Strategies for penile prosthesis placement in Peyronie's disease and corporal fibrosis

A Consistent Lack of Consistency in Defining the Acute and Chronic Phases of Peyronie's Disease: A Review of the Contemporary Literature

INTRODUCTION

Treatment recommendations for Peyronie's Disease (PD) differ based on whether a patient is in the acute/active versus chronic/stable phase of the disease, yet there are no agreed upon criteria for defining these clinical entities.

OBJECTIVES

To review the criteria used to define acute and chronic phase PD in modern PD intervention studies.

METHODS

We performed a search engine review to identify indexed publications for PD intervention studies and review articles / meta-analyses from the year 2011-2020. Outcomes results were catalogued and summarized across articles. As a result of the substantial heterogeneity of outcome measures and follow-up intervals, meta-analytic techniques were not applied to the data analysis.

RESULTS

We identified a total of 104 studies that met inclusion criteria and had available information for review (n = 79 primary intervention studies; n = 25 review articles/meta-analyses/guidelines). Among the queried studies, we were unable to identify a consensus with respect to the criteria used to define acute and chronic phases of PD. 33% of primary intervention studies did not specifically define their criteria for acute and chronic phase PD, despite referencing these populations as part of the inclusion criteria in many instances. Studies used heterogenous criteria including total symptom duration, duration of "stable" symptoms, and presence/absence of pain.

CONCLUSION

Due to varying definitions across the literature, we were unable to create a standardized definition of acute and chronic phase Peyronie's in terms of time. Our findings emphasize the need for greater consensus in defining the treatment cohorts with future studies that assess treatment for men with PD.

Pathophysiology and Grayscale Ultrasonography of Penile Corporal Fibrosis

INTRODUCTION

Penile corporal fibrosis may occur secondary to explantation of an infected penile prosthesis, severe penile trauma, refractory low-flow priapism, Peyronie's disease, or chronic intra-cavernous injection of vasoactive drugs. Other etiologies of corporal fibrosis, presenting primarily with erectile dysfunction, can develop in chronic smokers, hypertensive patients, alcoholics, diabetics, and after radical prostatectomy. Corporal erectile tissue fibrosis is a significant pathophysiologic component of erectile dysfunction; however, current ultrasound-based penile imaging protocols do not directly assess it.

OBJECTIVE

To determine if grayscale ultrasonography (US) is a suitable imaging modality to identify and assess penile corporal erectile tissue fibrosis.

METHODS

A PubMed literature review was performed for studies that detailed ultrasonographic methods and findings of pathologies causing penile corporal fibrosis. Our main outcome measure was the ultrasonographic findings of pathologies causing penile corporal fibrosis.

RESULTS

Grayscale US demonstrates the capability to detect and localize the fibrotic changes of the corpora cavernosa. Ultrasonographic findings capture penile corporal tissue heterogeneity including diffuse, circumscribed, or localized patterns.

CONCLUSION

Overall, grayscale US may be a useful and convenient imaging modality to assess penile corporal fibrosis secondary to explantation of an infected penile prosthesis, priapism, penile trauma, chronic intra-cavernous injection of vasoactive drugs, diabetes, Peyronie's disease, and vascular disease. While limited by the skill and knowledge of the US operator, the combined knowledge of pathophysiology and US may help clinicians identify and manage the underlying etiology of penile corporal fibrosis. Kim J, Drury R, Morenas R et al. Pathophysiology and Grayscale Ultrasonography of Penile Corporal Fibrosis. Sex Med Rev 2022;10:99-107.

Management of residual penile curvature after penile prosthesis placement

Residual penile curvature is a common situation following the implantation of a penile prosthesis in patients with Peyronie's disease. Currently, there is a variety of options for the correction of residual curvature, including penile modeling, plication techniques, as well as tunical incision/excision with or without grafting. A literature search of PubMed and Medline databases was conducted from 1964 until 2020, using search terms for all articles in the English language. In this article, we provide a review of the techniques and the outcomes, according to the published literature.

Intraoperative methods for residual curvature correction during penile prosthesis implantation in patients with Peyronie's disease and refractory erectile dysfunction

Peyronie's disease, or fibrous transformations of the tunica albuginea of the corpora cavernosa that cause penile curvature, is estimated to affect 3.2-8.9% of the male population. Treatment options for PD are based on the severity of the penile deformity and erectile function; of which surgical options include manual modeling during penile prosthesis implantation, plication, plaque incision, and grafting. Multiple approaches may be employed; each with its own advantages, limitations, and risk/benefit ratios. In this regard, we sought to review and highlight the current approaches for the management of residual curvature, optimal patient selection, and preoperative planning.

[Adjuvant surgical maneuvers in penile prostheses implant to improve their aesthetic and functional outcomes]

Penile prosthetic surgery is the definitive treatment for those patients with erectile dysfunction refractory to medical treatment. Although it associates satisfaction rates>90%, it is known that men with Peyronie's disease, body mass index>30kg/m² or those previously operated on radical prostatectomy have lower satisfaction rates than the general population. The main reasons for dissatisfaction are the subjective loss of penile length and glans' flaccidity. Given such circumstance, several adjuvant surgical techniques have been described to improve aesthetic and functional outcomes after the implant. In our review, we wanted to investigate the different maneuvers used in patients with Peyronie's disease, those used to avoid the reduction of penile length and those used to avoid the floppy glans syndrome.

Urethral Injury and the Penile Prosthesis

INTRODUCTION

The relative infrequency of urethral injuries during penile prosthesis implantation has caused the event to be understudied relative to the morbidity and cost associated with their management.

AIM

To draw attention to both acute intraoperative and delayed urethral injuries via cylinder erosion by compiling and evaluating the available literature on their cause, diagnosis, and management.

METHODS

A literature review was performed through PubMed from 1985 to 2018 regarding urethral injuries in the setting of penile prosthesis implantation. Comorbidities and anatomic factors that predispose a patient to a urethral injury were also queried.

MAIN OUTCOME MEASURES

The goal is to identify at-risk populations and assess options for managing distal, mid-pendulous, and proximal acute urethral injuries that occur in the setting of penile prosthesis implantation. We also examine strategies to manage prosthesis erosion into the urethra.

RESULTS

Although urethral injuries are rare, certain patient populations are at higher risk for the event. Injuries at various locations along the urethra present unique challenging and morbid clinical scenarios. However, there are a variety of management options available that allow a patient to ultimately void normally and have a successfully implanted penile prosthesis.

CONCLUSION

Overall, penile prostheses offer many patients an improved sexual quality of life. In the setting of prosthesis implantation both acute and delayed urethral injuries are rare, but their associated morbidity can undercut the benefits of the device. Our understanding of these injuries has matured, and we now possess management strategies that can mitigate the morbidity and frustration that accompany this complication. Carlos EC, Sexton SJ, Lentz AC. Urethral injury and the penile prosthesis. Sex Med Rev 2019;7:360-368.

The use of penile prostheses in the management of priapism

Priapism is a relatively uncommon condition that can result in erectile dysfunction (ED) and corporal fibrosis. Cases of prolonged priapism are particularly prone to ED, which arises when priapism is treatment refractory or had a delayed presentation. Due to the emergent nature of priapism, it behooves urologists to be familiar with all potential treatment modalities to minimize adverse outcomes. In this review paper, we aim to summarize the literature regarding the use of penile prosthesis (PP) implantation in the setting of ischemic priapism (IP). In some patients who present later or have prolonged initial treatment, early insertion of PP may be indicated.

Inflatable Penile Prosthesis Insertion in Men with Severe Intracorporal Fibrosis

OBJECTIVES

To retrospectively review a series of men who underwent attempted inflatable penile prosthesis (IPP) insertion into severely scarred corpora, and to analyze the surgical techniques and instruments that contributed to a successful outcome.

PATIENTS AND METHODS

All IPP procedures done by a high-volume prosthetic surgeon during a 5-year period were retrospectively reviewed. Fourteen patients with severe intracorporal fibrosis underwent 15 attempted IPP insertion procedures, and are the subject of this review.

RESULTS

A standardized surgical approach was employed for all patients. Thirteen of the 15 procedures were successful (i.e., an IPP was inserted, with satisfactory cylinder position). One procedure failed due to corporal obliteration. One patient underwent an initial failed attempt, but was successfully implanted 10 months later. Two of the 14 patients (14%) developed peri-prosthetic infection and were explanted.

CONCLUSION

IPP insertion into scarred corpora is difficult and occasionally impossible. We have developed a standardized surgical approach for these cases, using limited corporal excavation, followed by the use of sequential Uramix and then Carrion-Rossello cavernotomes, that we feel has improved our chance of a successful implant. However, due to the rarity of these cases, it is not possible to make definitive statements concerning the optimal surgical technique.

A review of surgical strategies for penile prosthesis implantation in patients with Peyronie's disease

The introduction of the inflatable penile prosthesis (IPP) has revolutionized the treatment of patients with both Peyronie's disease (PD) and erectile dysfunction (ED). A thorough literature review was performed in order to review the surgical strategies used to treat PD, using the PubMed online database with the keywords "penile prosthesis", "surgical management" and "Peyronie's disease". Patient satisfaction rates of 72-100% and partner satisfaction rates of 89% have been reported in the literature, although strong preoperative education may be needed to prepare patients for risks such as penile shortening, seen in up to 54% of patients. Three-piece IPPs are most commonly used, and when comparing the two most popular models (AMS 700 CX vs. Coloplast Titan), no significant differences were seen in functional outcomes or patient satisfaction. Simple insertion of an IPP has been shown to resolve curvature in 33-90% of patients, but surgeons may often need to also utilize ancillary straightening procedures for residual curvatures. Manual modeling can correct residual curvature with an 86-100% success rate, but with a 4% risk of urethral injury. When the post-modeling residual curvature exceeds 30 degrees, a plaque-releasing incision or plication is recommended to further reduce curvature. Grafting is recommended if the resulting incisional defect is larger than two centimeters. Alternative straightening techniques such as plication prior to IPP insertion, endoscopic plaque resection, the "scratch technique" and bone saw plaque incision have also been described.

Peyronie's disease: What's around the bend?

INTRODUCTION

Peyronie's disease (PD) is a fibrotic diathesis of the tunica albuginea that results in penile plaque formation and penile deformity, negatively affecting sexual and psychosocial function of both patients and their partners. In this review, we discuss the PD literature and PD treatment options, with special emphasis on potential future therapies.

METHODS

The PD literature was reviewed, and articles of interest were identified using keyword search in PubMed. Articles evaluating investigational and novel PD treatments were emphasized.

RESULTS

Existing PD treatment modalities are diverse and include oral, topical, intralesional, mechanical, and surgical therapies. Surgical treatment has high success rates and is indicated in men with significant, stable deformity. The United States Food and Drug Administration-approved intralesional collagenase Clostridium histolyticum injection therapy is a minimally invasive option with demonstrated efficacy in PD. Other nonsurgical therapies have been reported, including Botox and stem cell therapy, but these currently have little or equivocal evidence to support their efficacy.

CONCLUSIONS

Further research is essential to develop novel, safe, and effective minimally invasive PD treatment options. This work is ongoing, with the promise of specific, targeted, and highly effective therapies on the horizon.

Special considerations for placement of an inflatable penile prosthesis for the patient with Peyronie's disease: techniques and patient preference

Placement of an inflatable penile prosthesis (IPP) is the mainstay of surgical treatment for patients with Peyronie’s disease (PD) and concomitant medication-refractory erectile dysfunction. Special considerations and adjunctive surgical techniques during the IPP procedure are often required for patients with PD to improve residual penile curvature, as well as postoperative penile length. The surgical outcomes and various adjunctive techniques are not significantly different from one another, and selection of the appropriate technique must be tailored to patient-specific factors including the extent of the deformity, the degree of penile shortening, and preoperative patient expectations. The aims of this review were to assess the current literature on published outcomes and surgical techniques involving IPP placement in the treatment of PD. Patient satisfaction and preferences are reported, along with the description and patient selection for surgical techniques that include manual penile modeling, management of refractory curvature with concurrent plication, and correction of severe residual curvature and penile shortening with tunica release and plaque incision and grafting. A thorough description of the available techniques and their associated outcomes may help guide surgeons to the most appropriate choice for their patients.

Therapeutic advances in the treatment of Peyronie's disease

Peyronie's disease (PD) is an under-diagnosed condition with prevalence in the male population as high as 9%. It is a localized connective tissue disorder of the penis characterized by scarring of the tunica albuginea. Its pathophysiology, however, remains incompletely elucidated. For the management of the acute phase of PD, there are currently numerous available oral drugs, but the scientific evidence for their use is weak. In terms of intralesional injections, collagenase clostridium histolyticum is currently the only Food and Drug Administration-approved drug for the management of patients with PD and a palpable plaque with dorsal or dorsolateral curvature >30°. Other available intralesional injectable drugs include verapamil and interferon-alpha-2B, however, their use is considered off-label. Iontophoresis, shockwave therapy, and radiation therapy have also been described with unconvincing results, and as such, their use is currently not recommended. Traction therapy, as part of a multimodal approach, is an underused additional tool for the prevention of PD-associated loss of penile length, but its efficacy is dependent on patient compliance. Surgical therapy remains the gold standard for patients in the chronic phase of the disease. In patients with adequate erectile function, tunical plication and/or incision/partial excision and grafting can be offered, depending on degree of curvature and/or presence of destabilizing deformity. In patients with erectile dysfunction non-responsive to oral therapy, insertion of an inflatable penile prosthesis with or without straightening procedures should be offered.

PEYRONIE'S DISEASE: A REVIEW OF ETIOLOGY, DIAGNOSIS, AND MANAGEMENT

Peyronie's Disease (PD) is a superficial fibrosing disorder of the penis resulting in plaque formation and penile deformity. Once considered rare, PD has more recently been found in up to 13% of men, and can negatively affect sexual and psychosocial function of both patients and their partners. While the etiology of PD is unclear, it is thought to result from an inciting traumatic event followed by aberrant fibrosis or dysregulated wound healing. The evaluation of men presenting with PD includes a detailed history and physical exam, focusing on the penis in both the flaccid and erect states. PD is often associated with erectile dysfunction (ED), as well as several other comorbidities. Laboratory testing is not needed to diagnose PD, although given the associations between PD and systemic diseases including hypogonadism, diabetes, and cardiovascular disease, screening and work-up for these conditions in men with PD may be warranted. Treatment modalities for PD are diverse and include oral, topical, intralesional, mechanical, and surgical therapies. Oral, topical, and mechanical therapies generally have little evidence supporting their efficacy. Several intralesional therapies, including interferon α2b and collagenase Clostridium hystiolyticum have demonstrated efficacy in the treatment of PD. Surgical treatment, indicated in men with significant, stable deformity, includes plication of the tunica albuginea, plaque incision/excision and grafting, and placement of inflatable penile prosthesis (IPP) with or without additional maneuvers to achieve desired results, and has high success rates.