Peyronie Surgical Treatment

(1) The penis is degloved after a circumcision incision. Magnifying lenses 2.5 are used for better visualization. One of the cavernous bodies is punctured by a 21 scalpel, considering that, when necessary, both cavernous bodies can be punctured to achieve full erection by saline solution injection. The use of papaverin or prostaglandin can help full erection with saline solution injection.

Fig.1 - The intersection of the tangential lines to the penile axis a-a' and b-b' (red lines) determines the point of maximum curvature (P). A circumferential line is drawn (green line) from point P in the bisector of the angle formed by the lines a-a' and b-b'.W (red arrow) is equal to the distance of the two points of the long side (d-e) minus the equivalent distance (d'-e') in the short side of the penis (θ = 90◦).
(2) In cases of dorsal curvature, two tangential lines to the penile axis (red lines) are drawn on the proximal and distal straight segments (a-a' and b-b', resp.) toward the area of curvature of the erect penis (Fig.1).

(3) From the point of maximum curvature (P) located at the intersection of the lines a-a' and b-b', a circumferential line (green line) is drawn at the bisector of the angle formed by these lines (Fig.1).

(4) The point at which this circumferential line crosses the neurovascular bundle in the dorsal region and the urethra in the ventral region determines the region at which these structures must be separated from the tunica albuginea.
(5) The transverse incision in the tunica will be made along this circumferential line (green line) later. Then the erection is reversed.








(6) Two paraurethral incisions (c-c') are made where the circumferential line crosses the urethra to dissect Buck's fascia and its neurovascular bundle from the tunica around the complete circumference of the penis in all types of curvature, except at the level of the urethra (Fig. 2a, 2b).

(7) A new erection is induced and a circumferential line is drawn again, but this time on the tunica, where the circular incision will be made (Fig.2c).

Fig.2a - Paraurethral incisions (c-c') in Buck's fascia.
Fig.2b - Dissection of Buck's fascia and the neurovascular bundle from the tunica albuginea.
Fig.2c - Drawing of the circumferential line in the point of maximum curvature.
































(8) Complete penile straightening is achieved by a 5-mm incision in the intercavernous septum on each side of its intersection with the transverse incision in the circumferential line (Fig.3).

Fig.3a - Cutting of the intercavernous septum.
Fig.3b - Septal cutting in cases of dorsal, dorsolateral, or lateral curvature.
Fig.3c - Septal cutting in cases of ventral or ventrolateral curvature.
































(9) The width (W) of the defect should be the same as the difference between the long and the short sides of the penis. This measurement is calculated by the distance between any two complete circumferential lines perpendicular to the penile axis drawn on the straight penile segments, that is, outside the area of curvature (before d-d' and after e-e') (Fig.1).

(10) The difference (W) between d-e and d'-e' (red arrow, Fig.1) will be the size of the defect on each side of the urethra in cases of dorsal curvature (Fig.4a, 4c).

Fig.4a - Bifurcation of the transverse incision and the correspondent defects in the tunica albuginea in cases of dorsal curvatures. W = the width of the defect. L = the length of the defect. F and F' are the points from which the circular incision is forked.
Fig.4b -Preoperative dorsal curvature.
Fig.4c - Final result after straightening and graft suturing.
(11) On the circumferential line, a length of W/4 away from the site where itmeets the g line, points F and F' (Fig. 4a and 5) are determined to mark the start of bifurcation, which extends to either side of the g line at a length of W/2, thus generating a 120◦ angle (Fig.5); the resulting defect will be more simple and stable as a tripod.



Fig.5 - The starting point of the 120-degree bifurcation at the end of circumferential lines is established by marking a length of W/4 back from the intersection with the g line.W is the differences measured between the longer and shorter side of the penis that correspond to the width (W) of the tunica defect.
Fig.6a - Bifurcation of the transverse incision and the correspondent defects in the tunica in cases of ventral curvatures. W = the width of the defect. L = the length of the defect. F and F' are the points from which the circular incision is forked.
(12) Defect length (L) will be equivalent to the distance between the two paraurethral incisions for dorsal curvature, or between the two ends of the forkshaped incision for any type of curvature passing round the short side of the erect penis (Fig.4a, 6a, 7a).

(13) Once the circumferential line forked at the ends is determined, the incision is made in the tunica albuginea, producing a rectangular defect of an already known size.










Fig.6b - Preoperative ventral curvature.
Fig.6c - Urethral dissection.
Fig.6d - Final result after straightening and graft suturing.























(14) To facilitate graft suturing, a 5-mm dissection ismade between the 4 edges of the defect and the respective adjacent cavernous bodies. The graft is sutured and a new induced erection demonstrates complete penile straightening (Fig.4c).

(15) In cases of ventral curvature, the technique is similar but with the following differences: the forking of the transverse incision is made in the dorsal region near the intercavernous septum which has its dorsal insertion maintained (Fig.6).

(16) The urethra is dissected from its bed and the graft is placed between the urethra and the cavernous body (Fig.6c and 6d). A new induced erection demonstrates complete penile straightening (Fig.6b and 6d).

(17) Dorsolateral curvatures with a larger dorsal component and ventrolateral curvatures with a larger ventral component are corrected by the same technique as for dorsal or ventral curvatures, respectively.

Fig.7a - Bifurcation of the transverse incision and the correspondent defects in the tunica in cases of lateral curvatures. W = the difference between the short and long side. W' = a measure added on both side L = the length of the defect. F and F' are the points from which the circular incision is forked.
Fig.7b - Lateral curvature after a degloving procedure.
Fig.7c - Trapezoidal graft was drawn in the pericardium.
Fig.7d - Final result after straightening and graft suturing.



























(18) In cases of lateral curvature (Fig.7a), the defect turns out to have the shape of a trapezium instead of a rectangle as obtained in cases of dorsal and ventral curvature.
The shorter side of the trapezium can vary from 0.5 to 1 cm (W'). The longer side (W + W') is equal to the difference between the long and the short sides (W) of the penis (obtained as the other curvatures), added to the length of the smaller side of the trapezium (W'). The height of the trapezium (L) is measured as described for the other types of curvature (Fig.7a).
Thus this procedure avoids a defect of triangular shape which would make the graft procedure more difficult (Fig.7c and 7d).

(19) The graft is cut according to the measurements already made (i.e., width W and length L) but should be 1-2mm wider and longer than the defect to provide room for the suture. However, the graft should only be this size when the material used is not likely to shrink; otherwise, a percentage for graft shrinkage should be allowed.

(20) The length (L) of the defect should be measured with the penis erect and outside any constricted area to allow girth correction in constricted penile shaft area.

(21) Buck's fascia can be sutured on place. Penile degloving is reversed and foreskin, when present, is removed to avoid postoperative swelling and/or necrosis. Circumcision incision is closed with 5.0 poliglecaprone. A light compressive dressing is applied for 7 to 10 days. Although the patient can have spontaneous erection, a 6-week period of sexual abstinence is recommended. After a 6-month followup, alprostadil-induced erections are used to check penile straightening in those cases a penile prosthesis has not been implanted.





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