Combined Inflatable Penile Prosthesis Implantation and Grafting for the Treatment of Severe Penile Curvature Associated with Erectile Dysfunction (iGrafter Technique)

J. T S Filho, M. Horta, L. V Sanvido, L. G Fraga, N. M Filho, E. Pato, I. V Coimbra, P. M Goes, W. C Nahas, J. Hallak, B. C G Nascimento

INTRODUCTION AND OBJECTIVES: Peyronie's disease (PD) associated with refractory erectile dysfunction (ED) is one of the main indications for inflatable penile prosthesis (IPP) implantation, representing a surgical challenge. A conventional on-demand approach, globally accepted, advocates the implementation of adjuvant maneuvers, such as modeling and incisions after IPP implantation if no functional straightening is observed. In severe cases (>60°), however, modeling alone is much less effective than in mild deformities. Also, in this on-demand approach, IPP cylinder sizing is already defined once the need for incision is confirmed, limiting length restoration. Finally, if a tunical defect >2 cm is noted, a graft placement is suggested to avoid IPP herniation. This study presents a surgical video of a severe deformity treated with the upfront definition of IPP implantation combined with tunical incision and grafting, using the iGrafter technique, aiming to maximizing curvature correction and length restoration.

METHODS: We present a surgical video of a 64-year-old man with a 80° dorsal curvature, diabetes, severe erectile dysfunction (EHS 2) refractory to PDE5 inhibitors, and penile shortening. An inflatable penile prosthesis (AMS 700 CX Boston Scientific) was implanted after suturing the grafts in the convex site of the shaft, as guided by the iGrafter application available for free. A bovine pericardial graft was utilized.

RESULTS: In the presented case video, after measuring the short and long side, real-size images are generated to serve as mold of rulers and the graft that should be needed. A penoscrotal approach with penile degloving and cautious neurovascular bundle dissection was undertaken. Tunical incisions were made where indicated by the software rulers, creating lozenge-shaped defects. Grafts were secure with 5.0 Polydioxanone (PDS) continuum sutures. Implants were kept in the rigid position for 2 weeks. The patient resumed sexual activity with 8 weeks. Penile length increased from 11.5 cm preoperatively to 14 cm immediately postoperatively, stabilizing at 13.5 cm at postoperative day 60. The patient reported good prosthesis adaptation, functionality, and aesthetic satisfaction.

CONCLUSIONS: The combined use of inflatable penile prosthesis implantation with incision and grafting defined upfront provides satisfactory functional and aesthetic outcomes, ensuring reliable length restoration. This approach has proven to be a safe and effective strategy for the correction of severe penile deformities associated with refractory erectile dysfunction.

SOURCE OF FUNDING: The implant was donated by Boston Scientific

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