This study comprises a case series involving three patients, focusing on the insertion of Himplant® for concealing penile deformities and for augmenting the flaccid length and girth of the penis. Selection criteria for participants included a documented history of PD, prior treatment for PD with Xiaflex® and/or surgery, with persistent penile deformities post-treatment, and a history of circumcision. Patients experiencing penile indentation that led to instability or buckling during sexual intercourse and those with residual penile curvature exceeding 40 degrees were excluded. Preoperative and postoperative physical examinations were conducted to evaluate the characteristics of penile deformity and to measure dorsal penile girth and midshaft length with a paper ruler. Patients 1 and 3 opted out of having their photographs taken for record. Patient 2 consented to the dissemination of photographic material as part of this study.

We received general Institutional Review Board (IRB) approval for reporting outcomes associated with Penuma®/Himplant® procedures. However, this approval does not extend specifically to specialized subgroup analyses, such as the one conducted with this cohort. We believe that our existing general IRB approval sufficiently encompasses the patient population under study.

Case 1

Patient 1, a 54-year-old man, was diagnosed with PD in 2019 at the age of 52 years. At initial presentation, he had an estimated 45° dorsal and mild left lateral curvature with midshaft narrowing but no hinging. He used oral phosphodiesterase-5 inhibitors (PDE-5i) medications to augment his erections and sought treatment because of the bothersome curvature but observed no substantial benefits from traction therapy. Duplex ultrasound revealed a strong erection, a 50° dorsal and 20° left curve with mid-shaft narrowing, and no hinge effect. In 2021, he underwent tunica albuginea plication with extratunical grafting using a porcine dermal graft to correct the curvature and indentation. He reported satisfactory resolution of curvature and indentation correction but was dissatisfied with his loss of penile volume and girth that resulted from the plication surgery. Upon presentation at our clinic in 2022, examination of the patient’s penis revealed only narrowing of the penile shaft, but no curvature or indentation.

Case 2

Patient 2, a 64-year-old man with a history of chronic hypertension, hyperlipidemia, and male hypogonadism, was diagnosed with PD in 2014 at the age of 55. His degree of penile curvature prior to PD treatment was not recorded. He received three injections (0.9 mg) of Xiaflex® between 2014 and 2015 and underwent surgical plication in 2016. He reported satisfactory correction of curvature immediately post-operation but was bothered by loss of penile length. Over the next 4 years, the patient reported progressive recurrence of curvature and proximal shaft narrowing. Upon presentation to our clinic in 2022, examination of the patient’s erect penis revealed an estimated 40° dorsal and 20° left curvature with proximal shaft narrowing and a left lateral indentation but no hinging (Fig. 1A–C).

Fig. 1: [Patient 2] Pre- and post-operative images; Himplant®.

A Preoperative image; right view of erect penis; 40° dorsal and 20° left curvature. B Preoperative image; dorsal view of flaccid penis; proximal shaft narrowing and hourglass deformity. C Preoperative image; front view of flaccid penis; date of surgery. D High scrotal incision for Himplant®. E Himplant®; 16 cm length. F Postoperative image; right view of erect penis; correction of curvature. G Postoperative image; front view of flaccid penis; 3 days post-op.

Case 3

Patient 3, a 63-year-old man, was diagnosed with PD in 2017 at the age of 57. Evaluation of the erect penis revealed a 55° dorsal and 25° right curvature, reduced length (estimated 1.5 inches by the patient), and hinging. He received oral PDE-5i and four Xiaflex® injections (0.58 mg) in 2018. He subsequently reported satisfactory correction of the hinging and improved sexual function. However, over the next 15 months, he experienced progressive erectile dysfunction (ED), persistent bothersome curvature, and midshaft narrowing. Upon presentation at our clinic in 2022, examination of the patient’s erect penis revealed an estimated 30° dorsal and mild right curvature with midshaft narrowing but no hinging. This patient was offered an inflatable penile prosthesis since he had ED requiring oral therapy, which was worsening. He preferred to try the Himplant® first.

After undergoing their initial treatment for PD, all patients complained of mild residual deformity (curvature, indentation, and narrowing) that negatively affected their quality of life. The procedure for Himplant® placement to correct deformities and to provide girth enhancement was discussed with the patients. Written and verbal informed consent was obtained, including possible risks, complications, benefits, and alternatives, such as no surgery or an inflatable penile prosthesis. All patients chose to undergo Himplant® implantation which was performed between May 2022 through October 2022 through a high scrotal incision.

Intussusception of the penis through the lateral scrotal incision was more difficult due to prior degloving of the penis during surgical plication for Cases 1 and 2, and due to prior Xiaflex® injection therapy for Cases 2 and 3. As a result, adhesions between the underlying Dartos and Buck fascia were taken down sharply and great care was made to avoid thermal injury to the Dartos and skin side of the dissection. Such intricate dissection not only necessitates a high level of surgical dexterity but is also crucial for the successful insertion of Himplant®.

Himplant® Specifications

The Himplant® is a penile prosthesis made of medical-grade silicone that is implanted subcutaneously through a high scrotal incision along the penile shaft (Fig. 1D) [16]. Its wall thickness ranges longitudinally from 1.5 to 2.5 cm, and it is offered in three lengths: 14, 16, and 18 cm. All three patients in this study received the 16 cm Himplant® (Fig. 1E).

Patients were monitored postoperatively weekly for 2 months postoperatively and every 2–3 months thereafter. Patients were asked to complete the International Index of Erectile Function (IIEF), a 15-question, 5-scale measure of erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction [17]. Written consent was obtained prior to the procedure. Additionally, patients were asked the following questions with corresponding responses:

1.

What is your satisfaction with the implant? (Very high, high, medium, low, very low)

2.

How satisfied are you regarding penile girth enhancement with Himplant®? (Very high, high, medium, low, very low)

3.

How satisfied are you regarding correction of penile curvature? (Very high, high, medium, low, very low, N/A).