Surgery is generally reserved for stable Peyronie’s disease that prevents satisfactory intercourse. In published guidance, plication suits adequate length, good erections and non-severe curvature; grafting suits severe or complex deformity with good erections; a penile prosthesis suits erectile dysfunction unresponsive to medication. Each trades off shortening, sensation and erectile risk differently.
Peyronie’s disease is a fibrotic disorder of the tunica albuginea that causes penile curvature, indentation, shortening and, in some men, erectile dysfunction. Surgery is the definitive treatment for established deformity, but there are three distinct operations, each suited to a different anatomical and functional profile. This page sets out how surgeons choose between them, using a European position statement, a 2026 open-access comparison of the AUA, ISSM, CUA and EAU guidelines, and published outcome reviews. It describes each society’s position as it was summarized in those sources; consult the guideline texts for exact wording.
When is surgery needed?
The ESSM position statement says surgery is indicated when curvature, deformity or poor erectile quality prevents satisfactory intercourse, or when the deformity causes severe bother, and that it should be performed only after the disease has been stable for at least 6 to 12 months.[1] It describes about 6 months of stability as the accepted minimum, usually reached roughly 12 months after symptom onset.[1]
A 2026 comparison of four guidelines found that all require the deformity to be unchanged for at least 3 to 6 months, and that they differ on time since onset.[2]
| Source | Time since onset | Stability of deformity |
|---|---|---|
| AUA (2015) | Suggests more than 12 months | 3–6 months unchanged |
| ISSM (2016) and CUA (2018) | More than 6–12 months | At least 3–6 months unchanged |
| EAU (2025) | More than 9–12 months | At least 3 months unchanged |
| ESSM position statement (2022) | Stable at least 6–12 months | 6 months is the accepted minimum |
As summarized by Chierigo et al. (2026) and Osmonov et al. (2022).[2, 1] The 2026 review itself notes that thresholds for some societies are stated differently in its tables and text; confirm against the guideline before relying on a specific cut-off.
Practically, a man whose curvature is still changing, or who still has pain with erection, is generally not yet a surgical candidate. Ask for documented baseline measurements of curvature, length and erectile function; a penile Doppler ultrasound may be part of that assessment. Revision surgery, when needed, is recommended at least 6 months after the first operation.[1]
What the AUA guideline says about surgery
The American Urological Association’s Peyronie’s disease guideline (Nehra et al., Journal of Urology, 2015) grades evidence A to C and rates recommendations Strong, Moderate or Conditional; its panel states that the guideline “is not intended to be interpreted rigidly.”[6] As summarized in the 2026 comparison:[2]
- Timing: the AUA suggests waiting more than 12 months from onset, with 3 to 6 months of stable deformity.
- Plication and grafting: both are described for stable disease with adequate erectile rigidity, with or without pharmacotherapy or a vacuum device (Grade C). The summary states the AUA gives no guidance on choosing between plication and grafting, on plication technique, or on graft material.
- Penile prosthesis: for stable disease with erectile dysfunction, or a deformity that impairs intercourse, despite pharmacotherapy or a vacuum device (Grade C). The summary is internally inconsistent on whether the AUA prefers an inflatable device.
The same review reports that the CUA, EAU and ISSM do reserve grafting for more severe or complex deformity, and that the panels agree on four points: operate only after stabilization, prefer a prosthesis when erectile dysfunction does not respond to medication, avoid synthetic grafts, and recognize that no single technique has been proven superior.[2]
Decision matrix
| Factor | Favors plication | Favors incision / excision and grafting | Favors penile prosthesis |
|---|---|---|---|
| Degree of curvature | Non-severe: ISSM states minimal to moderate curvature; a 2013 review used under 60° and a single plane.[2, 3] | Severe, commonly cited as above 60° (CUA, ESSM); the EAU notes this threshold lacks unanimous panel consensus.[2, 1] | Under 30°, cylinder insertion alone may suffice; above 30°, manual modeling and further maneuvers may be needed.[1] |
| Penile length | Adequate length. ESSM suggests grafting when plication would cost more than 20% of length; a 2013 review used predicted loss under 20%.[1, 3] | Short penis, or concern about further loss (ISSM, CUA, EAU); plication that would cost more than 20% of length (ESSM).[2, 1] | ESSM reports a median length gain of about 3 cm in several series, and counsels that treatment may not restore pre-disease dimensions.[1] |
| Hourglass, hinge or indentation | Not suited to a significant hourglass causing a hinge (ISSM, CUA).[2] | Significant hourglass, indentation or hinge (ISSM, CUA, EAU, ESSM); ossified plaque (ESSM).[2, 1] | ESSM: complex deformities that would otherwise need grafting may be addressed with a prosthesis.[1] |
| Erectile function | Adequate rigidity, with or without medication or a vacuum device (AUA, as summarized).[2] | Preserved erections required; new erectile dysfunction is reported more often than after plication.[1] | Erectile dysfunction not responding to medication: EAU Strong recommendation (Level 2a); ESSM concurs.[2, 1] |
| Recommendation grade (as reported) | AUA Grade C; ISSM Level 3, Grade B; CUA Level 3, Grade C; EAU Level 3, Weak.[2] | AUA Grade C; ISSM Level 3, Grade B; CUA Level 3, Grade C; EAU Level 3, Weak.[2] | AUA Grade C; ISSM Level 3, Grade B; CUA Level 3, Grade C; EAU Level 2a, Strong.[2] |
Thresholds such as 60°, 30° and 20% length loss are conventions in position statements and reviews, not validated cut-offs. No comparative studies show one technique or graft to be superior.[1]
How the three operations differ
Tunical plication (shortening)
Plication shortens the tunica albuginea, usually at the point of maximal curvature, so the penis straightens at the cost of some length.[1] Named techniques include the Nesbit procedure, Yachia, 16-dot and simple plication.[3] The guidelines describe it for stable disease with adequate erections and length, non-severe curvature and no complex deformity (EAU: Level 3, Weak).[2] See penile plication surgery.
Plaque incision or excision with grafting (lengthening)
Grafting incises or excises the plaque and covers the defect with graft material, and is the option the guidelines describe for severe curvature, significant shortening or an hourglass deformity in men with good erections.[1, 2] ESSM reports higher rates of new erectile dysfunction than after plication.[1] ESSM strongly discourages synthetic grafts such as Dacron and Gore-Tex.[1] See dermal matrix grafting for Peyronie’s disease and the overview of Peyronie’s disease reconstruction.
Penile prosthesis
A prosthesis treats the erectile dysfunction and, in many men, the curvature in one operation. Mild to moderate curvature often straightens with the cylinders alone; if curvature persists above 30°, surgeons may model the penis manually and, if needed, add plication or grafting.[1] ESSM states that inflatable devices are superior to semirigid devices for curvature correction, rigidity, girth and concealability (Level 4, Grade C), while the EAU is described as reporting similar satisfaction for malleable devices.[1, 2] See inflatable vs malleable penile implant for that comparison.
Reported outcomes and complications
| Outcome | Plication | Grafting | Prosthesis |
|---|---|---|---|
| Curvature correction and satisfaction | Complete straightening 48%–100%; satisfaction 58%–96%.[1] | Straightening 67%–100%; satisfaction about 73%–97%.[1] | Straightening 84%–100%; satisfaction about 79%.[1] |
| Penile shortening | Reported in up to 74% in one series;[1] 13%–37% in Nesbit series in a 2013 review.[3] | 17%–29% at five years in one series of three graft materials (2013 review).[3] | Median gain about 3 cm in several series;[1] perceived shortening is the most frequent complaint after any implant.[7] |
| New or worse erectile dysfunction | De novo ED 0%–13% (Nesbit series) and 3%–12% (modified techniques) in a 2013 review.[3] | 4%–67% depending on study (for example 4% with buccal mucosa, 36% with vein); higher after grafting than after plication.[1] | Not applicable; rigidity comes from the device. |
| Loss of sensation | Glans hypoesthesia up to 53%, mostly mild; up to 29% fully resolved over 11–49 months.[1] | Up to 39% after incision and grafting; usually resolves within 12 months in many cases.[1] | Not quantified in the sources reviewed. |
| Recurrent or residual curvature | 0.5%–55% after shortening procedures.[1] | 8%–50% in several series; the ESSM text also cites a higher range elsewhere, reflecting inconsistency across series.[1] | Residual curvature above 20–30°: 0%–5% (2013 review).[3] |
| Other reported complications | Palpable sutures up to 71%; bulging or indentation 9%–16.7%.[1] | Palpable graft up to 50%; severe indentation up to 3%; glans necrosis up to 2.4%, with higher risk in diabetes, smoking and peripheral vascular disease.[1] | Mechanical malfunction 8%–12.5% and infection 1%–4.8% in series summarized in 2013.[3] |
Ranges come from heterogeneous, mostly retrospective series with different definitions and follow-up, and from reviews published in 2013 and 2022; they are not head-to-head comparisons. The ESSM authors note the International Index of Erectile Function is not validated in Peyronie’s disease.[1]
Graft material
A 2024 systematic review and meta-analysis of grafting without a prosthesis (58 studies, most single-arm and judged at high risk of bias) found that buccal mucosa grafts had the highest straightening rates and the least new erectile dysfunction, with the caveat that their benefit depended on lower preoperative curvature; TachoSil performed well even with greater curvature, and Tutoplast was associated with more postoperative erectile dysfunction. The authors conclude that randomized comparisons are still needed.[4] A 2013 review reported no consistent superiority of any graft and noted five-year recurrence of 13% with pericardium, 24% with small intestinal submucosa and 50% with dermis in one series.[3]
Non-surgical options (context only)
A 2013 review concluded that no non-surgical therapy was a clear, reliable cure, although several may reduce deformity or improve function. It reported no benefit from oral agents in placebo-controlled trials, curvature reduction of 30%–37% with intralesional collagenase versus 11%–21% with saline, small pilot data for traction, and no meaningful improvement in deformity from shockwave.[5] The 2024 meta-analysis notes that men with normal erections may also use intralesional injections, vacuum devices or traction.[4] Because the non-surgical review dates from 2013 and does not reflect later work, ask a specialist about current options.
Who should not choose each option
- Plication is a poor fit with a significant hourglass or hinge deformity, severe curvature, or length already so reduced that further loss is unacceptable.[2, 1]
- Grafting is a poor fit when erections are marginal or the man cannot accept a meaningful chance of new erectile dysfunction, since rates are higher than after plication.[1]
- A prosthesis is reserved for erectile dysfunction that does not respond to medication, or for complex deformity that would otherwise need grafting; it is not a first step for men whose erections are good.[1]
- Any surgery is premature while the deformity is still changing.[1, 2]
Cost and insurance
| Operation | Editorial cost band (USD) |
|---|---|
| Penile plication | $8,000 – $15,000 |
| Incision and grafting | $12,000 – $20,000 |
| Peyronie’s reconstruction (technique-dependent) | $10,000 – $20,000 |
| Malleable / inflatable prosthesis | $8,000 – $15,000 / $15,000 – $25,000 |
No published national price data exist for these operations; the bands are editorial estimates consistent with the site’s procedure pages and include surgeon, facility, anesthesia and device or graft costs. See Peyronie’s surgery cost and penile implant cost.
Peyronie’s disease is a recognized medical condition, and operations performed to restore the ability to have intercourse are more often submitted as medically indicated than cosmetic procedures. Coverage still depends on the plan and on documentation of deformity and function, so request pre-authorization and a written estimate before scheduling. No payer policy data were reviewed for this page.
Questions to ask your surgeon
- Is my disease stable by your criteria, and how will you document it?
- What are my curvature, length and erectile function, and which operation does that profile point to?
- How much shortening, loss of sensation and new erectile dysfunction should I expect with the technique you propose?
- If you recommend grafting, which material do you use, how often, and what are your own results?
- Do you perform plication, grafting and prosthesis surgery, and how many Peyronie’s operations do you perform each year?
- If straightening is incomplete at the time of surgery, what is the plan?
- What will insurance cover, and what happens if a revision is needed?
For choosing a surgeon, see how to choose a penile implant surgeon and our credential standard; for the erectile-dysfunction side of the decision, see ED treatments compared.
Sources
- Osmonov D, Ragheb A, Ward S, et al. ESSM position statement on surgical treatment of Peyronie’s disease. Sex Med. 2022;10:100459. https://pmc.ncbi.nlm.nih.gov/articles/PMC8847818
- Chierigo F, Fallara G, Tozzi M, et al. Guideline of guidelines: Peyronie’s disease (comparison of the AUA 2015, ISSM 2016, CUA 2018 and EAU 2025 guidelines). BJU Int. 2026;137(5):770–782. https://pmc.ncbi.nlm.nih.gov/articles/PMC13071548
- Mandava SH, Trost LW, Hellstrom WJG. A critical analysis of the surgical outcomes for the treatment of Peyronie’s disease. Arab J Urol. 2013;11(3):284–293. https://pmc.ncbi.nlm.nih.gov/articles/PMC4442995
- 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. https://pubmed.ncbi.nlm.nih.gov/38265253/
- Levine LA. Peyronie’s disease: a contemporary review of non-surgical treatment. Arab J Urol. 2013;11(3). https://pmc.ncbi.nlm.nih.gov/articles/PMC4442988
- 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 (PubMed record only; see the AUA for the full guideline text). https://pubmed.ncbi.nlm.nih.gov/26066402/
- Patel J, Zakkar B, Polchert M, Tannenbaum J, Dick B, Raheem O. Recent technological development of penile prosthesis: a literature review. Transl Androl Urol. 2024;13(1):165–184. https://pmc.ncbi.nlm.nih.gov/articles/PMC10891389
Cost figures are ranges and editorial estimates unless a source above states otherwise. This article is educational and is not medical advice.