Maximizing postoperative satisfaction in penile prosthesis surgery: the predictive power of preoperative length and its role in tailoring enhancement procedures.

Abstract

Background: Penile prosthesis implantation (PPI) is a common procedure for refractory erectile dysfunction (ED). Changes in penile size affect patient satisfaction.

Aim: To evaluate the predictive value of preoperative penile length measurements for postoperative sexual satisfaction following PPI, with or without lengthening procedures.

Outcomes: Postoperative satisfaction and penile length were evaluated at 3 months using both objective measurements and patient-reported assessments.

Methods: This prospective, randomized comparative study included 61 male patients with organic vascular ED refractory to medical treatment. Patients were divided into two groups:Group A (n = 31): Underwent suspensory ligament release (SLR) with lower penopubic Z-plasty, dorsal and ventral phalloplasty.Group B (n = 30): Underwent PPI alone via a ventral midline penoscrotal incision.

Results: The mean functional and visible penile lengths were significantly greater in Group A compared to Group B (P < .001 for both). The erectile dysfunction inventory of treatment satisfaction (EDITS) resting-state score was also significantly higher in Group A (55.2%) than in Group B (0.0%) (P < .001). A preoperative Functional Stretched Penile Length (FSPL) cutoff of 12.75 cm in Group A predicted postoperative satisfaction with 81.8% sensitivity and 71.4% specificity, while in Group B, a cutoff of 14.50 cm yielded 77.8% sensitivity and 94.7% specificity. Similarly, a Visible Stretched Penile Length (VSPL) cutoff of 10.75 cm in Group A predicted satisfaction with 81.8% sensitivity and 71.4% specificity, and a cutoff of 12.50 cm in Group B predicted satisfaction with 66.7% sensitivity and 94.7% specificity.

Clinical implications: Preoperative penile length serves as a predictor of postoperative satisfaction; patients with shorter lengths may benefit from adjunctive lengthening procedures, provided that risks are carefully weighed and thorough preoperative counseling is conducted to align expectations and optimize outcomes.

Strengths & limitations: This is the first study to establish preoperative penile length cutoffs predictive of postoperative satisfaction; while its randomized design strengthens validity, limitations include small sample size, single-center setting, lack of participant blinding, and exclusive evaluation of malleable implants, which may reduce clinical applicability and limit generalizability beyond high-volume surgeons performing SLR.

Conclusions: A preoperative FSPL of <12.75 cm or VSPL of <10.75 cm identifies patients most likely to benefit from concomitant lengthening procedures, while those exceeding these thresholds may achieve satisfactory outcomes without augmentation; thus, preoperative assessment of functional and visible stretched penile lengths serves as a valuable predictor of postoperative sexual satisfaction following PPI and highlights the importance of individualized surgical planning to optimize both functional and aesthetic results.