249 SURGERY FOR PEYRONIE’S DISEASE 25 PEYRONIE’S DISEASE WITHOUT IMPOTENCE Exposure and Mobilization of Dorsal Nerves and Vessels FIG. 25-1. Most surgeons use a de- gloving procedure via a circum- ferential skin incision around the base of the glans penis for expo- sure. Although this technique is a convenient way to dissect the pe- nile skin, some patients complain of decreased sensation after sur- gery despite the preservation of the dorsal nerves. FIG. 25-2. An alternative is to use a vertical incision, which parallels the plaque from the base of the glans penis to the base of the pe- nis, and to dissect only the skin sufficient for exposure of the nerves and plaque. The dissection and mobiliza- tion of the dorsal nerves and ves- sels are much easier if the penis is erect. The tension of the corporeal bodies provides strong backing for a clear margin of dissection. An artificial erection is induced either by a constant saline solu- tion infusion into the corpora cav- ernosa or a prostaglandin E 1 injec- tion (20 μg). FIG. 25-3. The dorsal nerves are visible with the naked eye. The surgeon injects saline solution be- tween the nerves and the erect corporeal bodies to facilitate the sharp dissection to separate the nerves from the adjacent tissues. The surgeon uses a pair of tenot- omy scissors and begins the dis- section laterally, working from each side and connecting in the midline. Dorsal nerves Glans penis Degloved penile skin Vertical penile incision Dorsal nerves 25-1 25-2 25-3
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249
SURGERY FOR
PEYRONIE’S DISEASE 25PEYRONIE’S DISEASE WITHOUTIMPOTENCEExposure and Mobilization ofDorsal Nerves and Vessels
FIG. 25-1. Most surgeons use a de-gloving procedure via a circum-ferential skin incision around thebase of the glans penis for expo-sure. Although this technique is aconvenient way to dissect the pe-nile skin, some patients complainof decreased sensation after sur-gery despite the preservation ofthe dorsal nerves.
FIG. 25-2. An alternative is to usea vertical incision, which parallelsthe plaque from the base of theglans penis to the base of the pe-nis, and to dissect only the skinsufficient for exposure of thenerves and plaque.
The dissection and mobiliza-
tion of the dorsal nerves and ves-sels are much easier if the penis iserect. The tension of the corporealbodies provides strong backingfor a clear margin of dissection.
An artificial erection is inducedeither by a constant saline solu-tion infusion into the corpora cav-ernosa or a prostaglandin E1 injec-tion (20 µg).
FIG. 25-3. The dorsal nerves arevisible with the naked eye. Thesurgeon injects saline solution be-tween the nerves and the erectcorporeal bodies to facilitate thesharp dissection to separate thenerves from the adjacent tissues.
The surgeon uses a pair of tenot-omy scissors and begins the dis-section laterally, working fromeach side and connecting in themidline.
Dorsal nerves
Glans penis
Deglovedpenile skin
Verticalpenile
incision
Dorsal nerves
25-1 25-2 25-3
250 Critical Operative Maneuvers in Urologic Surgery
FIG. 25-4. The dorsal nerves canbe retracted cephalad with a smallPenrose drain while the surgeoncontinues the dissection distallyand proximally.
FIG. 25-5. Often, after the dorsalnerves and tissues have been mo-bilized from the penile shaft, theplaque seems smaller than ex-pected. By visual inspection andfinger palpation of the erect penis,the surgeon can define the bound-ary of this fibrotic process.
FIG. 25-6. The surgeon’s strategy
is to perform the minimal amountof manipulation necessary to cor-rect the fibrotic curvature. Al-though most patients requiremore intervention, there are timeswhen a Nesbit plication stitch or asmall incision with or without agraft replacement is sufficient tocorrect the problem.1
FIG. 25-7. In other patients inwhom there is severe curvaturewith involvement of the midlineseptum, the surgeon must excisethe plaque.
Dorsal nerves
Peyronie’s plaque
25-4
Glans penis
Curvature fromPeyronie’s plaque
Corpus cavernosum
Urethra
25-5
Plicationstitch
Nesbit plicationstitch
Correction of Curvatureby Plication
25-6
Corpus cavernosum
Urethra
Peyronie’splaque involving
midline septum
25-7
Chapter 25 Surgery for Peyronie’s Disease 251
Primary Excision
A tightened tourniquet aroundthe base of the penis will preventexcessive venous back-bleedingonce the corporeal incision ismade. Dabbing the corporeal si-nuses with a sponge soaked in anepinephrine solution (1:100,000dilution) will aid in maintaining aclear operative field.
With the combined use of aknife and tenotomy scissors, thesurgeon first incises the lateralborder of the plaque on one side.
With Allis clamps placed on thecut edge of the plaque, the sur-geon can then free the sinus tissuefrom the plaque.
FIG. 25-8. When there is severeseptal scarring, it is critical thatthe surgeon avoid any injury tothe cavernosal arteries. By “hug-ging” the diseased tunica side withthe scalpel during dissection, thesurgeon shaves the sinus tissue off and preserves the maximal
amount of the corporeal sinus tis-sue as well as the cavernosal artery.
If these two arteries are injured,the patient will be rendered impo-tent.
FIG. 25-9. Many variations of a Z-plasty reconstruction can be usedto facilitate primary closure. Acontinuous stitch (3-0 or 4-0 PDS)is a watertight closure, and an in-terrupted stitch (2-0 PDS) at 2 cmintervals provides strength2 (A).
At the completion of the pri-mary corporeal closure, the girthof the penis is decreased. How-ever, after replacing the bulk ofthe dorsal nerves and vessels andafter reapproximating the penileskin, the narrowed girth will notbe obvious. The functional resultafter surgery is quite satisfactoryfor most patients (B).
FIG. 25-10. If the plaque is super-ficial, in some cases a simple inci-sion with graft replacement is suf-ficient to straighten the penis.3
Urethra
Corporacavernosa
Dissection forresection of densefibrotic tissueextending downmidline
Cross-sectional View
25-8
Incision withGraft Replacement
25-10
Glans penis
Excision withPrimary Anastomosis
(with Z-Plasty)
Peyronie’s plaque
PrimaryClosure After
Excision of Plaque
25-9
A
B
252 Critical Operative Maneuvers in Urologic Surgery
Excision with Graft Replacement
FIG. 25-11. If plaque excision leavesa large gap or even if an incisionof the Peyronie’s plaque results ina prominent gap, the surgeon hasthe option of using organic or in-organic graft substitutes:
Organic grafts, cadaveric dura1,3-9
1 Tunica albuginea2 Dermis3 Venous endotheliumInorganic grafts1 Dacron2 Gore-TexThe graft should first be ap-
proximated to one side of the pe-nile defect and then the redun-dant area of the graft should beexcised to create a good fit. Largegrafts with redundancy can leadto aneurysm and impotence.
After completion of the graftinterposition, the surgeon shouldinfuse saline solution into the cor-poreal bodies to check for anasto-motic suture line leakages. Thedorsal nerves and vessels are re-placed and the skin is reapproxi-mated.
Placement of a Foley catheter(14 Fr) into the bladder avoids thediscomfort of urinary difficulty.An ice pack over the penis andscrotum prevents excessive edema.
Terbutaline (5 mg) every 6hours postoperatively preventsspontaneous nocturnal penileerection.
PEYRONIE’S DISEASE WITHIMPOTENCEPlacement of Semirigid Prosthesis
Each corpus cavernosum shouldbe dilated with Hegar size 7 to 13dilators.
While dilating the corporealbodies, the surgeon may take thisopportunity to not only create anopen channel within each side butalso disrupt the dense plaque onthe tunica surface by a “cracking”manipulation.10
After placement of the correctsemirigid prosthesis, the curva-ture is corrected in the majority ofpatients.
An additional plication stitchon the opposite side and/or an in-cision across the Peyronie’s plaquemay be necessary to eliminate theresidual curvatures.11
Placement of Inflatable PenileProsthesis
We prefer to use nonexpand-able cylinders such as the CXmodel by American Medical Sys-tems in cases of Peyronie’s dis-ease. Expandable cylinders con-form to and even exaggerate thecurvature.
After the cylinders are placedin the corpora cavernosa, the sur-geon inflates the cylinders and in-spects to see if the curvature ispersistent. If it is, then electro-cautery is used to incise across thePeyronie’s plaque and expose partof the cylinder within.
FIG. 25-12. Incisions of 1 to 1.5 cmacross the plaque are usually suf-ficient to correct the curvature11,12
(A).An alternative is to excise the
plaque and replace the gap with agraft. Both organic and inorganicgrafts are used, such as Gore-Tex,Dacron, Dexon mesh, tunica al-buginea, cadaveric dura, and sa-phenous vein1,3-9 (B).
Graft Replacement
25-11
Chapter 25 Surgery for Peyronie’s Disease 253
A B
Graft
Penileprosthesis
Penileprosthesis
Incisionof Peyronie’s
plaque
Glans penis
25-12
K E YP O I N T S
PEYRONIE’S DISEASE WITHOUTIMPOTENCE� Exposure is gained via a circum-
ferential or vertical incision.� An artificial erection is induced.� Saline solution is injected to sep-
arate the dorsal nerves from thecorporeal bodies.
� The boundary of the plaque isidentified and excised with max-imal sinus preservation andpreservation of the cavernosalartery.
� In cases of severe midline septalplaque formation, the surgeonmust preserve the cavernosalartery within each corporealbody to preserve potency.
� Z-plasty closure of the residualcorpus cavernosum is performed.
� If the excision or incision resultsin a defect that is too large forprimary closure, a synthetic or
organic graft should be used tocover it.
� Terbutaline is administered toprevent nocturnal erection and aFoley catheter is inserted to pre-vent urinary retention.
� An ice pack applied to the groinarea reduces edema.
PEYRONIE’S DISEASE WITHIMPOTENCE� Dilatation of the corporeal bodies
with Hegar size 7 to 13 dilatorswith manipulation and “crack-ing” of the plaque is performed.
� The cylinders are placed. For asemirigid prosthesis, it may benecessary to take an additionalplication stitch and/or inciseacross the plaque. For an inflat-able prosthesis, we prefer thenonexpandable type of cylinders.
� If excision is necessary to removedense fibrotic tissue, the gap mayneed to be replaced with eitheran inorganic or organic graft.
P O T E N T I A LP R O B L E M S
� The plaque is much larger than ex-pected: Consider plaque incisionwith a patch graft
� Tear or division of some dorsalnerves: Continue the procedureand preserve the rest of the dor-sal nerves as much as possible
� Plaque is higher than expected: Di-vide plaque at the penis base
� Injury of corporeal cavernosal arter-ies on one side: Continue if thecontralateral side is intact → con-sider prosthesis insertion if per-mission has been obtained
� Urethral injury: Close the ure-thral injury → continue the pro-cedure with primary closure ofthe Peyronie’s defect rather thanthe use of a replacement graft(especially an inorganic graft) →perform antibiotic irrigation ofthe surgical wound and adminis-ter intravenous antibiotics in thepostoperative period
REFERENCES11 Fishman IJ: Complicated implanta-
tions of inflatable penile prostheses,Urol Clin North Am 14(1):217, 1987.
12 Karacaoglan N, Uysal A: The sevenflap-plasty, Br J Plast Surg 47:372,1994.
