International Journal of Impotence Research (2000) 12, 299±301
ß 2000 Nature Publishing Group All rights reserved 0955-9930/00 $15.00
www.nature.com/ijir
Saphenous vein harvesting by `stripping' technique and `W'-shaped
patch covering after plaque incision in treatment of Peyronie's
disease
S De Stefani1*, G Savoca1, S Ciampalini1, I Gattuccio1, F Scieri1 and E Belgrano1
1
Department of Urology, University of Trieste, Trieste, Italy
Harvesting of the saphenous vein tract by means of leg stripping is proposed in the treatment of
Peyronie's disease. The technique of W-shaped saphenous vein after plaque incision to correct
severe penile deformity associated with Peyronie's disease is described. Graft material was
obtained from the lower saphenous vein by means of distal `leg short stripping' technique. The size
and number of tunical incisions depended on the size of the plaque. A 15 cm venous segment is
generally suf®cient to cover the defect. The venous segment used was W-shaped, assembled with
6=0 polydioxanone (PDS) uninterrupted sutures and then sutured to the albuginea defect. In our
preliminary series of eight patients, penile shortening and erectile dysfunction is absent. Complete
correction of penile deformity was achieved in seven patients (87.5%). One patient had minimal
residual curvature (<20 ) which did not result in dif®culty with intromission. Saphenous
harvesting by the stripping technique is not an invasive procedure and is quick and simple to
perform. The W-shaped assembling technique is safe because the piece of saphena is kept intact
and may be suited properly to the albuginea defect. International Journal of Impotence Research
(2000) 12, 299±301.
Keywords: penis; Peyronie's disease; vein grafting; stripping
Introduction
Surgical management of Peyronie's disease is indicated when penile bending is very pronounced
and interferes with normal sexual intercourse.
Sometimes a pure aesthetic reason can create
psychological problems and surgery is indicated
also in this situation with the aim of avoiding the
onset of a psychogenic impotence. In case of slight
curvature a modi®ed Nesbit operation1 ± 3 is recommended because of the high probability of success
and low complication percentage. When curvature
is strong or in the presence of an hourglass
deformity, simple straightening of the shaft by
means of tunical plication is not advisable because
of the risk of excessive penile shortening. In these
cases the short side of the penis can be lengthened,
which involves plaque incision or excision and
grafting the defect with vein,4 ± 5 dermis,6 human
dura7 and tunica vaginalis.8 Saphenous vein graft
®rst described by Lue4 seems to give the best
aesthetic results and is burdened with the least
*Correspondence: S De Stefani MD, Clinica Urologica,
UniversitaÁ di Trieste, Ospedale di Cattinara, Strada di Fiume
447, 34149 Trieste, Italy.
Received 25 June 2000; accepted 16 November 2000
shortcomings. We describe a technique of patch
assembling in which saphena is kept intact and may
be suited properly to the albuginea defect. Saphenous harvesting by `short stripping' shortens the
operating time.
Materials and methods
Technique
A circumcision is carried out and the neurovascular
bundle is dissected by means of a centrifugal
approach. The centre of curvature is marked
following an arti®cial erection. The plaque is
identi®ed and incised transversally and the penis
stretched longitudinally in order to obtain a satisfactory penile lengthening and to measure the
albuginea defect. A piece of sterile paper is cut out
and adapted to the albuginea defect. Saphenous vein
is harvested by means of a `short stripping' technique similar to that commonly used in general
surgery. An incision is performed near the ankle
and a distal saphenous stripping is carried out as far
as to the knee by means of a 5th F. Wiruthan1
occlusion catheter (Figure 1). A 15 cm venous
segment is generally easily obtained and it is
Saphenous vein stripping and W-shaped patch in Peyronie's disease
S De Stefani et al
300
Figure 1 Distal short stripping.
Figure 3 The vein graft is sutured to the albuginea defect with its
endothelial side down.
disease underwent incision and venous patch
grafting. In eight of these patients the saphena was
harvested by stripping technique and the patch was
W-shaped.
Pre-operative evaluation included International
Index of Erectile Function (IIEF) questionnaire
(erectile function (EF) domain),9 penile eco-colorDoppler after 10 mcg injection of PGE1, photograph
of the penis during full erection, measurement of the
penile curvature and length. Patients pre-operatively impotent were excluded. Penile curvature
ranged from 62 to 90 (mean 75.2 ) and was dorsal
in the majority of cases (Table 1).
Figure 2 The vein is placed on a sterilised cork tablet and
moulded according to the tunica defect by means of 6=0 PDS
uninterrupted sutures, microsurgically placed.
suf®cient for covering the largest tunical defects.
The vein is then opened longitudinally to its full
extent and kept in saline. With the aid of an
operative microscope the vein is placed on a small
sterilised cork tablet, moulded according to the
piece of paper which was previously prepared and
de®nitively assembled by means of 6=0 PDS uninterrupted sutures (Figure 2). The graft is then
sutured to the albuginea defect with its endothelial
side down (Figure 3). A hydraulic erection is
induced by normal saline to assess the aspect of
curvature correction and the watertightness of the
suture. The penis is then lightly wrapped with a
Lyofoam1 dressing and an 8 F paediatric feeding
tube is placed as vesical catether for 24 h. An
Acrylastic1 bandage is wrapped around the leg until
healing is complete.
Patients
Between January and December 1999, 17 patients
with severe penile curvature due to Peyronie's
International Journal of Impotence Research
Results
Mean operating time was 107 min (range 90 ±
140 min). Mean follow-up was 13 months (range
7 ± 19 months).
Post-operative evaluation included IIEF score,
measurement of penile curvature and length. In
seven patients (87.5%) the penis had been straightened with no narrowing or indentation. One patient
had minimal residual penile curvature (20 ) which
did not result in dif®culty with intromission. None
of the patients complained of penile shortening and
potency was always preserved. Mean EF domain
score was 27.7 (Table 1). All patients had an overall
satisfaction with the aesthetic results.
Discussion
The different success rates of the numerous surgical
techniques for the treatment of penile deformity due
to Peyronie's disease indicate the failure to ®nd an
ideal procedure. Recently, Levine and Lenting10
proposed an algorithm for the surgical treatment of
Peyronie's disease and they underlined the impor-
Saphenous vein stripping and W-shaped patch in Peyronie's disease
S De Stefani et al
301
Table 1 Patient's characteristics and results
Patient
Penile curvature
degree=side
Preoperative
IIEF
Operating time
(mins)
1
2
3
4
5
6
7
8
70 =dorsal
62 =dorsal
65 =dorsolateral
90 =dorsal
90 =dorsal
85 =dorsal
73 =dorsal
67 =dorsal
24
26
24
22
24
22
25
26
135
140
110
95
90
105
95
90
tance of the type and degree of the deformity. They
concluded that simple curvatures with adequate
erectile capacity were candidates for conservative
procedure (tunical plicature and Nesbit's procedure).
On the other hand, they recommended a grafting
procedure for complex, bidimensional curvatures,
hourglass deformity and curvatures greater than 60 .
In fact, when the curvature is greater than 60 the
techniques of tunical plication may cause a penile
shortening which is unacceptable for some patients.
Plaque incision with graft replacement of the
tunica albuginea has enjoyed recent popularity in
patients with a preserved pre-operative potency.
Many autologous materials such as derma, tunica
vaginalis and vein have been used to cover the
albuginea defect with mixed results.5 ± 8 Complications include graft contraction, curvature relapse
and following erectile dysfunction. An additional
problem is that another incision is required to
harvest the graft.
According to Lue and El-Sakka4 and others5
we prefer the saphenous vein graft as a tunical
substitute. The W-shaped moulding saphenous graft
prepared by means of the described technique
prevents problems such as the undersize of the graft.
Clip application as described by Lue and El-Sakka4 for
the patch assembling is probably quicker than surgical
suture but we think that a metallic foreign body could
bother the patient more than a 6=0 absorbable suture
carried out using an operative microscope.
With the aim of avoiding two surgical incisions a
laparoscopic approach was recently proposed.11 We
prefer saphenous harvesting by the `short stripping'
technique because it is a less invasive procedure,
and is quicker and simpler to perform compared to
laparoscopy. In our experience total operating time
was lower than the operating time necessary for
standard Lue's procedure (107 vs 138 min).
Moreover, it should be stressed that, unlike other
vascular and by-pass surgery, saphenous vein graft
doesn't require collateral ligature and an absolute
intimal integrity when it is used for tunica albuginea
closure. In fact, in our series we never noted a
leakage from the graft with arti®cial erection after
completing the anastomosis of the graft to the
albuginea. Nevertheless the tract of the vein harvested by stripping technique was always long
enough for closure.
Follow-up
13
11
15
7
16
14
19
9
months
months
months
months
months
months
months
months
Residual curvature
Postoperative
IIEF
Ð
Ð
Ð
Ð
20
Ð
Ð
Ð
28
28
27
29
27
26
29
28
Conclusion
Plaque incision and venous patch substitution is
indicated in Peyronie's disease patients with a
curvature greater than 60 where potency has been
preserved. Following this procedure complete
straightening of the shaft is achieved in more than
80% of patients and the penile length is not altered.
Saphenous harvesting obtained by means of the
`short stripping' technique is a good, time saving
procedure, it is simple to perform and avoids
another surgical incision. Using 6-0 absorbable
uninterrupted sutures positioned under operative
microscope control is better than metallic clips
which can provoke discomfort and pain during
intercourse.
References
1 Nesbit RM. Congenital curvature of the phallus: report of three
cases with description of corrective operation. J Urol 1965; 93:
230.
2 Pryor JP, Fitzpatrick JM. A new approach to the correction of
penile deformity in Peyronie's disease. J Urol 1979; 122: 622.
3 Ralph DJ, Al-Akraa M, Pryor JP. The Nesbit operation for
Peyronie's disease: 16-year experience. J Urol 1995; 154:
1362 ± 1363.
4 Lue TP, El-Sakka AJ. Venous patch graft for Peyronie's disease.
Part 1: technique. J Urol 1998; 160: 2047 ± 2049.
5 Kadioglu A et al. Surgical treatment of Peyronie's disease with
incision and venous patch technique. Int J Impot Res 1999; 11:
75 ± 81.
6 Devine CJ, Horton CE. Surgical treatment of Peyronie's disease
with dermal graft. J Urol 1974; 111: 44 ± 49.
7 Kelami A. Replacement of tunica albuginea of corpus
cavernosum of penis using human dura. Urology 1975; 6:
464 ± 467.
8 Das S. Peyronie's disease: excision and autografting with
tunica vaginalis. J Urol 1980; 124: 818 ± 819.
9 Rosen RC et al. The International Index of Erectile Function
(IIEF): a multidimensional scale for assessment of erectile
dysfunction. Urology 1997; 49: 822 ± 830.
10 Levine LA, Lenting EL. A surgical algorithm for the treatment
of Peyronie's disease. J Urol 1997; 158: 2149 ± 2152.
11 Breda G. Peyronie's Disease: plaque excision and endoscopically harvested saphenous patch. Personal Communication to
Second Congress of European Society for Male Genital Surgery
(ESMGS), Milan, 25 ± 27 November 1999.
International Journal of Impotence Research