Penile suspensory ligament: anatomy, function, and clinical perspectives of its repair.

Background: The penile suspensory ligament (PSL) plays a significant role in penile support and erection and its injury or congenital absence may result in functional impairment of erectile function.

Aim: To describe the diagnosis and surgical repair technique for PSL abnormalities and overall outcomes.

Methods: A comprehensive review of the literature was performed to understand the anatomic relevance of the PSL and historical management of PSL defects. A contemporary method for PSL repair is described using a transverse infrapubic incision with placement of midline anchoring (non-absorbable braided) sutures between the tunica albuginea (TA) and symphysis pubis to correct penile position and instability.

Outcomes: Surgical success defined as degree of penile curvature and penile stability for sexual intercourse as well as patient and partner satisfaction rates were reviewed.

Results: Though limited in number, available case series in the literature indicate a success rate between 85-100%, and more recent reviews fall in the 85-91% range. Patient satisfaction rates vary from 82-88%, but some series included patients with penile dysmorphic disorder and Peyronie's disease, which are known to have higher dissatisfaction rates related to the underlying etiology itself. In patients with venogenic erectile dysfunction (ED), resolution was 100% but de novo ED occurred in 3-5%; these cases were all successfully managed medically.

Clinical Implications: This review addresses the diagnosis of PSL abnormalities and demonstrates a simple but effective repair technique to significantly improve erectile stability in men with acceptable risk.

Strengths And Limitations: This is a comprehensive review of the available research on PSL abnormalities that outlines its diverse patient presentation and a systematic method to diagnosis and repair PSL defects. The patient satisfaction rates are reasonably high but given the relatively rarity of this entity, larger longitudinal multi-institutional studies are required to further elucidate risks of de novo ED, penile shortening, and functional outcomes over the long-term.

Conclusion: PSL repair using permanent anchoring sutures or a fascial graft between the pubic symphysis and the TA of the corpora cavernosa is a safe and efficacious way to restore an important part of the penile suspensory apparatus that helps stabilize the penis during erection for normal sexual function.