Lengthening strategies for Peyronie’s disease

Abstract

Loss of penile length is a common complaint of men with Peyronie’s disease (PD), both before and after corrective intervention, which has a significant negative effect on patient quality of life. We sought to identify and describe the methods by which penile length can be preserved or increased. We conducted an extensive, systematic literature review, based on a search of the PUBMED database for articles published between 1990 and 2015. Articles with the key words “Peyronie’s disease”, “penile length” and/or “penile lengthening” were reviewed if they contained subjective or objective penile length outcomes. Only English-language articles that were related to PD and penile size were included. We found no evidence in the literature that medical therapy alone increases penile length. Classic inflatable penile prosthesis (IPP) placement, plication procedures, and the Nesbit procedure appear likely to maintain or decrease penile length. Plaque incision (PI) and grafting appears likely to maintain or increase penile length, but is complicated by risk of post-operative erectile dysfunction (ED). There are several surgical procedures performed concomitantly with IPP placement that may be suitable treatment options for men with comorbid ED, and consistently increase penile length with otherwise good outcomes concerning sexual function. These include the subcoronal penile prosthesis (scIPP), Egydio circumferential technique, the sliding technique, the modified sliding technique (MoST), and the multiple slice technique (MuST). In addition, adjuvant therapies such as penile traction therapy (PTT), post-operative inflation protocols, suspensory ligament relaxation, lipectomy, and adjuvant medical therapy for glans engorgement appear to increase subjective and/or objective penile length for men at high risk of decreased penile length after PD surgery. Considering the psychological burden of length loss in men with PD, providers with adequate volume and expertise should attempt, if possible, to maintain or increase penile length for men undergoing surgical intervention. There are several evidence-based, safe, and effective ways to increase penile length for these men and multiple emerging adjuvant therapies that may help ensure adequate length.

Penile Reconstructive Surgery in Peyronie Disease: Challenges in Restoring Normal Penis Size, Shape, and Function

“…Novel surgical techniques to improve penile lengthening and girth at the time of PPI placement with or without concurrent grafting have been described, such as circumferential incision [24], the double dorsalventral approach sliding technique [25], the modified sliding technique (MoST) [2627], and the multiple slice technique (MuST) [28]. The circumferential incision technique involves a circumferential incision at the point of maximal curvature of the tunica with mobilisation of the NVB, whereas the Egydio technique allows partial circumferential incision if the length is limited by the NVB [24].…”

“…In the sliding technique [25], both the NVB and urethra are mobilised, with 2 longitudinal incisions made in the lateral aspect of the TA of each corpus cavernosum and joined by hemi-circular incisions (the proximal hemi-circular incision connects dorsally and the distal connects ventrally), for complete transection of the corpora to stretch the penis to its maximum corrected length. The MoST technique is a modification of the sliding technique, with the major notable difference being the use of a single subcoronal incision with mobilisation and utilisation of the Buck's fascia to cover the defects in the TA, obviating the need for graft material [26], whereas MuST is a modification of MoST with multiple pairs of hemi-circumferential incisions enabling multiple sliding sections [28]. The average erect penile length gain achieved in patients who received circumferential incision was found to be around 2.5 to 3 cm, while for men who underwent sliding and various modified of sliding techniques, such as MoST or MuST, the penile length gain was reported to be between 2.5 and 4 cm [28].…”

“…The MoST technique is a modification of the sliding technique, with the major notable difference being the use of a single subcoronal incision with mobilisation and utilisation of the Buck's fascia to cover the defects in the TA, obviating the need for graft material [26], whereas MuST is a modification of MoST with multiple pairs of hemi-circumferential incisions enabling multiple sliding sections [28]. The average erect penile length gain achieved in patients who received circumferential incision was found to be around 2.5 to 3 cm, while for men who underwent sliding and various modified of sliding techniques, such as MoST or MuST, the penile length gain was reported to be between 2.5 and 4 cm [28].…”

“…It has been reported that up to 20% of patients reported diminished glans sensitivity following PPI placement, likely related to mobilisation of the NVB coupled with various lengthening strategies [28]. In addition, penile haematoma (up to 25%) and graft retraction (up to 10%) with residual curvature are not uncommon [2428].…”

2018 Canadian Urological Association guideline for Peyronie's disease and congenital penile curvature

“…There are three broad categories of TA plaque incision (double-Y, H-shaped, and Egydio geometric) that are made at the point/relative to the maximum curvature on the convex side of the penis, followed by placement of a graft material(autologous, allografts, xenografts, and synthetic) to repair the defect and potentially lengthen the shorter side of the penis. 1,3,[69][70][71][72]76,78,[86][87][88][89][90][91][92][93][94][95][96][97][98][99][100][101] There is a strong trend towards minimal TA disruption, therefore favoring incision or partial excision techniques;…”