Rigi10™ Malleable Penile Prosthesis
Also Known As
Peyronie's disease grafting surgery, Penile grafting for Peyronie's disease, Plaque incision and grafting, Plaque excision and grafting (typically partial), Tunica albuginea grafting, Penile reconstructive surgery for Peyronie's disease, Corporoplasty with grafting
Definition
Peyronie’s disease (PD) is an acquired, benign fibrotic condition characterized by the formation of inelastic plaques or scar tissue within the tunica albuginea, the normally elastic sheath surrounding the erectile tissue (corpora cavernosa) of the penis.1–3 Grafting techniques in the context of Peyronie’s disease refer to a category of surgical procedures designed to correct penile curvature or deformities, such as an hourglass shape, that result from these plaques and significantly impair sexual function or cause distress.7,10–13 The fundamental purpose of these techniques is to lengthen the concave (shorter) side of the penis, where the plaque is typically located, thereby straightening the penis while aiming to preserve or maximize penile length, which is a common concern for patients.7,15
The procedure generally involves making an incision into or excising (partially or completely, though complete excision is less common now due to higher risks of erectile dysfunction) the Peyronie’s plaque at the point of maximum curvature.5,19 This action creates a defect in the tunica albuginea. A graft, which is a segment of biological or synthetic material, is then meticulously measured and sutured into this defect to cover the exposed erectile tissue and restore the integrity of the tunica albuginea.5,14 By filling this gap, the graft allows the constricted side of the penis to expand to match the length of the convex (longer) side, thus correcting the curvature. Grafting techniques are typically indicated for patients with stable Peyronie’s disease (disease duration >12 months, stable phase >6 months, and pain-free) who have significant penile curvatures, often greater than 60 degrees, a short penis where plication techniques (which shorten the convex side) would lead to unacceptable length loss, or complex deformities like an hourglass narrowing.7,15,17,18 Patients undergoing grafting procedures must have satisfactory erectile function preoperatively, often documented with an Erection Hardness Score of ≥3, as these procedures carry a higher risk of postoperative erectile dysfunction compared to plication techniques.5
Clinical Context
Grafting techniques are clinically indicated for the surgical management of Peyronie’s disease (PD) in specific patient populations, primarily when the disease has stabilized (typically meaning no change in deformity or pain for at least 6–12 months) and the penile curvature is significant enough to interfere with sexual intercourse or cause patient distress.1,4 Surgical intervention is generally considered after conservative medical therapies have failed or are not appropriate. The most common scenario for recommending a grafting procedure is when a patient presents with a penile curvature greater than 60 degrees.1,7,15 In such cases, simpler plication techniques, which shorten the convex side of the penis, might lead to an unacceptable loss of penile length, making grafting a more suitable option to preserve length by incising or excising the plaque on the concave side and filling the defect.7,18 Another key indication is the presence of an hourglass deformity, where a circumferential plaque causes a narrowing of the penile shaft; grafting is necessary to release this constriction and restore penile girth at the affected segment.1 Furthermore, grafting may be chosen for patients who already have a subjectively short penis, even with lesser degrees of curvature, to avoid any further shortening that would occur with plication procedures.1
Patient selection criteria are crucial for successful outcomes. Firstly, patients must have stable Peyronie’s disease, as operating during the active inflammatory phase can lead to recurrence of the curvature.1,4 Secondly, and very importantly, patients must have adequate erectile function, both with and without phosphodiesterase type 5 (PDE5) inhibitors, often documented with an Erection Hardness Score (EHS) of 3 or 4 (where 4 is a fully rigid erection).5,7 This is because grafting procedures, which involve more extensive dissection of the neurovascular bundle and tunica albuginea compared to plication, carry a higher intrinsic risk of de novo erectile dysfunction or worsening of pre-existing erectile dysfunction.5,19 Therefore, if a patient has significant PD-associated curvature and concomitant erectile dysfunction that is unresponsive to medical therapy, the preferred surgical approach is typically the implantation of a penile prosthesis, with or without ancillary straightening maneuvers like plaque incision or modeling, rather than a standalone grafting procedure.4,12 Patients should also have realistic expectations regarding the outcomes of surgery, understanding that the goal is to achieve a functionally straight penis, but some residual curvature, penile shortening (though minimized compared to plication), or changes in sensation may occur.7,13 Preoperative counseling regarding these potential outcomes, including the risk of recurrent curvature (10–33% reported in some series), is essential.1,15
The surgical procedure for grafting typically begins with a circumcising or subcoronal incision to deglove the penis, providing access to the tunica albuginea and the Peyronie’s plaque.20 The neurovascular bundle, which contains the nerves and blood vessels responsible for sensation and erection, is carefully mobilized and protected. An artificial erection is then induced intraoperatively (e.g., by saline injection) to precisely identify the point of maximum curvature and the extent of the plaque.1,20 At this location, a transverse or longitudinal incision (e.g., H-shaped, Y-shaped, or rectangular) is made into the plaque, or a partial excision of the plaque is performed.5,8 This maneuver creates a defect in the tunica albuginea, allowing the penis to straighten. The chosen graft material (which can be autologous, such as vein, dermis, buccal mucosa, or tunica vaginalis, or non-autologous/allograft/xenograft, such as pericardium, small intestinal submucosa (SIS), or collagen fleece) is then tailored to the size and shape of the defect and meticulously sutured into place using fine, absorbable or non-absorbable sutures.5,14,21 The watertightness of the closure is often confirmed with a repeat artificial erection. Finally, the penile skin is re-approximated and sutured.
Expected outcomes include a significant reduction in penile curvature, allowing for satisfactory sexual intercourse for most patients. Success rates for penile straightening often range from 70% to over 90% in various series, depending on the graft material, surgical technique, and patient selection.7,15,21 However, some degree of penile shortening, often ranging from 0.5 to 2 cm, can still occur despite the length-sparing nature of the procedure, and this should be discussed preoperatively.7,13 Sensory changes, such as numbness or hypersensitivity of the glans, are also possible but are usually temporary. The recovery timeline typically involves a period of abstinence from sexual activity for 4–8 weeks to allow for adequate healing. Postoperative rehabilitation protocols, which may include penile stretching exercises, vacuum erection devices, or low-dose PDE5 inhibitors, are often recommended to help prevent graft contracture and optimize outcomes.1,13 Long-term patient satisfaction is generally high when appropriate patient selection, meticulous surgical technique, and comprehensive preoperative counseling are employed.7,21