Enhancing scientific discourse on penile girth augmentation: A critical appraisal of Chen et al.'s review

In a comprehensive review published in Current Urology in 2025, Chen et al.[1] provided a multifaceted examination of penile enhancement modalities. This study addresses the rising prevalence of small penis anxiety and the cultural emphasis on masculinity.[2,3] It synthesizes psychological underpinnings, nonsurgical interventions, and surgical advancements, offering valuable resources for urologists and andrologists. The scientific rigor of this review is evident in its systematic literature evaluation, which includes quantitative outcomes from diverse studies while maintaining professionalism through balanced discussions of efficacy, risks, and ethical considerations. This commentary critiques the strengths and limitations of the review, with a targeted focus on full-process management of penile girth enhancement via surgery or injection therapy and the innovative application of biomaterials. By emphasizing evidence-based practices, Chen et al.[1] have contributed to a field often marred by unregulated procedures, advocating for multidisciplinary approaches to optimize patient outcomes. 1. Scientific rigor and professionalism The authors demonstrated commendable rigor by aggregating data from over 20 studies. They used tables to summarize girth increases (e.g., 2.3–5 cm across modalities) and complications (e.g., infection rates of 2%–4.8%). Professionalism was maintained through the acknowledgment of evidence gaps, such as short follow-up periods and small cohorts and requires prospective trials with reproducible protocols. Psychological aspects were rigorously addressed, noting that 91% of men who perceived below-average size expressed dissatisfaction, which correlated with body dysmorphic disorder. The global perspective of the review, which incorporates data from Asia, Europe, and the Americas, enhances generalizability, although it could strengthen rigor by including meta-analyses and quality assessments. Limitations include potential selection bias in the cited studies, many of which were from high-volume centers, which may not reflect broader clinical realities. Nonetheless, the emphasis on patient-centered care—integrating the impact of sexual function on heterosexual and homosexual relationships—demonstrates ethical professionalism. Future enhancements could involve artificial intelligence–assisted predictive modeling for complication risks, aligning with emerging urological technologies. 2. Full-process management in penile girth enhancement Chen et al.[1] provided a comprehensive overview of full-process management in girth-enhancement procedures, including preoperative evaluation, intraoperative precision, and postoperative surveillance. This approach minimizes the risks associated with these procedures. 2.1. Preoperative management Rigorous assessment is emphasized, including nomogram-based measurements (e.g., average erect girth ~11.66 cm), to distinguish physiological micropenis from cases associated with spinal cord injury. Psychological screening identifies motivations, such as self-esteem (primary in approximately 50% of cases), with referrals for counseling to address dysmorphia. Professional protocols recommend multidisciplinary teams (urologists and psychologists) and informed consent detailing the potential risks (e.g., 4.3% complication rate for hyaluronic acid [HA] injections). Imaging (e.g., ultrasound) and functional tests (e.g., erectile function indices) are implied but should be explicitly standardized for enhanced rigor. 2.2. Intraoperative management For injections, techniques such as microdroplet administration of HA (20–20.56 mL) under local anesthesia achieve gains of 2.3 to 3.8 cm in girth, with a focus on sterile and even distribution to prevent the formation of nodules. Surgical procedures such as Penuma implant insertion via subpubic incisions preserve neurovascular structures, thereby reducing operative time and morbidity. The review professionally details anatomical considerations (e.g., Buck's fascia dissection) to mitigate the risk of erectile complications, although intraoperative checklists would further enhance the reproducibility of the procedure. 2.3. Postoperative management Follow-up appointments (6–48 months) were conducted to monitor girth retention (e.g., 2.2 cm at 18 months for polylactic acid) and potential complications (e.g., seroma in 4.8% of implant cases). Conservative treatments, such as antibiotics, were used to manage these complications. Adjunctive therapies, including vacuum therapy, were recommended to preserve the penis length. Satisfaction assessments (e.g., 81% “high” long-term) serve as a guide for revisions. The rigor of this phase was enhanced through the collection of quantified outcomes. However, the incorporation of biomarkers for inflammation could further improve monitoring. Overall, the comprehensive management framework promotes ethical practices. Nevertheless, integrating telemedicine with follow-up appointments could address accessibility concerns. 3. Biomaterials in penile girth enhancement This review elucidates the pivotal role of biomaterials in the pursuit of durable and biocompatible augmentation by focusing on the scientific mechanisms and outcomes associated with their utilization. Absorbable materials, such as HA,[4–6] a natural glycosaminoglycan, offer temporary gains of 2.3 to 3.8 cm through hydration and minimal immunogenicity. These materials degrade via hydrolysis over an 18-month period. Polylactic acid stimulates collagen production through fibroblast reactions, resulting in 1.6- to 2.7-cm increases with rare adverse events.[7] Nonabsorbable options, including polymethyl methacrylate microspheres, provide stable enhancements of 2.4 to 3.5 cm but are associated with nodularity in 52% of cases.[8] Despite providing 2.6 cm gains, liquid silicone poses embolism risks, necessitating cautious application (Table 1)[9,10]. Advanced biomaterials, such as acellular dermal matrices and biodegradable scaffolds (e.g., poly(lactide-co-glycolide)), facilitate tissue engineering by promoting vascularized collagen, leading to gains of approximately 3.15 cm with low complications. Although long-term histomorphometric data are required for a comprehensive evaluation, this review rigorously compared biocompatibility and resorption rates. Table 1 - Comparison of biomaterials. Biomaterial Girth increase (cm) Key complications Degradation time HA 2.3–3.8 Nodules (4.3%) 18 mo PLA 1.6–2.7 None serious Variable PMMA 2.4–3.5 Nodularity (52%) Nonabsorbable Silicone 2.6 Embolism risk Nonabsorbable PLA = polylactic acid; PMMA = polymethyl methacrylate. 4. Conclusions The comprehensive review of Chen et al.[1] exemplifies the rigorous and professional scholarship in the sensitive domain, advancing full-process management and biomaterial innovations for penile girth enhancement. This paves the way for safer interventions by addressing evidence gaps and ethical considerations. Future research directions include randomized trials and the integration of nanotechnology to enhance precision.