The History of Collagenase Clostridium Histolyticum

A Clinical Guide to the Treatment of Cellulite and Comprehensive Review of the Etiology, Pathophysiology, and Utility of Intervention

INTRODUCTION

Cellulite is a common esthetic concern affecting most women. Despite its prevalence, there is no consensus on the optimal treatment approach for cellulite, partly due to the complex and multifactorial nature of its pathophysiology. Understanding the underlying biological processes along with available treatment options is important to be able to effectively counsel patients on effective management of this condition. This review aims to focus on high-quality evidence behind pathophysiology of cellulite, severity and grading, and its available treatment options.

METHODS

A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to pathophysiology, grading scales, and applications of treatment options were utilized.

RESULTS

Using the existing CSS classification, an evidence-based algorithm is proposed for treatment of cellulite. Mild cellulite is best served with lifestyle modifications such as healthy diet, hydration, and exercise. Use of topicals in mild cellulite patients as adjuncts to lifestyle modifications have the highest efficacy, although there are inconsistent data on topical treatments. Moderate cellulite is best targeted with noninvasive treatment options including laser therapy, radiofrequency, and ultrasound. Radiofrequency demonstrates the strongest efficacy in the current peer-reviewed literature. Severe cellulite is recommended to be treated with minimally invasive approaches such as subcision and injectables.

CONCLUSION

Cellulite is a challenging cosmetic problem to treat, and thus multimodal treatment options should be considered in an attempt to achieve optimal outcomes and patient satisfaction. As the pathophysiology of cellulite is further elucidated, more targeted treatments may be developed in the future.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Cellulite: Current Understanding and Treatment

Cellulite is an aesthetically distressing skin condition that manifests as dimples and depressions, producing an uneven surface to the skin. Occurring in 80% to 90% of females, mostly on the thighs, buttocks, and hips, it is associated with profound negative psychosocial and quality of life issues. Its ethiopathogenesis and pathophysiology are likely to be multifactorial and complex and not fully understood. There is no effective treatment for cellulite, although a number of different treatment modalities are available, from noninvasive to minimally invasive. The efficacy of most treatments is unpredictable and improvements in cellulite appearance are short lived, although significant progress has been made with newer treatments. This review provides an update on the current state of knowledge about cellulite, with an emphasis on patient assessment and an individualized treatment approach for optimal results.

Level of Evidence 5

The use of collagen fleece to correct residual curvature during inflatable penile prosthesis implantation (PICS technique) in patients with complex Peyronie disease: a multicenter study

BACKGROUND

The PICS technique (penile implant in combination with the sealing) was recently described as a valuable option to correct residual curvature during inflatable penile prosthesis (IPP) implantation in patients with complex Peyronie disease (PD).

AIM

To report the surgical and functional outcomes of the PICS technique in a multicentric series of patients.

METHODS

A consecutive series of patients with complex PD who underwent PICS were recruited. Patients were from 2 European tertiary referral centers. Data regarding baseline characteristics and perioperative, postoperative, and functional outcomes were retrospectively evaluated.

OUTCOMES

Complete penile straightness, duration of operative time and hospital stay, as well as postoperative complications (including hematoma, IPP infection, and IPP mechanical failure) were recorded, whereas functional outcomes were evaluated through the administration of validated questionnaires at baseline and 12 months postoperatively: International Index of Erectile Function-5, Sexual Encounter Profile questions 2 and 3 (SEP-2 and SEP-3), and Erectile Dysfunction Inventory of Treatment Satisfaction.

RESULTS

Thirty-seven patients with a median age of 62 years (IQR, 57-70 years) were enrolled. Median preoperative curvature was 75° (IQR, 65°-77°). Median residual curvature after IPP implantation was 60° (IQR, 50°-70°). Overall, 31 patients (84%) achieved a totally straight penis. Only 6 patients (16%) experienced a residual penile curvature (<20° in all cases) after the procedure. No intraoperative complications were detected. Nine patients (24%) developed an early postoperative complication, 3 (8%) a transient fever, and 6 (16%) a genital hematoma. A single case of IPP acute infection requiring device explantation was recorded. The survey response rate was 100%. At the 12-month follow-up evaluation, the median IIEF-5 score was 23.5 (IQR, 22.2-25) with evident improvement vs the baseline value of 10 (IQR, 8-12). Accordingly, 92% of the patients responded positively to SEP-2 and SEP-3. For the Erectile Dysfunction Inventory of Treatment Satisfaction, patients recorded a median postoperative value of 25 (IQR, 21-30) 1 year after PICS.

CLINICAL IMPLICATIONS

Complex PD is an end-stage disease featured by severe penile curvature, penile shortening, and erectile dysfunction: the gold standard approach is deemed to be penile prosthesis implantation, aiming to address penile curvature and erectile dysfunction, but in a limited percentage of cases, additional maneuvers are deemed necessary to manage residual penile curvature.

STRENGTHS AND LIMITATIONS

Our study has some limitations: the retrospective nature, relatively short follow-up, and limited number of patients.

CONCLUSION

The PICS technique may represent a reliable and effective treatment option to address significant residual curvature after IPP implantation.

Peyronie's Disease: An Outcomes-Based Guide to Non-Surgical and Novel Treatment Modalities

The clinical landscape of Peyronie's disease is everchanging. There has been growing interest in non-invasive therapeutic options that could assist patients with achieving a meaningful reduction in penile curvature without surgical intervention. These therapies are wide-ranging in terms of their mechanisms of action, efficacies, and short- and long-term safety profiles. Recently, an abundance of outcomes literature on longstanding and novel non-surgical treatment modalities has been published. For sexual medicine providers hoping to offer patients the most up-to-date and evidence-based treatments for the management of Peyronie's disease, it can be challenging to gain a thorough understanding of this body of literature. In this clinical management review, the workup and current theories on the pathophysiology of Peyronie's disease are reviewed, and the most recent outcomes data on the currently available non-surgical treatment modalities are presented. With an accurate understanding of the current landscape of Peyronie's disease treatment, sexual health providers will be able to better evaluate and engage in evidence-based shared decision-making with their patients.

[Efficacy and safety of local injections treatments for Peyronie's disease: Review of the literature]

AIM

To assess the efficacy and safety of local injection used to reduce penile curvature in Peyronie's disease.

METHODS

A review of the literature was carried out according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyzes) on the Medline database in April 2020, with the research: "collagenase"[All Fields] OR "Interferon"[All Fields] OR "verapamil"[All Fields] OR "betamethasone"[All Fields] OR "hyaluronic acid"[All Fields] OR "Platelet-Rich Plasma"[All Fields] OR "Stem Cells"[All Fields] AND "peyronie's"[All Fields] AND Controlled Clinical Trial[ptyp]. Only controlled studies with placebo group were included in this review.

RESULTS

Of the 35 articles identified, 6 placebo-controlled studies were finally included. Intra-plaque injections of verapamil did not show improvement in penile curvature. Injections of interferon α 2b and clostridium histolyticum collagenase allowed a statistically significant improvement in terms of curvature reduction: 13.5 versus 4.5 degrees P<0.01) and 17 versus 9.3 degrees P<0.0001 respectively. However, interferon α 2b is not available in France for Peyronie's disease and clostridium histolyticum collagenase is no longer authorized since March 1, 2020. No controlled studies are available on corticosteroids, hyaluronic acid, platelet-rich plasma or stem cells injections.

CONCLUSION

To correct the deformity in Peyronie's disease in the chronic phase, there is no effective solution currently available in France based on controlled studies. Surgery retains its place for the correction of a curvature of at least 30° associated with a sexual handicap in the stable phase, however at the cost of potential adverse effects. Stem cell or Platelet-Rich Plasma injection might be an injectable therapeutic alternative but need controlled studies.

Evaluating collagenase Clostridium histolyticum administration protocols in the treatment of Peyronie's disease

PURPOSE OF REVIEW

Treatment of Peyronie's disease with collagenase Clostridium histolyticum (CCh) has gained world-wide adoption following the phase III clinical trials IMPRESS I and II. However, the optimal treatment parameters remain largely unknown. Many groups have made modifications to CCh treatment in Peyronie's disease in recent years. This review aims to discuss the variations in CCh treatment reported and associated outcomes.

RECENT FINDINGS

Variations in CCh treatment protocols include administering higher CCh doses (0.9 mg) less frequently (q1month), use of home penile modeling, use of angulating penile traction devices, and vacuum therapy devices. Authors have reported different injection techniques to include three-point fans and tunneling techniques. Patient selection has expanded to include and evaluate responses among men with some extent of plaque calcification, and ventral curves.

SUMMARY

Since publication of the IMPRESS trials, several variations of CCh treatment have been reported with similar treatment responses to the original trials. However, future studies are required with prospective, randomized comparative designs to identify the optimal treatment strategies for men with Peyronie's disease.

Minimally invasive therapies for Peyronie's disease: the current state of the art

Peyronie's disease (PD) is a relatively common condition that can result in significant penile deformity, sexual dysfunction, and psychological bother. Surgical straightening offers the highest probability of success during the stable phase of the disease. However, for men in the acute phase of PD or for those with less severe deformity who elect to avoid surgery, a variety of non-surgical treatment options are available. Oral therapies, including L-citrulline and pentoxifylline, are most useful as part of a combination regimen rather than as monotherapy. Intralesional therapy with IFN-α2b, verapamil, and collagenase clostridium histolyticum (CCH) can cause significant reduction in penile curvature, yet these results may not be clinically significant for men with more severe curvature. Further investigation into the timing of administration and optimal patient characteristics is required. Penile traction therapy offers a clinically significant improvement in penile length and curvature. However, this has traditionally required hours of daily therapy. Overall, a combination of oral, topical, injection and traction therapies may provide the most significant benefit among the non-surgical modalities for PD.

Strategies and current practices for penile lengthening in severe Peyronie's disease cases: a systematic review

Several strategies to optimize penile length in the presence of Peyronie's Disease (PD) have been described so far. In case of severe curvature and preserved erectile function, plaque incision/excision (PIG/PEG) are advisable in order to maximize penile length, despite the risk of postoperative erectile dysfunction (ED), recurrent curvature, or penile shortening. For men with PD deformities associated to a certain degree of ED several lengthening techniques associated to penile prosthesis (PPI) implantation can be considered. Because of the potential postoperative complications, the indication must be balanced between patient's risk factors and surgeon's experience. Furthermore, adjuvant surgeries, such as prepubic V-Y plasty, suspensory ligament release, suprapubic lipectomy, and ventral phalloplasty, can be performed simultaneously or in a staged fashion to maximize the outcomes. Restoration a decent penile length in the case of a severe PD represents a real challenge for reconstructive surgeons. We present a systematic review of the literature on the current practices for penile lengthening in severe PD, providing the reader with a practical overview on the existing surgical strategies and their surgical and functional outcomes.

Treatment for cellulite

Cellulite is a multifactorial condition that is present in 80% to 90% of postpubertal women and is one of the most intolerable esthetic imperfections. There are several theories on the pathophysiology of cellulite, and a number of different therapeutic regimens have been developed, from topical treatments to mechanical or energy-based devices. In this brief review, we summarize the scientific landscape to determine the clinical evidence with regard to the safety and efficacy of cellulite treatment options. Clinical protocols and the author’s experience using a combination of internal and external procedures are also discussed. Studies using laser and light modalities along with radiofrequency have shown improvements in cellulite and a good safety profile, but acoustic wave therapy, subcision, and the 1440-nm Nd:YAG minimally invasive laser have demonstrated the most beneficial results in cellulite reduction. Although there is paucity of scientific evidence for treatments that improve cellulite, future emerging options and their combination may pave the way to eradicate this primarily cosmetic esthetic concern.

Contemporary surgical and non-surgical management of Peyronie's disease

Numerous treatments have been proposed for Peyronie's disease (PD). As the evidence base has expanded, the field of operative and non-operative options for patients has narrowed. Collagenase clostridium hystolyticum (CCH) injection now comprises the medical option, and surgical possibilities entail penile plication, plaque incision/excision and grafting, and prosthesis implantation. Still, questions abound regarding the optimal approach and indication for each of these treatments. We conducted a review of literature exploring the contemporary management of PD with a particular focus on work since the last American Urologic Association's (AUA) guidelines update for PD. Recent results and discussion indicate trends toward minimal invasiveness, toward a more holistic approach to the PD patient, and away from algorithmic management, galvanized, in part, by data challenging long-held beliefs.

Enzyme Development for Human Islet Isolation: Five Decades of Progress or Stagnation?

In comparison to procedures used for the separation of individual cell types from other organs, the process of human pancreatic islet isolation aims to digest the pancreatic exocrine matrix completely without dispersing the individual cells within the endocrine cell cluster. This objective is unique within the field of tissue separation, and outlines the challenge of islet isolation to balance two opposing priorities. Although significant progress has been made in the characterization and production of enzyme blends for islet isolation, there are still numerous areas which require improvement. The ultimate goal of enzyme production, namely the routine production of a consistent and standardized enzyme blend, has still not been realized. This seems to be mainly the result of a lack of detailed knowledge regarding the structure of the pancreatic extracellular matrix and the synergistic interplay between collagenase and different supplementary proteases during the degradation of the extracellular matrix. Furthermore, the activation of intrinsic proteolytic enzymes produced by the pancreatic acinar cells, also impacts on the chance of a successful outcome of human islet isolation. This overview discusses the challenges of pancreatic enzymatic digestion during human islet isolation, and outlines the developments in this field over the past 5 decades.

Changes in the Effects of Peyronie's Disease After Treatment With Collagenase Clostridium histolyticum: Male Patients and Their Female Partners

Introduction

Collagenase Clostridium histolyticum (CCH) intralesional injection was efficacious for the management of Peyronie's disease (PD) in the double-blinded, randomized, placebo-controlled Investigation for Maximal Peyronie's Reduction Efficacy and Safety Studies I and II (IMPRESS I and II). Little is known about the consequences of PD or treatment on the sexual partners of affected men.

Aim

To assess the safety and efficacy of CCH treatment in men who received placebo in the IMPRESS I or II study and to evaluate the men's PD symptoms and partner bother as reported by female sexual partners.

Methods

In this phase 3, open-label study (NCT01685437), men (n = 189) received up to eight injections of CCH (0.58 mg/injection). Female sexual partners who provided informed consent at screening (n = 30) participated in the study.

Main Outcome Measures

Co-primary end points were change or percentage of change in penile curvature deformity and change in PD symptom bother domain score of the Peyronie's Disease Questionnaire (PDQ) from baseline to week 36. Participating women completed the PDQ for female sexual partners (PDQ-FSP) and the Female Sexual Function Index (FSFI).

Results

Statistically significant mean improvements were observed in penile curvature deformity (36.3% decrease; 95% CI = −41.6 to −30.9) and PDQ symptom bother score (2.4-point decrease; 95% CI = −3.0 to −1.8) from baseline to week 36. Most treatment-emergent adverse events were mild or moderate. After CCH treatment of their male partners, female sexual partners reported improvement (using the PDQ-FSP) in their male partner's PD symptoms and female bother regarding their partner's PD. The percentage of female sexual partners with sexual dysfunction (FSFI total score ≤ 26.55) also decreased after male partner treatment, from 75.0% at baseline to 33.3%.

Conclusions

These results support the safety and efficacy of CCH in the management of appropriate patients with PD and the potential benefits for patients' partners. Goldstein I, Knoll LD, Lipshultz LI, et al. Changes in the Effects of Peyronie's Disease After Treatment With Collagenase Clostridium histolyticum: Male Partners and Their Female Partners. Sex Med 2017;5:e124–e130.