Plaque Incision and Grafting Surgery (PIGS) is a specialized procedure in reconstructive urology designed to correct severe deformities of the penis. The surgery aims to restore the shape and function of the organ by addressing underlying scar tissue that causes unnatural curvature during erection. The fundamental purpose of PIGS is to straighten the penis and preserve or maximize its original length, which is a common concern for patients. This reconstructive technique involves making an incision into the scar tissue and using a biological patch to fill the resulting gap, allowing for expansion and alignment.
Understanding the Condition Requiring Surgery
The pathology necessitating PIGS is Peyronie’s disease (PD), a fibrotic disorder characterized by the formation of inelastic scar tissue, or plaque, within the tunica albuginea. This tunica albuginea is the strong, elastic sheath that normally encases the erectile cylinders of the penis. The presence of a stiff, non-elastic plaque prevents the tunica on one side from stretching fully, causing the shaft to bend sharply toward the side containing the scar.
Peyronie’s disease progresses through two distinct phases that determine the timing of surgical intervention. The acute phase typically lasts between 6 and 18 months and is characterized by active inflammation, pain during erections, and a curvature that is often changing or worsening. During this period, surgery is generally not recommended because the disease activity could lead to recurrence.
The condition is considered stable once it enters the chronic phase, defined by the resolution of pain and a curvature that has remained unchanged for at least three to six months. The plaque may also show signs of calcification. Surgical options like PIGS are only considered appropriate after this period of stability confirms the resulting deformity is fixed, making surgical correction definitive.
Criteria for Patient Selection
Selecting the appropriate patient for Plaque Incision and Grafting is a strict process, primarily because the procedure is more complex and carries a higher risk of complications compared to simpler techniques. The patient must have achieved disease stability, meaning the curvature and symptoms have been static for several months, typically at least six. Operating during the active, acute phase significantly increases the risk of the curvature recurring post-surgery.
A patient’s existing erectile function is a key requirement for PIGS candidacy. The procedure is reserved for men who possess satisfactory erectile rigidity, often defined as an Erection Hardness Score of 3 or 4, indicating a near-full or fully rigid erection, with or without the use of oral medications. Grafting procedures carry a risk of worsening erectile function, making good baseline rigidity a protective factor.
PIGS is primarily indicated for severe penile deformities, generally a curvature greater than 60 degrees. For lesser curvatures, a plication procedure might be chosen. However, PIGS is the preferred technique when the patient’s primary concern is preserving or maximizing penile length, as it corrects the deformity by lengthening the shortened, concave side. PIGS is also necessary for complex deformities like an hourglass narrowing, where the plaque constricts the girth of the shaft.
The Surgical Procedure Explained
The Plaque Incision and Grafting procedure is a technically demanding form of penile reconstructive surgery performed under general anesthesia. The process begins with a surgical incision, often a circumcising or subcoronal approach, which allows the surgeon to expose the underlying tunica albuginea. To precisely identify the extent of the deformity, a fluid-based artificial erection is then induced to demonstrate the exact location and angle of the maximum curvature.
The surgeon then carefully dissects and mobilizes the delicate neurovascular bundle, the network of nerves and blood vessels that run along the top of the penis, lifting it away from the plaque area. This step is critical to prevent nerve damage that could lead to post-operative numbness or loss of sensation. Once the plaque is isolated, the surgeon makes one or more incisions, often in an H-shape, Y-shape, or transverse pattern, directly into the fibrous tissue.
Alternatively, a partial excision of the plaque may be performed instead of just an incision. Cutting into or removing the stiff tissue relieves the tension on the shortened side, allowing the penis to be manually straightened. This maneuver creates a defect, or gap, in the tunica albuginea at the point of maximum curvature.
The next step involves measuring the size and shape of this defect and preparing the graft material. The graft, which acts as a patch, is then sutured into the tunical defect to cover the exposed erectile tissue. This patch provides structural support, reinforcing the tunica albuginea and allowing the constricted side to expand to match the length of the opposite side, thus maintaining or restoring length.
A variety of materials are used for the graft, including autologous tissue harvested from the patient, such as a segment of vein or temporalis fascia, or non-autologous materials. Commonly used non-autologous options include processed biological materials like bovine pericardium or specialized collagen fleece. These “off-the-shelf” grafts can reduce the operative time and avoid the need for a second donor site. Once the graft is securely sutured into place, the artificial erection is performed again to confirm complete straightening of the penile shaft before the surgical site is closed.
Recovery and Post-Operative Management
Immediately following Plaque Incision and Grafting surgery, a light compression dressing is applied to the penis to minimize swelling and support the surgical site. A temporary urinary catheter may be placed to ensure proper bladder drainage, though patients are often discharged on the same day or the day after the procedure. Patients are typically advised to take about a week off work, with pain generally managed with over-the-counter or mild prescription pain relievers.
A mandatory period of sexual abstinence is required to allow the graft to heal and integrate fully, which typically lasts at least six to eight weeks. During this healing period, patients are instructed to avoid any activity that causes penile engorgement, tension, or trauma. Swelling and bruising are common temporary side effects, and patients are often advised to gently massage the area starting a few weeks after the operation.
Post-operative rehabilitation is a crucial component of the recovery process, aimed at maximizing length preservation and preventing graft contracture. This rehabilitation often includes the daily use of a vacuum erection device (VED) or penile stretching/traction therapy. These methods help to mechanically stretch the penis and encourage the graft to heal at its full size. Patients are frequently prescribed a regimen of nocturnal phosphodiesterase-5 inhibitors, such as sildenafil or tadalafil, to enhance night-time erections and improve oxygenation to the newly placed graft tissue.
While the surgery successfully straightens the penis in a high percentage of patients, typically between 80% and 96%, patients should be prepared for potential outcomes. Some degree of temporary altered sensation, or numbness, in the glans is possible, though it often resolves over time. There is also a risk of developing new or worsened erectile dysfunction post-surgery, necessitating adherence to the rehabilitation protocol.