Tunica albuginea plication (TAP) for the treatment of Peyronie’s disease is indicated for penile curvatures less than 70 degrees in the absence of hinging or advanced narrowing, and/or when potential further penile shortening is tolerable to the patient. TAP is also indicated in patients with curvatures greater than 70° with co-existing mild erectile dysfunction as plaque excision and grafting does have an increased risk of erectile dysfunction [2, 4–8] The surgical goal with TAP is to correct the penile curvature to functional straightness which is defined by expert opinion as curvature <20° [2, 3].
39.2 General Principles
The principle of TAP is to identify the point of maximal curvature (PoMC) on the penile shaft and to shorten the opposing or convex aspect of the tunica albuginea to match the length of the contralateral side. The greater the curvature, the greater the shortening is needed on the convex side therefore TAP is best considered for mild to moderate curvature (<70°) and if compromising penile length is not unacceptable to the patient and/or their partner. This point is critical when discussing surgical options with patients and selecting cases for TAP preoperatively as 70–80% of patients already have loss of penile length from the PD due to the loss of tunica elasticity from the fibrotic disease process [1, 2, 9].
The advantages of penile shortening procedures when compared to penile lengthening procedures is that it is a relatively easier surgery with shorter operative time, which can offer straightening with a lower risk of postoperative erectile function for the properly selected patients [5, 10]. The critical disadvantage to plication procedures is the penile shortening which occurs on the convex side by definition but also the inability to correct “indentation” deformities which can result in an unstable erection due to hinging.
39.3 Excision Technique
Penile straightening by plication was first described by Nesbit in 1965. It was introduced as a surgical technique to correct congenital ventral chordee [11, 12]. This procedure involved an elliptical excision of the tunica albuginea on the convex side of the curvature. After the small wedge of tunica was excised, the elliptical tunical edges were approximated using permanent sutures . (Fig. 39.1) Reports of this early technique have shown correction of penile curvature in 91% and preservation of erectile function in 82–89% [13, 14].
39.4 Incision Technique
Several decades later, Yachia introduced the Heineke-Mikulitz technique to correct penile curvature . This technique differs from the Nesbit procedure in that the tunica is incised rather than excised. Full thickness vertical incision(s) measuring 0.5–1.5 cm in length is made on the tunica opposing the (PoMC). The vertical incisions are then closed transversely which will shorten the convex side and reduces the angulation of the erect penis. (Fig. 39.2) Minimizing the length of the vertical full thickness incision of the tunica albuginea is crucial, as transverse closure of the tunica edges of long incisions can create or exacerbate pre-existing narrowing of the penile shaft which may result in an unstable erection. Published series on this technique have showed a high number of patients reporting penile functional straightness (92–93%) [16–18].
39.5 Partial Thickness Incision Techniques
The technique that we routinely utilize at our institution is the modified Ducket-Baskin technique which was initially developed for correction of congenital curvature in children [19, 20]. This is a partial tunical incising technique that removes the outer longitudinal tunica fibers but preserves the inner circular fibers. We favor this technique as leaving the internal tunica fibers intact obviates the violation of the internal cavernosal erectile tissue, which should help preserve the patient’s penile rigidity. Removal of the external tunical fibers also debulks the plicated tunica, making the plication site less bulky. Permanent suture 2–0 Tevdek (Teleflex Medical, Research Triangle Park, NC) is placed in an inverted vertical mattress fashion to bury the knot. The primary approximation of the transverse incisions with Tevdek is re-enforced with one or more 3–0 PDS sutures placed in a Lembert fashion. This will also help to bury the Tevdek knot. This technique will be described in detail later in the Author’s Step-by-Step Operative Guide portion of the chapter (Fig. 39.3).
39.6 Incisionless Imbrication Techniques
Imbrication procedures are used as an alternative to avoid full-thickness incision of the tunica. The incisionless technique conceivably preserves erectile function by leaving the tunica intact. Limiting the potential compromise to penile rigidity is important as up to a third of men with PD already have some degree of erectile dysfunction . Essed and Schroeder published the first series using incisionless plication in five men with Peyronie’s disease, all treated with imbrication using non-absorbable sutures in a figure-of-eight pattern . Ebbehoj used a similar method of plication to correct congenital penile curvature . The incisionless imbrication procedure was further popularized by the 16-dot technique often referred to as the Lue procedure [24–26]. This penile shortening technique involved two extended parallel suture lines of Lembert-type plication utilizing permanent sutures (Fig. 39.4).
Several modifications of the 16-dot techniques have emerged recently. Osama Schaeer introduced a new method of imbrication known as the Double-Eight Plication technique. Standard plication suture lines are taken parallel to the outer longitudinal fibers of the tunica albuginea which the authors point out may be prone to tearing with erection and resulting in recurrent curvature . The Double-Eight plication technique follows the concept of the 16-dot plication but each figure-of-eight plication is placed in crisscrossing pattern which secures the tunica fibers in an interlocking manner reducing the likelihood of recurrence due to the sutures tearing through the tunic. The authors saw no recurrence in a series of 60 patients at an average follow-up of three years .
The Kiel Knots plication is another modification of the 16-dot plication that was created to make the plication knots less apparent and to improve the patient’s comfort level [27, 28]. The gaps between the plication sutures are closely spaced (about 5 mm apart) when compared to the original 16 dot plication technique in an effort to minimize relevance of the longer suture to maintain straightness. A thin superficial transverse slit about 5 mm long is made at the location of planned plication without violating the underlying corpora cavernosa. Each of these slits act as a trough for the knot to lay in and to be buried once the suture is tied down. (Fig. 39.5) Patients undergoing this method report less bothersome penile sensations associated with suture knots .