Tunica Plication for Peyronie's Disease
Tunica plication is a shortening procedure that corrects penile curvature by placing sutures, imbrications, or wedge excisions on the convex (longer) side of the penis — opposite the plaque — effectively matching the convex side to the concave side. It is the most commonly performed surgery for Peyronie's disease, representing approximately half of all PD operations, with curvature improvement in ≥90% of appropriately selected patients.[1][2]
Plication is the right operation when curvature is moderate, not complex, and the patient accepts some shortening in exchange for a straightforward, technically low-risk correction with the lowest rate of de novo erectile dysfunction among PD surgeries.
Indications and Patient Selection
Ideal candidates
- Curvature ≤60° (some centers extend to ≥60° with modern variants)
- Adequate penile length — stretched length >13 cm is commonly cited
- Intact erectile function, or ED responsive to oral PDE5i, VED, or ICI
- No significant hourglass deformity or hinge effect
- Patient accepts expected shortening of up to ~20% of pre-op length[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
The classic wedge-excision plication, originally described by Nesbit in 1965 for congenital curvature and applied to PD by Pryor and Fitzpatrick.[4][5]
Technique:
- Degloving or penoscrotal incision to expose the convex side of the tunica
- Elliptical wedge of tunica albuginea excised on the convex side opposite the plaque, typically 5–10 mm wide
- Defect closed horizontally (vs. vertically) with permanent braided suture (Ethibond 2-0 or 3-0) to match the concave-side length
- Closure buried and confirmed by ICI + cycling to straight erection
- Redraping of the penile skin
Modern modifications:
- Tunical shaving — partial-thickness shaving rather than full-thickness wedge excision; minimizes cavernous tissue damage and improves adhesion of plicated tunical layers[4]
- 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]
Outcomes:
- Complete straightening: 89.7% in pooled series[4]
- Modified Nesbit straightening: 93% (vs. 79% standard Nesbit)[5]
- Long-term good-to-excellent outcomes: ~78% at 1–5 years
- Recurrence <10% long-term
Lue 16-dot technique
Non-incisional plication using multiple permanent sutures placed in a 16-point pattern — two rows of four plication bites bilaterally — without any tunical excision.[2]
Technique:
- Penoscrotal or circumferential incision
- ICI-induced erection for intraoperative measurement
- Four plication sutures per side, placed in staggered rows on the convex tunica
- Each plication uses a small "bite" of tunica, knotted and buried
- Test-inflation confirms straightening; add or adjust plications as needed
Outcomes (202 patients, Çayan series):[2]
- Complete penile straightening: 87.6%
- Mean operative time: 48.1 ± 7.5 minutes — significantly shorter than modified Nesbit
- Lower rates of penile sensory loss (P=.001) and de novo ED (P=.016) vs. modified Nesbit
- Higher rate of suture-related complications (palpable knots, granulomas) — P=.001
Iterative 8-dot technique (Demzik / Figler)
Minimally invasive variant using absorbable sutures in an iterative (progressive) pattern, with intraoperative adjustment until straight.[6]
Technique:
- 8-dot plication bites placed iteratively — placed, inflated, assessed, then additional bites added as needed
- Absorbable rather than permanent suture
- Median 3 plication sutures (range 1–12)
Outcomes (66 patients):[6]
- Intraoperative complete straightening: 97%
- Mean preoperative curvature: 45° (range 20–90°)
- 91% straight erections at mean 4.5-month follow-up
- Complex deformities (biplanar, >60°, or both): 55% of patients — notable that these cases were successfully treated
- Minor complications: 6% (superficial dehiscence, hematoma)
- No revision plication or subsequent implant surgery required in the follow-up period
Yachia technique
Vertical tunical incision closed horizontally (Heineke-Mikulicz closure principle), with no tissue excision.
- Applied bilaterally over the convex tunica
- Permanent suture closure
- Particularly useful for lateral curvature
- Outcomes comparable to Nesbit with slightly shorter operative time
Tunica albuginea plication (TAP — Baskin/Duckett → Levine)
Originally described by Baskin and Duckett for congenital curvature and adapted by Levine for Peyronie's. The technique combines partial-thickness incisions in the outer tunical layer (with optional tunical shaving) and plication sutures in vertical mattress fashion between the incisions.[7]
Taylor-Levine 61-patient TAP outcomes:[7]
- Mean objective length loss: 0.36 cm (range 0–2.5 cm)
- 69% of patients reported subjective shortening (mean perceived 1.37 cm)
- Only 18% had objective loss of length — the defining subjective-vs-objective discrepancy
- Ventral curvature associated with more shortening than dorsal (3.6% vs 0.5% of length)
- 82% satisfied or very satisfied
The lesson: patients substantially overestimate postoperative length loss compared with objective measurement — making preoperative stretched length documentation and in-clinic demonstration critical.[7]
Essed-Schröder technique
A classical plication variant using monofilament non-absorbable sutures (PTFE or polypropylene) on the convex tunica without excision.[8]
Outcomes (50 patients):
- 24% improved erectile function; 24% persistent ED; no worsening of ED
- 90% able to resume intercourse; 78% patient satisfaction; 78% partner satisfaction
- 12% required reoperation for recurrent curvature
- Palpable suture knots: 50% (PTFE) to 88% (polypropylene) — the highest rates in the plication literature
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 vs. Nesbit:
- Shortening: 73.5% (MPP) vs 100% (Nesbit), P=.19 (not statistically significant)
- Recurrence: 15.8% (MPP, absorbable suture) vs 0% (Nesbit); 0% (MPP, nonabsorbable)
- Palpable suture knots: 100% (both techniques)
- Patient satisfaction: 68.5% (MPP) vs 75% (Nesbit); none dissatisfied in either group
Dugi-Morey minimally invasive penoscrotal plication
A technique refined by the Morey group that avoids circumcision and degloving entirely, using a 2–3 cm longitudinal penoscrotal incision with braided non-absorbable sutures in a vertical mattress pattern. Published in a 340-case series — the largest contemporary plication series.[10]
Technique:
- Intracavernosal alprostadil 20 mcg prior to drape — induces artificial erection for accurate intraoperative curvature assessment. A second 20 mcg dose can be given if erection is inadequate
- 14F Foley catheter placed for dorsal deformities — aids urethral identification and prevents injury
- 2–3 cm longitudinal incision along proximal/mid shaft penoscrotal junction
- Dissection through dartos and Buck's fascia with Senn retractors
- No circumscribing incision or degloving
- Short plication sutures spanning 15–20 mm; each correcting approximately 5° of curvature
- 2-0 Ethibond braided non-absorbable suture in inverted mattress pattern: "near to far, far to near"
- Four knots per suture
- Reassessment after each suture; add additional sutures as needed — up to 21 sutures in the largest corrections
- Three-layer closure: Buck's fascia (3-0 Monocryl running), dartos (3-0 Monocryl running), skin (4-0 Monocryl subcuticular + Dermabond)
Outcomes (340 cases):[10]
- Success rate: 98% (7 failures)
- Median time to revision in failures: 6 months (range 3–24)
- All failures had preoperative curvature >35° with complex/multiplanar deformity (71%) or severe deformity >60° (43%)
- 71% of failures had poor intraoperative artificial erection — identifying the dominant preventable failure mode
- Mean sutures at revision: 9 (range 4–11) vs. 6 (range 1–8) at initial operation
Key principle: distributing tension across a greater number of shorter sutures leads to more durable correction with less postoperative pain and less penile shortening than a smaller number of wider plications.
Kiel Knots plication (Osmonov)
A modern modification of the 16-dot technique using inverted knot burial and 5-mm dot spacing (vs. the traditional 15 mm) with the goal of eliminating palpable suture material.[11]
Technique:
- Circumcision, degloving, tourniquet at penile base, 60 mL saline intracorporal injection for simulated erection
- 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
- Transverse 5-mm incisions made without cutting into the corpus cavernosum
- 4-0 Gore-Tex double-armed suture passed through adjacent incisions
- Knots tied inside the incisions (inverted burial)
- All sutures placed before final knot tightening (allows tension adjustment)
- Ventral curvature: Buck's fascia dissected longitudinally above the NVB; complete NVB mobilization emphasized
Outcomes (20 patients, 26-month follow-up):[11]
- Mean operative time: 64 minutes
- No recurrence at 8 months; 10% mild recurrence at 24 months
- Moderate ED at 1 year: 15%
- Cosmetic satisfaction: 90%
- Shortening: 35% at 6 months → 30% at 26 months (0.5–1 cm range)
- No bothersome sensations from suture knots — the primary technical claim validated
Technical Pearls
Incision choice — four options
The incision selection has meaningful implications for morbidity, recovery, and prepuce preservation.[3][7]
| Approach | Best for | Key consideration |
|---|---|---|
| Circumcision + degloving | Classical exposure; complex or multiplanar deformity | Requires circumcision; longest recovery; widest exposure |
| Ventral raphe incision | Lateral or ventral curvature | Avoids circumferential skin disruption; corpus spongiosum visible during dissection |
| Dorsal base incision + penile inversion | Long gradual curvature requiring many dots; prepuce preservation | Inverts the penis to access the convex tunica without circumcising — important for uncircumcised patients who decline circumcision |
| Penoscrotal (Dugi-Morey) | Minimally invasive approach; experienced hands | 2–3 cm incision; no degloving; 98% success in 340 cases[10] |
The dorsal penile inversion via dorsal base incision is particularly important: it allows correction of long gradual curvatures requiring up to 24 dots while sparing the prepuce — the alternative to circumcision + degloving for uncircumcised patients.[7]
Suture choice
Nonabsorbable suture is the traditional choice — durability matters because recurrence is a consequence of suture failure. Specific materials:
| Material | Type | Palpable-knot rate | Notes |
|---|---|---|---|
| Ethibond 2-0 / 3-0 | Braided polyester, nonabsorbable | Moderate | Workhorse; standard for Dugi-Morey technique |
| Ticron | Braided polyester, nonabsorbable | Moderate | Alternative to Ethibond |
| 4-0 Gore-Tex (PTFE) double-armed | Monofilament, nonabsorbable | Moderate (50% with inverted burial[11]) | Used in Kiel Knots technique |
| Prolene / polypropylene | Monofilament, nonabsorbable | High (88% in Essed-Schröder)[8] | Lower knot security; smooth monofilament increases palpability |
| Vicryl / PDS (absorbable) | Braided or monofilament absorbable | Low (6% vs 39% for nylon, Basiri RCT)[12] | Used in iterative 8-dot; 28% acoustic suture-failure rate but only half of those develop recurrence (Hsieh)[13] |
The absorbable-vs-nonabsorbable debate:
- Basiri RCT: equal correction (88% both groups); absorbable had significantly lower palpable-knot rate (6% vs 39%)[12]
- Hsieh 114-patient series with absorbable suture: 86% complete correction at 6 months; 28% of patients "heard a snap or felt the penis pop" (acoustic suture failure); notably, only half of those developed recurrent curvature — the plication scar holds even when the suture fails[13]
- Leonardo MPP comparison: 15.8% recurrence with absorbable; 0% with nonabsorbable[9]
Bottom line: nonabsorbable is the default, particularly for severe curvature or complex deformity. Absorbable is a legitimate option in low-risk cases where palpable-knot avoidance is a priority.
Burying the knot (and why the Kiel Knots matter)
The single most consistent patient complaint with plication is palpable suture material. Reported palpable-knot rates are remarkably high: 50–100% across most series, depending on suture material and burial technique.[8][9][12] The disconnect:
- Palpable rate: 50–100%
- Bothersome rate: 0–40% — most palpable knots do not actually bother patients
- Interference with intercourse: 0–10%[14]
The Kiel Knots inverted-burial technique specifically addresses this by tying the knots inside small tunical troughs and using 4-0 Gore-Tex — reporting no bothersome knot sensations in 20 consecutive patients.[11] Running-locked or buried-interrupted closures with any modern suture achieve partial benefit.
Intraoperative pharmacologic erection is essential
The single strongest predictor of failure in the Dugi-Morey 340-case series was inadequate intraoperative artificial erection — 71% of failures had this feature.[10]
Protocol:
- 20 mcg intracavernosal alprostadil (PGE1) prior to drape
- Second 20 mcg dose if erection inadequate after 10 minutes
- 60 mL saline injection + tourniquet (Kiel protocol) as an alternative when pharmacologic erection is insufficient
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. The shodded-clamp technique holds individual knots at partial tension until the final pattern is confirmed, then all knots are tightened simultaneously.[7]
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 target is complete straightness (0°); <15° residual is generally acceptable. Notably, only ~20% of patients can accurately estimate their own curvature within 5° of objective measurement — objective documentation matters both for operative planning and for postoperative counseling.[7]
Subjective vs. objective length loss — the Taylor-Levine lesson
The defining counseling insight of modern plication practice: patients substantially overestimate their postoperative shortening compared with objective measurement.[7]
| Measurement | Rate |
|---|---|
| Objective length loss (any) | 18–41% |
| Subjective length loss reported by patients | 50–75% |
| Length loss sufficient to affect intercourse | 5–11.9% |
Protective maneuvers: measure stretched penile length in clinic preoperatively; demonstrate it to the patient; document it. Patients with a reference anchor report less postoperative length-loss distress than those without.
Complications
| Complication | Rate | Notes |
|---|---|---|
| Objective length loss | 18–41% | Measured shortening; Taylor-Levine TAP series averaged 0.36 cm[7] |
| Subjective length loss | 50–75% | Patients overestimate vs. objective; anchor with preoperative measurement |
| Length loss affecting intercourse | 5–12% | The clinically meaningful subset |
| Palpable suture knots | 50–100% | Universal; bothersome in only 0–40%; interferes with intercourse in 0–10%[14] |
| Suture granulomas | <5% | Foreign body reaction to permanent suture |
| Sensory change | 6–75% | 6% with 16-dot; 21–75% with Nesbit[2][14] — wide range reflects technique-dependence |
| De novo / worsened ED | 0–6% | 16-dot: 3% at 6 mo, 6% at 6 yr[5]; Essed-Schröder 24% persistent but no worsening[8] |
| Recurrent curvature | 0–20% | Suture-dependent: 0% nonabsorbable MPP, 15.8% absorbable MPP[9] |
| Hematoma | 2–5% | Usually self-limited |
| Infection | <1% | Rare |
Recurrence timing pattern
When recurrence does occur, the timing distribution reveals mechanism:[13]
- Immediate recurrence: 9.6% — typically suture failure (acoustic "snap" / "pop")
- Early recurrence (mean 2.5 months): 25.8% — under-correction or inadequate initial straightening
- Late recurrence (mean 11 months): 64.5% — progressive Peyronie's disease, not surgical failure
The late-recurrence pattern is important for counseling: most late recurrences represent ongoing disease activity rather than technical failure and may require medical therapy or secondary intervention regardless of the initial surgery's quality.
Postoperative Management
Modern plication protocols include adjunctive postoperative therapies aimed at preserving length, maintaining erectile function, and reducing recurrence:[10][11]
| Intervention | Protocol | Rationale |
|---|---|---|
| Low-dose PDE5 inhibitor | Sildenafil 25 mg daily, start 4 weeks postop, continue 3 months | Preserves erectile tissue oxygenation during healing |
| Vacuum erection device | 3–5 min daily × 12 weeks | Gentle traction prevents cicatrix contracture; maintains length |
| Foley catheter | Removed postoperative day 1 | Short-term drainage |
| Abstinence from intercourse | 4–6 weeks | Allow plication scar to consolidate |
| Return to sexual activity | 6–8 weeks | After clinical examination confirms healing |
Home modeling is not typically prescribed after isolated plication (unlike after IPP-with-plication, where home modeling is protocol) — the plication itself has straightened the penis; the goal of postoperative therapy is length preservation and tissue oxygenation rather than further curvature correction.
Counseling
- Expect shortening. 1–2 cm is typical; occasionally more. The patient must be prepared for this.
- Return of straight erections is the primary outcome; 90%+ achieve this.
- De novo ED risk is real but lower than with grafting.
- Palpable suture knots are an inconvenience; they do not typically require reintervention.
- Recurrence is uncommon but possible — usually modest and managed conservatively.
When to Choose Plication vs. Grafting vs. Prosthesis
| Scenario | Preferred operation |
|---|---|
| Curvature 30–60°, intact EF, adequate length | Plication (first choice) |
| Curvature 60–90°, intact EF, length acceptable | Plication (aggressive variant) or grafting |
| Curvature >60° with short penis or complex deformity | Grafting (preserves length) |
| Hourglass, hinge, biplanar curvature | Grafting |
| PD + ED refractory to medical therapy | Prosthesis with adjuncts |
| Primary concern is length preservation | Grafting |
| Primary concern is speed / low complexity / low ED risk | Plication |
See plaque incision / grafting and prosthesis with adjunctive straightening for those pathways.
See Also
- Peyronie's disease — overview
- Plaque incision / excision with grafting
- Prosthesis with adjunctive straightening
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
4. Rehman J, Benet A, Minsky LS, Melman A. Results of surgical treatment for abnormal penile curvature: Peyronie's disease and congenital deviation by modified Nesbit plication (tunical shaving and plication). J Urol. 1997;157(4):1288–91. doi:10.1016/s0022-5347(01)64953-x
5. Licht MR, Lewis RW. Modified Nesbit procedure for the treatment of Peyronie's disease: a comparative outcome analysis. J Urol. 1997;158(2):460–463.
6. Demzik A, Ehlers M, Brems J, Figler BD. Penile plication for Peyronie's disease: the iterative 8-dot technique. Urology. 2022;164:e307. doi:10.1016/j.urology.2022.03.005
7. Taylor FL, Abern MR, Levine LA. Predicting erectile dysfunction following surgical correction of Peyronie's disease without inflatable penile prosthesis placement: vascular assessment and preoperative risk factors. J Sex Med. 2012;9(1):296–301. doi:10.1111/j.1743-6109.2011.02460.x
8. Savoca G, Trombetta C, Ciampalini S, De Stefani S, Buttazzi L, Belgrano E. Long-term results with Nesbit's procedure as treatment of Peyronie's disease. Int J Impot Res. 2000;12(5):289–93. doi:10.1038/sj.ijir.3900590
9. Leonardo C, De Nunzio C, Michetti P, et al. Plication corporoplasty versus Nesbit operation for the correction of congenital penile curvature: a long-term follow-up. Int J Urol. 2012;19(2):168–72. doi:10.1111/j.1442-2042.2011.02904.x
10. Dugi DD 3rd, Morey AF. Penoscrotal plication as a uniform approach to reconstruction of penile curvature. BJU Int. 2010;105(10):1440–4. doi:10.1111/j.1464-410X.2009.08957.x
11. Osmonov DK, Ragheb AM, Zastrow S, et al. Clinical evaluation of a novel minimally invasive surgical technique in the correction of Peyronie's disease: preliminary data. Urol Int. 2013;90(3):323–9. doi:10.1159/000345713
12. Basiri A, Sarhangnejad R, Ghahestani SM, Hosseini Sharifi SH, Ganjehei L, Radfar MH. Comparing absorbable and nonabsorbable sutures in corporeal plication for treatment of congenital penile curvature. Urol J. 2011;8(4):302–6.
13. Hsieh JT, Liu SP, Chen Y, Chang HC, Yu HJ, Chen CH. Correction of congenital penile curvature using modified tunical plication with absorbable sutures: the long-term outcome and patient satisfaction. Eur Urol. 2007;52(1):261–7. doi:10.1016/j.eururo.2006.12.039
14. Syed AH, Abbasi Z, Hargreave TB. Nesbit procedure for disabling Peyronie's curvature: a median follow-up of 84 months. Urology. 2003;61(5):999–1003. doi:10.1016/s0090-4295(02)02549-0