# Peyronie's Reconstruction for Maximum Length and Girth Gain: Geometrical Principles

Authors: Paulo H. Egydio; Salvatore Sansalone
Journal: Advances in Urology
 (2008)

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## Abstract

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.


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## Body

## 1. Introduction

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 [1].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 [2]. Careful assessment of this associated condition is a key
to correctly determine the need for surgery and to ensure the success rate of
reconstruction procedures.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 [3, 4] can have it implanted during the reconstructive
procedure.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 [5].


## 2. Materials and Methods

### 2.1. Preoperative Evaluation

#### 2.1.1. Sexual and Medical History

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.


#### 2.1.2. Assessment of Penile Deformity, Rigidity, Vascular Status, and Arterial Anomalies

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 to20μg,
which allows evaluation of penile deformity and objective rigidity, and, with
Doppler ultrasound (DUS), provides essential data for vascular assessment
(arterial insufficiency and/or veno-occlusive dysfunction) as well as detection
and localization of collaterals between dorsal and cavernous arteries.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 [6]. In another
retrospective study, vascular status was correlated to the type of penile
deformity, demonstrating a relationship between type of curvature and penile
hemodynamics [7].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 [2].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 [8]. There are
patients with penile curvature and no palpable thickened tunica who undergo
surgery. Penile deformity, not the plaque, is the main complaint of a PD
patient. Surgery should focus on deformity correction rather than on plaques.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.


#### 2.1.3. Tunical-Lengthening Procedures Based on Geometrical Principles [9–13]

Surgical Technique
(1)
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.(2)
In cases of dorsal curvature,
two tangential lines to the penile axis (red lines) are drawn on the
proximal and distal straight segments (a-a′ and b-b′, resp.) toward the
area of curvature of the erect penis (Figure 1).(3)
From the point of maximum
curvature (P) located at the intersection of the linesa-a′ and b-b′, a
circumferential line (green line) is drawn at the bisector of the angle
formed by these lines (Figure 1).
(4)
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.(5)
The transverse incision in the tunica will be made
along this circumferential line (green line) later. Then the erection is
reversed.(6)
Two paraurethral incisions (c-c′) are made where the
circumferential line crosses the urethra to dissect Buck’s fascia and its
neurovascular bundle from the tunica around the complete circumference of
the penis in all types of curvature, except at the level of the urethra
(Figures 2(a), 2(b)).(7)
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 (Figure2(c)).
(8)
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 (Figure3).
(9)
The width (W) of the defect should be the same as the
difference between the long and the short sides of the penis. This
measurement is calculated by the distance between any two complete
circumferential lines perpendicular to the penile axis drawn on the
straight penile segments, that is, outside the area of curvature (before
d-d′ and after e-e′)  (Figure 1).(10)
The difference (W) between d-e and d′-e′ (red arrow,
Figure 1) will be the size of the defect on each side of the urethra in
cases of dorsal curvature (Figures 4(a), 4(c)).
(11)
On the circumferential line, a length ofW/4 away from
the site where it meets the g line, points F and F′ (Figures 4(a) and 5) are determined to mark
the start of bifurcation, which extends to either side of the g line at a
length of W/2, thus generating a 120° angle (Figure 5); the resulting
defect will be more simple and stable as a tripod.
(12)
Defect length (L) will be equivalent to the distance between the two paraurethral incisions for dorsal curvature, or between the two ends
of the fork-shaped incision for any type of curvature passing round the
short side of the erect penis (Figures 4(a), 6(a), 7(a)).(13)
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.(14)
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 (Figure4(c)).(15)
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 (Figure6).
(16)
The urethra is dissected from its bed and the graft is
placed between the urethra and the cavernous body (Figures6(c) and 6(d)). A
new induced erection demonstrates complete penile straightening (Figures 6(b)
and 6(d)).(17)
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.(18)
In cases of lateral curvature (Figure7(a)), the defect
turns out to have the shape of a trapezium instead of a rectangle as
obtained in cases of dorsal and ventral curvature. The shorter side of the
trapezium can vary from 0.5 to 1 cm (W′). The longer side (W + W′) is equal
to the difference between the long and the short sides (W) of the penis
(obtained as the other curvatures), added to the length of the smaller
side of the trapezium (W′). The height of the trapezium (L) is measured as
described for the other types of curvature (Figure 7(a)). Thus this
procedure avoids a defect of triangular shape which would make the graft
procedure more difficult (Figures 7(c) and 7(d)).
(19)
The graft is cut according to the measurements already
made (i.e., widthW and length L) but should be 1-2 mm wider and longer
than the defect to provide room for the suture. However, the graft should
only be this size when the material used is not likely to shrink;
otherwise, a percentage for graft shrinkage should be allowed.(20)
The length (L) of the defect should be measured with
the penis erect and outside any constricted area to allow girth correction
in constricted penile shaft area.(21)
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.Figure 1
The intersection of
the tangential lines to the penile axisa-a′ and b-b′ (red lines) determines the
point of maximum curvature (P). A circumferential line is drawn (green line)
from point P in the bisector of the angle formed by the lines a-a′ and b-b′. W (red arrow) is equal to the
distance of the two points of the long side (d-e) minus the equivalent distance (d′-e′) in
the short side of  the penis   (θ=90°).(a) Paraurethral incisions (c-c′) in Buck's fascia. (b) Dissection of Buck's fascia and the neurovascular bundle from
the tunica albuginea. (c)
Drawing of the circumferential line in the point of maximum curvature.
(a)(b)(c)(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)(b)(c)(a) Bifurcation
of the transverse incision and the correspondent defects in the tunica
albuginea in cases of dorsal curvatures.W = the width of the defect. L = the length of the defect. F and F′ are the
points from which the circular incision is forked. (b) Preoperative
dorsal curvature. (c) Final result after straightening and graft
suturing.
(a)(b)(c)Figure 5
The starting point
of the 120-degree bifurcation at the end of circumferential lines is
established by marking a length ofW/4 back from the intersection with the g
line. W is the differences measured
between the longer and shorter side of the penis that correspond to the width
(W) of the tunica defect.(a) Bifurcation
of the transverse incision and the correspondent defects in the tunica in cases
of ventral curvatures.W = the
width of the defect. L = the
length of the defect. F and F′
are the points from which the circular incision is forked. (b) Preoperative
ventral curvature. (c) Urethral
dissection. (d) Final result
after straightening and graft suturing.
(a)(b)(c)(d)(a) Bifurcation
of the transverse incision and the correspondent defects in the tunica in cases
of lateral curvatures.W = the
difference between the short and long side. W′ = a measure added on both side L =  the length of
the defect. F and F′ are the points from which the circular
incision is forked. (b) Lateral
curvature after a degloving procedure. (c) Trapezoidal graft was drawn in the
pericardium. (d) Final result
after straightening and graft suturing.
(a)(b)(c)(d)


### 2.3. Grafting

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 [14].
The disadvantage of using autologous grafting includes lengthening of operative
time, morbidity, and scarring on the harvest site. The amount of tissue may be
another limiting factor.Hellstrom and Reddy [15]
reported on using human cadaveric pericardium, as Chun et al. [16] as well as Levine and Estrada [17] did.
Leungwattanakij et al. [18] compared several types of
grafts in a rat model showing a low rate of inflammatory reactions with
cadaveric pericardium.Knoll [19] reported
the use of porcine small-intestine submucosa (SIS) grafts for tunical substitute, with promising results. Larger-sized and more
uniform patches are advantages of SIS grafts, but absorption on larger defects
must be slower, requiring the use of SIS with multilayer sheet.With the increasing use of tissue engineering,
new tunica albuginea substitutes may be developed [20, 21].
Advances in this area are prominent, and grafts will be available in the future
that are much more similar to the tunica albuginea, or acellular matrix that
may allow the tunica to be rebuilt, whether associated with cell culture and
seeding or not.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 [9].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.


### 2.4. Penile Prosthesis Implantation

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 [22].Rahman et al. [23]
reported penile plication surgery associated with penile prosthesis. The
inconvenience of this procedure is penile-length reduction. The higher the
curvature degree, the greater this reduction will be.Usta et al. [24]
reported the long-term results of surgical treatment for PD, showing that
penile prosthesis implantation and curvature correction with pericardium graft
added no risks of complications as compared to prosthesis implantation surgery
alone.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
[5, 9, 11], and concomitant implantation of malleable or inflatable prosthesis of
a size compatible with the longer side, as the shorter side has been elongated.Perovic and Djordjevic [25] described the
penile disassembly technique for distal penile deformity, which allows
excellent distal exposure for distal reconstruction.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 was3.2±0.3
cm (range 2.5–4.0 cm), and mean
graft length was 7.7±0.4 cm (range 7.5–8.5 cm).The mean
increase in functional penile size (dependent on curvature severity) was3.2±1.7
cm (1.5–5.5 cm).


## 2.1. Preoperative Evaluation

### 2.1.1. Sexual and Medical History

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.


### 2.1.2. Assessment of Penile Deformity, Rigidity, Vascular Status, and Arterial Anomalies

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 to20μg,
which allows evaluation of penile deformity and objective rigidity, and, with
Doppler ultrasound (DUS), provides essential data for vascular assessment
(arterial insufficiency and/or veno-occlusive dysfunction) as well as detection
and localization of collaterals between dorsal and cavernous arteries.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 [6]. In another
retrospective study, vascular status was correlated to the type of penile
deformity, demonstrating a relationship between type of curvature and penile
hemodynamics [7].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 [2].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 [8]. There are
patients with penile curvature and no palpable thickened tunica who undergo
surgery. Penile deformity, not the plaque, is the main complaint of a PD
patient. Surgery should focus on deformity correction rather than on plaques.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.


### 2.1.3. Tunical-Lengthening Procedures Based on Geometrical Principles [9–13]

Surgical Technique
(1)
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.(2)
In cases of dorsal curvature,
two tangential lines to the penile axis (red lines) are drawn on the
proximal and distal straight segments (a-a′ and b-b′, resp.) toward the
area of curvature of the erect penis (Figure 1).(3)
From the point of maximum
curvature (P) located at the intersection of the linesa-a′ and b-b′, a
circumferential line (green line) is drawn at the bisector of the angle
formed by these lines (Figure 1).
(4)
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.(5)
The transverse incision in the tunica will be made
along this circumferential line (green line) later. Then the erection is
reversed.(6)
Two paraurethral incisions (c-c′) are made where the
circumferential line crosses the urethra to dissect Buck’s fascia and its
neurovascular bundle from the tunica around the complete circumference of
the penis in all types of curvature, except at the level of the urethra
(Figures 2(a), 2(b)).(7)
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 (Figure2(c)).
(8)
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 (Figure3).
(9)
The width (W) of the defect should be the same as the
difference between the long and the short sides of the penis. This
measurement is calculated by the distance between any two complete
circumferential lines perpendicular to the penile axis drawn on the
straight penile segments, that is, outside the area of curvature (before
d-d′ and after e-e′)  (Figure 1).(10)
The difference (W) between d-e and d′-e′ (red arrow,
Figure 1) will be the size of the defect on each side of the urethra in
cases of dorsal curvature (Figures 4(a), 4(c)).
(11)
On the circumferential line, a length ofW/4 away from
the site where it meets the g line, points F and F′ (Figures 4(a) and 5) are determined to mark
the start of bifurcation, which extends to either side of the g line at a
length of W/2, thus generating a 120° angle (Figure 5); the resulting
defect will be more simple and stable as a tripod.
(12)
Defect length (L) will be equivalent to the distance between the two paraurethral incisions for dorsal curvature, or between the two ends
of the fork-shaped incision for any type of curvature passing round the
short side of the erect penis (Figures 4(a), 6(a), 7(a)).(13)
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.(14)
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 (Figure4(c)).(15)
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 (Figure6).
(16)
The urethra is dissected from its bed and the graft is
placed between the urethra and the cavernous body (Figures6(c) and 6(d)). A
new induced erection demonstrates complete penile straightening (Figures 6(b)
and 6(d)).(17)
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.(18)
In cases of lateral curvature (Figure7(a)), the defect
turns out to have the shape of a trapezium instead of a rectangle as
obtained in cases of dorsal and ventral curvature. The shorter side of the
trapezium can vary from 0.5 to 1 cm (W′). The longer side (W + W′) is equal
to the difference between the long and the short sides (W) of the penis
(obtained as the other curvatures), added to the length of the smaller
side of the trapezium (W′). The height of the trapezium (L) is measured as
described for the other types of curvature (Figure 7(a)). Thus this
procedure avoids a defect of triangular shape which would make the graft
procedure more difficult (Figures 7(c) and 7(d)).
(19)
The graft is cut according to the measurements already
made (i.e., widthW and length L) but should be 1-2 mm wider and longer
than the defect to provide room for the suture. However, the graft should
only be this size when the material used is not likely to shrink;
otherwise, a percentage for graft shrinkage should be allowed.(20)
The length (L) of the defect should be measured with
the penis erect and outside any constricted area to allow girth correction
in constricted penile shaft area.(21)
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.Figure 1
The intersection of
the tangential lines to the penile axisa-a′ and b-b′ (red lines) determines the
point of maximum curvature (P). A circumferential line is drawn (green line)
from point P in the bisector of the angle formed by the lines a-a′ and b-b′. W (red arrow) is equal to the
distance of the two points of the long side (d-e) minus the equivalent distance (d′-e′) in
the short side of  the penis   (θ=90°).(a) Paraurethral incisions (c-c′) in Buck's fascia. (b) Dissection of Buck's fascia and the neurovascular bundle from
the tunica albuginea. (c)
Drawing of the circumferential line in the point of maximum curvature.
(a)(b)(c)(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)(b)(c)(a) Bifurcation
of the transverse incision and the correspondent defects in the tunica
albuginea in cases of dorsal curvatures.W = the width of the defect. L = the length of the defect. F and F′ are the
points from which the circular incision is forked. (b) Preoperative
dorsal curvature. (c) Final result after straightening and graft
suturing.
(a)(b)(c)Figure 5
The starting point
of the 120-degree bifurcation at the end of circumferential lines is
established by marking a length ofW/4 back from the intersection with the g
line. W is the differences measured
between the longer and shorter side of the penis that correspond to the width
(W) of the tunica defect.(a) Bifurcation
of the transverse incision and the correspondent defects in the tunica in cases
of ventral curvatures.W = the
width of the defect. L = the
length of the defect. F and F′
are the points from which the circular incision is forked. (b) Preoperative
ventral curvature. (c) Urethral
dissection. (d) Final result
after straightening and graft suturing.
(a)(b)(c)(d)(a) Bifurcation
of the transverse incision and the correspondent defects in the tunica in cases
of lateral curvatures.W = the
difference between the short and long side. W′ = a measure added on both side L =  the length of
the defect. F and F′ are the points from which the circular
incision is forked. (b) Lateral
curvature after a degloving procedure. (c) Trapezoidal graft was drawn in the
pericardium. (d) Final result
after straightening and graft suturing.
(a)(b)(c)(d)


## 2.1.1. Sexual and Medical History

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.


## 2.1.2. Assessment of Penile Deformity, Rigidity, Vascular Status, and Arterial Anomalies

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 to20μg,
which allows evaluation of penile deformity and objective rigidity, and, with
Doppler ultrasound (DUS), provides essential data for vascular assessment
(arterial insufficiency and/or veno-occlusive dysfunction) as well as detection
and localization of collaterals between dorsal and cavernous arteries.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 [6]. In another
retrospective study, vascular status was correlated to the type of penile
deformity, demonstrating a relationship between type of curvature and penile
hemodynamics [7].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 [2].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 [8]. There are
patients with penile curvature and no palpable thickened tunica who undergo
surgery. Penile deformity, not the plaque, is the main complaint of a PD
patient. Surgery should focus on deformity correction rather than on plaques.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.


## 2.1.3. Tunical-Lengthening Procedures Based on Geometrical Principles [9–13]

Surgical Technique
(1)
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.(2)
In cases of dorsal curvature,
two tangential lines to the penile axis (red lines) are drawn on the
proximal and distal straight segments (a-a′ and b-b′, resp.) toward the
area of curvature of the erect penis (Figure 1).(3)
From the point of maximum
curvature (P) located at the intersection of the linesa-a′ and b-b′, a
circumferential line (green line) is drawn at the bisector of the angle
formed by these lines (Figure 1).
(4)
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.(5)
The transverse incision in the tunica will be made
along this circumferential line (green line) later. Then the erection is
reversed.(6)
Two paraurethral incisions (c-c′) are made where the
circumferential line crosses the urethra to dissect Buck’s fascia and its
neurovascular bundle from the tunica around the complete circumference of
the penis in all types of curvature, except at the level of the urethra
(Figures 2(a), 2(b)).(7)
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 (Figure2(c)).
(8)
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 (Figure3).
(9)
The width (W) of the defect should be the same as the
difference between the long and the short sides of the penis. This
measurement is calculated by the distance between any two complete
circumferential lines perpendicular to the penile axis drawn on the
straight penile segments, that is, outside the area of curvature (before
d-d′ and after e-e′)  (Figure 1).(10)
The difference (W) between d-e and d′-e′ (red arrow,
Figure 1) will be the size of the defect on each side of the urethra in
cases of dorsal curvature (Figures 4(a), 4(c)).
(11)
On the circumferential line, a length ofW/4 away from
the site where it meets the g line, points F and F′ (Figures 4(a) and 5) are determined to mark
the start of bifurcation, which extends to either side of the g line at a
length of W/2, thus generating a 120° angle (Figure 5); the resulting
defect will be more simple and stable as a tripod.
(12)
Defect length (L) will be equivalent to the distance between the two paraurethral incisions for dorsal curvature, or between the two ends
of the fork-shaped incision for any type of curvature passing round the
short side of the erect penis (Figures 4(a), 6(a), 7(a)).(13)
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.(14)
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 (Figure4(c)).(15)
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 (Figure6).
(16)
The urethra is dissected from its bed and the graft is
placed between the urethra and the cavernous body (Figures6(c) and 6(d)). A
new induced erection demonstrates complete penile straightening (Figures 6(b)
and 6(d)).(17)
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.(18)
In cases of lateral curvature (Figure7(a)), the defect
turns out to have the shape of a trapezium instead of a rectangle as
obtained in cases of dorsal and ventral curvature. The shorter side of the
trapezium can vary from 0.5 to 1 cm (W′). The longer side (W + W′) is equal
to the difference between the long and the short sides (W) of the penis
(obtained as the other curvatures), added to the length of the smaller
side of the trapezium (W′). The height of the trapezium (L) is measured as
described for the other types of curvature (Figure 7(a)). Thus this
procedure avoids a defect of triangular shape which would make the graft
procedure more difficult (Figures 7(c) and 7(d)).
(19)
The graft is cut according to the measurements already
made (i.e., widthW and length L) but should be 1-2 mm wider and longer
than the defect to provide room for the suture. However, the graft should
only be this size when the material used is not likely to shrink;
otherwise, a percentage for graft shrinkage should be allowed.(20)
The length (L) of the defect should be measured with
the penis erect and outside any constricted area to allow girth correction
in constricted penile shaft area.(21)
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.Figure 1
The intersection of
the tangential lines to the penile axisa-a′ and b-b′ (red lines) determines the
point of maximum curvature (P). A circumferential line is drawn (green line)
from point P in the bisector of the angle formed by the lines a-a′ and b-b′. W (red arrow) is equal to the
distance of the two points of the long side (d-e) minus the equivalent distance (d′-e′) in
the short side of  the penis   (θ=90°).(a) Paraurethral incisions (c-c′) in Buck's fascia. (b) Dissection of Buck's fascia and the neurovascular bundle from
the tunica albuginea. (c)
Drawing of the circumferential line in the point of maximum curvature.
(a)(b)(c)(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)(b)(c)(a) Bifurcation
of the transverse incision and the correspondent defects in the tunica
albuginea in cases of dorsal curvatures.W = the width of the defect. L = the length of the defect. F and F′ are the
points from which the circular incision is forked. (b) Preoperative
dorsal curvature. (c) Final result after straightening and graft
suturing.
(a)(b)(c)Figure 5
The starting point
of the 120-degree bifurcation at the end of circumferential lines is
established by marking a length ofW/4 back from the intersection with the g
line. W is the differences measured
between the longer and shorter side of the penis that correspond to the width
(W) of the tunica defect.(a) Bifurcation
of the transverse incision and the correspondent defects in the tunica in cases
of ventral curvatures.W = the
width of the defect. L = the
length of the defect. F and F′
are the points from which the circular incision is forked. (b) Preoperative
ventral curvature. (c) Urethral
dissection. (d) Final result
after straightening and graft suturing.
(a)(b)(c)(d)(a) Bifurcation
of the transverse incision and the correspondent defects in the tunica in cases
of lateral curvatures.W = the
difference between the short and long side. W′ = a measure added on both side L =  the length of
the defect. F and F′ are the points from which the circular
incision is forked. (b) Lateral
curvature after a degloving procedure. (c) Trapezoidal graft was drawn in the
pericardium. (d) Final result
after straightening and graft suturing.
(a)(b)(c)(d)


## 2.3. Grafting

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 [14].
The disadvantage of using autologous grafting includes lengthening of operative
time, morbidity, and scarring on the harvest site. The amount of tissue may be
another limiting factor.Hellstrom and Reddy [15]
reported on using human cadaveric pericardium, as Chun et al. [16] as well as Levine and Estrada [17] did.
Leungwattanakij et al. [18] compared several types of
grafts in a rat model showing a low rate of inflammatory reactions with
cadaveric pericardium.Knoll [19] reported
the use of porcine small-intestine submucosa (SIS) grafts for tunical substitute, with promising results. Larger-sized and more
uniform patches are advantages of SIS grafts, but absorption on larger defects
must be slower, requiring the use of SIS with multilayer sheet.With the increasing use of tissue engineering,
new tunica albuginea substitutes may be developed [20, 21].
Advances in this area are prominent, and grafts will be available in the future
that are much more similar to the tunica albuginea, or acellular matrix that
may allow the tunica to be rebuilt, whether associated with cell culture and
seeding or not.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 [9].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.


## 2.4. Penile Prosthesis Implantation

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 [22].Rahman et al. [23]
reported penile plication surgery associated with penile prosthesis. The
inconvenience of this procedure is penile-length reduction. The higher the
curvature degree, the greater this reduction will be.Usta et al. [24]
reported the long-term results of surgical treatment for PD, showing that
penile prosthesis implantation and curvature correction with pericardium graft
added no risks of complications as compared to prosthesis implantation surgery
alone.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
[5, 9, 11], and concomitant implantation of malleable or inflatable prosthesis of
a size compatible with the longer side, as the shorter side has been elongated.Perovic and Djordjevic [25] described the
penile disassembly technique for distal penile deformity, which allows
excellent distal exposure for distal reconstruction.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 was3.2±0.3
cm (range 2.5–4.0 cm), and mean
graft length was 7.7±0.4 cm (range 7.5–8.5 cm).The mean
increase in functional penile size (dependent on curvature severity) was3.2±1.7
cm (1.5–5.5 cm).


## 3. Results and Discussion

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 45.2±27.1
months (range 6–96 months). The
cases with greatest curvature showed the best intraoperative gain in penile
length. The gain in functional penile size was maintained in patients who kept
penile straightening and was reduced by up to 0.5 cm in those who developed
curvature postoperatively. The preoperative erection status was preserved in most
cases whose preoperative evaluation by Doppler ultrasound showed peak systolic
velocity over 40 cm/s and end-diastolic velocity under 3 cm/s. Follow-up of
cases with concomitant implantation of inflatable penile prostheses showed
preserved penile straightening. Satisfactory penile sensitivity was maintained.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.


### 3.1. Discussion

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 linesd-d′ and e-e′ may be drawn at any positions in the
straight portion of the penis because the difference (W) between the two sides
will always be the same. The crossing of the tangential lines a-a′ and b-b′on
any line parallel to the axis of the penis will always be at the bisector of
the angle formed between them. The incomplete circumferential incision permits
breaking all lines of force, allowing the correction of the curvature on two
planes (dorsolateral or ventrolateral) by the same incision.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 [9, 15]; when graft shrinkage is likely, a
percentage should be added to the dimensions of the defect.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.


## 3.1. Discussion

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 linesd-d′ and e-e′ may be drawn at any positions in the
straight portion of the penis because the difference (W) between the two sides
will always be the same. The crossing of the tangential lines a-a′ and b-b′on
any line parallel to the axis of the penis will always be at the bisector of
the angle formed between them. The incomplete circumferential incision permits
breaking all lines of force, allowing the correction of the curvature on two
planes (dorsolateral or ventrolateral) by the same incision.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 [9, 15]; when graft shrinkage is likely, a
percentage should be added to the dimensions of the defect.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.


## 4. Conclusions

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.



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*Source: 205739-2008-12-03.xml*