The question is clearly a good one and important to recognize that the indications for surgical correction depend upon several factors, and first and most importantly that the deformity of the penis interferes with sexual activity enough that it is difficult or impossible to perform penetrative sex. With this in mind, several protocols have been developed over the last decade, which have all agreed to the following. If the penile deformity is not severe (less than 60-70 degrees), and there is no significant indentation, hourglass deformity or hinge effect, then penile straightening with a plication operation is indicated.
The Nesbit is one of the first plication operations and there are many variants, and the results are pretty much the same with a high rate of satisfactory straightening and very low worsening of erectile function. There is one concern with any plication operation including the Nesbit, which includes possible shortening of the penis. This is why we limit the men to be offered type of procedures so that with less than 70 degrees of curvature, as this will less rule and should not result in substantial loss of length. This has been confirmed in a recent publication in the January, Journal of Urology by Laurence Levine, MD and associates.
On the other hand, when a grafting procedure would be indicated when the curvature is severe (exceeding 70 degrees), and/or there is substantial narrowing which results in an unstable penis, which is also called a hinge effect. In this circumstance because of the greater severity of this problem, a more advanced operation is indicated. In this circumstance, the area of maximum scarring is either incised or excised, and then the defected is covered with a graft of which there is a variety available today. The risk of penile shortening is much less with the grafting procedure, but the rate of erectile dysfunction following grafting is higher because of the exposure of the underlying vascular tissue and the potential for postoperative venous leakage. Studies have been done to look at who would be most at risk for developing erectile dysfunction following a grafting procedure, and for the most part these studies have revealed that the quality of erectile function preoperatively can help predict postoperative results. That is to say men who have some compromise to their erections preoperatively are not likely to get better and may get worse. Therefore, it is the opinion of most experts that the grafting procedure be performed in men who have excellent quality rigidity, but severe deformity. In this circumstance, reported erectile dysfunction after surgery ranges from 5-15% in individuals undergoing this operation. It is also for this reason that I feel strongly that experts in the field of penile reconstruction for Peyronie’s disease perform the grafting procedure, as this is delicate surgery that requires experienced hands. The Nesbit procedure or other plication operations are less risky, and therefore may be performed by any urologist who is comfortable with this technique. It would also be useful to note that the goal of penile straightening procedures is to create a functionally straight penis. This is defined as residual curve of less than 20 degrees which should not interfere with penetrative sex.
This type of curvature is best treated with surgery. The type of surgery depends upon several factors. If there is Peyronie’s disease which has caused substantial shortening, or the penis is already short then there is likely to be further shortening when correcting a downward (ventral) curvature. The amount of shortening depends upon the degree of curvature. The more severe the curvature, the greater the amount of shortening. Studies have shown that the amount of length loss in men with curvature of less than 60 degrees tends to the in 1-1½ cm range, but when it is in excess of 60 degrees, more curvature is possible.
On the other hand if the curvature is severe (more than 70 degrees) and a grafting procedure is performed to correct it, there is a reported higher risk of erectile dysfunction, which approaches 50% of men undergoing grafting for downward curvature. For men with congenital downward curvature, these men typically have increased elasticity and long penises. In these patients, I always recommend a plication operation instead of a grafting procedure. This is because the degree of shortening in the man with congenital curvature tends to be less bothersome, and there is a substantially lower rate of postoperative erectile dysfunction with the plication procedure. For men who have Peyronie’s disease, severe ventral curvature and borderline erectile dysfunction, it is best to consider placement of a penile prosthesis with simultaneous straightening of the penis. In this circumstance, the prosthesis will support the straightening and allow satisfactory postoperative rigidity for sex.