Clinical and penile Doppler outcomes using a modified, tourniquet free, Nesbit plication for severe Peyronie's disease

Abstract

Background: Penile curvature (PC) can be surgically corrected by plication techniques or Nesbit corporoplasty. These shortening techniques can be complicated by post-operative: penile shortening, recurrent PC, palpable suture knots and erectile dysfunction. Furthermore, Nesbit procedures require the use of a penile tourniquet to avoid intraoperative bleeding. This observational study aims to assess the results of Nesbit modified corporoplasty, avoiding intraoperative use of tourniquet without risk of bleeding. The objective is to reduce penile ischemic anatomical and functional damages such as long-term erectile dysfunction.

Methods: Between January 2010 and March 2019, a total of 64 patients with congenital penile curvature (CPC) and Peyronie's disease (PD) underwent surgical correction with a Nesbit modified technique first time described by Rolle et al., with minimal technical differences. The operation notes were retrospectively reviewed. In particular, we evaluated pre- and post-operative erectile functions using IIEF-5 score, penile Doppler ultrasonography and overall patient satisfaction.

Results: During operations, no intraoperative bleeding was noted, and no short-term complications such as hematomas or neurovascular bundle lesions were reported. At 6 months, no palpable subcutaneous indurations and no sensory change were detected. Post-operative penile shortening was reported in 38 (59.4%) patients (mean 0.83±0.79 cm), but it did not influence the high overall satisfaction rate of 91.4%. Only 2 patients reported a slightly partial recurrence of curvature (<15%) with no need for a redo surgery. Mean IIEF-5 score increased from 17.1±5.2 to 20.8±3.9 at 6 months and 21.8±3.4 at 12 months (P<0.001 in both cases). Mean PSV also significantly increased at the end of follow-up (28.5±6.1 at baseline vs. 31.0±7.1 at 12 months, P=0.03).

Conclusions: Considering the optimal results in terms of erectile functions increasing and absence of PC recurrence (>15°), we think that Nesbit modified corporoplasty without tourniquet application during reconstruction is a safe and effective surgical procedure for all kind of shortening corporoplasty to reduce the time of penile ischemia, preventing even serious consequences for the normal physiology of erection.

Keywords: Modified Nesbit corporoplasty; Peyronie’s disease (PD); congenital penile curvature (CPC); hypoxic-ischemic damages.

Figure 1

Assessment of penile curvatures. (A) Ventral penile curvature and phimosis. (B) Circumcision and penile degloving, artificial erection induction to confirm the curvature.

Figure 2

Tunica albuginea plication. (A) Second step of Nesbit modified corporoplasty without use of tourniquet. (B) Neurovascular bundles dissection and tunica albuginea plication with allis forceps. (C) Horizontal mattress continuous suture under allis forceps.

Figure 3

Albugineal tissue removal. (A) Third step of Nesbit modified corporoplasty. (B) Albugineal tunica incision with scalpel. (C) Albugineal excess tissue removal. (D) Absence of bleeding without tourniquet.

Figure 4

Suture of the albugineal breach. (A) Albugineal tunica breach ensuring. (B) Over and over interrupted absorbable suture.

Figure 5

Assessment of penile correction. (A) Artificial erection induction to check curvature correction. (B) Buck’s fascia periurethral interrupted absorbable suture.

Figure 6

Penile skin closure. (A) Corpora cavernosum closure. (B) Penile skin coronal suture. (C) One-month follow-up with complete curvature resolution. (D) Excellent cosmetics results.

Figure 7

Correlation between erectile disfunction assessed by IIEF-5 and peak systolic velocity (PSV) score pre- and post-operative. IIF-5 and PSV positively correlate both at baseline (A) and after a follow-up of 12 months (C). (B) At baseline, 72.7% and 27.3% of patients with normal PSV had no- or mild-ED, respectively, compared to 20.6% and 41.2% of patients with PSV into grey zone and 5.3% and 21.1% of those with abnormal PSV. Most cases with moderate or severe ED (57.1%) had abnormal PSV. (D) At follow-up after 12 months, all patients with normal PSV did not reported ED. Moreover, a large proportion (58.5%) of cases without ED had a PSV into grey zone, while 2.4% (vs. 6.3% preoperative) continue to have abnormal PSV. The majority of patients with abnormal PSV had mild ED (53,8%) or mild-to-moderate ED (38.5%) vs. 26.8% and 2.9%, respectively, of those having PSV into grey zone. Statistical analyses were performed by Pearson r correlation coefficient (A and C) and chi-square (χ²) test (B and D).

Figure 8

Association between cause of penile curvature and presence of plaques with severity of erectile disfunction and peak systolic velocity (PSV). (A) None of the patients with congenital penile curvature (CPC) had abnormal PSV compared to 35.8% of those with Peyronie’s disease (PD). (B) Patients with CPC showed a normal or grey zone PSV (63.6% and 36.4%, respectively) vs. 7.5% and 56.6% of those without. (C) 24.3% and 32.4% of patients with plaques vs. 14.8% and 7.4% of those without had mild-to-moderate or moderate-or-severe ED. (D) Only one (3.7%) patients without plaque reported abnormal PSV vs. 48.9% of those without, whereas none of patients with plaques presented normal PSV compared to 40.7% of those without plaques. Statistical analyses were performed by chi-square (χ²) test.