Treatment of penile curvature--how to combine the advantages of simple plication and the Nesbit-procedure by superficial excision of the tunica albuginea

The effectiveness of penile curvature treatment by cavernous body rotation and plication of the tunica albuginea

Background

There are several approaches to the surgical treatment of the penile curvature conditionally divided into three large groups: tunica albuginea plication (TAP), corpus cavernosum rotation (CR), and transplantation of various materials. The study aims to compare the effectiveness of TAP and CR techniques in the treatment of penile curvature. There was a prospective randomized study of the effectiveness of surgical treatment of patients with an established diagnosis of the penile curvature from 2017 to 2020 in Irkutsk, Russian Federation. The final analysis of the results included 22 cases.

Results

The analysis of the comparative intergroup effectiveness of the treatment performed based on the criteria established in the study showed good treatment results in 8 (88.8%) patients in the CR group and 9 (69.2%) patients in the TAP group (p = 0.577). The other patients obtained satisfactory results. There were no negative outcomes. Simple logistic regression analysis showed that the preoperative flexion angle > 60 degrees (OR 2.7; 95% CI 0.12; 5.28; p = 0.040) was significant in predicting the complaints of penile shortening during TAP. Both methods are safe, effective, and bring minimal risk of complications.

Conclusion

Thus, the effectiveness of both treatment methods is comparable. However, TAP surgery is not recommended for patients with an initial curvature of more than 60 degrees.

Surgical Correction of Adult Congenital Penile Curvature: A Systematic Review

BACKGROUND

Congenital penile curvature (CPC) is corrected surgically by various corporoplasty or tunica albuginea plication techniques, but the optimal surgical approach is not well-defined.

AIM

To provide a comprehensive evaluation of the published literature pertaining to outcomes with penile plication and corporoplasty techniques for surgical management of CPC. To determine if plication or corporoplasty offers superior outcomes in surgical correction of CPC.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Checklist. The following databases were queried from inception to March 18, 2020 to search for studies describing surgical treatment of CPC: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus.

OUTCOMES

Objective and subjective postoperative outcomes including penile straightening, shortening, penile sensory changes, and reoperation rates for both corporoplasty and tunica albuginea plication were summarized.

RESULTS

Fifty-five articles comprising 2,956 patients with CPC who underwent a plication procedure (n = 1,375) or corporoplasty (n = 1,580) were included. The definition of "treatment success" varied widely and most often involved subjective patient reporting (22 studies; 40%) or objective assessment (15 studies; 27%). We considered curvature correction to be satisfactory if there was self-reported patient satisfaction or residual curvature after correction of <20˚. Reported rates of successful straightening ranged from 75 to 100% and 73 to 100% for plication and corporoplasty, respectively. A comprehensive and accurate assessment of surgical outcomes for CPC correction, such as satisfactory penile straightening, reoperation rates, glans sensory changes, and other complications was limited by significant inter-study heterogeneity with respect to the reporting of treatment outcomes.

CLINICAL IMPLICATIONS

While both plication and corporoplasty appear to be safe and effective options in the treatment of CPC, definitive conclusions cannot be drawn with respect to treatment superiority due to low-quality study design, methodology flaws, and significant heterogeneity in reporting.

STRENGTH & LIMITATIONS

This report represents the most comprehensive review of CPC surgical management. However, there is a significant lack of standardization in the reporting of treatment outcomes for CPC, thereby limiting the reliability of the published data summarization encompassed by our review.

CONCLUSION

Both plication and corporoplasty demonstrate high success rates and relatively low complication rates in the treatment of CPC, albeit with low-level evidence available in most research publications. Robust comparison of the surgical techniques used to correct CPC is limited by significant variation in reporting methods used in the literature. C. J. Britton, F. A. Jefferson, B. L. Findlay, et al. Surgical Correction of Adult Congenital Penile Curvature: A Systematic Review. J Sex Med 2022;19:364-376.

Efficacy of one- and two-stage segment urethroplasty for severe chordee with congenital short urethra

Objectives

The aim of this study was to analyze the efficacy of segment urethroplasty to treat severe chordee with congenital short urethra and compared one‐stage and two‐stage segment urethroplasty. This procedure involved urethral transection to correct the chordee, and urethroplasty was performed to restore natural penile length.

Methods

We retrospectively studied a cohort of patients with severe chordee and congenital short urethra who underwent one‐ or two‐stage segment urethroplasty at our institution between February 2006 and May 2020. We evaluated the efficacy of the procedures based on the incidence of complications.

Results

A total of 37 children were included in this study: 25 were treated with two‐stage segment urethroplasty and 12 were treated with one‐stage segment urethroplasty. The median length of neourethra in the one‐stage repair group (3.21 cm) was similar to that in the two‐stage repair group (3.23 cm; P > 0.05). Of the 37 patients, 32 (86.5%) were cured after urethroplasty. There were three patients with complications in the one‐stage repair group (one urethral fistula and two urethral strictures) and two patients with fistula in the two‐stage repair group. Among the five patients with complications, the three fistulas were successfully repaired through reoperation and the two urethral strictures were cured after urethral dilatation. No patient had diverticulum or recurrent chordee.

Conclusions

Segment urethroplasty achieved satisfactory outcomes in the treatment of severe chordee with congenital short urethra. This can restore natural penile length, and the recurrence rate of severe chordee is low. The overall success rate of the two‐stage procedure tends to be better than that of the one‐stage procedure.

[French Urological Association (AFU) guidelines for Peyronie's disease assessment and treatment]

INTRODUCTION

Peyronie's disease is a common cause for consultation in urology. Many controversies surround its treatment. No French Guidelines have been published so far. The Committee of Andrology and Sexual Medicine of the French Association of Urology therefore offers a series of evidence-based recommendations.

MATERIALS AND METHODS

These recommendations are made according to the ADAPTE method, based on European (EAU, ESSM), American (AUA, ISSM) and Canadian (CAU) recommendations, integrating French specificities due to the availability of treatments, and an update of the recent bibliography.

RESULTS

The assessment of the disease is clinical. Patients with functional impairment or significant psychological repercussions may be offered treatment. The benefits and drawbacks of each treatment should be explained to the patient. Regarding non-surgical treatments, no available treatment has market authorization in France. Vitamin E is not recommended. Analgesic (oral or low-intensity shock waves) or proerectile treatments may be offered as needed, as well as traction therapy. Due to the unavailability of collagenase injections, verapamil injections may be offered. Surgical treatments are to be considered in the stabilized phase of the disease, and consist of performing a plication, an incision-graft or the placement of a penile implant according to the patient's wishes, the curvature and the penis size, as well as erectile function. Combination treatments can be offered.

CONCLUSION

The management of Peyronie's disease is complex, and the levels of evidence for treatments are generally low. The success of treatment will depend on the quality of the initial assessment, the patient's information and understanding of the expected effects, and the practitioner's experience.

[Reconstructive possibilities for Peyronie's disease]

The surgical treatment of Peyronie's disease involves a multistage procedure with increasing invasiveness. In addition to precise knowledge about the existing surgical treatment procedures, the indication and the informed consent process of the patient is extremely important. The dissatisfaction with the surgical results for many patients is due to false expectations and positivistic representations. If we can avoid this and make the right decisions during surgery, even these difficult-to-treat patients can be treated successfully.

Scrotal septum detachment during penile plication to compensate for loss of penile length compared with conventional surgical technique

Purpose

To evaluate the efficacy and safety of penile elongation featuring simple scrotal septum detachment from the penile base to compensate for the loss of penile length during penile plication in patients with Peyronie's disease compared with conventional penile plication.

Materials and Methods

We conducted a retrospective analysis of 38 patients (24–75 years of age) with Peyronie's disease who underwent penile plication with or without our novel technique from January 2009 to May 2018. Penile elongation was achieved by release and detachment of the scrotal septum from the penile base to the level of the scrotal fat tissue. The objective outcome of change in stretched penile length (SPL) and the subjective outcome of patient perception of postoperative penile length were compared between groups. Any postoperative complications were recorded.

Results

Of the 38 patients, 16 underwent penile plication with scrotal septum detachment (elongation group) and 22 underwent penile plication only (conventional group). The postoperative mean SPL was increased in the elongation group and decreased in the conventional group (1.2±1.3 cm vs. −0.5±0.3 cm, p<0.001). Fourteen of 16 patients (87.5%) in the elongation group reported perceived penile lengthening after surgery, whereas 17/22 patients (77.3%) in the conventional group complained of penile shortening. We encountered no procedure-related complications such as hematoma, infection, or necrosis in either group.

Conclusions

Simple detachment of the scrotal septum from the penile base afforded both objective and subjective penile elongation without any severe complications compared with conventional penile plication.

[Operative therapy of Pyronie's disease]

The operative therapy of Pyronie's disease (penile induration) follows a staged scheme. If the deviation is > 45° a complex operative treatment in the sense of plaque incision and excision with subsequent defect coverage is necessary. This operation should be carried out under optical magnification to safeguard the vessel-nerve bundle. Defect coverage can currently be carried out using a collagen fleece with excellent outcome but alternative patches are also still available. The focus in patient management is on a realistic preoperative estimation of the situation in order to avoid any unrealistic preconceptions and expectations by the patient.

A retrospective comparative study of traction therapy vs. no traction following tunica albuginea plication or partial excision and grafting for Peyronie's disease: measured lengths and patient perceptions

INTRODUCTION

Loss of penile length is a recognized and common consequence of Peyronie's disease (PD). Traction therapy (TT+) has been reported to decrease post-op length loss as well as increase stretched penile length (SPL) prior to surgery.

AIM

The aim of this study was to study patient outcomes with penile length change and patient satisfaction after surgery following tunica albuginea plication (TAP) and partial plaque excision and grafting (PEG) with or without postoperative TT.

METHODS

Retrospective analysis was performed from our cohort of Peyronie's reconstructive surgery between 2007 and 2010. SPL was measured dorsally from pubis to corona and recorded at the initial office visit and then compared to most recent postoperative visit. Patients were then stratified by procedure and whether TT was used (TT+ and TT-; TAP N = 52 [27 TT+ and 25 TT-] and PEG N = 59 [36 TT+ and 23 TT-). Traction therapy was initiated for >2 hours a day for 3 months typically starting 3-4 weeks postoperatively. A non-validated mailed questionnaire assessed patient perceptions.

RESULTS

Mean length change seen in TAP (TT+) was 0.85 cm (0.25-1.75) vs. -0.53 cm (-1.75 to 0.5) in TAP (TT-) (P < 0.001). The mean length change seen in PEG (TT+) was 1.48 cm (0-6) vs. PEG (TT-) 0.24 cm (-1 to 2.5 cm) (P < 0.001). Sixty-one percent of surveys were returned; 85% lost length prior to the initial office evaluation, with an average of -2.5 cm lost. Importantly, in those who used traction, there was no perceived length loss, 58% reported a mean erect length gain of 1.1 cm. However, only 54% of all patients were satisfied with their current erect length.

CONCLUSIONS

Loss of length in men with PD remains a serious concern. It appears that postoperative TT can result in length preservation, and in many, a measured and perceived length gain following correction of the curvature.

Traction therapy for men with shortened penis prior to penile prosthesis implantation: a pilot study

INTRODUCTION

Loss of penile length after penile prosthesis implantation is one of the most common complaints. There is no recognized reliable technique to gain length once the device is placed.

AIMS

This noncontrolled pilot study was designed to evaluate the efficacy and safety of external penile traction therapy in men with a shortened penis used before inflatable prosthesis implantation.

METHODS

Ten men with drug refractory erectile dysfunction and a complaint of a shorter penis as a result of radical prostatectomy in four, prior prosthesis explantation in four, and Peyronie's disease in two were entered into this trial. External penile traction was applied for 2-4 hours daily for 2-4 months prior to prosthesis surgery.

MAIN OUTCOME MEASURES

Baseline stretched penile length (SPL) was compared with post-traction SPL and postimplant inflated erect length. A non-validated questionnaire assessed patient satisfaction.

RESULTS

All men completed the protocol. Daily average device use was 2-4 hours and for up to 4 months. No man had measured or perceived length loss after inflatable penile prosthesis placement. Seventy percent had measured erect length gain compared with baseline pre-traction SPL up to 1.5 cm. There were no adverse events.

CONCLUSION

External traction therapy appears to result in a preservation of penile length, as no man had measured or perceived length loss following prosthesis placement, but in fact, a small length gain was noted in 70% of the subjects with no adverse events. The protocol is tedious and requires compliance to be effective. External traction therapy prior to inflatable penile prosthesis placement appears to preserve and possibly result in increased post-prosthesis implant erect length.

[Modificated plication technique of the tunica albuginea in penis curvature correction]

We present our penile curvature treatment experience in Peyronie's disease and cogenital curvature, using a modificated plication technique of the tunica albuginea with Prolene inverted sutures covered with Vicryl ones. The first suture gives security to the plication and the second one hides the first dots avoiding the nonabsorbable sutures bother.

Factors affecting the loss of length associated with tunica albuginea plication for correction of penile curvature

PURPOSE

Loss of length is a common postoperative complaint of the patient who undergoes surgical correction of penile curvature. We investigate the factors influencing complications in patients who have undergone TAP for PD and chordee.

MATERIALS AND METHODS

A total of 102 patients underwent TAP for PD (68) or chordee (34) between 1997 and 2004. Data were gathered on each patient's preoperative complaints, physical examination, Doppler ultrasound, operative data and postoperative complaints. For the purposes of this study penile length was measured from pubis to corona along the dorsal surface of the stretched phallus.

RESULTS

Mean ages at surgery for men with PD and chordee were 53 and 24, respectively. A range of 1 to 6 plications were performed on each patient (mean 3) with an acceptably straight penis (curve less than 20 degrees) being achieved in 99% of patients. Mean followup for our patient population was 29 months and revealed only 1 patient with residual curvature. The mean loss in length after TAP was 0.36 +/- 0.5 cm with a range of 0 to 2.5 cm. When calculated as a percent of length lost from preoperative length, the postoperative percent length lost was 2.4%. When stratified into groups based on direction of curvature, the patients with ventral or ventrolateral curve had the highest percent loss of length. A 1-way ANOVA of these groups proved the differences between each group to be statistically significant (p = 0.04). Length change also significantly correlated with preoperative stretched penile length and the severity of curvature as measured in degrees in the operating room at time of surgery. Parameters that did not demonstrate a statistically significant impact on penile shortening included patient age, number of plications performed, plaque size, and hinge/narrowing effect due to a PD plaque.

CONCLUSIONS

The TAP procedure is a safe and effective means of correcting penile curvature, with similar overall outcomes between patients with PD and chordee. Shortening of the penis does commonly occur but is dependent on direction and degree of curvature, as well as the length of the phallus.

New plication technique for the treatment of congenital penile curvature

Introduction:  Conditions that cause curvature of the erect penis also lead to difficulties with intercourse. The present study presents an effective surgical treatment for congenital penile curvature. Methods:  Between March 1996 and August 2004, 49 patients were diagnosed with congenital penile curvature at the Toho University Omori Hospital Reproduction Center, Tokyo. Of these, 27 eligible patients underwent surgical treatment. The operative technique used involved the tunica albuginea being exposed and a number of vertical incisions were made through its superficial layers. The superficial layer of the tunica albuginea was then resected using scissors. Inverted plication sutures were then placed in the raw surface of the corpus cavernosum using 2-0 nylon. In addition, 2-0 polyglactic acid (Vicryl) sutures were placed on either side of each nylon suture knot. Results:  Of a total of 49 patients, 27 eligible patients underwent surgical treatment with no serious postoperative complications. All 27 patients were able to sustain intercourse. There were no new cases of erectile dysfunction, penile pain or penile shortening. There were no recurrences of penile curvature. Conclusions:  This new partial thickness shaving, inverted sutures reinforced with dissolving sutures plication method is an extremely effective surgical treatment for congenital penile curvature, with a superior safety profile. (Reprod Med Biol 2005; 4: 255-258).