The only purpose of all surgical methods of treating Peyronie’s disease is to correct erectile deformation and to create conditions for successful sexual intercourse. In this case, a “functionally straight” penis is considered with a curvature of less than 20°. The curvature during erection less than 30°, as a rule, does not affect a fully-fledged sexual intercourse both for a man and for his sexual partner.
Thus, when deciding on the rationale for surgical treatment of Peyronie’s disease, three main preoperative factors should be taken into account:
degree of penis deformation;
degree of penis rigidity (stiffness) during erection;
patient’s interest in sexual activity.
Degree of deformation.
The main indication for surgical treatment of Peyronie’s disease is precisely the curvature (deformation) during erection, and not the size or number of plaques. It is erectile deformation that reduces the quality of life of the patient and his sexual partner, hindering active sexual life. If the curvature does not exceed 30°, and if there is no complex curvature in the form of “loops” or an “hourglass” symptom, then surgical treatment should not be recommended (with the exception of extensive calcined plaques, which in the absence of treatment can gradually increase in size and lead to a strong curvature). In these cases, men with Peyronie’s disease should go through a comprehensive conservative treatment or dynamic observation (if a patient is not interested in therapy). About how to determine the angle of deformation during erection, read HERE.
Degree of rigidity (stiffness) during erection.
If penis hardness during erection and sex (even with the use of PDE-5 inhibitors) is low (1 – 2 points according to the Erection Hardness Scale (EHS)), pharmacodoplerography (ultrasound) of the vessels should be recommended, and the option of phalloprosthesis with parallel correction of curvature should be considered (only in the presence of erectile dysfunction resistant to pharmacotherapy!). In case of adequate hardness during erection (3 – 4 EHS points), the option of surgical treatment aimed at straightening of the penis should be recommended.
If a man with Peyronie’s disease has signs of erectile dysfunction, pharmacotherapy (ultrasound) of vessels is mandatory along with assessment of the of male hormones level.
Patient’s interest in sexual activity.
The patient’s desire to continue sexual life is a crucial point in answering the question about the rationale for surgical treatment of Peyronie’s disease. There is only one purpose of surgery in Peyronie’s disease: to achieve straightening of the penis during erection and assure normal sexual activity. Therefore, it makes no sense to conduct surgical treatment aimed at eliminating erectile deformation in a patient who does not plan to have sexual life. Surgery should not be recommended to a patient who wants just to get rid of the “indurations” under the skin, since they embarrass him, or because the patient mistakenly fears the rebirth of these “indurations” in a malignant tumor. Conservative therapy or dynamic observation should be recommended to such patients; in some cases, a psychotherapist’s consultation may be recommended.
Types of surgery in Peyronie’s disease
In case of surgical treatment of Peyronie’s disease, two main types of surgical interventions aimed at eliminating the curvature are currently used:
Shortening operations are carried out if the following criteria are met:
curvature during erection does not exceed 60°;
the absence of destabilizing complex curvatures in the form of “hourglass” or “loops”;
the patient is satisfied with the predicted length of the penis after surgery* (learn HERE how to calculate the difference between the convex and concave surface of the curved penis and thus determine what extent of shortening should be expected after surgery).
* In each case only individual approach is acceptable in addressing this issue. In this case, the patient should know the length of his penis, which he will “lose” during surgery due to the plication (corrugation) of the longer (convex) surface of the tunica albuginea of the penis, before the surgery. Therefore, it is very important to correctly calculate the lost length of the penis before surgery – see HERE for recommendations on such calculations.
The principle of all shortening techniques in Peyronie’s disease is that the correction of erectile deformation is performed by shortening the convex side of the tunica albuginea. As a result, the convex and concave sides become equal in length.
Shortening operations can be divided into 2 groups:
1) methods with opening the tunica albuginea;
2) methods without opening the tunica albuginea (i.e. plication operations).
Methods with opening the tunica albuginea have a number of disadvantages (risks):
— threat of bleeding after a damaged integrity of tunica albuginea;
— damage to the urethra;
— damage to the neurovascular bundle.
In the postoperative period, there is a risk of inflammation of cavernous bodies (cavernitis) with subsequent scarring, which in turn leads to erectile dysfunction. It is also possible to reduce the sensitivity of the penis head, hematoma, and even the development of acute urinary retention. The disadvantage of such techniques is the risk of reducing the diameter of the penis.
Shortening operations without opening the tunica albuginea are the least invasive surgical procedure that allows correcting erectile deformation in patients with Peyronie’s disease.
Advantages of techniques without opening the tunica albuginea:
— such operations are technically easier and take less time;
— reduced risk of bleeding and injury of tunica albuginea and cavernous tissue;
— minimal risk of erectile dysfunction;
— usually less risk of damage to the neurovascular bundle and urethra.
Currently, operations without opening the tunica albuginea (the so-called plication operations) are considered the “gold standard” of surgical treatment of simple forms of curvature in Peyronie’s disease.
Disadvantages of techniques without opening the tunica albuginea:
— penis shortening;
— palpable sutures on the tunica albuginea still remain in the postoperative period;
— pain may preserve for a long time.
Summary: according to various studies, 1) at least 85% of patients had a satisfactory result and noted the straightening of the penis after performing a shortening operation; 2) erectile dysfunction after surgery was observed in no more than 13% of cases; 3) temporary impairment of sensitivity (hypesthesia) occurs not often than in 21% of cases after shortening operations.
Lengthening operations – dissection or excision of the plaque with the closure of the tunica albuginea defect by biomaterial (grafting) – are carried out if the following criteria are met:
curvature during erection more than 60°;
presence of destabilizing complex curvature in the form of “hourglass” or “loops”.
During such operations, the penis is not shortened, but rather lengthened from the side of the plaque (the concave side during erection). Such operations are the “gold standard” in the correction of erectile deformation of more than 60°, as well as complex curvatures in the form of “hourglass” or “loops”.
There is still no ideal biomaterial for grafting in Peyronie’s disease. Any of the existing biomaterials has both advantages and disadvantages. To date, the most preferred materials, in terms of biomechanical properties and histocompatibility, are cattle pericardium, large subcutaneous vein, stretched polytetrafluoroethylene, own Buck fascia, tunica albuginea of cavernous bodies, neurovascular bundle.
Summary: according to various studies, 1) at least 74% of patients had a satisfactory result and noted the penis straightening after the lengthening operation; 2) erectile dysfunction after surgery ranges from 5% to 53% of cases (thus, the risk of erectile dysfunction in lengthening operations is much higher than in shortening ones (up to 13%), which is associated with significant damage to the neurovascular bundle, traumatization of the tunica albuginea and the adjacent cavernous tissue, as well as due to the inflammatory response of cavernous tissue to biomaterial; 3) temporary (from several weeks to several months) decrease in the sensitivity of the head (hypesthesia) occurs in almost 100% of cases after lengthening operations, which is associated with the release of the neurovascular bundle.
Any patient should understand that any surgical intervention is associated with risk. The surgery is not only a risk, but also serious emotional stress and fears for a man and, perhaps, his sexual partner. In order to avoid major disappointments after surgical treatment, as well as to prevent the occurrence of conflict situations and misunderstandings between the doctor and the patient, the latter must necessarily be informed about the advantages and disadvantages of the surgery, about the possible risks and complications, about the expected or unforeseen prognosis associated with surgical intervention (residual curvature, relapse of erectile deformation, loss of length, reduction of penis rigidity, presence of palpable sutures on the tunica albuginea, etc.).
The doctor should discuss with the patient the option of cutting the skin on the penis; the patient should decide whether it is necessary to preserve the foreskin (in some cases, the preservation of the foreskin increases the risk of a number of complications: edema of the foreskin, phimosis, paraphimosis).
An important component of the successful treatment of Peyronie’s disease is mandatory postoperative rehabilitation, aimed at reducing the risk of possible complications and the recovery period in both shortening and lengthening operations. Read more about rehabilitation HERE.