Case 1
Patient 1, a 54-year-old man, was diagnosed with PD in 2019 at the age of 52 years. At initial presentation, he had an estimated 45° dorsal and mild left lateral curvature with midshaft narrowing but no hinging. He used oral phosphodiesterase-5 (PDE-5) inhibitors to augment his erections and sought treatment because of the bothersome curvature but observed no substantial benefits from traction therapy. Duplex ultrasound revealed a strong erection, a 50° dorsal and 20° left curve with mid-shaft narrowing, and no hinge effect. In 2021, he underwent tunica albuginea plication with extratunical grafting using a porcine dermal graft to correct the indentation. Upon presentation at our clinic in 2022, he reported satisfactory resolution of curvature and indentation correction but was dissatisfied with his loss of penile girth that resulted from the plication surgery.
Case 2
Patient 2, a 64-year-old man with a history of chronic hypertension, hyperlipidemia, and male hypogonadism, was diagnosed with PD in 2014 at the age of 55 years. His degree of penile curvature prior to PD treatment was not recorded. He received three injections (0.9 mg) of Xiaflex® between 2014 and 2015 and then underwent surgical plication in 2016. He reported satisfactory correction of curvature immediately post-operation but was bothered by loss of penile length. Over the next 4 years, the patient reported progressive recurrence of curvature and proximal shaft narrowing (Figs. 1–3). Upon presentation at our clinic in 2022, examination of the patient’s erect penis revealed an estimated 40° dorsal and 20° left curvature with proximal shaft narrowing and midshaft indentation but no hinging.
Case 3
Patient 3, a 63-year-old man, was diagnosed with PD in 2017 at the age of 57 years. Evaluation of the erect penis revealed a 55° dorsal and 25° right curvature, reduced length (estimated 1.5 inches by the patient), and hinging. He received oral PDE-5i and four Xiaflex® injections (0.58 mg) in 2018. He subsequently reported satisfactory correction of the hinging and improved sexual function. However, over the next 15 months, he reported experiencing progressive erectile dysfunction (ED), persistent bothersome curvature, and midshaft narrowing. Upon presentation at our clinic in 2022, examination of the patient’s erect penis revealed an estimated 30° dorsal and mild right curvature with midshaft narrowing but no hinging. This patient was offered an inflatable penile prosthesis since he had ED requiring oral therapy, which was worsening. He preferred to try the Himplant® first.
Himplant® was performed in all three men in May 2022 through October 2022. After undergoing their initial treatment for PD, all patients complained of mild residual deformity (curvature, indentation, and narrowing) that negatively affected their quality of life. The procedure for Himplant® placement to correct deformities and to provide girth enhancement was discussed with the patients. Written and verbal informed consent was obtained, including possible risks, complications, benefits, and alternatives, such as no surgery or an inflatable penile prosthesis. All patients chose to undergo Himplant® implantation. In accordance with applicable regulations and guidelines, Institutional Review Board approval was not deemed necessary for this case series study.
Himplant ® Procedure
A 4-cm incision was made lateral to the base of the penis on the left side of the upper scrotum. It was deepened through the Dartos and fatty tissues. The suspensory ligament was identified, and surrounding attachments were released, but the ligament was preserved. A pocket was created between the Dartos and Buck’s fascia over the dorso-lateral body of the penis bilaterally. The penis was intussuscepted through the lateral scrotal incision to better expose the coronal sulcus through delicate blunt and sharp dissection distally in the loose plane between the superficial Dartos fascia and Buck’s fascia. Attachments under the dorsal aspect of the coronal sulcus were released between 3 and 9 o’clock positions. The area was irrigated repeatedly throughout the procedure with 0.05% Chlorhexidine Gluconate (Irrisept®, Irrimax, Gainesville, FL). Based on the length and girth of the flaccid penis and penile skin elasticity, the appropriate size of Himplant® was selected and opened in the sterile field. The prosthesis was then immersed in an antibiotic solution containing rifampicin and gentamycin. The distal lateral corners of the implant were trimmed using Mayo scissors to ensure proper sizing and fit to the patient’s anatomy. The distal margin of the implant was sutured to the tunica albuginea at the coronal shaft junction using interrupted figure-of-eight 2 − 0 and 3 − 0 Ethibond® sutures. The penile skin was returned to its normal anatomic position to insure proper positioning of the Himplant®. The thick proximal base of the prosthesis was trimmed to an appropriate length to sit in the previously created infrapubic pocket. All bleeding points were controlled with bipolar cautery, primarily on the penile side of the dissection, with minimal-to-no cautery on the Dartos aspect of the dissection. A Jackson-Pratt drain was placed and anchored to the skin. The Dartos muscle was closed over the implant using 2 − 0 Vicryl in an interrupted fashion, the subcutaneous tissue was closed using 3 − 0 Monocryl in an interrupted fashion, and the skin was closed using 4 − 0 Monocryl in a continuous fashion. The penis was dressed in a loosely applied Kling wrap, which was removed the next day in the clinic. On the third day, the patients returned for removal of the Jackson-Pratt drain.
The patients were prescribed oral antibiotics for 2 weeks postoperatively. For 6 months daily, the patients were instructed to apply a penile compression sleeve (Urowrap®, Elteeza Inc., Sherman Oaks, CA, USA) to reduce postoperative swelling, protect the penile skin, and facilitate uniform capsular formation around the implant. Sexual activity was discouraged for 8 weeks.
Patients were monitored postoperatively weekly for 2 months postoperatively and every 2–3 months thereafter.