Division of the penile suspensory ligament often leads to less than satisfactory results in augmentation phalloplasty

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Apr 5 2006

Division of the penile suspensory ligament with or without the additional procedures of suprapubic fat pad excision and inverted VY plasty is a simple and commonly used penile lengthening technique. A recent study by C. Y. Li and colleagues from London examined patient satisfaction with penile suspensory ligament division for penile augmentation.

The manuscript is published in the March 2006 issue of European Urology.

The suspensory ligament of the penis is comprised of two components, the suspensory ligament proper and the arcuate subpubic ligament that attaches the tunica albuginea to the midline of the pubic symphysis. Its function is to support the erect penis in an upright position to aid in vaginal penetration. Surgical division of this ligament may allow the penis to lie in a more dependent position and therefore give the appearance that the penile length has increased.

Various penile lengthening procedures have been described; the most widely used is division of the penile suspensory ligament to gain some length at the expense of slight instability. The average penile length in white men is 12.5 cm + 2.7 cm and the most common request for penile enhancement surgery is in patients with a normal penile size who have a subjective altered body perception, rather than a clinical assessment that their penis is too small. This is known as penile dysmorphic disorder.

Over a 7 year period, 42 patients underwent division of the penile suspensory ligament for penile lengthening. Twenty-seven patients (64%) had penile dysmorphic disorder as the preoperative diagnosis. Outcomes were assessed objectively based on increase in flaccid stretched penile length and subjectively using rates of patient satisfaction. The procedure is outlined in detail with intraoperative photos included. With the penis stretched, a transverse or inverted V suprapubic incision was used to divide the suspensory ligament close to the pubic symphysis until all midline attachments have been freed. In latter patients in the series, a small silicone buffer, a testicular prosthesis was placed in this space and anchored to the base of the pubic symphysis to prevent reattachment of this ligament and to push the penis forward. In obese patients, excision of the suprapubic fat pad was performed. Patients were then encouraged to perform penile stretching with either weights, a vacuum constriction device, or the use of a penile stretcher device.

Analysis of the results revealed that the mean increase in stretched penile length was 1.3 cm + 0.9cm (range -1.0 to +3.0cm) when the suspensory ligament was divided. The only specific technique that significantly lengthened the penis (0.7 + 1.0 cm) was the addition of the silicone buffer to prevent ligamentous reattachment following division. The mean increase in penile length was 1.6 cm and 1.2 cm in those that performed and those that did not perform postoperative penile stretching- this was not statistically significant.

Overall only 35% of the patients were satisfied with the outcome of the surgery. Satisfaction rates were lowest in patients with dysmorphobia (27%) or Peyronie’s disease (17%). A second operative procedure was requested in 20 men with 17 undergoing an additional division. Only 2 patients were eventually satisfied with their penile length, raising the overall satisfaction rate to 40%. Complications were low with 4 men having postoperative wound infections and a wound breakdown in one; all five men were managed conservatively.

The authors suggest that men with penile dysmorphic disorder should be evaluated by a psychiatrist and be discouraged from surgery. Surgical intervention should be reserved as a last resort and only when the patient understands the limitations of the expected outcome.

By Michael J. Metro, MD