The nationwide multicenter series by Costa Silva et al. [1] provides a relevant contribution to the evolving debate on graft selection in the surgical management of Peyronie’s disease (PD). In a field where high-quality comparative data remain limited, their cohort of 88 patients undergoing lengthening corporoplasty with collagen fleece (TachoSil®) between 2016 and 2024 demonstrates satisfactory curvature correction and overall procedural safety, although postoperative erectile dysfunction (ED, 38.6%) and residual curvature (19.3%) remain significant concerns. The solid sample size and multicentric design strengthen the study’s external validity and provide a realistic representation of current clinical practice.

The search for the ideal graft in PD reconstructive surgery remains one of the major challenges in andrology. An optimal graft should be resistant to traction yet flexible enough to restore natural tunical elasticity; show excellent biocompatibility, and integrate without contraction or inducing inflammation—all while being readily available and easy to apply, cost-effective, and associated with minimal donor-site morbidity. None of the currently available materials fulfills all these requirements. Historically, a wide spectrum of autologous, heterologous, and synthetic grafts has been used, each offering advantages but also relevant limitations. Many surgeons have progressively abandoned autologous grafts to reduce operative time and avoid the morbidity associated with a second incision. Others have preferred collagen fleece (TachoSil®) because of its hemostatic properties, suturless application and reduced surgical time [2].

TachoSil® consists of an equine collagen sponge coated with human fibrinogen and thrombin. When the material comes into contact with tissue moisture, a fibrin clot forms within seconds, securing adhesion to the tunical defect and achieving effective hemostasis. This sutureless adhesion minimizes manipulation of the corporal tissue, reduces the risk of suture-related ischemia, and facilitates rapid and uniform defect coverage. These properties make TachoSil® particularly suitable after plaque incision or excision, where coverage and sealing of the tunical defect are critical [3].

Despite these benefits, histological and experimental data consistently showed that collagen fleece acts primarily as a mechanical and hemostatic barrier, rather than a regenerative scaffold. While the underlying corpora cavernosa remain preserved, studies in animal models have demonstrated that no true regeneration of the tunica albuginea or neovascularization occurs beneath the patch, even at two months post-implantation [4]. Nonetheless, clinical results have been encouraging, with high intraoperative success rates and acceptable short- to mid-term outcomes [5, 6].

The median follow-up reported by Costa Silva et al. [1] (31 months) provides valuable mid-term insight into postoperative results. However, it would be particularly informative to assess outcomes at longer follow-up. Previous experiences with other grafts have revealed late recurrences of curvature and progressive ED, often due to delayed graft contraction or chronic inflammatory remodeling [7]. Long-term monitoring is therefore essential to determine whether collagen fleece maintains its mechanical stability and whether the initial correction remains durable over time.

A crucial aspect of PD surgery is patient selection—specifically, determining when to perform lengthening corporoplasty versus proceeding directly to penile prosthesis implantation. This decision remains a delicate balance between preserving erectile function and avoiding multiple procedures. Early implantation can prevent secondary surgery and corporal fibrosis but may also entail penile shortening and prosthesis-related complications. Conversely, grafting alone carries a risk of postoperative ED that may eventually necessitate prosthesis placement. Defining the ideal timing and patient profile for each approach is key to optimizing outcomes, emphasizing the importance of preoperative counseling and shared decision-making.

The complication rates reported by Costa Silva et al. [1]—hematoma 8%, infection 2.3%, ED 38.6%, and residual curvature 19.3%—align closely with previously published data. Similar figures have been observed in multicenter and single-center studies using TachoSil® or other grafts, where postoperative ED ranged from 5% to 48% [8]. These consistent findings suggest that, while collagen fleece provides clear intraoperative advantages—such as ease of use, reduced bleeding, and avoidance of suture-related trauma—it does not appear to significantly alter the long-term risk of de novo ED. A detailed distinction between new-onset ED and deterioration of preexisting dysfunction would further clarify functional outcomes. Similarly, quantitative reporting of penile length changes would strengthen the interpretation of postoperative results, given the high patient sensitivity to this parameter.

Despite extensive research over the past decades, no grafting material has demonstrated unequivocal superiority. The variability in patient cohorts, surgical techniques, and outcome definitions continues to obscure comparative interpretation. Furthermore, most studies such as the one from Costa et al. [1], are retrospective or non-randomized, often lacking standardized measures of penile curvature, length, or validated functional scales. From a biological perspective, the trade-off persists: materials that integrate well may contract, while inert materials rarely promote regeneration.

The study by Costa Silva et al. [1] adds meaningful evidence to the understanding of collagen fleece grafting in PD. Moving forward, the field should prioritize prospective, randomized, multicenter trials directly comparing TachoSil® with other established grafts. Rigorous documentation of curvature correction, penile length, and validated patient-reported outcomes will be fundamental to achieve reproducible results. At the same time, translational research should aim to develop next-generation grafts capable not only of mechanical coverage but also of promoting tunical remodeling and vascular regeneration.

In conclusion, collagen fleece remains a technically appealing and reliable option for tunical reconstruction in Peyronie’s disease, combining ease of use with strong hemostatic properties. However, its long-term functional efficacy requires careful interpretation. The ultimate goal remains clear: to minimize postoperative erectile dysfunction, reduce the need for sequential surgeries, and ensure patient-tailored surgical strategies supported by long-term, standardized follow-up.

All authors have no substantial or indirect commercial financial incentive associated with publishing the article