Background: Enlargement of the testicles involves the placement of an implant. Testicular enlargement is different than testicular replacement in that a testicle is in place and the space it occupies is requested to the enlarged. This can be done by one of two methods, side by side implant placement and wrapping the existing the testicle using it as an inner core with surrounding implant material.
The side by side technique is more effective when the testicular implant is at least 50% bigger by volume or in length and width than the natural testicle. By being appreciably bigger it overwhelms the existing testicle and pushes it aside largely making it invisible. If there is not this discrepancy between implant and the natural testicle size one can easily end up with a 4-ball appearance. The wraparound testicle implant adds thickness to the entire outer testicular surface and is the most appealing testicular enlargement concept. But it also posed the most challenges as keeping the two together as a combined larger testicle is not assured. Postoperative separation or extrusion of the testicle out of the implant can potentially occur. This risk is partially related to the size of the natural testicle and the size of the inner chamber of the wrap around implant. If there are significant differences between the two (0.5cm or greater) the risk of extrusion may be significant.
Penoscrotal webbing, aka the turkey neck of the penis, is when a web of skin expends from the shaft of the penis down onto the scrotum blunting the penile-scrotal angle. Its correction is done by excision of bilateral triangles of skin from a midline incision down the center of the lowest hanging part of the web. Once this skin is excised there is a large open area in the upper half of the scrotum which could be a convenient point of access for testicle implants.
Case Study: This male had testicular asymmetry with the left testicle being appreciably smaller than that of the right. He had been on testosterone supplementation for a long time. He was advised by his urologist that if the smaller left testicle was removed it may make the remaining testicle work harder to produce testosterone and thus keep its size. With this as the background he desired overall testicular enlargement. In addition he also has penoscrotal webbing. He desired all four procedures at the same time. (Left testicle removal and implant replacement, right wrap around testicle implant and penoscrotal webbing correction.
Custom testicle implants were made for him with a solid 6.5cm for the left and a custom wrap around implant with a hollow 3.75cm chamber. While not of clinical significance the compressibility of the two type of implants is different and expected.
Under general anesthesia a midline incision was initially made down the center of the penoscrotal web. Skin flaps were raised bilaterally. This provided good access to find the small retracted left testicle and remove it. The solid 6.5cm testicle implant was then placed and the implant pocket closed.
The right testicle was dissected out and completely freed on its attached cord. The custom wraparound implant was placed around it by a special suture technique to both pull it into the inner chamber of the implant but to secure it there as well. It was then dropped into the implant pocket and closed.
The excess skin from the webbing was lastly removed and a midline closure performed.
Penoscrotal webbing correction and the placement of large custom testicle implants can be done at the same time. But it is prudent to not remove any scrotal skin until the implants are placed as the large implants are going to require more skin to allow for a tension free scrotal skin closure.
Case Highlights:
1) There are three methods of testicle implant augmentation, side by side, wraparound and replacement implants. The replacement method involves an orchiectomy and immediate implant placement.
2) An orchiectomy may allow for a larger testicle implant placement than the side by side technique.
3) Penoscrotal webbing correction can be done at the same time as the placement of testicle implant and through the same incision.
Dr. Barry Eppley
Indianapolis, Indiana