Page 101 - Remedial Andrology

residual curvature [1096]. In patients with PD and ED not responding to medical treatments, penile prosthesis
implantation can be considered with correction of the curvature including adjunct techniques (modelling,
plication or incision/excision with grafting).

Penile degloving with associated circumcision (as a means of preventing post-operative phimosis) should be
considered the standard approach for all types of procedures, although modifications have been described.
Only one study has suggested that circumcision is not always necessary (e.g., in cases where the foreskin
is normal pre-operatively) [1097]. Non-degloving techniques have been described that have been shown to
prevent ischaemia and lymphatic complications after subcoronal circumcision [1098, 1099].

There are no standardised questionnaires for the evaluation of surgical outcomes. Data from well-designed
prospective studies are scarce, with low levels of evidence. Data are mainly based on retrospective single-
centre studies, typically non-comparative and non-randomised, or on expert opinion [1002, 1100]. Therefore,
surgical outcomes must be treated with caution.

8.2.3.2.1 Tunical shortening procedures
For men with good erectile function, adequate penile length, without complex deformities, such as an
hourglass or hinge type narrowing abnormality, and non-severe curvature, a tunical shortening procedure
can be considered an appropriate surgical approach. Numerous different techniques have been described,
although they can be classified as excisional, incisional and plication techniques.

In 1965, Nesbit was the first to describe the removal of tunical ellipses opposite to the point of maximum
curvature with a non-elastic corporal segment to treat CPC [1101]. Thereafter, this technique became
a successful treatment option for PD-associated penile curvature [1102]. This operation is based on a
5-10 mm transverse elliptical excision of the tunica albuginea or ~1 mm for each 10° of curvature. The overall
short- and long-term results of the Nesbit operation are excellent [1103-1107]. Some modifications of the
Nesbit procedure have been described (partial thickness shaving instead of conventional excision; underlapped
U incision) with similar results, although these are in non-randomised studies [1108-1112].

The Yachia technique is based on a completely different concept, as it utilises the Heinke-Mikowitz principle
for which a longitudinal tunical incision is closed transversely to shorten the convex side of the penis. This
technique, initially described by Lemberger in 1984, was popularised by Yachia in 1990, when he reported a
series of 10 cases [1113-1118].

Pure plication techniques are simpler to perform. They are based on single or multiple plications performed
without making excisions or incisions, to limit the potential damage to the veno-occlusive mechanism [1004,
1119-1135]. Another modification has been described as the ’16-dot’ technique that consists of application
of two pairs of parallel Essed-Schroeder plications tensioned more or less depending on the degree of
curvature [1112, 1136-1138]. The use of non-absorbable sutures or longer-lasting absorbable sutures may
reduce recurrence of the curvature (Panel expert opinion). Results and satisfaction rates are both similar to the
incision/excision procedures.

In general, using these tunical shortening techniques, complete penile straightening is achieved in > 85%
of patients. Recurrence of the curvature and penile hypo-aesthesia is uncommon (~10%) and the risk of
post-operative ED is low. Penile shortening is the most commonly reported outcome of these procedures.
Shortening of 1-1.5 cm has been reported for 22-69% of patients, which is rarely the cause of post-operative
sexual dysfunction and patients may perceive the loss of length as greater than it actually is. It is therefore
strongly advisable to measure and document the penile length peri-operatively, both before and after the
straightening procedure, whatever the technique used (Table 30).

As mentioned above, there are multiple techniques with small modifications and all of them have been reported
in retrospective studies, most of them without comparison between techniques and therefore the level of
evidence is not sufficient to recommend one method over another.

100 SEXUAL AND REPRODUCTIVE HEALTH - MARCH 2021