This page has been consolidated. The scratch technique, Antonini protocol, manual modeling, plication-over-IPP, PICS grafting, Shaeer's punch, and length-restoration techniques are now covered together on the canonical IPP with Adjunctive Straightening page. The detailed historical and technique content below is preserved for direct-link readers.
The Scratch Technique and Endocavernosal Plaque Disruption
The scratch technique is an endocavernosal plaque disruption method performed from inside the corpora cavernosa, through the corporotomy incisions made for inflatable penile prosthesis (IPP) placement, without the need for penile degloving, circumferential skin incision, or neurovascular bundle mobilization.[1][2]
Scratch is an endocavernosal adjunct to modeling performed before IPP cylinder placement. Shaeer's related punch technique reached septal plaques; Antonini did not evaluate ventral curvature and cautioned against ventral scratching except in experienced hands.[1][2] The related Shaeer punch technique extends the concept by using a punch forceps to formally excise plaque from inside the corpus.
Anatomic Rationale — Why Endocavernosal?
The defining feature: plaque disruption is performed from within the corpus cavernosum, through the same corporotomy used for cylinder placement. Endocavernosal plaque access has these reported features relative to external plaque surgery:
- No NVB mobilization. The dorsal neurovascular bundle is not mobilized in the described approach; postoperative sensory loss was not observed in the 26-patient punch series.[2]
- Incision approach. Antonini used an infrapubic approach without degloving[1]; Shaeer used subcoronal degloving in 12/26 punch cases[2].
- Septal access; ventral caution. Shaeer's punch cohort included ventral and septal plaques, with the spongiosum protected near the urethra; septal plaques were not removed in its external comparator. Antonini did not evaluate ventral scratch and cautioned against it except in experienced hands.[2][1]
The Antonini Scratch Technique
Described by Antonini and colleagues in a 145-patient prospective series published in Journal of Urology in 2018.[1]
Step-by-step
- Map deformity and perform corporotomy. Antonini induced a saline artificial erection, marked the pathology externally, and used an infrapubic IPP approach in all 145 patients.[1]
- Use the external plaque mark. After corporotomy and dilation, guide internal disruption by the plaque marked during the saline artificial erection, before cylinder placement.[1]
- Endocavernosal disruption. In Antonini's protocol, an 80-mm nasal speculum is opened transversely across the plaque, followed by longitudinal internal scratching with a No. 12 scalpel blade before cylinder placement.[1]
- IPP insertion. Standard cylinder placement, rear-tip extender selection, and deployment
- Full inflation and assessment. Device inflated to maximum; residual curvature measured by goniometer
- Further correction if needed. Antonini added Wilson modeling after implant placement when needed; the cohort did not evaluate plication or grafting as part of this protocol.[1]
Clinical outcomes (Antonini 145 patients)
Baseline:
- Mean preoperative IIEF-5: 9.8 ± 2.3
- Plaques distributed across proximal third, middle third, and subcoronal regions
Immediate postoperative residual curvature:
| Plaque location | After scratch, IPP, and modeling when needed |
|---|---|
| Proximal third | 21.5° ± 4.5° |
| Middle third | 17.3° ± 4.8° |
| Subcoronal | 14.1° ± 3.1° |
Combined protocol: vacuum therapy for 3 minutes twice daily for 12 weeks; curvature assessed at 24 weeks:[1]
| Plaque location | Residual curvature at 24-week follow-up |
|---|---|
| Proximal third | 8.7° ± 2.5° |
| Middle third | 9.1° ± 2.9° |
| Subcoronal | 7.7° ± 0.9° |
Functional outcomes:
- Mean IIEF-5 at 6 months: 18.9 ± 3.1 (P<0.001 improvement); 24.1 ± 3.6 at 1 year
- The authors described complications as minimal, although Table 1 lists 33/145 (22.7%) early postoperative events and 14/145 (9.6%) longer-term events.[1]
The 12-Week Vacuum Therapy Co-Protocol
At discharge after scratch, IPP placement, and modeling when needed, mean residual curvature was 14.1–21.5° by plaque location.[1] At 24-week follow-up after a prescribed 12-week VED course, mean residual curvature was 7.7–9.1° by plaque location.[1]
Protocol:
- Vacuum erection device applied twice daily
- 3 minutes per session
- 12 weeks total.[1]
- Begin 2 weeks after discharge, without a constriction ring.[1]
Rationale: Antonini proposed that postoperative VED stretches the tunica during healing.[1]
Antonini prescribed twice-daily vacuum therapy after scratch plus IPP, but did not report an adherence analysis.[1]
The Shaeer Punch Technique
A more aggressive endocavernosal variant: instead of simply scratching the plaque, punch forceps are used to formally excise tissue from within the corpus.[2]
Technique
- Corporotomy and dilation
- Small punch forceps (typically 3–4 mm) introduced through the corporotomy
- Punches of plaque tissue excised from inside the corpus; the surgeon works along the tunical surface corresponding to the plaque, taking multiple small bites
- IPP cylinders placed
- Inflation and assessment
Outcomes — Shaeer series
26 patients treated with punch plus a penile prosthesis versus 18 retrospective excision-grafting plus prosthesis comparators:[2]
| Parameter | Punch technique | Excision-grafting |
|---|---|---|
| Preoperative curvature | 58.1° ± 11.7° | 58° ± 14.8° |
| Straight after surgery | 26/26 | 18/18 |
| Additional operative time | 7.3 ± 1.7 min | 50.8 ± 11.1 min |
| Operative time reduction vs. excision-grafting | 85% | |
| Glans hyposthesia | 0% | 39% |
In this retrospective matched comparison, all 26 punch patients and all 18 grafting patients were straight postoperatively.[2] Mean additional plaque-surgery time was 7.3 versus 50.8 minutes, and glans hyposthesia was reported in 0/26 versus 7/18.[2]
Advantages of Endocavernosal Techniques
Compared with external plaque incision or grafting (PEG):[2][3]
| Advantage | Mechanism |
|---|---|
| Minimally invasive | No degloving; no circumferential skin incision |
| NVB preservation | Dorsal bundle not mobilized in the described punch approach; no sensory loss observed in 26 patients[2] |
| Urethral exposure | External urethral dissection was avoided; no urethral injury was observed in 26 punch patients.[2] |
| Reduced operative time | 85% less additional plaque-surgery time versus excision-grafting in the 26-versus-18-patient comparison[2] |
| Preserved sensation | 0/26 with sensory loss after punch plus prosthesis vs. 7/18 (39%) reporting glans hyposthesia after excision-grafting plus prosthesis[2] |
| Infection | Infection occurred in 1/26 punch and 2/18 excision-grafting patients.[2] |
| Septal access | Punch reached septal plaques that were not removed in Shaeer's external excision-grafting comparator.[2] |
| No graft material required | Avoids graft placement and its material cost.[2] |
Limitations and Caveats
Residual curvature without vacuum adjunct
In Antonini's combined scratch, IPP, and modeling-as-needed protocol, mean curvature at discharge was 14.1–21.5° by plaque location.[1] Options for residual deformity include:
- Discuss Antonini's 12-week postoperative VED adjunct; its independent benefit remains untested.[1]
- Additional intraoperative maneuvers (modeling, plication) are added, or
- Residual curvature is judged acceptable for intercourse
Patient selection
- Studied selection and timing. Antonini performed scratch before cylinder insertion for stable curvature >30° or indentation/hourglass deformity in men with refractory ED; mean baseline curvature was 65.8°.[1]
- Severe baseline curvature (>60°) does not alone determine a grafting adjunct; reassess residual deformity after IPP placement and modeling.[1][5]
- Calcified plaques. Shaeer reported calcification in 11/26 punch patients, but neither series compared punch with scratch in this subgroup.[2]
- Heavily fibrotic corpora. Scratch disrupts a localized Peyronie plaque before cylinder insertion; its effect on diffuse corporal fibrosis or cylinder space was not evaluated in Antonini's cohort.[1]
Technique variability and terminology
The literature uses overlapping terms ("scratch technique," "manual modeling with scratching," "endocavernosal plaque disruption," "transcorporeal plaque surgery"), sometimes interchangeably. The distinction is between:
- Manual modeling. External bending of the inflated device to fracture the plaque (see manual modeling)
- Scratch technique. Internal disruption of the plaque with an instrument through the corporotomy
- Punch technique. Internal formal excision of plaque tissue with punch forceps through the corporotomy
Many surgeons combine modeling and scratching, applying scratches inside the corpus and then modeling externally after cylinder placement.
Integration into the Adjunctive Ladder
In the retrospective Hammad 2025 multicenter series, manual modeling with or without the scratch technique was used in 74.7% of 499 PD-IPP cases, making it the most common adjunct.[4]
Proposed escalation sequence. The ICSM 2024 consensus lists modeling, plication, plaque incision or excision, and grafting for deformity persisting after prosthesis placement. Scratching is described in a combined-treatment series and is not a separately endorsed step in that consensus.[3][5][6][1][8]
- Initial maneuver: Manual modeling for persistent curvature after IPP insertion; transcorporeal scratching is a separately described adjunct performed before cylinder insertion.[1][5]
- Residual curvature after modeling. For curvature >30°, choose a shortening or lengthening procedure according to deformity, penile length, and defect size; plication is one option.[11]
- Plaque incision, excision, or grafting. These are options for persistent deformity after prosthesis placement in the ICSM consensus; it gives no fixed 40–60° third-line threshold.[8]
See prosthesis with adjunctive straightening for the complete algorithm.
Postoperative Adjuncts
Vacuum therapy (Antonini protocol)
- 3 minutes twice daily
- 12 weeks total, beginning 2 weeks after discharge, without a constriction ring.[1]
- In the combined scratch, IPP, and VED cohort, mean curvature was 14.1–21.5° at discharge and 7.7–9.1° at 24-week follow-up.[1]
Home modeling (Moncada protocol)
- Begin 4 weeks postoperatively
- Manual bending of the inflated device opposite the residual curvature
- Daily sessions for 6 months
- In an uncontrolled series of 76 men with <45° residual curvature, 94.7% reached ≤10° at 6 months[7]
See manual modeling for detailed home-modeling protocol.
Early prosthesis activation
Bream's general IPP instructions begin device cycling 2–3 weeks after surgery if the incision has healed; this practice has not been compared with Antonini's VED protocol after scratch.[12][1]
PDE5 inhibitors
A randomized trial of 123 men receiving a three-piece IPP (11 with Peyronie disease) found that sildenafil 50 mg daily for one month produced higher erectile-function and sexual-life scores at 2–3 months, with no between-group difference at 6 or 12 months.[10]
Complications
In Antonini's combined scratch, IPP, optional modeling, and VED cohort, 33/145 (22.7%) had early complications[1]; Shaeer reported infection in 1/26 punch-plus-prosthesis patients[2].
| Complication | Rate |
|---|---|
| Glans hyposthesia | 0/26 after punch plus prosthesis versus 7/18 (39%) after excision-grafting plus prosthesis in one comparison[2] |
| Infection | 1/26 after punch plus penile prosthesis versus 2/18 after excision-grafting plus prosthesis in one retrospective comparison.[2] |
| Scrotal hematoma or swelling | 24/145 (16.6%) in Antonini's combined-treatment cohort (18 mild, 6 severe).[1] |
| Cylinder damage during scratching | Theoretical; cylinders are placed after scratching in most protocols |
| Prosthesis-related complications | Antonini reported 3/145 (2.1%) impending lateral cylinder extrusions and 3/145 (2.1%) mechanical failures; comparative risk versus standard IPP is unknown.[1] |
| Urethral injury | None in the 26-patient punch series.[2] |
| Neurological or sensory injury | None observed in Antonini's 145-patient combined cohort or Shaeer's 26-patient punch cohort.[1][2] |
Adjunctive Technique Comparison
| Technique | Reported angle or correction (study-specific endpoint) | Operative time | Complications | Graft required |
|---|---|---|---|---|
| Scratch + IPP ± modeling + 12-week VED | 14.1–21.5° at discharge → 7.7–9.1° at 24-week follow-up[1] | Scratch-specific time not isolated | 33/145 (22.7%) early complications[1] | No |
| Punch plus prosthesis | Straight after surgery in 26/26[2] | 7.3 ± 1.7 min additional plaque-surgery time | Infection 1/26; glans hyposthesia 0/26[2] | No |
| Manual modeling (with/without scratch) during IPP | Median curvature reduction 26° [20°, 39.5°] in the Hammad cohort[4] | Minimal | Urethral perforation 4/138 (3%) in the Wilson–Delk modeling series[9] | No |
| Optimal modeling (Lucas) | Mean 47.8° before modeling → 10.6° afterward in 40 patients[13] | Mean total operative time 82.7 versus 75.8 min in nonmodeled comparators (P=.15) | No complications reported in 80 patients at mean 29.9 months[13] | No |
| Tunical plication | Median correction 40° [28.8°, 41.2°] in the Hammad plication subgroup[4] | Moderate | Palpable sutures, shortening | No |
| Grafting adjunct during IPP | Median curvature correction 55° [48.8°, 73.8°] in Hammad grafting subgroup[4] | 50.8 ± 11.1 min additional plaque-surgery time in Shaeer excision-grafting comparator[2] | Glans hyposthesia 7/18 (39%) in Shaeer comparator[2]; hematoma | Yes |
Clinical Implications
Scratch and punch are described endocavernosal approaches during prosthesis surgery; operative-time comparison is available for punch versus excision-grafting, not for scratch. Reported implications and limits include:[1][2]
- Avoid planned NVB mobilization; Shaeer observed no glans hyposthesia in 26 punch patients.[2]
- In Shaeer's retrospective comparison, punch added 7.3 ± 1.7 minutes versus 50.8 ± 11.1 minutes for excision-grafting; scratch-specific comparative time was not measured.[2]
- In Antonini's uncontrolled combined-treatment series, 136/145 had residual curvature ≤15° at one year; the separate contributions of scratch and VED are unknown.[1]
- Have been described as adjunctive maneuvers in selected PD-IPP reports; the ICSM 2024 moderate recommendation lists modeling, plication, plaque incision/excision and grafting for persistent deformity after prosthesis placement.[1][2][8]
- Shaeer's punch reached septal plaques that were not removed in that study's external excision-grafting comparator.[2]
Patient counseling should emphasize:
- Antonini's combined-treatment cohort had mean residual curvature of 14.1–21.5° at discharge by plaque location; individual results vary.[1]
- Discuss the 12-week VED schedule used by Antonini and the separate home-modeling protocol; neither has been shown necessary for correction after scratch plus IPP.[1][7]
- Gradual improvement over 6 months
- In Antonini's combined cohort, mean IIEF-5 rose from 9.8 before surgery to 18.9 at 6 months, while 33/145 (22.7%) had early postoperative complications.[1]
See Also
- Peyronie's disease — overview
- Manual modeling
- Prosthesis with adjunctive straightening
- Plaque incision / excision with grafting
References
1. Antonini G, De Berardinis E, Del Giudice F, et al. Inflatable penile prosthesis placement, scratch technique and postoperative vacuum therapy as a combined approach to definitive treatment of Peyronie's disease. J Urol. 2018;200(3):642–647. doi:10.1016/j.juro.2018.04.060
2. Shaeer O, Soliman Abdelrahman IF, Mansour M, Shaeer K. Shaeer's punch technique: transcorporeal Peyronie's plaque surgery and penile prosthesis implantation. J Sex Med. 2020;17(7):1395–1399. doi:10.1016/j.jsxm.2020.03.018
3. Berookhim BM, Karpman E, Carrion R. Adjuvant maneuvers for residual curvature correction during penile prosthesis implantation in men with Peyronie's disease. J Sex Med. 2015;12 Suppl 7:449–454. doi:10.1111/jsm.13001
4. Hammad MAM, Barham DW, Simhan J, et al. A multicenter evaluation of penile curvature correction in men with Peyronie's disease undergoing inflatable penile prosthesis placement. J Sex Med. 2025;22(2):349–355. doi:10.1093/jsxmed/qdae192
5. Conlon WJ, Herzog BJ, Hellstrom WJG. Residual penile curvature correction by modeling during penile prosthesis implantation in Peyronie's disease patients. Int J Impot Res. 2023;35(7):639–642. doi:10.1038/s41443-023-00694-5
6. El-Khatib FM, Huynh LM, Yafi FA. Intraoperative methods for residual curvature correction during penile prosthesis implantation in patients with Peyronie's disease and refractory erectile dysfunction. Int J Impot Res. 2020;32(1):43–51. doi:10.1038/s41443-019-0215-y
7. Moncada I, Krishnappa P, Ascencios J, Lopez I, Martinez-Salamanca JI. Home modeling after penile prosthesis implantation in the management of residual curvature in Peyronie's disease. Int J Impot Res. 2021;33(6):616–619. doi:10.1038/s41443-020-0325-6
8. Chung E, Ziegelmann M, Lin HC, et al. "Management of Peyronie's disease: recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024)." Sex Med Rev. 2026;14(1):qeaf068. doi:10.1093/sxmrev/qeaf068
9. Wilson SK, Delk JR 2nd. "A new treatment for Peyronie's disease: modeling the penis over an inflatable penile prosthesis." J Urol. 1994;152(4):1121–1123. doi:10.1016/S0022-5347(17)32519-3
10. Wang J, Wu P, Liu Q, et al. "Effect of a three-piece inflatable penile prosthesis combined with a phosphodiesterase-5 inhibitor on erectile dysfunction." J Int Med Res. 2021;49(4):300060520985365. doi:10.1177/0300060520985365
11. European Association of Urology. "Penile curvature." EAU Guidelines on Sexual and Reproductive Health. Online chapter, accessed 2026-10-08. Guideline chapter
12. Bream M. "Penile prosthesis: post op cycling instructions." Urological Associates, P.C. Updated 2020. Practice instructions
13. Lucas JW, Gross MS, Barlotta RM, et al. "Optimal Modeling: an Updated Method for Safely and Effectively Eliminating Curvature During Penile Prosthesis Implantation." Urology. 2020;146:133–139. doi:10.1016/j.urology.2020.08.055