Peyronie Disease Procedures

Peyronie disease causes fibrous plaque of the tunica albuginea with penile curvature and deformity (hourglass or hinge effect). The modern approach has shifted away from cutting the tunica: since collagenase Clostridium histolyticum (Xiaflex) was FDA-approved in December 2013, intralesional injection has become the first-line option and many patients now avoid surgery. When surgery is needed, the emphasis is on preserving the tunica and erectile function. The goal of any intervention is to restore function for intercourse, not to recreate the pre-disease penis. Peyronie disease as a condition is covered in the Andrology topic; this page is the procedural reference.

Patient Selection and Workup

• History and examination — take a full sexual history including erectile rigidity, and examine for other fibroproliferative conditions: Dupuytren contracture (palms) and Ledderhose disease (plantar surfaces).
• Characterise the deformity — assess the erect penis from a patient-supplied photograph or, preferably, after intracavernosal injection of a vasoactive agent (more objective for rigidity and deformity). Document curvature degree and direction, girth, any hourglass or hinge effect, stretched penile length, and sensation; photograph the erect penis for planning and follow-up.
• Penile ultrasound — scan the flaccid penis dorsally and ventrally with a high-frequency probe to map plaque, septal/intracorporal fibrosis, and corporal anatomy. Note plaque calcification and measure the tunica thickness over a calcified plaque to judge whether tunica-sparing excision is feasible. Add a color-duplex study of arterial/venous function if grafting is planned.
• Timing — operate only in the chronic, stable phase, usually 12–18 months after onset with the deformity stable for at least 3–6 months.
• Surgical indications — deformity preventing penetrative intercourse, extensive or painful ossified plaque, or a patient who wants rapid results after failed conservative therapy.
• Counseling — explain the risks of penile surgery: shortening, recurrence of deformity, decreased sensation, persistent pain, postoperative ED, and possibly poor cosmesis. Patient satisfaction is moderate at best even with good anatomical correction, largely from the emotional impact of not restoring the original penis.

Treatment Algorithm

Management is staged by disease phase. The active phase (a changing, often painful deformity, up to ~18 months) is managed non-surgically; surgery is reserved for stable disease — unchanged for ≥ 3–6 months and usually ≥ 1 year from onset — that compromises intercourse or has failed conservative therapy. Deformity rarely self-corrects (curvature improves in only ~12–13%), and the surgical goal is a functionally straight penis (< 30° residual).

Non-Surgical Options

• Active phase — NSAIDs for pain; ESWT is a pain-only option (it does not reduce curvature and may worsen it).
• Penile traction — the first-line non-invasive treatment in the stable phase (wear ≥ 3 h/day); reduces curvature and increases stretched length and girth.
• Intralesional collagenase (with modelling) — for curvature 30–90° with intact erections and a single, non-calcified dorsal or lateral plaque; it does not treat pain or ED, and is not used for ventral plaques, hourglass deformity, or curvature > 90°. Verapamil and interferon-α2b are alternatives; corticosteroids are not recommended.

Surgical Options

Procedure	Best for	Trade-offs
Plication (Nesbit, Yachia, 16-dot — tunical shortening)	Simple curvature < 60° with adequate length	Simpler and preserves rigidity, but shortens the penis; recurrence ~10%
Plaque incision/excision + grafting (tunical lengthening; pericardial or porcine SIS graft, never synthetic)	Complex curvature > 60°, large plaque, or hourglass deformity	Restores length but higher risk of reduced rigidity; needs strong preoperative erections (poor for ventral curves)
Penile prosthesis (inflatable, ± modelling or grafting)	Refractory ED with deformity, or profound instability	Gold standard when ED coexists; commonest complaint is length loss; modelling's main risk is urethral injury

Collagenase (Xiaflex) Injection

Collagenase is the preferred initial treatment for men with intact erections and a single, non-calcified dorsal or lateral plaque causing curvature of 30–90°. It is the only FDA-approved Peyronie drug and improves curvature but not girth or length (it does not treat pain or ED); it is not used for ventral plaques, hourglass deformity, or curvature > 90°, and was withdrawn in Canada and Europe in 2020. Xiaflex must be given by a provider certified under the Xiaflex REMS (Risk Evaluation and Mitigation Strategy). A treatment cycle is two injections 1–3 days apart followed by 6 weeks of modeling/stretching; cycles may be repeated at ≥ 6-week intervals, up to four cycles per plaque (IMPRESS I/II showed ~17° versus 9° curvature improvement against placebo).

Injection Technique

1. Mark the target — induce a pharmacologic erection rigid enough to identify and mark the plaque, then let the penis return to flaccid before injecting.
2. Anesthetise — infiltrate bupivacaine 0.25% over the plaque and wait 5–10 minutes.
3. Draw up — reconstitute the Xiaflex powder with 0.39 cc of supplied diluent; with a hubless syringe (0.01-mL graduations, fixed 27-gauge ½-inch needle) withdraw 0.25 mL (containing 0.58 mg).
4. Position the needle — grasp the plaque, apply antiseptic, and insert the needle transversely through the width of the dorsal plaque until it can advance no farther (mid-plaque); resistance to minimal plunger depression confirms position.
5. Inject — deliver 0.58 mg into the plaque of the flaccid penis, once on each of two days 1–3 days apart.

Modeling

• Perform a modeling procedure 1–3 days after the second injection of each cycle and teach the patient to stretch the flaccid penis 10 times daily, 60 seconds each, for 6 weeks to maximise length gained.

Aftercare and Complications

• Warn of significant pain for several days and bruising over the shaft, pubis, or scrotum; avoid intercourse for 2–3 weeks. For men on aspirin or anticoagulants, apply a compression dressing for 1–2 days.
• Penile fracture — a popping sound/sensation with sudden loss of erection needs emergency assessment (see Penile Fracture Repair).
• Tunica albuginea herniation — collagenase can thin the tunica; the laterally thinner tunic is most prone.

16-Dot Plication

A tunical-shortening procedure for primary or post-collagenase residual curvature in men with good rigidity. It is best for simple curvature < 60° in men with adequate length who can tolerate some shortening (recurrence ~10%).

Technique

1. Erection — supine under light sedation and local anesthesia, induce a rigid pharmacologic erection (papaverine ± phentolamine via a 25-gauge needle), or create a saline artificial erection (21-gauge scalp needle with proximal manual compression). A proximal tourniquet is avoided — it can underestimate curvature and, over the dorsal nerve, cause numbness.
2. Anesthetise and assess — bupivacaine 0.25% to the incision site or a penile ring block; confirm the degree and laterality of the curve.
3. Incision — longitudinal (direct visualisation, least morbidity) or a circumcising incision ~1 cm from the corona (if already circumcised, desiring circumcision, or avoiding a longitudinal scar).
4. Expose and mark (dorsal curvature) — incise Buck fascia longitudinally adjacent to the corpus spongiosum and expose the ventral tunica along the curve; mark the centre, then entry/exit dots 0.5–1 cm apart and 2–3 mm lateral to the corpus spongiosum. Every four dots make one suture; most curves need two or three sets per side (16 or 24 dots), occasionally four pairs (32 dots).
5. Place and tune the sutures — pass 2-0 braided polyester nonabsorbable suture through the full thickness of the tunica, tie a single throw, and clamp each half-knot with a rubber shod; re-induce a rigid erection, check straightness, and loosen/tighten as needed.
6. Other directions — for ventral curvature place sutures between the deep dorsal vein and the paired dorsal arteries; for lateral curvature place them on the lateral convex side after dissecting Buck fascia and the neurovascular bundles off the tunica.
7. Close — 4-0 absorbable suture to the Dartos and absorbable suture to skin; apply a loose compressive dressing.

Extratunical (Reinforcement) Grafting — Hourglass Deformity

Reinforces and thickens the thin segment of the shaft to correct an hourglass deformity without disrupting the tunica, avoiding the ED risk of tunical-lengthening grafts. It is a newer approach without long-term follow-up.

Technique

1. Setup — supine, light sedation + local; rigid erection (papaverine ± phentolamine); ring block or bupivacaine 0.25%; mark the deformity.
2. Expose — circumcising incision and deglove the penis in the plane between the deep Dartos and Buck fascia.
3. Correct curvature first — if a curve coexists, correct it (e.g. plication) before addressing the hourglass.
4. Prepare the graft — choose a graft (Tutoplast = gamma-irradiated acellular cadaveric pericardium or fascia lata), tailor it, and soak in antibiotic solution for 5–10 minutes.
5. Secure and size — fix the graft to the tunica with interrupted 3-0 polydioxanone (PDS), sizing it for the erect penis to avoid shortening or trapping. Double or triple the thickness if needed, or make it thicker peripherally and thinner centrally by folding the ends.
6. Close — irrigate, minimise graft-skin contact, and close in three layers (4-0 polyglactin deep; 5-0 mattress skin for a longitudinal incision, or running/interrupted skin for a circumferential one).
7. Dress and follow up — check glans perfusion at 1 hour, remove the dressing at 24 hours, teach self-dressing for 5–7 days, and resume intercourse at 6–8 weeks.

Tutoplast is favored because it is thin, conforms to irregular surfaces, has high tensile strength with multidirectional elasticity, and acts as a scaffold for tissue ingrowth — avoiding the donor-site morbidity and added operative time of autologous grafts (vein, dermis, fascia).

Tunica-Sparing Calcified Plaque Excision

Peels a calcified or ossified plaque off the preserved overlying tunica when the plaque itself is the problem.

Technique

1. Setup — supine under general anesthesia; rigid artificial erection (pharmacologic or saline); assess the deformity and plaque location.
2. Incision — local or ring block, then a circumcision incision (best for multiple deformities) or longitudinal incision. If plication is planned, place those sutures before excising the plaque.
3. Expose — define the corpus spongiosum in the Dartos–Buck plane, clear the ventral tunica, and raise a soft-tissue flap carrying the lateral neurovascular bundle to the 1- or 11-o'clock position (side of the plaque) to spare the dorsal bundle. Inject dilute phenylephrine to abort the erection before excision.
4. Excise — calcified plaques sit on the inner tunica next to erectile tissue; make a lateral longitudinal #15-blade incision onto the plaque, slightly larger than it, leaving adequate dorsal tunic. With fresh blades and 2.5× loupe magnification, scrape the plaque off the undersurface of the tunica — a slow process that can take hours.
5. Close — repair the tunical defect with interrupted 3-0 PDS started at the corners (watertight, avoids shortening); close skin in two layers with 5-0 polyglactin. Check glans perfusion at 1 hour, remove the dressing at 24 hours, and avoid intercourse for 6–8 weeks.

If calcification extends beyond the area to be excised, ossiectomy preserves tunic into which a graft can be sutured.

Incision/Excision and Grafting

Tunical-lengthening reserved for complex curvature > 60°, a large plaque, or a destabilising hinge or hourglass. It carries the highest postoperative ED risk and needs strong preoperative erections (a poor choice for ventral curves), but remains appropriate in selected, well-counseled men.

Vein Graft (Lue)

• Do not induce a pharmacologic erection — it increases bleeding and impairs visualisation. If a saphenous graft is used, abduct the donor leg in a frog-leg position.
• Circumcision incision and deglove; elevate Buck fascia just lateral to the corpus spongiosum. For dorsal curvature, ligate the deep dorsal vein and gently displace the dorsal nerves and vessels aside.
• Make an H-shaped relaxing incision through the plaque — do not excise it; vary the H shape to the curve.
• Harvest greater saphenous vein (≈ 1 cm wide when opened; take ~2 cm extra as it contracts the least of any biologic graft). Prepare it on a silastic block, join segments with 5-0 Maxon and titanium staples, sew the corners first (4-0 Maxon) then run a locking suture, cover with Buck fascia, and test with a saline erection.

Dermal Graft (Devine)

• Harvest an ellipse of dermis over the iliac crest (dermatome ~0.012 inch), tack and run the graft into the defect, and allow for ~20–25% contracture. A "humpback" with artificial erection can be controlled with a longitudinal nonabsorbable bolster suture.
• Many other graft materials are described: autologous tunica albuginea (crura), dermis, buccal mucosa, tunica vaginalis, temporalis fascia, fascia lata, small-intestine submucosa, and Tutoplast (pericardium/fascia lata); synthetic grafts are avoided.

Postoperative Course

A graft may contract over the first 3 months; have the patient massage and gently straighten the erect penis from 2 weeks, with intercourse safe by 6–8 weeks and the graft softening by 3 months. If potency does not return, a penile prosthesis can be placed later — after confirming the impotence is organic.

Prosthesis with Straightening

For men with ED plus curvature, a penile prosthesis is placed and the penis straightened in the same operation by modeling, plication, or plaque incision.

• Modeling — with an inflatable prosthesis partially inflated to the point curvature appears, forcibly straighten until a cracking sound is heard; repeat until fully inflated and as straight as possible, confirming the corporotomies stay closed. If curvature persists, make transverse incisions through the plaque, avoiding the cylinders and urethra; a defect < 2–3 mm needs no coverage.
• Plication — ideally preplace the 16-dot sutures before implanting (for a known severe curve) through the same penoscrotal incision, dissecting distally over Buck fascia to the corona and everting the penis — this avoids needling the device and limits its exposure. Alternatively, implant first, then deflate and back the cylinder out on its distal guidance suture to place the sutures safely before replacing and inflating.
• Plaque incision ± tunical reinforcement — for a severe hourglass, cut the narrow tunica with cutting current (with the prosthesis inflated) until the restriction "pops"; leave a defect < 2–3 mm open, or cover a larger one with a Tutoplast "wrap" sutured with 3-0 PDS, protecting the prosthesis and urethra.

Postoperative Care

• Do not suppress erections — they aid straightening and perfusion — but discourage all sexual activity for 6–8 weeks. Use a loose circumferential dressing for a few days plus ice packs for the first 48 hours.
• Rehabilitation (men without a prosthesis) is critical: penile massage, a low-dose bedtime PDE5 inhibitor to enhance nocturnal blood flow and nourish the graft, and penile traction therapy from 3–4 weeks postop, 3 or more hours daily for 3 months to limit length loss and guide straight healing.
• Complications — hematoma (inadequate hemostasis, displaced dressing, or a strong erection, especially 6–8 weeks out; may need ultrasound-guided evacuation); infection (can cost the graft or prosthesis, or leave a chronic sinus); knot-site pain after plication (treat with anesthetic/steroid injections, up to ~6 sessions); glanular anesthesia after extensive neurovascular-bundle mobilisation; skin loss from too-tight a dressing; and return of curvature after grafting from graft contraction (usually resolves by 3–6 months; disease may recur on the opposite side).