Stesura Seveso


135Archivio Italiano di Urologia e Andrologia 2014; 86, 2

NOTE ON SURGICAL TECHNIQUE

Pseudo-capsule “coffin effect”: How to prevent penile 
retraction after implant of three-piece inflatable prosthesis

Enrico Caraceni 1, Lilia Utizi 2, Giovanni Angelozzi 3

Department of Urology, Civitanova Marche Hospital, Italy.

Objective: Following three-component
implantation of a penile prosthesis, some

patients are dissatisfied with their penile length. This may
be due to the procedure by itself or pre-existing risk fac-
tors or psychological reasons. We supposed that formation
of a restricted pseudo-capsule due to a late prosthesis acti-
vation can inhibit later system expansion. We aimed to
identify the presence or absence of penile retraction after
implant and to prevent it by immediate prosthesis activa-
tion after implantation. 
Material and methods. Forty-six patients operated with
three-piece inflatable penile prosthesis (AMS 700 CX o
LGX) were enrolled. In 27 patients prosthesis was first
activated four weeks after surgery (NEA group) and in 19
patients prosthesis was activated immediately after  surgery
(DEA group). Length and girth of the penis was evaluated
before (in DEA group) and after the surgical procedure.
Results. The average post implant dorsal length of the
erect penis in group NEA was found 3.28 cm shorter than
in group with early activation (DEA). In DEA group there
was no lenght difference between pre-operative stretching
(14.57 cm) and post operative erection (14.98 cm). When
early activation was not performed, the clinical result was
a smaller penis in erect phase.
Conclusion. Reduced lenght of the penis after implantation
can be caused by the presence of a pseudo-capsule that
limits the elongation of the prosthesis and of the penis
(“coffin effect”). Timing of first activation seems to be the
key in order to prevent the risk of penile retraction after
implantation. Early activation is identified as the best
measure to maintain the length of the pre implant erect
penis after the prosthetic hydraulic implant.

KEY WORDS: Penile prosthesis length; Penile retraction; Early
activation; LGX penile prosthesis; AMS 700 CX penile prosthesis;
Coffin effect, Three piece penile prosthesis; Size of the penis;
Shortening of the penis.

Submitted 23 December 2013; Accepted 29 March 2014

Summary

No conflict of interest declared

pointment can be severe and in some cases can lead to
loss of use of the prosthesis even when it is working well.
First Montorsi et al. in 2000 (4) reported that about 30%
of patients complained a decrease in penile size after
three-piece prosthesis implantation.
The authors explained the finding as follows: this dissat-
isfaction is linked with the loss of engorgement of the
glans or to the recall of the natural preexisting erection,
or to the pre-operatory penis size loss.
Deveci et al. in 2007 (5) wrote there were no statistically
significant differences in penile length after the surgery
compared to preoperative measurements in a group of
56 patients affected of erectyle dysfunction (ED) of vari-
ous nature, excluding Peyronie’s disease. Patients had the
penile length measured at the beginning of the operation
prior to device implantation (stretched flaccid length),
and at 1 and 6 months postoperatively (dorsal length
with activated prosthesis). Length was measured from
the pubic bone to meatus along the dorsum of the shaft.
They did not find significative difference in preoperative
stretched penis and postoperative penile length with the
activated device. In their experience about two of three
patients (72%) surprisingly complained decreased in
penile length. They explained that this feeling might be
related to a comparison with their penile length before
the onset of ED, or to pre-implant penile length reduc-
tion related to radical prostatectomy or other penile
fibrotics changes. They concluded that patient and part-
ner education from the beginning may limit unrealistic
expectations after implantation. Patient should be
advised that penile implants may not restore the full
length once achieved by natural erections. Treatment sat-
isfaction appears not to be fully dependent on subjective
penile length and then the failure in sizing (told by 72%
of their patients) is not real but subjective.
Montague (6) in 2007 published a review of literature on
the penis size matter after penile implants. He recognized
that it is likely that inflatable penile prosthesis implanta-
tion does not provide a prosthetic erection quite as long
as a natural erection. He believed that the loss of penile
sizing could be attributed to the fact that prosthetic erec-
tion does not include glans tumescence or to penile
retraction due to preoperatory factors, like radical
prostatectomy. However, he concluded it is necessary to
speak to the patient telling him: “your preoperative

DOI: 10.4081/aiua.2014.2.135

INTRODUCTION
Following implants of a penile prosthesis some couples
are dissatisfied with penile length and girth (1-3). This
may be one reason for implant dissatisfaction: disap-



Archivio Italiano di Urologia e Andrologia 2014; 86, 2

E. Caraceni, L. Utizi, G. Angelozzi 

136

stretched penile length will approximately be like your erect
length after prosthetic surgery”.
Shaeer et al. (7) in a recent paper published in Sexual
Medicine in 2010 about his surgical technique to
improve penile size after inflatable prosthesis implanta-
tion, classified the possible causes of the loss of penis size
after implantation. They wrote “decrease in size may some-
times be a mental impression due to unrealistic expectations,
poor counseling, or dysmorphophobia”. 
Alternatively, diminished phallic size may be real and due
to the inherent nature of the procedure or to a preexisting
pathology. The latter includes cases of fibrosis following
radiotherapy, neglected priapism, and Peyronie’s disease,
all of which exhibit shortening and/or narrowing, or cases
with overhanging suprapubic fat leading to concealment.
In such cases, diminished size is not a result of the proce-
dure itself, but rather due to an ignored preexisting com-
plaint of undersized phallus, shadowed by erectile dys-
function (ED), a complaint that the physician failed to rec-
ognize and address. On the other hand, actual diminution
in size may be iatrogenic, caused by the procedure itself.
Shaeer and al recognized that there is a real loss of penis
size after implantation techniques and proposes expansion
to correct the defect and improve patient and partner’s sat-
isfaction. However, he lacked the demonstration of his
statements about the real loss in size after installation. His
work is only about the surgical technique to supersize the
penis following penile prosthesis implantation.
Levine and Rybak in 2011 (8) concluded that there is not
recognised reliable technique to gain length once the
device is placed and proposed the use of external traction
therapy prior to inflatable penile prosthesis placement to
solve the problem. Moskovic (9) obtained the same
results in a case treated using the same method of Levine.
Finally, other authors proposed preoperatory Vacuum
Device treatment (10, 11). We believe the loss of length
and girth of the penis after prosthetic hydraulic implant
is a multi-factorial phenomenon: preexisting factors like
obesity, penile fibrosis (post priapism or post induratio
penis plastica), pelvic surgery (radical prostatectomy,
cystectomy or abdominal amputation of the rectus) can
reduce “per se” penile size (12, 13), but in addition to
these factors pseudo-capsule formation could play an
important role in reducing the penis after implant.
In fact in case of late activation of the prosthetic device a

pseudo-capsule can form around the deactivated empty
implant that is smaller in size with respect to the fully
activated implant. When the prosthesis is activated after
three or four weeks, as recommended by the manufac-
turers (14, 15), it cannot expand further due to the
resistance of pseudo-capsule, which is so far fully
formed. In other words the pseudo-capsule prevents the
full prosthesis expansion, thus determining a reduction
of the true size of the penis working like an inextensible
wall. We have called this phenomenon “coffin effect” of
pseudo capsule. The “coffin effect” should be added to
other predisposing factors of penile size reduction and it
is always present. If the prosthesis is not left inflated
immediately after the surgery and for subsequent two or
three weeks the result will be a smaller penis with simi-
lar dimensions to the non activated prosthesis.
Aim of this study was to identify the presence or absence
of penile retraction after implant with three-component
prosthesis and to evaluate the possibility to prevent it by
immediate activation of the prosthesis after the surgical
procedure without use of other device or other surgical
strategies before or after the operation (16-19).

CONCLUSIONS
According to our observations we confirmed the occur-
rence of a “true” penile shortening after prosthetic
implant (11.70 cm in the NEA group).
This can be caused by the formation of a pseudo capsule,
that develops around the non activated implant that acts
as a “wall” that subsequently prevents the prostesis
expansion and the potential elongation of the penis after
implantation. The pseudo capsule limits the dimension
of the penis and the prosthesis can only move like a “slid-
ing door” inside it forward during activation and back-
ward when it is deactivated. The result is a larger penis
in flaccid state but smaller in erect phase expecially when
early activation was not performed. The implant can
work like an expander, if well used, but the size of the
penis is limited by the pseudocapsule. This “coffin effect”
explains the retraction and the lower elasticity of the
penis that can occur after implantation as a consequence
of the formation of the pseudo capsule. The decreased
elastic capacity of the penis after penile prosthesis
implantation involves a lower difference between penile

length in flaccid and erect state and larger
length and girth of the flaccid penis.
This is confirmed by the observation that
early activation as an effective measure to
prevent penile shortening after implanta-
tion. LGX implant can improve the length
(15.35 in DEA group versus 11.90 in NEA
group) and girth (12.43 in DEA group ver-
sus 11.90 in NEA group) of the penis only if
early activated. In conclusions early activa-
tion is a measure to prevent the loss of
length of the erect penis after implantation.

Materials and Methods, Results, Tables and
Discussion are fully described in Supple -
mentary materials posted on www.aiua.it

Length preoperative Girth preoperative
(available with fic in 12 patients,        

with str. in 14 patients)

Group Δ Δ1
ICI          STR
2.61        3.23

DEA (lgx and cx) 2.75

Length postoperative Girth postoperative

Group �Δ �Δ1
NEA (lgx and cx) 1.55 1.02
DEA (lgx and cx) 1.65 1.69

Table.

Penile elasticity (Δ and Δ 1).



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137Archivio Italiano di Urologia e Andrologia 2014; 86, 2

Early activation to prevent penile retraction after prosthesis implant 

Correspondence
Enrico Caraceni, MD
Director of Department of Urology - Civitanova Marche Hospital
Civitanova Marche, Italy
ecarace@libero.it

Lilia Utizi, Clinical Psychologist (Corresponding Author)
Sexual Behavior Consultant - Department of Urology - Civitanova
Marche Hospital
Civitanova Marche, Italy
l.utizi@libero.it.

Giovanni Angelozzi, MD
Department of Urology - Civitanova Marche Hospital
Civitanova Marche, Italy
giovauro@yahoo.it