0022-5347/03/1692-0599/0

THE JOURNAL OF UROLOGY

Copyright 2003 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 169, 599 602, February 2003

Printed in U.S.A.

DOI: 10.1097/01.ju.0000046638.36848.a7

CORPOREAL PLICATION FOR THE TREATMENT OF CONGENITAL

PENILE CURVATURE
GARY W. CHIEN

AND

SHERIF R. ABOSEIF

From the Department of Urology, Kaiser Permanente Medical Center, Los Angeles, California

ABSTRACT

Purpose: We evaluated the long-term outcome, effectiveness and patient satisfaction of corporeal plication for the correction of congenital penile curvature.
Materials and Methods: A total of 25 patients with congenital penile curvature were included
in the study. Mean age was 39 years (range 15 to 45). Patients with Peyronies disease, and/or
chordee associated with hypospadias or evidence of erectile dysfunction were excluded from
analysis. All procedures were done on an outpatient basis using local anesthesia. The technique
of corporeal plication consists of placing longitudinal plication sutures of 2-zero braided polyester
on the opposing side of curvature until it is corrected during artificially induced erection. A
standardized questionnaire was then completed via telephone interview to assess results as well
as the patient satisfaction rate.
Results: A total of 22 patients were available for evaluation. Successful results at up to 312
years (range 1 to 42 months, mean 18) of followup were achieved in 21 of the 22 patients (95%).
Success was defined as the correction of curvature and a patient satisfaction rate of 75% or
greater. Curvature was ventral in 20 cases, dorsal in 2 and left lateral in 3. Shortening of the
penis after surgery was noted by 4 patients (18%), of whom 3 nevertheless had a satisfaction rate
of 75% or greater. In 2 patients postoperative hematoma resolved spontaneously. Mean operative
time was 50 minutes and 22 of the 25 patients (88%) received local anesthesia.
Conclusions: Corporeal plication is a simple, minimally invasive surgical procedure that
proved to be effective for congenital curvature of the penis compared with other, more extensive
penile reconstruction surgery.
KEY WORDS: penis; abnormalities; questionnaires; surgical procedures; minimally invasive

As patients present to physicians with an increasing frequency of sexual dysfunction complaints, penile curvature is
increasingly diagnosed. Most penile curvature diagnosed is
acquired, such as that due to Peyronies disease in approximately 1% of men. Curvature is caused by plaques on the
tunica albuginea, which are thought to be the result of local
inflammation and fibrosis from repeat trauma.1
Congenital penile curvature is much more rare, occurring
in approximately 0.4/1,000 men.2 The deformity is caused by
a disproportion of the corpora cavernosa and corpora spongiosum, resulting in dorsal or ventral curvature, or of the 2
corpora cavernosa, resulting in lateral curvature. It is usually only apparent when the penis is erect.3 In some cases
curvature is severe enough to interfere with sexual intercourse.
Many methods of repair have been described for correcting
congenital penile curvature. Most groups achieve penile
straightening by segmental resection of the tunica albuginea.
The goals of surgical treatment are to correct curvature with
the least morbidity and preserve erectile function and penile
length. In this study, we evaluated the long-term outcome,
effectiveness and patient satisfaction of corporeal plication
for correcting congenital penile curvature.
MATERIALS AND METHODS

Of the 25 patients with congenital penile curvature included in our study 22 completed our evaluation. Mean age
was 39 years (range 15 to 45). All patients were evaluated
preoperatively with a history and physical examination. The
chief complaint of these patients was lifelong penile curvature during erection. All patients were asked to present a
Accepted for publication September 27, 2002.

photograph of the curvature. All directions of curvature, including dorsal, lateral and ventral, were recorded in our
study. Patients with evidence of penile plaques palpated
during examination, such as that due to Peyronies disease
and/or chordee associated with hypospadias, were excluded
from study. Other exclusion criteria included pain with erection, evolving curvature, pediatric patients 14 years old or
younger and any evidence of erectile dysfunction. All patients
were evaluated with intracavernous injection of vasoactive
agent in the office to determine the degree of curvature and
erectile function. They were informed of all possible results
of plication surgery, including penile shortening and subcutaneous suture palpation. Postoperative factors evaluated included the type of anesthesia (general endotracheal,
spinal or local) and operative time. The patients were
asked to answer a standardized questionnaire via a telephone interview (see Appendix). We defined success as a
patient satisfaction rate of 75% or greater and the correction of penile curvature.
TECHNIQUE

The patients received intravenous sedation with local penile block or general anesthesia (3). Artificial erection was
induced by intracavernous injection of 10 g. prostaglandin
E1. For ventral curvature a circumferential incision similar
to that of circumcision was made and the penile skin was
degloved (fig. 1). For dorsal curvature a midline ventral penile incision was made. The maximum area of curvature was
assessed by visual inspection. The entry and exit points of the
plication sutures were then marked (fig. 2). Two or 3 longitudinal plication sutures of 2-zero braided polyester were
placed through the full-thickness tunica albuginea on the

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CORPOREAL PLICATION FOR CONGENITAL PENILE CURVATURE

FIG. 1. Penis is degloved, artificial erection is induced, demonstrating ventral penile curvature, and area of plication sutures is
marked.

FIG. 2. Plication sutures are placed without isolating neurovascular bundles.

FIG. 3. Plication sutures are tied, correcting penile curvature

opposite side of curvature. For ventral penile curvature plication sutures were placed on each side of the neurovascular
bundle, avoiding the deep dorsal vein, dorsal arteries and
nerves. The sutures were advanced approximately 1 cm. at
each entry and exit point, avoiding the intervening circumflex veins. The neurovascular bundles were visualized but
not dissected. For dorsal curvature the plication sutures were
placed on each side of the urethra. Curvature was corrected
when the plication sutures were tied in square knots 5 times
(fig. 3). Tension on the sutures was adjusted until the penis
was completely straight on visual inspection. If the penis was
over or under corrected, sutures were loosened or tightened.
The sutures were tied with minimal tension to prevent tissue
strangulation. The penile skin was then approximated with
interrupted 3-zero chromic sutures. At the end of the procedure if the penis was still rigid, a 21 gauge butterfly needle
was inserted into the corpora cavernosum and 5 to 10 cc blood
were aspirated. Epinephrine (500 g.) was injected every 3 to
5 minutes until the penis was completely flaccid. A pressure
dressing was then applied. The patients were discharged
home on the day of surgery.

curvatures were noted in the patients, including ventral in

20, dorsal in 2 and left lateral in 3. All patients had at least
90-degree curvature.
After surgery successful results were achieved in 21 of the
22 patients (95%). Shortening of the penis was noted by 4
men (18%), of whom 3 nevertheless had a satisfaction rate of
75% or greater for penile straightening. Therefore, these
cases were considered successful. A single man in whom
treatment was considered to have failed was dissatisfied due
to penile shortening.
Complications and morbidity were minimal. All patients
were discharged home as outpatients. In 2 cases postoperative hematoma resolved conservatively with compression and
observation. Mean operative time was 50 minutes (range 40
to 65). Of the 25 patients 22 underwent intravenous sedation
with local penile block. The remaining 3 men required general anesthesia. In 1 patient who underwent simultaneous
inguinal hernia repair with penile plication general anesthesia was the best option. The remaining 2 patients who received general anesthesia were the initial 2 in our series.

RESULTS

DISCUSSION

Of the 25 patients in our series 22 were available to complete the telephone interview. Followup was up to 312 years
(range 1 to 42 months, mean 18). Preoperatively various

Penile curvature can result from congenital abnormality or

plaque formation involving the tunica albuginea. Although
these conditions present with penile deformity as the chief

CORPOREAL PLICATION FOR CONGENITAL PENILE CURVATURE

complaint, the etiology and pathogenesis of these entities are

quite different. Congenital penile curvature is usually the
result of disproportion of the corpora cavernosa and corpora
spongiosum. It usually presents early in life without any
associated erectile dysfunction. On the other hand, deformities secondary to plaque formation, commonly referred to as
Peyronies disease, are the result of trauma to or autoimmune disease of the tunica albuginea. They commonly
present in the fifth and sixth decades of life, and most patients have other co-morbidities, including penile shortening
and erectile dysfunction.1
Since 1947, several surgical techniques have been described to correct penile deformities.4 However, there has
been little differentiation between Peyronies disease and
congenital curvature in terms of repair. The Nesbit procedure, described in 1965, is one of the oldest procedures.5 It is
performed by excising 1 or multiple elliptoid wedge resections of tunica albuginea at its maximal convexity opposite
the curvature and then closing with running absorbable sutures to correct curvature. Although it is thought to be the
standard procedure for treating acquired penile curvature,6
the Nesbit procedure has many disadvantages. It is relatively
invasive, involving dissection of the 2 neurovascular bundles
with excision of the tunica albuginea. It may result in hematoma, glans numbness, impotence, penile shortening and under or over correction. This procedure is performed with the
patient under general anesthesia since it is not well tolerated
under local anesthesia. Andrews et al noted that 16% of
Nesbit failures were secondary to suture breakage.7
Some modifications of the Nesbit procedure have been
described for congenital penile curvature that are less invasive and provide patients with equal clinical success but less
morbidity.8 11 Sassine et al reported a 95% success rate in a
10-year followup series using modified corporoplasty for congenital penile curvature, in which a longitudinal incision is
made on the tunica and the defect is closed with sutures by
pulling the longitudinal defect lateral.8 More incisions are
made until curvature is corrected. Rehman et al also reported
100% success in 6 patients with congenital curvature using
plication and a tunical shaving procedure.9 Of the tunica 50%
is shaved off in the form of an ellipse. The defect is closed
with sutures until curvature is corrected. Although many of
these procedures are less morbid than the original Nesbit
procedure, most still require surgical intervention involving
tunical incision, vein grafting and/or plication.
Plication surgery was first introduced by Essed and
Schroeder as an alternative treatment for Peyronies disease.12
In the original description they recommended mobilization of
the urethra or neurovascular bundles. This technique was further modified by Baskin and Lue, who described a method13
similar to what we used in the current study. This technique
offers many advantages over other procedures. It avoids dissection of the neurovascular bundles and urethra with its potential
complications. It does not require excision or incision of the
tunica albuginea, thus, avoiding damaging healthy erectile tissue. In addition, it avoids over or under correction since tension
on the plication sutures can be easily adjusted to achieve a
perfectly straight penis.
However, plication correction has met with limited success
for Peyronies disease. Patients who have acquired penile
deformity frequently have concomitant shortening of the penis. Since corporeal plication can potentially shorten the
penis, this procedure has not gained popularity. Chahal et al
followed 44 patients with Peyronies disease who underwent
penile plication for a mean of 4 years.14 Of the patients 57%
reported deterioration in overall quality of life and 90% noticed a shorter penis.
In contrast, patients with congenital penile curvature do
not usually believe that inadequate penile length is a problem. Therefore, plication surgery, which is less morbid than
tunical incision, could potentially yield better results in this

601

select population. Hsieh et al followed a series of 22 men with

congenital penile curvature who underwent a tunica albuginea plication procedure (11) or the Nesbit procedure (11).15
Results favored the plication procedure (10 of 11 cases successful) over the Nesbit procedure (8 of 11 successful) at a
mean followup of 25 months. The single unsuccessful result
in the plication group was due to penile shortening.
Our study followed a similar patient population that underwent a simple tunica plication procedure. We chose 2-zero
braided polyester suture for its tensile strength and because
it is nonabsorbable. Our plication procedure aims to achieve
minimal morbidity by placing longitudinal plication sutures
onto the maximal curvature of the tunica without excising it.
We noted a high success rate of 95% at a followup of up to 312
years. Furthermore, all procedures were performed on an
outpatient basis with most patients tolerating local anesthesia. Incidentally, none of the patients in our series was noted
to complain of palpating the sutures. Also, only 18% of patients complained of penile shortening and only 1 was dissatisfied with the degree of shortening. Our success rate is
slightly higher than that recently reported by Gholami and
Lue.16 However, in that series patients with Peyronies disease as well as congenital curvature were included.
We acknowledge that, although to date this procedure has
resulted in excellent patient satisfaction, there are several
shortcomings of our study. Our sample size and the followup
period reflect the beginning phase of our study. It is possible
that the sutures may eventually weaken and break, causing
recurrent curvature. However, we believe that since plication
surgery is minimally invasive, the limited number of patients
in whom treatment fails may undergo secondary plication
surgery or another modality of penile reconstruction. In addition, since our study was retrospective, we did not randomly compare the plication procedure to the standard
Nesbit procedure.
Nevertheless, we observed that simple plication for correcting congenital penile curvature has many advantages. It does
not require dissection of the neurovascular bundle or urethra
with the potential problems of bleeding, penile numbness
and hematoma. It also does not require any excision or incision of the healthy tunica albuginea, which could result in
erectile dysfunction or herniation through the tunica.
Furthermore, it also avoids the possibility of over or under
correction. Our results also show that penile plication has not
only a high surgical success rate, but also high patient satisfaction. Operative time is short with minimal anesthesia
required and it is performed on an outpatient basis, minimizing hospital cost and patient morbidity. When selected carefully, patients with congenital penile curvature should undergo plication as an alternative to other, more invasive
corrective surgery.
CONCLUSIONS

Corporeal plication is a simple surgical procedure that

proved to be effective for congenital curvature of the penis
with a high patient satisfaction rate. It can avoid more extensive penile reconstruction surgery in carefully selected
patients. It can be performed on an outpatient basis with
minimal morbidity.
APPENDIX: CONFIDENTIAL POSTOPERATIVE PATIENT
QUESTIONNAIRE

Please answer the following questions. All answers are

strictly confidential and have no effect on your future
medical care. This information will not be reflected in
your medical records.
Name:
MR#:
Date of Surgery:
Todays Date:

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CORPOREAL PLICATION FOR CONGENITAL PENILE CURVATURE

1. Were you sexually active with intercourse prior to surgery?

Yes
No
2. If no, how long have you been having problems with
sexual intercourse prior to surgery?
3. Are you currently sexually active?
Yes
No
4. If yes, how satisfied are you with your surgical results?
100%
75%
50%
25%
5. Is the curvature of your penis corrected?
100%
75%
50%
25%
6. Have you noticed any changes in the length of your
penis?
Shorter
Longer
No change

7.

8.

9.

10.

REFERENCES

1. Abseif, S. R. and Tamaddon, K. A.: Peyronies disease: an update.

In: Sexual Dysfunction in Medicine. London: Remedica
Publishing Ltd., vol. 1, p. 34, 1999
2. Ebbehoj, J. and Metz, P.: Congenital penile angulation. Br J
Urol, 60: 264, 1987
3. Duckett, J. W.: Hypospadias. In: Campbells Urology, 7th ed.
Edited by P. C. Walsh, A. B. Retik, E. D. Vaughan, Jr. and A. J.
Wein. Philadelphia: W. B. Saunders Co., vol. 2, p. 2099, 1998
4. Lowsley, O. S. and Gentile, A.: An operation for the cure of
certain cases of plastic induration (Peyronies disease) of the
penis. J Urol, 57: 552, 1947
5. Nesbit, R. M.: Congenital curvature of the phallus: report of
three cases with description of corrective operation. J Urol, 93:
230, 1965
6. Ralph, D. J., Al-Akraa, M. and Pryor, J. P.: The Nesbit operation

11.
12.
13.
14.

15.

16.

for Peyronies disease: 16-year experience. J Urol, 154: 1362,

1995
Andrews, H. O., Al-Akraa, M., Pryor, J. P. and Ralph, D. J.: The
Nesbit operation for Peyronies disease: an analysis of the
failures. BJU Int, 87: 658, 2001
Sassine, A. M., Wespes, E. and Schulman, C. C.: Modified coporoplasty for penile curvature: 10 years experience. Urology,
44: 419, 1994
Rehman, J., Benet, A., Minsky, L. S. and Melman, A.: Results of
surgical treatment for abnormal penile curvature: Peyronies
disease and congenital deviation by modified Nesbit plication
(tunical shaving and plication). J Urol, 157: 1288, 1997
Daitch, J. A., Angermeier, K. W. and Montague, D. K.: Modified
corporoplasty for penile curvature: long-term results and patient satisfaction. J Urol, 162: 2006, 1999
Yachia, D.: Modified corporoplasty for the treatment of penile
curvature. J Urol, 143: 80, 1990
Essed, E. and Schroeder, F. H.: New surgical treatment for
Peyronies disease. Urology, 25: 582, 1985
Baskin, L. S. and Lue, T. F.: The correction of congenital penile
curvature in young men. Br J Urol, 81: 895, 1998
Chahal, R., Gogoi, N. K., Sundaram, S. K. and Weston, P. M.:
Corporal plication for penile curvature caused by Peyronies
disease: the patients perspective. BJU Int, 87: 352, 2001
Hsieh, J. T., Huang, H. E., Chen, J., Chang, H. C. and Liu, S. P.:
Modified plication of the tunica albuginea in treating congenital penile curvature. BJU Int, 88: 236, 2001
Gholami, S. S. and Lue, T. F.: Correction of penile curvature
using the 16-dot plication technique: a review of 132 patients.
J Urol, 167: 2066, 2002