Comparative Outcomes of Subtunical Microdissection and Grafting Versus Classical Plaque Incision and Grafting in Complex Peyronie's Disease

Peyronie's disease is a fibrotic disorder of the tunica albuginea characterized by the formation of inelastic plaques within the penile shaft. These plaques may lead to penile curvature, indentation deformities, hinge effect, penile shortening, and difficulties during sexual intercourse. In patients with severe deformity or functional impairment, surgical correction remains the most effective treatment option. Plaque incision and grafting has traditionally been considered the standard surgical technique for complex Peyronie's disease, particularly in patients with severe curvature, multiplanar deformities, hourglass narrowing, or hinge effect. However, this approach requires tunical incision and graft placement, which may potentially increase the risk of postoperative erectile dysfunction, sensory changes, or graft-related complications.

Subtunical microdissection has recently been proposed as an alternative surgical approach aimed at reducing structural disruption of the tunica albuginea. In this technique, the plaque is approached through careful dissection beneath the tunical layer in order to release the deforming forces responsible for penile curvature while preserving the structural integrity of the tunica albuginea. The procedure is performed under approximately 3.5× optical magnification using surgical loupes, and the subtunical plane is meticulously dissected using microsurgical instruments. This technique allows controlled separation of fibrotic tissue from surrounding tunical structures with the aim of minimizing extensive tunical incision and reducing surgical trauma.

Despite the theoretical advantages of this technique, the clinical outcomes of subtunical microdissection have not yet been systematically compared with those of classical plaque incision and grafting in patients with complex Peyronie's disease.

The aim of this study is to compare the anatomical and functional outcomes of subtunical microdissection and classical plaque incision and grafting in patients with complex Peyronie's disease. Complex Peyronie's disease will include patients presenting with severe penile curvature, multiplanar deformity, hinge effect, hourglass deformity, or large plaques causing significant functional impairment.

In both surgical approaches, plaque incision and grafting is performed using the same graft material in order to standardize the procedure and minimize confounding variables. A bovine pericardium graft is used in all cases. In the classical technique, plaque incision is performed followed by graft placement. In the subtunical microdissection technique, plaque release is achieved through controlled subtunical dissection performed under approximately 3.5× optical magnification with microsurgical instruments. After adequate straightening is achieved, graft reconstruction is performed using the same bovine pericardial graft material.

The graft dimensions are calculated according to the geometric principles described by Egydio in order to achieve adequate defect coverage and penile straightening. All surgical procedures are performed by the same surgical team using a standardized operative technique. A uniform anesthesia protocol is also applied to all participants in order to minimize variability related to perioperative management.

Participants who meet the eligibility criteria and require surgical correction will undergo either subtunical microdissection or classical plaque incision and grafting according to the surgical approach selected by the treating surgeon. Patients will be followed prospectively after surgery to evaluate penile straightening, erectile function, and patient-reported outcomes.

The primary outcome of the study will be successful penile straightening, defined as a postoperative residual curvature of less than 30 degrees. Secondary outcomes will include changes in erectile function, patient satisfaction, penile length changes, perioperative complications, and the need for additional corrective procedures.

By comparing these two surgical approaches, this study aims to determine whether subtunical microdissection can provide effective curvature correction while potentially preserving erectile function and reducing surgical morbidity. The findings of this study may contribute to improving surgical decision-making and optimizing treatment strategies for patients with complex Peyronie's disease.