The Scratch Technique and Endocavernosal Plaque Disruption
The scratch technique is an endocavernosal plaque disruption method performed from inside the corpora cavernosa — through the corporotomy incisions made for inflatable penile prosthesis (IPP) placement — without the need for penile degloving, circumferential skin incision, or neurovascular bundle mobilization.[1][2]
It sits alongside manual modeling as a minimally invasive adjunct during IPP surgery for Peyronie's disease, offering the ability to disrupt septal and ventral plaques that external approaches cannot reach. The related Shaeer punch technique extends the concept by using a punch forceps to formally excise plaque from inside the corpus.
Anatomic Rationale — Why Endocavernosal?
The defining feature: plaque disruption is performed from within the corpus cavernosum, through the same corporotomy used for cylinder placement. This offers three advantages that external approaches cannot:
- No NVB mobilization — the dorsal neurovascular bundle is never exposed, eliminating a primary source of postoperative sensory loss
- No degloving — no circumferential skin incision means no skin-flap devascularization risk and faster recovery
- Access to septal and ventral plaques — plaques deep within the septum between corpora, or on the ventral surface adjacent to the urethra, are easier to reach from inside than from outside
The Antonini Scratch Technique
Described by Antonini and colleagues in a 145-patient prospective series published in Journal of Urology in 2018.[1]
Step-by-step
- Standard corporotomy and dilation — per the surgeon's preferred IPP approach (penoscrotal, infrapubic, or subcoronal)
- Palpation of plaques from within the corporotomy — with the corpora dilated but before cylinder insertion, the surgeon introduces a finger or instrument and palpates the tunical plaque from the inside
- Endocavernosal disruption — the plaque is "scratched" with a sharp or blunt instrument (fine scissors tip, fine curette, or sharp needle) — multiple small incisions or scratches are made in the fibrotic tissue to disrupt its continuity
- IPP insertion — standard cylinder placement, rear-tip extender selection, and deployment
- Full inflation and assessment — device inflated to maximum; residual curvature measured by goniometer
- Escalation if needed — manual modeling, plication, or grafting added if residual curvature remains significant
Clinical outcomes (Antonini 145 patients)
Baseline:
- Mean preoperative IIEF-5: 9.8 ± 2.3
- Plaques distributed across proximal third, middle third, and subcoronal regions
Immediate postoperative residual curvature:
| Plaque location | Post-scratch + IPP only |
|---|---|
| Proximal third | 21.5° ± 4.5° |
| Middle third | 17.3° ± 4.8° |
| Subcoronal | 14.1° ± 3.1° |
Combined with postoperative vacuum therapy (3 min twice daily × 24 weeks):
| Plaque location | Final residual curvature |
|---|---|
| Proximal third | 8.7° ± 2.5° |
| Middle third | 9.1° ± 2.9° |
| Subcoronal | 7.7° ± 0.9° |
Functional outcomes:
- Mean IIEF-5 at 6 months: 18.9 ± 3.1 (P<0.001 improvement)
- Minimal complications
- No urethral or neurovascular injury reported
The 24-Week Vacuum Therapy Co-Protocol
The Antonini paper's most important contribution is the recognition that scratch technique alone leaves moderate residual curvature (14–21° depending on plaque location) — but when combined with a structured 24-week postoperative vacuum therapy protocol, residual curvature decreases to 7–9° across all locations.[1]
Protocol:
- Vacuum erection device applied twice daily
- 3 minutes per session
- 24 weeks total (6 months)
- Begin approximately 4 weeks postoperatively
Mechanism: Gentle longitudinal traction during the cicatrix-remodeling phase prevents contracture of the fractured plaque and extends the intraoperative correction into the early healing period.
Patient compliance with the vacuum protocol is essential — and is the main limitation of the technique. Patients who will not perform daily VED are not ideal candidates for scratch-only approaches.
The Shaeer Punch Technique
A more aggressive endocavernosal variant: instead of simply scratching the plaque, punch forceps are used to formally excise tissue from within the corpus.[2]
Technique
- Corporotomy and dilation
- Small punch forceps (typically 3–4 mm) introduced through the corporotomy
- Punches of plaque tissue excised from inside the corpus — the surgeon works along the tunical surface corresponding to the plaque, taking multiple small bites
- IPP cylinders placed
- Inflation and assessment
Outcomes — Shaeer series
26 patients treated with punch + IPP vs. 18 matched controls treated with excision-grafting:[2]
| Parameter | Punch technique | Excision-grafting |
|---|---|---|
| Preoperative curvature | 58.1° ± 11.7° | 58° ± 14.8° |
| Complete straightening | 100% | 100% |
| Additional operative time | 7.3 ± 1.7 min | 50.8 ± 11.1 min |
| Operative time reduction | –85% | |
| Glans hyposthesia | 0% | 39% |
The punch technique achieved equivalent straightening with 85% less operative time and no sensory loss. This single comparison captures the core value proposition of endocavernosal approaches.
Advantages of Endocavernosal Techniques
Compared with external plaque incision/grafting (PEG):[2][3]
| Advantage | Mechanism |
|---|---|
| Minimally invasive | No degloving; no circumferential skin incision |
| NVB preservation | Dorsal bundle never exposed → no sensory loss |
| Urethral safety | No external dissection near urethra → no urethral injury risk |
| Reduced operative time | 85% reduction vs. excision-grafting |
| Preserved sensation | 0% hypoesthesia in punch series vs. 39% with excision-grafting |
| Lower infection risk | Shorter operative time + less tissue dissection |
| Access to inaccessible plaques | Septal plaques reachable from inside that cannot be approached externally |
| No graft material required | Avoids graft cost, graft-related complications, and graft-associated ED risk |
Limitations and Caveats
Residual curvature without vacuum adjunct
Scratch technique alone typically leaves 14–21° residual curvature (Antonini data). This is acceptable only if:
- Patient will comply with the 24-week vacuum therapy protocol, or
- Additional intraoperative maneuvers (modeling, plication) are added, or
- Residual curvature is judged acceptable for intercourse
Patient selection
- Best for mild-to-moderate curvature after IPP insertion — 20–60°
- Severe curvature (>60°) may require more aggressive techniques (grafting / PICS)
- Calcified plaques may be difficult to disrupt with scratch alone — may yield better to punch technique
- Heavily fibrotic corpora benefit from the technique because the scratch also opens up space for cylinder expansion
Technique variability and terminology
The literature uses overlapping terms — "scratch technique," "manual modeling with scratching," "endocavernosal plaque disruption," "transcorporeal plaque surgery" — sometimes interchangeably. The key distinction is between:
- Manual modeling — external bending of the inflated device to fracture the plaque (see manual modeling)
- Scratch technique — internal disruption of the plaque with an instrument through the corporotomy
- Punch technique — internal formal excision of plaque tissue with punch forceps through the corporotomy
Many surgeons combine modeling + scratching, applying scratches inside the corpus and then modeling externally after cylinder placement.
Integration into the Adjunctive Ladder
Per the Hammad 2025 multicenter data, manual modeling with or without scratch technique is used in 74.7% of PD-IPP cases — establishing it as the dominant first-line adjunct.[4]
Recommended approach:[3][5][6]
- First-line: Manual modeling ± scratch technique after IPP insertion
- Second-line (if residual curvature >30°): Concurrent tunical plication
- Third-line (if residual curvature >40–60° or complex deformity): Plaque incision + grafting (PICS)
See prosthesis with adjunctive straightening for the complete algorithm.
Postoperative Adjuncts
Vacuum therapy (Antonini protocol)
- 3 minutes twice daily
- 24 weeks total
- Reduces residual curvature from 14–21° to 7–9° across plaque locations[1]
Home modeling (Moncada protocol)
- Begin 4 weeks postop
- Manual bending of inflated device opposite residual curvature
- Daily sessions × 6 months
- 94.7% achieve ≤10° residual at 6 months[7]
See manual modeling for detailed home-modeling protocol.
Early prosthesis activation
Some surgeons advocate early daily cycling of the inflated device (beginning 2–3 weeks postop) as an alternative to formal vacuum therapy — the daily inflation-deflation cycle provides similar remodeling benefit without external device use.
PDE5 inhibitors
Low-dose daily PDE5 inhibitors (sildenafil 25–50 mg) can enhance erectile tissue oxygenation in the healing phase; limited evidence, but low risk.
Complications
Complications are minimal with endocavernosal approaches, reflecting their minimally invasive nature:[1][2]
| Complication | Rate |
|---|---|
| Temporary decreased penile sensation | Rare (0% in Shaeer punch series; 39% in comparator excision-grafting) |
| Infection | 1–4% (not elevated over standard IPP) |
| Hematoma | Uncommon |
| Cylinder damage during scratching | Theoretical — cylinders are placed after scratching in most protocols |
| Prosthesis-related complications | No increased risk vs. standard IPP |
| Urethral injury | None reported |
| Neurovascular injury | None reported |
Adjunctive Technique Comparison
| Technique | Median correction | Operative time | Complications | Graft required |
|---|---|---|---|---|
| Scratch + vacuum therapy | 12–14° immediate → 6–9° final | Minimal additional | Minimal | No |
| Punch technique | Complete straightening | +7 min | Minimal; no sensory loss | No |
| Manual modeling alone | 26° [20°, 39.5°] | Minimal | Urethral perforation 1–3% | No |
| Optimal modeling (Lucas) | 37° (47.8°→10.6°) | +7 min | None reported | No |
| Tunical plication | 40° [28.8°, 41.2°] | Moderate | Palpable sutures, shortening | No |
| Plaque incision + grafting | 55° [48.8°, 73.8°] | +50–120 min | Sensory loss (6–39% with external), hematoma | Yes |
Clinical Implications
The scratch and punch techniques represent minimally invasive, time-efficient approaches for PD-IPP surgery that:[1][2]
- Avoid NVB mobilization and associated sensory complications
- Reduce operative time dramatically vs. grafting
- Provide adequate curvature correction when combined with postoperative vacuum therapy
- Serve as excellent first-line adjunctive maneuvers before escalating to more invasive techniques
- Offer access to septal plaques that external approaches cannot reach
Patient counseling should emphasize:
- Expectation of moderate residual curvature immediately postoperatively (14–21°)
- Necessity of compliance with 24-week vacuum therapy or home-modeling protocol
- Gradual improvement over 6 months
- Excellent functional outcomes with minimal complications
See Also
- Peyronie's disease — overview
- Manual modeling
- Prosthesis with adjunctive straightening
- Plaque incision / excision with grafting
References
1. Antonini G, De Berardinis E, Del Giudice F, et al. Inflatable penile prosthesis placement, scratch technique and postoperative vacuum therapy as a combined approach to definitive treatment of Peyronie's disease. J Urol. 2018;200(3):642–647. doi:10.1016/j.juro.2018.04.060
2. Shaeer O, Soliman Abdelrahman IF, Mansour M, Shaeer K. Shaeer's punch technique: transcorporeal Peyronie's plaque surgery and penile prosthesis implantation. J Sex Med. 2020;17(7):1395–1399. doi:10.1016/j.jsxm.2020.03.018
3. Berookhim BM, Karpman E, Carrion R. Adjuvant maneuvers for residual curvature correction during penile prosthesis implantation in men with Peyronie's disease. J Sex Med. 2015;12 Suppl 7:449–454. doi:10.1111/jsm.13001
4. Hammad MAM, Barham DW, Simhan J, et al. A multicenter evaluation of penile curvature correction in men with Peyronie's disease undergoing inflatable penile prosthesis placement. J Sex Med. 2025;22(2):349–355. doi:10.1093/jsxmed/qdae192
5. Conlon WJ, Herzog BJ, Hellstrom WJG. Residual penile curvature correction by modeling during penile prosthesis implantation in Peyronie's disease patients. Int J Impot Res. 2023;35(7):639–642. doi:10.1038/s41443-023-00694-5
6. El-Khatib FM, Huynh LM, Yafi FA. Intraoperative methods for residual curvature correction during penile prosthesis implantation in patients with Peyronie's disease and refractory erectile dysfunction. Int J Impot Res. 2020;32(1):43–51. doi:10.1038/s41443-019-0215-y
7. Moncada I, Krishnappa P, Ascencios J, Lopez I, Martinez-Salamanca JI. Home modeling after penile prosthesis implantation in the management of residual curvature in Peyronie's disease. Int J Impot Res. 2021;33(6):616–619. doi:10.1038/s41443-020-0325-6