Penile Plication Techniques and Anatomical Insights

Penile plication is a surgical approach used to correct penile curvature, primarily in conditions like Peyronie’s disease. It involves strategically placed sutures to straighten the shaft without removing tissue, making it a less invasive option compared to grafting procedures. This technique is widely utilized due to its effectiveness and relatively low risk of complications.

A clear understanding of penile anatomy and suture placement is essential for optimizing outcomes. Different variations of the procedure exist, each with specific advantages depending on the severity and location of the curvature.

Penile Curvature Basics

Penile curvature can be congenital or acquired, with Peyronie’s disease being the most common cause in adults. This condition results from fibrotic plaque formation within the tunica albuginea, the dense connective tissue surrounding the corpora cavernosa. These plaques create inelastic areas, leading to asymmetric erections where the unaffected side expands normally while the fibrotic region restricts expansion, causing the shaft to bend. The degree of curvature varies, with some cases exceeding 60 degrees, significantly impairing sexual function and causing discomfort.

The biomechanics of penile curvature are influenced by the tunica albuginea’s structure, which consists of an inner circular and outer longitudinal layer of collagen fibers. In a healthy penis, these layers allow uniform expansion during erection. When fibrosis disrupts this architecture, the mechanical imbalance results in deviation toward the affected side. The location of the plaque determines the direction of curvature—dorsal plaques cause an upward bend, ventral plaques lead to downward curvature, and lateral plaques result in sideward deviation. Complex curvatures, involving multiple plaques or hourglass deformities, present additional challenges in correction.

Severity assessment relies on both patient-reported symptoms and objective measurements. The angle of curvature is typically evaluated using an artificial erection test, where vasoactive agents induce rigidity for precise measurement. Curvatures exceeding 30 degrees are more likely to interfere with penetrative intercourse, prompting surgical intervention. Pain, erectile dysfunction, and psychological distress further influence treatment decisions, as untreated cases can worsen over time.

Surgical Goal of Plication

The primary objective of penile plication is to counteract the asymmetric contracture of the tunica albuginea by shortening the convex side of the penis, restoring a straighter erection. Unlike grafting techniques, which require excision of fibrotic tissue and replacement with a patch, plication preserves vascular integrity and minimizes the risk of sensory loss or erectile dysfunction. By strategically placing non-absorbable sutures along the unaffected side, surgeons generate a compensatory force that offsets the curvature without extensive dissection. This makes plication a preferred option for patients with adequate penile length and curvatures below 60 degrees.

Achieving optimal results hinges on precise suture placement to ensure uniform tension distribution across the tunica albuginea. By reducing the functional length of the longer side, the shorter, fibrotic region is no longer the dominant force dictating curvature. The number and placement of sutures depend on the degree and direction of deviation, with most techniques favoring a midline or slightly lateral approach to avoid neurovascular compromise. Studies show that well-executed plication can achieve curvature corrections exceeding 85%, with long-term satisfaction rates surpassing 80%.

A key consideration in this procedure is the trade-off between straightening and penile shortening. Since the approach reduces the length of the convex side rather than elongating the concave side, some degree of length loss is inevitable. However, this reduction—typically ranging from 5 to 15 mm—is generally modest and well tolerated in patients with sufficient baseline length. Preoperative counseling helps set realistic expectations, particularly for individuals concerned about post-surgical changes in appearance or sensation. Objective measurements and visual modeling can improve confidence and satisfaction.

Tissue Layers and Suture Placement

The structural composition of the penis plays a crucial role in the effectiveness of plication techniques. The tunica albuginea, a dense fibrous sheath encasing the corpora cavernosa, is the primary target for suture placement. Its bilaminar organization—an outer longitudinal layer and an inner circular layer—allows for controlled expansion during erection but also dictates how sutures distribute tension when correcting curvature. The ideal suture depth must penetrate the tunica sufficiently to maintain stability without compromising underlying erectile tissue, which could lead to venous leakage or diminished rigidity.

Suture selection and technique influence both the durability of correction and the likelihood of postoperative complications. Non-absorbable sutures, such as polyester or polypropylene, are favored for their long-term tensile strength. The choice between simple interrupted, horizontal mattress, or parallel plication techniques depends on curvature severity and surgeon preference. Horizontal mattress sutures provide broader force distribution, reducing the risk of localized buckling, while parallel plication methods allow finer adjustments in tension. Improper suture spacing—either too close together or too widely distributed—can create secondary deformities like narrowing or indentation, highlighting the importance of meticulous planning.

Intraoperative considerations refine the precision of suture placement. Surgeons often employ artificial erection tests using vasoactive agents to assess real-time correction before securing knots. This step ensures that the applied tension effectively counteracts the curvature without excessive shortening. Avoiding the dorsal neurovascular bundle and lateral perforating veins is essential to preserving sensation and minimizing bleeding. Some modifications, such as buried or minimally invasive sutures, have been explored to reduce palpable knot discomfort, a common postoperative complaint.

Technique Variations

Surgical approaches to penile plication have evolved to accommodate different curvature severities, patient preferences, and anatomical considerations. One widely used method is the Nesbit procedure, which involves excising small ellipses of tunica albuginea from the convex side before suturing the edges together. While effective, this technique requires tissue removal, making it more invasive than pure plication techniques. The Yachia method modifies this approach by making longitudinal incisions in the tunica that are then closed transversely, achieving straightening while preserving more structural integrity.

For a less aggressive correction, the Essed-Schroeder technique offers a purely plicational approach, relying on strategically placed non-absorbable sutures without excision. This method is particularly beneficial for moderate curvature cases where patients wish to avoid the risks associated with tunical resection. Some variations refine this approach by using parallel or running sutures to distribute tension more evenly, reducing the likelihood of indentation or palpable knots. Recent adaptations have also incorporated absorbable sutures in select cases to mitigate long-term discomfort, though this modification may slightly increase the risk of recurrence.