partial plaque excision and grafting (peg) for peyronie's ... · partial plaque excision and...
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Surgical TechniquesPartial Plaque Excision and Grafting (PEG) for Peyronie’s Disease
Laurence A. Levine, MD
Department of Urology, Rush University Medical Center, Chicago, IL, USA
FIGURE 1
Peyronie’s disease is characterized by a fibrous inelastic scar of the tunica albuginea that often results in a penile deformity.Peyronie’s disease may present as difficulty with penetration, or penetration that causes discomfort to the partner. Men with <12months disease, progressive deformity, or painful erections may be considered candidates for non-surgical therapy, although there islimited evidence of benefit with respect to deformity reduction. Non-surgical therapies include vitamin E, colchicine, pentoxifylline,traction therapy, and vacuum therapy as well as intralesional injection with verapamil or interferon. Surgery is an option in specificinstances.
Fibrous plaque causes
penile curvature
Peyronie’s curvatureNormal tunica albuginea
seen in cross section
Fibrous plaque consistent
with Peyronie’s disease
Pentoxifylline
O
OO
N
NN
N
Intralesional injection
of verapamil or interferon
Vacuum device
© 2011 International Society for Sexual Medicine
1842 J Sex Med 2011;8:1842–1845
Surgical Techniques
FIGURE 2
Surgical reconstruction is indicated for disease that is: stable for more than 6 months, with erect deformity that is painless, a compromisedability to engage in coitus secondary to deformity and/or inadequate rigidity, and when there is extensive plaque calcification. The partialplaque excision and grafting (PEG) procedure starts with the preoperative erection deformity angle measured. A circumferential deglovingskin incision is fashioned, followed by longitudinal opening of Buck’s fascia. The neurovascular bundle is elevated if the plaque involvesthe dorsal and/or lateral surface. The PEG surgical technique involves a single partial excision of the Peyronie’s plaque centered over thearea of maximum penile curvature and/or indentation, typically carried out to the 3 and 9 o’clock positions on the shaft bilaterally. Withthe penis on full stretch, stay sutures are placed at the four corners of the defect using 4–0 polydioxanone. The corners may be extendedradially to enhance girth correction. The lateral longitudinal aspects of the defect should be equivalent, ultimately forming a rectangulardefect.
Excision of fibrous
plaque
Stay sutures
Elevated
neurovascular
bundle
Erectile tissue
Tunica albuginea
Preop measurement of penile
curvature using goniometer
Dorsal penile curvature during
preop erection
Stay sutures
Excised fibrous plaque
Intraoperative elevation of
neurovascular bundle
J Sex Med 2011;8:1842–1845 1843
Surgical Techniques
FIGURE 3
The stay sutures are used to stretch the defect and ensure accurate measurement, usually ranging from 2–5 cm longitudinally and 4–7 cmtransversely. Tutoplast (Coloplast, Minneapolis, MN, USA) Processed Human Pericardium is carefully sized to the defect. As this graftdoes not contract, only add 3–4 mm to the measured defect size in both length and width. The graft is then secured to the corners of thedefect and to the tunical edges using running 4-0 polydioxanone sutures, taking care to suture from the tunica to the graft.
Suturing of Tutoplast®
processed human pericardial
graft over defect created by
removal of fibrous plaque
using running 4-0
polydioxanone suture
Determination of Tutoplast® graft size
Elevated
neurovascular bundleStay sutures
Stay sutures
Stay sutures
Fashioning of appropriately-sized
Tutoplast® graft material
1844 J Sex Med 2011;8:1842–1845
Surgical Techniques
FIGURE 4
Buck’s fascia is closed with a running 4–0 chromic suture, and the penile skin incision is closed with interrupted 4–0 chromic sutures ina horizontal mattress fashion. The postoperative erectile angle is measured. If residual curvature warrants correction, tunica plication isrecommended. Postoperative rehabilitation includes: massage, manual stretch therapy, phosphodiesterase type 5 (PDE5) inhibitor therapy,and daily penile traction therapy is recommended to begin 2–4 weeks postoperatively for 3 months.
The Surgical TechniquesSection is sponsored in part byColoplast
Tutoplast graft sutured
over defect
Neurovascular bundle returned to
native location
Dorsal penile curvature
during preop erection
Straight penis during
postop erection
Postop compression dressing
J Sex Med 2011;8:1842–1845 1845