Penile reconstructive surgery for PD is largely divided into 3 major types: penile plication (shortening the convex side), graft surgery (lengthening the concave side of the tunica albuginea [TA] by incision or partial excision of the plaque with the use of various graft materials for closure of the defect), and penile prosthesis implants (PPIs) with or without adjunctive measures, such as penile remodelling, plication, and grafting (Table 1).

Penile plication techniques are generally recommended in men with mild to moderate penile curvature (less than 60°) without concurrent hour-glass or hinge-defect deformity. The original penile plication procedure was described by Nesbit in 1965 and involves the excision of an ellipsoid area of tissue from the TA on the opposite side of the penis to the most prominent point of penile curvature, thereby shortening of the convex side of the penis after closure of the tunica defect [6]. The mobilization of the neurovascular bundle (NVB) for the correction of ventral deformities can be achieved by medial or lateral dissection of the NVB depending on the surgeon's expertise [7]. Several modifications of the Nesbit procedure have been published, including the use of multiple small superficial TA excisions with primary closure and TA U-shaped flaps [8]. The Yachia [9] procedure involves modification of the Nesbit technique based on the Heineke-Mikulicz principle, with a single long incision or multiple small incisions made longitudinally in the TA and subsequently closed horizontally to shorten the convex side of the penis. Another penile plication technique, first described by Essed and Schroeder [10], utilises the placement of nonabsorbable sutures over the convex side of the TA, without the need for excision of the TA or mobilization of the NVB. More recently, Gholami and Lue [11] popularised the 16-dot (2 pairs of plication) or 24-dot (3 pairs of plication) plication technique without tunical incision or excision, which avoids any mobilisation of the NVB or corpus spongiosum.

Penile lengthening surgery with graft reconstruction is ideal for patients with severe penile length loss, significant curvature, and/or prominent hour-glass deformities, but without underlying ED. The graft is applied to the defect following incision of the most prominent point of the convex penis, usually where the Peyronie plaque resides, thereby achieving penile lengthening. Historically, total plaque excision was designed to ‘remove the diseased tunica’, but this invariably leads to a higher postoperative ED rate. Plaque incision or partial excision is now the preferred technique, instead of plaque excision, to avoid compromising the underlying veno-occlusive mechanism while removing sufficient calcified plaque so that grafting is possible [1213]. The surgical technique for graft surgery is generally uniform, and medial or lateral dissection of the NVB may be preferred depending on the plaque location, as a complete dissection of the plaque attachment to the NVB is vital to prevent the recurrence of curvature. The graft material is positioned following plaque incision and is sutured to the edges of the TA to restore tunical tissue integrity. Three major incision techniques have been described in the literature: the double-Y technique, the H-shape technique, and, more recently, the Egydio technique [1]. Whereas the double-Y incision is performed by widening the bifurcation angle of double-Ys, the H-shape technique involves the use of a single, almost complete circumferential-relaxing incision applying geometrical principles. The Egydio technique comprises 4 tripod-shaped forks of 120°, producing a simpler configuration of the tunical defect, which supposedly enables easy suturing of the graft during the procedure [14]. While controversy remains as to which surgical technique is superior, a recent theoretical study analysing these 3 techniques reported that a modified double-Y incision was likely associated with fewer complications and better geometry [15].

Three types of graft materials have been described: autologous grafts, allografts (or xenografts), and synthetic grafts. The use of synthetic materials, including polyester and polytetrafluoroethylene, has largely been abandoned due to higher risks of infection, tissue fibrosis (secondary graft inflammation), graft contracture (due to the inelasticity of the synthetic material), and allergic reactions [1617]. An ideal graft material should be readily available, does not contract, is inexpensive, is resistant to infection, and is able to preserve erectile function. The choice of graft material is likely to be determined by the surgeon's experience, the patient's preference, and the availability of graft material [1]. Since a single ideal graft material has not been established and there is great variation in clinical outcomes, the surgeon's experience, the availability of materials, and features of the patient and the disease play an equally important role in the type of surgical procedure and the choice of a graft material. Advances in technology have resulted in better allograft materials with comparable outcomes to those of autografts [18]. However, the risk of graft contracture remains a concern, as it may lead to future penile curvature and a long-term risk of ED [19].

For men who have poor-quality erections and/or do not respond adequately to pharmacological or vacuum therapy for their ED, a PPI is recommended at the time of penile reconstructive surgery [20]. It is accepted that inflatable PPIs are associated with higher functional satisfaction and lower persistent curvature rates than malleable implants [2021]. In patients with mild curvature (less than 30°), a PPI alone may result in satisfactory straightening of the penis. However, for men with considerable residual penile curvature (greater than 30°) following the placement of a PPI, other options, such as manual modelling, penile plication, and/or plaque incision with or without grafting, should be undertaken at the time of surgery [2122]. Manual penile modelling can be performed with the prosthesis fully inflated by bending the penile prosthesis in the contralateral direction to the curvature for a short period of time (e.g., 30–60 seconds). The tubing between the pump and the cylinders should be occluded with rubber-shod haemostats to protect the pump from high-pressure damage [21]. In addition, when performing the modelling process, excessive pressure on the glans penis should be avoided to prevent urethral erosion by the cylinder tip. An alternative approach is to pre-place plication sutures using the 16-dot method before implanting the prosthesis and then tying them down to correct the curvature [23]. A residual curvature of less than 30° will often improve over time since the prosthesis will act as an internal tissue expander to correct the deformity in the coming months. However, if there is a substantial residual curvature or persistent hour-glass deformity, then releasing incisions can be made on the concave (or abnormal) side and graft patching is recommended, especially if there is a tunical defect greater than 2 cm (in any dimension), to avoid recurrence of penile curvature or herniation of the prosthesis cylinders [20].

Novel surgical techniques to improve penile lengthening and girth at the time of PPI placement with or without concurrent grafting have been described, such as circumferential incision [24], the double dorsalventral approach sliding technique [25], the modified sliding technique (MoST) [2627], and the multiple slice technique (MuST) [28]. The circumferential incision technique involves a circumferential incision at the point of maximal curvature of the tunica with mobilisation of the NVB, whereas the Egydio technique allows partial circumferential incision if the length is limited by the NVB [24]. In the sliding technique [25], both the NVB and urethra are mobilised, with 2 longitudinal incisions made in the lateral aspect of the TA of each corpus cavernosum and joined by hemi-circular incisions (the proximal hemi-circular incision connects dorsally and the distal connects ventrally), for complete transection of the corpora to stretch the penis to its maximum corrected length. The MoST technique is a modification of the sliding technique, with the major notable difference being the use of a single subcoronal incision with mobilisation and utilisation of the Buck's fascia to cover the defects in the TA, obviating the need for graft material [26], whereas MuST is a modification of MoST with multiple pairs of hemi-circumferential incisions enabling multiple sliding sections [28]. The average erect penile length gain achieved in patients who received circumferential incision was found to be around 2.5 to 3 cm, while for men who underwent sliding and various modified of sliding techniques, such as MoST or MuST, the penile length gain was reported to be between 2.5 and 4 cm [28].

While penile reconstructive surgery remains the standard of care for many men with PD, it is not without significant risks, and many of them may be permanent [1]. Several factors, such as the severity and the site of curvature, the type of plaque incision, the patient's age and medical comorbidities, and preoperative erectile function, are key determinants of postoperative ED risk [2930].

Penile plication surgery invariably results in penile shortening and requires an adequate preoperative assessment to ensure that patients have adequate penile length and no associated destabilizing penile deformity. Studies evaluating the clinical outcomes following the Nesbit procedure showed high success rates of penile straightening (79%–100%) and overall patient satisfaction (67%–100%) [6313233]. The estimated stretched penile length loss has been reported to be up to 3 cm in some series [63132]. The reported patient satisfaction rates after the Yachia procedure were similarly high (72%–100%) [3435]. While plication surgery is often thought to preserve erectile function, mobilisation of the neurovascular bundle (NVB) and disruption of cavernosal integrity can result in the loss of penile tactile sensation (24%) and ED (12%) [1011].

The saphenous vein is probably the most commonly utilised autologous graft material owing to its ease and reliability of harvesting, large surface area, good compliance, and easy tissue perfusion [363738]. Furthermore, it has been hypothesized that the nitric oxide secreted from the endothelium may prevent haematoma formation and improve erectile function [39]. However, in an animal model, buccal mucosa tissue appeared to perform better than vein tissue, dermis, aponeurosis, and peritoneum in terms of tissue elasticity, lengthening, and morphological properties of the graft, which was likely due to its rich vascular blood supply providing good graft nourishment [40]. Although previous studies have reported high functional and anatomical success rates in autologous grafts [4142], complications such as, de novo ED, penile length loss, and persistent and/or recurrent curvature are not uncommon, especially in the longer term [43]. Furthermore, harvest site complications such as wound haematoma and contracture, altered sensation, and potential inclusion cysts requiring secondary surgery are likewise not uncommon.

The mid-term outcomes of allograft surgery are similar to those of autologous grafts, but with the perceived advantages of a shorter operation time and no harvest-site-associated complications [1]. While short-term data on various allograft materials, such as dermal, cadaveric fascia lata, and 4-layered small intestinal submucosa grafts showed relatively low complication rates [4445], long-term data highlighted the increasing prevalence of issues related to graft reconstruction, such as subsequent penile length loss (22%), recurrence of curvature (up to 80%), glans hypoesthesia (17%), and postoperative ED (67%) [19]. Due to the inadvertent operative risk of diminished rigidity, men with suboptimal preoperative penile erection should avoid grafting surgery and/or be prepared to undergo subsequent PPI placement [46].

The reported risk of urethral injury at the time of penile remodelling following PPI placement is relatively low, if remodelling is done in a controlled manner (i.e., over 30 to 60 seconds with the tubing between the pump and the cylinders occluded with rubber-shod hemostats) [2147]. Published studies comparing the clinical outcomes and patient satisfaction rates between the 2 major penile prostheses showed no significant difference in mechanical survival, that both PPIs provided similar penile strengthening, and that most patients would undergo the same operation again [21].

It has been reported that up to 20% of patients reported diminished glans sensitivity following PPI placement, likely related to mobilisation of the NVB coupled with various lengthening strategies [28]. In addition, penile haematoma (up to 25%) and graft retraction (up to 10%) with residual curvature are not uncommon [2428]. Serious complications such as glans necrosis (2%) can occur due to compromised glans vascularity, and the ensuing glanular loss is often associated with cardiovascular disease, diabetes, smoking, previous prosthesis explantation, and previous radiation [2848]. In addition, the risk of prosthetic infection and explantation should not be underestimated in this cohort of patients, with prosthesis infection reported in 7% of cases due to a longer operative time and concurrent use of graft material.