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Plaque Incision / Excision with Grafting

Plaque incision or excision with grafting (PIG / PEG) is the tunical lengthening arm of the Peyronie's disease (PD) surgical algorithm. It corrects curvature by releasing or partially removing the contracted plaque on the concave side and patching the tunical defect with a graft. Unlike plication (which shortens the convex side), PIG/PEG lengthens the concave side, preserving or even increasing penile length while correcting severe and complex deformities — at the cost of higher technical complexity and a meaningfully elevated risk of de novo erectile dysfunction.[1][2]

This is the operation of choice for severe curvature (> 60°), complex deformity (hourglass, hinge, biplanar), and patients whose short starting length makes plication-associated shortening unacceptable.

Terminology — incision vs excision​

The terms PIG and PEG are used interchangeably in the literature but describe distinct plaque-management approaches:

TermDefinitionCurrent role
Plaque incision (PIG)Plaque is incised (cut through) but not removed; resulting tunical defect is graftedMost commonly performed today — preserves native tissue, smaller defects
Partial plaque excision (PEG)Most fibrotic / calcified portion of plaque excised; surrounding tunica preservedLevine's preferred approach — removes the dominant scar without sacrificing peripheral tunica
Complete plaque excisionEntire plaque removedRarely performed today — larger defects, higher ED rates, no demonstrated superiority[6]

The AUA Guideline uses the inclusive phrase "plaque incision or excision and/or grafting" to encompass all variants.[1]

Indications​

Per the Levine surgical algorithm and the AUA 2015 PD Guideline (Moderate Recommendation; Grade C), PIG/PEG is appropriate for:[1][2][3][11]

  • Curvature > 60° where plication would produce unacceptable shortening
  • Complex deformity — hourglass, hinge effect, compound / biplanar curvature
  • Short penis where length preservation is the dominant goal
  • Adequate erectile rigidity for coitus (with or without PDE5i / VED / ICI)
  • Stable disease phase (typically ≥ 12 months from onset)

The 2026 BJU Guideline-of-Guidelines confirms consensus across AUA, EAU, CUA, and ISSM that PIG/PEG is reserved for patients with preserved erectile function; penile prosthesis is preferred for refractory ED.[11]

Patients to counsel against. In the Langbo / Levine series of 251 PEG patients, 22% were initially advised to undergo IPP but elected PEG — these patients had significantly lower postoperative ability to engage in intercourse (51% vs 76%) and a higher rate of eventual IPP conversion (13% vs 4%), reinforcing the importance of the algorithm.[10]

Technique — Plaque Incision vs. Partial Excision​

Partial plaque excision with grafting (PEG)​

The most commonly employed approach. Partial — not complete — plaque excision preserves the underlying neurovascular structures of the penis and avoids the unnecessary trauma of complete excision.

Steps:

  1. Degloving or subcoronal incision with full penile mobilization
  2. Dorsal neurovascular bundle mobilization (Lue technique) — the bundle is lifted off the tunica to expose the dorsal plaque; alternatively left in place with lateral exposure for lateral plaques
  3. H-shaped or Y-shaped relaxing incision through the plaque on the concave side
  4. Partial excision of the densest portion of the plaque (if calcified)
  5. Graft harvest and sizing — graft cut to overlap the tunical defect by 2–3 mm on all sides
  6. Graft suturing into the tunical defect with running non-absorbable monofilament suture (Prolene 4-0 or 5-0) or absorbable suture (PDS)
  7. ICI + cycling to confirm straightening with the graft in place
  8. Closure of Buck's fascia and redraping

Plaque incision without excision (relaxing incisions + grafting)​

Incisions through the plaque without excision — the plaque is divided to allow the concave side to open up, and the resulting defect is grafted. Preferred when the plaque is densely adherent to the neurovascular bundle or when excision would risk NVB injury.[4]

Outcomes (90 patients after CCH failure, Cocci series):[4]

  • Bovine pericardium graft: 51.2%; collagen fleece: 48.8%
  • Median postoperative penile length: 13.0 cm (IQR 12.0–15.0)
  • Overall complication rate: 4.4%
  • Curvature recurrence >20°: 4.4%
  • Overall satisfaction: 95.6%

Incision patterns​

Several incision configurations have been described:

PatternDescriptionNotes
H-incision (Lue 1998)[12]Two parallel longitudinal incisions connected by a transverse incision through the plaqueMost widely used; rectangular defect; controlled expansion. Choi 2021 (n=21, > 60° curvature with bovine pericardial graft) — curvature 70° → 5°
Double-Y / stellateY-shaped incisions at each end of the plaque (or cruciate)Diamond-shaped defect; useful for focal plaques
Single relaxing incisionOne transverse incision across the plaqueSimplest; for mild contractures
Egydio geometricMultiple relaxing incisions placed by geometric calculationMathematically derived for precise lengthening — Sansalone 2011 European multicenter (n=157) achieved mean intraoperative length gain 2.5 cm (range 1.7–4.1 cm); 88% complete straightening at median 20 mo[13]
Egydio Tunica Expansion Procedure (TEP)Multiple staggered small cuts on the tunica without graft, used with IPPn=416, mean penile gain 3.3 cm with curvature correction in 287 PD cases[14]

The Hatzichristodoulou "sealing" technique​

A widely adopted modern variant using collagen fleece (TachoSil, Evarrest) as a suture-free sealing graft after partial plaque excision.[5]

Steps:

  1. Penile degloving; NVB mobilization
  2. Partial plaque excision on the concave side
  3. Collagen fleece applied over the tunical defect — the fibrin-coated surface activates on contact with bleeding tissue and forms a watertight seal
  4. Gentle pressure for 3–5 minutes to ensure adherence
  5. No suture fixation required for the graft

Outcomes (319 consecutive patients):[5]

  • Median operative time: 79.8 minutes (range 50–130)
  • Intraoperative complete straightness: 93.7%
  • Mean penile length increase: 1.1 ± 0.6 cm (P=.017)
  • At median 47.2-month follow-up: 91.2% maintained complete straightness
  • Glans sensation returned to baseline: 94%
  • Patient satisfaction: 87.8%; partner satisfaction: 84.3%
  • Only 11 Clavien-Dindo grade 1 complications across the series

Graft Materials​

Buccal mucosa graft (BMG) — autologous​

Meta-analysis of 17 studies:[6]

OutcomeValue
Success rate98.6%
Satisfaction92.1%
De novo ED rate1.7%
Penile shortening rate1.1%
IIEF-5 change+1.69 points
Length of affected side+1.99 cm

BMG has become a favored graft material because it shares biological characteristics with the tunica (thin, flexible, well-vascularized after take), has minimal donor-site morbidity (inner cheek), and produces excellent functional outcomes. For BMG harvest and handling, see buccal mucosa graft — foundations.

Collagen fleece (TachoSil, Evarrest)​

  • Suture-free application — eliminates graft-site suturing time
  • Hemostatic effect — simultaneously seals tunical bleeding
  • Cost-effective and widely available
  • Reduced operative time vs. sutured grafts
  • Comparable outcomes to pericardium allograft[7]

Bovine / cadaveric pericardium (Veritas, Tutoplast, CorMatrix)​

  • Longest track record in PD grafting
  • Reliable handling and suture retention
  • Cadaveric pericardium associated with highest patient satisfaction (OR 61.4) in one large satisfaction analysis[8]
  • Comparable outcomes to hemostatic patches but longer operative time (166 vs 122 minutes)[7]

Porcine small intestinal submucosa (SIS; Cook Biodesign)​

  • Remodels to host tissue over 6–12 months
  • Good handling; acceptable outcomes
  • Higher cost than some alternatives

Dermal graft — autologous​

  • Historical standard (Devine)
  • Meaningful donor-site morbidity (abdominal or inguinal harvest)
  • Now less commonly used given superior alternatives

Saphenous vein — autologous​

  • Lown ED rate in some series
  • Donor-site consideration (saphenous vein harvest)
  • Longer operative time

Tunica vaginalis — autologous​

  • Adjacent tissue, easily harvested
  • Thin and flexible
  • Useful in revision settings where other materials have been used
  • Ainayev 2022 head-to-head TV vs BMG (n=40): equivalent technical success (90% both at 24 mo), equivalent IIEF-5 improvement, equivalent length gain[15]

Comparative graft data​

Natsos 2024 systematic review and meta-analysis of grafts in PD surgery without prosthesis:[16]

  • BMG — highest penile straightening rates and least de novo ED
  • TachoSil collagen fleece — best overall performance when preoperative curvature was taken into account (used for more severe curvatures, still excellent results)
  • Tutoplast (cadaveric pericardium) — higher incidence of postoperative ED
  • No randomized comparative trials exist to definitively establish graft superiority

Saphenous vein vs BMG (Danacıoğlu 2021, n=41) — no significant differences in IIEF, length, or partner satisfaction; residual curvature 13.1% (SV) vs 11.2% (BMG).[17]

SIS vs collagen fleece — matched-pair analysis (Rosenhammer 2019, n=43 each, median curvature 80°): CF significantly faster (80 vs 104 min, p < 0.001); SIS had significantly more shortening (28% vs 5%, p = 0.007).[18]

Special Scenario: Compound / Biplanar Curvature​

For severe compound curvature (primary + secondary plane), PEG alone is often insufficient — supplemental plication in a second plane is typically required. The Levine group's 240-patient series with 161 compound-curvature patients:[3]

  • Average primary curvature: 79° (range 35–140°)
  • Average secondary curvature: 36° (range 20–80°)
  • After PEG, average residual curvature: 30° — requiring 1–6 additional plication sutures
  • At 61-month follow-up:
    • Recurrent curvature: 12.4%
    • Net change in penile length: +0.36 cm
    • Decreased penile sensation: 13%
    • Able to engage in penetrative sex: 79%

The takeaway: for the most complex cases, the operation is PEG on the primary curve + plication in the second plane, and the patient should be counseled to expect a multi-element reconstruction.

Post-CCH Failure Surgery​

A growing patient population: men who attempted intralesional CCH (Xiaflex) first and either did not achieve sufficient correction or developed complications (corporal rupture). The Cocci multicenter study showed that PEG / plaque incision with grafting after CCH failure is safe and effective, with >95% satisfaction and <5% complication rates[4] — contradicting earlier concerns that CCH-induced tissue changes would compromise subsequent grafting.

Microscopic Electric Rotary Grinding​

A novel technique using fine electric rotary grinding (a modified dental-grade burr or equivalent) to precisely remove fibrotic plaque tissue under microscopic visualization, followed by grafting with tunica vaginalis or bovine pericardium.[9] Reported to offer more precise plaque removal with preservation of adjacent tunica; adopted in selected Chinese and European centers; not widely adopted in U.S. practice.

Outcomes​

Straightening​

  • Complete straightening: 80–100% across contemporary series
  • Modern large series (collagen fleece sealing, Hatzichristodoulou 319 pts): 93.7% immediate, 91.2% durable[5]
  • BMG systematic review: 98.6% success[6]

Length​

Unlike plication, grafting preserves or modestly increases length — typically 1.0–1.5 cm length gain on the affected side, net overall effect close to neutral or slightly positive.[5]

Erectile function​

The defining downside: de novo ED rates range from 1.7% (BMG meta-analysis)[6] to 21% (Levine PEG long-term)[10] to 46% (Mulhall series)[19], depending on patient selection, graft material, and ED definition. Mechanism is thought to involve veno-occlusive dysfunction at the graft–native-tunica interface.[1][8]

Mulhall predictors of postoperative ED (Flores / Mulhall 2011, multivariable analysis; n=56): degree of preoperative curvature, Egydio incision technique (larger tunical defects), patient age, and baseline venous leak. Mulhall's group discourages PIG in older men, those with venous leak, and those with profound curvature.[19]

Levine predictors (Taylor / Abern / Levine 2012; n=109): neither preoperative cardiovascular risk factors (HTN, DM, smoking) nor duplex parameters (PSV, EDV, RI) significantly predicted postoperative ED. Rate was 10% TAP, 21% PEG.[20]

Montorsi 2000 (n=50, vein graft, highly selected RigiScan + Doppler-normal cohort) — only 6% ED, illustrating the patient-selection range across series.[21]

Comparative head-to-head — Yafi 2018 prospective multi-institutional​

CCH vs plication vs PEG (n = 57):[22]

OutcomeCCH (n=18)Plication (n=14)PEG (n=25)p
Mean curvature correction23.3° (34.4%)72.0° (92.2%)71.8° (94.9%)0.001
Mean IIEF-5 change+5.7+4.9+2.2NS
Mean SPL change−0.2 cm−1.0 cm+0.9 cm0.001

PEG and plication both achieve > 90% curvature correction; PEG associated with small length gain while plication produces modest shortening.

Sensation​

Temporary decreased sensation in 6–13%; usually resolves over 6–12 months. Permanent hypoesthesia is uncommon with NVB-preserving technique.[5]

Complications​

ComplicationRate
De novo ED1.7–25% (modern 1–5%)
Decreased sensation (transient)6–13%
Hematoma16–24% in some series
Recurrent curvature4–12%
Infection<2%
Graft-related (rupture, migration)<1%
Urethral injuryVery rare

The Langbo Lesson — Patient Selection Matters​

A Levine-group analysis examined patients who were counseled toward prosthesis (based on suboptimal erectile rigidity) but elected for PEG instead:[10]

  • Lower postoperative ability to engage in intercourse: 51% vs 76% (compared with patients selected for PEG based on adequate rigidity)
  • Higher rate of eventual penile prosthesis implantation: 13% vs 4%

The takeaway: PEG should be offered only to patients whose erectile function supports it. Patients with borderline ED who choose PEG over prosthesis have worse long-term outcomes and higher crossover-to-prosthesis rates.

Counseling​

  • Length is preserved — this is the primary advantage over plication
  • ED risk is real — 1–25% depending on graft, technique, and baseline function
  • Recovery is longer than plication — typically 6–8 weeks before return to sexual activity
  • Complex deformities may require combined PEG + plication — multi-element operations are expected for compound curvatures
  • Patient selection is critical — patients counseled toward prosthesis who insist on PEG have materially worse outcomes

PIG/PEG vs Plication — Head-to-Head​

FeaturePIG / PEGPlication (TAP / 16-dot / PSP)
MechanismLengthens concave sideShortens convex side
Ideal curvature> 60° and/or hourglass / hinge< 60–70° without complex deformity
Penile length effectPreserved or gained (+0.2 to +1.99 cm)Shortened 0.3–1.0 cm or unchanged
De novo ED risk1.7–21% (higher)3–10% (lower)
Operative timeLonger (80–165 min)Shorter (48–80 min)
Curvature correction80–98.6%87–97%
ComplexityHigher (NVB mobilization, graft handling)Lower (suture-only)
Sensory changesMore common (NVB mobilization)Less common
Best long-term satisfaction series87.8% (Hatzichristodoulou 319 pts, 47 mo)[5]82% (Taylor-Levine TAP 90 mo)

See Also​

Videos​

Peyronie's Disease: Plaque Incision and Grafting Live Surgery
Dr. Ashish Sabharwal (2024)
Peyronie's Disease Surgery: Plaque Incision and Grafting
Dr. V. G. Gupta (2021)

References​

1. Nehra A, Alterowitz R, Culkin DJ, et al. Peyronie's disease: AUA guideline. J Urol. 2015;194(3):745–753. doi:10.1016/j.juro.2015.05.098

2. Levine LA, Lenting EL. A surgical algorithm for the treatment of Peyronie's disease. J Urol. 1997;158(6):2149–2152. doi:10.1016/s0022-5347(01)68184-9

3. Chow AK, Sidelsky SA, Levine LA. Surgical outcomes of plaque excision and grafting and supplemental tunica albuginea plication for treatment of Peyronie's disease with severe compound curvature. J Sex Med. 2018;15(7):1021–1029. doi:10.1016/j.jsxm.2018.04.642

4. Cocci A, Ralph D, Djinovic R, et al. Surgical outcomes after collagenase clostridium histolyticum failure in patients with Peyronie's disease in a multicenter clinical study. Sci Rep. 2021;11(1):166. doi:10.1038/s41598-020-80551-3

5. Hatzichristodoulou G, Fiechtner S, Pyrgidis N, et al. Suture-free sealing of tunical defect with collagen fleece after partial plaque excision in 319 consecutive patients with Peyronie's disease: the sealing technique. J Urol. 2021;206(5):1276–1282. doi:10.1097/JU.0000000000001933

6. Badr H, Bettocchi C, Alsalem A, et al. Surgical treatment of Peyronie's disease by plaque incision and buccal mucosa graft: a systematic review and meta-analysis. Asian J Androl. 2026. doi:10.4103/aja202543

7. Farrell MR, Abdelsayed GA, Ziegelmann MJ, Levine LA. A comparison of hemostatic patches versus pericardium allograft for the treatment of complex Peyronie's disease with penile prosthesis and plaque incision. Urology. 2019;129:113–118. doi:10.1016/j.urology.2019.03.008

8. Gamidov S, Shatylko T, Gasanov N, et al. Long-term outcomes of surgery for Peyronie's disease: focus on patient satisfaction. Int J Impot Res. 2021;33(3):332–338. doi:10.1038/s41443-020-0297-6

9. Jin DC, Luo Y, Wang P, et al. Microscopic electric rotary grinding of plaques combined with graft repair in the management of Peyronie's disease. J Vis Exp. 2024;(205). doi:10.3791/66305

10. Langbo WA, Wang V, Bajic P, Levine L. Long-term outcomes after plaque excision grafting for Peyronie's disease and subanalysis of patients who undergo the procedure despite preoperative counseling against it. J Sex Med. 2023. doi:10.1093/jsxmed/qdad164

11. Chierigo F, Fallara G, Tozzi M, et al. Guideline of guidelines: Peyronie's disease. BJU Int. 2026;137(5):770–782. doi:10.1111/bju.70201

12. Lue TF, El-Sakka AI. Venous patch graft for Peyronie's disease. Part I: technique. J Urol. 1998;160(6 Pt 1):2047–2049. doi:10.1097/00005392-199812010-00029

13. Sansalone S, Garaffa G, Djinovic R, et al. Long-term results of the surgical treatment of Peyronie's disease with Egydio's technique: a European multicentre study. Asian J Androl. 2011;13(6):842–845. doi:10.1038/aja.2011.42

14. Egydio PH. An innovative strategy for non-grafting penile enlargement: a novel paradigm for tunica expansion procedures. J Sex Med. 2020;17(10):2093–2103. doi:10.1016/j.jsxm.2020.05.010

15. Ainayev Y, Zhanbyrbekuly U, Gaipov A, et al. Comparison of technical success and adverse events of plaque incision and grafting methods in patients with Peyronie's disease: tunica vaginalis versus buccal mucosa. Urology. 2022;170:226–233. doi:10.1016/j.urology.2022.07.063

16. Natsos A, Tatanis V, Kontogiannis S, et al. Grafts in Peyronie's surgery without the use of prostheses: a systematic review and meta-analysis. Asian J Androl. 2024;26(3):250–259. doi:10.4103/aja202358

17. Danacıoğlu YO, Çolakoğlu Y, Yenice MG, et al. Comparison of two different grafts for the surgical treatment of Peyronie's disease. Andrologia. 2021;53(3):e13987. doi:10.1111/and.13987

18. Rosenhammer B, Sayedahmed K, Fritsche HM, et al. Long-term outcome after grafting with small intestinal submucosa and collagen fleece in patients with Peyronie's disease: a matched-pair analysis. Int J Impot Res. 2019;31(4):256–262. doi:10.1038/s41443-018-0071-1

19. Flores S, Choi J, Alex B, Mulhall JP. Erectile dysfunction after plaque incision and grafting: short-term assessment of incidence and predictors. J Sex Med. 2011;8(7):2031–2037. doi:10.1111/j.1743-6109.2011.02299.x

20. Taylor FL, Abern MR, Levine LA. Predicting erectile dysfunction following surgical correction of Peyronie's disease without inflatable penile prosthesis placement: vascular assessment and preoperative risk factors. J Sex Med. 2012;9(1):296–301. doi:10.1111/j.1743-6109.2011.02460.x

21. Montorsi F, Salonia A, Maga T, et al. Evidence-based assessment of long-term results of plaque incision and vein grafting for Peyronie's disease. J Urol. 2000;163(6):1704–1708.

22. Yafi FA, Diao L, DeLay KJ, et al. Multi-institutional prospective analysis of intralesional injection of collagenase clostridium histolyticum, tunical plication, and partial plaque excision and grafting for the management of Peyronie's disease. Urology. 2018;120:138–142. doi:10.1016/j.urology.2018.06.049