(043) Tensile Contention: A Novel Reconstructive Technique for Unstable Erections Secondary to Penile Suspensory Ligament (PSL) Deficiency
Authors: Calopedos R , Testa G , Deva A 
Published: February 2024

Abstract

Introduction
PSL division remains the mainstay of cosmetic penile lengthening surgery. Its proponents argue that superficial PSL can be divided without risking erection destabilisation. However, there are multiple published reports on resultant significant sexual dysfunction (SD) and a paucity of literature on how to manage it. The only published technique successfully re-established erection angle by placing rows of interrupted 1-0 non-absorbable sutures between the dorsal tunica albuginea (TA) and pubic symphysis (PS).

Objective
1. Describe a novel technique for PSL reconstruction using tensor fascia lata (TFL) graft 2. Assess safety and feasibility

Methods
Design: Single institution, case series Population: 3 men who presented with marked hypermobility to the extent that erect penis could be distracted almost parallel to thighs. All described difficulty in achieving penetration and inability to maintain intercourse. Additionally, 2/3 men complained of debilitating pain at base of penis during flaccidity. None reported pre-morbid erectile (ED) or ejaculatory dysfunction (EjD). PSL deficiency aetiologies were cosmetic/iatrogenic (2/3) and traumatic from caudal distraction of erect penis (1/3). All men understood procedure was experimental and agreed to use of their unidentified information in this study. Intra-operatively, all had complete PSL disruption without visible remnants.

Results
Technique: After pubic rami were exposed through infra-pubic incision, a 7cm strip of TFL was harvested from right thigh (Figure 1). Proximal graft fixation achieved with two Mitek mini-anchors, placed into rami on either side of PS, and reinforced by suturing remaining proximal free edge to subpubic (arcuate) ligament with 2-0 Ticron (Figure 2). The inferior aspect of the graft was divided into two ‘limbs’ then both secured to the inferolateral aspect of the proximal corporal TA using interrupted 2-0 Ticron horizontal-mattress sutures. This overlay technique avoided need to suture near the dorsal neurovascular structures. Graft tension for desired angle was determined intraoperatively with artificial erection test prior to distal fixation (Figure 3). Once sutured in place, further micro-adjustments were possible to achieve optimal angle and account for rotational deformities by placing imbricating sutures to either distal limb. Outcomes: All patients were followed up at 1, 3 and 12 months post-operatively. All were satisfied with their angle of erection and were now able to enjoy intercourse without recurrence of their presenting complaints. Apart from donor site pain and genital bruising, there were no other complications and no need to revise or explant the TFL graft. None of the patients complained of de-novo ED, EjD or penile shortening.

Conclusions
PSL reconstruction using TFL graft is a safe and feasible technique in men with PSL deficiency. It achieved durable restoration of erection angle and cured pain during flaccidity. This technique has several potential benefits: (1) It does not rely on the integrity of non-absorbable sutures, which can break/tear-out of TA. (2) Mitek anchors, commonly used for tendon reconstruction in articulating joints, allow osseointegration of autologous tissue. (3) Suture failure is mitigated by broad area of stitching. (4) Tailoring is possible once graft is secured. (5) If length remains a patient priority, a degree of distraction can be preserved without compromising durability.

Disclosure
No.