Lengthening strategies for Peyronie's disease

Abstract

Loss of penile length is a common complaint of men with Peyronie's disease (PD), both before and after corrective intervention, which has a significant negative effect on patient quality of life. We sought to identify and describe the methods by which penile length can be preserved or increased. We conducted an extensive, systematic literature review, based on a search of the PUBMED database for articles published between 1990 and 2015. Articles with the key words "Peyronie's disease", "penile length" and/or "penile lengthening" were reviewed if they contained subjective or objective penile length outcomes. Only English-language articles that were related to PD and penile size were included. We found no evidence in the literature that medical therapy alone increases penile length. Classic inflatable penile prosthesis (IPP) placement, plication procedures, and the Nesbit procedure appear likely to maintain or decrease penile length. Plaque incision (PI) and grafting appears likely to maintain or increase penile length, but is complicated by risk of post-operative erectile dysfunction (ED). There are several surgical procedures performed concomitantly with IPP placement that may be suitable treatment options for men with comorbid ED, and consistently increase penile length with otherwise good outcomes concerning sexual function. These include the subcoronal penile prosthesis (scIPP), Egydio circumferential technique, the sliding technique, the modified sliding technique (MoST), and the multiple slice technique (MuST). In addition, adjuvant therapies such as penile traction therapy (PTT), post-operative inflation protocols, suspensory ligament relaxation, lipectomy, and adjuvant medical therapy for glans engorgement appear to increase subjective and/or objective penile length for men at high risk of decreased penile length after PD surgery. Considering the psychological burden of length loss in men with PD, providers with adequate volume and expertise should attempt, if possible, to maintain or increase penile length for men undergoing surgical intervention. There are several evidence-based, safe, and effective ways to increase penile length for these men and multiple emerging adjuvant therapies that may help ensure adequate length.

Keywords: Peyronie’s disease (PD); length; lengthening; modified sliding technique (MoST); multiple slice technique (MuST); plaque incision (PI) and grafting; sliding technique; subcoronal penile prosthesis (scIPP).

Figure 1

The modified sliding technique (MoST). This image shows the MoST with the penis at full stretch. To the right of the image, one can see the fully dissected Buck’s fascia containing the neurovascular bundle. To the left, the urethra and corpus spongiosum has been dissected off of the corpora. In the center, the tunica has been incised laterally with two longitudinal incisions connected by a distal ventral and a proximal dorsal hemi-circumferential incision. Rather than grafting as would be seen in the sliding technique, the distal defect is covered by the compressed cavernosum and spongiosum and the proximal defect will be covered with the re-approximated Buck’s fascia.

Figure 2

The multiple slice technique (MuST) with hemi-circumferential and longitudinal incisions. This figure shows the MuST with the penis at full stretch. The illustration (A) demonstrates the penis with the urethra (left) and Buck’s fascia (right) dissected off of the corpora cavernosa. The blue lines denote the points of incision into the tunica. The illustration (B) demonstrates the lengthening of the tunica after the incisions are made and the penis placed on stretch. The image (C) gives an intraoperative perspective. One can see the fully mobilized neurovascular bundle within Buck’s fascia (right), and the isolated corpus spongiosum (left) surrounded by a Penrose drain. Tubing connecting to the inflatable penile prosthesis cylinders has been placed through proximal corporotomy incisions (bottom). No grafting material is used with this technique. Rather, Buck’s fascia is closed over the defects.

Figure 3

The multiple slice technique (MuST) with forked incisions. This figure demonstrates the MuST with multiple forked incisions. (A) Penis with Peyronie’s curvature; (B) longitudinal lines which demarcate the beginning of the dissection of Buck’s fascia; (C) multiple forked incisions in the tunica albuginea which allow for curvature relaxation; (D) erect penis following tunical incisions; (E) postoperative appearance.

Figure S1

Surgical techniques that increase penile length (68). Available online: http://www.asvide.com/articles/987