(191) Excision and Grafting with Concomitant Dorsal Plication for Ventral Plaque with Urethral Tethering
Authors: Howell S , Khalafalla K , Wang R 
Published: February 2024

Abstract

Introduction
Peyronie's disease, a condition characterized by penile curvature, approximately affects 9% of men. Surgical interventions are often employed to address this bothersome condition, and these can include techniques such as plication of the tunica albuginea, incision or excision of the plaque with grafting procedures, and penile prosthesis implantation. The recommended treatment options vary depending on the specific constellation of symptoms and underlying conditions experienced by the patient.

Objective
We present a case of severe ventral curvature and penile shortening due to urethral tethering, resulting in residual curvature even after undergoing plaque excision and grafting.

Methods
The patient is a 65-year-old gentleman with a history of metastatic renal cell carcinoma, deep vein thrombosis status post inferior vena cava filter placement as well as anticoagulation with apixaban, and diabetes mellitus who presented with a complaint of progressive penile curvature over his past 12 months. His secondary complaints included difficulty and pain with intercourse. He noted a 90-degree ventral erection. He denies any history of penile trauma, surgery, or pelvic radiation, though he did report chest radiation for his metastatic kidney cancer. Penile doppler noted a large ventral mid penile plaque measuring 9.5x7.7x5 mm. Due to the severe, bothersome curvature, the patient was recommended excision and grafting (Tutoplast). Intraoperatively, a 2.5 cm x 3.0 cm plaque was excised and a Tutoplast pericardial allograft was used to cover the corporal defect. However, due to urethral tethering the patient still had residual curvature. We opted to perform a dorsal tunica albuginea plication using the Lue 16 dot technique.

Results
Penile plication remains a tool in the armamentarium of the reconstructive urologist and andrologist for penile curvature arising from Peyronie’s disease. However, in the setting of severe curvature, the penile length loss arising from plication alone can be prohibitive. Therefore incision, or excision with grafting has been implemented with significant sparing of penile length. On the other hand, there is a limit to which length can be maintained and occasionally the tethering of the corpus spongiosum can result in residual curvature. Contralateral tunical plication is therefore an option to be performed concomitantly with grafting procedures. This combination is uncommon but has been reported. In our approach, the patient’s severe curvature was improved with ventral plaque excision and grafting. However, his residual curvature at this stage was able to be corrected with minimal effect on his penile length by applying a dorsal plication technique with minimal additional risk. During the follow-up after the surgery, the patient reported a smooth recovery without any complications. There was no residual curvature, and the patient was able to achieve normal erections sufficient for intercourse without the need for additional measures.

Conclusions
The correction of severe ventral curvature deformity can be challenging, the surgeon should be prepared to perform additional correction procedures if penile straightening was limited by the tethering of the neurovascular bundle or urethra. Excision and grafting of ventral plaque with concomitant dorsal tunica plication for residual curvature in settings of urethral tethering is a safe viable and effective option with excellent functional results.

Disclosure
No.