P.H.E. and F.E.K. contributed equally to the work.
Paulo H. Egydio, Centre for Peyronie's Disease Reconstruction, Rua Joaquim Floriano 533 Cj. 902, Sao Paulo 04534-011, Brazil. e-mail: firstname.lastname@example.org
What's known on the subject? and What does the study add?
The association between Peyronie's disease (PD) and erectile dysfunction (ED) is reported to be 20–70%. Frequently, men who suffer from both ED and PD do not respond to erectogenic medication. In such cases, a simple straightening operation does not provide any benefit to the patient, as inadequate rigidity still impedes sexual intercourse. For these patients, surgical correction of the curvature should be performed with simultaneous penile prosthesis implantation. Penile prosthesis implantation guarantees a functional straight penis. Almost all patients report adequate rigidity for sexual intercourse postoperatively; however, in up to 50% of cases, patients are dissatisfied with the postoperative penile length. In cases of penile prosthesis implantation for PD, a simultaneous penile lengthening procedure should be performed to increase postoperative satisfaction rates.
We report our experience using a novel method for restoration of penile length and girth in patients with PD by grafting. Our study shows that penile prosthesis implantation with concomitant penile lengthening and girth restoration based on circumferential tunica albuginea incision is highly effective for extensive penile shaft reconstruction to correct severe penile shortening and narrowing, resulting in maximum penile length gain and girth restoration, regardless of plaque characteristics.
• To report patient outcomes and satisfaction with our technique for penile length and girth restoration in severe Peyronie's disease (PD).
PATIENTS AND METHODS
• Between November 2006 and November 2011, 105 men with severe PD and erectile dysfunction (ED) underwent surgical correction using our new approach.
• The technique consists of penile prosthesis implantation with concomitant penile lengthening and girth restoration through circular and longitudinal incisions in the tunica albuginea according to geometric principles.
• The overall patient satisfaction rate was 89.4%.
• The mean (sd; range) functional penile length gain was 3.6 (0.7; 2–5) cm. Patient satisfaction with penile length gain was 95.2%.
• Three patients (2.9%) developed retraction with residual curvature of up to 30°, but no re-operation was necessary.
• In one (1%) patient, the prosthesis had to be removed because of wound infection.
• At a mean (sd; range) follow-up of 18.2 (5.9; 6–46) months, 104 patients (99%) were able to have sexual intercourse.
• Our surgical approach for penile length and girth restoration leads to high patient satisfaction rates and excellent functional outcomes.
• Our surgical approach is a safe and valid therapeutic method for the treatment of severe PD associated with ED.
Erectile Dysfunction Index of Treatment Satisfaction.
Peyronie's disease (PD) is characterized by the development of scar tissue in the tunica albuginea, making it less elastic and causing penile deformity. This condition invariably leads to a decrease in penile functional length and has significant negative psychological effects . Surgical intervention is the best treatment option and should be used after failure of clinical treatments provided the patient experiences functional penile inadequacy . Surgery should only be offered when the acute, inflammatory phase of the disease has stopped and the condition is completely stable .
Severe cases of PD are associated with a shortening and narrowing of the penis and with erectile dysfunction (ED). The association between PD and ED is reported to be 20–70% [4–6]. This association may be attributable to plaque, as the co-existence of cardiovascular risk factors or diffuse vascular disease is seen in two-thirds of patients with PD . Frequently, men who have both ED and PD do not respond to erectogenic medication. In these men, a simple straightening operation does not provide any benefit to the patient, as inadequate rigidity still impedes sexual intercourse; therefore, surgical correction of the curvature should be performed with simultaneous penile prosthesis implantation. Prosthesis implantation should also be considered in patients with ED and complex anatomical deformities, since the risk of decreased erectile function after graft surgery alone is significant . Current data show that the risk of postoperative ED is probably associated with the preoperative erectile status and surgical technique . The highest risk for postoperative ED is seen among patients who require larger grafts, are >60 years old, or require ventral grafts [8,9].
Penile prosthesis implantation guarantees a functional straight penis. Almost all patients report adequate rigidity for sexual intercourse postoperatively, but in up to 50% of cases patients are dissatisfied with the postoperative penile length . In cases of penile prosthesis implantation for PD, therefore, a simultaneous penile lengthening procedure should be performed to increase postoperative satisfaction rates.
We report our experience using a novel method for restoration of penile length and girth in patients with PD by grafting; this method preserves glans sensitivity and ability to achieve orgasm.
PATIENTS AND METHODS
Between November 2006 and November 2011, 105 patients with disabling PD and associated ED underwent our surgical approach for penile length and girth restoration with concomitant penile prosthesis implantation. A detailed medical and sexual history was obtained, including the duration and progression of symptoms, erectile function, medication use, and history of trauma. All patients reported severe ED associated with PD.
During a preoperative outpatient evaluation, each patient received an intracavernous injection of 20 µg of prostaglandin E1 (PGE1) to assess the degree of penile curvature objectively. In addition, erectile function was assessed using dynamic echo colour duplex sonography. All patients showed an inadequate response to PGE1, with evidence of arterial insufficiency (peak systolic velocity, <30 cm/s). A compression of the crura was necessary in almost every patient to assess the degree of curvature objectively. The mean (sd; range) angle of the curvature was 75.3 (21.2; 0–100)°.
Penile prosthesis implantation was offered to patients whose disease had been stable for at least 6 months and who had failed to obtain sufficient penile rigidity for sexual intercourse after receiving erectogenic medication.
The patients provided informed consent, and possible side effects were explained, including incomplete straightening, recurrent curvature, change in glans sensitivity, penile prosthesis infection, and mechanical failure of the erectile device. The mean (range) preoperative International Index of Erectile Function questionnaire score was 9 (4–15). All patients complained of severe penile shortening.
Our technique is based on the geometrical principles of the Egydio technique [11,12]. Additionally, a circular tunica albuginea incision  was performed at the point of maximum curvature for reconstructing the penile girth and length. Inflatable two- or three-piece or malleable penile prostheses were implanted for maximum restoration of length and girth (Table 1). Pericardium grafts were used to cover the defects (Braile, Biomedica, Sao Paulo, Brazil). Ethical approval was obtained.
Table 1. Type of penile prostheses implanted
Type of prosthesis
No. of patients (%)
*American Medical System, Minnetonka, MN, USA. †Coloplast, Humlebaek, Denmark.
The operation is performed under magnifying lenses (2.5×) using a no-touch technique to the skin to prevent infection. After degloving the penis, the neurovascular bundle is mobilized (Fig. 1). If scar tissue is detected under the neurovascular bundle, a superficial incision is performed for maximum restoration of neurovascular bundle length. Artificial erection is induced with PGE1 or papaverine and saline solution injection to obtain and maintain a full erection. The geometric principles of the Egydio technique [11,12] are applied to determine the size of the graft and the placement of the tunical incision (Fig. 2). Once the circumference of the penis has been measured to determine the girth of the graft, two lines tangential to the penile axis are drawn on the proximal and distal straight segments of the shaft; the intersection point of these lines determines the point of maximum curvature. Circumferential incision of the tunica albuginea is then carried out from the point of maximum curvature.
Traction on the glans penis is held to determine if the shaft of the penis is elongated to the maximum length of the dissected neurovascular bundle. If addition of extra length is possible, the urethra is dissected (Fig. 3). The urethra is more elastic than the neurovascular bundle and is not a limiting factor in penile length restoration once the peri-urethral tissue has been removed, therefore, extensive dissection of the urethra is unnecessary.
In cases of severe penile shortening without curvature, a circular tunica incision  is made after dissection of the neurovascular bundle and urethra, restoring the length of the penis to the maximum length of the dissected neurovascular bundle. This maximum length depends on the elasticity of the dissected neurovascular bundle (Fig. 4).
Once the maximum length has been restored, a tunnel is created between the tunica and sponge tissue on the dorsal aspect of the shaft. The tunnel is created proximally and distally to the transverse incision to create sufficient space for the penile prosthesis cylinders, which are inserted under direct visualization. Creation of a tunnel on both sides of the cavernous body, parallel to the dorsal septum, is recommended.
Next, the increase in length must be added to the previously determined graft measurements based on the geometrical tunica incision (Fig. 5). Once the maximum length is restored, the penile shaft is measured to determine the proper size of the cylinder to be inserted. The graft is cut to match the size of the geometrical tunica incision plus the extra length obtained by the supplementary circular tunica incision (Fig. 6).
Narrowing of the penile shaft can be corrected. First, the length of the graft must be measured outside the narrowing area, i.e. in the area of normal calibre in a fully erect penis. A longitudinal tunica incision (lateral or dorsal) is performed on both cavernous bodies. The width of the longitudinal graft is defined by the difference in the measurements between the area of normal penile girth and the area of narrowing. These measurements must be obtained during maximum erection before performing any tunica incision (Figs 6 and 7).
In the case of a malleable penile prosthesis, the cylinders are inserted using the same tunica incision and the graft is sutured to the tunica. For inflatable penile prosthesis, it is recommended that the graft be sutured in place before insertion of the cylinders, which is performed with an extra corporotomy on both crura.
Once the reconstruction and penile prosthesis implantation are completed, the cavernous body is filled with antibiotic solution (vancomycin [500 mg] and gentamicin [240 mg] diluted in 400 mL of the saline solution used for irrigation during surgery) under pressure using a syringe. The pericardium graft is now sutured circumferentially with 4/0 poliglecaprone or polydioxanone sutures. Graft-to-graft suture in cases of girth enhancement should be performed using non-absorbable sutures (4.0 nylon or prolene). The penile skin is then regloved, and the circumcision incision is closed. The penis is kept wrapped in a light compressive dressing band from the corona of the glans to the base of the penis for 7 days. The scrotum is wrapped with an adhesive band and left in place for 7 days in cases of pump insertion. Patients were discharged on postoperative day 1 and were prescribed cefuroxime for 10 days. In patients using an inflatable penile prosthesis, it is recommended that the prosthesis be kept semi-inflated (∼50%) for at least 2 weeks to avoid development of scar tissue and re-curvature or cylinder misplacement.
Postoperative follow-up started 4–6 weeks after surgery. Patients were encouraged to start sexual activity once the penile skin wounds were completely healed and the patient felt comfortable. Surgical outcomes and postoperative complications were recorded at the follow-up appointments that were scheduled at 6 months and yearly thereafter. At the 6-month follow-up, erect penile length was measured and patient satisfaction was assessed in 104 patients using the Erectile Dysfunction Index of Treatment Satisfaction (EDITS) questionnaire . One patient who required early postoperative penile prosthesis explantation was not included in the evaluation, since he did not have a functional penis.
The mean (range) age of the patients at the time of treatment was 56.3 years (range, 32–75 years). After a mean (sd; range) follow-up of 18.2 (5.9; 6–46) months, all patients (n = 104; 99.0%) except one, who had the prosthesis removed after postoperative development of a wound infection, were able to perform satisfactory sexual intercourse; the infection rate was 1.0% (1/105). Those who had an inflatable penile prosthesis were able to cycle the device correctly and to achieve rigidity adequate for penetration. The mean (sd; range) functional penile length gain was 3.6 (0.7; 2–5) cm. No intraoperative complications occurred.
Three patients who were implanted with an inflatable penile prosthesis developed retraction with some residual curvature of up to 30° (2.9%), but no additional curvature correction was necessary since these patients were satisfied with their sexual intercourse and functional outcome. Glans sensitivity, ability to achieve orgasm and ejaculation were preserved.
A total of 104 patients answered the modified EDITS questionnaire at the 6-month follow-up appointment. Results are shown in Table 2. Ninety-three patients (89.4%) were satisfied with the cosmetic and functional result of the procedure. One patient was very dissatisfied with the procedure (1.0%) based on subjective unsatisfactory gain in penile length after reconstruction, despite a functional penis.
Table 2. Patients' satisfaction at 6 months according to EDITS (n = 104)
Outcome, n (%)
Somewhat satisfied (3)
Somewhat dissatisfied (4–5)
Somewhat confident (3)
Somewhat dissatisfied (4–5)
Postoperative loss of sensation
Significant loss of sensation (1–2)
Minimal loss of sensation (3)
Unsure/no loss of sensation (4–5)
Postoperative penile length
Somewhat satisfied (3)
Loss of length due to surgery
There is no consensus on the most appropriate technique for treating patients with PD, and various techniques are presently used. Although there are several surgical options for the correction of PD-associated penile curvature, including plaque excision, plication, onlay grafting and prosthesis implantation with penile modelling, only the last method can address both ED and anatomical deformation of the penile shaft [3,5]. The Egydio technique, which consists of plaque incision and grafting according to geometrical principles, is a valid and highly effective surgical approach for the correction of penile deviations. Recently, a European multicentre study showed that the procedure is a safe and easily reproducible technique for the correction of penile curvature, with excellent cosmetic and functional results . Nevertheless, it must be kept in mind that PD correlates with severe ED; therefore, straightening operations in such cases may not provide the desired benefit, as inadequate rigidity may persist and impede sexual intercourse. Patients with PD and arterial insufficiency, severe ED, complex anatomical deformities, and those with a shortened penis are best served with penile prosthesis implantation [3,16,17].
Chung et al.  recently published data on penile prosthesis implantation. Most of the 955 men studied were satisfied with the surgical outcomes, and 90% of the men stated that they would undergo prosthesis implantation again. Satisfaction rates for inflatable penile prosthesis range between 60 and 96% [10,16,19]. According to our experience, satisfaction levels were similar between those patients with inflatable and those with malleable prostheses. Careful preoperative assessments regarding the patient's perspective, device selection and realistic information about penile length and girth restoration are main reasons for the similar satisfaction rates.
Interestingly, Akin-Olugbade et al.  reported that satisfaction levels of patients with PD and penile prosthesis implantation are lower than those of the general implant population. The underlying reason is penile shortening. A 60° curvature for the implantation of a penile prosthesis means that the concave tunica albuginea side is 2.5–3 cm shorter than the convex side . Levine et al.  recently showed that almost 60% of patients with PD felt that they had lost penile length before surgery owing to the underlying disease and up to 54% reported that they had lost further length after prosthesis implantation. Wang et al. showed that penile prosthesis implantation is associated with a reduction in postoperative penile length; the authors reported a mean loss of 0.74 cm .
Rolle et al.  recently published the description of a new lengthening procedure based on a ventrodorsal incision of the tunica albuginea, penile prosthesis implantation, and double-dorsal ventral patch grafting with porcine small intestinal submucosa. The mean length gain was reported to be 3.2 cm; however, the study only included three patients.
Our technique overcomes the potential side effects associated with penile prosthesis implantation among patients with PD. Penile prosthesis implantation with concomitant penile lengthening and girth restoration based on a circular tunica incision  according to geometrical principles is a safe, valid, and reliable technique in patients with PD who have severe ED and penile shortening; however, it is very important to avoid creating false expectations in patients about the recovery of the original size of the penis, since the maximum recoverable size of the penis is based on the length and elasticity of the neurovascular bundle . Patients must be informed that PD may have caused structural alterations that shorten the neurovascular bundle.
Almost two decades ago, Wilson and Delk  published their initial experience with a novel technique of modelling the penis over an inflatable penile prosthesis. The inflatable penile prosthesis can be an effective treatment method for the correction of penile curvature , but in 19–42% of patients undergoing only cylinder implantation, an additional straightening procedure will be necessary because of residual curvature . DiBlasio et al.  showed that such penile modelling appears to exert stress on the prosthesis, leading to a higher rate of device malfunction. Furthermore, this group of authors showed that PD independently predicts component malfunction. These findings should be further investigated to determine the underlying cause of malfunction in patients with PD.
Overall, the modelling procedure is an effective method for PD correction, but we believe that this manoeuvre does not result in any length gain, which is the central concern of patients undergoing such surgical intervention. The modelling procedure during penile prosthesis implantation is a straightening but not a lengthening procedure and should not be offered to patients who complain of unacceptable loss in penile length. Modelling the penis over an inflatable penile prosthesis may predispose patients to earlier mechanical failure [27,28]. From our point of view, adequate length and girth restoration is only feasible with corporoplasty similar to that used in our technique, combined with grafting and penile prosthesis implantation.
The crucial criterion to distinguish between patients that should be managed with penile modelling [25,28] or with our technique is the maximum penile length, which is limited by the length of the dissected neurovascular bundle. This fact should be mentioned preoperatively in order to create a realistic expectation of the postoperative outcome. If the patient is very dissatisfied with his current penile length a reconstruction should be offered. An elaborated preoperative assessment of the patients' history and the patients' point of view on the amount of penile shortening based on a pharmacologically induced erection should guide the decision process. It is a matter of fact that the amount of penile shortening is best described by the patient himself and not by the physician; therefore, the patients' point of view plays another crucial role in the decision process.
In contrast to our technique, the modelling technique [25,28] measures the length of the corpora cavernosa without prior tunica albuginea reconstruction. This leads to an unavoidable selection of a shorter penile prosthesis. After our restoration technique the maximum length of the penis is restored and the most appropriate penile prosthesis can be selected. This will assure the best functional outcome for the patient. Our data showed that the use of a circumferential graft during penile prosthesis implantation prevented further shortening and led to a mean (sd; range) length gain of 3.6 (0.7; 2–5) cm. Our approach resulted in 89.4% patient satisfaction. We postulate, therefore, that it is not enough just to provide a rigid penis, because patient satisfaction may not be achieved with a postoperatively smaller penis.
In conclusion, the present data show that penile prosthesis implantation with concomitant penile lengthening and girth restoration based on circumferential tunica albuginea incision is a safe, valid, and reliable technique. This technique is highly effective for extensive penile shaft reconstruction to correct severe penile shortening and narrowing, resulting in maximum penile length gain and girth restoration, regardless of plaque characteristics. Although the ability to perform sexual intercourse again after surgery is important, restoration of length and girth are also critical for recovering self-esteem and for patient satisfaction.