Peyronie's disease has been associated with penile shortening and some degree of erectile dysfunction. Surgical reconstruction should be based on giving a functional penis, that is, rectifying the penis with rigidity enough to make the sexual intercourse. The procedure should be discussed preoperatively in terms of length and girth reconstruction in order to improve patient satisfaction. The tunical reconstruction for maximum penile length and girth restoration should be based on the maximum length of the dissected neurovascular bundle possible and the application of geometrical principles to define the precise site and size of tunical incision and grafting procedure. As penile rectification and rigidity are required to achieve complete functional restoration of the penis and 20 to 54% of patients experience associated erectile dysfunction, penile straightening alone may not be enough to provide complete functional restoration. Therefore, phosphodiesterase inhibitors, self-injection, or penile prosthesis may need to be added in some cases.
Peyronie’s disease (PD) is characterized by scar tissue development in
the tunica albuginea, which makes it less elastic, causing penile deformity,
and is invariably associated with a decrease in penile functional length. The
condition has an impact on quality of life, and a significant psychological
effect on 77% of patients [
Surgical decision is made after clinical treatment failure, when penile deformity (curvature, narrowing, or indentation) and plaques are completely stabilized, and pain has been absent for at least 6 months, provided that the patient experiences functional penile inadequacy.
Association
between PD and erectile dysfunction (ED) is seen in 20% to 54% of cases [
Penile deformity is consistently associated with functional length reduction, since the penis curves because one of its sides has lost more elasticity than the other.
A curved penis has a short and a long side. If an attempt is made to straighten it by shortening the longer side, this may not be satisfactory for the patient, because a decrease in final penile length may result. This decrease is proportional to the degree of penile curvature. It is possible during pharmacologically induced erection to estimate the penile size if the long side is going to be reduced and it is recommended to ask the patient whether that length will be enough to make him satisfied.
Therefore, for selected cases, surgical treatment should focus on functional penile-length restoration. Lengthening the shorter side is the alternative that provides maximum gain in penile length.
Surgical
treatment is aimed at providing good penile function (i.e., rectification as
well as adequate length and enough rigidity to enable healthy sexual activity).
The geometrical technique is the most precise procedure to lengthen the short
side, thereby recovering the length lost by scarring. Penile straightening is
indicated for patients with normal spontaneous erection or erectile dysfunction
that responds to medication, whereas those with untreatable erectile
dysfunction requiring penile prosthesis [
The
size of the prosthesis is compatible with the longer side, as the shorter side
is the one to be lengthened. Maximum length restoration was possible and
limited by the length of the dissected neurovascular bundle [
Preoperative evaluation should include complete clinical history as well as assessment of comorbidities, such as diabetes, heart/vascular/coronary conditions, arterial hypertension, smoking, alcohol consumption, signs and symptoms of hypogonadism, and regular medications, which may affect erection.
A detailed history should be obtained on associated erectile dysfunction, either prior to or concomitant with Peyronie’s disease, as well as risk factors contributing to the development of the condition, such as sexual partner’s lubrication status, achievement of an erection that continues until ejaculation, premature or late ejaculation, or inadequate habits that may cause injury to the tunica albuginea. A history of phosphodiesterase-5 (PDE5) inhibitor use is a key to establishing the presence of associated erectile dysfunction, as well as the response of this condition to the medication, the patient’s tolerance to its side effects, and his compliance with treatment.
PD is consistently associated with shorter penile length. Some patients experience symmetric loss of elasticity, with little or no deformity. In such cases, a decrease in penile length may be the sole complaint.
A complete evaluation is essential in cases of sexual inadequacy with possible surgical indication. Patients with erectile dysfunction may need specific treatment, and assessment of their response to treatment before surgery is considered as a therapeutic option.
For deformity assessment, physical examination of a flaccid penis may reveal a palpable thickened tunica. Penile size may be determined by pulling the glans penis forward and upward to the position of a normal erection and asking the patient to indicate to which extent PD has shortened his penis.
Erection assessment is essential to establish surgical indication as well as the most appropriate surgical procedure. Penile tumescence, or partial rigidity, is often mistaken for erection, and the objective test of pharmacologically induced erection may change the therapeutic plan.
Rigidity
assessment is performed both subjectively, as reported by the patient, and
objectively, as observed by the physician after intracavernous injection (ICI)
of alprostadil 10 to
After ICI, the
patient holds his penis in an erection position, and the ultrasound scanning of
thickened areas of the tunica, associated or not with calcification, is
initiated. The measurement of flow indices—peak systolic
velocity (PSV), end diastolic velocity (EDV), and calculated resistive index
(RI)—begins at least 5
minutes thereafter, and a correlation of these indices to penile rigidity is established.
One clinical study reported 44% of arterial anomalies and 10% of distal
collateral arteries between dorsal and cavernous arteries [
Evaluation of
patient’s and partner’s satisfaction and long-term results after surgical
treatment for Peyronie’s disease has shown that PSV values of 35 cm/s or above
and RI higher than 0.9 were considered as parameters for a normal penile
vascular system. EDV values above 5 cm/s were considered diagnostic for
veno-occlusive dysfunction [
Information on penile arterial anatomy may be very useful for the surgeon to select the type of surgical technique to be used. Knowledge of the existence of a collateral branch is important to safely dissect the neurovascular bundle.
Because penile
size before PD is unknown, information from the patient on the perceived extent
of his penile length reduction is relevant. During erection induction for
deformity assessment, the patient must be asked how satisfied he would be with
the length resulting from straightening his penis by diminishing the longer
side, as it is being shown to him, and which would be the extent of length loss
compared to his penile size before PD. Penile length reduction by PD is very
likely to have occurred when more than one site of fibrosis is seen, or when
there is fibrosis on opposite sides. However, even if a thickened tunica cannot
be palpated, longer-side reduction is not ruled out, since microstructural
changes are enough to decrease the elasticity of the tunica [
During or shortly after DUS, penile rigidity is objectively compared to self-reported rigidity. This allows more objective assessment of rigidity. If it is lower with the test, both crura penis are pressed to maximum rigidity to assess penile deformity, which will be apparent with maximum rigidity, while the other hand assesses axial rigidity by pressing on the glans to mimic a penetration attempt. If deformity is not pronounced and with good rigidity allows good axial stability, providing penile functionality, surgical treatment may not be indicated. A good erectile response to oral or injected medications may restore penetration ability in such cases.
Soon after this assessment, the patient is asked to palpate his penis and, by progressively relieving pressure on crura, to report the extent of rigidity, he observes in an ideal setting of sexual stimulation. The physician is thereby provided with an objective evaluation, and, if a rigidity deficit is proven, the patient’s ED can be treated. The physician will establish what a good rigidity is, and whether this desired goal can be achieved by the patient.
The penis is degloved after a
circumcision incision. Magnifying lenses 2.5 are used for better
visualization. One of the cavernous bodies is punctured by a 21 scalpel,
considering that, when necessary, both cavernous bodies can be punctured
to achieve full erection by saline solution injection. The use of
papaverin or prostaglandin can help full erection with saline solution
injection. In cases of dorsal curvature,
two tangential lines to the penile axis (red lines) are drawn on the
proximal and distal straight segments ( From the point of maximum
curvature (P) located at the intersection of the lines
The point at which this circumferential line crosses
the neurovascular bundle in the dorsal region and the urethra in the
ventral region determines the region at which these structures must be
separated from the tunica albuginea. The transverse incision in the tunica will be made
along this circumferential line (green line) later. Then the erection is
reversed. Two paraurethral incisions ( A new erection is induced and a circumferential line is
drawn again, but this time on the tunica, where the circular incision will
be made (Figure
Complete penile straightening is achieved by a 5-mm
incision in the intercavernous septum on each side of its intersection
with the transverse incision in the circumferential line (Figure
The width ( The difference (
On the circumferential line, a length of
Defect length ( Once the circumferential line forked at the ends is
determined, the incision is made in the tunica albuginea, producing a
rectangular defect of an already known size. To facilitate graft suturing, a 5-mm dissection is made
between the 4 edges of the defect and the respective adjacent cavernous
bodies. The graft is sutured and a new induced erection demonstrates
complete penile straightening (Figure In cases of
ventral curvature, the technique is similar but with the following
differences: the forking of the transverse incision is made in the dorsal
region near the intercavernous septum which has its dorsal insertion
maintained (Figure
The urethra is dissected from its bed and the graft is
placed between the urethra and the cavernous body (Figures Dorsolateral curvatures with a larger dorsal component
and ventrolateral curvatures with a larger ventral component are corrected
by the same technique as for dorsal or ventral curvatures, respectively. In cases of lateral curvature (Figure
The graft is cut according to the measurements already
made (i.e., width The length ( Buck’s fascia can be sutured on place. Penile degloving
is reversed and foreskin, when present, is removed to avoid postoperative
swelling and/or necrosis. Circumcision incision is closed with 5.0
poliglecaprone. A light compressive dressing is applied for 7 to 10 days.
Although the patient can have spontaneous erection, a 6-week period of
sexual abstinence is recommended. After a 6-month follow-up, alprostadil-induced
erections are used to check penile straightening in those cases a penile
prosthesis has not been implanted.
The intersection of
the tangential lines to the penile axis
(a) Paraurethral incisions (
(a) Cutting of the intercavernous septum. (b) Septal cutting in cases of dorsal, dorsolateral, or lateral curvature. (c) Septal cutting in cases of ventral or ventrolateral curvature.
(a) Bifurcation
of the transverse incision and the correspondent defects in the tunica
albuginea in cases of dorsal curvatures.
The starting point
of the 120-degree bifurcation at the end of circumferential lines is
established by marking a length of
(a) Bifurcation
of the transverse incision and the correspondent defects in the tunica in cases
of ventral curvatures.
(a) Bifurcation
of the transverse incision and the correspondent defects in the tunica in cases
of lateral curvatures.
An ideal graft should be ready to use; available in various sizes; have good tensile strength and low potential for inflammatory reactions; infection-resistant, with minimal or no risk for disease transmission; and be cost-effective.
Several types of grafts have been used,
including biologic autografts—dermis, veins, penile
crura, dura mater, tunica vaginalis, fascia lata—and
allografts/xenografts—cadaveric
pericardium, porcine small-intestine submucosa, acellular dermis, or synthetic
grafts: polytetrafluoroethylene, Dacron, or sylastic [
Hellstrom and Reddy [
Knoll [
With the increasing use of tissue engineering,
new tunica albuginea substitutes may be developed [
A discussion concerning the best graft often involves postoperative outcomes, although the type of relaxing incision or excision has varied. Postoperative outcomes are not solely dependent on the graft used.
A personal experience with bovine
pericardium associated with plaque excision gave discouraging results. In
contrast, results were promising when using the same type of graft associated
with a relaxing incision procedure [
In another personal experience, in four cases, it was necessary to remove the pericardium graft 2.5 to 8 months after surgery (in three cases due to infection in immunocompromised patients and in one case due to absorption of graft-graft suture with dehiscence and local hematoma formation); no leakage was seen after saline-induced erection, and the operative sites were left without grafts. After the recovery period, patients still have good-quality erections and axial rigidity, and are capable of having sexual intercourse. This has shown that grafts may even be absorbable, that is, the tunica may be allowed to rebuild on the structure of the graft, provided that this allows no new blood-vessel formation, which may lead to veno-occlusive dysfunction.
It is expected that all patients have a hematoma under the graft following a grafting procedure. A personal series of 20 patients were followed for 8 months, after which the hematoma disappeared in 50% and remained as a laminar hematoma in 50%, not causing any disturbance of penile functionality based on rigidity. It is a matter of concern to maintain a large hematoma that limits the expansion of sponge cavernous tissue based on the concealed fibrotic area in the outer part of the sponge tissue. The graft is important during this period to block leakage from the sponge tissue and to maintain good penile shape.
Of the four patients who had their grafts removed and had no leakage, two maintain a permanent constriction area at the site of the removed graft, which was filled by the hematoma underlying the graft.
With the purpose of trying to maintain a minimal hematoma under the graft until blockage occurs in the outer part of the sponge cavernous tissue, a light compressive postoperative dressing is applied to be kept in place for 7 to 10 days, and the patient is started on a PDE5 inhibitor at bedtime on the 7th to 10th postoperative day, to stimulate smooth muscle relaxation, thereby expanding the cavernous tissue and compressing the hematoma as a means to help it be absorbed or transformed into a laminar shape that does not affect axial rigidity. These medications are particularly important for patients with preoperative ED, and of utmost interest to reduce the hematoma and maintain physical therapy with stimulated or reflex nocturnal erections. Early postoperative use of a vacuum device can only increase the hematoma underlying the graft, owing to negative pressure.
Patients with PD and ED that are
nonresponsive to oral or injectable treatment will be candidates for penile
prosthesis implantation. Depending on the type and degree of penile deformity,
associated procedures (e.g., modeling, Nesbit/plication, or incision/excision as
well as grafting for penile rectification and/or correction of constrictive
lesions) may be necessary [
Rahman et al. [
Usta et al. [
Our personal experience is that pericardium
reconstruction has not increased the risk for infection and complications. This
may be due to the fact that pericardial tissue, in contrast to vein and dermal
grafts, needs no imbibition to survive. That is why we prefer reconstruction
with pericardium grafting according to geometric principles and single incision
[
Perovic and Djordjevic [
From April 1999 through September 2007, 521 patients who underwent geometrical incision correction were followed up: 311 patients underwent surgical straightening without penile prosthesis implantation and 210 patients underwent reconstruction with concomitant penile prosthesis implantation (malleable prostheses for 141; inflatable two pieces for 48; and inflatable three pieces for 21 patients). Patient preference was the criteria for prosthesis type choice.
A
bovine pericardium graft (Braile-Biomedica and HP-Biopróteses,
SP, Brazil)
was sutured into the defect and its size trimmed to 1 to 2 mm wider and longer
than the tunical defect in order to include this extra size in the suturing
procedure. The suture was continuous, with poliglecaprone 4.0. The greater the
curvature, the greater the graft size is. Mean graft width was
The mean
increase in functional penile size (dependent on curvature severity) was
311 patients underwent straightening procedure by geometrical principles and grafting without concomitant penile prosthesis implantation. Penile deformities were distributed as follows: dorsal 46% (143/311), dorsolateral 30% (93/311), lateral 12.5% (39/311), ventral 6% (19/311), and ventrolateral 5.5% (17/311). Mean penile curvature was 75±15.7° (range 45–120°). The technique corrected both deformities in 15.5% (48/311) of patients with Peyronie's disease associated with penile constriction.
In four cases, it
was necessary to remove the pericardium graft 2.5 to 8 months after surgery (in
three cases due to infection in immunocompromised patients and in one case due
to absorption of graft-graft suture with
dehiscence and local hematoma formation); no leakage was seen after
saline-induced erection, and the operative sites were left without grafts.
After the recovery period, patients still have good-quality erections and axial
rigidity, and are capable of having sexual intercourse. Follow-up by prostaglandin-induced erection of
Peyronie patients who did not receive prostheses has shown penile straightening
in 87% and residual curvature of up to 15° in 7% and up to 30° in 6% which does not disturb penile functioning when a good erection was
obtained, either associated with PDE-5 inhibitors or not. A second surgery with
penile prosthesis implantation was performed in 15% of cases whose follow-up
showed deterioration of erectile function. The mean follow-up period was
Even the patients who had deterioration on penile rigidity and underwent a second surgical procedure for penile prosthesis implantation recovered penetration ability and re-established satisfactory sexual intercourse. Patient satisfaction is obtained when patients recover their ability for penetration while maintaining orgasm.
The technique herein presented is a standardized procedure since it is based on geometrical principles and meets, as no other technique previously presented, the needs of most patients. It can be applied irrespective of the characteristics of the plaque or type of curvature caused by Peyronie’s disease, either associated with concomitant penile prostheses implantation or not.
The dissection of the neurovascular bundle has been standardized for all cases by means of the two paraurethral incisions in Buck’s fascia. At this level, the circumflex veins are of lesser caliber, thus permitting their cauterization, which means a smaller number of ligatures. Furthermore, when the dissection is done ventrally, these manipulations are made far from the dorsal nerves of the penis, which means a lesser risk of damaging them. Another favorable aspect is that the dissection under the bundle may be limited to the area of the curvature, allowing the possibility of its being extended if necessary. This smaller dissection of the bundle in the dorsal region minimizes the risk of lesions to the eventual collaterals between the dorsal and cavernous arteries.
The puncture
of one or more of the corpora cavernosa to induce and maintain a full erection
is of great importance for the correct application of these geometrical
principles which define the most appropriate site for the incision in the
tunica albuginea. The lines
In lateral curvatures, a rectangular defect is created by cutting the intercavernous septum insertion in both dorsal and ventral regions. Due to the risk of erectile dysfunction that can be caused by incisions in the intercavernous septum on the dorsum and ventrum to create a rectangular tunical defect, a trapezoidal shape was chosen for the defect because, as in the other examples given, it is made by cutting the intercavernous septum at just one point (dorsal side).
The intercavernous septum may be involved in the pathogenesis of the deformity of the penis. The septal incision on both sides of the transverse incision in the shorter side of the tunica albuginea is a key to adequate lengthening of the short side and complete straightening of the penis. The traction of the penis after the incision in the tunica albuginea, the septal incision, and the dissection of the tunica albuginea from the spongy tissue of the cavernous body allowed checking whether complete straightening of the penis had been achieved. Neurovascular bundle dissection can be extended when the bundle restricts penile straightening.
A tripod-shaped bifurcation with legs 120 degrees apart from each other provides a most stable structure, allowing, according to the surgeon, better results in view of a simpler configuration of the defect in the tunica, a geometrical, more easily constructed graft shape, and a simpler suturing procedure. The bifurcations in this technique also permitted relaxation of constricted areas in the tunica and correction of associated constrictive lesions. The bifurcations in the dorsal region for ventral curvatures should not cross the intercavernous septum.
The size of the tunical defect can be calculated before tunical incision by applying the geometrical principles during a full erection, thereby allowing graft preparation even at the physician’s office by induced erection.
The graft
to be used may match the defect size if no graft shrinkage is likely, as is the
case with pericardium grafts [
The length of the defect should be measured on an erect penis; in cases of constriction at the curvature site, it should be measured on a constriction-free site for appropriate girth restoration.
Under these circumstances, only one incision and one graft are necessary, provided that the penis shows a single point of maximum curvature (with two preferential directions only). If there are two significant curvatures at different points of the penis, two grafts may be made as described. Thus complementary plication—which not only harms the healthy side but also shortens the penis—may be avoided.
The technique herein described allows the standardization of a single tunical incision procedure that may be reproducible in multicenter studies, leading to a better understanding of the advantages and disadvantages of different types of graft material.
This single incision technique, applying geometrical principles, is a standardized procedure for the correction of any penile curvature, either associated with tunical constriction or not, providing maximum penile gain and girth restoration. The present technique is effective to correct all types of penile curvature, regardless of plaque characteristics. The improvement of tissue engineering techniques will contribute to the development of grafts that are increasingly close to the ideal for tunica albuginea replacement.