INTRODUCTION — Peyronie's disease, an acquired, localized fibrotic disorder of the tunica albuginea, can cause significant penile deformity and lead to sexual dysfunction and psychological trauma (figure 1). The nature and extent of Peyronie's plaque, and therefore the severity or complexity of penile deformity, varies widely.
Early medical intervention is the first line of therapy and is likely to be more effective when the disease is evolving, although new medications such as collagenase may play an important role in even stable and long-lasting disease. Once Peyronie's disease has reached a stable phase, surgery may be offered, but only for penile deformity that compromises sexual function.
This topic will review the indications for surgery in Peyronie's disease, approaches to surgical correction, and complications of surgical management.
The diagnosis and medical management of Peyronie's disease are discussed elsewhere. (See "Peyronie's disease: Diagnosis and medical management".)
SURGICAL INDICATIONS — Surgical management is indicated for patients whose Peyronie's disease has persisted for more than 12 months and is associated with a penile deformity compromising sexual function. It is important to delay surgery until Peyronie's disease has been stable for at least three months because surgical results can be compromised by active disease [1,2].
Other indications include men who failed Xiaflex therapy (collagenase clostridium histolyticum) and patients with extensive calcifications or indentations or hourglass deformities that are unlikely to improve with Xiaflex therapy. However, due to the increasingly successful outcomes with Xiaflex injection and modeling, the number of surgeries for Peyronie’s disease has decreased significantly in our practice. (See "Peyronie's disease: Diagnosis and medical management", section on 'Collagenase Clostridium histolyticum'.)
Surgery is not indicated for plaque without curvature, or minimal degrees of curvature, though "minimal degree" is a subjective measurement. The main determinant is whether sexual intercourse without pain (for patient or partner) is possible [3]. Curvature that does not preclude intercourse does not warrant surgery. (See "Peyronie's disease: Diagnosis and medical management".)
Concurrent implantation of a penile prosthesis is indicated in men with Peyronie's disease and erectile dysfunction (ED) unresponsive to oral agents or intracavernous injection therapy. (See 'Penile prosthesis' below and "Surgical treatment of erectile dysfunction", section on 'Indications'.)
PREOPERATIVE EVALUATION — A thorough review of the patient's medical and surgical history and a physical examination are performed. (See "Preoperative medical evaluation of the healthy adult patient".)
Medications that could potentially increase the risk of bleeding (eg, warfarin) are generally discontinued 7 to 10 days prior to the procedure. Aspirin may be continued if it is felt to be necessary by the patient's cardiologist or other medical providers (eg, to prevent coronary stent thrombosis). (See "Perioperative medication management", section on 'Medications affecting hemostasis' and "Perioperative management of patients receiving anticoagulants".)
The following elements of the preoperative evaluation are specific to penile reconstructive procedures:
Color duplex ultrasound evaluation of erectile capacity — A preoperative penile duplex ultrasound combined with intracavernous injection of a vasoactive agent is performed if distal flaccidity is present or erectile function is in question. A plain penile ultrasound in the flaccid state is also very helpful in identifying plaque size, number, location, and extent of calcification as well as intracavernous fibrosis. (See "Evaluation of male sexual dysfunction".)
Ultrasound assesses the nature and location of the Peyronie's plaque and penile vascular anatomy, identifying any arterial and/or venous components of erectile dysfunction (ED), if present. This information is particularly useful if grafting is being considered because the probability of developing ED is increased in men with penile vascular insufficiency.
Preoperative penile photographs/measurements — Preoperative penile photographs should be obtained of the erect penis to document penile length, nature (dorsal, ventral, lateral), and degree of curvature for future reference and for medicolegal purposes. Photographs in multiple views can be taken by the patient at home or in the office by inducing an artificial erection by injecting a vasodilating medication, such as alprostadil. Patients who are unable to take home photographs or who have concomitant erectile dysfunction (with which home photographs may be misleading) should be offered in-office injections. In general, in-office evaluation is superior, as the clinician can assess instability; additionally, home photographs may not truly represent the reality, as patients may be too embarrassed to get an adequate erection.
Choice of surgical approach — The most important factor determining surgical success is selection of the appropriate surgical procedure for a given patient. No one procedure is suitable for all cases of Peyronie's disease. Surgical options include tunical shortening (eg, plication), tunical lengthening (eg, grafting), or implantation of penile prostheses (which may be combined with adjuvant procedures to allow for resolution of deformity) [4].
Important factors to consider in determining the best surgical approach include the length of the penis, configuration (eg, hourglass, curved) and severity of the deformity, erectile capacity, and patient expectations [2,5]. Most curvature deformities are dorsal, although Peyronie's presentations are widely varied. A complete urologic examination is performed.
●For a penis with a simple (and some complex multiplanar) curvature <60º, adequate length, and intact erectile function, a tunical shortening procedure (ie, tunica wedge resection, plication) technique is appropriate. This procedure will not correct an hourglass deformity or hinge effect. When performed on appropriately selected men, simplified tunical shortening (ie, pure plication such as the 16 dot plication procedure) offers satisfactory results and minimizes surgical morbidity. Plication can also be performed on men with curvature >60°, but patients need to be well informed about the penile shortening that will occur. (See 'Plication' below.)
●For a very short penis, the presence of a severe curvature (>60º), narrowing deformity (eg, hourglass, severe indentation), and good erectile function, tunical lengthening with plaque incision and graft placement may at least partially restore penile length and/or girth. (See 'Grafting' below.)
●For curvature associated with significant ED, a penile prosthesis can be placed, and additional corrective procedures (plication or grafting) are performed if the prosthesis does not provide adequate straightening. (See 'Penile prosthesis' below.)
●To minimize the development of ED after surgery and simplify the procedure, we recommend extra-tunical grafting with Tutoplast to correct hourglass deformity [6] and tunica-sparing surgery for large calcifications [7].
Patient counseling — A thorough preoperative discussion is essential and should review preparation, complications, and realistic long-term outcomes associated with the planned surgery. Patients are informed of the risks of temporary or permanent penile hypoesthesia or anesthesia, future plaque formation, recurrent curvature, and risk of de novo or worsened ED. (See 'Complications' below.)
If erectile function is compromised preoperatively, the risk of further dysfunction is increased. Patients with a history of cardiovascular disease (ie, coronary artery disease [CAD] or peripheral artery disease [PAD]), diabetes, or smoking also have an increased long-term risk for ED, independent of the surgery performed for Peyronie's disease [8]. (See "Epidemiology and etiologies of male sexual dysfunction".)
Patients with ED or significant risk factors for future ED should be counseled regarding the placement of a penile prosthesis at the time of surgery. A prosthesis may also be placed at a later date as the need arises. (See 'Penile prosthesis' below.)
Patient expectations about postoperative penile length should also be addressed. Penile shortening often accompanies Peyronie's disease and is dependent on direction and degree of curvature and original penile length [9]. Patients, however, may have unrealistic recollections of their erect penile length prior to the onset of Peyronie's disease, and premorbid penile measurements are rarely available. The patient is informed that plication surgery may result in a straight erection but is not likely to restore any length and in fact will likely reduce length. With tunical lengthening procedures (ie, grafting), only approximately 1/2 to 1 inch of additional length can be expected (depending on the degree of curvature), and studies indicate that even grafting procedures should not truly be viewed as "lengthening" procedures [10]. It is important to document and review the preoperative stretched penile length with the patient.
Uncircumcised patients are informed that certain incisions may necessitate circumcision to prevent the postoperative complication of foreskin necrosis, which can be difficult to manage. The aesthetic and sensory ramifications of circumcision should be explained. (See "Neonatal circumcision: Risks and benefits".)
SURGICAL ANATOMY
Tunica albuginea — The tunica albuginea is a tough layer of fibrous connective tissue surrounding the bilateral corpora cavernosa of the penis (figure 2). The tunica is typically the target in Peyronie's disease surgery, with either plication of the side opposite the plaque or incision/grafting the same side as the plaque.
Neurovascular bundle — The neurovascular bundle runs along the dorsal aspect of the penis in a groove between the corpora cavernosa (figure 2). In the distal penis, the nerves spread out and may reach almost to the corpus spongiosum, although there is variability as to where the nerves ramify. The neurovascular bundle consists of the dorsal penile vein and paired dorsal arteries and nerves. Preserving the neurovascular bundle is critical since injury may lead to glans hypoesthesia or even necrosis. The neurovascular bundle is often intimately adherent to the underlying Peyronie's plaque; releasing these structures is often the hardest component of reconstructive surgery.
GENERAL APPROACH — Reconstructive procedures for Peyronie's disease are typically performed as an ambulatory procedure or with overnight observation either in an ambulatory or inpatient setting. Plication procedures can be performed with local anesthesia and monitored sedation; general or regional anesthesia may be more appropriate for more complicated procedures. (See "Overview of anesthesia".)
Prior to the incision, a single dose of a first-generation cephalosporin is given. The patient is positioned supine and the operative area depilated with a clipper. Bladder drainage is generally not required unless a penile prosthesis will be placed. If the saphenous vein will be used as a graft, the nondominant lower extremity is slightly flexed and abducted and prepped separately [11]. (See "Placement and management of urinary bladder catheters in adults".)
Following sterile preparation, an artificial erection is induced by injecting normal saline with 60 mg of papaverine into the corpus cavernosum; this aids in preprocedure planning and intraoperative assessment of surgical results. The site of greatest curvature and plaque is marked, the incision made in the skin, and the penis degloved to access the tunica albuginea; the choice of incision (circumferential below the glans, or longitudinal) depends upon the nature of the planned surgery.
An uncircumcised patient who receives a circumferential incision often requires a concomitant circumcision unless the incision is placed within 1 cm of the coronal sulcus; profound lymphedema or even foreskin necrosis has been reported with prepuce-preserving techniques. Patients must be informed of the aesthetic and sensation ramifications of this. (See 'Patient counseling' above.)
A longitudinal or penoscrotal incision may be advantageous in managing a dorsal curvature. This approach is also associated with improved healing and avoids lymphedema and the need for circumcision; however, visible scarring will result unless the incision is placed along the ventral penile raphe [12].
TECHNIQUES — Complementary techniques employed in the surgical management of Peyronie's disease include plication, grafting, or placement of a penile prosthesis. Tailored approaches are often required to manage the variety of plaque-induced penile deformities associated with Peyronie's plaques.
Each of the techniques can be performed with or without plaque incision, which facilitates tunica mobility. An H-shaped incision in the exterior surface of the plaque is often all that is needed. Plaque excision involves complete removal of the plaque and is associated with higher rates of erectile dysfunction, graft contracture, and late recurrence of curvature. Plaque excision used to be the standard approach [11]. In most of the cases, however, a tunica-preserving procedure can be performed and the calcified portion of the plaque removed via a lateral approach. This approach eliminates the need for grafting and decreases the incidence of postoperative erectile dysfunction [7].
Plication — Straightening the penis with plication is accomplished by shortening the convex side of the penis (ie, opposite the plaque). All plication procedures result in loss of penile length as the tunica albuginea is shortened on the longer side to match the shorter side [9]. Since the stretched penile length is determined by the shorter, less elastic side, the objective loss of penile length after plication is often less than what is perceived by the patient.
Thus, plication should only be performed in men with adequate penile length and generally only if the curvature is less than 60º (figure 3). If curvature is greater than 60°, plication can still be performed provided penile length is adequate and may be particularly useful if the patient is not willing to accept the risk of de novo loss of erectile rigidity associated with grafting.
Soft, braided, permanent, or delayed absorbable sutures are used because they are the least noticeable under the skin.
Plication is performed with or without plaque incision. When the tunica albuginea is plicated without incision (ie, pure plication), normal anatomy is minimally disrupted. Since dorsal curvature is the most prevalent, plication of the ventral surface avoids the need to dissect the dorsal neurovascular bundle.
The most common plication techniques are:
●Nesbit procedure – One or more ellipses of the tunica albuginea are excised from the convex side (ie, tunica wedge resection), and the tunica is plicated at the most prominent portion of the curvature [13].
●Yachia procedure – Longitudinal incisions in the tunica albuginea on the convex side are closed horizontally (ie, Heineke-Mikulicz principle) [14].
●Lue procedure – The Lue procedure, also known as the "16 dot" minimal tension approach, is a pure plication procedure consisting of two or three pairs of plications to cover the entire length of the pendulous portion of the penis on the convex side [15,16]. Paired sutures are placed in the tunica albuginea and tension adjusted to straighten the curvature prior to completing the ties on the erect penis that was induced with intracavernous injection of papaverine.
Grafting — Men with Peyronie's disease who have a short penis, extensive plaque, or severe (>60º) or complex deformities will require a grafting procedure. Grafting the concave side of the penis serves to lengthen that side and, therefore, straighten the penis (figure 4).
Dissection of the neurovascular bundle and/or corpus spongiosum may be required depending upon the location of the deformity; injury to the dorsal neural complex with loss of glans sensation may result.
Opening the tunica albuginea often worsens erectile function. Patients must be aware of this risk and should be counseled regarding the option of penile prosthesis implantation, either at the same setting or as a staged procedure [17]. (See 'Complications' below and 'Patient counseling' above.)
Graft materials — Following management of the plaque, a graft is placed. The choice of graft material depends upon several factors, including type of deformity, efficacy, and availability [18]. Grafting materials include:
●Autologous tissue (eg, saphenous vein, fascia lata, rectus fascia, tunica vaginalis, dermis, buccal mucosa). Vein patch is a commonly used autograft material and is harvested from the distal saphenous vein; if a larger graft is needed, the proximal saphenous vein can be used. The saphenous vein is spared in patients with significant cardiovascular disease (ie, coronary artery disease [CAD], peripheral artery disease [PAD]); these patients may need the saphenous vein for future bypass grafting.
●Allograft or xenograft materials (eg, cadaveric or bovine pericardium, engineered dermal graft, porcine small intestinal submucosa [SIS], equine collagen fleece) [19-21]. These acellular matrices allow regenerative in-growth of native tissues. The main advantage of allograft tissues is elimination of the need for tissue harvesting.
●Synthetic grafts (eg, polytetrafluoroethylene [PTFE]). The use of synthetic materials is discouraged due to increased incidence of infection and postoperative inflammation leading to perigraft fibrosis [1,3,21]. (See 'Complications' below.)
Penile prosthesis — The treatment of choice for patients with Peyronie's disease and significant erectile dysfunction is placement of a penile prosthetic implant with or without manual modeling and with or without penile reconstruction.
Patient satisfaction is higher with inflatable penile prostheses than malleable devices (picture 1) [1,22]. Either a two-piece (picture 2) or three-piece (picture 3) prosthetic is used. (See "Surgical treatment of erectile dysfunction", section on 'Inflatable'.)
The correction of penile curvature can be accomplished solely by implantation of the penile prosthesis in patients with mild-to-moderate curvature. Manual modeling over the prosthesis may be required to correct more significant deformities (eg, >30º curvature) [23]. Penile reconstruction (plaque incision/grafting) can be performed before or after implant placement in patients with severe or complex deformities or calcified Peyronie's plaque [24].
Manual modeling is a process by which the tunica plaque is fractured over the inflated prosthetic cylinder at the time of implantation. When successful, the modeling procedure causes splitting and rupturing of the fibrotic plaques. To perform manual modeling, the penis is forcibly bent in a direction opposite the curvature [23]. Bending pressure is maintained on the penis for 90 seconds. The process is repeated at least two times with the prosthesis fully inflated between bending. During manual modeling, the prosthetic cylinder must be protected to prevent injury, and the distal penis must be carefully controlled to avoid urethral injury. Afterwards, the penile implant is left partially inflated for six weeks to prevent contraction of the tunica defect, which could lead to recurrent curvature.
An alternative approach is to correct the penile curvature with plication sutures. If the patient is known to have penile curvature, plication sutures should be placed before corporotomy is made and tied after the cylinders are inflated if the curvature remains [24]. If the curvature is identified after prosthesis has already been placed, the prosthetic cylinders should be pulled out of the corpora before any plication sutures are placed to avoid needle puncture of the cylinders.
Dressing — Following the reconstructive procedure, a petrolatum gauze is placed on the incision and covered loosely with a gauze pad. A snug, self-adhesive wrap (eg, Coban) is placed around the penis from distal to proximal and then squeezed gently to make it snug but not constrictive.
POSTOPERATIVE CARE — Depending upon the nature and length of the procedure and degree of postoperative pain, overnight observation may be indicated.
Pain management — Intravenous or oral pain medications are given, as needed. (See "Management of acute perioperative pain in adults".)
An ice pack is applied intermittently to the penis for the first 24 hours to lessen pain and swelling.
Dressing — On the first postoperative day, patients are taught how to change their dressing and are instructed to perform daily dressing changes for 5 to 10 days. The patient may shower but should keep the dressing dry, which can be accomplished by applying a condom or a plastic bag. Water immersion is avoided for five weeks.
Patient instructions — Patients are instructed to:
●Resume activities as tolerated. If the patient has received a prosthesis, heavy lifting and soaking of the wound should be avoided for four weeks.
●Return to work in a few days depending upon speed of recovery.
●Watch for signs of infection (ie, fever, redness, excess swelling, discharge, increasing pain), particularly if a prosthesis has been placed.
●Arrange to be seen by the surgeon if infection develops or if there are any other concerns.
Sexual activity — The patient is instructed not to engage in sexual intercourse or masturbation for four to eight weeks, depending on the surgery.
FOLLOW-UP CARE — Follow-up in the office varies depending upon the nature of the procedure and the patient's recovery. Following the placement of a prosthesis, the patient is scheduled to return to the clinic in approximately two to six weeks to learn how to use the device.
COMPLICATIONS — The complications associated with correction of Peyronie's disease deformities are dependent upon the technique used for reconstruction. General complications include surgical site infection, penile hematoma, penile narrowing or indentation, phimosis, sensory abnormalities, and erectile dysfunction.
Erectile dysfunction, like sensory abnormalities, is more likely to occur in procedures that require dissection and mobilization of the neurovascular bundle and opening of the corpora cavernosa.
Erectile dysfunction — Erectile dysfunction (ED) is reported to occur in up to 20 percent of patients postoperatively. In retrospective reviews, pure plication (ie, Lue procedure) has been associated with the least risk of ED compared with standard plication (ie, Nesbit, Yachia) and grafting procedures [13,16,21]. Patients with preexisting ED are more likely to experience worsened sexual function, though ED can develop de novo. Up to 45 percent of patients with preexisting ED will suffer a further decline [25,26]. Long-term, additional deterioration in both erectile and orgasmic function has been observed [25]. Patients with preexisting ED should be counseled appropriately. (See 'Patient counseling' above.)
Graft complications — The use of grafting materials is associated with additional complications that include persistent pain, which may be due to neurologic injury; graft bulging (ie, herniation); graft infection; or graft contracture leading to penile shortening or recurrent curvature [19,27]. Surgical site infection can also occur at the site of autogenous tissue harvest.
If the patient notices a bulging of the graft, which can occur two to three months postoperatively, a duplex ultrasound is performed. If a hematoma is identified, an aspiration procedure is performed. If no hematoma is identified, observation is continued. Reoperation may be required if the bulge is chronic and clinically significant (ie, causing difficulty with or precluding sexual intercourse).
Penile implant complications — The complications associated with penile implants are discussed elsewhere. (See "Surgical treatment of erectile dysfunction".)
OUTCOMES — With an appropriately chosen technique taking into consideration patient-specific characteristics, reconstruction for Peyronie's disease achieves satisfactory results in the majority of men [1,18,25,27]. Long-term satisfaction with return to sexual activity was high for both patient (86 percent) and partner (77 percent) in a retrospective evaluation of 61 patients [28]. Curvature is corrected in most patients; however, minor residual and recurrent curvature is reported for all the techniques described.
Plication (Yachia, Nesbit, Lue) achieves penile straightening in 67 to 100 percent of patients with a low risk for postoperative sexual dysfunction [1,14,16,29,30]. The primary concern for these patients is the degree of penile shortening. While some degree of penile shortening occurs in all patients, few have difficulty with penetration [13]. Residual curvature rates vary from 7 to 21 percent and may be due to suture absorption, slippage, or breakage [16] (see 'Plication' above). Persistent painful erection from permanent sutures occurs in a small number of patients after plication procedures. If pain persists for more than six months and is refractory to steroid injection, surgical removal of the sutures may be needed.
For patients who undergo grafting procedures, patient satisfaction and curvature correction rates are the highest (>90 percent) with autogenous vein grafting (table 1) compared with other grafting materials in retrospective reviews [1,19,25,27,28,31,32]. Recurrent curvature occurs in 12 to 16 percent of patients following vein graft procedures [25,28]. Other grafting materials (ie, dermis, pericardium, small intestinal submucosa [SIS]) have been evaluated, but clinical outcomes are inconsistent and not superior to autogenous vein grafts [1,28,31].
The use of penile implants in the treatment of Peyronie's disease produces satisfactory correction of curvature with adequate erectile function in more than 85 percent of patients in most large series [1,22,33]. (See "Surgical treatment of erectile dysfunction", section on 'Penile prostheses'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Peyronie's disease".)
SUMMARY AND RECOMMENDATIONS
●Peyronie's disease is an acquired, localized fibrotic disorder of the tunica albuginea that can cause significant penile deformity and lead to sexual dysfunction and psychological trauma. (See 'Introduction' above.)
●Surgical management is indicated for patients whose Peyronie's disease has persisted for more than 12 months, is refractory to medical treatment, and is associated with a penile deformity compromising sexual function. (See 'Surgical indications' above and "Peyronie's disease: Diagnosis and medical management".)
●The length of the penis, nature (eg, hourglass, curved) and severity of the deformity, erectile capacity, and patient expectations are important factors to consider when determining the surgical approach. (See 'Choice of surgical approach' above.)
●Surgical techniques used for penile reconstruction in Peyronie's disease include plication, grafting, or placement of a penile prosthesis. Plication shortens the convex side of the penis, whereas grafting techniques lengthen the concave side. Penile implants are used in patients with preexisting erectile dysfunction. Plaque incision is often combined with these techniques to improve the mobility of the plaque. (See 'Techniques' above.)
●Erectile dysfunction (ED) occurs in up to 20 percent of patients following surgical reconstruction for Peyronie's disease and can occur without a prior history of ED; however, ED is more likely to complicate procedures requiring dissection of the neurovascular bundle and placement of a graft, or in patients with preexisting ED. (See 'General approach' above.)
●For patients with a dorsal curvature less than 60°, we suggest ventral plication as the initial surgical approach (Grade 2C). Although generally used for curvatures less than 60°, plication can be used for greater degrees of curvature, provided there is sufficient penile length, and it may be particularly useful if the patient is not willing to accept the risk of de novo loss of erectile rigidity associated with grafting. (See 'General approach' above.)
●For patients with curvatures greater than 60°, we suggest plaque excision and grafting (Grade 2C). (See 'General approach' above.)
●In those patients with preexisting ED, we suggest implantation of a penile prosthetic in conjunction with penile reconstruction (Grade 2B). (See 'Patient counseling' above and 'Complications' above.)
