The success of PD reconstruction is defined by a postoperative penile curvature of less than 20 degrees, erectile function, and the ability to have sexual intercourse.1 However, reduced penile length and pain or discomfort caused by extensive plaque may be further dysfunctional aspects of PD, requiring corresponding surgical strategies. Two possible surgical strategies for penile lengthening in severe PD cases are: 1) partial incision (PIG) or partial excision and grafting (PEG) without PPI implantation or 2) PPI with simultaneous TA incision and grafting. Various grafts have been used to close the tunica albuginea defect following plaque incision or partial plaque excision: autologous grafts, allografts/xenografts (tissue engineering grafts), and synthetic grafts. The graft should be readily available, be resistant to infections, promote hemostasis, be associated with minimal postoperative contracture, and be cost-effective [11]. Most synthetic grafts have been dismissed due to fibrotic tissue reactions, graft contracture, allergic reactions, and a higher risk of infection [3]. Xenografts are preferred because they have better outcomes, lack donor site morbidity, and require less operating time than autografts [11]. The small intestine submucosa currently represents one of the most frequently used xenografts in PD surgery [4]. A technique of plaque excision and grafting with collagen fleece coated with tissue sealant (TachoSil; Mycomed; Konstanz, Germany) has been described [8]. Collagen fleece includes fibrine glue coating, which precludes the need for fixation or suturing and provides a hemostatic effect. Grafting using collagen fleece needs less operating time because fixation is not required. However, more extensive incisional techniques to the tunica albuginea, application of the patch without fixation, and the requirement of mobilization of the NVB for PIG/PEG are surgical aspects that might influence the perioperative and postoperative course of the patients. Here, the question of whether the technique should be reserved for cases with curvatures > 60° arises, given the fact that the usually less invasive plication procedures are recommended in curvatures < 60° by most guidelines.
In our study, we identified a significant association between DM and severe curvature: the number of patients with DM was significantly higher in the severe curvature subgroup > 60°. Both subgroups were however similar regarding age, hospital stay, operative time, early results and complications. Moreover, we discovered no significant differences of operating time or early postoperative complications between the two subgroups of > 60° or < 60° curvatures, indicating that the technique may be applied with the same risk profile, irrespective of the dimension of the deviation.
Using CFG after partial excision in 63 men, Hatzichristodoulou and collaborators reported [8] that 84% had total penile straightening at immediate follow-up in an earlier series. The mean (range) dorsal curvature was 67° (30°‒100°), and the mean (range) operating time was 94 (65‒165) minutes. Overall, 17% of those patients experienced a mild residual curvature of less than ten degrees. This technique’s success has been described in patients with dorsal, dorsolateral, or ventral curvatures [8, 10, 12].
The penile straightening rates of CFG patch grafting studies range from 83–93.7% [8, 10, 13]. Horstmann et al. retrospectively compared 32 patients undergoing plication (Nesbit or Essed‒Schroeder technique) versus 43 patients who underwent CFG. They reported similar perioperative and postoperative complications in both groups. There were no differences in terms of satisfaction rates between the study groups. Overall, 21 patients (66%) with plication and 36 patients (84%) with GFG had a straight or almost straight penis postoperatively. However, patients treated with plication reported better outcomes regarding erectile function, penile length, and sensation. Moreover, approximately 60% of patients said they would choose the same intervention again [10].
Compared to the less invasive character of plication techniques for PD, a decrease in penile sensation (penile hypoesthesia, glans numbness) has been reported in 3–31% of the cases with PD after surgery, which can lead to sexual dysfunction.3 The mobilization of the NVB is considered responsible for this usually transient decreased sensation. Resolution was reported within 12 months after surgery in up to 100% of the cases [4]. In our study, a decrease in penile sensation was observed in 9% of the patients, without any difference between the surgical subgroups.
The incidence of postoperative hematoma, bleeding, and infection remained low overall (2%-4.5%). However, one patient developed postoperative glans necrosis. This complication has never been reported after plication procedures, but after grafting procedures, it has been reported in up to 2.4% of cases [4].
Recently, Falcone et al. compared CFG and porcine small intestine submucosa grafts in patients who underwent plaque incision with grafting and penile prosthesis. After a mean follow-up of 35 months, the groups had no significant differences regarding postoperative outcomes. However, using CFG was associated with significantly shorter mean operating time (128.8 for TachoSil grafting versus 148.8 for SIS, p < 0.0001) and lower costs [14]. The reduced operating time with CFG was associated with a reduced risk of infections [7].
Some limitations of the present study must be considered. The study design was retrospective and thus limited to the available data that is routinely collected. In addition, only early postoperative follow-up was considered. The medium-term and long-term outcomes remain unknown from our study but might reveal substantial subgroup differences of functional outcomes or late complications.