Peyronie's disease (PD) is a localized connective tissue disorder of the penis characterized by scarring of the tunica albuginea. Fibrous plaque(s) deposited within the tunica albuginea impedes the expansion of the tunica during erection, resulting in shortening, penile bending, indentation, and, often, pain. PD is regularly associated with the onset of erectile dysfunction (ED). PD is a prevalent condition, impacting 3% to 9% of men [12], and is a common cause of quality of life impairment [3].

Surgical therapy remains the gold standard treatment for men in the stable or chronic phase of PD (at least 1 year from the time of onset and at least 6 months of no change in penile deformity) who are unable to engage in satisfactory coitus and fail medical treatment, or when the patient requests the most rapid and reliable end result [45].

There are several types of surgical techniques applied to PD, which can be categorized into three types: tunica plication, plaque incision or partial excision, and grafting [6]. Important factors that contribute to surgical planning include degree of curvature, presence of a hinge effect, penile length, and erectile function [7].

Surgical intervention aims to correct the penile curvature or deformity, preserve or restore erectile function, and prevent loss of penile length and girth. Among procedures, the major concern with applying tunical plication procedures for complex Peyronie curvature is the associated potential for penile length loss [8].

Although grafting has been recommended for patients with complex penile curvature [5], plaque incision with plication has also recently been shown to be effective and results in high patient satisfaction in complex biplanar curvatures [910].

In our study, we attempt to evaluate the safety and efficacy of surgical intervention on 22 patients, who underwent penile plication with plaque incision regardless of the degree of curvature, by analyzing the functional results and complications, with a mean follow-up of 39 months.

Between 2009 and 2014, 22 patients underwent penile plication with plaque incision, and complete subjective and objective postoperative data were available (Table 2).

The mean follow-up period was 39 months. As in preoperative evaluation, patients were grouped by preoperative degree of penile curvature as follows: Group I, mild (n=5, 22.7%); Group II, moderate (n=11, 50.0%); and Group III, severe (n=6, 27.3%). After the operation, each group had a lesser degree of curvature, regardless of the degree of preoperative curvature (2° for mild, 7° for moderate, 14° for severe; p<0.001) and the '5-degrees of correction per plication suture' rule for our technique was confirmed in simple and complex curvatures [910].

Measured mean penile length loss was not significantly different among the 3 groups: 0.5 cm (range, 0.3~0.7 cm) for mild, 0.6 cm (range, 0.2~1.0 cm) for moderate, and 0.6 cm (range, 0.2~1.0 cm) for severe groups (p=0.52). Therefore postoperative shortening of the penis by more than 1.5 cm did not occur in any patient.

At initial postoperative follow-up, the same number of patients from each group reported penile pain after 1 month (1 patient from each group; p=0.91).

We considered as residual a curvature >20° 6 months after surgery. After plication with plaque incision, 21 patients presented minimal penile curvature under 20° while 1 patient (4.8%) in the severe group did not. The one patient with residual curvature showed impaired sexual intercourse and required reoperation (p=0.80). In reoperation, the penile curvature was completely corrected only by plaque incision without plication.

At the time of the long-term follow-up (mean, 39 months), 19 patients (86.4%) maintained valid erectile function (IIEF-5>21), whereas the remaining 3 patients (13.6%) reported that they had suffered a decline in erection quality over the years. The most frequent complication was subcutaneous penile edema in 3 patients (13.6%), which, however, resolved spontaneously within 3 months and did not result in problems during sexual intercourse, such as vaginal penetration. No patient suffered a urethral injury.

Despite the limitations of this retrospective review, which covered only 22 patients who underwent the surgical technique, the results of a standardized telephone survey were available for 17 patients, telephone follow-up was added for tracking patients, the postoperative outcome was re-evaluated, and reliability was calibrated (Table 3).

In telephone follow-up, two patients refused the telephone survey, and three were lost to follow-up, yielding a response rate for evaluable patients of 77.3% (17 of 22 patients). The rigidity of erections after surgery was sufficient for vaginal penetration in 82.4% of patients (14 of 17 patients), and this result was similar in IIEF-5 for long-term follow-up: 19 patients (86.4%) had an IIEF-5 score >21. As an inevitable complication, minimal penile shortening (<1.5 cm) was reported by 14 patients (82.4%), but this did not adversely affect sexual intercourse (0%) and all patients found the penile shortening to be acceptable.

This report presents the postoperative outcomes and therapeutic effect of the multiple slit on plaque incision with plication technique as a modified technique for the surgical treatment of PD, which is an intractable disease. Our results have indicated good success for the correction of curvature, maintenance of erectile function, and patient-reported treatment satisfaction.

In PD, although conservative approaches will succeed in relieving pain for most, they do not have a significant effect on penile curvature and surgical intervention is often needed. The optimal timing for operative intervention is greater than 12 months after the onset of symptoms and more than 3 months from plaque stabilization [5].

Several major surgical strategies are employed in PD [11]. Currently available surgical options in PD include tunical plication procedures such as the Nesbit wedge resection and the various plication modifications, which are performed on the convex side of the penis. The first reported technique was the Nesbit procedure, which entails excision of a piece of the tunica albuginea on the contralateral side of the curvature [1213]. Since then, modified Nesbit, Yachia, Essed-Schroeder, Duckett-Baskin-Levine, and 16-dot or 24-dot plication techniques have been reported [814151617]. These techniques have reasonable success rates with common limitations, including penile shortening, ED, plaque progression, palpable nodule, and recurrence [1819].

Tunical lengthening procedures with the use of a graft and incision, or excision of the plaques (the Lue procedure) are performed on the concave side of the penis and are more suitable for more technically difficult cases where curvature is severe, plaques are large, and deformities are present [520212223]. This involves making an H-shaped incision in the plaque and inserting a vein graft into the incision [2324]. But ED, numbness of the glans penis, and shortening of the penis, although less than in the Nesbit procedure, can still occur. Furthermore, these procedures are more complex and may involve the additional morbidity of harvesting autologous tissue. More extensive disruption of tunical integrity has been implicated as a cause of the subsequent loss of rigidity often found with grafting techniques [2122]. And these procedures are more costly and require greater experience in the surgeon. The reasons for patient dissatisfaction among those undergoing this type of procedure are the residual curvature due to graft contraction and postoperative ED due to venous leakage from the incision or resection of large plaques, or due to venous leakage that is secondary to the replacement of the graft material by the scar tissue.

Penile prosthesis implantation is typically reserved for patients with PD and concurrent ED, especially non-responders to medical management [42526].

Recently there have been reports that the incision on plaque technique without grafting is effective for correcting penile curvature. The first description of a minimally invasive, intracorporal technique for PD repair was reported by Bella et al [27]. Bella et al [27] reported that in 23 patients with localized Peyronie's plaque, dissection allowed atraumatic introduction of the blade along the inside wall of the tunica to the plaque, which was incised using multiple passes at varying angles from within the corpora, and correction of the deformity was successful in all but 2 patients (less than 10° residual curvature) without grafting.

Our modified technique, multiple slit, has different characteristics than various existing procedures like excision of plaques with grafting. Our report contains several differences from the report of Bella et al [27]. Bella et al [27] used saline for confirming the preoperative erection in plaque incision with plication, and incisions for plaques were not made through the full thickness of the tunica albuginea. In our study, normal saline was not injected into the corporal body because it requires frequent injection and leads to inaccurate curvature correction due to temporary loss of rigidity after several tunical stitches during the operation. In addition, it led to postoperative subcutaneous edema and could not produce a uniform line of penile skin. At first, multiple longitudinal plaque incision was done at the depth of the full thickness of the tunica in our study, because incision through the full thickness of tunica made the tunica flat and pliable. Consequently, multiple incision releases the main restriction from the plaque, therefore residual correction of curvature is easier with minimal plication on the contralateral convex side.

A plaque in the penile shaft site causes contraction with adjacent tissues and decrease in penile circumference and thickness; therefore the penile site distal to the plaque has decreased rigidity during erection in some patients. Multiple slits on the plaque without excision of the plaque released tension around the plaques, and increased the circumference of the tunica at the level of the plaque. Additional injection of triamcinolone was helpful for preventing recurrence at the site of the incised plaques.

Although plication sutures like the 16-dot or 24-dot plication techniques are effective for correcting penile curvature, they entail postoperative penile shortening as an inevitable complication [8]. Plaque disruption, as with multiple incisions on the plaques, minimizes or eliminates the need for plication sutures, thereby limiting penile shortening in men with more pronounced curvature.

Multiple slit is a minimally-invasive technique for plaques, unlike grafting, and is effective in correcting severe penile curvature greater than 60°. In our study, the grafting and excision of plaques was not done for correcting the curvature even in patients with degrees of curvature greater than 60°. After plication with plaque incision alone, 21 patients presented minimal penile curvature under 20°, while 1 patient (4.8%) in the severe group did not. Postoperative minimal curvature did not cause problems in sexual intercourse and in the telephone follow-up, 94.1% of patients reported erections sufficient for intercourse and a treatment satisfaction of 82.4%. ED or disruption of tunical integrity, often found with grafting techniques, did not occur in our study, because multiple longitudinal incision to the plaques did not damage neurovascular bundles.

Therefore, as a modified technique, multiple slit on plaque with plication shows differences from previously reported procedures including the Nesbit procedure, the Lue procedure, and plaque incision with grafting. The first difference is that it does not need grafting, the second is that it is applicable for severe penile curvature greater than 60°, and the third is that it does not produce penile shortening greater than 1.5 cm.

Greenfield et al [28] reported that in a review of 102 patients, the direction of curvature (ventral and ventrolateral) and the degree of curvature measured at the time of surgery (particularly when >60°) significantly predicted the amount of penile length loss. But in our study, the measured mean of penile length loss was not significantly different among the 3 groups: 0.5 cm (range, 0.3~0.7 cm) for mild, 0.6 cm (range, 0.2~1.0 cm) for moderate, and 0.6 cm (range, 0.2~1.0 cm) for severe groups (p=0.52). And postoperative shortening of the penis greater than 1.5 cm did not occur in any patient.

Even in telephone follow-up, the most common self-reported complaint was penile shortening, for which all patients were counseled at the clinical assessment. However, none of the 17 patients who reported decreased length indicated that it had had an adverse effect on sexual function. Therefore, most patients accepted minimal shortening less than 1.5 cm and did not sense intromission, per our telephone follow-up. The majority of patients reported improvements in curvature and their global condition postoperatively, regardless of primary curvature complexity. While objective measurements of erect penile geometry were not repeated postoperatively, the positive reported outcomes from patients suggest that plication is durable well beyond 3 years.

The penile plication technique has traditionally been recommended as the standard treatment in patients with PD who have curvature less than 60° [4829]. In any type of surgical procedure for PD, there are some potential postoperative risks; these include penile shortening, ED, penile numbness, and unresolved curvature [4]. Our study reveals that, in the severe plication group (>60°), only 1 patient complained about postoperative penile pain and had repeated plication procedures, whereas the other 5 patients had no significant symptoms or complications such as ED or residual penile curvature, but did experience a significant correction of penile curvature.

In a report of 89 PD patients treated with a Nesbit plication since 1990, 91% reported complete correction of curvature and 89% had preserved erectile function [30]. In our study, 95% reported excellent surgical outcomes that showed complete correction of penile curvature and 86% had preserved erectile function.

Therefore, multiple slit on plaque with plication may be a simple, minimally-invasive, safe, and effective technique by comparison with previous techniques. Despite the excellent cosmetic and functional results, this study represents a retrospective, single-institution review with limited follow-up from some patients. Additionally, any study on PD relies on patient-reported outcomes. Thus in the future, we anticipate multi-centered studies with plication and plaque incision for various degrees of penile curvature and more objective postoperative outcomes.

As a modified technique, multiple slit on plaque with plication is a simple, minimally-invasive and effective technique for correcting penile curvature in patients with PD, regardless of curvature severity, even with curvature greater than 60°. And the degree of penile curvature does not significantly predict the amount of penile length loss.