What are the treatment options for penile curvature after penile prosthesis implantation?

Treatment of Penile Curvature After Penile Prosthesis Implantation

For residual penile curvature after penile prosthesis placement, perform adjunctive intraoperative procedures in a stepwise fashion: start with manual modeling for curvatures >30°, then proceed to plaque incision with grafting for persistent significant deformity, or use plication for moderate residual curvature. 1

Algorithmic Approach to Residual Curvature

Step 1: Initial Assessment After Cylinder Insertion

• Mild-to-moderate curvature often resolves with cylinder insertion alone 1
• If residual curvature is ≤30°, no additional intervention is typically needed 1
• If curvature persists >30°, proceed to Step 2 1

Step 2: Manual Modeling (First-Line Adjunctive Technique)

• Manual modeling is the first option for curvatures >30° and was used in 74.7% of cases in a large multicenter cohort 1, 2
• This technique provides median curvature correction of 26.0° 2
• The "scratch" technique can be combined with modeling for enhanced correction 2
• Modeling is difficult with semi-rigid devices, which is why inflatable prostheses are strongly preferred 1, 3

Step 3: Plaque Incision and Grafting (For Severe Residual Curvature)

• If significant curvature persists after modeling (typically >40°), proceed to plaque incision with or without grafting 1, 4
• Grafting provides the highest median curvature correction of 55.0° and is particularly effective for severe deformities (60-90° preoperative curvature) 2
• The PICS technique (Penile Implant in Combination with the Sealing technique) uses self-adhesive collagen fleece (TachoSil) that requires no sutures, preventing device puncture and reducing operative time to approximately 117 minutes 4, 5
• After maximal inflation, perform plaque incision at the point of maximum curvature using electrocautery, which removes tension and allows straightening 4
• Cover the tunica defect with collagen fleece that adheres without sutures 4, 5
• This technique achieved total straightening in 80% of patients, with the remaining 20% having ≤10° residual curvature that did not interfere with intercourse 4

Step 4: Plication (Alternative for Moderate Curvature)

• Plication can be used for moderate residual curvature and achieves median correction of 40.0° 2
• Used in only 4.8% of cases in recent series, typically reserved for specific anatomical situations 2
• Combined plication with prosthesis placement is well-tolerated with no reported complications in early series 6

Graft Selection for Plaque Incision Procedures

When grafting is required, four graft types are available 1:

• Autografts (dermis, vein, fascia, buccal mucosa) - from the patient
• Allografts (pericardium, fascia lata) - from donors
• Xenografts (bovine/porcine materials, small intestinal submucosa)
• Synthetic grafts - generally NOT recommended due to infection risks 1
• Collagen fleece (TachoSil) - increasingly preferred as it requires no sutures and prevents device puncture 4, 5

Critical Timing and Patient Selection

• Surgery requires stable disease for 3-6 months before intervention 1, 7, 8
• Adjunctive procedures are frequently necessary to achieve optimal outcomes, with 82.4% of patients requiring additional correction beyond prosthesis insertion alone 1, 2
• The available evidence suggests no correlation between surgical complexity and infection or revision rates 1

Expected Outcomes and Complications

• Curvature improvement post-surgery occurs at >80% in all reviewed studies 1
• Patient satisfaction is generally high but lower in Peyronie's patients than general ED cases, primarily due to length concerns 1
• No immediate or late complications occurred in the PICS technique series with mean follow-up of 15.1 months 4
• Infection rates with modern antibiotic-coated devices are 1-2% 3

Common Pitfalls to Avoid

• Do not use semi-rigid prostheses - modeling cannot be effectively performed, and you won't know if modeling is needed until the operation begins 1, 3
• Avoid suture fixation of grafts when possible - the collagen fleece technique prevents device puncture from needle sticks 4, 5
• Do not attempt correction in active disease - outcomes are poorly documented and stable disease is a prerequisite 7, 8
• Counsel patients preoperatively about length concerns - this is the primary source of dissatisfaction in Peyronie's patients undergoing prosthesis surgery 1