Surgical Treatment of Peyronie’s Disease: A Critical Analysis

Tunica albuginea underlap--a new modification of the Nesbit procedure: description of the technique and preliminary results

INTRODUCTION

We describe a new surgical technique for the treatment of penile curvature that combines features of the Nesbit procedure with features of tunical plication. U-shaped flaps of tunica albuginea are freed from the corpus cavernosum. The flaps are brought under the remaining tunica albuginea and are fixated with single absorbable sutures. As the defects of the tunica are sealed tightly and with high tensile strength by double layers of tunica albuginea, correction of the abnormal curvature is achieved.

AIM

To present our experience with a new surgical technique for the treatment of penile curvature.

METHODS

Between 2008 and 2011, 50 patients underwent the underlap technique because of Peyronie's disease (37) or congenital penile deviation (13) in a single center.

MAIN OUTCOME MEASURES

Preoperative and postoperative evaluation included the Erection Hardness Score (EHS) and the Symptom Score for Induratio penis plastica (IPP-SSC), a symptom score for penile deviation that was based on a consensus of regional andrologists. Clinical data concerning the early postoperative outcome were analyzed retrospectively using standardized items.

RESULTS

Mean age ± standard deviation was 59.7 ± 8.4 years for patients with Peyronie's disease and 34.1 ± 7.8 years for patients with congenital penile deviation. The mean follow-up period was 27 months. The major complication rate was 4%, overall satisfaction 86%. Intraoperative correction of the curvature was achieved in 100%, significant relapse occurred in 6%. The mean difference of preoperative and postoperative IPP-SSC was 8.1 (95% confidence interval [CI] 7.24 to 8.96). The mean difference of preoperative and postoperative EHC was -0.03 (95% CI -0.16 to 0.09).

CONCLUSIONS

Preliminary results obtained with the underlap technique showed promising outcome with minimal morbidity. The new technique might have three main advantages: more flexible intraoperative correctability of the curvature, tighter sealing of the tunical defects, and greater tensile strength of the plications.

Decorin as a new treatment alternative in Peyronie's disease: preliminary results in the rat model

The purpose of this study is to investigate the effect of decorin, a naturally occurring proteoglycan with anti-transforming growth factor beta (TGF-β) activity, on the rat model of Peyronie's disease (PD). Twenty-five adult male Sprague-Dawley rats were divided in three groups: I) TGF-β (0.5 μg) injected (n: 8); II) TGF-β injected and decorin treated (n: 8); and III) controls (n: 9). Decorin (0.5 μg per day) was given with intracavernous injection on the second, third, fourth and fifth day following TGF-β injection. All rats underwent electrical stimulation of the cavernous nerve after 6 weeks. Intracavernosal and arterial blood pressures were measured during this procedure. Cross-sections of the rat penises were examined using Mason trichrome and H&E stains. Statistical analyses were carried out using one-way anova. Histopathological examinations confirmed the Peyronie's-like condition in TGF-β-injected rats, which exhibited a thickening of the tunica albuginea (TA), when compared to controls. Disorganisation of collagen on the TA was also prominent in TGF-β-injected rats, but not in decorin-treated and control rats. Decorin-treated rats showed significantly higher maximal intracavernosal pressure (MIP) responses to cavernous nerve stimulation, when compared to group 1 (P < 0.05). Our results indicate that decorin antagonises the effects of TGF-β in the rat model of PD and prevents diminished erectile response to cavernous nerve stimulation.

[Trans-scrotal penile degloving, a new procedure for corporoplasties]

INTRODUCTION

The subcoronal approach is the most widely used skin degloving procedure for corporoplasty. Although it is relatively easy and it fully exposes the corpora cavernosa, it is not free from several complications (subcoronal lymphedema, decrease of glans sensitivity, paraphimosis, distal skin necrosis), which sometimes require a postoperative circumcision, or a preoperative prophylactic circumcision.

AIM

To describe our own degloving approach, the "Trans-scrotal Penile Degloving (TPD)", that is suitable for most corporoplasties, and to present the outcomes.

METHODS

This is a retrospective analysis conducted on 89 patients (pts) presenting with different penile diseases, and submitted to the TPD during Corporoplasty, from February 2008 to July 2010: Congenital curvature (26 pts); Peyronie's Disease (PD) with penile curvature (18 pts); PD with erectile dysfunction and curvature (25 pts); Redo surgery with complex tunica albuginea remodeling and prosthesis implant (20 pts). The TPD approach calls for a 5 cm incision to be placed ventrally on the scrotal raphe at the penile base: penile degloving is then easily carried out up to the coronal line. Subsequently, the dorsal neurovascular bundle is normally isolated and all types of different corporoplasties can be carried out.

RESULTS

Any complication occurring during or after surgery has been registered. Patient follow-up controls were performed on day 7, month 1 and month 3 post-surgery: -No pre- or post-operative circumcision procedures were required; -There was no evidence of post-operative preputial edema or penile skin necrosis or loss of glans sensitivity; -In 6 patients, we noted a mild scrotal sub-dartos hematoma, which reabsorbed spontaneously.

CONCLUSIONS

TPD, which represents an evolution of our previous combined subcoronal-trans-scrotal approach, may be advantageously performed in most corporoplasties with optimal aesthetic and functional outcomes, and may replace in many cases the subcoronal approach without its associated complications.

Activin Receptor-Like Kinase 5 Inhibitor Attenuates Fibrosis in Fibroblasts Derived from Peyronie's Plaque

Purpose

Transforming growth factor-β1 (TGF-β1) is the key fibrogenic cytokine associated with Peyronie's disease (PD). The aim of this study was to determine the antifibrotic effect of 3-((5-(6-Methylpyridin-2-yl)-4-(quinoxalin-6-yl)-1H-imidazol-2-yl) methyl)benzamide (IN-1130), a small-molecule inhibitor of the TGF-β type I receptor activin receptor-like kinase 5 (ALK5), in fibroblasts isolated from human PD plaque.

Materials and Methods

Plaque tissue from a patient with PD was used for primary fibroblast culture, and we then characterized primary cultured cells. Fibroblasts were pretreated with IN-1130 (10 µM) and then stimulated with TGF-β1 protein (10 ng/ml). We determined the inhibitory effect of IN-1130 on TGF-β1-induced phosphorylation of Smad2 and Smad3 or the nuclear translocation of Smad proteins in fibroblasts. Western blot analyses for plasminogen activator inhibitor-1, fibronectin, collagen I, and collagen IV were performed to evaluate effect of IN-1130 on the production of extracellular matrix proteins.

Results

The treatment of fibroblasts with TGF-β1 significantly increased phosphorylation of Smad2 and Smad3 and induced translocation of Smad proteins from the cytoplasm to the nucleus. Pretreatment with IN-1130 substantially inhibited TGF-β1-induced phosphorylation of Smad2 and Smad3 and nuclear accumulation of Smad proteins. The TGF-β1-induced production of extracellular matrix proteins was also significantly inhibited by treatment with IN-1130 and returned to basal levels.

Conclusions

Overexpression of TGF-β and activation of Smad transcriptional factors are known to play a crucial role in the pathogenesis of PD. Thus, inhibition of the TGF-β signaling pathway by ALK5 inhibitor may represent a promising therapeutic strategy for treating PD.

Simultaneous penile lengthening and penile prosthesis implantation in patients with Peyronie's disease, refractory erectile dysfunction, and severe penile shortening

INTRODUCTION

Due to loss of length, patients who had penile prosthesis implantation for Peyronie's disease (PD) show a statistically significant reduction in their levels of satisfaction when compared with the general implant population.

AIM

The aim of this study is to report our experience of penile lengthening with circumferential graft during penile prosthesis implantation in patients with PD and severe penile shortening.

METHODS

Between March 2006 and February 2008, 23 patients with PD, refractory erectile dysfunction, and severe penile shortening underwent penile lengthening with circumferential graft and concomitant implantation of an inflatable penile prosthesis.

MAIN OUTCOME MEASURES

Surgical outcome and complications have been recorded during postoperative follow-up. Patients' satisfaction has been assessed 6 months postoperatively with the administration of the modified Erectile Dysfunction Index of Treatment Satisfaction (EDITS) questionnaire.

RESULTS

After an average follow-up of 22 months (range 6-36), 20 patients attended all the postoperative follow-up visits and returned the EDITS questionnaire. An average length gain of 2.8 cm (range 2.2-4.5) was recorded, and all patients were able to cycle the device and engage in penetrative sexual intercourse. Patient recorded complications included diminished glans sensitivity in four (20%) and persistent dorsal curvature of less than 15° in three (15%). Overall, 18 patients (90%) were satisfied with the cosmetic and functional result of surgery.

CONCLUSION

Penile lengthening with circumferential graft during penile prosthesis implantation in patients with PD represents a safe and reproducible technique that yields higher satisfaction rates than penile prosthesis implantation alone in patients with severe penile shortening.

A Population-Based Study of Peyronie's Disease: Prevalence and Treatment Patterns in the United States

Purpose. To estimate the US prevalence of Peyronie's disease (PD) from patient-reported data and to identify diagnosis and treatment patterns. Methods. 11,420 US males ≥18 years old completed a brief web-based survey regarding the presence of PD, past treatments, and penile symptoms (Phase 1). Phase 1 respondents with PD diagnosis, history of treatment, or PD-related symptoms then completed a disease-specific survey (Phase 2). Results. Estimated prevalence of PD ranged from 0.5% (diagnosis of PD) to 13% (diagnosis, treatment, or penile symptoms). Thirty-six percent of Phase 2 participants reported that penile symptoms interfered with sexual activities. Of participants who sought treatment for penile symptoms (n = 128), 73% initially saw a primary care physician, 74% did not receive treatment from their first doctor, and 92% were not diagnosed with PD. Conclusions. PD may be underdiagnosed/undertreated in the US. Improved awareness is needed of PD symptoms and treatment options among health care professionals.

Human acellular matrix graft of tunica albuginea for penile reconstruction

INTRODUCTION

Penile curvature is one of the most common male conditions, affecting nearly 10% of men, and can impair sexual intercourse. Tunica albuginea (hTA) plays a key role in penile curvature, and reconstructive procedures may be necessary for its substitution. Although several grafts have been proposed for hTA repair, the ideal graft is not yet available.

AIM

The aim of this article is to evaluate a new human tunica albuginea acellular matrix (hTAAM) as potential graft for penile reconstructive procedures.

METHODS

Twelve penises were obtained during sex reassignment surgeries from male-to-female transsexual patients. After dissection, hTAs were assigned into two groups according to the decellularization methods: polyethylene glycol (PEG) 1000 method following ultraviolet-C radiation, and Triton X-100 modified method.

MAIN OUTCOME MEASURES

Structural analyses were assessed by hematoxilin and eosin, Masson's trichrome, Weigert's, and picrosirius-polarization staining methods. Total protein, total glycosaminoglycan (GAG), and nucleic acid (DNA and RNA) concentrations were assessed by specific biochemical analyses. Uniaxial strength tests were performed to evaluate biomechanical properties.

RESULTS

All hTAAMs presented no nuclear or cellular remnants. Total protein concentration was significantly higher in PEG 1000 hTAAM. Despite GAG concentration decreased significantly in hTAAM, Triton X-100 hTAAM retained the highest GAG concentration (1.0 ± 0.42 µg HexUr/mg dry tissue, P > 0.05). All decellularization methods were efficacious to remove nucleic acids. The maximal break point presented no difference between hTA and hTAAM groups (P > 0.05).

CONCLUSIONS

PEG 1000 and Triton X-100 decellularization methods provide equally successful hTAAMs, preserving original structural and biochemical properties.

Surgical option for the correction of Peyronie's disease: an autologous tissue-engineered endothelialized graft

INTRODUCTION

Surgical treatment is indicated in severe cases of Peyronie's disease. Incision of the plaque with subsequent graft material implantation is the option of choice. Ideal graft tissue is not yet available.

AIM

To evaluate the use of an autologous tissue-engineered endothelialized graft by the self-assembly method, for tunica albuginea (TA) reconstruction in Peyronie's disease.

METHODS

Two TA models were created. Human fibroblasts were isolated from a skin biopsy and cultured in vitro until formation of fibroblast sheets. After 4 weeks of maturation, human umbilical vein endothelial cells (HUVEC) were seeded on fibroblasts sheets and wrapped around a tubular support to form a cylinder of about 10 layers. After 21 days of tube maturation, HUVEC were seeded into the lumen of the fibroblast tubes for the endothelialized tunica albuginea (ETA). No HUVEC were seeded into the lumen for the TA model. Both constructs were placed under perfusion in a bioreactor for 1 week.

MAIN OUTCOME MEASURES

Histology, immunohistochemistry, and burst pressure were performed to characterize mature tubular graft. Animal manipulations were also performed to demonstrate the impact of endothelial cells in vivo.

RESULTS

Histology showed uniform multilayered fibroblasts. Extracellular matrix, produced entirely by fibroblasts, presented a good staining for collagen 1. Some elastin fibers were also present. For the TA model, anti-human von Willebrand antibody revealed the endothelial cells forming capillary-like structures. TA model reached a burst pressure of 584 mm Hg and ETA model obtained a burst pressure of 719 mm Hg.

CONCLUSIONS

This tissue-engineered endothelialized tubular graft is structurally similar to normal TA and presents an adequate mechanical resistance. The self-assembly method used and the autologous property of this model could represent an advantage comparatively to other available grafts. Further evaluation including functional testing will be necessary to characterize in vivo implantation and behavior of the graft.

The management of residual curvature after penile prosthesis implantation in men with Peyronie's disease

OBJECTIVE

• To report our experience in the management of residual curvature after implantation of a penile prosthesis in men with Peyronie's disease (PD).

PATIENTS AND METHODS

• From January 1985 to June 2009, 62 (29%) of the 209 patients with PD that have undergone the insertion of a penile prosthesis have required an additional straightening procedure to correct the residual curvature after the insertion of the cylinders of the implant. • The types of additional manoeuvres, their success in correcting the residual curvature and eventual complications have been reported.

RESULTS

• Among the additional straightening procedures, modelling was more successful in achieving straightening when performed on an inflatable device (84%) than on a malleable implant (54%). • If the curvature persisted after modelling or if the curvature was ventral, straightening was achieved with tunical plications or incision with or without grafting.

CONCLUSION

• Although it is common for the simple implantation of cylinders alone to straighten the penis, some patients will present a residual curvature that must be successfully corrected with additional straightening procedures.

Medium-term follow-up of plaque incision and porcine small intestinal submucosal grafting for Peyronie's disease

The best surgical option for the management of severe cases of Peyronie's disease is currently a matter of debate. To determine medium-term outcomes and complications after treatment of severe Peyronie's disease by porcine small intestinal submucosa (SIS) grafts, we retrospectively reviewed 33 consecutive plaque incisions followed by 4-ply SIS grafting in 28 patients (2002-2009). Postoperative complications, penile length preservation, de novo ED, penile curvature correction and curvature recurrence rates were recorded. Median patient age was 54 years (38-69 years). Median preoperative curvature was 90° (30-90°) (stable for at least 6 months). Six patients (21%) had preoperative ED. There were few postoperative complications (no cases of infection, haematoma (n=2), penile hypoesthesia (n=1), patch rejection and migration (n=1)). Subjective penile shortening and de novo ED were observed in 7 (25%) and 3 (11%) patients, respectively. The success rate for the procedure (straight penis or curvature ≤20° and ability to have intercourse) was 67% (22/33). Four patients achieved curvature correction after a repeat procedure with a new SIS graft. Eleven patients experienced recurrence within 3 months of surgery. After a median follow-up of 9 months (3-94), 22 patients (79%) had a satisfactory curvature correction.

Circumcision is not mandatory in penile surgery

OBJECTIVE

To assess the outcome of not circumcising patients having surgery to correct a congenital or acquired curvature, through a subcoronal approach.

PATIENTS AND METHODS

In a series of 251 consecutive patients (mean age 46 years, range 17-74) that had their penis straightened by either a Lue (86), or a Nesbit procedure (162) or a combination of both (three) between 2000 and 2008, a subcoronal circumferential incision was used for the degloving in 241. Among the 183 patients who had not been previously circumcised, 22 presented with a tight foreskin and were offered a circumcision; six of them refused to be circumcised. Of the remaining 161 patients, 115, including two who had previous penile surgery, opted not to be circumcised.

RESULTS

After a median (range) follow-up of 5.5 (1-50) months, secondary circumcision was performed in three of the six patients with a tight foreskin, in one of the 113 (0.8%) with a normal retractable foreskin and in one of the two who had had previous penile surgery and had a normal foreskin.

CONCLUSIONS

Circumcision should not be considered as a routine part of penile surgery unless a significant phimosis is present or revisional surgery is contemplated.

Extracorporeal Shock Wave Therapy as First Line Treatment in Patients with Peyronie's Disease

Introduction

Extracorporeal Shock Wave Therapy (ESWT) is a minimal invasive treatment for patients with Peyronie's Disease (PD). Currently, however, controversial data exist on the efficacy of ESWT as first-line treatment.

Methods

We performed a prospective, randomized, double blind, placebo-controlled trial to evaluate the efficacy of ESWT in a group of 100 patients with disease duration <12 months, naive to previous treatments, with a single plaque, erectile dysfunction and/or painful erections and/or penile recurvatum. Patients were randomized to undergo ESWT or Placebo. The Storz Duolith device was employed for treatments. A non-functioning probe was employed as placebo. Treatments were administered in four sessions at weekly intervals. The following evaluations were performed at baseline and at 12- and 24-week intervals from treatment: IIEF-5 (International Index of Erectile Function) questionnaire, VAS (Visual Analogue Scale), plaque size measurement, penile curvature measurement.

Results

Only patients treated with ESWT reported a significant improvement of mean VAS score and of mean IIEF-5 score at a 12-week follow-up. Mean plaque size and mean curvature degree did not improved significantly in patients treated with ESWT but showed a significant worsening at the 24-week follow up compared to baseline values in the placebo group.

Conclusions

ESWT can improve significantly painful erections and erectile functions in patients with PD naive to other treatments. Moreover, ESWT can stabilize plaque size and penile curvature thus preventing disease progression.

Surgical treatment of Peyronie's disease by plaque incision and grafting with buccal mucosa

BACKGROUND

Plaque incision and tunical grafting is widely used to correct penile curvatures secondary to Peyronie's disease (PD), but there is no consensus on the ideal graft to be used.

OBJECTIVE

To evaluate the efficacy, safety, and reproducibility of plaque incision and buccal mucosa grafting (BMG) in the correction of severe penile curvatures secondary to PD.

DESIGN, SETTING, AND PARTICIPANTS

Fifteen patients reporting normal erections and stable curvature (>12-mo duration) entered this prospective study carried out at two university hospitals.

INTERVENTION

All patients underwent plaque incision and BMG.

MEASUREMENTS

Preoperative evaluation included the International Index of Erectile Function (IIEF-5) and penile duplex ultrasounds with measurement of curvature and length of affected side. Follow-up visits were scheduled at 1, 3, 6, and 12 mo postoperatively, then yearly. Three-mo postoperative evaluation included IIEF-5, patient and partner satisfaction, and intracavernous injection test with evaluation of penile rigidity, straightness, and length; patient and partner satisfaction was recorded at all subsequent visits.

RESULTS AND LIMITATIONS

Mean patient age was 56.3 yr and mean penile curvature 72 degrees ; five patients had a two-sided curvature with mean second curvature of 37 degrees . There were no complications. All patients resumed unassisted intercourse 1 mo after surgery. Three-mo postoperative evaluation showed 100% penile straightening, 1.8-cm mean increase in length of affected side, no curvature recurrence or de novo erectile dysfunction, 1.6 mean increase in IIEF-5 score, and patient and partner satisfaction of 93.3% and 100%, respectively. Although results remained stable at subsequent follow-up (mean 13.1 mo), a greater number of patients and longer follow-up are needed before drawing any definite conclusions.

CONCLUSIONS

BMG provided excellent short-term results, probably because its prompt revascularisation, suggested by the fast return of spontaneous erections, prevented shrinkage, which is the main cause of graft failure. It also proved to be safe and reproducible, thus representing a valuable treatment option for PD.

Risk factors for emotional and relationship problems in Peyronie's disease

INTRODUCTION

Peyronie's disease (PD) occurs in 3-9% of all men. Little is known regarding the specific psychological or emotional disruptions to sexuality associated with PD.

AIM

Our primary aim was to identify risk factors associated with psychosocial difficulties in men with PD.

METHODS

This cross-sectional study enrolled patients from a single clinical practice. Detailed medical histories, physical examinations, and a PD-specific questionnaire were used to define clinical characteristics. Odds ratios (ORs) were used as a measure of association.

MAIN OUTCOME MEASURES

Emotional and relationship problems were determined by "yes" or "no" answers to two specific questions.

RESULTS

The mean age of all PD patients (N = 245) was 54.4 years (range 19.4-75.6); 62% were married, and 59% presented within 2 years of disease onset. The overall prevalence of emotional and relationship problems attributable to PD was 81% and 54%, respectively. Among men who had relationship problems, the prevalence of emotional problems was 93%. In men with emotional problems due to PD, relationship issues were observed in 62%. Multivariable analysis revealed that emotional difficulties (OR 6.9, P < 0.001) and ability to have intercourse (OR 0.4, P = 0.004) were independently associated with relationship problems. Relationship problems (OR 8.0, P < 0.001) and loss of penile length (OR 2.7, P = 0.02) were significant independent predictors of emotional problems after adjustment for the ability to maintain erections, low libido, and penile pain.

CONCLUSIONS

Among men with PD, there is a very high prevalence of emotional and relationship problems. Loss of penile length and inability to have intercourse are strong predictors of these problems and as such make ideal targets for intervention. Medical and surgical therapies may enhance quality of life through their ability to improve sexual function. Further research will characterize the ways in which individual symptoms affect emotional and psychological well-being.

MR imaging of nonmalignant penile lesions

Magnetic resonance (MR) imaging is potentially useful in the assessment of many benign penile diseases. When T1- and T2-weighted sequences are used, MR imaging can clearly delineate the tunica albuginea and can be used to diagnose penile fracture and Peyronie disease; in both conditions, MR imaging may help refine the surgical approach. It is also useful in cases of priapism; in these cases, intravenously administered contrast material can help assess the viability of the corpora cavernosa and the presence of penile fibrosis. In the assessment of a penile prosthesis, MR imaging provides excellent anatomic information and is the investigation of choice. In the evaluation of erectile dysfunction, MR imaging has limited value, and for urethral stricture, it has not yet proved adequately superior to other modalities to justify its routine use.

The Role of Penile Color-Duplex Ultrasound for the Evaluation of Erectile Dysfunction

INTRODUCTION

In the era of orally active agents, dynamic penile color-duplex ultrasound (D-PCDU) is not considered a necessary first screening for all patients with erectile dysfunction (ED). Various parameters, such as peak systolic flow velocity, end diastolic velocity, resistance index, acceleration time, and degree of arterial dilatation, have been suggested for the diagnosis of vascular ED by D-PCDU.

AIM

To highlight the clinical utility and evidence-based interpretation of D-PCDU criteria.

METHODS

Extensive, unsystematic PubMed literature search reviewing relevant data on D-PCDU in the evaluation of male ED.

RESULTS

The advantage of ultrasound is the minimally invasive nature of the procedure and the ability to screen patients to identify a normal arterial response of cavernous arteries. Men with sexual dysfunctions above 55 years of age and comorbidities are more likely to have multi-organ vascular dysfunction and may necessitate further testing because erectile failure may be the first presenting symptom requiring investigation and treatment even in the absence of cardiovascular risk factors. All patients affected with Peyronie's disease and younger men with persistent ED, a history of pelvic traumas, or fractures of the penile shaft should be offered ultrasonographic penile blood flow studies before referral to surgery or more invasive vascular investigations.

CONCLUSIONS

In the near future, D-PCDU may be used in preference to patients presenting with or without vascular risk factors, particularly those not responding to first-line orally active drugs and seeking an explanation as to why these agents failed.

The natural history of Peyronie's disease: an ultrasonography-based study

OBJECTIVES

To define ultrasonographic patterns reflecting different states of Peyronie's disease (PD) and to use them to evaluate the natural history of the disease.

MATERIAL AND METHODS

Diagnosis of PD was based on medical and sexual history, physical examination, intracavernosal injection test, and penile ultrasonography. Patients with penile fracture history were excluded from the study. Three groups were formed according to ultrasonographic patterns: solitary hyperechoic lesion without acoustic shadow (group A), moderately hyperechoic multiple scattered calcified lesions with acoustic shadows (group B), dense calcified hyperechoic plaque with acoustic shadow (group C). All patients entered a watchful waiting protocol for 1 yr followed by a new penile ultrasonography.

RESULTS

Ninety-five 95 patients with PD were included in the study (mean age, 57.2+/-9.1 yr; mean duration of disease, 12.9+/-8.9 mo). Risk factors associated with cardiovascular disease were present in 79 of 95 patients (83.16%). Eleven (11.6%), 35 (36.8%), and 49 (51.6%) patients were classified into groups A, B and C, respectively. At the end of the study, in group A, reduction of fibrotic lesions and curvature angle was noticed in 9 of 11 (81.8%) patients, whereas plaque formation was noticed in 2 of 11 (18.2%) patients. In group B, plaque and curvature reduction was noticed in 15 of 35 (42.9%) and 12 of 35 (34.3%) respectively, whereas in the rest a dense calcified plaque was noticed. In group C, no ultrasonographic evidence of improvement was noticed; curvature angle was reduced in 4 of 49 (8.2%), owing to the extension of the plaque circumferentially. Significant hemodynamic changes were noticed at the two time points tested (30.53% diagnosed with vascular disease at baseline vs. 46.32% at the end of the study, p=0.03).

CONCLUSIONS

Corporal ultrasonography in patients with PD allows objective evaluation and classification of disease. The density of echogenic areas and presence of acoustic shadows are predictors of disease stability.

Investigation of the antifibrotic effect of IFN-gamma on fibroblasts in a cell culture model of Peyronie's disease

OBJECTIVE

A broad spectrum of options is available for treatment of Peyronie's disease; however, the effects of minimally invasive therapy are generally inadequate. Although useful, oral drugs must be administered at onset of the disease. Only a few patients request penile surgery. Therefore, new medical treatments for Peyronie's disease are needed. A better understanding of the pathogenesis of Peyronie's disease is required to facilitate development of these new medical treatments. Several studies have described an increased level of TGF-beta in the fibrotic plaques of patients with Peyronie's disease, underscoring this important signalling pathway in the onset and/or development of Peyronie's disease.

METHODS

Plaque biopsies were taken from 16 patients with Peyronie's disease. Furthermore, 7 patients without Peyronie's disease were biopsied to provide control material. Fibroblasts were cultured from biopsy tissue, and cultured fibroblasts were stimulated with TGF-beta1, BMP-2, IFN-gamma, and IFN-gamma combined with one of the other stimuli. Protein was extracted from treated fibroblasts and prepared for immunoblots. The membranes were probed for phosphorylated Smad and total Smad to indicate activation of TGF-beta signalling.

RESULTS

An agonistic effect of IFN-gamma on TGF-beta signalling was observed. Stimulation with TGF-beta1 increased levels of phospho-Smad2 and phospho-Smad3. After stimulation with TGF-beta1 and IFN-gamma combined, the levels of phospho-Smads were higher than those observed with stimulation withTGF-beta1 alone.

CONCLUSIONS

The profibrotic effect of TGF-beta1 is enhanced by IFN-gamma in fibroblasts from patients with Peyronie's disease. The inhibitory effects of IFN-gamma on the TGF-beta pathway do not appear in Peyronie's disease. Therefore, IFN-gamma cannot be taken as a useful tool in the therapy of Peyronie's disease.

Graft Materials in Peyronie's Disease Surgery: A Comprehensive Review

OBJECTIVE

To discuss the currently used graft materials in Peyronie's surgery.

METHODS

A MEDLINE search was conducted till the end of September 2006 on the surgical treatment of Peyronie's disease, and all aspects of the graft materials used for Peyronie's surgery were examined.

RESULTS

Currently available interposing graft materials may be classified in three categories: autologous tissues, extracellular matrix (ECM) tissues, and synthetic materials. Each grafting material in these categories has its own advantages and drawbacks in terms of tissue properties, antigenicity, availability, and cost-effectiveness. Saphenous vein grafts are the most widely used among autologous grafts, with acceptable functional outcomes in the long term. Other graft materials include tunica vaginalis, fascia lata, rectus fascia, and buccal mucosa, with variable results. Despite numerous advantages in terms of tissue compatibility, the major drawback of autologous grafts is tissue harvesting that to morbidities and longer operative durations. For this reason, the use of readily available ECM tissues as the products of tissue engineering is recommended by some authors. Among ECM grafts, cadaveric and bovine pericardia have satisfactory mid-term outcomes. However, longer follow-ups with an adequate number of patients are lacking. On the other hand, recent evidence suggests that small intestinal submucosa may be associated with high rate of operative failure and complications. Generally, synthetic materials are no longer used in grafting procedures in Peyronie's surgery because of their antigenicity and inappropriate functional properties. For prosthesis surgery, pericardia as well as autologous rectus fascia grafts are probably the most suitable graft materials because of their suitable tissue characteristics that satisfy the mechanical demands of the prosthesis.

CONCLUSION

Saphenous vein grafting from autologous tissues and pericardium from ECM tissues have satisfactory results. However, further research and clinical studies are needed in order to determine the optimal graft material.

Congenital Penile Curvature: Dermal Grafting Procedure to Prevent Penile Shortening in Adults

OBJECTIVES

We report the results of a derma graft corporoplasty in a selected group of patients with congenital penile curvature (CPC) who refused a simple plication technique for the risk of penile shortening, even if minimal.

METHODS

Between January 1995 and January 2004, 15 potent patients with CPC underwent corporoplasty with inguinal derma graft, with or without tunica albuginea plication. Mean age was 26.6 years (range 19-36). Six patients had a simple lateral left curvature, three had a simple lateral right curvature, four had a ventro-lateral left curvature, one patient had a ventro-lateral right curvature, and one patient had ventral curvature. In nine patients the preoperative mean IIEF-5 score was 22.55 (range 21-24). All the patients were evaluated after three, six and 12 months.

RESULTS

One graft was placed in one patient (6.6%), seven (46.6%) received one graft and underwent a tunica albuginea plication, four (26.6%) received two grafts, three (20%) received two grafts and underwent tunica albuginea plication. A residual curvature after three, six and 12 months was present respectively in all (100%), seven (46.6%) and one (6.6%) patients. No patients had a decrease of penile length. The mean difference in the IIEF-5 score before and after the surgical procedure was not statistically significant.

CONCLUSIONS

Surgical correction of CPC with derma grafts in potent patients restores penile straightening with no postoperative shortening and preserves normal erectile capacity. Patient satisfaction indicates that the proposed technique may be used in selected cases.

Surgical treatment of Peyronie's disease: a single center experience with 145 patients

OBJECTIVES

To assess the outcomes of the surgical techniques used in Peyronie's disease (PD) surgery.

PATIENTS AND METHODS

One hundred fifty patients received surgical treatment for PD. Fifteen and 75 patients underwent simple corporoplasties and incision of the plaque, and venous (IV) grafting, respectively, whereas 60 patients with erectile dysfunction underwent penile prosthesis implantation. At follow-up, the erectile function and penile deformity were assessed at 3 and 12 mo postoperatively, and every 6 mo thereafter.

RESULTS

Postoperative results were satisfactory in 14 of 15 patients with simple corporoplasties, with a mean angle of deformity and follow-up of 51.0 degrees +/-14.9 degrees and 21.0+/-9.7 mo, respectively. Among patients undergoing IV grafting with sapheneous vein (mean curvature angle: 61.6 degrees +/-19.5 degrees ), 70 were regularly seen with a mean follow-up of 41.7+/-35.1 mo. Penile curvature was completely straightened in 53 (75.7%) patients, whereas 12.8% and 11.4% had residual curvature less than 20 degrees and more than 20 degrees , respectively. The mean degree of penile curvature of patients with penile prosthesis was 46.9 degrees +/-20.1 degrees . Straightening of the penis was accomplished with implantation of the prosthesis only, manual modeling, plaque incision and grafting (autologous rectus fascia in the majority), incision of the plaque, and penile plication in 35%, 30%, 33.3%, 1.6%, and 1.6%, respectively. In the prosthesis group, two patients had recurrent curvatures.

CONCLUSIONS

IV grafting is a good option with satisfactory mid- and long-term outcome. Insertion of the prosthesis only and manual modeling correct the curvature in the majority of the patients. For the remaining patients, autologous rectus fascia is an appropriate graft material.

Reconstructive surgery of the penis

PURPOSE OF REVIEW

Diseases of the penis are common, and the aim now is the preservation of function and cosmesis of the penis using modern penile reconstructive techniques. Penile cancer, Peyronie's disease and trauma are the three pathologies assessed.

RECENT FINDINGS

Modern conservative organ-sparing surgery in penile cancer has shown that good oncological control can be gained by 2 mm margins that allow preservation of sexual function. Early intervention in the traumatic penis gives better results whereas the Nesbit operation is still the gold standard for Peyronie's disease as the quest for an alternative graft to saphenous vein continues.

SUMMARY

The current operations of choice in penile reconstruction are glansectomy and skin grafting to fashion a neoglans in penile cancer and the Nesbit operation or saphenous grafting for Peyronie's disease.

Systematic evidence-based analysis of plaque injection therapy for Peyronie's disease

OBJECTIVE

We evaluated the peer-reviewed urology literature for intraplaque injection of medication for Peyronie's disease and assessed the quality of studies via rigorous evidence-based medicine criteria.

METHODS

We performed a search of peer-reviewed literature looking at all agents used to treat Peyronie's disease by intraplaque injections. These were then evaluated using the Oxford Centre for Evidence-Based Medicine criteria, which ranks studies from strongest (level 1) to weakest (level 5) strength of evidence.

RESULTS

Of the 19 studies found involving injection therapy for Peyronie's disease, 17 showed positive results. Six studies using injectable corticosteroids were identified and though all showed positive results, they were of level 4 quality. Two collagenase injection studies (one level 4 and one level 2 study) were identified, both of which showed positive results. All four verapamil injection studies found (three level 4 and one level 2 study) showed positive results. Seven papers involving interferon alpha2-beta injections were evaluated (six level 4 and one level 1 study), five of which showed positive outcomes and two of which showed no significant benefit.

CONCLUSIONS

Ninety percent of the studies regarding Peyronie's disease showed positive outcomes. Unfortunately, most of these have not offered convincing evidence-based data, with only one positive study meeting level 1 Oxford criteria for clinical efficacy. Standardised outcome measures were not used, making comparisons difficult. These results reveal the need for the development of validated outcome measures and well-designed controlled trials to determine optimal therapeutic intervention for this disorder.