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Welcome to the Why Urology podcast with Dr. Todd Brandt.

This podcast is my personal attempt to teach you about your genito-urinary tract, what can go wrong, and how your urologist may just become your superhero.

The name of the podcast comes from my ongoing need to answer the question that I get so often from patients, friends, and family, “Why Urology? Why did you choose to become a urologist?”

Mar 28, 2021

In this episode I answer the ten question about Nesbit Plication, as surgery used to treat curvature of the erect penis caused by Peyronie's Disease.

We first discussed Peyronie's Disease in episode 72 of this podcast.

Question #1. Doctor, what is my diagnosis? Can you describe it?

Peyronie’s disease is a scarring process of the penis that creates a classic triad of symptoms: curvature, pain, and palpable deformity on the penis. It can also create erectile dysfunction. 

Its incidence is estimated at around 1 in 10 men.

Peyronie’s disease can affect a man’s penis with severe symptoms of pain or curvature with erection that affects his ability to be sexually active. Most men have mild to moderate symptoms that may hinder, but not prohibit, sexual activity.

Why does the penis bend?  The curvature of the penis is due to the fact that scar tissue does not stretch as well as normal tissue, so with erection that area of the penis does not expand with the blood filling the corpora. The penis is then pulled towards the scar tissue. Most men will have a bend upward.

Peyronie’s disease usually presents as a rather sudden onset of pain and curvature during erection that, like any scar tissue, changes over time.  We usually think about Peyronie’s having two phases, the active and the stable phase

What we call the active phase of Peyronie’s, the sudden onset of symptoms and the changing curve afterwards, may last up to 18 months or more as the scarring continues to change the shape, size, and curve of an erection. The stable phase of Peyronie’s disease is when the scarring has stopped shaping the penis and a man is left with a stable, unchanging deformity that no longer is painful.

Determining the phase of Peyronie’s Disease is critical prior to a surgery. Surgery on the penis to correct its shape or curvature can be considered when a patient has reached the stable phase of erectile dysfunction, when there is a stable curvature--no pain, no progression.

Question #2: What is the procedure you are recommending? Describe the procedure.

The Nesbit plication “tucks” or plicates the tunica albuginea of the penis on the side opposite of the curvature. Think about putting a pleat in a pair of pants or alternatively altering a suit. The surgeon can simply place a suture in the tunica to pull it together, like a pleat or alternatively, the plication procedure can remove a piece of the tunica and sew the edges back together, like fitting a suit.

The plication pulls the penis back to straight equal and opposite to the formed Peyronie’s plaque.

The procedure is done as an outpatient, in the hospital or surgery center, under general or spinal anesthesia. While a patient is asleep the surgeon exposes the tunica albuginea of the penis, creates an artificial erection to expose and measure the curvature, places the appropriate suture to correct the curvature, and then closes and bandages the incision.

The man then wakes up and goes to the recovery area to prepare for going home the same day.

Question #3: What are the goals and benefits and what can I expect to gain from this procedure?

The goal is to create a straight and firm penis for sexual activity. The goal is not a cosmetic result. This is important. Many men are concerned about and how their erection looks, but it’s the function that the surgeon cares about. A man with a small curve of the penis that does not inhibit sexual activity should not be considering this procedure.

Question #4: What are the risks?

 

As with any surgical procedure bleeding, infection, and anesthetic risks exist but there are three unique risks to this procedure that should be discussed: failure to correct the curvature, penile shortening and subsequent erectile dysfunction.

Failure to correct the curvature can happen when the artificial erection created intraoperatively doesn’t simulate the actual erection a man gets during normal sexual activity.  Subsequently, there is potential for over-correction or under-correction of the curvature or failure to identify a secondary curve. Fortunately most all men have a very good result from this procedure.

Erectile Dysfunction can also occur. The tunica albuginea of the penis is the part of the penis that gets firm during an erection. The tunica is responsible for the trapping of the blood. Peyronie’s can affect the ability of the penis to trap blood but so can sutures placed into the tunica result in erectile dysfunction.

Finally let’s discuss penile shortening can occur as well.  The peyronie’s disease limits the stretch to the penis on the one side of the penis. By tucking or plicating the side opposite we have effectively shortened the overall length of the penis. This is a major potential drawback to the procedure. Alternative procedures exist that can maintain length, but are more complicated and carry greater risk.

Question #5: Are there alternative procedures? 

Yes, there are alternatives to a Nesbit plication: Xiaflex injections, traction therapy, excision and grafting techniques, and penile prostheses.

Question #6: Is this a common procedure?

The Nesbit plication is a common  procedure.

Question #7: Why now? Can I wait to have this procedure?

Timing of a Nesbit plication is critical.  There are two phases of Peyronie’s disease. There is an active phase, usually the first 6 months to 2 years of the problem where a man has ongoing curvature and discomfort. The plaque at this time is evolving and even has some ability for the curvature to correct itself. We do not want to operate in this phase. If we correct curvature in the active phase then the penis may develop more deformity after the surgery.

In the second phase of Peyronie’s the scarring is what we call “stable” and there is no further curve or deformity developing within the penis. A man should wait to have surgery until he knows the curve is stable.

Question #8: How do I prepare for this procedure?

There is no special preparation for this procedure. Get preoperative clearance by your primary care physician for the anesthesia. Stop blood thinning medication at an appropriate time before surgery. Follow your surgery center guidelines for NPO status. Get to the surgery center on time. Have plans for your care after and for going home on the same day of your procedure.

Question #9: How do I recover from this procedure? 

Recovery from this procedure takes a full six weeks before you are allowed to be sexually active. This is probably the most important part of this procedure. Resuming sexual activity too early can cause disruption of the suture line resulting in failure of the procedure.

The initial phase of recovery takes a full two weeks. There will be some pain, especially with erection. Swelling and bruising are common and begin to resolve in 7-10 days. Ice packs can help reduce swelling.

You will be able to shower. The incision line needs minimal dressing with antibiotic ointment. There are no dietary restrictions. You will most likely be able to stay on or resume all medication as prior to surgery, including any blood thinners.

Most men can go back to light activity right away, taking care to protect the penis during physical activity, and resume heavier physical activity within a week or two.

Your individual surgeon and postoperative needs will determine your postoperative care.

Question #10: How do I pay for this procedure? Is it covered by insurance?

Most insurance carriers will cover this procedure. Some do not. As with any procedure verify your coverage prior to your operation. Your insurance carrier will want to know the specifics of what the procedure is, who is performing it, where, and on what date.  Insurance companies like to authorize a specific event for surgery, not just a general procedure type.