Incision and grafting for severe Peyronie's disease (CME)

Peyronie's Disease is a wound healing disorder involving growth of fibrous plaques in the tunica albuginea, and often results in abnormal penile curvature and subsequent development of erectile dysfunction. A 59-year-old man with a history of untreated penile trauma who presented with a 6-year history of worsening penile curvature that interfered with sexual functioning and resulted in associated erectile dysfunction.

The patient's Peyronie's Disease was evaluated in clinic with a focused physical exam and a penile vasculature study using a color duplex Doppler ultrasound. Since the patient did not have proper insurance coverage for an inflatable penile prosthesis, but did have normal arterial flow with only boderline veno-occlusive disease, he instead underwent an incision and grafting procedure. After degloving the penis, a lateral approach parallel to the corpus spongiosum was used to enter Buck's fascia and isolate the neurovascular bundles. The fibrous plaque was incised with a residual tunical defect of 4 x 5 cm, and covered with a pericardial graft.

Preoperatively, artificially induced erection during the patient's Doppler study demonstrated dorsal curvature greater than 80 degrees. Intraoperatively, after completing the incision and grafting procedure, artificial erection demonstrated minimal (less than 15 degrees) residual curvature. At his 1-week postoperative visit, he reported spontaneous erections and minimal pain. One month postoperatively, his incisions were well healed and an artificially induced erection continued to demonstrate minimal curvature.

Management of severe Peyronie's Disease with significant penile curvature is a challenging clinical problem. In extreme cases, placement of an inflatable penile prosthesis with ancillary techniques usually gives the best clinical outcome. Although more difficult to execute in severe cases, incision and grafting represents an acceptable alternative in the appropriately selected patient.