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Tunica Plication for Peyronie's Disease

Tunica plication corrects penile curvature by folding the convex (longer) tunica opposite the plaque with sutures, without tunical incision or excision, so that the convex side matches the concave side.[52] Nesbit excision and Yachia incision are distinct tunical-shortening corporoplasties.[52] It is a commonly performed operation for Peyronie's disease (PD). PD-only retrospective series reported complete correction in 86.3% (Savoca) and 91% (Cantoro).[18][32] In mixed congenital/PD cohorts, Çayan reported 87.6% complete straightening after 16-dot plication and 89.7% after modified Nesbit; Gholami–Lue reported straight erections in 93% at six months.[2][18][30][32] No randomized trial has established that one plication technique is better than another.[3]

For PD that compromises intercourse, document resolution of pain and at least three months of curvature stability before surgery. Plication is considered for moderate, non-complex curvature when erectile rigidity and length are adequate and the patient accepts possible shortening in exchange for a comparatively simple correction.[52] In one single-center series, among 109 of 218 men with pre- and postoperative erectile-function data, postoperative ED developed in 10% after plication and 21% after plaque excision with grafting.[7]

Indications and Patient Selection​

Ideal candidates​

  • Curvature ≤60° (some centers extend to ≥60° with modern variants)[3]
  • Adequate penile length. Stretched length >13 cm is commonly cited[3]
  • Intact erectile function, or ED responsive to oral PDE5i, VED, or ICI
  • No significant hourglass deformity or hinge effect
  • Predicted shortening is no more than 20% of preoperative length, and the patient accepts the risk of shortening.[3]

Relative contraindications​

  • Curvature >60–70° without mitigating factors (consider grafting)
  • Complex deformity (hourglass, hinge, biplanar) where shortening alone will not correct
  • Pre-existing short penis where additional shortening is unacceptable
  • ED unresponsive to medical therapy (consider prosthesis pathway)

Plication Techniques​

Modified Nesbit procedure​

Originally described by Reed Nesbit for congenital penile curvature and later adapted by Goldstein 1984 for adult PD and congenital curvature.[15][4][5] The principle of shortening the convex side to match the concave side underlies all tunical-shortening operations for curvature.

Technique:

  1. Degloving or penoscrotal incision to expose the convex side of the tunica
  2. Artificial erection induced intraoperatively to localize maximal curvature
  3. Elliptical wedge of tunica albuginea excised on the convex side opposite the plaque, typically 5–10 mm wide
  4. Defect closed horizontally with permanent braided suture (Ethibond 2-0 or 3-0) to match the concave-side length
  5. Closure buried and confirmed by repeat artificial erection
  6. Redraping of the penile skin

Sislow rule of thumb (1989). The number of 1-cm wedges of tunica to excise equals the measured difference in centimeters between the convex and concave surfaces, measured from the pubis to the mid glans. The rule was described for congenital curvature and reported in 6 patients.[16]

Modern modifications:

  • Tunical shaving (Rehman 1997). Partial-thickness shaving replaces full-thickness wedge excision. The authors report less bleeding, avoidance of cavernous tissue damage and better adhesion of the plicated tunical layers[4]
  • Superficial shaving (Schneider 2003). Combines simple plication with Nesbit-style superficial excision of the outer layer of the tunica albuginea, with the aim of limiting bleeding and cavernous tissue damage[17]
  • Vertical incision, horizontal closure (Heineke-Mikulicz principle). Running locked permanent suture with knots buried beneath the tunica for watertight closure with no palpable knot material[5]
  • Geometrical modified Nesbit (Vicini 2016). A geometric principle for wedge sizing applied to all curvature types. In 74 patients (25 congenital, 49 PD) all were corrected, 92% were completely satisfied, no relapse above 15° occurred and 74% reported some shortening[19]

Outcomes:

SeriesnFollow-upStraighteningSatisfactionShorteningDe novo ED
Rehman 1997 (tunical shaving)[4]32 (26 PD, 6 congenital)1–5 yr—PD: 19/26 reported good-to-excellent outcome; congenital: 6/6 satisfied——
Licht–Lewis comparative[5]30 modified, 28 standard Nesbit—93% modified vs 79% standard; difference not statistically significant———
Savoca 2004 (largest long-term)[18]218median 89 mo86.3% complete83.5%17.4% reported 1.5 to >3 cm; 2.3% reported intercourse difficulty from shortening—
Vicini 2016 (geometrical modified)[19]74 (25 congenital, 49 PD)12 wk, 12 and 24 mo100%92%74%Not reported
Savoca 2000 (Nesbit)[8]157 of 213mean 72 mo—87.9% satisfied14% (1.3% interfered with intercourse)Not reported; 136/157 (86.7%) had postoperative IIEF-5 > 21
Falcone 2020 (tertiary referral, modified corporoplasty)[20]87/145 with complete data (26 PD, 61 congenital)Function at 12 mo; surgical outcomes median 110 moRecurrent curvature 9.2%; residual <20° 13.8%—26.4% dissatisfied with length38.5% in PD; 3.2% in congenital

In the Yafi 2018 prospective nonrandomized comparison (57 men; CCH 18, plication 14, PEG 25; median follow-up 12 months), mean curvature change was 72.0° (92.2%) with plication, 71.8° with PEG and 23.3° with CCH.[21] Surgical options gave greater curvature correction than CCH in this nonrandomized cohort.[21] A separate 2023 randomized trial compared CCH plus RestoreX plus sildenafil with surgery plus RestoreX plus sildenafil (19 completers per arm). At three months, patient-reported erectile function was improved or unchanged in 100% of CCH respondents versus 68% of surgery respondents, and perceived penile length was longer or unchanged in 88% versus 16%; unchanged sensation was reported by 75% versus 11%.[55] Median IIEF-EF change was similar (+1.5 versus +2.5 points; P = .91), and 50% versus 21% were “very satisfied” (P = .08).[55] Secondary objective outcomes favored surgery for median composite-curve improvement (84% versus 54%), while median flaccid coronal-length change was −0.5 versus +1.0 cm and surgery had 50 versus 13 adverse events (events, not patients).[55] Eighteen of 19 surgery patients had plication and one had incision/grafting.[55]

Population-specific outcomes

  • Congenital penile curvature patients consistently have better outcomes than PD patients: less shortening, less de novo ED, lower recurrence.[2][20]
  • Age > 35 yr, PD (acquired) etiology and postoperative complications were independent risk factors for de novo ED in the Falcone series.[2][20]
  • Mean length change in prospective Yafi 2018 plication arm: −1.0 cm.[21]

16-dot technique (Gholami-Lue)​

First described by Gholami and Lue 2002 in 132 consecutive patients (ages 16–79; curvatures 30–120°) as a simplified incisionless alternative to Nesbit and Yachia.[30] The technique uses multiple parallel pairs of non-absorbable sutures placed under minimal tension on the convex tunica, distributing the corrective force across many small plications rather than concentrating it in one or two large excisions.

Technique:

  1. Artificial erection (intracavernosal papaverine / trimix / saline) to localize maximal curvature
  2. Penile exposure in the original series depended on curve direction: ventral longitudinal for dorsal curvature, circumcising or dorsal longitudinal for ventral curvature, and circumcising or lateral longitudinal for lateral curvature.[30] Later Dugi–Morey and Adibi–Morey penoscrotal approaches without degloving have been described.[10][35]
  3. Two parallel rows of 8 dots on the convex tunica opposite maximal curvature; 5 mm spacing within row, 8–10 mm between rows
  4. Place paired 2-0 braided polyester sutures through the full tunical thickness at the marked sites; temporarily clamp the knots, adjust under the maintained pharmacologic erection, and secure all sutures at minimal tension.[30]
  5. Reassess curvature during the maintained erection; add a third suture pair (24 dots) for a longer curvature arc when needed.[30]
  6. Check for persistent rigidity from the pharmacologic erection; if present, aspirate cavernosal blood and treat until flaccid before closing Buck’s fascia and skin.[30]

Outcomes:

SeriesnEtiologyFollow-upStraighteningRecurrenceDe novo EDSuture issues
Gholami-Lue 2002 (original)[30]132 operated; 124 contacted116 PD, 16 CPCStraightness at 6 mo; recurrence at mean 2.6 yr93% reported straight / 7% acceptable at 6 mo15% reported recurrence4 reported worsened EFPalpable bumps expected
Çayan 2019[2]202CPC + PDlong-term87.6% complete—Significantly lower than Nesbit (p = 0.016)Significantly higher than Nesbit (p = 0.001)
Cantoro 2014[32]89PDmean 103 mo91% complete—Not reported; 88.7% had postoperative IIEF-5 > 21Suture issues not reported; 8.9% had transient glans-sensitivity loss
Salem 2018 (buried-knot)[31]18 operated; 15 followed8 CPC, 7 PD among those followed3 and 6 mo; later 1–2 yr15/15 straight at 6 mo2/15 slight recurrence (<20°) by 1–2 yr2/15 reported worsened EFNo knot complaints reported among followed patients

Advantages. Shorter operative time than modified Nesbit in one comparative series (mean 48 versus 63 min, p = 0.001); lower de novo ED and sensory-loss rates than Nesbit in that series; may avoid formal NVB mobilization for dorsal curvature, but the original series describes intervascular dissection for ventral curvature and magnified NVB dissection in some lateral cases; intraoperatively adjustable; useful as salvage after failed Nesbit (12 of the original 132 patients).[2][30]

Disadvantages. Suture-related problems are the main drawback: 50–88% of patients can notice the sutures and 10–33% report discomfort.[33][34] Suture-related complications were more frequent than with Nesbit in the Çayan series.[2] Recurrence was 15% at a mean of 2.6 years in the original series.[30]

Modifications addressing suture morbidity:

  • Salem 2018 buried-knot modification (n = 18). Knots tucked into plicated tunical tissue; among 15 followed patients, none reported knot complications or bother, and all had straight erections at three and six months.[31]
  • Papagiannopoulos / Levine 2017 hybrid. Fewer permanent sutures supplemented by absorbable; 4.9% of 81 survey respondents reported bothersome nodules at mean 56.3-month survey follow-up; 4/142 operated patients (2.8%) underwent repeat intervention.[33]
  • Suture-material optimization (van der Horst 2003). PTFE (Gore-Tex) was significantly better tolerated than polypropylene (50% versus 88% noticed sutures; 10% versus 40% discomfort).[34]

Iterative 8-dot technique (Demzik / Figler)​

Demzik / Ehlers / Brems / Figler 2022. Minimally invasive variant developed to address the two main 16-dot limitations: permanent-suture morbidity, and the need for systematic incremental correction in complex deformities.[6]

Innovations:

  • Absorbable sutures. Rationale: by the time the suture dissolves, sufficient fibrosis has formed at the plication site to maintain correction
  • Iterative stepwise placement. Single 8-dot plication suture placed; repeat artificial erection; additional sutures added one at a time as needed (median 3 sutures, range 1–12), allowing precise incremental correction without overcorrection[6]
  • Minimally invasive ventral incision in 64%; avoids degloving[6]

Technique:

  1. Papaverine erection and curvature assessment
  2. 2 cm ventral penoscrotal incision (or circumcising); distal mobilization without degloving
  3. Single 8-dot plication suture on the convex side using absorbable suture (figure-of-eight or mattress configuration)
  4. Repeat erection; assess correction
  5. Additional 8-dot sutures placed iteratively until straight
  6. Confirmatory final erection

Outcomes (n = 66; median age 58; curvature 20–90°):[6]

  • Intraoperative complete straightening: 97%.[6] The 2 failures were due to inability to maintain intraoperative erection
  • 91% straight erections at mean 4.5-mo follow-up[6]
  • 55% had complex deformities (biplanar 38%; curvature >60° in 50%; both 11%) and 14% had a hinge effect. At mean 4.5-month follow-up, 91% overall reported straight erections; no hinge-case intraoperative failure or recurrence was observed.[6]
  • Minor complications 6% (superficial dehiscence, hematoma); no major complications[6]
  • No revision plications; no patients proceeded to penile implant
  • Median 3 sutures (range 1–12)

Penoscrotal plication without degloving (Adibi-Morey lineage)​

An evolution applicable to both 16-dot and 8-dot techniques and used in the Morey-group series. Adibi 2012 reported the no-degloving approach for complex deformities. In the Hudak 2013 patient-reported outcomes (n = 154 treated, 132 responders), 96% reported curvature improvement, 93% reported erections adequate for intercourse and 95% considered their condition improved.[36] Stretched penile length showed no measurable decrease in 84%.[35][36] For complex deformities (≥ 60° or biplanar), correction averaged 5–6° per suture, with SPL unchanged in 69% and increased in 16%.[35]

Suture debate — absorbable vs non-absorbable​

This is one of the most debated issues in plication surgery:

ApproachAdvantageDisadvantage
Non-absorbable (Ethibond / Gore-Tex / Prolene)Permanent mechanical support; an EAU-endorsed option alongside slowly absorbed polydioxanone[52]Among 55/88 followed patients with PD or congenital curvature, 50% noticed PTFE sutures versus 88% polypropylene; discomfort was 10% versus 40% at mean 30 months[34]
Early-absorbing polyglactin (Vicryl)No palpable knots or granulomas were reported among 103/114 questionnaire completers at 41.5-month median follow-up in Hsieh’s congenital-curvature series.[13]Suture failure occurred in 32/114 (28%) at median 38.5 days, with higher risk below age 24; EAU cautions against early-absorbing sutures for PD repair.[13][52]
Slowly absorbed polydioxanone (PDS)EAU lists it as an alternative to nonabsorbable sutures for PD repair.[52]Hsieh’s polyglactin series did not test PDS or establish PDS-specific failure or knot rates.[13]
Hybrid (Papagiannopoulos / Levine)In 81/142 survey respondents at mean 56.3 months, 4.9% reported bothersome nodules; the authors described curvature correction as durableRequires meticulous technique[33]
Iterative 8-dot (Figler)Fully absorbable + iterative placement; 91% reported straight erections at mean 4.5-month follow-upLong-term durability not yet established[6]

EAU 2026 advises non-absorbable sutures with buried knots, or slowly absorbed sutures such as polydioxanone, because early-absorbing sutures (for example Vicryl) lose strength before fibrosis reinforces the repair and are linked to recurrent curvature.[52]

EAU 2026 positions. For Peyronie's disease it suggests tunical shortening as the first option when length and rigidity are adequate, curvature is not severe and no hourglass or hinge deformity is present , and states that no shortening technique has proven superior.[52] The ICSM 2024 consensus cautions that tunical excision followed by plication may have a higher complication rate .[58] Its pooled series report straightening of 88.5% (Nesbit), 95.5% (Yachia), 96.9% (16-dot) and 94.2% (simple plication), any shortening in roughly 22% to 69% and de novo ED of about 3% to 10%.[52] For congenital curvature it recommends the Nesbit or Yachia procedure or plication, with or without neurovascular bundle dissection , deferring surgery until after puberty because penile growth is incomplete; extratunical grafting corrects hourglass or hinge deformity with a lower ED risk than grafting the tunica.[52] First reported by Reed-Maldonado, Alwaal and Lue as an alternative to plaque incision or excision specifically for bothersome indentation or hourglass deformity, extratunical grafting places graft material outside the tunica albuginea at the site of indentation, often combined with plication for milder concurrent curvature, avoiding both neurovascular bundle mobilization and a tunical incision, the proposed mechanism for its lower sensory-change and ED risk versus tunical grafting. In the original series (36 patients, 18 with at least 6 months of follow-up, one excluded from analysis), all 17 evaluable patients reported satisfactory resolution of the deformity, 16 of 17 were very satisfied or satisfied, and 2 of 17 (11.8%) reported slight penile hypoesthesia.[53] This is a relatively new technique with limited long-term follow-up; open questions include the ideal graft material and whether the graft should sit above or below Buck's fascia.[53]

Plication approach comparison​

Feature16-dot (Gholami-Lue)Iterative 8-dot (Figler)Penoscrotal (Dugi-Morey)
Tunical excision/incisionNoneNoneNone
SutureNon-absorbableAbsorbableNon-absorbable
IncisionOriginal: ventral longitudinal for dorsal curvature; circumcising or longitudinal for ventral/lateral curvature; later penoscrotal variants[30][10]Ventral minimally invasive in 64%[6]Penoscrotal without degloving[10]
Iterative assessmentAfter all suturesAfter each sutureAfter all sutures
Complex deformitiesCurvature up to 120° in original mixed cohort[30]55% complex in PD cohort[6]Biplanar or ≥60° in complex subgroup[35]
Straightening rate87.6% complete in a mixed cohort; 93% reported straight at 6 mo in a separate mixed cohort[2][30]97% completely straight intraoperatively; 91% reported straight at mean 4.5 mo[6]45/48 (93%) single-procedure success; 7/340 (2%) underwent repeat plication for insufficient straightening[10][50]
Palpable knotsPalpable bumps described; 12% of 124 patients assessed at long-term follow-up (mean 2.6 yr) reported bother from knots[30]—Nonabsorbable sutures used[10]
De novo EDNot separately measured; 4/132 (3%) reported worse EF at 6 mo and 8/124 (6%) at mean 2.6 yr[30]——
Recurrence15% of 124 reported recurrence at mean 2.6 yr[30]Recurrence not quantified at mean 4.5 mo; no revisions[6]7/340 (2%) procedural failures in review; recurrence not separately quantified[50]
SPL changeShortening expectedNot specifically reportedIn complex subgroup: unchanged in 29 (69%), increased in 7 (16%)[35]

Yachia technique (Heineke-Mikulicz corporoplasty)​

First described by Daniel Yachia in 1990 as a simpler alternative to the classic Nesbit. Applies the Heineke-Mikulicz pyloroplasty principle to the tunica: a longitudinal incision on the convex side is closed transversely, achieving the same shortening effect without removing any tunical tissue.[22]

Advantages over classic Nesbit:

  • No tunical tissue excision. A full-thickness tunical incision is closed transversely.[22][52]
  • Reduced NVB and corpus spongiosum manipulation. The longitudinal incision is placed at a distance from these structures, which need not be mobilized
  • Less risk of injury to underlying erectile tissue
  • Adaptable. Number and length of incisions can be tailored to curvature severity

Technique:

  1. Artificial erection (saline and tourniquet or intracavernosal vasoactive)
  2. Penile exposure: degloving or non-degloving (Dell'Atti 2019 comparison: WDG 48 min versus DG 66 min, p < 0.05; equivalent functional outcomes)[27]
  3. One or more longitudinal full-thickness incisions through the tunica on the convex side, opposite maximal curvature, at a safe distance from the NVB / spongiosum
  4. Transverse (horizontal) closure of each incision with nonabsorbable or slowly absorbed suture such as polydioxanone (Heineke–Mikulicz principle); avoid early-absorbing Vicryl because of recurrent-curvature risk.[52]
  5. Repeat artificial erection to confirm straightening; add incisions if residual curvature persists
  6. Buck's fascia and skin closed in standard fashion

Angermeier's technique preferences. Angermeier (a co-author of the Daitch 1999 series above) described a single longitudinal incision with each planned corporotomy site exposed by elevating Buck's fascia, marked by applying and adjusting Allis clamps during artificial erection before incising between the clamp marks; his preferred closure was a buried interrupted 3-0 Prolene stitch at the incision's midpoint followed by a running 3-0 PDS line, with artificial erection repeated to confirm correction.[54]

Giammusso modification for ventral curvature. Yachia plasty is performed in the bed of the deep dorsal vein after it is ligated and resected. In their initial 12-patient report, the authors described the technique as avoiding dorsal NVB manipulation while bringing the tunical edges together.[25][26] Bagnara 2021 Giammusso-modification series (206 operated for congenital ventral curvature; 198 followed): 189/198 (95%) were completely satisfied, 4/198 (2%) reported recurrence, and 6/198 (3%) reported penile shortening.[26]

Outcomes table:

SeriesnEtiologyFollow-upStraighteningSatisfactionShorteningDe novo ED
Yachia 1990[22]10PD + CPC—All successful———
Sassine 1994[23]5532 CPC, 23 PDup to 10 yr95%———
Daitch 1999[24]28 (19 surveyed long term)19 PD, 9 CPCmean 24.1 mo in 19 respondents25/28 (89%) excellent / 2/28 (7%) good15/19 (79%) satisfied11/19 (58%) noticed some1/28 (4%) early detumescence
Giammusso 2004[25]12Ventral CPC + PD—100%83%67% (1–2.5 cm)11/12 (92%) reported no erectile-function change; de novo ED not specified
Nyirády 2008 (HM in 62 of 87; overall series)[28]87 telephone respondents (of 116 operated)CPCmean 89 mo93.1% (one operation, all techniques)Reported as better with HM than plication17% (15/87)0/87 respondents complained of de novo ED
Dell'Atti 2019[27]64CPC + PDmean 20.8 mo100% functional100%9–10%—
Bagnara 2021[26]206 operated; 198 followedCongenital ventral curvature onlyAssessed through 24 mo and annually—189/198 (95%) satisfied6/198 (3%) reported shortening1/198 (0.5%) reported ED at 5 yr, without organic dysfunction on examination

Popken's modified corporoplasty versus Nesbit-Kelâmi (retrospective, unrandomized, n = 105 congenital curvature). Popken closed the tunical edges with a continuous intratunical suture and buried knots, which differs from Yachia's transverse closure of a longitudinal incision.[29]

MetricPopken modified corporoplastyNesbit-Kelâmi
Postoperative hematoma6%18%
Late palpable indurations16%44%

In Nyirády 2008, 87 of 116 patients operated over a 20-year period completed a retrospective telephone survey at mean follow-up of 89 months (Heineke-Mikulicz 62, Nesbit 18, plication 7); recurrence was less common with the Heineke-Mikulicz technique, and the authors report it as significantly better than plication.[28] The plication group was small.

Tunica albuginea plication (TAP — Levine algorithm)​

TAP in the literature is used in two overlapping ways: as a generic term for any suture-based plication of the tunica albuginea without excision (encompassing Essed-Schröder, Lue 16-dot, and modifications), and as the specific technique refined by Laurence Levine beginning in 1997, which forms the tunical-shortening arm of the Levine surgical algorithm alongside plaque excision and grafting (PEG) and IPP. Levine's TAP series carries the longest follow-up in the PD plication literature (up to 147 months).[37][38][40]

The Levine surgical algorithm (1997 to 2013 update):[37][38]

Curvature / StatusProcedure
Curvature < 60°, no hourglass / hinge, adequate rigidityTAP (preferred)
Curvature ≥ 60° or significant hourglass / hinge, adequate rigidityPEG (plaque excision + grafting)
Inadequate rigidity unresponsive to pharmacotherapyPenile prosthesis

The 2013 update extended the TAP threshold to < 60–70° in selected cases when length is acceptable.[38]

Technique:

  1. Preoperative duplex ultrasound and ICI (trimix); SPL measured pubis-to-corona
  2. Intraoperative artificial erection to localize maximal curvature
  3. Incision choice. Historically circumcising or subcoronal with degloving; Seyer 2025, a retrospective single-surgeon series of 189 penile-straightening operations (125 TAP and 64 plaque-grafting procedures), compared ventral penile-raphe with subcoronal incisions. Within 3 months, wound complications occurred in 9/94 (9.6%) ventral versus 3/95 (3.2%) subcoronal cases (p = 0.081); the authors conclude that both can be considered[39]
  4. Identify the convex side opposite maximal curvature (ventral / ventrolateral for dorsal curve; dorsal for ventral curve, avoiding NVB)
  5. Parallel rows of horizontal mattress plication sutures through partial-thickness tunica, mean 3 plications (range 1–6) per patient[41]
  6. Suture-material evolution (Levine 2007 to 2017 update). Originally non-absorbable braided (Ethibond, Gore-Tex); Papagiannopoulos / Levine 2017 modification limits permanent sutures. In 81 surveyed men (of 142) at a mean of 56 months, 19.8% reported nodularity (historical 50–88%), 4.9% reported bothersome nodules and 2.8% of the 142 underwent repeat intervention[33]
  7. Repeat artificial erection; residual curvature ≤ 15° accepted

Long-term TAP-vs-PEG outcomes (Taylor & Levine 2008, n = 142, chart review plus survey; mean follow-up TAP 72 mo, range 8–147 / PEG 58 mo, range 6–185):[40]

OutcomeTAP (n = 61)PEG (n = 81)
Curvature < 30° at follow-up (patient-reported)93%91%
Rigidity as good or better than preop81%68%
Rigidity adequate for coitus (± PDE5i)90%79%
Mean SPL change+0.6 cm (range −3.5 to +3.5)+0.2 cm (range −1.5 to +2.0)
Sensation as good or better than preop69%69%
Able to achieve orgasm98%90%
Very satisfied / satisfied82%75%

The TAP group had an objective mean +0.6 cm change in flaccid stretched penile length after correction.[40]

Greenfield-Lucas-Levine 2006 length-loss predictors (n = 102; 68 PD / 34 CPC):[41]

  • Mean length loss: 0.36 ± 0.5 cm (only 2.4% of preop length)[41]
  • Factors associated with greater shortening: ventral / ventrolateral curvature direction (p = 0.04), greater preoperative curvature, shorter preoperative SPL
  • Not significant: age, number of plications, plaque size, hinge / narrowing
  • Outcomes were similar between PD and CPC; 99% achieved acceptable straightness (residual curve < 20°) at mean follow-up of 29 months[41]

Algorithm outcomes (Papagiannopoulos & Levine 2015, single-institution retrospective review, 390 reported overall; abstract lists 114 TAP / 159 PEG / 114 IPP, which sum to 387; mean FU 17 mo):[42]

  • No significant difference across the three groups in satisfaction with rigidity, bothersome residual curve, or ability to engage in intercourse
  • Among men assessed postoperatively, 88.4% were able to engage in penetrative intercourse; 84.9% were satisfied with curvature correction, and 70% were satisfied with rigidity[42]
  • The groups were assigned by disease severity and were not randomized

TAP for CPC with worsening deformity (Ziegelmann / Farrell / Levine 2020, retrospective, n = 60; 21 CPC-WC and 39 CPC-only):[43]

  • Mean curvature was 62° (SD 23); CPC-WC patients were older than CPC-only patients (median 34 vs 24 yr) and more likely to have a discrete palpable tunical scar and diminished penile elasticity on examination[43]
  • Satisfactory straightening: 93% overall (90% CPC-only, 100% CPC-WC)[43]

PEG for acute angulation versus PEG plus supplemental TAP for compound curvature (Chow / Sidelsky / Levine 2018, n = 240; 79 PEG alone, 161 PEG plus supplemental TAP):[44]

In this retrospective series, men with compound curvature had an average residual curvature of 30° (range 20–50°) after PEG, requiring 1–6 supplemental TAPs to reach functional straightness (<20°). At an average follow-up of 61 months, recurrent curvature (11.4% vs 12.4%; p = 0.33), penile length change (+0.57 vs +0.36 cm; p = 0.27) and decreased penile sensation (6% vs 13%; p = 0.12) did not differ significantly between PEG alone and PEG plus TAP, respectively.[44]

TAP for indentation deformity. In a retrospective series of 35 men (Roadman / Levine 2024), extra-tunical grafting with TAP gave persistent correction on examination in 89.6% at a median of 23.5 months. The graft was palpable in 74.3% in the flaccid state and 8.6% when erect. The approach has been described for corporal indentation without hinge.[45]

TAP as IPP adjunct. The AUA states clinicians may perform adjunctive modeling, plication or incision/grafting when significant deformity persists after prosthesis insertion , and found no correlation between surgical complexity and infection or revision rates.[1] Whether to place the plication sutures before or after the cylinders is a technical choice that the guideline does not address: placing them first avoids damaging the device and allows tension adjustment after inflation, whereas plicating after insertion may be unnecessary if modeling alone corrects the curvature.

Severe-curvature application (Li 2022, n = 72). After 16-dot plication, 29/32 (90.6%) patients with curvature > 60° reported complete straightening at one year (versus 36/40 [90.0%] with ≤ 60°), and 32/32 in the severe group reported shortening.[46] In this retrospective series, postoperative IIEF-EF, erectile pain, penile sensitivity and suture-knot outcomes did not differ significantly between patients whose deformity had been stable for ≥ 3 mo versus < 3 mo at 1-year follow-up.[46]

Distinguishing features of TAP versus other plication techniques:

FeatureTAP (Levine)16-dot (Gholami-Lue)Classic NesbitYachia
Tunical excisionNoNoYes (wedges)No
Tunical incisionNoNoYesYes (longitudinal)
Suture (modern)Hybrid (Papagiannopoulos / Levine)Non-absorbableNon-absorbableNon-absorbable
Mean plications3 (1–6)2 suture pairs (16 dots); 3 pairs for 24-dot repair[30]1–3 wedges1–3 incisions
Mean SPL change+0.6 cm (objective)Mean not reported in the original 16-dot series[30]−0.36 to −1.5 cm−1 to −2.5 cm
Straightening93% reported <30° at survey (61 PD; mean 72 mo)[40]87.6% complete (202 with PD or CPC)[2]86.3% complete (218 PD; median 89 mo)[18]25/28 (89%) excellent (19 PD, 9 CPC)[24]
Bother from nodules or suture knots (different endpoints)4.9% bothersome nodules among 81 hybrid-TAP survey respondents[33]12% bothered by suture knots in the original 16-dot series[30]——
Long-term FUUp to 147 moUp to 103 moUp to 89 moUp to 89 mo

Essed-Schröder technique​

A classical plication variant using monofilament non-absorbable sutures (PTFE or polypropylene) on the convex tunica without excision.[34]

Outcomes (van der Horst 2003; 55 of 88 patients evaluable, including 30 with Peyronie disease and 25 with congenital curvature; mean follow-up 30 months):[34]

  • Suture awareness in the mixed Peyronie/congenital cohort: 15/30 (50%) with PTFE and 22/25 (88%) with polypropylene[34]
  • Suture discomfort in the mixed Peyronie/congenital cohort: 3/30 (10%) with PTFE and 10/25 (40%) with polypropylene[34]
  • 3 patients had recurrent deviation (2 polypropylene, 1 PTFE)

Multiple Parallel Plication (MPP)​

Non-incisional technique using multiple deep plication sutures at the point of maximal curvature, without any tunical incision or removal.[9]

Leonardo comparison versus Nesbit (congenital curvature; 31 of 62 patients re-evaluated; 19 plication, 12 Nesbit; mean follow-up 38 and 40 months):[9]

  • Recurrent curvature requiring surgical correction occurred 1–3 months after plication in 3/19 (15.8%), all with absorbable sutures, versus 0/12 after Nesbit (p = 0.15); no recurrence was reported with nonabsorbable plication sutures[9]
  • Minimal persistent deviation was reported in 6 plication patients (31%) versus 6 Nesbit patients (50%; p = 0.29)[9]
  • Minimal glans and prepuce hyposensitivity was reported in 7 plication patients (38%) versus 9 Nesbit patients (75%; p = 0.03)[9]
  • Shortening (73.5% vs 100%), palpable knots (100% in both) and satisfaction (68.5% vs 75%) are also reported for this comparison

Morey penoscrotal plication (PSP) — UT Southwestern lineage​

The Morey penoscrotal plication is a minimally invasive, suture-only tunical plication performed through an approximately 2 cm longitudinal penoscrotal incision without penile degloving, developed by Allen F. Morey and colleagues at UT Southwestern. The Morey group reports it for all curvature directions and severities, including complex biplanar and severe (≥ 60°) deformities, and it accommodates synchronous IPP placement.[10][35][36]

Core philosophy:

  1. Uniform ventral approach. Single ventral incision corrects dorsal, ventral, lateral, and biplanar curvatures
  2. No degloving. Avoids circumferential dissection; lower edema, sensory loss, wound morbidity and operative time are proposed advantages of the technique.[50] A 2025 retrospective cohort of plication and grafting found wound events in 9/94 ventral-incision versus 3/95 subcoronal-incision cases (P = .081).[39]
  3. No tunical incision or excision. Pure suture-based plication
  4. Broad indications. Selected severe and biplanar cases have been treated with penoscrotal plication; in one retrospective series, only 102/327 (31%) completed the long-term survey, and between-severity differences in patient-reported outcomes were not detected.[51]

Technique:

  1. Intracavernosal alprostadil 20 mcg prior to drape (induces artificial erection); second 20 mcg dose if inadequate[50]
  2. 14F Foley catheter for dorsal deformities; aids urethral identification
  3. 2–3 cm longitudinal incision along proximal / mid-shaft penoscrotal junction
  4. Dissection through dartos and Buck's fascia with Senn retractors; no circumscribing incision or degloving
  5. Tissue retracted distally / laterally as needed to access the convex tunica
  6. For dorsal plication (ventral curvature): Buck's fascia retracted to access dorsal tunica with minimal NVB displacement; no formal mobilization required
  7. Short plication sutures spanning 15–20 mm, each approximately 5–6° correction per suture
  8. 2-0 Ethibond braided non-absorbable in inverted mattress pattern ("near to far, far to near"); 4 knots per suture
  9. Reassess after each suture; add until straight (range 4–17 sutures)
  10. Three-layer closure: Buck's fascia (3-0 Monocryl), dartos (3-0 Monocryl), skin (4-0 Monocryl subcuticular and Dermabond)

Morey-group outcomes:

SeriesnKey finding
Dugi & Morey 2010 (origin)[10]48Median correction 28°; median 6 sutures; SPL unchanged; 93% (45/48) single-procedure success
Adibi-Hudak-Morey 2012 complex[35]102 (43 complex)Biplanar (n=11): primary 45° → 10°, secondary 35° → 5° (mean 7 sutures, ~5°/suture). Severe ≥ 60° (n=32): 70° → 15° (mean 11 sutures, ~6°/suture). SPL categories were reported for 42 of 43 complex patients: unchanged in 29, increased by mean 0.65 cm in 7, and decreased by 0.5 cm in 6
Hudak-Morey 2013 PROs[36]154 treated; 132 surveyed at mean 14 moAmong respondents, 96% reported curvature improvement, 93% adequate-for-intercourse erections, and 95% overall improvement; mean 7 sutures simple vs 10 complex (p < 0.005). Across the series, 84% had no measurable SPL decrease, but 103/132 survey respondents (78%) perceived shortening
Chung-Tausch-Morey 2014 dorsal-vs-ventral-vs-lateral[47]215 (118 with complete data)Among 118 patients with complete data, differences among dorsal (n=17), ventral (n=65), and lateral (n=36) plication were not detected for correction (p=0.33), satisfaction (p=0.64), or objective length loss of 0.3–0.8 cm (p=0.24)
Reddy-McKibben 2018 long-term[51]327 treated; 102 (31%) responded at median 59.5 moSevere (n=51) vs mild/moderate (n=51): curvature correction in 91% overall; curvature improvement reported by 74.5% in each group; similar PD Questionnaire metrics, subjective shortening (62.7%) and IIEF-5. On multivariate analysis, worsening sexual function was associated with age (OR 1.07) and higher preoperative IIEF (OR 1.14)
Chung-Scott-Morey 2014 synchronous IPP + plication[48]18Mean curvature 39° (range 30–60°) corrected to <5° on average (range <5–12°) with a median of 4 sutures; same incision for both procedures
Ly 2023 functional penile length[49]28Intraoperative FPL, before incision → immediately after correction: 11.1 → 12.5 cm (average +12.8%)

Failure-mode analysis from a retrospective review of 340 minimally invasive plications (Morey group, as reported by Cordon 2017):[50]

  • Repeat plication for insufficient straightening: 7/340 (2.1%; 97.9% did not undergo repeat plication); median time to revision 6 months (range 3.4–27.4)[57]
  • All failures had preoperative curvature > 35°
  • In this series, 5 of 7 failures (71%) had a poor intraoperative response to intracavernosal injection; the authors suggested that inadequate rigidity could mask deformity and contribute to under-correction[50]
  • Mean sutures at revision 9 (range 4–11) versus 6 (range 1–8) at initial operation

Perceived versus objective length. In the Hudak series (154 treated; 132 surveyed at mean 14 months), 84% had no measurable SPL decrease, yet 103/132 survey respondents (78%) reported perceived shortening.[36] Ly 2023 measured functional penile length (erect, pubis to glans tip in a straight line, disregarding curvature) intraoperatively before incision and immediately after correction in 28 patients. FPL increased on average by 12.8% ± 6.6% (11.1 to 12.5 cm), which suggests that curvature correction restores usable straight-line length.[49]

Dorsal plication for ventral curvature. Chung 2014 established that the same ventral penoscrotal incision can access the dorsal tunica with minimal NVB displacement, with no formal NVB mobilization required. Among 118/215 patients with complete data, correction and satisfaction differences by plication direction were not detected in this retrospective study; equivalence was not tested.[47]

Synchronous IPP and plication. Both procedures share the same penoscrotal incision; Chung-Scott-Morey 2014 reported 18 patients with mean preop curvature 39° corrected to < 5°; all 15 satisfaction-survey respondents reported improvement at mean 11 months. In the Hudak series, 11 of 154 patients (7%) underwent IPP and plication, and the 10 survey respondents reported improvement similar to plication-alone respondents.[36][48]

Expanded indications challenging the traditional < 60° threshold:

  • Severe deformity (curvature ≥60° or biplanar curvature ≥35°). Reddy 2018 (retrospective, 31% survey response) reported similar long-term patient-reported outcomes to mild or moderate curvature[51]
  • Biplanar curvature. Both planes corrected at about 5° per suture[35]
  • All curvature directions. Same ventral approach[47]
  • Combined with IPP. Same incision[48]
  • Hinge effect. A 66-patient retrospective iterative 8-dot series included hinge deformity in 14%; no hinge-case intraoperative failure or recurrence was observed during mean 4.5-month follow-up.[6] EAU recommends tunical shortening for patients without hourglass or hinge narrowing .[52]

Traditional selection algorithms favor plication when penile length can accommodate shortening and anticipated loss is <20% of erect or stretched length.[38]

Principle. The rationale for a greater number of shorter sutures is to distribute tension, which is intended to give durable correction with less postoperative pain and less penile shortening than a few wide plications.

Kiel Knots plication (Osmonov)​

A modern modification of the 16-dot technique using inverted knot burial and 5-mm dot spacing (versus the traditional 15 mm) with the goal of eliminating palpable suture material.[11][50]

Technique:

  1. Circumcision, degloving, tourniquet at penile base, 60 mL saline intracorporal injection for simulated erection[50]
  2. Dorsal curvature. Buck's fascia dissected bilaterally parallel to the urethra. 8 bilateral dots (16 total) marked 5 mm apart from sulcus coronarius to base
  3. Transverse 5-mm incisions made without cutting into the corpus cavernosum
  4. 4-0 Gore-Tex double-armed suture passed through adjacent incisions
  5. Knots tied inside the incisions (inverted burial)
  6. All sutures placed before final knot tightening (allows tension adjustment)
  7. Ventral curvature. Buck's fascia dissected longitudinally above the NVB; complete NVB mobilization emphasized

Outcomes (20 patients, at least 26-month follow-up; small preliminary series, as summarized by Cordon 2017):[50]

  • Mean operative time: 64 minutes
  • Mild recurrent penile deviation was reported in 2 of 20 patients (10%) after 24 months; the cohort included 12 acquired and 8 congenital curvatures[11]
  • Moderate ED on IIEF at 1 year: 3/20 (15%); all three had acquired penile deviation and mild ED on preoperative Doppler[11]
  • Cosmetic satisfaction: 18/20 (90%) in the mixed congenital/acquired cohort[11]
  • Shortening: reported by 7/20 (35%) during the first 6 months; measured erect-length loss of 0.5–1 cm in 6/20 (30%) after 26 months[11]
  • No bothersome suture-knot sensations were reported

Technical Pearls​

Incision choice — four options​

Incision choice affects morbidity, recovery and prepuce preservation.[3]

ApproachBest forKey consideration
Circumcision + deglovingClassical exposure; complex or multiplanar deformityRequires circumcision; widest exposure
Ventral raphe incisionLateral or ventral curvatureAvoids circumferential skin disruption; corpus spongiosum visible during dissection
Dorsal base incision + penile inversionLong gradual curvature requiring many dots; prepuce preservationInverts the penis to access the convex tunica without circumcising, for uncircumcised patients who decline circumcision
Penoscrotal (Dugi-Morey)Minimally invasive approach; experienced hands2–3 cm incision; no degloving; 7/340 (2.1%) underwent repeat plication for insufficient straightening in a Morey-group review[50]

The dorsal penile inversion via dorsal base incision allows correction of long gradual curvatures requiring up to 24 dots while sparing the prepuce, as an alternative to circumcision and degloving for uncircumcised patients.

Suture choice​

Nonabsorbable suture is the traditional choice, and early recurrence after plication has been attributed to suture failure. Specific materials:

MaterialTypePalpable-knot rateNotes
Ethibond 2-0Braided polyester, nonabsorbable—Used in the Dugi-Morey technique[50]
TicronBraided polyester, nonabsorbableModerateAlternative to Ethibond
4-0 Gore-Tex (PTFE) double-armedMonofilament, nonabsorbable50% noticed sutures (15/30 with mixed Peyronie/congenital deviation; not knot-specific)[34]Used in Kiel Knots technique with knots buried
Prolene / polypropyleneMonofilament, nonabsorbable88% noticed sutures (22/25 with mixed Peyronie/congenital deviation; not knot-specific)[34]Lower knot security; smooth monofilament increases palpability
Vicryl / PDS (absorbable)Braided or monofilament absorbableVicryl: 1/17 (6%) reported palpable sutures versus 7/18 (39%) with nylon in Basiri; PDS was not tested[12]Used in iterative 8-dot; Hsieh reported polyglactin suture failure in 32/114 (28%) congenital-curvature patients, half with residual or recurrent curvature > 15°[13]

The absorbable-vs-nonabsorbable debate:

  • Basiri RCT (congenital curvature, 35 men completing, follow-up 6–9 months). Similar rates of ≥ 75% correction (88% in both groups); absorbable suture had a lower palpable-knot rate (6% versus 39%, p = 0.04)[12]
  • Hsieh retrospective series of 114 patients with congenital curvature, absorbable suture. Complete straightness in 57% and residual or recurrent curvature ≤ 15° in a further 29% at 6 months; 28% had suture failure (median 38.5 d), of whom only half had curvature > 15°[13]
  • Leonardo comparison: 3 recurrences in 19 plication patients, all with absorbable sutures[9]

Nonabsorbable suture is the usual default, particularly for severe or complex deformity. When avoiding permanent knots, EAU advises a slowly absorbed suture such as polydioxanone rather than early-absorbing Vicryl, which can lose tensile strength before fibrosis supports the repair.[52]

Burying the knot (and why the Kiel Knots matter)​

The single most consistent patient complaint with plication is palpable suture material. Suture awareness and palpability varied by material and endpoint: van der Horst reported noticed sutures in 15/30 (50%) PTFE and 22/25 (88%) polypropylene recipients; Basiri reported palpable sutures in 1/17 (6%) Vicryl and 7/18 (39%) nylon recipients; Leonardo reported three recurrences after absorbable sutures in 19 congenital-curvature plication patients.[34][9][12] The disconnect:

  • Suture awareness after Essed-Schröder plication: 15/30 (50%) with PTFE and 22/25 (88%) with polypropylene in van der Horst’s mixed congenital/Peyronie cohort[34]
  • Suture discomfort after Essed-Schröder plication: 3/30 (10%) with PTFE and 10/25 (40%) with polypropylene in the mixed congenital/Peyronie cohort[34]
  • Bumpy or narrowed areas after Nesbit: 7 of 42 questionnaire respondents (17%)[14]

The Kiel Knots inverted-burial technique specifically addresses this by tying the knots inside small tunical troughs and using 4-0 Gore-Tex. No bothersome knot sensations were reported in 20 patients.[11][50] Running-locked or buried-interrupted closures with any modern suture give partial benefit.

Intraoperative pharmacologic erection is essential​

In the Morey-group review of 340 plications, 5 of the 7 failures had a poor intraoperative response to intracavernosal injection.[50]

Protocol:

  • 20 mcg intracavernosal alprostadil (PGE1) prior to drape (Morey-group protocol)[50]
  • Second 20 mcg dose if erection is inadequate[50]
  • 60 mL saline injection and tourniquet (Kiel protocol) for simulated erection[50]

The artificial erection is used for (1) intraoperative curvature measurement, (2) precise dot marking, and (3) final confirmation of straightening before closure.

Differential suture tension for multiplanar curvature​

For biplanar or compound deformities, plication sutures in both planes can be placed and tied with differential tension, correcting the primary curvature more aggressively and the secondary curvature to a lesser degree. A shodded-clamp technique has been described that holds individual knots at partial tension until the final pattern is confirmed, then all knots are tightened simultaneously.

Plaque thinning / incision adjunct​

In selected severe cases approaching the 60° threshold, thinning or incising the plaque itself on the concave side allows modest lengthening that reduces the amount of convex-side shortening required. This extends plication into territory previously reserved for grafting.

Intraoperative goniometric measurement​

A goniometer is used to objectively document pre- and post-plication curvature. The operative goal is a functionally straight penis rather than a fixed 0° target; <20° residual curvature was accepted in the Levine series, and the ability to have penetrative intercourse remains the clinical endpoint.[41][50][52]

Subjective vs. objective length loss — the Taylor-Levine lesson​

Patients report more shortening than is measured. In the Hudak series, 103 of 132 survey respondents (78%) perceived shortening at mean 14 months, while 84% of 154 treated patients had no measurable SPL decrease.[36] The ranges below combine reported series.

MeasurementRate
Measured stretched-length loss (any)25/154 (16%) in Hudak[36]
Subjective length loss reported by patients21/42 (50%) in Syed’s Nesbit survey at median 84 months[14]; 103/132 (78%) in Hudak’s plication survey at mean 14 months[36]
Reported functional impact of length lossDifficult intercourse in 5/218 (2.3%) after Nesbit for Peyronie disease at median 89 months in Savoca[18]; affected sexual activity in 7% after 16/24-dot plication in Gholami–Lue's mixed congenital/acquired cohort[30]

Counseling practice: measure stretched penile length in clinic before surgery, show the measurement to the patient, and document it. The EAU advises measuring and documenting penile length both before and after straightening because patients may perceive length loss as greater than it is.[52]

Complications​

ComplicationRateNotes
Objective length loss25/154 (16%) in Hudak[36]Greenfield measured mean stretched-length loss of 0.36 cm in 102 TAP patients with Peyronie disease or chordee[41]
Subjective length loss21/42 (50%) in Syed’s Nesbit survey at median 84 months[14]; 103/132 (78%) in Hudak’s plication survey at mean 14 months[36]Hudak found perceived shortening more often than measured stretched-length loss; anchor with preoperative measurement
Functional impact of length loss5/218 (2.3%) reported difficult intercourse after Savoca's Nesbit procedure[18]; 7% reported affected sexual activity after Gholami–Lue's 16/24-dot plication[30]Different patient-reported endpoints in separate series
Suture awareness / contour findingsMaterial- and endpoint-specificBasiri reported palpable sutures in 1/17 Vicryl and 7/18 nylon recipients; van der Horst reported noticed sutures in 15/30 PTFE and 22/25 polypropylene recipients; 7/42 Syed Nesbit survey respondents described bumpy or narrowed areas[14][12][34]
Suture granulomas0.46–3.60% across six plication studies[1]Foreign-body reaction to suture
Sensory change9/42 (21.4%) in Syed’s Nesbit survey; 24/218 (11%) had major glans sensory change in Savoca’s PD-only Nesbit cohort at median 89 months[18]In a separate mixed congenital-curvature and Peyronie cohort, sensory loss was significantly more frequent after modified Nesbit than 16-dot plication; the Nesbit series reported sensory change in 9 of 42 questionnaire responders at a median 84 months[2][14].
De novo / worsened EDCohort- and technique-specificGholami–Lue: in a mixed congenital/Peyronie cohort, 4/132 (3%) reported worse erectile function at six months and 8/124 (6%) at mean 2.6 years after 16/24-dot plication[30]; Taylor: 10% developed postoperative ED after TAP among the 109/218 patients with complete erectile-function data across both surgery groups[7]; Falcone: 38.5% de novo ED in 26 acquired-curvature patients after modified corporoplasty[20]
Recurrent curvature3/19 (15.8%) in LeonardoThree recurrences at 1–3 months in a congenital-curvature plication cohort; all three patients had received absorbable sutures[9]
Hematoma0–10.91% across nine plication studies[1]Reoperation for hematoma: 0–1.38% across five studies
Wound infection0–6.70% across 13 plication studies[1]Reported study range

Recurrence timing pattern​

In Andrews’s selected series of poor outcomes after Nesbit surgery, 31 men had persistent or recurrent deformity >30°; their timing and reasons were:[56]

  • Immediate persistent deformity from surgical error: 3/31 (9.7%)[56]
  • Early recurrent deformity from suture failure: 8/31 (25.8%) in the Andrews Nesbit failure subset[56]
  • In the same Andrews Nesbit failure subset, 20/31 (64.5%) developed deformity after 11 months as Peyronie disease progressed[56]

In Peyronie's disease, recurrence can also reflect ongoing disease activity (Rehman 1997 attributed 7 of 32 recurrences to progression), so counseling covers both technical and disease-related recurrence.[4]

Postoperative Management​

Cordon et al. describe the sildenafil, vacuum-device and next-day catheter practices below for the Kiel Knots technique.[50]

InterventionProtocolRationale
Low-dose PDE5 inhibitorSildenafil 25 mg daily, start 4 weeks postop, continue 3 monthsKiel Knots authors' recommended postoperative adjunct
Vacuum erection device3–5 min daily × 12 weeksKiel Knots authors’ postoperative recommendation[50]
Foley catheterRemoved postoperative day 1Short-term drainage
Abstinence from intercourse4–6 weeksAllow plication scar to consolidate
Return to sexual activity6–8 weeksAfter clinical examination confirms healing

Home modeling is not typically prescribed after isolated plication (unlike after IPP-with-plication, where home modeling is protocol).

No plication-specific VTE recommendation exists in the AUA or EAU guidelines. Plication is a short outpatient or short-stay penile procedure; apply the general risk framework (age, obesity, prior VTE, malignancy, prolonged operation or immobility) on the VTE Prophylaxis page rather than a procedure-specific rule.

Counseling​

  • Expect shortening. Mean measured loss was 0.36 cm after TAP in Greenfield’s mixed Peyronie/chordee cohort, 0.3–0.8 cm after plication without degloving among Chung’s patients with complete follow-up, and 1.0 cm in Yafi’s 14-patient tunical-plication arm.[41][47][21] Reported shortening varied across series: Gholami–Lue reported 0.5–1.5 cm among patients noticing shortening after 16/24-dot plication in a mixed congenital/Peyronie cohort[30]; Giammusso reported 1–2.5 cm in 8/12 after modified Yachia corporoplasty in a mixed congenital/acquired cohort[25]; and Savoca reported 1.5 to >3 cm in 38/218 after Nesbit for Peyronie disease[18] (see technique tables above). Patients consistently perceive more shortening than is objectively measured (see Subjective vs. objective length loss above), so the patient must be prepared for this regardless of the measured result.
  • Return of straight erections is a primary goal; Savoca reported complete correction in 86.3% of 218 Nesbit patients with complete follow-up at median 89 months, while Gholami and Lue reported straight erections at six months in 93% of their 132-patient mixed congenital/Peyronie 16/24-dot plication cohort.[18][30]
  • De novo ED risk exists; among 109 of 218 patients with complete erectile-function data in Taylor’s series, postoperative ED occurred in 10% after plication versus 21% after grafting.[7]
  • Palpable suture knots do not typically require reintervention.
  • Recurrent curvature was reported by 15% after the 16/24-dot technique at mean 2.6 years and by 9.2% of Falcone’s 87 patients with complete data (61 congenital, 26 acquired) after modified corporoplasty at median 110 months.[30][20]

When to Choose Plication vs. Grafting vs. Prosthesis​

ScenarioPreferred operation
Curvature 30–60°, intact EF, adequate lengthPlication (first choice)
Curvature 60–90°, intact EF, length acceptableDiscuss tunical lengthening ; plication is an option in selected patients accepting shortening, based mainly on retrospective severe-curvature series.[51][52]
Curvature >60° with short penis or complex deformityConsider tunical lengthening with grafting to limit further shortening ; length preservation or gain is not assured[52]
Hourglass or hinge narrowing with adequate erectile functionConsider tunical lengthening with grafting ; extra-tunical grafting has been described for indentation[52]
Biplanar curvature without hourglass or hinge narrowing, with adequate length and rigidityConsider plication in selected cases and counsel about shortening[51][52]
PD + ED refractory to medical therapyProsthesis with adjuncts
Primary concern is limiting further shorteningConsider tunical lengthening with counseling that postoperative length gain is not assured[52]
Primary concern is speed / low complexity / low ED riskPlication

See plaque incision / grafting and prosthesis with adjunctive straightening for those pathways.

See Also​

Videos​

16-Dot Technique for Penile Curvature Correction
Dr. Zin Abouelfadel (2022)

References​

1. Nehra A, Alterowitz R, Culkin DJ, et al. Peyronie's disease: AUA guideline. J Urol. 2015;194(3):745–753. doi:10.1016/j.juro.2015.05.098

2. Çayan S, Aşcı R, Efesoy O, et al. Comparison of patient's satisfaction and long-term results of 2 penile plication techniques: lessons learned from 387 patients with penile curvature. Urology. 2019;129:106–112. doi:10.1016/j.urology.2019.02.039

3. García-Gómez B, González-Padilla DA, Alonso-Isa M, Medina-Polo J, Romero-Otero J. Plication techniques in Peyronie's disease: new developments. Int J Impot Res. 2020;32(1):30–36. doi:10.1038/s41443-019-0204-1

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20. Falcone M, Ceruti C, Preto M, et al. Long-term surgical, functional, and patient reported outcomes of a modified corporoplasty: a tertiary referral center experience. J Sex Med. 2020;17(9):1779–1786. doi:10.1016/j.jsxm.2020.06.002

21. Yafi FA, Diao L, DeLay KJ, et al. Multi-institutional prospective analysis of intralesional injection of collagenase clostridium histolyticum, tunical plication, and partial plaque excision and grafting for the management of Peyronie's disease. Urology. 2018;120:138–142. doi:10.1016/j.urology.2018.06.049

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