Page 105 - Remedial Andrology

8.2.3.2.5 Recommendations for surgical treatment of penile curvature

Recommendations Strength rating
Perform surgery only when Peyronie’s disease (PD) has been stable for at least 3 months Strong
(without pain or deformity deterioration), which is usually the case after 12 months from the
onset of symptoms, and intercourse is compromised due to deformity.
Prior to surgery, assess penile length, curvature severity, erectile function (including Strong
response to pharmacotherapy in case of erectile dysfunction [ED]) and patient expectations.
Use tunical shortening procedures as the first treatment option for congenital penile Weak
curvature and for PD with adequate penile length and rigidity, non-severe curvature and
absence of complex deformities (hourglass or hinge). The type of procedure used is
dependent on surgeon and patient preference, as no procedure has proven superior to its
counterparts.
Use tunical lengthening procedures for patients with PD and normal erectile function, Weak
without adequate penile length, severe curvature or presence of complex deformities
(hourglass or hinge). The type of graft used is dependent on the surgeon and patient
factors, as no graft has proven superior to its counterparts.
Use the sliding techniques with caution, as there is a significant risk of life changing Strong
complications (e.g., glans necrosis).
Do not use synthetic grafts in PD reconstructive surgery. Strong
Use penile prosthesis implantation, with or without any additional procedure (modelling, Strong
plication, incision or excision with or without grafting), in PD patients with ED not
responding to pharmacotherapy.

8.2.3.3 Treatment algorithm
As mentioned above, in the active phase of the disease, most therapies are experimental or with low evidence.
In cases of pain, LI-ESWT, tadalafil and NSAIDs can be offered. In cases of curvature or penile shortening,
traction therapy has demonstrated good responses.
When the disease has stabilised, intralesional treatments (mainly CCH) or surgery may be used.
Intralesional treatments may reduce the indications for surgery or change the technique to be performed but
only after full patient counselling, which should also include a cost-benefit discussion with the patient.
The decision on the most appropriate surgical procedure to correct penile curvature is based
on pre-operative assessment of penile length, the degree of curvature and erectile function status. In non-
complex and non-severe deformities, tunical shortening procedures are acceptable and are usually the
method of choice. This is typically the case for CPC. If severe curvature or complex deformation is present
(hourglass or hinge), or if the penis is significantly shortened in patients with good erectile function (preferably
without pharmacological treatment), then tunical lengthening is feasible, using any of the grafts previously
mentioned. If there is concomitant ED, which is not responsive to pharmacological treatment, the best option
is the implantation of a penile prosthesis, with or without a straightening procedure over the penis (modelling,
plication, incision or excision with or without grafting). The treatment algorithm is presented in Figure 11.

104 SEXUAL AND REPRODUCTIVE HEALTH - MARCH 2021