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Surgery – Plication

How To Straighten A Bent Penis – Plication

Patients who have immature disease are advised that they are not candidates for surgery to straighten the penile curvature until the disease is mature. Those who have mature disease, and only have mild curvature that does not in any way interfere with intercourse are discouraged from undergoing penile reconstruction penis curvature correction at our Center. Patients with erectile dysfunction, an inability to obtain and maintain a quality erection, are first treated for erectile dysfunction as surgery to correct curvature generally does not correct problems with rigidity.

A significant percentage of patients referred to our center have mature disease with good rigidity and persistent disabling penis curve that significantly interferes with penetration. Disabling curvature can be defined as a bent penis with angulation so severe as to completely prevent penetration, or penis curvature curvature that causes discomfort to the partner of the patient. These patients are the ideal candidates for corrective surgery.

Some of our patients are under the impression that the curvature can be corrected if the plaque were removed. However, the plaque is something adherent to the tunica albuginea but is a change within the tunica itself. In the example of the rubber balloon where part of the rubber could be replaced with plastic, removal of the plastic would create a hole in the balloon. Similarly, simple removal of the plaque would create an open defect in the substance of the penis. Therefore, surgery to correct curvature is not directed towards simple plaque removal. The curvature with erections is caused by one side being longer than the opposite side. This disparity can be corrected by making the short side longer or making the long side shorter.

Plication, making the long side shorter

Surgical treatment options to straighten penis curvature include a plication procedure where the long side is shortened. One way to accomplish this is to place non-absorbable placating sutures in the tunica albuginea opposite the curvature to straighten the penis. Advantages of this method of penile curvature correction include technical ease and decreased dissection and operative time. However, one disadvantage is if the suture were to ever break, there can be recurrence of the curvature. Moreover, some patients find the permanent sutures and knots uncomfortable. At the Center for Reconstructive Urology, we favor wedge excision plications with a 2 layer closure. Upward curvature can be corrected by plicating the undersurface (ventral aspect) of the penis. Given that the urethra is midline, we place plication sutuers on each side of the urethra as shown.

Peyronies ventral

This surgery begins with a circumcising incision to “de-glove” the penis, exposing the tunica albuginea and sensitive nerves and blood vessels adherent to the tunica. These structures are very carefully dissected away from the tunica using optical magnification and fine specialized instruments.

The patient is then given an artificial erection. Saline is rapidly infused into the spongy tissue inside the penis as compression is applied under the scrotum to restrict outflow. The area of maximal curvature is identified, and temporary placating sutures are placed. An artificial erection is again achieved to confirm beneficial straightening.

Peyronies ventral

The plications are made then permanent with creation of an oval shaped incision (excising a portion of the tunica) and a 2 layer closure using absorbable sutures that eventually dissolve.

When there is downward ventral curvature, the penis can be plicated on the top dorsal surface.

Peyronies dorsal

The penile skin is “degloved” using a circumcising incision exposing the neurovascular bundles (nerves and arteries going to the head of the penis). These important structures are carefully dissected away from the tunica of the penis. This is a technically challenging maneuver and one reason expertise in penile surgery can influence the outcome. Wedge excisions are performed. In this example, there are 2 excisions, but the number and location of the excisions are based on the location and degree of curvature. The defects are then closed in a 2 layer closure. The neurovascular structures are then re-positions in the normal location, and the skin is then closed.

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