Peyronie’s Disease (PD) remains a challenging and clinically significant morbid condition. Since its first description by François Gigot de la Peyronie, much of the treatment for PD remains nonstandardized. PD is characterized by the formation of fibrous plaques at the level of the tunica albuginea. Clinical manifestations include morphologic changes, such as curvatures and hourglass deformities. Here, we review the common surgical techniques for the management of patients with PD.
Before the times of François Gigot de la Peyronie, men have been plagued with the disfiguring and painful disease eventually known as Peyronie’s disease (PD). Curvature develops from the rigid inelastic tunical scar, secondary to macro-/microtrauma in individuals either predisposed genetically or with an underlying disease process of the network of elastic fibers and collagen bundles. This condition causes severe psychological, mental, and physical stress. The pain, erectile dysfunction, and curvature/defect caused by the plaque can prevent proper coitus, potentially resulting in embarrassment and frustration, which may lead to inability to maintain sexual relations.
Despite the attempts to uncover the pathophysiology behind PD, it still remains an enigma. It has an estimated prevalence of 3–9% although its incidence has increased in recent years [
PD can be characterized by two separate phases. The active (acute) phase is characterized by a painful and evolving plaque, inflammation, and progression of the curvature. This usually lasts 6 to 18 months. Approximately 10% of patients will have improvement in their disease. The majority of patients will experience maintenance or worsening of the defect. Once the disease has been stable for approximately 6 months, this is considered the stable (chronic) phase, at which time surgical treatment is appropriate [
In the 18th century, de la Peyronie attempted to treat this ailment by recommending mercurial rubs and bathing in the waters of the River Berges [
Once the surgeon has determined that the plaque is stable and painless a surgical approach can be taken. Surgical approaches in treating PD have also evolved over time. Table
Reconstructive surgery | Prosthesis with or without grafting or molding |
Shortening | |
Plication, wedge resection | |
Lengthening | |
Autologus |
In 1965, Nesbit reported his technique for the treatment of congenital chordee [
It was not until 1979 that Pryor and Fitzpatrick applied this technique to the treatment of PD [
Rehman et al. also reported their modification to the classic Nesbit operation [
In 1990, Yachia reported his variation to the classic Nesbit operation by incorporating the Heineke-Mikulicz principle [
A number of studies have been performed showing a wide range of patient satisfaction and successful correction of the penile curvature with these tunical shortening surgeries. However, due to the disruption of an intact tunica, and the dissection necessary to expose the area of interest, the Nesbit and Yachia techniques have also been plagued with some degree of erectile dysfunction, increase in patient discomfort, and some reported loss of penile tactile sensation [
Essed and Schroeder introduced the simplest way to surgically treat PD. They described shortening the longer side of the phallus by simple plication with nonabsorbable sutures [
With the advent of simple penile plication procedures for the treatment of PD, the armamentarium for treating this condition has grown. The plication technique allows for a rapid and simple surgery, without necessitating dissection of the neurovascular bundle or urethra. It also spares the tunica from being excised or incised, decreasing the morbidity associated with the surgery, and may even be performed under local anesthesia [
After the initial introduction of simple penile plication for the treatment of PD pioneered by Essed and Schroeder, there have been a number of modifications to the technique. The initial reports involved shortening the longer side of the tunica albuginea, and applying the necessary amount of stress to the knot required to straighten the phallus, without the need to excise or incise the tunica [
In 2002, Gholami and Lue introduced a modification to the original penile plication surgery. Their “16-dot” plication technique allows for distribution of knot tension, making the suture less likely for the suture to tear through the tunica. This also allows less patient discomfort and less episodes of recurrence. They reported that 85% of patients maintained a straight erection over 2.6 years. There was however, some shortening involved, but in only 7% of patients did this cause any functional problems. Twelve percent of patients reported bothersome knots and 11% reported some penile pain with the use of the 2-0 braided, permanent polyester sutures [
One of the downsides to the penile plication technique is permanent palpation of the knots, leading to discomfort, focal or erectile pain, and penile induration. This has led to yet another modification, the use of absorbable suture in penile plication surgery.
In 2001, the concept of using absorbable suture was first introduced. Hsieh et al. reported using 2-0 absorbable polygalactic acid (Vycril) suture for their modified tunical plication technique for the treatment of congenital curvature [
At our institution, we have one of the first series utilizing absorbable suture and longitudinal incisions for the treatment of PD [
Most critics of absorbable sutures state that they result in a higher rate of curvature recurrence, because of the possibility of plication breakdown after suture material has been reabsorbed. When compared to nonabsorbable suture, absorbable sutures have been shown to result in similar suture failure rates, likely secondary to tissue cut-through of the tunica. Basiri et al. compared plication using absorbable Vicryl suture versus nonabsorbable nylon suture. Both groups had some mild recurrence of curvature and had high-success rates, but patient satisfaction was found to be higher in the Vicryl group because the occurrence of palpable knots was lower in the Vicryl group [
Despite multiple advances in penile plication procedures, its applicability to PD is still limited. Those with complex deformities such as hourglass deformities, lateral indentations, or curvatures >60–70° may not be appropriately treated with this technique [
Since penile plication is considered a tunical shortening procedure, it is not recommended for patients with shorter phallic lengths. Penile shortening has been reported among 41–90% of patients in the literature, but most patients do not report enough shortening to prevent coitus [
Patients with good erectile function with complex curvatures, those with >60° defects, destabilizing hinge defects, and/or shorter phallus, the ideal treatment choice is incision or excision of the plaque and patch grafting. In 1950, Lowsley and Boyce first reported performing plaque excision and grafting with fat for the treatment of PD [
A number of different graft materials have been used over the past decades, and the search for the ideal graft—readily available, pliable, inexpensive, nonthrombogenic, and resistant to infection—has yet to be discovered. Grafts can be divided into three groups: autologous, synthetic, and nonautologous (Table
Autologous grafts include dermis, vein, tunica vaginalis, temporalis fascia, and buccal mucosa. They have the advantage of causing less inflammatory reaction and lower potential for wound infection as compared with synthetic nonautologous grafts. Unfortunately, autologous grafts are associated with higher surgical morbidity and increased surgical time, because a separate incision has to be made and the graft tissue harvested. This can lead to infection and pain at the graft site.
There have been many studies involving the use of vein grafts for the treatment of PD, especially when patients have more complex anatomical abnormalities. Studies have shown that using a venous graft allows for better elasticity and durability. The vascular endothelium of the graft provides a more physiologically compatible tissue. Usually, the saphenous vein is used because of its ease in harvesting, large surface area providing sufficient length and width, and, when compared to other vein-grafting sites, lower morbidity [
Patch grafts for PD using venous tissue have historically had high patient satisfaction and penile straightening rates, upwards into the 90%, especially within the first 12 months. Interestingly, long-term follow-up shows a decrease in satisfaction and straightening. Kadioglu et al., reported their experience with 145 patients, with a mean follow-up of 41.7 months. Only 75.7% reported “completely straightened” penile curvature, while the other 12.8% had less than 20°, and 11.4% reported curvatures >20° residual curvature [
Synthetic grafts are no longer recommended because of increased risk of infection, allergic reaction, enhanced inflammation causing fibrosis, and higher rates of contracture [
Nonautologous grafts include pericardium, dermis, fascia lata, dura mater, and porcine dermis. These are divided into two groups: allografts and xenografts. Currently, the two most popular nonautologous xenografts are bovine pericardium and porcine small intestinal submucosa grafts. These two grafts have the advantage of reducing morbidity associated with harvesting of an autologous graft and decreased hypothetical risk of transferring prions and other infectious processes associated with allografts. Serefoglu and Hellstrom compared dermal, pericardial, and small-intestinal submucosal (SIS) grafting, showed similar satisfaction rates and penile curvature correction rates [
Plaque incision involves initial evaluation in the operating room with an artificial erection, followed typically by a circumcising incision and degloving of the penis. If a ventral plaque is easily accessible via a direct ventral incision, this can be performed longitudinally over the plaque. Next, the neurovascular bundle is dissected off the tunica albuginea within Buck’s fascia, with sharp dissection when necessary (Figure
The “Achilles Heel” of plaque excision or incision and patch grafting has always been worsening erectile dysfunction because of the more extensive dissection and tunical manipulation necessary. For this reason, proper preoperative erectile function evaluation should be undertaken. This includes history and physical, standardized erectile function questionnaires, and possibly intercavernosal injection with Doppler ultrasound examination to assess for arterial insufficiency, venous leak, and evaluation of the plaque.
Interestingly enough, even with penile lengthening procedures, such as incision or excision and grafting, a proportion of patients still subjectively report a significant decrease in penile length. Some studies report a 35% rate of subjective penile shortening. In 2000, Montorsi et al. objectively reported regarding patient penile length after excision and patch grafting. At 32-month follow-up they noted no change in mean penile length postoperatively, when compared to preoperative length. Regardless, up to 40% of patients still reported subjective shortening [
In 1997, Licht and Lewis compared the classic Nesbit, modified Nesbit, and tunical incision and grafting procedures [
In 2008, Kim et al. reported a study comparing tunical plication versus plaque incision and saphenous vein grafting [
To date, there is no high level of evidence-based data to suggest, which is the best surgical treatment of PD. The perfect treatment choice must be determined by a two-way conversation between the urologist and the patient, keeping in mind the severity of disease, patient preference, and surgeon comfort. There have been studies comparing the different surgical modalities, but the results have not been consistent. A major pitfall includes a lack of standardized training regimens throughout teaching facilities. Moreover, due to the specialized nature of this pathology few providers manage this disease on a high volume basis. All this compounds the outcomes analysis since some reports come from institutions with very little experience managing PD patients. It is our impression that surgical management is currently the only treatment modality to provide acute and satisfactory outcomes to the morphologic deformities associated with PD.