Penile Plication Without Degloving Enables Effective Correction of Complex Peyronie's Deformities

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Penile Plication Without Degloving Enables Effective Correction of Complex Peyronie's Deformities
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  Male Sexual Dysfunction Penile Plication WithoutDegloving Enables EffectiveCorrection of Complex Peyronie’s Deformities Mehrad Adibi, Steven J. Hudak, and Allen F. Morey OBJECTIVE  To present our initial experience with extended plication repair for men with severe and/orbiplanar penile curvature. MATERIALS ANDMETHODS A review of men who underwent plication repair for complex penile deformity (biplanarcurvature or curvature  60°) was performed. All patients underwent tunical plication via a 2-cmpenoscrotal incision mobilized distally along the penile shaft without degloving. Angle of curvature, direction(s), stretched penile length (SPL), and number of sutures were recorded. RESULTS  Among 102 patients treated with plication surgery, 43 (44%) had complex penile deformity.Among 11 men with biplanar curvature, median angle in the primary plane of curvature wascorrected from 45° to 10° and secondary plane was corrected from 35° to 5° using an average of 7 sutures (5° correction per suture). Among 32 men with severe curvature, median angle of curvature was corrected from 70° to 15° using an average of 11 sutures (6° correction per suture).SPL was unchanged in 29 (69%), increased an average of 0.65 cm in 7 (16%), and decreased 0.5cm in only 6 (14%) patients. At a mean follow-up of 15.3 months, repeat plication was requiredin 2 patients and 2 required penile prosthesis. CONCLUSION  Penile plication without degloving appears to be safe and effective for correction of complex penilecurvature without significant impact on penile length.  UROLOGY  79: 831–835, 2012. © 2012Elsevier Inc. All rights reserved. S ince Nesbit’s initial 1965 report, plication tech-niques have been a mainstay for surgical correctionof penile deformities in men with Peyronie’s dis-ease. 1 The Essed-Schroeder modification in 1985 intro-duced a new era in which straightening could beachieved without tunica albuginea incision. 2 Since then,several variations and/or combinations of the these 2procedures have been popularized, 3,4 including Lue’s 16-dot plication 5 among others. 6,7 Although advantages of plication surgery include the relative ease and speed of the procedure, most authorities advise reserving its useexclusively for men with mild or moderate penile curva-ture, 8 using plaque incision/excision and grafting in caseswith curvature  60° and/or biplanar penile curvature. 9,10 We report our 4-year experience with extended plicationsurgery without degloving in patients with severe and/orbiplanar penile curvature in an effort to assess the feasi-bility of this alternative, minimally invasive approach. MATERIAL AND METHODS A retrospective review was conducted among men having sur-gical treatment of penile curvature deformities by the seniorauthor at our tertiary center from August 2007 to September of 2010. A subset of patients were analyzed with severe penilecurvature (defined as  60°), or biplanar penile deformity (de-fined as curvature in 2 planes, eg, dorsal and lateral) havingsurgical correction by plication. All men had persistent penilecurvature that had been painless for a period of at least 6months and was severely compromising or precluding inter-course.Preoperative determination of severity and direction of cur-vature was assessed during initial office history and/or docu-mented by patient autophotograph—additional preoperativeoffice testing was not performed. Patients with mild or moderateerectile dysfunction were liberally prescribed oral phosphodies-terase-5 inhibitors both pre- and postoperatively to confirmadequacy of rigidity sufficient for penetration and to stabilizethe penis during intercourse; those with normal rigidity andthose who responded well to oral medications were offeredpenile straightening surgery. Those with refractory erectile dys-function unresponsive to medical therapy were offered a penileprosthesis and were excluded from this study. Surgical Technique The surgical technique used was an extended version of Lue’s“16-dot” technique 5 without circumcision, as described by Dugi etal. 11 After induction of anesthesia, immediately before surgical From the Department of Urology, University of Texas Southwestern Medical Center,Dallas, Texas, USAReprint requests: Allen F. Morey, M.D., UT Southwestern Department of Urology,Moss Building, 8th Fl., Ste 112, 5323 Harry Hines Boulevard, Dallas, TX 75390-9110. E-mail: Allen.morey@utsouthwestern.eduSubmitted: November 16, 2011, accepted (with revisions): December 22, 2011 © 2012 Elsevier Inc. 0090-4295/12/$36.00  831 All Rights Reserved doi:10.1016/j.urology.2011.12.036  preparation in the operating room, all men received an intracor-poral injection of 20  g alprostadil; if response was poor, a secondinjection was given. An initial stretched penile length (SPL)measurement was documented in all cases by the senior author.While an assistant stabilized and compressed the inferior corporabilaterally, photographs were taken from both lateral and inferiorperspectives—angles were determined from intraoperative photo-graphs of the erect penis before and after correction (Fig. 1). Surgical correction of penile curvature was accomplished byplication of the tunica albuginea through a 2-cm penoscrotalincision on the convex surface of the deformity, directly con-tralateral and proximal to the most concave portion of thecurvature, regardless of the degree or complexity of the cur-vature. Penile degloving, dorsal neurovascular mobilization,and plaque incision/excision and grafting were not per-formed. The proximal shaft incision was mobilized over the midand distal penile shaft and/or laterally by the use of Senn retractorsand/or skin hooks as needed to promote placement of additionalplication sutures in multiple planes depending on the severity anddirection of curvature. A ventral incision just lateral to theurethra was used for dorsal and/or lateral deformities—a Foleycatheter was used when necessary to facilitate identification of the urethra. For ventral curvatures, the incision was createdon the opposing, dorsal aspect of the penis, and longitudinalsutures were placed in the thin sulcus next to the dorsal penilevein medial and parallel to the neurovascular bundle. Figure 1.  Preoperative anterior  (A)  and lateral  (B)  images of 80° left lateral penile curvature. Correction of penile deformity via 2-cm right lateral penile shaft incision ( C ,  solid bracket  ), which was displaced as needed for plication suture placement( dashed bracket  ) is demonstrated in postoperative anterior view. Postoperative lateral view ( D ) illustrates profound degreeof correction without loss of penile length (SPL measured 16 cm before and after plication). 832  UROLOGY 79 (4), 2012  A series of parallel and consecutive braided nonabsorbable poly-ester sutures (2-0 ethibond, Ethicon, Somerville, NJ) were placedin the tunica albuginea in a buried, interrupted, vertical mattressfashion to imbricate the curvature. Each suture was placed to spana total distance of approximately 15 mm (2 needle passages, eachcovering approximately 7 mm with a 1-mm gap in between su-tures). Successive plicating sutures were placed along the convexsurface of the penis while the incision was retracted distally usinga two-prong skin hook as far as necessary to attain completecorrection.Buck’sfasciaanddartosfasciawereclosedwithrunning3-0 chromic to completely cover the plication suture knots andreduce tension on the skin closure, performed with 4-0 interruptedchromic. A compressive Coban (3 M, St. Paul, MN) penile wrapwas applied, which patients were instructed to remove and replacedaily over the following week.Intraoperative photographs and SPL measurements were re-peated immediately after plication. All SPL measurements (beforeandafterplication)wereobtainedbymeasuringthedorsaldistancebetween the pubic symphysis and the tip of the penis while onmaximal stretch with a metal ruler by the senior author. Photo-graphs were used to determine the angle of maximum curvature—angles were measured between a line drawn from the base of thepenis along the proximal shaft intersecting another line extendingfrom the urethral meatus along the distal shaft. For men withbiplanar curvature, the primary plane of curvature was defined asthe plane with the larger angle. Pre- and postoperative angles wereobtained for both primary and secondary planes of curvature. Thetotal number of plicating sutures used was recorded.Patients were discharged immediately after surgery and in-structed to return for follow-up at 6 weeks, and then again asneeded. At each follow-up visit, patients were routinely askedabout their satisfaction with straightening and any complica-tions or concerns. Men who were asymptomatic and content atthe 6-week appointment were offered, but not required, tocontinue routine follow-up, whereas those with unresolvedproblems were followed continuously until resolution wasachieved. Statistical Methods Data were tabulated and analyzed in Excel (Microsoft, Red-mond, WA). Comparison of nonparametric continuous vari-ables was performed with the Mann–Whitney rank-sum test.Statistical significance was set at  P  .05 and reported  P  valuesare 2-sided. This study was approved by the University of TexasSouthwestern Medical Center Institutional Review Board. RESULTS Among 102 patients who underwent plication for penilecurvature, 43 (43%) had severe or biplanar penile defor-mity (Table 1). Dorsolateral penile deformities predom-inated in both the severe curvature group (18 [56%]dorsal, 8 [25%] lateral, 6 [19%] ventral) and in thebiplanar deformity group (9 [82%] dorsal and lateralcurvatures vs 2 [18%] with ventral and lateral). Themedian operative time was 54 minutes (range 30-127) forboth the severe deformity group and for the biplanardeformity group (range 28-103). All patients were suc-cessfully discharged home immediately postoperatively.Most returned to work within 1 week of surgery—manythe day after. Quantifying the Correction Among men in the group with severe curvature, themedian degree of correction was 54° (range 40-88). Anaverage of 11 sutures (range 4-20) were used per patient(roughly 6° of correction per plication suture). In thebiplanar group, the median degree of correction was 35°(range 10-70) and 25° (range 10-42) in the primary andsecondary planes of curvature, respectively—an averageof 7 plication sutures (range 4-10) were used per patient(roughly 5° of correction obtained per suture). Overall,there was no significant difference in SPL before and afterplication for either group ( P    .86). The vast majority(86%) had either no change or a slight increase in SPL.Among the 6 (14%) men with reduction of SPL docu-mented, average loss of length was 0.5 cm (range 0-1)(Table 2). Table 1.  Surgical outcomes of nondegloving plication in men with severe or biplanar penile curvatureSevere curvature  Biplanar curvature  No. (%) 32 (74)  11 (26)  Age (y) (range) 58 (21-72)  57 (38-67)  Median pre-op angle (range) 70° (60-88)  Primary plane 45° (20-90) Secondary plane 35° (20-75)  Median post-op Angle (range) 15° (0-30)  Primary plane 10° (0-20) Secondary plane 5° (2-10)  Median degrees correction (range) 54° (40-88)  Primary plane 35° (10-70) Secondary plane25° (10-42)  Mean number of sutures (range) 11 (7-21)  7 (4-10)  Mean degree correction per suture 6° 5°Mean pre-op SPL (cm) 14.56 14.90Mean post-op SPL (cm) 14.52 14.95 Table 2.  Comparison of stretched penile length measure-ments before and after plication of complex peniledeformity Unchanged Increased DecreasedPatients, n (%) 29 (69) 7 (16) 6 (14)Avg change inSPL (cm)0 0.65 0.5 UROLOGY 79 (4), 2012  833  Outcomes Wound-related complications were rare and minor. Mildpain with erections was common immediately after sur-gery but was generally self-limited. Only 4 patients re-ported persistent pain with erections at 4-6 weeks, whichresolved with conservative therapy within the following2 months in all patients. At a mean follow-up of 15.3months, 39 (92%) men had satisfactory results after theplication procedure, defined as curvature   30° duringerection. Repeat plication was required in 2 patients(4%) because of persistence of curvature—these wereboth severe, biplanar deformities that were effectivelysalvaged by placement of additional tunical placationsutures at a second setting. Two other patients (4%) hadprogressive erectile dysfunction resulting in penile pros-thesis implantation, which was performed uneventfully. No patients complained of significant penile shorteningor loss of sensation. COMMENT Plication for Correction of Severe Penile Curvature To our knowledge, this is the first large reported seriesassessing the feasibility of plication in men with severe orbiplanar curvature. Building on our promising initial re-sults with plication as a uniform approach to reconstruc-tion of penile curvature, 11 this experience appears tosuggest its appropriateness for use in complex patients.We demonstrated that even men with severe peniledeformity can be safely corrected without grafting (from70-15° on average).We calculated an average of 6° of correction per pli-cation suture and propose that this can be used as areasonable preoperative metric for calculating the num-ber of sutures required to correct a given angle of curva-ture. The average number of sutures used in the biplanargroup was less than in the severe group (7 vs 11), likelybecause of the smaller preoperative curvature angles. Byplacing the plication sutures between the 2 planes of curvature, adequate correction may be achieved withfewer plication sutures in bidirectional cases than insevere unilateral deformities.Our favorable results corroborate those of the UCSFtunical plication series, 5 although that report was notlimited to complex deformities (average angle of curva-ture 64°, one-third with biplanar curvature). In Lue’ssrcinal 16-dot technique description, a circumcising in-cision was used liberally to deglove the penis for lateral orventral deformities, reserving the ventral longitudinalincision for correction of dorsal deformities only. In ourmodification without circumcision, a small (2 cm) lon-gitudinal incision was undertaken in all cases; its positionwas centered on the proximal shaft contralateral to thecurve, regardless of the degree or direction of the curva-ture, and was displaced by the use of Senn and/or skinhook retractors distally, proximally, and contralaterally asneeded for additional suture placement.We used a “multidot” approach, using more plicationsutures over a smaller distance (each covering roughly 15mm) to progressively reduce tension, tying each imme-diately after placement while progressively assessing thecorrection. In Lue’s srcinal description, only 4-6 plica-tion sutures were used, and these were tied only after allwere placed. Despite our aggressive approach placingmultiple tunical sutures, plication appears to require lessoperative time and trauma compared with reports of similarly complex patients treated by grafting. Kim et alnoted similar findings, reporting that average operativetime for plication (71 minutes) was dramatically less thangrafting cases (234 minutes). 12 Furthermore, we havenoted that burying tunical suture knots in a verticalmattress configuration beneath separately closed layers of Buck’s fascia and the tunica dartos renders them virtuallyimperceptible.We were surprised to find that penile length was un-changed or greater after plication in most patients, andthat the few having shorter postoperative measurementdemonstrated a trivial penile length reduction of no morethan 1 cm. We believe the explanation for this findingis that as the pathologic penile shaft changes from itsinitial, parabolic shape to a straighter axis during plica-tion, the vector of the distal penis is altered more so thanthe absolute shaft length. Our experience adds to a grow-ing list of reports dispelling the theoretical risk of penileshortening attributed to plication. 12-16 Levine also ob-served that SPL was actually 0.6 cm greater after plica- tion in 142 patients. 9 Gholami et al 5 noted that only40% of patients reported penile shortening of a mere0.5-1.5 cm at 6 months postoperatively. Greenfield et al 14 also documented a mean loss of length of only 0.36 cmafter plication. We suspect that the negligible penileshortening documented in each of these series is becausethe fibrotic plaque has already shortened the penile shaft,and that placement of tunical sutures on the long sidemerely acts to “balance” the penis without further short-ening. Collectively, these data indicate that even place-ment of multiple tunical plication sutures can be ex-pected to achieve dramatic penile straightening withnegligible changes in length. Safety Considerations Plication offers a “no-touch” approach to the delicatedeep and distal penile structures, thus avoiding compli-cations relating to mobilization of the neurovascular bun-dles and urethra. Our modification provides the benefit of low morbidity, short convalescence, and technical easethrough a minimally invasive proximal shaft incision thatobviates the need for penile degloving. Avoidance of degloving prevents distal ischemic or lymphatic compli-cations of the mobilized foreskin. 11 Although traditional algorithms 9,10 for reconstructionof potent men with penile curvature   60° and/or bidi-mensional curvature advocate plaque incision/excisionand grafting with dermis, 17 porcine small intestinal sub- 834  UROLOGY 79 (4), 2012  mucosa, 18 saphenous vein, 19 and/or human cadavericpericardium, 20 problems attributed to grafting proceduresinclude graft contracture, persistent curvature, neurovas-cular injury, and postoperative erectile dysfunction. 10,21 Although randomized studies comparing plication vsgraft procedures do not exist, recent evidence suggestssafety advantages in favor of plication. In 2008, Kim et alcompared subjective patient reports after tunical plica-tion (n    35) and plaque incision and saphenous veingrafting (n  32) at 1 year follow-up, 12 noting that graftpatients were plagued more often by complications, suchas loss of penile sensation, rigidity, and the ability to haveintercourse ( P  .03). Limitations Although our average follow-up time of 15 months maynot account for recurrence of curvature (because of dis-ease progression and/or plication suture breakage) over alonger term of follow-up, we have been impressed by therelative lack of complications encountered throughoutthis 4-year experience. Although our results suggest thatplication is a safe and effective initial strategy for correc-tion of many men with severe or biplanar penile defor-mity, some with advanced deformities may be better suitedto grafting procedures; for example, those with significantnotching or hour-glass deformities, while straighter afterplication, often harbored persistent lateral notching andwere counseled to expect this preoperatively. Fortu-nately, notching or hourglass deformity is uncommon,reported in only 12.6% of 703 Peyronie’s patients over a13-year period. 22 Photographic assessment of penile curvature may lackprecision, but was performed in a standardized manner inthis series using both lateral and anterior images in eachcase. Similarly, although penile length measurementswere obtained in an unblinded manner, a standard tech-nique was used by a single senior surgeon in all casesbefore and after correction. Because penile length mea-surements were not obtained during follow-up appoint-ments, the relationship of intraoperative measurementsto subsequent penile length measurements during long-term follow-up cannot be established. We believe thatSPL measurement is a valid objective finding worthy of reporting, perhaps even more so than patient-reportedassessments of penile length, which are notoriouslyshorter after virtually any surgical intervention involvingthe penis or urethra. 23 Although plication appears to bereasonable for repair of complex penile deformities, sys-tematic evaluation of patient-perceived satisfaction overthe long term is warranted. The goal of this report,however, was simply to demonstrate the feasibility of thisminimally invasive approach in a pilot study of challeng-ing patients. CONCLUSIONS Plication appears to be a promising, minimally invasivestrategy for the surgical correction of complex peniledeformity. Penile length is not substantially altered afterplication of even complex penile deformities. References 1. Savoca G, Scieri F, Pietropaolo F, et al. Straightening corporo-plasty for Peyronie’s disease: a review of 218 patients with medianfollow-up of 89 months.  Eur Urol . 2004;46:610-614.2. Essed E, Schroeder FH. New surgical treatment for Peyronie dis-ease.  Urology . 1985;25:582-587.3. Giammusso B, Burrello M, Branchina A, et al. Modified corporo-plasty for ventral penile curvature: description of the technique andinitial results.  J Urol . 2004;171:1209-1211.4. Rehman J, Benet A, Minsky L, et al. Results of surgical treatmentfor abnormal penile curvature: Peyronie’s disease and congentialdeviation by tunical shaving and plication.  J Urol . 1997;157:1228-1291.5. Gholami SS, Lue TF. Correction of penile curvature using the16-dot plication technique: a review of 132 patients.  J Urol . 2002;167:2066-2069.6. Hatzichristou DG, Hatzimouratidis K, Apostolidis A, et al. Cor-poroplasty using tunica albuginea free grafts for penile curvature:surgical technique and long-term results.  J Urol . 2002;167:1367-1370.7. Mantovani F, Patelli E, Castelnuovo C, et al. “Straightening-reinforcing” technique for congenital curvature and Peyronie’s dis-ease.  Urol Int . 2005;75:201-203.8. Tran V, Kim DH, Lesser TF, et al. Review of the surgical ap-proaches for Peyronie’s disease corporeal plication and plaque in-cision with grafting.  Adv Urol . 2008; Epub November 2008.9. Levine LA, Lenting EL. A surgical algorithm for the treatment of Peyronie’s disease.  J Urol . 1997;158:2149-2152.10. Ralph D, Gonzalez-Cadavid N, Mirone V, et al. The managementof Peyronie’s disease: evidence-based 2010 guidelines.  J Sex Med .2010;7:2359-2374.11. Dugi DD 3rd, Morey AF. Penoscrotal plication as a uniform ap-proach to reconstruction of penile curvature.  BJU Int . 2010;105:1440-1444.12. Kim DH, Lesser TF, Aboseif SR. Subjective patient-reported ex-periences after surgery for Peyronie’s disease: corporeal plicationversus plaque incision with vein graft.  Urology . 2008;71:698-702.13. Taylor FL, Levine LA. Surgical correction of Peyronie’s disease viatunica albuginea plication or partial plaque excision with pericar-dial graft: long-term follow up.  J Sex Med . 2008;5:2221-2228.14. Greenfield JM, Lucas S, Levine LA. Factors affecting the loss of length associated with Tunica albuginea plication for correction of penile curvature.  J Urol . 2006;175:238-241.15. Chien GW, Aboseif SR. Corporeal plication for the treatment of congenital penile curvature.  J Urol . 2003;169:599-602.16. Friedrich MG, Evans D, Noldus J, et al. The correction of penilecurvature with the Essed-Schröder technique: a long-term fol-low-up assessing functional aspects and quality of life.  BJU Int .2000;86:1034-1038.17. Devine CJ, Horton CE. Surgical treatment of Peyronie’s diseasewith a dermal graff.  J Urol . 1974;111:44-49.18. Knoll LD. Use of small intestinal submucosa graft for the surgicalmanagement of Peyronie’s disease.  J Urol . 2007;178:2474-2478.19. Lue TF, El-Sakka AI. Venous patch graft for Peyronie’s disease.Part I: technique.  J Urol . 1998;160:2047-2049.20. Levine LA, Estrada CR. Human cadaveric pericardial graft for thesurgical correction of Peyronie’s disease.  J Urol . 2003;170:2359-2362.21. Taylor FL, Levine LA. Peyronie’s disease.  Urol Clin North Am .2007;34:517-534.22. Cakan M, Akman T, Oktar T, et al. The clinical characteristics of Peyronie’s patients with notching deformity.  J Sex Med . 2007;4:1174-1178.23. Coursey JW, Morey AF, McAninch JEA, et al. Erectile functionafter anterior urethroplasty.  J Urol . 2001;166:2273-2276. UROLOGY 79 (4), 2012  835
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