Patients who fail to respond to drug therapy for Peyronie's disease and who have curvature for longer than 12 months are considered candidates for surgical intervention. While some men may improve their curvature spontaneously, many men will progress over the first 12 months and have persistent and complete inability to achieve penetration because of either the magnitude of the penile curvature or secondary erectile dysfunction (ED). All patients considered candidates for surgical reconstruction undergo vascular evaluation to identify if the patient?s erection function is adequate. Doing this allows the clinician to predict which patients may have worsening of their erectile function following penile reconstruction. In part the operative intervention that is selected for the individual patient is based upon the preoperative erectile function. At the Sexual Medicine Program at The New York Presbyterian Hospital the vascular test of choice is dynamic infusion cavernosometry/cavernosography (DICC), although many centers use duplex Doppler penile ultrasonography (DUS).
Which corrective operation is chosen is based on a number of criteria which include (i) preoperative erectile function (ii) preoperative erectile length and (iii) the magnitude and complexity of the curvature and (iv) patient and partner expectations and goals. There are 3 major types for operations for Peyronie's disease.
Penile Plication Procedures
This group of procedures generally involves performing a tuck procedure on the side opposite to the scar (plaque), thus shortening the long side of the penis. Its advantages include its simplicity, excellent preservation of preoperative erection ability, and high patient satisfaction. The disadvantages include loss of penile length, which in the medical literature is reported to occur in 46-100% of patients. Patients who are considered excellent candidates for this procedure include those with ample penile length who have a simple curvature without any associated deformity (waisting, hinge and hour-glass effects).
Plaque Incision/Excision and Grafting
This group of procedures involves the complete or partial excision of the plaque or its incision with the placement of a graft into the space left by the excision/incision technique. Multiple graft materials have been used, including dermis, cadaveric fascia, cadaveric pericardium, saphenous vein and intestinal submucosa. The advantage of this approach is that it is typically not associated with loss of penile length. Its disadvantages include the development of postoperative ED in men with poor erectile function preoperatively, and prolonged loss of penile sensation in approximately 10% of men. Ideal candidates for this approach are men with shorter penile length, irrespective of their degree or complexity of curvature who have normal erectile function preoperatively. Men who present with hour-glass deformity or waisting are also best served by plaque incision and grafting.
Penile Prosthesis Surgery
The placement of a penile implant allows immediate correction of the penile curvature as well as permitting fully rigid erections (see Penile Implant page on this website). It is associated with excellent postoperative patient satisfaction rates, however, it is associated with the low incidence of the risks and complications of penile prosthetic surgery (infection, malfunction, re-operation). It is generally reserved for men with combined ED and penile curvature. At our center, all men with combined ED and Peyronie's disease are commenced on pills or penile injections for the ED first, prior to deciding on penile implant surgery. If these drugs are effective then the patient is considered a candidate for penile plication procedures combined with ED drug therapy.