Plaque incision and grafting with penile prosthesis placement via non-degloving approach for complex biplanar Peyronie's disease and erectile dysfunction

Abstract

Objective: Surgery remains the gold standard treatment option for men with complex Peyronie's disease (PD). Historically, most surgical procedures for this condition have been performed through a circumcision with penile degloving. When combined with penile prosthesis (PP) placement, circumcision with degloving could serve as a potential risk for glans ischemia. A ventral non-degloving approach has been previously described for patients undergoing complex reconstruction at the time of inflatable PP placement. This video aims to show the efficacy and safety of the non-degloving approach for a man undergoing plaque incision and grafting with PP placement for the management of complex biplanar PD and erectile dysfunction. Patients and Surgical Procedure: This approach is offered for men with complex PD and ED requiring complex reconstruction at the time of PP placement . A ventral incision is made from the frenulum down to the penoscrotal junction. Paraurethral incisions are made to elevate the neurovascular bundle away from the tunica albuginea while maintaining the continuity of the skin and Dartos fascia to the glans penis at all times. Plaque incision is made for curvature correction, the PP is placed and a graft is placed to cover the defects. Fascial layers and skin are then closed. Results: Correction of the deformity is achieved. Between October 2018 to May 2023, a total of 110 patients underwent PP placement with correction of PD of which 79 underwent PP with plaque incision/excision with grafting via the ventral non-degloving approach. As with other cases involving PP placement, potential complications associated to this procedure include edema, infection (n = 2), herniation of the prosthetic cylinder (n = 2), glans ischemia (n = 0), recurrence of curvature (n = 0), device malposition (n = 0) and device malfunction (n = 1). There were no cases of phimosis reported in our series and a total of 2 cases of paraphimosis were reported which were easily reduced by the patient without requiring additional medical or surgical intervention. Our preferred patch of use is Tachosil® (Baxter); or Evarrest® (Ethicon) if Tachosil is not available. Tutoplast® cadaveric pericardium (Coloplast Corp) is preferred in cases in which the defect is larger than 3 cm in length. Average time of the procedure is 150 min. Conclusion: The non-degloving approach remains a feasible option for men undergoing plaque incision and grafting at the time of PP placement. This approach theoretically may decrease the risk of glans ischemia while maintaining adequate surgical exposure and cosmesis that may increase patient satisfaction.