The Multiple-Slit Technique (MUST) for Penile Length and Girth Restoration
Paulo H. Egydio, MD and Franklin E. Kuehhas, MD
FIRST PUBLISHED: December 20, 2017 – The Journal of Sexual Medicine
Penile shortening can have a profound psychological effect on men, who may have trouble having sexual intercourse and suffer from a lower quality of life. Shortening can occur a result of Peyronie’s disease (PD), prostate cancer treatment (e.g., radical prostatectomy, androgen suppression with or without radiation), failed Nesbit procedures, and recurrent priapism.
Therapy-resistant erectile dysfunction (ED) often accompanies these conditions. Men in this situation may benefit from penile prosthesis implantation, but some surgical approaches can lead to further shortening and, in turn, worsen already existing emotional problems.
The multiple-slit technique (MUST) aims to restore penile length, girth, and function in patients with penile deformities affecting penile anatomy and severe ED. The MUST has been developed from other types of lengthening techniques, including the sliding technique, the circular tunica incision technique with grafting, and the modified sliding technique (MOST).
This study examined the functional and subjective outcomes in patients who had concomitant length and girth restoration with the MUST.
The study involved 138 men with severe therapy-resistant ED associated with penile shortening or narrowing. All of the men were unable to have penetrative intercourse and were dissatisfied with their sex lives.
The men ranged in age from 40 to 72 years, with an average age of 55 years. Sixty percent had Peyronie’s disease, 25% had severe ED, and 10% had undergone radical prostatectomy.
The men underwent the MUST between July 2013 through January 2016. Thirty-five patients received a 3-piece inflatable penile prosthesis; the remaining 103 received a malleable prosthesis.
The men completed the International Index of Erectile Function (IIEF) before surgery and at a 6-month follow-up point. They also completed the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) at the 6-month follow-up visit.
Preoperative and postoperative changes in penile length, along with intraoperative and postoperative complications, were also noted.
At the start of the study, patients reported a mean subjective penile shortening of 3.2 centimeters. Forty-five percent of the patients had shaft constriction. For men who had Peyronie’s disease, the mean axial deviation was 55 degrees.
Patients were followed for an average of 15.2 months. Operative time for inflatable prostheses was 140 minutes; malleable prostheses took an average of 100 minutes.
Men gained length in a range of 2 to 5 centimeters (average: 3.1 cm – note: measurements reported using erect length, which is improved by curvature correction alone and does not necessarily correlate with concomitant increases in true stretched penile length). All cases of penile curvature were straightened.
None of the men needed to have their device removed due to infection. One man had glans necrosis and needed further surgeries.
Average scores on the IIEF increased from 22 points to 61 points between the start of the study and the 6-month follow-up visit.
Risks and complications of the MUST should be noted: “Extensive mobilization of the neurovascular bundle and of the urethra and the constant traction on the penis are potential risk factors for complications, such as partial loss of sensitivity of the glans, glans necrosis, and glans ischemia. Maneuvers to lower the risk of devastating complications need to be implemented.”
The MUST is a newer technique and requires further study. Experts caution that given the possibility for severe complications, additional validation is required by additional groups prior to routine implementation.