• Our aim is to provide free detailed comprehensive manual for urologic surgical procedures. This site should serve as a valuable reference for urologic residents and medical students in training.

  • Peyronie’s Disease. Surgical Repair of Ventral Penis Curvature.

    About the Authors

    Dr. Nelson Bennett, MD

    Dr. Nelson Bennett, MD

    Dr. Nelson Bennett, MD graduated from Mercer University with a degree Biomedical Engineering in 1995. He went to medical school at The University of Pittsburgh School of Medicine and then went on to complete a residency in Urologic Surgery at the University of Pittsburgh Medical Center. After finishing a 2-year fellowship at Memorial Sloan-Kettering Cancer Center in Sexual Medicine and Surgery, he joined the faculty at the Lahey Hospital and Medical Center in Burlington, MA.

    As a board certified urologist and microsurgeon, Dr. Nelson Bennett specializes in the management of erectile dysfunction, Peyronie’s disease, disorders of ejaculation and orgasm, low testosterone levels, male infertility, penile implant, and varicocele.

    Dr. Bennett has authored numerous articles and presented research work on a national and international level. He is an active member of the Sexual Medicine Society of North America (SMSNA), the International Research Impotence Society (ISSM), and American Urologic Association (AUA). He routinely is asked to review research manuscripts for the leading urology journals.

    Institute of Urology

    Lahey Hospital and Medical Center

    41 Mall Road

    Burlington, MA 01805

    Phone: (781) 744-8334

    Dr. Bennett’s website link.

    KAMAL NAGPAL MD, MBBS, MS, MRCS, PhD

    Dr. Kamal Nagpal, received his MBBS and Master of Surgery (MS) from the University College of Medical Sciences, Delhi. He then received his PhD from the Imperial College, London. He has published numerous articles about patient surgical safety including the prestigious New England Journal of Medicine. He presented his research efforts internationally. As of 2014, he is a chief resident at Lahey Hospital and Medical Center, Burlington, MA, USA.

    SURGICAL VIDEO

    Surgical Correction of Peyronie’s Disease with Ventral Curvature.

    Plaque excision and grafting technique.

    Introduction

    Francois Gigot de la Peyronie, French physician, gave the first description of the peyronie’s disease in 1743.1 Peyronie’s disease (also known as induratio penis plastica) is an acquired disorder of tunica albuginea and is characterized by formation of plaque of fibrous tissue. It is most common in middle-aged men and its prevalence is estimated to be 0.4-1%.2 It is also associated with other fibrotic disorders including Dupuytren disease, Ledderhose disease (contracture of the plantar fascia) and tympanosclerosis. Etiology of the disease is not known but is presumed due to the buckling trauma of the penis usually during intercourse causing capillary shears and extravasation of blood and subsequently fibrosis.

    There are two phases of this disease.3 The first is an active phase, which is associated with painful erections and changing penile deformity. Quiescent secondary phase is the second phase in which there is a stabilization of the deformity. This is not always the case and sudden development of painless deformity has been seen in upto one-third of the patients.

    The management of Peyronie’s disease often requires no more than resassurance of the patient. A myriad of oral therapies has been suggested but supportive evidence for these options had been scant. There is a combination of Vitamin E and colchicine which is a well-tolerated evidence based option.

    Indications & Contraindications of Surgical Management

    Indications for surgery include deformity that precludes intercourse and/or erectile dysfunction that precludes intercourse. Surgical correction should not be done until atleast 12 months after the onset and after the symptoms have been stable for 3, and preferably 6 months.

    It is essential for the patient to have a correct expectation of the outcome and give a proper informed consent.

    Special anatomy Consideration

    • Always be careful of urethra in the midline and mobilize it before excising lateral and ventral plaques
    • Dorsal neurovascular bundle should be dissected off and preserved before excising the dorsal plaques.

    Patient Position and Special Instruments

    • Supine- Frog-legged
    • Lone-star retractor, Tutoplast {Cadeveric graft (pericardium)}

    Steps of Procedure

    • Patient was prepped and draped exposing the penis and scrotum.
    • 16 F Foley catheter was placed.
    • Approximately 6 cm ventral penile incision was made over the ventral aspect of penile shaft.
    • Dartos and Bucks fascia were incised.
    • Urethra was exposed.
    • Artifical erection was performed with 19 G butterfly needle using 100 units of papaverine.
    • Curvature and torsion of the penis was noted. Penis was detumesced by aspiration.
    • Lonestar was placed and hooks were put at 3,6,9 & 12’o’clock position
    • At the onset, small window was made between the urethra and the corpora. Penrose was inserted in that window which was then used for retraction to dissect whole of the urethra off the corpora. Urethra was then completely dissected off the corpora using tenotomy scissors. At all time care was taken not to injure the urethra.
    • Plaque on the left corpora was then palpated and it was skeletonized using sharp dissection.
    • Plaque i.e tunica over the corpora was then marked. Incision was then made with no. 11 blade. Plaque was then excised using tenotomy scissors leaving the corporal erectile tissue behind.
    • Edges of the tunica were then freed up from the erectile tissue to allow placement of graft.
    • 2-0 silk sutures are placed at 4 corners to measure the graft length. Ruler is then used to measure the graft size.
    • Cadaveric pericardium was then prepared at the backtable. In this case 2, 4 cm strips were sutured at the ends using 4-0 PDS to make a 8 cm strip. Cadaveric pericardium was chosen as it resists contraction.
    • Graft was then sutured to the tunica using 4-0 PDS. Long end was sutured using continous suture and short end was sutured using interrupted suture. Water-tight closure was done.
    • After suturing, artificial erection was again performed to check for any leaks and for any remaining deformity. Any areas of leaks are further closed using same 4-0 PDS sutures.
    • In this case there was a left lateral torsion. This was corrected by putting 0- Ticron sutures on the right lateral tunica using 8 point fixation (using modified Nesbitt’s technique).
    • Articial erection was again performed to ensure good erection without any deformity. There was no more curvature left.
    • Drain was placed under dartos using butterfly tubing which is connected to vaccutainer connector.
    • Closure was done in layers. Dartos was closed with 4-0 vicryl. Skin was approximated with 4-0 Monocryl.
    • Dressing was done with telfa, guaze and conform.

    Complications

    Apart from bleeding, infection, erectile dysfunction is more common with this procedure as it involves excision of the plaque and aggressive dissection. Penile shortening, recurrent curvature and sensation changes are other complications. However, this procedure maintains the penile length in comparison to plication.

    Key Points

    • Reassurance of the patients is required in most cases of Peyronie’s disease
    • Surgical correction should not be done until atleast 12 months from the onset and plaque is stable for 3 months.
    • Plaque excision and grafting gives good straightening but with increased risk of postoperative erectile dysfunction.
    • Penile prosthesis is a good option for patients with severe erectile dysfunction.

    References

    1. Androutsos G. [Francois Gigot de La Peyronie(1678-1747), benefactor of surgery and supporter of the fusion of medicine and surgery, and the disease that bears his name]. Prog Urol 2002;12:527-33.

    2. Gelbard MK, Dorey F, James K. The natural history of Peyronie’s disease. J Urol 1990;144:1376-9.

    3. Hellstrom WJ. History, epidemiology, and clinical presentation of Peyronie’s disease. Int J Impot Res 2003;15 Suppl 5:S91-2.

    Leave a Reply

    You must be logged in to post a comment.