Dr. Eid's view on maximizing erection length and quality, RTE's , Post-op Care

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Hawk

Below Is Dr. Eid's official view as provided to me. I thought some might be interested.
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Maximizing penile size, quality of erection and cosmetic appearance of a penis with a penile implant.
Patient's need to be aware of key issues that determine the penile length, feel of the cylinders, quality of erection
and cosmetic appearance of the penis after the penile implant procedure.

First, a penile implant has limitations and although satisfaction rates are extremely high, an inflatable penile
implant will not function exactly like a "normal" penis. The flaccid penis with an implant cannot retract like a "normal"
penis. The flaccid penis, therefore, will always be longer than before the implant was inserted.

Second, when the cylinders are deflated, the flesh of the penis will no longer be under tension and will retract
causing the deflated cylinders to bend and fold inside the shaft of the penis like an accordion. The folds will be more
prominent and palpable with the Coloplast Titan than with the AMS cylinders. In a beefy overweight patient with the
metabolic syndrome, for example, this will not be an issue, but in a very thin frail elderly patient, this may be
uncomfortable and unsightly. In general, the deflated AMS cylinders are more comfortable and softer than the deflated
Coloplast cylinders.

Third, to date, nothing exists in the world to make the erect penis longer (including vacuum devices, traction or
surgery). And neither the Coloplast nor the AMS LGX will increase the length of the erect penis. At best the length of
the erect penis with the implant will be the same as the length of the erect penis measured before the implant
procedure in the standing position after a penile injection test.

Finally, the health of the tunica albuginea (the thick layer that surrounds the erectile muscle) also will impact
the size of the implanted penis, as does the postoperative care, which I will discuss later. In a patient with vascular
disease or diabetes, the tunica may be thickened and loses its elasticity limiting its ability to stretch. This may
decrease the overall length of the pre-implanted erect penis. So does Peyronie's disease, which in a patient with Erectile Dysfunction may
not be revealed until the patient is in the OR. It is vital that the stretched penile length is measured
preoperatively with and without a penile injection test preferably in the standing position in order to provide the
patient with realistic postoperative expectations regarding size.

Several surgical techniques will allow the surgeon to maximize the postoperative length including surgical
approach peno-scrotal (below the penis) vs. infra-pubic (above the penis), use of the "No-Touch" technique,
positioning of the patient on the OR table, advanced knowledge of the size of the stretched penis and type of
anesthesia.

Type of anesthesia
Spinal anesthesia - as opposed to general anesthesia, will make the body numb from the waist down and blood will
pool into a relaxed penis. The penis will stretch by itself allowing the surgeon to place the longest possible cylinders
that will fit. The surgeon can also immediately see the size and measure the stretched penis before the start of the surgery.
General anesthesia - does not have the same relaxing effect on penile tissue and the surgeon will have to manually stretch
the penis to estimate the length of the penis. This is the equivalent of comparing the length of the manually stretched penis
when not sexually aroused with the length when sexually active. No-Touch technique and preoperative measurement
of the penis

As previously mentioned, knowledge of the pre-implantation length is very useful in maximizing post-
operative length. After the cylinders are inserted in the penis and before the corporotomies are closed, the
cylinders are inflated and the erect penis measured. This measurement can be compared with the pre-implantation
measurement. If the length of the cylinders needs to be adjusted, the "No-Touch" technique enables the surgeon to
remove and reposition the cylinders and adjust their length without contaminating the cylinders with skin bacteria.
Urologists not using the "No-Touch" technique, fearing infection, may not perform a size adjustment just to gain a
centimeter or less. This will result in an undersized penis. Also if the penis was not measured before the implant
operation, the surgeon may not be aware of the discrepancy in size. Most urologists do not measure and document the
length of the stretched penis before the implant is performed. More information on the "No-Touch" technique
including ten-year data in over 3000 consecutive patients is available on my website. Surgical approach
Performing the surgery through a midline scrotal incision will not only result in a better cosmetic outcome
(scar will be concealed by the natural raphe) but also will maximize length. Making a transverse incision above the
penis or below the penis will result in a more distal (closer to the glans penis) incision onto the shaft of the penis often
beyond the body plane or bodyline. Input cylinder tubes that exit the penis and connect the cylinders to the pump
are more likely to be visible and palpable by the patient and partner. Scar tissue will also form on the part of the penis
that is supposed to stretch with an erection decreasing the overall length of the erect penis. Regarding the "above the
penis" surgical approach, tubing from the cylinders will exit the base of the shaft at the 12 o'clock position and
make a 180 degree turn to reach the scrotal pump. This tubing will, therefore, be palpable at the base of the lateral
aspect of the shaft of the penis on the right, may rub and be painful during intercourse and even limit the depth of
penetration. This can be particularly annoying for the thin patient.

Patient's operative position
Flexing the OR table at the pubis, positioning the patient's head and feet down with pelvis up and with the
head of the table tilted downward will enable the surgeon to access the proximal crus (towards the body) or base of the
penis. Positioning the legs with the knees bent outward and feet touching will also enable more proximal access of the
crus of the penis. With this approach tubing exiting the shaft of the penis is oriented straight down towards the
pump, resulting in buried, non-palpable or visible input tubing.

This will result in a better cosmetic outcome and the tubing will not interfere with deeper penetration during
intercourse. Also, scar tissue will form deep in the scrotum on the fixed portion of the shaft of the penis and is less
likely to decrease the stretched length. Optimal scrotal pump positioning is facilitated with this approach as well.
The pump needs to be accessible far away from the shaft at the base of the penis yet concealed slightly behind the
testicles. This is more difficult to perform through other surgical approaches. Most urologists perform the penile
implant with the patient supine and flat on the operating table.

Choice of implant cylinder
The AMS cylinders are tunical independent and will only expand to 18mm girth (a mesh prevents further
expansion). This is more than adequate for many patients. For patients requiring cylinder length of 20cm or more this
lateral expansion may not be enough and better rigidity will occur with the wider Coloplast cylinders (the longer
cylinders expand to 21mm plus). The Coloplast cylinders are tunical dependent and if the tunica is not healthy or
thin, the rigidity will not be as good as with the AMS cylinders.

The Coloplast cylinders expand fully against the tunica and overtime this can cause thinning and atrophy the tunica
albuginea which will cause the penis to become very wide and less rigid. On the other hand, use of the AMS cylinders
in the larger and wider penises will cause inadequate rigidity of the penis as well as a flat appearance of the shaft
of the erect penis. The urethra, which is usually at the bottom of the shaft, will instead nestle between the
narrower AMS cylinders. It's important to have all types, makes and sizes of cylinders for every case, because often
the surgeon may not have pre-operative knowledge of all the variables necessary to select the best cylinder option for
that particular individual. For practical reasons, most urologists will use the same brand of penile implant for
every patient.

The issue of rear tips extenders
The inflatable cylinder is made of a non-inflatable rear portion that measures 4.5cm (AMS) and 5 cm (Coloplast)
and an inflatable anterior portion of variable length. So, for example, a 20cm Coloplast cylinder will only have 15cm of
inflatable distal portion. The fixed proximal portion also has a thinner diameter. For the AMS cylinders, that diameter
is only 9mm. Often surgeons will increase the length of the proximal portion with rear tip extenders to adjust the size of
the cylinders, rather than choosing a cylinder of the correct length. For example, if a patient measures 20cm and the
doctor is committed to using an AMS device he will have to use an 18cm with 2cm rear tip extenders. Therefore only
13.5cm out of the total 20cm inflates; the rear, which now measures 6.5cm, is thin and non-inflatable. The unstable
junction where the inflatable portion connects with the fixed rear portion will now be located in a more distal
position in the penile shaft and the erection will have a hinge effect, wobble and point downward when the
cylinders are inflated. This may not affect the overall length of the penis but will decrease the quality of the erection.
Instead a better choice would have been to use a 20cm Coloplast (AMS does not make a 20cm). Most urologists,
including yours truly, were trained believing that the crus of the penis does not play a significant role on the quality of
the erection and that placing a thin non-inflatable implant would not affect the outcome. Use of rear tip extenders
decreases the quality of the erection.

Post-operative care
During the first three months after the surgery, when not cycling, the cylinders must be kept fully deflated in order to maintain
the reservoir fully inflated. This will allow scar tissue to form on a full reservoir and prevent auto-inflation later on.
This means that the penis will heal over deflated cylinders and scar tissue will form over cylinder folds and curvatures.
A long wide penis with deflated cylinders may retract by as much as two inches. If the implant is not inflated early in
the immediate two weeks after the surgery, it may heal in this foreshortened dimension, causing permanent deformity
and reduced inflated length. In order to be able to inflate early one must be able to feel all of the components of the
pump, inflating bulb and deflation footprint. The more experienced the surgeon and the more precise the surgical
technique the less swelling and pain will occur after the surgery. Incisions and dissection must be kept at a
minimum and meticulous surgical hemostasis must be achieved so that the patient's postoperative risk of
hematoma and swelling is reduced. This will enable the patient to feel the components of the pump early after the
procedure and inflate and deflate as soon as possible. Think of it as rehab after an orthopedic procedure. If the shoulder
is kept in a sling for several postoperative weeks, the shoulder will freeze in that position. Post-op bed rest for 48
hours with ice followed by daily hot baths will minimize swelling and accelerate healing. Unfortunately, in most
general urology practices, post-operative care is often relegated to ancillary staff with little knowledge of these
issues. It is vital, especially for the larger stretchy penises that inflation and deflation of the cylinders is started as
soon as possible in order to prevent healing in a retracted foreshortened state.

Maximizing length and quality of the erection, as well as cosmetic appearance, depends on many factors perhaps
the most important being the practice implant volume and surgeon's experience.
Prostatectomy 2004, radiation 2009, currently 70 yrs old
After pills, injections, VED - Dr Eid, Titan 22cm implant 8/7/18
Hawk - Updated 10/27/18 - Peyronies Society Forums

Suicidal

Thank you for posting this. How is your experience with the implant so far? Do you need any pills for glans engorgement or does the implant support the glans perfectly and there is no need for pills or urethrals suppositories? Some people told me that even if you can stay hard forever with the implant, after ejaculation it will not be pleasant to continue the intercourse. How is your experience in this? And last of the too many questions.. I understand that your surgery was performed by dr. Eid. I have to chose between Kramer and Eid. What did make you chose Eid over Kramer?
Thank you for your help
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Torontobased

Hi Hawk,

Thanks for posting, it's very informative. In the case of unhealthy tunica, is there not much that can be done to avoid size reductions than? My tunica appears to be very damaged all over, I feel it's more scar tissue than healthy tissue, and it has me very concerned as the active phase is not resolving and I am shrinking at faster and faster rates. Is what Dr. Eid saying that I have no hope of regaining size, mostly girth but some length from an implant, and that I can only expect shrinkage? I have been holding out hope that an implant could correct some but I know not all of my size loss, would grafting with implant help mitigate the size loss concerns of a very thickened tunica? Also, how would implanting during the active phase and a size loss prevention method work? Would that also create concerns of further size loss?
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Stepone

I am wondering if you should do an update on this post you have from 2018.
Dr. Eid's official review as provided by me".
The post says that the new implant should be kept deflated for 3 months. This is under the title of Post Operative Care.
Obviously that official review is no longer true.

StepOne
Nesbit surgery 2015, 66 years young, Titan Implant 4/25/19, 22cm, Dr. Lentz, Duke University NC

Hawk

In response to questions
Stepone - I am not sure it does need to be updated.  I think the statement about keeping the cylinders deflated is just not real clear from a casual reading.  Dr. Eid stresses the importance of inflating early under Post-op Care.  It seems that what he means by keeping the cylinders deflated is to make sure that when you are not performing a post-op cycling to totally deflate the cylinders so the scar capsule around the reservoir form to accommodate a fully filled reservoir (fully deflated cylinders).  Certainly, he is advising against Drs. sending patients home partially inflated for several weeks as some doctors do.

Suicidal - my experience on a scale of 1 - 10 is at least a 9.75.  Sensation and sex is all I could hope for and I have been a sexually-oriented male since my youth.  I have a history of multiple orgasms (up to 5) from one erection and intercourse session that lasted over an hour not counting foreplay.  I have been told by specialist that such ability is very rare.  I share this only to let you know that I know how to compare an implant to a very functional natural penis. I gained more than half of what I lost back even though I fought with ED and Peyronies Disease for over a decade before the implant.    The only thing that could be improved is a fat engorged glans during erection.  My glans is not floppy and very well supported and normal looking and very functional.  I could probably use a urethral suppository to totally engorge the glans but I see no need.  I have used a VED about 5 times in two years, more as an experiment.  When I did my glands was bigger and tighter than it ever was even at 18 years old with a natural erection.  I am not sure my wife noticed the difference and it certainly did not feel or perform any better for me.

Torontobased -I held off for a decade concerned about size loss.  What an idiotic error that was.  First off, size loss will get worse, not better while you wait.  Next, a GREAT surgeon will give you more than you have now thru whatever means you are using to get an erection.  It might take a year to know your final size but most will be regained in 3 months.  A GREAT surgeon will promise you a minimal size when he takes pre-surgical measurements and documents those measurements.  If he does not document presurgical measurements then he can dismiss your concerns if you lose size so never settle for that.  Remember that there is no contest between a 10 " penis that can never maintain an erection and a 5' penis that can go every time and go forever.  Certainly potentially gaining only half of your legth back to get a great functioning penis is better than gaining no legth back and having ED because you avoided surgery.  
Prostatectomy 2004, radiation 2009, currently 70 yrs old
After pills, injections, VED - Dr Eid, Titan 22cm implant 8/7/18
Hawk - Updated 10/27/18 - Peyronies Society Forums

samsung

Hi Hawk, good to have you back.

Quick question, I have heard you say this before and it makes me nervous. And makes me wonder why everyone doesn't just immediately get an implant. You said, "First off, size loss will get worse, not better while you wait."

Is this true? Does it always get worse and do you always lose size over time? Because if so, this forum should not logically exist. It should just be an implant forum. Because no one wants to lose size under any circumstances.
45 y.o. Single. Onset of symptoms (pain-stinging like a wasp) @ 6/2018. No sudden injury. Curve developed slowly. 40 deg. dorsal. Hourglassing. Torsion to left flaccid. 4 rounds xiaflex. Restorex, DMSO+, heat, arginine, cialis, lipoic acid, vit. K2

tomas1

Sorry if I jumped in uninvited, but I believe you do lose size unless you use a VED.
I strongly recommend using one before getting an implant.
85 years old.
Implanted 01/22/19 by Dr Avila.
18cm AMS 700 CX, 3.5cm RTE 100cc reservoir
Diagnosed with Gleason  6 prostate cancer.
Monitoring it for now.

Hawk

Tomas, you are not only welcome but encouraged to jump in on topic anywhere on the forum without apology if you have something to add.

Samsung, I am not saying that every man with Peyronies Disease will continue to lose size.  It would not apply to a man whose Peyronies Disease has stabilized and who can still get erections.  My comment was directed at those who have significant Erectile Dysfunction or who have recurring active Peyronies Disease. In these men,wiithout intervention in some form, elastin is replaced with scar tissue.  That equals size loss.  It can also result in further deformity.  The reason healthy males get Night Time Erections from infancy is to maintain penile health.  In their absence the tissue is not oxygenated.  VED and traction can be used along with other means to attempt to stop or reduce this process but they must be continued fairly diligently and they are no guarantee.

An implant stops this process, presumably because it it applies at least minimal traction 24/7.  That is why a man with an implant has a longer flaccid length.  His penis can never contract and shrivel up and scar in a shortened state.  Of course cycling the implant exerts length and girth traction and sexual activity usually encourages at least some additional blood flow.
Prostatectomy 2004, radiation 2009, currently 70 yrs old
After pills, injections, VED - Dr Eid, Titan 22cm implant 8/7/18
Hawk - Updated 10/27/18 - Peyronies Society Forums