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Penile Curvature: Surgical Technique and Complications

Indications for Surgical Treatment of Penile Curvature

A stable (no change for at least 6 months) and significant (difficult sexual intercourse, painful plaques) penile curvature may be treated by surgery. Three principle treatment options exist:

• Nesbit or plication technique: the penis is straightened by shortening the healthy opposite side. The technique is suitable for patients with penile curvature under 60 degrees, sufficient penile length, sufficient erectile function and no hourglass deformity. Advantages: no mechanical weakening of the penile shaft by grafting. Disadvantages: substantial deviations can only be straightened with a significant loss in penile length.
• Surgery with plaque incision and grafting: the plaques on the affected side are excised or incised; after straightening of the penis the defect of the tunica albuginea is covered with a graft. The technique is suitable for patients with penile curvature over 60 degrees, insufficient penile length, hourglass deformity and with sufficient erectile function. Penile straightening is possible without shortening of the penis, but grafting can lead to a significant mechanical weakening of the penile shaft and a deterioration in erectile function.
• Implantation of a penile prosthesis: with straightening of the penile shaft. The technique is suitable for patients with significant curvature and erectile dysfunction with insufficient response to treatment options.

Contraindications

• Coagulation disorders, increased surgical risk due to comorbidity
• Active non-stable Peyronie disease: usually a disease duration of more than one year and no change in curvature for at least six months is advised.
• The following techniques are unsuitable for patients with erectile dysfunction that is refractory to therapy.

Surgical Technique of Penile Curvature Operations

Preoperative Preparations

Exclude or treat urinary tract infections. Perioperative antibiotic prophylaxis. Supine position. Spinal or general anesthesia.

Surgical Approach:

Circumcising incision and complete exposure of the penile shaft. Alternatively, a longitudinal incision over the area of concern can be performed.

Mobilization of the Dorsal Neurovascular Bundle:

Incise the Buck fascia on both sides lateral to the neurovascular bundle and mobilize the dorsal nerves and vessels from the corpus cavernosum. This maneuver is necessary for plication of a ventral curvature or incision and grafting of a dorsal curvature.

Artificial Erection:

An artificial erection is possible with the injection of alprostadil or papaverine. As an alternative, inject saline with a butterfly needle into the corpus cavernosum at the base of the penis. For distal curvatures, a vessel loop as tourniquet can be placed. For proximal lesions, finger compression is used to reduce outflow.

Nesbit Procedure:

Excise oval defects of the tunica albuginea (depending on the curvature) on the convex side of the curvature. Close the tunica albuginea with interrupted non-absorbable 2-0 sutures to straighten the penile shaft. The suture should be watertight, which is tested with an intraoperative artificial erection (Nesbit et al., 1965). A modified technique recommends a longitudinal incision of the tunica albuginea and horizontal closure (Yachia, 1990).

Correction of penile curvature using the Nesbit procedure: oval defects of the tunica albuginea are sutured to straighten the penile shaft.

Plication Procedure:

The shortening of the tunica albuginea at the convex side of the curvature is done with sutures (Essed, 1985). Usually four non-absorbable sutures (2-0) with buried knots are used, the points of the needle passage are marked on the corpus cavernosum beforehand (16 dot repair).

Correction of penile curvature using the plication procedure with buried knots.

Incision/Excision and Grafting:

A plaque incision on the concave side is done to allow straightening of the shaft. Some authors advocate complete excision of the plaques. The resulting defect in the tunica albuginea must be covered after straightening:

• Dermal graft: a suitable donor site is at the lower flank above the anterior superior iliac spine. Remove the stratum corneum with a dermatome. The dermis graft should be 20–25% larger than the defect in the tunica albuginea. The subcutaneous adipose tissue must be completely removed from the back of the dermis. Skin sutures at the donor site. The dermis graft is sutured in place with PDS 2-0. The surgical result and the tightness of the suture are checked by an artificial erection.
• Vein graft: e.g., great saphenous vein, which is opened longitudinally and several segments are anastomosed side-to-side to form a suitable graft. Disadvantages are the potential morbidity of the graft harvesting and the loss of the vein for future cardiac bypass surgery.
• Other material: e.g., Tachosil (cell-free material) or Tutopatch (human fascia lata). Purchasable grafts offer advantages: the harvesting procedure is unnecessary and the graft has a constant quality.

Correction of penile curvature using incision and grafting: the mobilization of the dorsal neurovascular bundle is necessary for dorsal curvature. H-shaped relaxing incisions are done to straighten the shaft (left). The defect is covered with a graft (right).

Wound Closure:

Close the Buck fascia with a running suture 3-0. Place small suction drains between Tunica dartos and Buck fascia. Close the skin with rapid absorbable 4-0 sutures. Insert a transurethral catheter to allow bed rest. Compress the wound and the penile shaft with an elastic bandage.

Postoperative Care

Remove drains and catheter after 1–2 days. No sexuell activity for 6–8 weeks, but after two weeks gentle stretching and manipulation to prevent adhesions and graft contractions is allowed. After three weeks, erections should be enhanced with PDE5 inhibitors and vacuum devices. Penile traction should be applied for straight healing. Stable graft healing suitable for sexual intercourse can be expected after two months.

Complications of Curvature Operations

Hematoma, infection, recurrence of curvature, hourglass deformity, erectile dysfunction, nerve injury with glans hypesthesia.

References

A. Nehra et al. “AUA Guideline: Peyronie’s Disease,” 2015. [Online]. Available: https://www.auanet.org/guidelines-and-quality/guidelines/peyronies-disease-guideline.

EAU-Guidelines: Sexual and Reproductive Health

Essed und Schroeder 1985 ESSED, E. ; SCHROEDER, F. H.: New surgical treatment for Peyronie disease.
In: Urology
25 (1985), Nr. 6, S. 582–7

Nesbit 1965 NESBIT, R. M.: Congenital Curvature of the Phallus: Report of Three Cases with Description of Corrective Operation.
In: J Urol
93 (1965), S. 230–2

Nesbit 2002 NESBIT, R. M.: Congenital curvature of the phallus: report of three cases with description of corrective operation. 1965.
In: J Urol
167 (2002), Nr. 2 Pt 2, S. 1187–8; discussion 1189

Yachia 1990 YACHIA, D.: Modified corporoplasty for the treatment of penile curvature.
In: J Urol
143 (1990), Nr. 1, S. 80–2

  Deutsche Version: Technik der Zirkumzision