Surgery for Peyronie's Disease. Which is the perfect procedure?

Surgery still represents the best solution in patients with stable Peyronie's Disease. The aim of surgery in Peyronie's Disease is to guarantee a penis straight and rigid enough to allow the patient to resume sexual activity with confidence. 

At present, more than 50 different types of procedures have been described in the literature and the question "is one technique better than another?" is perfectly legitimate. However, unfortunately the answer is "no".

The reason why there are many type of procedures is not only that different techniques are indicated according to the type of the deformity, the degree of penile shortening and the quality of the erections, but also that a perfect type of procedure still does not exist, as none of the procedures can bring back the exact pre Peyronie's Disease size and shape of the penis.

Surgical procedures available at present can be subdivided in 3 main cathegories: 1) Simple plication procedures; 2) Complex corporoplasty with plaque incision and grafting; and 3) Penile prosthesis implantation with additional straightening procedures. Each one of these categoris has its own indications, advantages and disadvantages. 

Penile prosthesis implantation is indicated in patients with refractory erectile dysfunction or with a degree of erectile dysfunction and complex deformity and/or severe penile shortening. This procedure guarantees adequate correction of the deformity and the rigidity necessary to engage in penetrative sexual intercourse.

Simple corporoplasties (such as Nesbit, Yahia and Tunica Albuginea Plication or TAP) are indicated if the curvature is less than 60 degrees, if penile shortening is not excessive and if there is no waist deformity. These procedures are not associated with postoperative worsening of the quality of the erections and are reasonalbly simple to perform. These procedure induce straightening by shortening the longer side of the shaft (the one ont affected by Peyronie's Disease). It is estimated that a shortening of 1 cm is necessary to correct 20 degrees of curvature and therefore these procedures are not indicated for curvatures of more that 60 degrees, as this would require a shortening of 3 cm at least to produce adequate straightening.

Complex corporoplasties involving plaque incision and grafting (such as the Lue procedure) are nieche procedures due to their complexity and therefore need to be performed only by experienced large volume surgeons in order to achieve adequate results. 

Patients with good quality erections and complex deformity, waist, severe shortening and curvatures of more than 60 degrees are the only candidates for this type of procedure. As plaque incision and grafing can worsen the quality of the erection in around 15% of cases, patients with a preexistent degree of erectile dysfunction are not candidates for this procedure, as they are likely to become fully impotent afterwards, and should be offered penile prosthesis implantation instead.

Finally, when discussing Peyronie's Disease surgery, it is very important to adequately counsel the patient and manage patient's expectation. Once the patient is fully counselled about the risks and benefits of each procedure, he can make an informed decision of the procedure he wants to undergo. In order to achieve higher patient's satisfaction levels, patient's expectations need to be realistic. In particular, the patient needs to accept that surgery will not remove Peyronie's Disease or restore fully the shape and size of the penis before the onset of the disease, but it will render the penis straight and rigid enough to engage in penetrative sexual intercourse with confidence.