Scrotoplasty at Time of Penile Implant is at High Risk for Dehiscence in Diabetics

Nikhil K. Gupta MD; Randy Sulaver MD; Charles Welliver MD; Michael Kottwitz MD; Luke Frederick MD; Danuta Dynda MD; Tobias S. Köhler, MD

FIRST PUBLISHED: March 6, 2019 – The Journal of Sexual Medicine

DOI:https://doi.org/10.1016/j.jsxm.2019.02.001

Introduction

Many men complain of a perceived loss in penile length after penile prosthesis implantation. For this reason, some implanters perform a scrotoplasty during implantation procedures. Scrotoplasty does not actually lengthen the penis but improves the patient’s perception of penile length.

Scrotoplasty involves “altering the ventral penile skin at the penoscrotal junction.” Because skin is removed around the incision, there is an increase in tension on the closure site, likely increasing the risk of wound complications.

Past studies on scrotoplasty in this context have focused more on benefits than risk factors or complications. The current study discusses surgical outcomes and risk for wound dehiscence as well as risk factors for wound complications.

Methods

A retrospective review was conducted on 103 patients (average age 61.8 years) who underwent initial inflatable penile prosthesis (IPP) placement and scrotoplasty between February 2009 and July 2014. All procedures were performed by the same surgeon. Outcomes and wound complications (particularly dehiscence) were noted, along with perioperative outcomes like surgical time, implant cylinder and rear tip length, and drain output.

A standard penoscrotal implant approach was used for all procedures. Scrotoplasty technique changed over time, starting with a V-Y technique and, after several wound healing problems, it was changed to a transverse incision with vertical closure.

Skin dehiscence was defined as “any wound where the entire epidermis was not reapproximated or any sub-dermal layer could be seen, even if pin-point.” Minor dehiscence (<5mm and intact suture line) was managed conservatively with observation and oral antibiotics; moderate dehiscence (>5mm and <2cm, without impending erosion of implant components) was managed with 1-2 interrupted sutures after appropriate betadine prep, aiming to reduce tension and not to perform a watertight suture line. Patients with major dehiscence (impending erosion or extrusion) were taken to the operating room for washout-exchange.

Results

Of the 103 men who underwent scrotoplasty, 15 experienced wound dehiscence.

• Nine cases were mild and healed secondarily without incident.
• Five cases were moderate and healed with one or more additional stitches.
• The one major case was discovered 35 days after surgery. The IPP device was exposed, and the patient underwent surgery again, during which the IPP was replaced with a malleable implant.

Seventy-three percent of the men with dehiscence had diabetes, compared to 43% of the men who did not experience dehiscence.

A univariate analysis revealed that men with diabetes were 4.33 times more likely to have dehiscence than men without diabetes. After logistic regression, patients with diabetes were 6.1 times more likely to have dehiscence than men without diabetes.

60% of the patients who experienced dehiscence had a V-Y wound closure, compared to 21% of the men who did not have this type of closure.

The following variables did not appear to increase the odds of dehiscence: hypertension, age, Peyronie’s disease as a cause of erectile dysfunction (ED), performing penile modeling, smoking status, implant manufacturer, and high vs. low longitudinal closure.

Discussion

The finding that dehiscence was more common among men with diabetes was not surprising, as past studies have shown diabetes to be a risk factor for surgical wound complications.

Scrotoplasty technique changed over time. The V-Y technique was used at first, but “resulted in dehiscence of the point of the recessed edge at an unacceptable rate.”

“[T]he presence of the implant seems to stretch the penis and the closure and places too much tension for such a wound closure to stay intact.”

A revised technique that involves the removal of a check-shaped area of skin and a vertical wound closure “appears to be more resistant to dehiscence.”

Implanters are encouraged to properly reinforce wounds and to consider avoiding scrotoplasty in patients with diabetes (especially men with small scrotums), as the procedure could increase the risk for prosthesis infection.

Limitations included the retrospective study design, single institution series, and lack of long-term follow-up.

Conclusion

“Implanters should carefully consider the risks and benefits of scrotoplasty in patients with diabetes, because diabetes increased the risk of dehiscence after scrotoplasty. Approximation of wound separation after penile prosthesis implantation with stitches in an out-patient clinic appears safe.”