Slideshow of Penile Plication
These pictures demonstrate the technique of correcting penile curvature with plication.
Surgery to correct straighten a bent penis in a man with Peyronie’s Disease begins with a skin incision. In this picture of Peyronie’s Disease surgery, the skin is marked circumferentially approximately 1 cm proximal to the area where the head of the penis (glans penis) meets the shaft, called the coronal sulcus.
In this Peyronies Disease surgery picture, the skin is incised. This is called a circumcising incision, even though in this case, an actual circumcision (removal of foreskin) is not performed. Our surgery to correct penile curvature is performed under general anesthesia.
Penis Plaque Surgery
After the skin is incised, the penile skin is “degloved” and brought down to the base of the penis. The penis plaque is deep to the skin and other tissues. In this picture of surgery to correct upward penile curvature, after the skin is degloved, the urethra (surrounded by a structure called corpus spongiosum) and the erectile bodies called the corpora cavernosa can be seen.
In this photograph of surgery to straighten penile curvature, saline is rapidly infused into the penis as the base of the penis is compressed to create an “artificial erection”. The abnormal area where the penis is crooked can be seen. Plications are then performed on the opposite side. When there is upward penile curvature, the plications are performed on the undersurface of the penis.
Curved Penis Tunica
After the penile skin is degloved and the area of penile curvature is identified, the neurovascular structures (that contain nerves to the glans penis) must be moved to the side, exposing the tissue to be plicated to straighten the bent penis. This tissue is called the tunica albuginea. This dissection is performed under optical magnification, and expertise is required to safely expose this tunica without damaging the sensitive nerves.
Penis Plication Marking
A pen was used to mark the exposed tunica albuginea to be plicated. The removal of the tissue between the yellow lines will shorten the penis in that area by an amount corresponding to the distance between the lines. When there is penile curvature, the long side is shortened to tilt the bent penis straight.
Penile Plication Compare
In this Peyronie’s Disease surgery photograph, the neurovascular bundles have been mobilized on the right side of the undersurfase of the penis (ventral-lateral) which is on the left side of the picture, and the area to be plicated is marked. This picture demonstrates the comparison of the appearance before and after the mobilization.
When upward penile curvature is corrected, we plicate along the undersurface of the penis on both sides of the urethra. In this photo, the neurovascular bundles have been lifted off the tunica albuginea. The urethra is in between the areas to be plicated. Curvature could also be corrected by mobilizing the urethra and performing a midline plication. However, it is our preference to not disturb the urethra to best protect the urethra from possible injury.
Penile Test Plication
Before actually making a permanent change to the penis, we first perform a temporary plication using suture to pinch the area to be plicated. In this photograph of penile plication surgery for Peyronie’s Disease, the suture has been placed but has not yet been tied.
Penile Plication Tied
After the temporary plication suture is placed, the suture is tied. An artificial erection is then performed to confirm that the plication of this area will help straighten the bent penis. We will then remove the temporary suture and perform a permanent plication to correct the penile curvature by performing an oval shaped excision of tissue and a 2 layer closure.
Peyronies Plication Completed
Plications have been performed with one plication on each side of the urethra along the undersurface of the penis. Our preference is to use absorbable suture that will eventually dissolve so that the patient does not feel the knots of permanent sutures.
Ventral Penile Plications
When there is severe penile curvature, multiple plications are needed to fix a curved penis. In this patient where the penis is abnormally bent upwards, there was only partial correction of the curvature after a single plication on each side of the urethra. We then performed additional plications, and this straightened the penis, which was confirmed with an artificial erection.
Congenital Curvature Plication
Another cause of an abnormal penis is Congenital Penile Curvature. Men who report life long curvature, especially to the side, are born with unequal development of the tunica albuginea of the penis. During an erection, one side is abnormally longer than the opposite side, and this causes a bent penis. In this photograph, plication is performed to fix the penile curvature.
Dorsal Penis Plication
When there is downward penile curvature, which is less common than an upward bent penis, the plications are performed along the top of the penis to tilt the penis back upward. In this patient, 3 plications were required. Prior to surgery, he had disabling 90 degree downward penile curvature. After surgery, his penis was straight and he was able to resume sexual intercourse.
After the plications are all performed and the penis is straight, the neurovascular bundles are then replaced to again cover the tunica albuginea. In this Peyronie’s Disease surgery picture, on one side, the neurovascular tissue is being repositioned to cover the exposed tunica albuginea as it did before the surgery.
Bent Penis Straightened
Before the skin is closed following penile plications to correct curvature, a final artificial erection is performed to confirm that the bent penis was straightened. In this photograph, the artificial erection revealed that the penis is now completely straight.
Peyronies Surgery Complete
The skin incision here has been closed with absorbable sutures. These sutures do not have to be removed as eventually, they dissolve. We leave a small tube under the skin for less than 24 hours to drain any blood. However, bleeding after surgery is rare and to date, we have never had the complication of significant bleeding after penile curvature correction surgery.
Slideshow of Penile Grafting
These pictures demonstrate the technique of correcting penile curvature with grafting.
Dorsal Penis Plaque
When graft or plication surgery is performed, a circumferential skin incision is made, and the penis is “degloved”. In this picture of actual Peyronie’s Disease surgery, the dorsal aspect of the penis (top part) is seen, and this is generally the area where the penile plaque is felt in patients with upward penile curvature.
Penis Surgery Exposure
The graft is place on the tunica albuginea of the penis that is deep to the neurovascular bundles. These bundles provide sensation and blood flow to the glans penis and must be mobilized to exposed the tunica albuginea. There is a vein that runs along the middle of the top of the penis called the dorsal vein, and this is first identified.
The dorsal vein can be removed without consequence. When we remove the dorsal vein, we can then see the tunica albuginea along the midline where there are no neurovascular structures. In this photograph of Peyronie’s Disease surgery, the vein is being removed as branches are cauterized or tied.
After the dorsal vein is removed, there is an indentation down to the tunica albuginea. We then, under optical magnification, carefully dissect the adherent neurovascular bundles away from the tunica albuginea without cutting through or damaging these sensitive structures.
In this Peyronie’s Disease surgery picture, the neurovascular bundles are being dissected away from the tunica abluginea. The tunica albuginea contains the penile plaque. Although some surgeons use a “penile tourniquet” to control bleeding during this dissection, we never need to use this device.
Penis Plaque Exposing
The tunica albuginea is further exposed in this surgery photograph. The tunica abluginea is like a rubber balloon that expands and becomes more rigid when filled with fluid. The penile plaque is an inelastic scar of the tunica albuginea, and when the scar involves the tunica on the top part of the penis, there is upward curvature with erections. Graft surgery to straighten the bent penis lengthens the scarred area.
Additional Distal Exposure
In some men with Peyronie’s Disease, the affected tunica albuginea extends towards the tip of the penis. In this surgery photograph, the neurovascular structures re mobilized all the way to the glans penis itself in preparation for incision of the tunica and placement of graft tissue to correct the penile curvature.
Once the neurovascular bundles are fully mobilized in the area of maximum penile curvature, which is confirmed with an artificial erection, the tunica albuginia containing the plaque is marked, and will then be incised. One option is to excise the plaque and graft. However, there is a greater risk of erectile dysfunction with plaque excision, and the plaque is generally only excised when so calcified and hard, the graft cannot be sutured to the affected area.
There are several different tissues that can be used as graft material during Peyronie’s Disease surgery. This is a picture of a dermal graft harvested from an area of the abdomen called the “love handle”. The tissue called dermis is between the skin and the fat. An advantage of this tissue is that it is readily available in a very adequate amount.
Another graft material used by surgeons during graft repair to correct the penile curvature associated with Peyronie’s Disease is a vein graft from the dorsal vein of the penis and/or veins of the leg. We do not prefer to use veins as the quantity of material is less limited with dermal grafts.
Dorsal Dermal Graft
In this Peyronie’s Disease surgery photograph, subsequent to penile plaque incision, a dermal graft has been placed as a patch to lengthen the shortened portion of the penis. After the graft is sutured in place under optical magnification, an artificial erection is performed to assess the extent of curvature correction.
Second Penis Graft
Although a single dermal graft can often completely straighten an abnormally bent penis in a man with Peyronie’s Disease, in more severe cases, additional grafts are required to completely correct the penile curvature. In this surgery picture, a graft has been placed along the mid portion of the penis, and distal upward curvature towards the glans penis remains. A second graft area is marked. In this patient, there was complete penile curvature correction after the placement of a second dermal graft.
During Peyronie’s Disease surgery, after the grafts are placed, the neurovascular bundles are re-positioned to cover the exposed tunica albuginea and grafts. The skin incision is then closed with absorbable suture after small temporary drains are placed. These drains are removed prior to discharge from the hospital.
Patients are often referred with immature Peyronie’s Disease. They are not candidates for surgery. Corrective repair to straighten a bent penis is only an option when the penis curvature is stable and there is no erectile dysfunction unresponsive to medication. After a complete history and physical exam is performed, we provide an education to our patients so that they understand why they have a crooked penis and why they have pain with erections (not in all cases). We then discuss all options including medical management. It is necessary to objectively discuss each option and the risks and potential benefits of each option as a patient can not give proper legal informed consent to a treatment choice without knowing the alternatives.
When a patients has stable mature disease and has good erectile function and penile curvature, we ask if the curve interferes with sexual relations or not. In some cases, the curve completely prevents penetration. In other cases, positions are limited, or intercourse may be uncomfortable to the partner of the patient. These are valid reasons to pursue surgical correction of the curvature. Surgery to straighten a curved penis is generally covered by insurance and not considered cosmetic. When the curve is not disabling and mild, some patient desire surgery because they find the curvature embarrassing and psychologically troublesome. These patients are counseled that they really should weigh the risks vs benefits of surgery.
At the Center for Reconstructive Urology, we have a very high success rate and a very low complication rate. Dr. Gelman is fellowship trained and experienced expert in surgery to correct penile curvature. However, surgery is never without risk. We feel that when there is no functional impairment, the patient should carefully consider observation. Surgery to correct penile curvature is technically challenging and is best performed by a Urologist with specialized training, expertise, and extensive experience in male reconstructive surgery.