Stesura Seveso 337Archivio Italiano di Urologia e Andrologia 2015; 87, 4 CASE REPORT Penile prosthesis implant with bi-triangular excision and graft for surgical therapy of Peyronie’s disease: A case report Alexandre de Freitas Miranda 1, Bruno Lopes Cançado Machado 2 1 Reconstructive Urology and Andrology Section, Department of Urology, Ipanema Federal Hospital and Urogenital Research Unit, State University of Rio de Janeiro, UERJ, Rio de Janeiro, Brazil; 2 Urological Private Practice, Rio de Janeiro, Brazil. We present a case of a 65-year-old man, who presented with moderate erectile dysfunction and a dorsal penile deviation of 60° caused by Peyronie’s disease. The patient underwent bi-triangular- shaped plaque excision, followed by grafting and implanta- tion of inflatable penile prosthesis. Complete penile straight- ening, without mechanical or geometric abnormalities, was achieved using bi-triangular excision and grafting. Postoperatively, the patient reported high satisfaction with the results and could perform sexual intercourse naturally. This novel technique corrects any degree of penile curvature, permits malleable and semi-rigid penile prosthesis implanta- tion, avoids penile length loss, and eliminates additional incisions. To our knowledge, this case is the first in the liter- ature in which the bi-triangular technique was successfully used for penile prosthesis implantation secondary to Peyronie’s disease. This new technique appears to be a good solution to correct penile curvature during penile prosthesis implantation for the treatment of Peyronie’s disease associ- ated with erectile dysfunction. KEY WORDS: Peyronie’s disease; Surgery; Graft; Penile prosthe- sis; Erectile dysfunction. Submitted 30 June; Accepted 30 September Summary No conflict of interest declared. may represents a challenging procedure and in some cases require another incision to access distal defects. Herein we report the first case of PPI using the bi-trian- gular excision and graft (2). CASE REPORT Here we present a case of a 65-year-old man, without comorbidities, who presented with moderate ED and required a phosphodiesterase type 5 inhibitor to have sexual intercourse. He had a dorsal penile deviation of 60° caused by PD. The penile plaque had been stable for 1 year. Artificial erection was induced with 0.9% of NaCl solution injected into the corpora cavernosa, punctured with a 21G butterfly needle. The technique described by Austoni et al. was used to deglove the penis and isolate the neurovascular bundle (3). We marked two triangles on the patient’s tunica albuginea. The bases of the trian- gles were equal to the disparity between the long and short sides of the curvature (w), and the sum of the tri- angles’ heights was equal to ¾ of the corpora cavernosa circumference (L) (Figure 1A). The apexes of the trian- gles were located at the middle of the curvature on the concave side (Figure 1A). After the excision of the trian- gles and rectification of the penis, the corpora cavernosa defect acquired a rectangular shape, with longitudinal and transversal lengths equal to w and L, respectively (Figure 1B). The defect was closed by a bovine peri- cardium graft 4.5 × 8.25 cm in size (Figure 1C). Finally the Buck’s fascia was closed, and the penis re-gloved (Figure 1D). Another 2-cm longitudinal incision was made on each cavernous body to perform the PPI. The fluid reservoir was inserted into the retropubic space through an inguinal ring using the scrotal incision made to deglove the penis. The pump was placed on the sub- cutaneous space of the scrotum. A 14-Fr Blake drain was inserted into the scrotum for 24 h. The patient reassumed sexual intercourse 6 weeks after surgery. Complete penile straightening, without mechan- ical or geometric abnormalities, was achieved using bi- triangular excision and grafting. Postoperatively, the patient reported being highly satisfied with the results and could perform sexual intercourse naturally. DOI: 10.4081/aiua.2015.4.337 INTRODUCTION Peyronie’s disease (PD) is a connective tissue disorder characterized by tunica albuginea fibrosis that can gener- ate penile deformity with curvature, narrowing, and shortening and, in 41% of cases, is associated with erec- tile dysfunction (ED). PD is often associated with psy- chological disturbance and has a male population preva- lence of 3-9%. Penile prosthesis implantation (PPI) is a treatment for patients with PD and ED non-responsive to oral treat- ment. During the implantation, the surgeon may need to perform manual modeling, plaque incision if residual curvature after modeling is greater than 30°, and, if the defect created by the incision is greater than 2 cm, place- ment of a graft. Segal et al. reported that 53.6% of patients underwent PPI and modeling required plaque incision with or without a graft (1). The graft insertion Archivio Italiano di Urologia e Andrologia 2015; 87, 4 A. de Freitas Miranda, B. Lopes Cançado Machado 338 REFERENCES 1. Segal RL, Cabrini MR, Bivalacqua TJ, Burnett AL. Penile straightening maneuvers employed during penile prosthesis surgery: technical options and outcomes. Int J Impot Res. 2014; 26:182-5. 2. Miranda AF, Sampaio FJ. A geometric model of plaque incision and graft for Peyronie's disease with geometric analyses of different techniques. J Sex Med. 2014; 11:1546-53. 3. Austoni E, Altieri VM, Tenaglia R. Trans-scrotal penile degloving, a new procedure for corporoplasties. Urologia. 2012; 79:200-10. Correspondence Alexandre de Freitas Miranda, MD (Corresponding Author) contato@alexandremiranda.com.br Urogenital Research Unit, State University of Rio de Janeiro Av 28 de Setembro, 87, Fundos, Vila Isabel Rio de Janeiro, RJ, Brazil, 20551-030 Bruno Lopes Cançado Machado, MD blc1904@hotmail.com Rua Visconde de Pirajá, 595, sala 1406, Ipanema Rio de Janeiro, RJ, Brazil, 22410-002 CONCLUSIONS To our knowledge, this case is the first in the literature in which the previously reported bi-triangular technique was successfully applied for PPI secondary to PD, vali- dating our previous measures and findings. This new technique appears to be a good solution to correct penile curvature during penile prosthesis implantation for the treatment of PD associated with ED. Discussion and Supplementary Re fe rences are posted as Supplementary Materials on www.aiua.it Figures 1a, b, c, d. Surgical procedure. A) Penile degloving with the two triangles marked. B) Defect resulting after bi-triangular excision. C) Penile rectification and tunica albuginea defect closed by bovine pericardium graft. D) Inflatable penile prosthesis implantation after re-gloving.