What are the considerations for plication with plaque incision in surgical treatment of Peyronie’s disease?

Surgical Treatment of Peyronie's Disease: Plication with Plaque Incision

For patients with stable Peyronie's disease and adequate erectile function, plaque incision with grafting combined with plication procedures offers excellent curvature correction with high satisfaction rates and should be considered when significant penile deformity prevents satisfactory sexual intercourse. 1

Patient Selection and Timing of Surgery

• Surgery should only be considered in patients with stable disease, typically defined as symptoms present for at least 12 months and stable curvature for 3-6 months 1
• Surgical outcomes for patients with active disease are not well documented, making stable disease a prerequisite for intervention 1
• Patients should have adequate erectile function (with or without pharmacotherapy/vacuum device therapy) to be candidates for plication with plaque incision 1

Advantages of Combined Plication with Plaque Incision

• Combination approach addresses both curvature correction and plaque-related issues simultaneously 2
• Curvature improvement rates are excellent, with success rates of 90% or higher for plication and 80% or higher for plaque incision with grafting 1
• Plication procedures have minimal risk of de novo erectile dysfunction compared to more extensive surgeries 2
• The combined approach allows for correction of complex deformities including multiplanar curvature and severe degrees of angulation 2, 3

Surgical Techniques and Considerations

• Plaque incision creates defects in the tunica albuginea that require grafting to maintain structural integrity 4
• Various graft materials can be used, including:
  • Buccal mucosa grafts - showing excellent short-term results with 100% penile straightening in some studies 4
  • Porcine dermal matrix and bovine pericardium xenografts - both showing similar long-term outcomes 5
  • Vein grafts (such as deep dorsal vein) - effective for correcting severe angulations (>60 degrees) 3
• Contralateral plication can be combined with plaque incision and grafting to achieve optimal straightening 3
• Different surgical approaches can be used, including circumcision with degloving, ventral raphe, dorsal penile inversion, and penoscrotal incisions 2

Expected Outcomes and Potential Complications

• Curvature improvement occurs in 80-100% of cases with combined techniques 4, 5, 3
• Potential for increased penile length on the affected side (average 1.8 cm in some studies) 4
• Most patients can resume sexual intercourse within 1 month after surgery 4
• Patient satisfaction rates are high (>80% would undergo surgery again) 5

Potential Complications and Pitfalls

• Penile shortening may occur in some patients (reported in 12 out of 24 patients in one study) 3
• Palpable nodules may develop at the graft site (more common with bovine pericardium grafts) 5
• Palpable knots at plication sites (reported in 5 out of 24 patients in one study) 3
• Recurrence of curvature is possible but uncommon 4, 5
• Erectile dysfunction is a potential complication, particularly in patients with pre-existing risk factors 3

Alternative Surgical Options

• For patients with erectile dysfunction unresponsive to medical therapy, penile prosthesis implantation with adjunctive procedures should be considered instead 1
• For simpler cases with less severe curvature, plication alone may be sufficient 2
• For patients with severe deformities preventing intercourse despite medical therapy, penile prosthesis surgery may be more appropriate 1

Follow-up and Monitoring

• Regular follow-up evaluations should assess penile straightening, erectile function, and patient/partner satisfaction 4, 5
• Long-term monitoring is important as some complications may develop over time 5