339 Archivio Italiano di Urologia e Andrologia 2022; 94, 3 ORIGINAL PAPER No conflict of interest declared. INTRODUCTION Men have always been worried about penis size, which can seriously affect their self-esteem. They have the tendency to seek their identity in the penis with the belief that ‘‘bigger is better’’. The stigmas of a small penis, as well as the increas- ing media influence on sexual issues, have created an increase demand for penile enhancement (1). The term microphallus or micropenis is referred to a penis that is formed normally but is of a small size (less than 7-8 cm during erection or stretched state) and it is probably asso- ciated with abnormal production, or a reduced activity, of LH hormone (2). On the other hand, the altered percep- tion of the organ size is called “dysmorphophobia”. These patients present with a normal-sized penis but are dissat- isfied both in a flaccid state and during erection (3, 4). It is mandatory for these patients to undergo a psychosexu- al counselling and try to avoid surgery. The demand for penile lengthening had a tremendous increase in recent years. According to the published data, majority of men who request penile enhancement surgery usually have a nor- mally sized and normally functioning penis (5). In our experience, the most common request for penile length- ening comes from patients that suffer from the so-called ‘‘locker room syndrome”, i.e. anxiety and embarrassment arising from changing in front of the others. At present, no current consensus guidelines are available for treat- ment of patients with a normal-sized penis (6). The short penis can be congenital or acquired. The con- genital small penis is defined as measurements of < 7-8 cm upon erection. The acquired disorders are caused by Peyronie’s disease or outcomes of partial penectomy for penile carcinoma. Finally, there are cases of relative short penis due to excess pubic fat. The reported normal length of an adult flaccid penis ranges between 7.6 cm and 10.7 cm, and between 11.4 cm and 14.8 cm in erection (7). The increase in length following surgery that is required to satisfy the patient is not well established and is not adequately emphasized in the medical literature. Introduction: We report our long experience in the surgical treatment of patients request- ing penile lengthening by suspensory ligament release and placement of a custom-made soft silicone pubo-cavernous spac- er. The aim was to show that with this surgical technique the results obtained are maintained over time. It is crucial to achieve postoperative satisfaction of these patients who show fragility and self-esteem problems. Methods: From 1999 to 2020, we treated 245 patients with con- genital or acquired penile brevity. We carefully analysed the preoperative and postoperative (at 6, 12, 24 and 48 months) penile size of the patients to evaluate whether this technique could allow the long-term maintenance of aesthetic results. We also assessed preoperative erectile function and we focused on the psychological aspects to avoid surgery in patients with dysmorphophobia. This original technique involves the section of the suspensory ligament and the implantation of a silicone spac- er between the pubic symphysis and the corpora cavernosa. This spacer is conformed to the patient anatomy and maintains the relationship between the anatomical structures unchanged over time. Sexual self-esteem and patient satisfaction were assessed with the APPSSI questionnaire. Results: The mean increase in penile length was about 2.5 cm in flaccid state and 1.9 cm in stretched state. There were no injuries of the neurovascular bundle or urethra, and no erectile dysfunction was noted. These results persisted at 6, 12, 24 and 48 months without significant differences. Over 80% of patients stated that they were completely satisfied with the results obtained. This satisfaction remained stable along follow up. Conclusion: The section of the suspensory ligament and the implant of the soft silicone spacer provide real penis elongation with satisfactory results that persist over time. This technique avoids the frequent complication of short-term shortening due to the scar adhesions of the edges of the dissected ligament. The high aesthetic satisfaction of patients is stable at controls at 6, 12, 24 and 48 months. KEY WORDS: Penile lenghthening; Penile augmentation; Penile elongation; Pubo-cavernous spacer; Small penis; Suspensory ligament release. Submitted 8 September 2022; Accepted 9 September 2022 Penile lenghthening original technique using a pubo-cavernous spacer. Long term results from a series of over 200 patients Antonio Rossi 1 , Giovanni Alei 2 , Marco Frisenda 1 , Antonio Tufano 1 , Pietro Viscuso 1 , Guglielmo Mantica 3 , Pierluigi Bove 4 , Rosario Leonardi 5 , Alessandro Calarco 6 1 Maternal and Infantile and Urologynaecological Sciences Department, Sapienza University of Rome, Rome, Italy; 2 Department of General Surgery and Plastic Aesthetic Surgery, Sapienza University of Rome, Rome, Italy; 3 Policlinico San Martino, Genova, Italy; 4 San Carlo di Nancy Hospital, Rome, Italy; 5 Casa di Cura Musumeci-Gecas, Gravina di Catania (CT), Italy; 6 Department of Urology, “Cristo Re” Hospital, Rome, Italy. DOI: 10.4081/aiua.2022.3.339 Summary