Journal of Investigative Surgery, 24, 44–48, 2011

Copyright
C Informa Healthcare USA, Inc.

ISSN: 0894-1939 print / 1521-0553 online

DOI: 10.3109/08941939.2010.526682

ORIGINAL RESEARCH

Tunica Albuginea Reefing: A Novel Technique for the

Treatment of Erectile Dysfunction
Olfat el-Sibai, MD, PhD,1 Ali A. Shafik, MD, PhD,2 Ismail A. Shafik, MCh, MD3

1
Department of Surgery, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt, 2 Professor of Surgery,
Department of Surgery and Experimental Research, Faculty of Medicine, Cairo University, Cairo, Egypt, 3 Assistant
Professor of Surgery, Department of Surgery and Experimental Research, Faculty of Medicine, Cairo University, Egypt
J Invest Surg Downloaded from informahealthcare.com by Universitat de Girona on 11/04/14

ABSTRACT
Background: “Tunica albuginea (TA) reefing” is a modification of Shafik’s “TA overlapping” operation. Both tech-
niques are based on the fact that in venogenic erectile dysfunction patients, the TA exhibits degenerative and at-
rophic collagen and elastic fibers causing its subluxation and flabbiness. This had led to loss of the veno-occlusive
mechanism of the TA and venous leakage during erection. Aim: Reefing of the redundant tissue by bilateral ex-
cision of an ellipse of the TA provides a more effective correction of the TA and achieves a good support of the
corpora cavernosa during tumescence. Material and Methods: The study included 24 patients with a mean age of
33.5 ± 1.7 SD years. Intracorporal pressure was measured preoperatively and postoperatively. After penile de-
For personal use only.

gloving, an ellipse was excised from both lateral aspects of the penile shaft, extending from the glans penis to its
root, and the two edges of each wound were reefed by continuous Dexon suture. Results: The TA ellipses were
taken as biopsies and revealed degenerative changes when stained with hematoxylin and eosin and Masson’s
trichrome stain. Postoperatively, there was an intracorporal pressure increase (p < .01) in 20 out of 24 patients
of the study and a decrease in 4 out of 24. Six months after operation, the patients showed significantly (p <
.01) improved scores for the domain of erectile function over the preoperative scores. Conclusion: The reefing op-
eration corrects the TA flabbiness to a greater extent, lends more support to corporal tissue, and improves the
veno-occlusive mechanism.
Keywords: tunica albuginea, impotence, erectile dysfunction, penis, venous ligation

INTRODUCTION The intracorporal pressure (ICP) during erection

Failure of adequate venous occlusion has been pro-
posed as one of the most common causes of venogenic
impotence [1]. The cause of veno-occlusive dysfunc-
tion is not exactly known. Several pathophysiological
processes have been advocated, which include the
presence of large venous channels draining the cor-
pora cavernosa (CC); [2–5] mentioned that the venous
leakage is not a venous disease but a result of impaired
cavernous tissue.
The venogenic erectile dysfunction (VED) is treated
by penile vein ligation if other less invasive measures
have failed to induce adequate erection [6]. The failure
of venous ligation was ascribed to the presence of ex-
travenous channels in imaging films [7]. In the opin-
ion of Shafik et al. [8], these treatment modalities try to
manage a secondary effect rather than the primary etio-
logical factor of VED, which explains the unsatisfactory
results of treatment.
was found to be significantly lower in VED patients
than in healthy controls.
The collagen fibers of the tunica albuginea (TA)
of these patients exhibited degenerative and atrophic
changes, which appear to have effected TA subluxa-
tion and flabbiness. Such TA changes presumably lead
to diminution or loss of the TA veno-occlusive mecha-
nism and decrease of ICP. Accordingly, it was hypothe-
sized that overlapping of the subluxated and flaccid TA
would effect a competent veno-occlusive mechanism
during erection. Aiming at correction of the tunical sub-
luxation and flabbiness, Shafik et al. [8] devised a tech-
nique under the name of “tunical overlapping opera-
tion.” The improvement following the operation seems
to be attributable to the correction of TA flabbiness and
better support of the corporal tissue during erection.
The aim of this study is to assess a modification of
the TA overlapping operation under the name of “TA
reefing” on the effect of maintaining proper erection.

Address correspondence to Olfat El-Sibai, MD, PhD, Ahmed Shafik Hospital, 7 Gamal Salem St., Off. Mossadek St. Dokki 12311 Giza, Egypt.
E-mail: shafik@ahmedshafik.com
44
 Tunica Albuginea Reefing 45

MATERIAL AND METHODS

Subjects

The study included 24 patients with a mean age of 33.5

± 1.7 SD years (range 27–41 years), who had VED of a
mean duration of 5.3 ± 1.3 SD years (range 2–7 years).
They had been subjected to many treatment modalities
such as medications including Viagra, intracavernous
injection of vasodilators, and venous ligation, but all re-
mained unsatisfactory in achieving adequate erection.
The patients gave history of partial erection for only
1.8 ± 0.4 SD min (range 1.2–2.3 min). Clinical exami-
nation and endocrinal profile were normal. The penile
biothesiometry and the resting penile brachial indices
showed normal parameters. Doppler ultrasound re-
vealed venous leakage. Dynamic cavernosometry and
J Invest Surg Downloaded from informahealthcare.com by Universitat de Girona on 11/04/14

cavernosography demonstrated an incompetent veno-

occlusive mechanism.
Consent was given by all patients of the study af-
ter they had been informed about the nature of the
operation and its possible results. The study was ap-
proved by the Review Boards and Ethics Committees
of the Cairo and Menoufia Universities’ Faculties of
Medicine.
For personal use only.

Methods

Both operations, the TA reefing and the TA overlapping FIGURE 1 Diagram illustrating the
steps of TA reefing: (a) incision into
[8], are based on the same hypothesis, but in the former,
lower third of TA extending from corona
an ellipse of TA tissue from the two lateral aspects of glandis to penile root, (b) undermining
the penile shaft are excised, and the TA is reefed. of the TA flap from CC, (c) excision of
The ICP was measured before and immediately af- an ellipse of TA, and (d) two edges of
ter the operation as well as two weeks, two months, and the TA wound were reefed by continu-
ous 3–0 Dexon suture.
six months thereafter. This is done with a 21-gauge nee-
dle inserted into one of the CC and connected to a strain
gauge pressure transducer (Statham 230B, Oxnard, CA,
contralateral aspect of the penis. The skin was closed
USA).
with 4–0 chromic catgut sutures (Figures 2–4).
A catheter was placed in the urethra, and the penis
The urethral. catheter was removed, and the ICP
was degloved through a circumcision incision. The pe-
was measured again at the end of the operation. The
nis was stretched to lie horizontally straight by pulling
on the stay silk stitch applied to the tip of the glans
penis.
A tourniquet was applied to the root of the penis. A
longitudinal incision was made in the lower third of the
lateral aspect of the penis, which should extend from
just before the corona glandis to the penile root. The in-
cision divided all of the dartos skin, Buck’s fascia, and
the TA. The upper flap of the TA incision was under-
mined from the CC (Figures 1a and b).
An ellipse of TA tissue was excised with a maximum
width of 0.8–1.3 cm and taken as biopsy (Figure 1c).
Then, the two edges of the TA wound were sutured to-
gether in a reefing manner by using a continuous su-
ture of 3–0 Dexon (Figure 1d). FIGURE 2 Operative procedure showing lon-
The subcutaneous tissue was sutured in another gitudinal incision on the lateral and lower third
layer. All steps of this procedure were repeated on the shaft of penis (TA was very thick).

C 2011 Informa Healthcare USA, Inc.
 46 O. el-Sibai et al.

RESULTS

The postoperative period was smooth without compli-

FIGURE 3 Excision of an ellipse of TA.
patients were given antibiotics for three postopera-
J Invest Surg Downloaded from informahealthcare.com by Universitat de Girona on 11/04/14
cations, but 14 patients were complaining of frequent
diurnal and nocturnal erections awakening them and
staying for 3–6 min. They started on the third postop-
erative day and lasted throughout their hospital stay
and for 30–45 days thereafter. Five patients needed se-
dation to abort the painful erections.
Before operation, the mean ICP in 20 out of 24 pa-
tients measured 4.5 ± 2.1 cm H2 O, while 14.3 ± 1.2 cm
H2 O in the immediate postoperative period (Table 1).
The ICP taken two weeks as well as two and six months
after operation showed a significant increase in the 20
patients (p < .01). In the remaining four patients, the
ICP increased significantly during the immediate post-
operative period and two weeks thereafter but showed

tive days and were advised to abstain from sexual
intercourse for the first four postoperative weeks. The
follow-up period ranged from 8 to 12 months (mean
10.7 ± 1.8). The clinical efficiency of the operation was
evaluated six months after the operation, using the In-
ternational Index of Erectile Function questionnaire,
which is based on the score for five separate response
domains [9] and addresses the issues of erectile func-
tion, orgasmic function, sexual desire, intercourse satis-
For personal use only.
significant reduction with no significant difference (p >
.05) against preoperative levels (Table 1).
The erectile function domain of the 20 out of 24 pa-
tients of the study had better scores six months after
operation compared with the preoperative scores (Ta-
ble 2): they showed significant improvement of the do-
mains of erectile function, orgasmic function, sexual
desire, intercourse satisfaction, and overall satisfaction
(p < .001). All of the 20 patients were satisfied with the

faction, and overall satisfaction. The final score for each
domain was computed as the sum of the scores given
to the individual questions in each domain.
The measurements were repeated twice in the indi-
vidual subject, and the mean value was calculated. The
results were analyzed statistically using the student’s
t-test, and values were given as mean ± SD. Differences
assumed significance at p < .05.
The TA biopsy was fixed in 10% formalin, dehy-
drated in graded alcohol, and processed for histolog-
ical examination. It was stained with hematoxylin and
eosin and with Masson’s trichrome stain, the latter
staining collagen and elastic fibers blue and smooth
muscle red for photomicrography.
results of the operation and did not complain of the
diametric reduction of the penile shaft during sexual
intercourse.
The remaining four patients, who had no erections
before operation, achieved partial erection, but their
scores for erectile function domain were unsatisfac-
tory (Table 2). Their ICP exhibited improvement im-
mediately and two weeks postoperatively, but two and
six months after operation had not improved to full
erection.
Microscopic examination of TA biopsies showed de-
generative changes and atrophy of collagen fibers. The

TABLE 1 ICP of 24 patients before and immediately after, as

well as two weeks, two months, and six months postoperation
of the TA reefing

ICP (cm H2 O)

20 patients 4 patients

Operation Mean Range Mean Range

Before 4.6 ± 2.1 3–6 4.2 ± 1.2 3–5

Immediately after 14.3 ± 1.2∗∗ 10–17 12.1 ± 1.4∗∗ 9–15
After two weeks 13.1 ± 2.1∗∗ 9–16 10.8 ± 2.1∗∗ 8–14
After two months 12.8 ± 1.7∗∗ 9–17 6.5 ± 1.7∗ 5–7
After six months 13.5 ± 2.2∗∗ 9–16 5.1 ± 2.2∗ 4–6

Note: Values are given as mean ± SD. Postoperative p values were

FIGURE 4 Two edges of TA wound reefed by compared with the preoperative p values.
∗
continuous suture (Dexon 3–0). p > .05; ∗∗ p < .01.

Journal of Investigative Surgery


TABLE 2 Scores of International Index of Erectile Function of 24 patients before and six months after TA reefing
Erectile Orgasmic
No. of patients function function
20
Before treatment 8.9 ± 2.3 5.9 ± 2.2
After treatment 27.3 ± 1.6∗∗∗ 7.9 ± 1.2∗∗
4
Before treatment 9.8 ± 2.1 5.9 ± 2.3
After treatment 10.5 ± 1.1∗ 6.4 ± 1.6∗
Note: Values are given as mean ± SD. Values of p before treatment were compared with those after treatment.
∗
p > .05; ∗∗ p < .01; ∗∗∗ p < .001.
elastic fibers were fragmented and recoiled and some-
times scarce or completely absent from the specimens.
J Invest Surg Downloaded from informahealthcare.com by Universitat de Girona on 11/04/14
DISCUSSION
The here-described new surgical approach was used
for the patients of this study after they had earlier been
unsuccessfully subjected to many lines of the known
conservative therapies for VED.
In VED, the ability of achieving and maintaining full
For personal use only.
erection is impaired by excessive venous outflow. Nor-
mally, the venules, which drain the sinusoidal spaces,
approach the CC periphery and form the subtunical
venular plexus [10].
Small veins exit from the plexus through the TA as
emissary veins and drain into the circumflex veins or
directly into the deep dorsal vein. The position of the
subtunical venular plexus between the sinusoids and
the TA allows for its compression and occlusion, while
the smooth muscle and the sinusoids relax and expand
against the TA during tumescence. This occlusion acts
to trap the blood within the penis [10, 11]. Many stud-
ies reported that the TA has a significant role in the
veno-occlusive mechanism of the penis during erection
[12, 13, 10, 11]. The loss of this veno-occlusive func-
tion leads to leakage of penile blood causing impotence
[10, 11]. As the TA is mainly composed of noncompli-
ant collagen fibers, it occludes the penile venous out-
flow by compressing the subtunical venular plexus and
perforating emissary veins passing through it. Further-
more, under normal physiologic conditions, the TA is
responsible for morphologically shaping the penis dur-
ing erection [8].
The collagenous structure gives the TA a textile na-
ture, which firmly supports the penile architecture dur-
ing penile tumescence. This TA textile nature with its
circularly and longitudinally oriented collagen fibers
lends the TA an adaptability to adjust its length and
breadth according to the penile status, whether flac-
cid or erected. Owing to their inelasticity, the colla-
gen fibers limit excessive tunical stretch during penile
tumescence. This mechanism prevents tunical sublux-


C 2011 Informa Healthcare USA, Inc.
Tunica Albuginea Reefing 47
Intercourse Overall
Sexual desire satisfaction satisfaction
4.8 ± 1.6 6.1 ± 2.3 3.6 ± 1.2
6.8 ± 1.2∗∗ 11.1 ± 1.1∗∗ 9.6 ± 1.3∗∗∗
6.1 ± 2.2 7.5 ± 2.2 4.4 ± 1.1
6.7 ± 1.6∗ 7.8 ± 1.6∗ 4.9 ± 0.6∗
ation and flabbiness, which may result from repeated
penile tumescence occurring during the sexual life.
Meanwhile, an atrophic subluxated TA would not only
disrupt the “venous-leak proof” effect of the TA but
also disturb the solidity of the erected penis during the
process of vaginal penetration and thrusting [14].
The histopathological study of the TA biopsies of the
patients of the study demonstrated degenerative and
atrophic changes in collagen and elastic fibers. This was
responsible for the subluxation and flabbiness of the
TA.
According to the hypothesis, impairment or loss of
the TA veno-occlusive mechanism in VED patients re-
sults from degenerative and atrophic changes of colla-
gen and elastic fibers in their TA [8]. TA reefing is based
on these facts.
Both operations, the TA overlapping [8] and the TA
reefing, aim at correcting the subluxated and flabby TA.
While the TA overlapping operation devises a unilat-
eral plane for the correction through a longitudinal in-
cision and does not excise the undermost tissue layer
of the longitudinally folded TA before suturing, the TA
reefing operation offers a more extensive correction of
the redundant TA through excision of a TA ellipse on
either side of the penile shaft.
Surprisingly, in the TA reefing operation, the 14 pa-
tients felt frequent erection from the third postoper-
ative day. The immediate improvement in the penile
tumescence is due to excision of a good amount of the
flabby TA tissue. It results in the creation of an efficient
veno-occlusive mechanism, which seems to play an im-
portant role in correcting the disordered erectile mech-
anism. This fact also bears positively on the patient’s
self-confidence and supports the process psychologi-
cally.
Therefore, the success rate of this technique is as
high as 83%, while the failures come to 17%. This could
be due to insufficient removal of the subluxated TA.
In conclusion, the TA reefing technique for treatment
of VED is simple, easy, and without complications; it
aims at correction of the TA flaccidity and subluxa-
tion, support of corporal tissue, and improvement of
the veno-occlusive mechanism.
 48 O. el-Sibai et al.
Nomenclature
CC corpora cavernosa
ICP intracorporal pressure
TA tunica albuginea
VEDvenogenic erectile dysfunction
Declaration of Interest: The authors report no conflict
of interest. The authors alone are responsible for the
content and writing of this paper.
REFERENCES
[1] Rajfer K, Rosciszewski A, Mehringer M. Prevalence of cor-
poral venous leakage in impotent men. J Urol. 1988;140:
J Invest Surg Downloaded from informahealthcare.com by Universitat de Girona on 11/04/14
69–71.
[2] Dalkin BL, Carter MF. Venogenic impotence following der-
mal graft repair for Peyronie’s disease. J Urol. 1991;146:
849–851.
[3] Hauri D, Alund G, Spycher M, et al. Venous leakage—a new
therapeutic concept. Urologe 1991;30:267–271.
[4] Iacono F, Barra S, DeRosa G, et al. Microstructural dis-
orders of tunica albuginea in patients affected by Pey-
For personal use only.
ronie’s disease with or without erection dysfunction. J Urol.
1993;150:1806–1809.
[5] Metz P, Ebbehoj J, Uhrenholdt A, et al. Peyronie’s disease
and erectile failure. J Urol. 1983;130:1103–1104.
[6] Lewis R. Surgery for erectile dysfunction. In: Campbell’s
Urology, 7th ed. Walsh PC, Retik AB, Vaughan ED, Wein AJ,
eds. Philadelphia, PA: WB Saunders; 1998:1215–1235.
[7] Hsu GL, Hsieh CH, Wen HS, et al. Penile venous anatomy:
an additional description and its clinical application. J An-
drol. 2003;24:921–927.
[8] Shafik A, Shafik IA, El-Sibai O, et al. Tunica albuginea over-
lapping: a novel technique for the treatment of erectile dys-
function. Andrologia 2005;37:180–184.
[9] Goldstein I, Lue TF, Padma-Nathan H, et al. Oral sildenafil
in the treatment of erectile dysfunction. Sildenafil Study
Group. N Engl J Med. 1998;338:1397–1400.
[10] Fournier GR, Juenemann K, Lue TF, et al. Mechanisms of
venous valvular system. J Urol. 1987;127:1099–1100.
[11] Montague DK, Lakin MM. False diagnosis of venous leak
impotence. J Urol. 1992;148:148–149.
[12] Ebbehoj J, Wagner G. Insufficient penile erection due to
abnormal drainage of cavernous bodies. Urology 1979;13:
507–510.
[13] Fitzpatrick TJ. Penile intercommunicating venous valvular
system. J Urol. 1982;127:1099–1100.
[14] Shafik A, Shafik IA, El-Sibai O, et al. On the pathogenesis
of penile venous leakage: role of the tunica albuginea. BMC
Urol. 2007;7:14.
Journal of Investigative Surgery