Peyronie Disease: Plication or Grafting

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Surgery for Peyronie disease

Surgery is recommended for patients with stable PD and poor coital function. This poor function may result from the penile curvature, from hourglass deformity resulting in distal flaccidity, or from ED caused by the PD plaque or venoocclusive dysfunction. Surgery is usually avoided during the active phase of the disease, and this provides an opportunity for patients to pursue medical therapies. Montorsi and colleagues8 recommend waiting at least 12 months from the end of the active phase of PD

Evaluation of patients for surgery

Key factors in evaluating patients for proper placement in the surgical treatment algorithm are degree and complexity of curve, baseline penile length and percent of estimated loss of length with correction, and baseline erectile function. All of these factors are easily evaluated, mostly through physical examination, with the exception of baseline erectile function.

Determining a patient’s baseline erectile status is of prime importance in selecting the surgical treatment that will lead to a

Nesbit and Modified Nesbit

The Nesbit procedure was first described in 1965 for correcting congenital penile curvature caused by corporeal disproportion.19 Pryor and Fitzpatrick20 first described the use of the procedure for PD. Plication procedures require that the tunica opposite the Peyronie plaque and penile curvature be excised or plicated, or both, to correct the curvature. After an artificial erection is obtained using injectable saline and the Gittes technique, or with injection of a vasoactive substance into the

Tunica-lengthening procedures

Plaque incision or excision with placement of grafts has been used successfully for patients with severe penile curvature, for complex hourglass deformity, and in men with preoperative significant penile shortening secondary to PD. In 1950, Lowsley and Boyce41 first reported a series of patients with PD who underwent plaque excision with a fat graft, but there was no follow-up report of success.

Various materials have been used including dermis,42 temporalis fascia,43 vein,44, 45, 46, 47

Penile prosthesis implantation

In patients found on preoperative assessment to have severe ED and PD, the best combined treatment is implantation of a penile prosthesis. The tunica-lengthening and tunica-shortening procedures described may provide a straight penis, but many will have some detrimental impact on erectile function. Patients are obviously not well served by a straightened penis that is incapable of becoming erect.

While all types of prostheses have been tried,58 the 2-piece or 3-piece IPP has emerged as the

Summary

PD is an incurable, sexually debilitating disease resulting in penile deformity, coital failure, and significant psychological stress for patients and their partners. Urologists have an opportunity to help men suffering from PD to improve their lives and the lives of their partners.

Appropriate treatment should be individualized and tailored to the patient’s goals and expectations, disease history, physical examination findings, and erectile function. After medical therapy is considered and the

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