The Yachia procedure is a modification of the Nesbit technique that utilizes the Heineke-Mikulicz principle, where a single long incision or multiple small incisions are made longitudinally in the TA and subsequently closed horizontally to shorten the convex side of the penis (Yachia 1990). Reported patient satisfaction rates after the Yachia procedure range between 80 and 100 % (Daitch et al. 1999; Rehman et al. 1997) (Table 4.1). Despite this procedure is not commonly used depending on the surgical experience, this operation should be within the surgical armamentarium of urologists dealing with sexual medicine. The major reasons for dissatisfaction of Nesbit and Yachia procedures were the loss of penile tactile sensation (24 %) and ED (12 %) owing to elevation of the NVB and disruption of cavernosal integrity, respectively (Essed and Schroeder 1985).

The penile plication technique, originally described by Essed-Schroeder is the least invasive and thus the most commonly used surgical option for tunical shortening. No absorbable sutures are placed over the convex side of the TA, without the need for excision of TA tissue or mobilization of NVB in order to achieve a straight penis (Essed and Schroeder 1985). Plication procedures result in penile shortening similar to Nesbit and Yachia procedures and therefore recommended only in patients with adequate penile length and good baseline erectile function without any destabilizing deformity. Since NVB is not mobilized, fewer complications, such as reduced penile sensation and retarded ejaculation, are seen in comparison with aforementioned techniques.

In a quality of life assessment performed by Van der Horst et al., 28 men with PD who underwent plication were retrospectively evaluated after 30 months (Van Der Horst et al. 2004). Patients reported penile straightening, penile shortening, postoperative ED, and sensory changes at rates of 100, 74, 35.7, and 28 %, respectively, with an overall satisfaction rate of 67.8 % (Table 4.1). Similarly, Kadioglu et al. reported penile straightening in 14 of 15 men who had a preoperative mean penile curvature of 51° after a mean follow-up of 24 months (Kadioglu et al. 2008). All patients reported penile shortening, and none complained of ED. In another series, more than 90 % of patients reported penile straightening with a postoperative ED rate of approximately 10 % (Greenfield et al. 2006; Taylor and Levine 2008). Gholami and Lue reported a 16-dot (two pairs of plication) or 24-dot (three pairs of plication) plication technique depending on the severity of the curvature with minimal tension using multiple parallel plications (Gholami and Lue 2002). After a mean follow-up of 2.6 years, 93 % of 116 patients had straight erections, and only 4 % of them complained of decreased erectile function. However, recurrence of the curvature was observed in 15 % of patients and approximately 41 % of them complained of penile shortening—the most commonly encountered adverse outcome of plication surgery.

The penoscrotal plication technique had been described for reconstruction of penile curvature in 45 men with PD (Dugi and Morey 2010). The technique was performed with a 2 cm longitudinal incision at the penoscrotal junction opposite the direction of maximal curvature and carried down through Buck’s fascia to expose the TA, where parallel sutures are placed in vertical mattress fashion parallel to the urethra. Penile straightening was achieved in all patients with an overall satisfaction rate of 93 %. Despite evaluating relatively small cohort of patients with limited follow-up (only 34 were performed within 2 years), the technique described by the authors is promising since it is applicable for almost all curvatures, including severe or biplanar ones. The major advantage of the technique is the avoidance of circumcision to prevent distal ischemic and lymphatic complications. This technique has been performed recently for a larger patient population (n = 102) with a severe or biplanar curvature in 43 % of them and a similar follow-up time, 15 months. The results of this study look promising with only 4 % residual curvature and erectile dysfunction rates and penile shortening of 14 % (Adibi et al. 2012).

Tunica albuginea plication (TAP), modification of the Baskin-Duckett procedure, is another procedure that merit mentioning. In this technique, plication was performed by using suturing in an inverted fashion after tunical shaving. Meanwhile the plication is subsequently reinforced with several additional interrupted sutures in a Lembert fashion. Levine et al. evaluated the outcomes of TAP technique in a cohort including 100 patients with a median curvature angle of 49° and reported that 93 % of the patients had curvatures less than 30° after a median follow-up of 72 months (Taylor and Levine 2008).

In summary, the major advantages of plication procedures are that they are simple, less invasive than other tunical shortening techniques, and associated with better preservation of erectile function. However, penile shortening (especially after correction of curvatures greater than 60° which may lead to shortening up to 2 cm), the need for mobilization of NVB that may lead to NVB injury and more length loss in ventral curvatures, and augmentation of an existing hourglass deformity or hinge effect due to the need for longer plications are potential disadvantages of these procedures (Ralph et al. 2010; Greenfield et al. 2006). Consequently, plication techniques are currently more utilized because extensive surgical experience except ventral curvatures is not needed.

Generally, penile lengthening surgery is reserved for men with adequate erectile capacity having severe penile length loss, curvatures greater than 60°, or prominent hourglass deformities (Ralph et al. 2010). These procedures involve incision of the plaque at the point of maximum concavity and insertion of a graft to repair the defect, with resultant penile lengthening. Gelbard and Hayden recommend plaque incision rather than full plaque excision because PD affects the entire TA and excision of the plaque might cause irreversible dysfunction of the veno-occlusive mechanism of the penis (Gelbard and Hayden 1991).

The operative procedure is similar for all grafting techniques. After performing a circumcising incision and degloving the skin to the base of the penis to provide exposure of the entire shaft, an artificial erection is created with an intracorporal injection of vasoactive agent. As a side note, degloving of penile skin without the circumcision incision has been defined by using a 5 cm ventral incision from the scrotal raphe to penile base, and it has been performed for over 80 patients with either congenital curvature or PD and erectile dysfunction (Austoni et al. 2012). For dorsally located plaques, Buck’s fascia is opened from the dorsal side of the penis, and the deep dorsal vein is removed at the most prominent area of curvature. The NVB on the dorsolateral aspect of the corpora cavernosa is carefully dissected up to the healthy tissue (approximately 1 cm) with medial or lateral dissection off the underlying TA under loupe magnification (Pryor and Ralph 2002). For dorsally located plaques, medial dissection performed through the bed of the dorsal vein is probably more suitable than lateral dissection for dorsally located plaques. However, adequate lateral exposure is important for patients with severe lateral curvatures or hourglass deformities and might not be obtained with the medial approach.

Subsequently, plaque incision is performed, and graft material is positioned and sutured to restore tunical tissue integrity. Egydio et al. described the use of a single, almost complete circumferential-relaxing incision instead of traditionally used H incision, applying geometrical principles and suitable for all kinds of curvatures (Egydio et al. 2004). Tripod-shaped forks of 120° produce a simpler configuration of the tunical defect, which allows for easy suturing of the graft during the procedure. This technique has the potential to be the standard technique for plaque incision in the future.

Historically, three types of grafts have been described: autologous grafts, allografts (or xenografts), and synthetic grafts (Ralph et al. 2010). Synthetic materials, including polyester and polytetrafluoroethylene, are not used anymore owing to increased rates of infection, fibrosis resulting from significant inflammation around the graft site, contracture owing to inelasticity of the material used, and risk of allergic reactions (Kadioglu et al. 2007).

The ideal graft material should be readily available, pliable, inexpensive, resistant to infection, and able to preserve erectile capacity. In addition, experience of the physician, patient preference, and type of deformity can influence the selection of graft type (Kadioglu et al. 2007). Currently, investigations to determine the ideal graft material continue, and there are no robust data from comparative studies. In this search for a novel graft, an absorbable sealant patch for topical application consisting collagen, fibrin glue, fibrinogen, and human thrombin was tried as a grafting material. In a study with 43 patients who underwent tunical incision/excision and patch application, postoperative penile straightness, shortening, ED, and satisfaction rates were reported as 93, 93, 21, and 51 %, respectively, with similar satisfaction to tunical shortening procedures (Horstmann et al. 2011). Preoperative erectile status of the patient and the type of intervention are more significant predictors of postoperative ED than graft type (Levine et al. 2005). In 46 % of the patients who underwent grafting surgery with cadaveric pericardium had significant reductions in erectile capacity (>6 point IIEF score reduction) and degree of preoperative curvature (>60°), the type of plaque incision (Egydio), patient age (>55), and presence of venous leak were demonstrated to be independent predicators of this reduction (Flores et al. 2011). Similar to these results, in a study with 218 patients who underwent plication or grafting, no correlation was found between postoperative ED and comorbid diseases except DM (Chung et al. 2011). Although a higher ED rate in grafting procedure was shown in comparison with plication (21 % vs. 10 %), this distinction did not reach statistical significance (Taylor and Levine 2012).

Autologous grafts are derived from the recipient of the graft. These grafts can provide the advantage of easy incorporation into host tissue with decreased incidence of local inflammatory reaction. Since Lowsley and Boyce first used autologous grafts for patients with PD in 1950, there have been many studies assessing the outcomes of autologous materials, including the buccal mucosa, saphenous vein, preputium, dermis, TA, tunica vaginalis, fascia lata, and rectus sheath (Table 4.2).

Replacement of the plaque with buccal mucosa was first reported in 2005 (Shioshvili and Kakonashvili 2005). In animal experiments, they found that buccal mucosa was better than the vein, dermis, aponeurosis, and peritoneum in terms of elasticity, lengthening, and morphological properties of the graft. In their prospective cohort of 26 men, 24 achieved complete penile straightening within 2–6 months after surgery, and only 4 patients complained of penile shortening after a mean follow-up of 3.2 years. The authors concluded that the rich vascular blood supply of buccal mucosa provides good graft nourishment. In a recent study, Cormio et al. evaluated 15 patients who underwent plaque incision and buccal mucosa grafting and reported 100 % penile straightening with no postoperative ED after 13 months (Cormio et al. 2009). However, significant disadvantages of the procedure such as oral numbness (16 %) and tightness (32 %) caused by tissue harvesting still persisted after 1-year follow-up (Dublin and Stewart 2004). Despite the use of the buccal mucosa as a potential graft material due to its favorable graft properties, its side effects due to tissue harvesting are a major concern that probably limits its wide acceptance. Moreover, there are some concerns that buccal mucosa may produce inclusion cysts requiring secondary surgery (Levine et al. 2009).

Subsequently, Teloken used TA harvested from patients’ own proximal crura for avoiding immunogenic problems of adopting another organ tissue to TA such as retraction of the graft due to fibrosis and decrease cosmetic alterations (Teloken et al. 2000). Schwarzer reported satisfactory penile straightening in 26 of 31 patients; 4 patients had minimal residual curvatures (Schwarzer 2005). In another study, a surgical technique combining the Nesbit procedure with TA-free grafting to decrease the penile shortening caused by the Nesbit procedure by grafting the opposite site has been defined (Hatzichristou et al. 2002). The authors noted no recurrence except one with mild curvature in 13 patients after a mean follow-up of 39.5 months. Despite being based on a rational idea, it should be noted that only small grafts can be obtained with this method and surgery related to the proximal crura might lead to problems such as narrowing of the proximal corpus cavernosum that might be a problem for the future implantation of penile prosthesis and weaken the support of the penis.

The use of dermal grafts has become less popular because of high rate of de novo veno-occlusive dysfunction due to decreased tunical wall tension on the graft site. Historically, Krishnamurti reported the results of the first use of penile dermal flap for defect reconstruction in 17 PD patients with a follow-up of 3 months to 4 years (Krishnamurti 1995). All patients had adequate erectile function, and none of them had penile shortening or graft contracture during the follow-up. Recently, Radopoulos et al. (2009) reported the preliminary results of penile curvature correction with preputial skin graft in 14 patients. After 12-month follow-up, eight patients were evaluated, and six of them had complete penile straightening; whereas the remaining two patients had a residual curvature less than 20°. Despite two patients reported worsening of erections in comparison with preoperative situation, no patients mentioned any complications including de novo ED at the end of follow-up. The authors mentioned that the tight structure of the foreskin’s keratinized squamous epithelium functions to prevent venous leakage owing to the unfavorable outcomes of dermal grafts and the small number of patients in these studies, and the preputial skin is not a first-line option for graft material.

The saphenous vein is the most commonly used graft material for tunical lengthening owing to ease and reliability of harvesting, large surface area, and increased compliance with thin vascular walls that can be perfused from corporal bodies (Chang et al. 2012). Moreover, it is hypothesized that the nitric oxide secreted from endothelium might prevent hematoma formation and improve erectile function (Nowicki et al. 2004; Tsui et al. 2002). After the first report of saphenous vein grafting by Brock et al. in 1993, El-Sakka et al. reported the outcomes of 112 patients with a mean follow-up of 18 months (El-Sakka et al. 1998). Penile straightening was achieved in 95.5 % of patients with a 92 % satisfaction rate, while 12 % of the patients reported decreased potency, and 17 % had penile shortening. In another study, Kalsi et al. reported the results of 113 patients with PD and a mean penile curvature of 64.5°. After a mean follow-up of 12 months, penile straightness was observed in 86 % of patients. Postoperative ED and penile shortening were present in 15 and 25 % of the patients, respectively. The authors noted the risk factor for de novo ED as greater angle (mean angle 76°) of deformity and concomitant risk factors for ED such as diabetes, hypertension, and ischemic heart disease (Kalsi et al. 2005). Similarly, we used the same technique in 75 patients with a mean angle of curvature of 61° and reported the outcomes of 70 patients after a mean follow-up of 41.7 months (Kadioglu et al. 2008).

In this series, penile curvature was completely straightened in 53 (75.7 %) patients, while 9 (12.8) patients and 8 (11.4 %) patients had residual curvature less than 20° and greater than 20°, respectively. Other studies performed with saphenous vein grafting reported overall rates for successful penile straightening, penile shortening, and patient satisfaction ranging between 72–96 %, 17–40 %, and 88–100 %, respectively (Adeniyi et al. 2002; Akkus et al. 2001, 2012; De Stefani et al. 2000) (Table 4.3).

Although midterm outcomes of venous grafting studies are satisfactory, the success of surgery decreases in the long run. In 2004, Montorsi et al. reported the results of 50 men after 5 years. All patients noted penile length loss and 6 of them had persistent or recurrent curvatures. Postoperative ED was present in 11 patients and diminished orgasmic function in 41 % of the cohort (Montorsi et al. 2004). Only 60 % of the patients were satisfied with the outcomes of the operation. Kalsi et al., reported 40 patients with vein grafting followed for 5 years and demonstrated a postoperative ED rate of 22.5 %, and a length loss was observed in 35 % of the patients (Kalsi et al. 2005). In these studies, decreased penile rigidity and penile shortening were the reasons of dissatisfaction. It is worth mentioning that the unfavorable outcomes of the former studies are generally attributed to the large vein grafts leading to de novo veno-occlusive dysfunction. In addition, worsening of erectile capacity due to risk factors in time may also contribute to ED which is the main dissatisfaction of these patients. By contrast, Hsu et al. reported the outcomes of 48 patients who underwent plaque incision and vein grafting with long-term follow-up.