by European Society of Sexual Medicine Today Magazine, Milan, Italy, 3 December 2011

Which is, in your opinion, a good candidate for penile enlargement?

A good candidate for penile enlargement is a person with appropriate anatomy in whom we can achieve realistic result and who is psychologically normal and stable, with realistic appreciation and expectations from surgery.

He must understand that the surgery is not magic, that we can achieve limited results of penile enlargement and that postoperative course and physiotherapy may be necessary to achieve the goal. He must be aware of possible complications and ready for longer healing period if they appear. Shortly, patient should be very mature, realistic and accepting possible limited (i.e.; less then expected) result.

We can do realistic penile enlargement by circular albugineal incision/s and grafting only in patients who need penile prosthesis implantation. This is a very radical procedure and patients must be aware of this.

Which is NOT, in your opinion, a good candidate for penile enlargement surgery?

The person with unrealistic expectations, insufficiently informed or a patient with some covered psychological problems. Most often it is body dysmorphic disorder, but it can be also something more serious. Rarely, there are patients who like to be operated on and change surgeons and countries in order to satisfy their goal. Surgeons should be very careful with proper estimation of the patient's psychological profile and aware of realistic possibilities of penile enlargement.

Taking in consideration the rate of psychiatric disorders in some men looking for penile enlargement, do you make them undergo psychological evaluation before surgery?

I am always trying to reject patients for penile enlargement since more then 90% of them are in normal range. Most of them will give up of surgery if we explain to them this fact as well as if we speak honestly about realistic possibilities of surgery. I seldom send patients to a psychiatrist because I always refuse to do the surgery if I estimate that there is psychological problem underneath. Sending patients to psychiatrist/psychologist is usually passing of responsibility to someone else.

Regarding surgical technique, which technical approach do you like best? Section of penile suspensory ligament? Y-V plasty? Do you use pediculated cutaneous and subcutaneous flaps? Do you use testicle prostheses? Do you use penoscrotal Z-plasty? Do you perform abdominal lipectomy.

We do penile lengthening surgery in patients with appropriate anatomical features — with extensive suspensory ligament, high penopubic and penoscrotal angle, excessive suprapubic fat, signs of intersexuality and severe dartos fibers that pull the penis toward the scrotum, short penile skin after circumcision or other surgeries.

With conventional techniques, real lengthening of cavernosal bodies is not possible, of course. What is only possible is more penile exposure, i.e.; proximal mobilization of penopubic and penoscrotal angle. I do not prefer V-Y plasty because in that way we move the pubic skin onto the penile base with an unsatisfactory aesthetic result and usually significant scarring.

Pedicled skin flaps are used when penile skin needs to be reconstructed — usually from the scrotum. After ligamentolysis is advisable to mobilize and place some healthy fatty tissue between pubic bone and the penis in order to prevent their reattachment. We never use testicular prosthesis or something similar for this purpose due to high risk of complications. Pubic liposuction/pubectomy is offered to all patients with prominent mons pubis. As I mentioned before, real penile corpora lengthening could be achieved in patients who are candidates for penile prosthesis implantation.

We can do subtotal penile disassembly with NVB and urethral mobilization and after that one or two circular incisions, undermining of cavernosal tissue and circular grafting; follows implantation of penile prosthesis. This way, we can realistically extend the penis for 2-4cm, depending on initial penile size and elasticity of the tissue. It’s a very radical procedure and should be reserved only for experienced surgeons.

Is there any tricky steps in the surgery? Could you give us some personal considerations and advice?

There are few tricks like I mentioned — placement of the fatty tissue under symphysis, fixation of the basal penile skin to the albuginea around the penile base to prevent postoperative skin sliding, releasing penoscrotal dartos fibers which pull the penis toward scrotum, excision of high scrotal pterygium, placement of suction drainage after liposuction/ lipectomy, proper penile dressing in stretched position using elastic dressing with its fixation to subcoronal skin for 5-7 days, etc.

In addition, do you use any engineering technique? When and how? What is your opinion about cellular matrix for penile enlargement?

In the last eight years we have used tissue engineering for penile girth enhancement. Specially designed PLGA scaffolds are prepared in a laboratory and seeded with cultivated fibroblasts from the dartos fascia. They are implanted and fixed between dartos and Buck's fascia.

Postoperatively, they induce both seeded and fibroblasts from surrounding multiplication while they are slowly reabsorbed over the period of 4-6 months, sometimes more. Eventually, scaffolds disappear and, in their place, remains thickened, nearly normal dartos tissue. The technique is safe with minimal and small complications that are easy to solve.

The drawback of the technique is variable result after long-term follow-up. We did not practice acellular matrix for penile widening. I just re-operated on several patients due to graft mobilization or patient's dissatisfaction. In all of them, the graft was very loose and in my opinion the result was not good.

Do you leave any drain? When do you discharge the patient?

I place active drainage whenever I am not satisfied with hemostasis, as for any other surgery. The patient is discharged on the next day. Sometimes they stay longer, according to how they wish.

Do you recommend sexual intercourse? How long after surgery?

Sexual intercourse is advised usually 6-8 weeks after surgery, according to the healing progress.

Penile tractor devices (i.e.: Jes-extender, Andropenis)? Yes or no? When? For how long? How many hours a day?

Postoperative physiotherapy is mandatory after the majority of penile surgeries in order to do intermittent stretching for 15-20 minutes, a few times per day.

Do you routinely use PDE-5i after surgery or any other method for "penile rehab"?

We do prescribe to the patients PDE-5i daily, starting from the second postoperative day until they start with physiotherapy.

Which are, in your opinion, the realistic results for an enlargement technique? What degree of enlargement are we expected to achieve?

According to our experience, patients with appropriate anatomy can expect extension of “penile exposure” from 2-5 cm. Patients with circular grafting and prosthesis can expect from 2-4 cm, and girth enhancement with PLGA scaffold from 0.5-2.5 cm.

Which are the most frequent complications? How could we prevent and manage them?

Hematoma, temporary swelling, seroma after scaffolds, preputial lymphoedema, temporary penile shortening after scaffolds, etc. Correction is very simple — with careful work and intensive postoperative patients follow-up.