on testosterone replacement therapy as a result. It was also recommended that the patient wear a penile traction device (FastSize®; FastSize LLC, Aliso Viejo, CA, USA) for 8 hours each day, in addition to using the VED twice daily as described above. The device was to be used in 2-hour intervals of continuous penile traction with 20-minute breaks in therapy per the manufacturer’s guidelines; thus, the patient completed four sessions of therapy daily. At a follow-up visit 3 weeks after starting combined penile traction device and VED therapy, the patient’s stretched penile length was measured at 10.8 cm, indicating a total gain of 0.8 cm (0.3 cm incremental gain). Eight months after his initial presentation, the patient reported compliance with both his FastSize device and the VED and was noted to have gained a total of approximately 2 cm of length over the entirety of therapy with a stretched penile length of 12 cm. At this point in his the treatment, the distal extent of the corporal cylinders was noted to reach below the coronal sulcus. His serum total testosterone at this time was 350 ng/dL and he was continued on testosterone replacement therapy. At 10 months follow-up, the patient reported continued compliance with both devices and was measured to have a stretched penile length of 12.3 cm, demonstrating a total increase in stretched penile length of 2.3 cm over the course of his regimen. Throughout this treatment regimen, repeated prostate-specific antigen levels were undetectable. Twelve months after presenting to our clinic, the patient underwent revision of his IPP, with removal of the original 15-cm AMS prosthesis and replacement with 18-cm (bilateral 15 cm cylinders + 3 cm tips) AMS 700 LGX prosthesis. The operation was performed without complications and the patient was discharged home on the same day without complications. Four weeks postoperatively, the IPP cylinders were noted to be appropriately placed with both

Penile Traction Therapy for IPP Revision

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Figure 1 Changes in penile measurement recorded in the medical record and by patient report. VED stretched length was assessed by the patient and measured from the mons pubis to the tip of the glans under VED suction. * denotes that post-traction stretched length was measured preoperatively, whereas all other post-traction measurements were performed at least 4 weeks after surgery.

tips at the mid-glans, and were easily completely inflated using the scrotal pump. The patient was advised to use the device as desired for sexual intercourse at this time. Importantly, there were no changes in skin sensation and the patient did not experience any signs or symptoms of infection. Eight weeks postoperatively, the patient and his female partner reported that they were both very satisfied with the device, expressing no concerns regarding initiation and maintenance of vaginal penetration during intercourse. Flaccid penile length was 10.0 cm and IPP erect penile length was 13.8 cm, representing a gain of 4.4 cm (or 1.7 inches) from pre-traction therapy. Although the patient reported an increase in girth, no measurements were collected to document this outcome. Figure 1 summarizes the available penile length measurements before and after penile traction therapy. The patient specifically acknowledged that his erect length was no longer a concern as compromising the maintenance of vaginal penetration during intercourse and attributed increased length to his penile traction-enabled revision IPP surgery. Discussion

We report here the first evidence that penile traction therapy may be able to increase penile corporal length and thus the size of prosthetic penile corporal cylinders inserted in patients undergoing IPP placement. The patient presented here underwent approximately 8 months of daily penile traction therapy, as well as 1 year of VED therapy, in the setting of a previously placed IPP that limited his ability to maintain vaginal penetration during sexual intercourse with his partner due to a suboptimal erect length. The patient reported no complications associated with penile traction

device (e.g., skin irritation, sensory changes, and cutaneous erosions) and VED therapy and was able to undergo IPP revision with a gain of 2.25 cm in erect length with the new device. Several studies have demonstrated the efficacy of penile traction therapy to ameliorate penile curvature associated with PD and increase the length of a normal penis. Gontero et al. attempted to demonstrate these outcomes in a Phase II study of a penile traction device (Andropenis®) [5]. After 6 months of therapy, patients experienced a 4° reduction of penile curvature, a 0.8 cm increase in stretched penile length, and a 1.3 cm increase in flaccid length. Although this study included just 15 patients, the change in curvature compared to baseline was marginally significant (P = 0.056) and the authors remarked that they believe the change to be clinically significant. However, it is unknown whether subjects used other therapies for PD during the study period, although they were asked to discontinue treatments for ED during the study. Additionally, the 6-month follow-up may not allow for optimal outcomes for PD patients using this device. Levine et al. evaluated the use of the FastSize® penile traction device in a 10-patient pilot study for the treatment of PD and observed an average of a 22° reduction in penile curvature (approximately one-third of baseline) and an increase in stretched penile length of just under 1 cm [7]. It is important to note that there was significant variability in daily penile traction usage (2–8 hours per day) and a weak positive trend between usage greater than 4 hours, and favorable outcomes were observed. This study also recruited patients with greater average penile curvature, which could potentially explain the relatively more dramatic results when compared to the Gontero et al. study described above. Finally, the curvature reduction J Sex Med 2011;8:607–611

610 itself may partially explain the increase in penile length. Gontero et al. also reported on the use of 6 months of penile traction therapy for cosmetic purposes [6]. In a study of 21 patients, 95% of whom presented because of a perceived small penis as a result of dysmorphophobia or a relative length reduction after penile surgery, significant gains in both stretched and flaccid penile length were observed in all patients during the study period. Importantly, these gains were preserved over an additional 6-month observation period that compared baseline penile length and girth to 12-month outcomes. Average gains in flaccid and stretched penile length were 2.1 cm and 1.3 cm, respectively, for dysmorphophobic patients. Gains were greater for patients with surgically shortened penises where flaccid and stretched penile lengths were increased by 2.6 cm and 2.5 cm, respectively. Similar to the findings in our report, most of the gains were experienced in the first month of therapy, although significant gains were also observed at 3- and 6-month follow-up. No significant changes in penile girth were observed. This pattern, as applied to the patient in this case report, suggests that most of the gains in penile length are the result of penile traction despite multimodality therapy. However, future studies are needed to compare and discern the specific contribution of each of these therapeutic modalities to penile length changes. In contrast to the aforementioned studies, this case report involves the impact of RP on penile length. While the gains in penile corporal length observed in the patient presented were approximately double those described in other published reports, RP patients typically sustain postoperative penile shortening on the order of nearly 10% of baseline length [8]. Additionally, the early use of a VED has been noted to preserve penile length, implying that there may be some reversibility associated with the observed loss of length [9]. Our results suggest that post-RP patients may benefit from penile length preservation therapy using a VED and may further benefit from penile traction therapy to potentially reverse post-RP reductions in penile length. As a case report, our isolated experience with penile traction therapy prior to revision of a penile prosthesis cannot speak to the broad applicability of this intervention for increasing the size of the prosthesis used. Importantly, penile length after penile prosthesis placement has been shown to correlate with overall sexual health and treatment J Sex Med 2011;8:607–611

Moskovic et al. satisfaction [4]. Therefore, pre-implant penile traction therapy to increase the implant length (and erect penile length) may be an important paradigm to investigate in a larger population. However, we cannot assess whether this intervention would have a beneficial impact on naïve penile corpora since this patient had an implant in place during therapy. Importantly, the presence of a working IPP prior to revision likely contributed to the corporal expansion experienced by this patient after the surgery. It is possible that revision surgery would allow for a larger corporal cylinder to be placed. However, the repeated physical exams and repeated penile length measurements indicate that the patient experienced a functional increase in penile length after his treatment. Our evaluation of the above patient did not objectively assess prerevision sexual function with validated measures and is unable to quantitatively assess the impact of the larger penile implant on the patient’s and partner’s sexual health. However, both the patient and his partner qualitatively reported functional success and increased satisfaction on follow-up. Finally, the patient in this report was on three different therapies; thus, we are unable to definitively credit any single modality of treatment for increased corporal length, although the pattern of penile length suggests a benefit from traction therapy. Importantly, testosterone replacement in this patient may have contributed to improved libido and overall sexual satisfaction, but given that testosterone levels have not been shown to correlate with increased penile length in adults, the patient’s testosterone levels are unlikely to have impacted his outcome [10]. The impact of testosterone replacement on corporal health, thus its role in enhancing the effectiveness of penile traction therapy, is beyond the scope of this report but may be a factor in this patient’s response to traction therapy. Although the patient discussed in this case did not experience any problems associated with his penile traction therapy, larger studies are needed to investigate the incidence of skin trauma, pain, and morphological changes to the penis resulting from this mechanical manipulation. In light of these findings, it is possible that penile traction therapy may increase corporal length to enable placement of a larger penile prosthesis. And while unable to draw definite conclusions regarding the efficacy of penile traction therapy, this report raises many interesting questions related to its impact on penile length. Additionally, the effectiveness of penile traction therapy

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Penile Traction Therapy for IPP Revision compared to other modalities of penile length preservation/expansion (e.g., VED) is an area requiring investigation. Larger studies assessing whether penile traction therapy can favorably impact post-IPP outcomes are necessary to more thoroughly and objectively assess this possibility and determine whether this therapy is valuable for penile lengthening prior to IPP implantation. Corresponding Author: Mohit Khera, MD, MBA, MPH, Scott Department of Urology, Baylor College of Medicine, 6620 Main Street, Suite 1325, Houston, TX 77030, USA. Tel: 713-798-6593; Fax: 713 798 6593; E-mail: [email protected] Conflict of Interest: None. Statement of Authorship

Category 1 (a) Conception and Design Daniel J. Moskovic; Mohit Khera (b) Acquisition of Data Daniel J. Moskovic; Mohit Khera (c) Analysis and Interpretation of Data Daniel J. Moskovic; Mohit Khera; Larry I. Lipshultz; Alexander W. Pastuszak

Category 2 (a) Drafting the Article Daniel J. Moskovic; Alexander W. Pastuszak (b) Revising It for Intellectual Content Daniel J. Moskovic; Larry I. Lipshultz; Mohit Khera

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Category 3 (a) Final Approval of the Completed Article Daniel J. Moskovic; Alexander W. Pastuszak; Mohit Khera; Larry I. Lipshultz

J Sex Med 2011;8:607–611