Peyronie’s disease (PD) can exert a detrimental effect on the patient’s sexual and psychological well-being. The etiology and pathogenesis of PD are not fully elucidated, but are likely related to repetitive microtrauma in genetically susceptible men resulting in the formation of fibrotic plaques involving the tunica albuginea (TA) of the corpora cavernosa, which will lead to penile deformities (curvature, shortening and hourglass/indentation deformity).^1,2

Most of the published research on PD focused on curvature, which is the more common deformity. Several treatment options are available to treat penile curvature, including clostridial collagenase injection and surgical procedures such as plication or plaque incision/excision with grafting. Little has been published on managing volume-loss deformities such as hourglass, indentation or distal penile narrowing. Previous standard management for these deformities is surgical intervention in the form of incision and grafting. However, this surgical option carries the inherent risk of erectile dysfunction and sensory changes.³

Ziegelmann et al evaluated clostridial collagenase monotherapy in men with indentation/hourglass (girth discrepancy >10%).⁴ Only 8% (3/40) experienced girth improvement, despite mean curvature improvement of 19 degrees. On the other hand, El-Khatib et al reported mean curvature improvement of 19.2 degrees (39%) in men with indentation/hourglass, and 64% (11/17) reported subjective girth improvement.⁵ Of note, no objective girth measurements were performed.

In 2017, we presented our extra-tunical grafting technique for managing volume-loss deformities (hourglass/indentation).⁶ This technique avoids incising the TA and places the graft on top of the Buck’s fascia without disrupting it, thereby avoiding the neurovascular bundle. We presented a series of 36 patients, with 6–44 months, followup for 18 patients. Patients reported satisfactory girth improvement with preserved erectile function. Two patients reported mild penile hypoesthesia. In our study we demonstrated the use of cadaveric human fascia lata as the graft material.⁶ However, other graft materials can be considered (figs. 1–4).

Figure 1. Extra-tunical grafting technique is suitable for indentation and hourglass deformities.

Figure 2. Wrapping the graft around the TA on top of Buck’s fascia.

Figure 3. The graft is secured lateral to the spongiosa.

Figure 4. Final result is assessed with induced erection.

This technique’s primary benefit is protecting erectile function while providing cosmetic benefit through correcting the volume-loss deformity. Therefore, if the patient has refractory erectile dysfunction he will need penile prosthesis insertion, in which case the technique might still be considered as an adjunct maneuver. The technique can also be performed in conjunction with plication for curvature correction as demonstrated in our paper. Since multiple layers of graft can be sutured to the TA to “repair” the hourglass deformity, this technique can also be used to improve the hinge effect caused by the deformity. We always recommend extensive counseling preoperatively for proper patient selection. It is critical to confirm that the volume-loss deformity is the main concern for the patient and not another issue such as penile shortening. This is to avoid patient dissatisfaction postoperatively. Most recently, Diao et al from the University of Texas Southwestern showed the safety and efficacy of this technique in a retrospective study of 19 patients with median followup of 59 days.⁷

This technique is an important addition to the current armamentarium of different techniques and options to treat PD. If the right patient is chosen, the technique will have satisfactory results.