This web only provides the extract of this article. If you want to read the figures and tables, please reference the PDF full text on Blackwell Synergy. Thank you.
- Clinical Experience -
Surgical treatment of Peyronie's disease: choosing the best approach to improve patient satisfaction
Paulo H. Egydio
Urology Institute, Rua Iguatemi, 192 Cj. 42, São Paulo 01451-010, Brazil
Aim: To discuss important points on medical history, preoperative evaluation, real expectations, and selection of the
appropriate surgical procedure to improve patient satisfaction after surgical procedures for Peyronie's disease.
Methods: Recent advances in approaches to Peyronie's disease are discussed based on the literature and personal experiences.
Issues concerning surgical indication, patient selection, surgical techniques, and grafting are discussed. Lengthening
procedures on the convex side of the penile curvature by means of grafting offer the best possible gain from a
reconstruction standpoint. Penile rectification and rigidity are required to achieve a completely functional penis. Most
patients experience associated erectile dysfunction (ED), and penile straightening alone may not be enough to restore
complete function. Twenty-five patients were submitted to total penile reconstruction on length and girth with
concomitant penile prosthesis implant. The maximum length restoration was possible and limited by the length of the
dissected neurovascular bundle. The mean age was 55.4 years (32_69 years) and the mean angle of curvature
74.2 ± 22.4° (0_100°). Pericardial grafting was used to cover the defect. The mean follow-up time was 11.2 ± 5.9
months (3_22 months). Results: Mean functional penile length gain was 3.40 ± 0.73 cm (2_5 cm). Penile prosthesis
maintained the penis straight. No infections occurred. Sexual intercourse was restored in all patients and all reported
recovered self-esteem. Conclusion: Improving patient satisfaction with the surgical treatment includes proper
preoperative evaluation on stable disease, penile shortening, vascular and erectile status, patient decision and selection as
well as extensive discussion on surgical technique for restoring functional penis (length and rigidity). Length and girth
restoration is very important for self-esteem and patient
satisfaction. (Asian J Androl 2008 Jan; 10: 158_166)
Keywords: Peyronie's disease; erectile dysfunction; induratio penis plastica; penile induration; tunica albuginea; surgical technique; penis;
graft; surgery; penile reconstruction
Correspondence to: Dr Paulo H. Egydio, Urology Institute, Rua Iguatemi, 192 cj. 42, São Paulo 01451-010, Brazil.
Tel: +55-11- 9194-9090 Fax: +55-11-3077-3644
Peyronie's disease (PD) is characterized by scarring of the tunica albuginea, which loses elasticity, resulting in
penile deformity. The condition is invariably associated with penile reduction, and has major impact on quality of life
and significant psychological effects . Prevalence is 3_9% according to Rochelle and Levine . Recent evidence
suggests that the prevalence of PD is similar to that of diabetes mellitus and renal calculi .
Usta et al.  have shown that erectile dysfunction (ED) is strongly associated with PD raging from 20% to 54%.
This is relevant when choosing the optimal surgical reconstructive treatment.
Provided the stability of the condition is established, surgical treatment will be indicated upon medical treatment
failure. Stability is defined as at least 1 year of disease and at least 6 months of non-progression or regression of penile
deformity and/or plaque, and absence of pain.
When surgical treatment is indicated, it must be individualized, aiming not only at restoring penile function but also
restoring as much as possible the previous status of the patient.
2 Materials and methods
2.1 Preoperative evaluation
2.1.1 Sexual and medical history
Preoperative evaluation should include complete
clinical history as well as assessment of comorbidities, such
as diabetes, heart/vascular/coronary conditions, arterial
hypertension, smoking, alcohol consumption, signs and
symptoms of hypogonadism, and regular medications,
which may affect erection.
A detailed history should be obtained on associated
ED prior to, or concomitant with, PD, as well as risk
factors contributing to the development of the condition,
such as sexual partner's lubrication status, achievement
of an erection that continues until ejaculation, premature
or late ejaculation, or inadequate habits that may cause
injury to the tunica albuginea. A history of
phosphodiesterase 5 (PDE-5) inhibitor use is key to establishing the
presence of associated ED, as well as the response of
this condition to the medication, patient's tolerance to its
side effects, and his compliance with treatment.
Surgical treatment may be indicated in penile
deformities that have been stable for at least 6 months and
functionally impair or preclude intercourse. PD is consistently
associated with decreased penile length. Some patients
experience symmetric loss of elasticity, with little or no
deformity. In such cases, a decrease in penile length may
be the sole or the main complaint. It is very important
during evaluation to ask the patient how much length has
been lost after the onset of the fibrotic condition. This
can be corroborated after erection induction and objective
evaluation by the patient and physician.
2.1.2 Assessment of penile deformity, rigidity, vascular
status, and arterial anomalies
A complete evaluation is essential in cases of sexual
inadequacy with possible surgical indication. Patients
with ED may need specific treatment as well as
assessment of their response to treatment before surgery is
considered as a therapeutic option.
For deformity assessment, physical examination of
a flaccid penis may reveal a palpable thickened tunica.
Penile size may be determined by pulling the glans penis
forward and upward to the position of a normal erection
and asking the patient to indicate to which extent PD has
shortened his penis.
Erection assessment is essential to determine whether
surgery is indicated, as well as the most appropriate
surgical procedure. Penile tumescence, or partial rigidity, is
often mistaken for erection, and the objective test of
pharmacologically induced erection may change the
Rigidity assessment is performed both subjectively,
as reported by the patient, and objectively, as observed
by the physician after intracavernous injection (ICI) of
alprostadil 10_20 µg, which allows evaluation of penile
deformity and objective rigidity, and, with Doppler
ultrasound (DUS), provides essential data for vascular
assessment (arterial insufficiency and/or veno-occlusive
dysfunction) as well as detection and localization of
collateral vessels between dorsal and cavernous arteries.
After ICI, the patient holds his penis in erection
position, and the ultrasound scanning of thickened areas
of the tunica, associated or not with calcification, is
initiated. The measurement of flow indices-peak
systolic velocity (PSV), end diastolic velocity (EDV), and
calculated resistive index (RI) begins at least 5 min
thereafter, and a correlation of these indices to penile
rigidity is established.
Information on penile arterial anatomy may be very
useful to the surgeon in selecting the type of surgical
technique to be used. Knowledge of the existence of a
collateral branch is important in safely dissecting the
neurovascular bundle. If you have collateral arteries at the
site of the maximum point of curvature the Nesbit type
procedure should be discussed with the patient or if
associated ED is documented a reconstruction and graft
associated with penile prosthesis implantation must be
discussed at preoperative evaluation.
Because penile size before PD is unknown,
information from the patient on the perceived extent of his penile
length reduction is relevant. During erection induction
for deformity assessment, the patient must be asked how
satisfied he would be with the length resulting from
straightening his penis by diminishing the longer side, as
it is being shown to him, and which would be the extent
of length loss compared to his penile size before PD.
Further decrease in penile length by PD is very likely to
have occurred when more than one site of fibrosis is seen,
or when there is fibrosis on opposite sides. However,
even if a thickened tunica cannot be palpated, longer-side
reduction is not precluded, because microstructure
changes are enough to decrease the elasticity of the tunica.
There are patients with penile curvature and no palpable
thickened tunica who undergo surgery. Penile deformity,
not the plaque, is the main complaint of a PD patient.
Surgery should focus on deformity correction rather than
As mentioned before, preoperative vascular
assessment is very important to define functional status and
some vascular anomalies of particular interest in regards
to further surgical procedures. Schaeffer et
al.  report 44% of arterial anomalies and 10% of distal
collateral arteries between dorsal and cavernous arteries. In a
retrospective study, Kendirci et al.  correlated
vascular status to type of penile deformity, demonstrating a
relationship between type of curvature and penile hemodynamics.
Evaluating patient's and partner's satisfaction and
long-term results after surgical treatment for PD, Usta
et al.  reported that PSV values of 35 cm/sec or above
and RI greater than 0.9 were considered as parameters
for a normal penile vascular system. EDV values greater
than 5 cm/s were considered diagnostic for
During or shortly after DUS, penile rigidity is
objectively compared to self-reported rigidity. This allows
more objective assessment of rigidity. If it is lower with
the test, both crura penis are pressed over the pubic bone
to obtain maximum rigidity in order to assess actual
penile deformity while the other hand assesses axial rigidity
by pressing on the glans to mimic an attempt at
penetration. If deformity is not pronounced and with good
rigidity allows reasonable axial stability and functionality,
then surgical treatment may not be indicated. A good
erectile response to oral or injectable medications may
restore penetration ability in such cases.
Soon after this assessment, the patient is asked to
palpate his penis and, by progressively relieving pressure
on crura, to report the extent of rigidity he observes in
an ideal setting of sexual stimulation. The physician is
thereby provided with an objective evaluation, and, if a
rigidity deficit is proven, the patient's ED can be treated.
The physician will state what a good rigidity is, and if
this desired goal can be achieved by the patient.
Mulhall et al.  published an algorithm for
ED-associated PD and the need for intraoperative adjuvant
maneuvers in PD when associated with penile prosthesis
2.2 Surgical alternatives
2.2.1 Tunical-shortening procedures
The Nesbit, modified Nesbit, and other plication
procedures may be indicated when penile length reduction
has little impact on quality of life, self-esteem, and penile
These procedures are associated with penile length
reduction, which, in addition to a diffuse elasticity
decrease of the tunica including the longer side, as occurs
in some cases of PD, may further add to penile length
loss (from PD and from surgery).
The size of the penis when pulled to the erection
position corresponds largely to the size expected after
these procedures . This is the size to be shown to
the patient before surgery.
Gholami and Lue  reported a 16- or 24-dot
plication technique using parallel, minimal-tension dots to be
minimally invasive because it requires no dissection of
the neurovascular bundle.
Van der Horst et al.  highlighted the importance
of choosing appropriate sutures for plication procedures
in order to prevent the development of granuloma and
pain, which can impair the patient's quality of life.
Polytetrafluoroethylene sutures resulted in only 13% of
patients complaining of postoperative pain, versus 52%
with polypropylene sutures.
Giammusso et al.  published a modified Yachia
procedure consisting of resecting the deep dorsal vein and
performing a longitudinal incision and transversal suture
with absorbable suture (3.0 polydioxanone) on the venous
bed, achieving 100% rectification with no need to
mobilize the neurovascular bundle. The use of absorbable thread
may prevent pain and definitive palpability of the stitch as
may occur with nonabsorbable sutures.
Bokarica et al.  recommend basing the surgical
technique selection on penile length and curvature degree,
so that procedures that shorten the longer side of the
penis would be indicated for cases of curvature that is
less than 60 degrees with a preoperative penile length in
erection greater than 13 cm. They further state that the
satisfaction of most patients, in spite of significant penile
length loss, was largely due to proper patient selection
and preoperative information.
Although these longer side-reducing procedures for
correction of penile curvature are less invasive, they are
consistently associated with a decrease in penile length.
2.2.2 Tunical-lengthening procedures
220.127.116.11 Excisional procedures
A drawback to excisional procedures is the fact that
not all patients have palpable plaques at the time of surgery;
in the case of multifocal plaques, the issue is which ones
should be removed; the tunica albuginea may be injured
diffusely, and not plaque-restricted, so that removal and
grafting may not be enough to correct the curvature and
restore length properly, requiring the addition of other
relaxing incisions. Because deformity, not plaque, is the
patient's main complaint, surgical procedures should
address deformity. Reports on excisional procedures
using different biologic or synthetic grafts show various
outcomes, which may be associated with excision itself
rather than grafting. There are reports of an association
between excisional procedures and increased rates of ED;
it is therefore suggested that they be replaced by incision
and grafting [15, 16].
With these explanations and the experience from
literature a consensus has almost been reached that the
use of relaxing incisions is the best treatment option.
18.104.22.168 Incisional procedures
In 1995, Gelbard  published a paper including
different types of relaxing incisions suggested for each
specific type of penile deformity.
In 1998, Lue and El-Sakka  described the H-incision. The main issue has always been to determine
the site, size, and number of such incisions on the
curvature area [15, 16, 19]. There are reports of many
surgeons who had to add complementary plication
procedures after grafting . This implies longer-side
reduction and no achievement of the best possible gain in
penile length from a reconstructing procedure.
In 1999, Lue and El-Sakka  described the
lengthening shortened penis caused by PD using circular
Egydio et al. [21, 22] described the geometric
principles applied to a single incision model of "tripod-shaped
120-degree forks," resembling the Mercedes-Benz logo
, with the purpose of accurately determining the site
and size of a single relaxing incision that could be adapted
to individual cases.
2.2.3 Surgical technique of single geometrically
determined incision [21, 22, 24_26]
A saline-induced erection is obtained and the area
neurovascular bundle dissection is marked by two
para-urethral incisions on Buck's fascia at the curvature area.
Dissection is performed until both sides meet along
Erection is again induced and maintained to mark
two lines tangential to penile axis drawn on proximal and
distal straight areas of the penile shaft (a_a' and b_b'). A
point (P) is generated at the intersection site from which
a circumferential line is drawn at the bisector of the angle
formed by the two tangential lines (Figure 1).
The width of the defect to be created on the tunica
must be equivalent to the difference between
measurements on shorter and longer penile sides, corresponding
to the difference of distances between any two
circumferential lines perpendicular to penile axis on straight
penile segments, i.e. outside the curvature area. The
difference (W) between d_e and d'_e' corresponds to the
width of the defect on either side of the urethra in cases
of dorsal curvature (Figure 2).
On the circumferential line, a length of W/4 away
from the site where it meets the g line, points F and F'
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 (Figure 3) resulting defect will be
more simple and stable as a tripod. Defect length (L)
will be equivalent to the distance between the two
para-urethral incisions for dorsal curvature, or between the two
ends of the fork-shaped incision for any type of
curvature (Figure 4).
A relaxing incision is based on deformity rather than
on plaque features and/or available graft size only.
Because the defect is produced by expansion rather than
replacement, it produces predictable tunica-defect size
that should be measured in full erection and individualized.
This technique uses a single, incomplete, circumferential,
relaxing incision forked at the ends by precise
application of geometric principles, to determine the exact
incision site in the tunica or plaque so that the shorter side
may be lengthened to equal the longer side, and to create
a simpler defect in the tunica to make grafting placement
easier. In the case of calcified plaques, the outer
longitudinal layer of the tunica may be preserved, and the
calcified inner circular layer may be removed at the
transverse incision site (Figure 5).
Perovic and Djordjevic  described the penile
disassembly technique for distal penile deformity, which
allows excellent distal exposure.
The geometrical tunical incision technique was combined
for penile straightening with maximum penile length gain.
An ideal graft should be ready to use, available in
various sizes, have good tensile strength and low
potential for inflammatory reactions, be infection-resistant, with
minimal or no risk for disease transmission, and
Several types of grafts have been used, including
biologic autografts-dermis, vein, penile crura, dura mater,
tunica vaginalis, fascia lata- and
allografts/xenografts-cadaveric pericardium, porcine small-intestine submucosa,
acellular dermis, or synthetic grafts: polytetrafluoroethylene,
Dacron, or silastic . The disadvantages of using
autologous grafting include increased surgical time,
increased morbidity, and scarring on the harvest site. The
amount of tissue may be another limiting factor,
especially for vein and penile crura autografts.
Hellstrom and Reddy  reported on using human
cadaveric pericardium, as did Chun et
al.  and Levine and Estrada . Leungwattanakij
et al.  compared several types of grafts in a rat model showing a low rate
of inflammatory reactions with cadaveric pericardium.
Knoll  reported the use of porcine small-intestine
submucosa (SIS) grafts as a tunical substitute, with
promising results. Larger-sized and more uniform
patches are advantages of SIS grafts, but absorption on
larger defects must be slower to avoid constriction at
the graft site, requiring the use of SIS with multi-layers.
With the increasing use of tissue engineering, new
tunica albuginea substitutes may be developed [34, 35].
Advances in this area are pronounced, and in the future,
grafts will be available that are much more similar to the
tunica albuginea, or an acellular matrix that may allow
the tunica to be rebuilt, whether associated with cell
culture and seeding or not.
A discussion concerning the best graft often involves
postoperative outcomes, although the type of relaxing
incision or excision has varied. Postoperative outcomes
are not solely dependent on the graft used.
Personal experience with cadaveric bovine
pericardium associated with plaque excision gave discouraging
results. In contrast, results were promising when using
the same type of graft associated with a relaxing incision
In another personal experience with four cases, it
was necessary to remove the pericardium graft 2.5 to
8.0 months after surgery (in three cases due to infection in
immunocompromised patients and in one case due to absorption of graft-graft suture with dehiscence and
local hematoma formation); no leakage was seen after
saline-induced erection, and the operative sites were left
without grafts. After the recovery period, patients still
have good-quality erections and axial rigidity, and are
capable of having sexual intercourse. This has shown
that grafts may even be absorbable, i.e. the tunica may
be allowed to rebuild on the structure of the graft,
provided this allows no new blood-vessel formation, which
may lead to veno-occlusive dysfunction.
It is expected that all patients have a hematoma
under the graft following a grafting procedure. A personal
series of 20 patients were followed for 8 months, after
which the hematoma disappeared in 50% and remained
as a laminar hematoma in 50%, not causing any
disturbance of penile functionality based on axial rigidity. It is
a matter of concern to maintain a large hematoma that
limits the expansion of spongy cavernous tissue based
on the concealed fibrotic area in the outer part of the
spongy tissue. The graft is important during this period
to block leakage from the spongy tissue and to maintain
good penile shape.
Two of the four patients who had their grafts
removed and had no leakage maintain a permanent
constriction area at the site of the removed graft, which was
filled by the hematoma underlying the graft.
With the purpose of trying to maintain a minimal
hematoma under the graft until blockage occurs in the outer
part of the spongy cavernous tissue, a light compressive
postoperative dressing is applied to be kept in place for 7 to
10 days, and the patient is started on a PDE-5 inhibitor at
bedtime on the 5th to 7th postoperative day, to stimulate
smooth muscle relaxation, thereby expanding the cavernous
tissue and compressing the hematoma as a means to help it
be absorbed or transformed into a laminar shape that does
not affect axial rigidity. These medications are particularly
important for patients with preoperative ED, and of utmost
interest to reduce the hematoma and maintain physical therapy
with stimulated or reflex erections. Early postoperative use
of a vacuum device can only increase the hematoma
underlying the graft, due to negative pressure.
2.4 Penile prosthesis implantation
Patients with PD and ED that are nonresponsive to
oral or injectable treatment will be candidates for penile
prosthesis implantation. Depending on the type and
degree of penile deformity, associated procedures (e.g.,
modeling , Nesbit/plication, or incision/excision and
grafting for penile rectification and/or correction of
constrictive lesions) may be necessary .
Rahman et al.  reported penile plication surgery
associated with penile prosthesis. The inconvenience of
this procedure is penile length reduction. The higher the
curvature degree, the greater this reduction will be.
Usta et al.  reported the long-term results of
surgical treatment for PD, showing that penile prosthesis
implantation and curvature correction with pericardium
graft added no risks of complications as compared to
prosthesis implantation surgery alone.
Twenty-five patients were submitted to total penis
reconstruction on length and girth with concomitant
penile prosthesis implant. The maximum length
restoration was possible and limited by the length of the
dissected neurovascular bundle. The mean age was 55.4
years (32_69 years) and the mean angle of curvature 74.2
± 22.4° (0_100°). Pericardium graft covered the defect.
The mean follow-up time was 11.2 ± 5.9 months (3_22
Personal experience is that pericardium
reconstruction has not increased the risk for infection and
complications. This may be due to the fact that
pericardial tissue, in contrast to vein and dermal grafts, needs
no imbibition to survive. That is why we prefer
reconstruction with pericardium grafting according to
geometric principles and single incision [21, 22], and
concomitant implantation of malleable or inflatable two or
three-piece prosthesis of a size compatible with the longer
side, as the shorter side has been elongated. In my
opinion, the best time for grafting length restoration is
when reconstruction associated with penile prosthesis
implantation is indicated (Figure 6).
Even those patients with mild or no curvatures but
with significant penile length reduction because of
diffuse tunica elasticity damage should undergo
reconstruction by circular incision and graft. Penile size recovery
in these cases is limited by the size of the neurovascular
bundle dissected, as the urethra, composed by spongy
tissue, stretches easily (Figure 7).
For patients reporting major penile size loss even with
small curvatures, circular graft reconstruction should be
considered, aiming at maximum penile size recovery
within the limits of the neurovascular bundle dissected.
Diffuse shaft constriction should be corrected with
lateral grafting as well (Figure 8).
Glans disassembly will not be necessary when no
transversal distal reconstruction is required (Figure 9).
It is important to note that all these penile
reconstruction procedures associated to implantation of a
prosthesis (malleable or inflatable two or three-pieces) were
exclusively performed by skin circumcision incisions.
Mean functional penile length gain was 3.40 ± 0.73
cm (2_5 cm). Penile prosthesis maintained the penis
straight. No infection was observed. Sexual intercourse
was restored in all patients that resulted in improved
satisfaction and self-esteem.
Recovery of penile length is limited by the dissected
neurovascular bundle length. Bundle dissection
maintained glans sensitivity without ischemic complications
and with preserved orgasm.
The technique herein presented is based on tunical
incision irrespective of the plaque characteristics and
localization. It may be used to correct all types
of curvature, whether associated with constriction or not. This
reconstructive surgical approach including extensive
preoperative discussion with patients produced the highest
The dissection of the neurovascular bundle was
standardized for all cases by means of the two para-urethral
incisions in Buck's fascia. At this level the circumflex
veins were of narrower caliber, thus facilitating their
cauterization, which means a reduced number of ligatures;
the manipulation of the bundle is made far from the
dorsal nerves of the penis, and as the deep dorsal vein is
preserved even with stretch of the bundle it protects the
nerves against damage preventing their lesion; the
dissection may be limited to the area of the curvature
allowing possible extension for maximum length elongation
according to the requirements of individual patients. The
risk of lesions to the collaterals of the dorsal arteries is
minimized with a smaller dissection associated with
preoperative Doppler ultrasound to define the sites of these
collaterals when present.
Creation of a full erection is of great importance for
the accurate application of these geometrical principles
and consequent determination of the appropriate tunical
incision site. The difference between longer and shorter
sides, which defines the width of the defect (W), can be
measured between any two points on the straight
portions of the penis because it will always be the same.
Sectioning the septum on both edges of the tunical
incision on the shorter side of the penis is key to adequate
lengthening of the shorter side and complete penile
straightening. Complete penile straightening can be
checked by penis traction after final tunical and septal
incision and tunical dissection from the spongy tissue of
the corpus cavernosum. If the neurovascular bundle is
restricting penile straightening, its dissection may be
Tripod-shaped 120-degree forking produces a simpler configuration of the tunical defect, resulting in
geometrically-shaped grafts that can be easily sutured.
Forking also permits the relaxation of constricted areas on
the tunica and the correction of associated constrictive
lesions at the site of curvatures.
When geometrical principles and induced erection
are used, the size of the defect in the tunica albuginea
can be calculated before the incision is made, enabling
previous graft preparation.
If the graft is not likely to shrink, as is the case with
pericardium [21, 29], its size should match the size of
the defect. For grafts known to be likely to shrink, such
as dermis , a percentage should be added to the
dimensions of the graft to compensate for the shrinkage.
The length of the defect should be measured on an
erect penis and at a point without constriction. Under
these circumstances, only one incision and graft are
necessary, providing that the penis presents only one point
of maximum curvature. If there are two significant
curvatures at different points of the penis, two grafts should
be made as described. Complementary plication should
be avoided whenever possible, as it not only damages
the healthy side but also leads to penile shortening.
The present technique permits standardization of a
tunical incision procedure that may be reproducible in
multicenter studies leading to a better understanding of
the advantages and disadvantages of the different types
of graft materials [30, 32, 40].
This incision technique applying geometrical
principles is a standardized procedure for the correction of
any penile curvature, whether associated with tunical
constriction or not, resulting in maximum penile gain.
Preoperative assessment of penile length and curvature
degree is important for proper selection of the surgical
procedure to optimize patient satisfaction. It must be
emphasized that even patients with a penis longer than
13 cm may not accept the size reduction imposed by the
disease and the surgical procedure. Such patients are
candidates for grafting procedures.
The present technique is effective for correcting all types
of penile deformity, regardless of plaque characteristics.
Future measures to prevent treatment failures include
assessment at full rigidity performing geometrically
determined relaxing incisions with known defects, and
developing more adequate grafts. Procedures that shorten
the penis are to be employed cautiously, and not without
extensive preoperative discussion. Prosthesis
implantation is indicated for cases of inadequate rigidity. The
improvement of tissue engineering techniques will
contribute to the development of grafts increasingly closer
to the ideal for tunica albuginea replacement.
1 Gelbard MK, Dorey F, James K. The natural history of Peyronie's
disease. J Urol 1990; 144: 1376_9.
2 Rochelle JC, Levine LA. Survey of primary care physicians and
urologist regarding peyronie's disease. J Urol 2005; 173 (Suppl).
254 (Abstract 941).
3 Christopher JS, Chelsea M, Ridwan S. Peyronie's disease: the
epidemiology, aetiology and clinical evaluation of deformity.
BJU Int 2005; 95: 729_32.
4 Usta MF, Bivalacqua TJ, Tokatli Z, Rivera F, Gulkesen KH,
Sikka SC, et al. Stratification of penile vascular pathologies in
patients with Peyronie's disease and in men with erectile
dysfunction according to age: a comparative study. J Urol 2004;
5 Schaeffer EM, Jarow JP Jr, Vrablic J, Jarow JP. Duplex
ultrasonography detects clini-cally significant anomalies of penile
arterial vasculature affecting surgical approach to penile
straightening. Urology 2006; 67: 166_9.
6 Kendirci M, Nowfar S, Gur S, Jabren GW, Sikka SC, Hellstrom
WJ. The relationship between the type of penile abnor-mality
and penile vascular status in patients with Peyronie's disease. J
Urol 2005; 174: 632_5.
7 Usta MF, Bivalacqua TJ, Sanabria J, Koksal IT, Moparty K,
Hellstrom WJ. Patient and partner satisfaction and long-term
results after surgical treatment for Peyronie's disease. Urology
2003; 62: 105_9.
8 Mulhall J, Anderson M, Parker M. A surgical algorithm for men
with combined Peyronie's disease and erectile dysfunction:
functional and satisfaction outcomes. J Sex Med 2005; 2: 132_8.
9 Mulhall J, Ahmed A, Anderson M. Penile prosthesis surgery for
Peyronie's disease: defining the need for intra-operative
adjuvant maneuvers. J Sex Med 2004; 1: 318_21.
10 Greenfield JM, Lucas S, Levine LA. Factors affecting the loss of
length associated with tunica albuginea plication for correction
of penile curvature. J Urol 2006; 175: 238_41.
11 Gholami SS, Lue TF. Correction of penile curvature using the
16-dot plication tech-nique: a review of 132 patients. J Urol
2002; 167: 2066_9.
12 Van der Horst C, Martinez-Portillo FJ, Melchior D, Bross S,
Alken P, Juenemann KP. Polytetrafluoroethylene versus
polypropylene sutures for Essed-Schroeder tunical plication. J
Urol 2003; 170: 472_5.
13 Giammusso B, Burrello M, Branchina A, Nicolosi F, Motta M.
Modified corporoplasty for ventral penile curvature: Description
of the technique and initial results. J Urol 2004; 171:1209_11.
14 Bokarica P, Parazajder J, Mazuran B, Gilja I. Surgical treatment
of Peyronie's disease based on penile length and degree of
curvature. Int J Impot Res 2005; 17: 170_4.
15 Pryor J, Akkus E, Alter G, Jordan G, Lebret T, Levine L,
et al. Peyronie's Disease. J Sex Med 2004; 1: 110_5.
16 Kalsi J, Minhas S, Christopher N, Ralph D. The results of plaque
incision and venous grafting (Lue procedure) to correct the penile
deformity of Peyronie's disease. BJU Int 2005; 95:1029_33.
17 Gelbard MK. Relaxing incisions in the correction of penile
deformity due to Peyronie's disease. J Urol 1995; 154: 1457_60.
18 Lue TF, El-Sakka Al. Venous patch graft for Peyronie's disease.
Part I. Technique. J Urol 1998; 160: 2047_9.
19 Montorsi F, Salonia A, Maga T, Bua L, Guazzoni G, Barbagli G,
et al. Evidence-based assessment of long-term results of plaque
incision and vein grafting for Peyronie's disease. J Urol 2000;
20 Lue TF, El-Sakka Al. Lengthening shortened penis caused by
Peyronie's disease using circular venous grafting and daily
stretching with a vacuum erection device. J Urol 1999; 161:1141_4.
21 Egydio PH, Lucon AM, Arap S. Treatment of Peyronie's
disease by incomplete circumferential incision of the tunica
albuginea and plaque with bovine pericardium graft. Urology 2002;
22 Egydio PH, Lucon AM, Arap S. A single relaxing incision to
correct different types of penile curvature: surgical technique
based on geometrical principles. BJU Int 2004; 94: 1147_57.
23 Tornehl CK, Carson CC. Surgical treatment of Peyronie's disease.
Urol Clin N Am 2005; 32: 479_85.
24 Seftel A. Treatment of Peyronie's disease by incomplete
circumferential incision of the tunica albuginea and plaque with
bovine pericardium graft. J Urol 2002; 168: 869 (Editorial
25 Egydio PH, Lucon AM, Arap S. A single relaxing incision to
correct different types of penile deformity in Peyronie's disease:
geometrical principles. J Urol 2003; 169 (Suppl): 275.
26 Egydio PH. Surgical straightening with tunica incision and
grafting technique_single relaxing incision based on geometrical
principles. In: Levine LA, editor. Peyronie's Disease Textbook:
A Guide to Clinical Management. Totowa: Hymana Press, 2006.
27 Perovic SV, Djordjevic ML. The penile disassembly technique in the
surgical treat-ment of Peyronie's disease. BJU Int 2001; 88: 731_8.
28 Kendirci M, Hellstrom WJ. Critical analysis of surgery for
Peyronie's disease. Curr Opin Urol 2004; 14: 381_8.
29 Hellstrom WJ, Reddy S. Application of pericardium graft in the
surgical management of Peyronie's disease. J Urol 2000; 163:
30 Chun JL, Mc Gregor A, Krishnan R, Carson CC. A comparison of
dermal and ca-daveric pericardial grafts in the modified
Horton-Devine procedure for Peyronie's disease. J Urol 2001; 166: 185_8.
31 Levine LA, Estrada CR. Human cadaveric pericardial graft for
the surgical correction of Peyronie's disease. J Urol 2003; 170:
32 Leungwattanakij S, Bivalacqua TJ, Yang DY, Hyun JS, Hellstrom
WJ. Comparison of cadaveric pericardial, dermal, vein, and
synthetic grafts for tunica albuginea substitution using a rat model.
BJU Int 2003; 92: 119_24.
33 Knoll LD. Use of porcine small intestinal submucosa graft in the
surgical management of Peyronie's disease. Urology 2001; 57:
34 Schultheiss D, Lorenz RR, Meister R, Westphal M, Gaboouev AI,
Mertsching H. Functional tissue engineering of autologous
tunica albuginea: a possible graft for Peyronie's disease surgery.
Eur Urol 2004; 45: 781_6.
35 Eberli D, Susaeta RA, Yoo JJ, Atala A. Novel acellular collagen
matrix for Peyronie's repair. J Urol 2005; 173 (Suppl):254.
36 Wilson SK, Delk JR. A new treatment for Peyronie's disease:
modeling the penis over an inflatable prosthesis. J Urol 1994;
37 Mulcahy JJ, Wilson SK. Management of Peyronie's disease with
penile prostheses. Int J Impot Res 2002; 14: 384_8.
38 Rahman NU, Carrion RE, Bochinski D, Lue TF. Combined
penile plication surgery and insertion of penile prosthesis for
severe penile curvature and erectile dysfunction. J Urol 2004;
39 Devine CJ Jr, Horton CE. Surgical treatment of Peyronie's
disease with a dermal graff. J Urol 1974; 111: 44_9.
40 Carson CC, Chun JL. Peyronie's disease: surgical management:
autologous materials. Int J Impot Res 2002; 14: 329_35.