Penile Plication With or Without Degloving of the Penis Results in Similar Outcomes

A new treatment of concealed penis: symmetrical pterygoid flap surgery

PURPOSE

Considerable controversy exists regarding the surgery for concealed penis. We describe a new technique for repairing concealed penis by symmetrical pterygoid flap surgery.

METHODS

From January 2016 to July 2022, we evaluated 181 cases of concealed penis that were surgically treated using the symmetrical pterygoid flap surgery. We measured the penile size preoperative and 2, 4, 12 weeks, and 1 year postoperative to confirm the improvement. A questionnaire was administered to the patients and parents to assess satisfaction regarding penile size, morphology, and hygiene.

RESULT

The perpendicular penile length was1.59±0.32cm preoperative and 3.82±1.02 cm after the procedure (p < 0.05), and 4.21±1.91cm after one year of postoperative (p < 0.05). The overall satisfaction of patients was 97.89%, while the overall satisfaction of older children patients (age>7) was 75.24%. Parents focus more on the penile exposure size, while patients focus more on the penile morphology. Almost every patient had postoperative penile foreskin edema. However, this symptom had spontaneously resolved by 4-6 weeks. The complications such as skin necrosis, tissue contracture, or wound infection were 4.42%.

CONCLUSION

The symmetrical pterygoid flap surgery is an effective surgical technique for the management of concealed penis in children producing predictable results and excellent satisfaction of the parents and patients.

Plication for Correction of Congenital Penile Curvature: With or Without Degloving?

Introduction

Previously, incisionless plication (IP) for correction of congenital penile curvature (CPC) has been performed after penile degloving via a circumscribing incision.

Aim

To describe our experience with non-degloving incisionless penile plication (NDIP) for correction of CPC and compare these outcomes with those of men who underwent degloving incisionless penile plication (DIP).

Methods

We conducted a retrospective review of men ≤ 45 years of age who underwent incisionless penile plication for correction of CPC between 2008 and 2020 at two adult tertiary hospitals. Patients underwent either NDIP, performed through a 2-3 cm longitudinal incision along the proximal-to-mid shaft opposite the point of maximum penile curvature, or DIP via a sub-coronal circumscribing incision.

Main Outcome Measures

Surgical and patient-reported outcomes were compared between the non-degloving and degloving groups.

Results

Among the 38 men (mean age, 26 years) who met the inclusion criteria, 25 underwent NDIP, including 6 patients with biplanar curvature (2 Ventral, 4 Dorsal, 6 Lateral). Thirteen patients underwent DIP, including 1 patient with biplanar curvature (1 ventral, 1 lateral). Curvature reduction was 50 ± 23 degrees for the NDIP group and 36 ± 10 degrees for the DIP group (P = .04). Five (20%) patients in the NDIP group and nine (69%) patients in the DIP group experienced a reduction in stretched penile length following plication (SPL) (P = .01). One patient in the NDIP group underwent an additional plication for recurrent curvature.

Conclusion

Both NDIP and DIP are safe and highly efficacious techniques for the correction of CPC.

Kusin SB, Khouri RK, Dropkin BM, et al., Plication for Correction of Congenital Penile Curvature: With or Without Degloving?. Sex Med 2021;9:100462.

Preventing the need for revision surgery after penile plication reconstruction of Peyronie's deformities

BACKGROUND

The need for repeat penile plication (PP) for persistent penile deformity has previously been associated with (I) poor initial erectile response to intracavernosal injection (ICI), (II) an inadequate number of corrective sutures, and (III) a lack of sutures along the proximal shaft of the penis. We present our current experience with PP after implementing corrective measures to assess whether our need for revision surgery was reduced.

METHODS

We performed a retrospective review of patients who underwent PP for Peyronie's disease (PD) between 2009-2018 and had a minimum follow-up of 6 months. We updated our surgical technique in 2016 by (I) using supplemental intracorporal saline injections if the initial erection response to prostaglandin E1 injection was inadequate, (II) increasing numbers of corrective plication sutures, and (III) emphasizing more proximal suture placement. Patients were stratified into two groups and outcomes compared (prior technique versus current technique).

RESULTS

Of 472 PP patients who met inclusion criteria, 340 (72%) plication patients before 2016 were compared to 132 (28%) performed after 2016. The revision rate in the current cohort (1.5%, 2/132) decreased by more than half compared to the previous cohort (3.8%, 13/340). Mean preoperative angle of curvature was similar between the two groups (50.4 vs. 51.4 degrees, P=0.64), while the average residual postoperative degree was smaller in the current group (7.36 vs. 2.14 degrees, P<0.001). Fewer sutures were used in the early cohort than in the current (7.63 vs. 8.38, P=0.04). After revision, all cases were functionally straight, with a mean postoperative curvature of 4 degrees at a median follow-up of 10.6 months (IQR, 2.08-20.7).

CONCLUSIONS

Ensuring adequate rigidity with additional ICI and focusing a greater number of corrective sutures in a more proximal location appears to help prevent the need for revision plication surgery.

Plication techniques in Peyronie's disease: new developments

To date, surgical correction remains the gold standard for patients with stable Peyronie's disease (PD) due to its high efficacy and low morbidity. Among the surgical procedures, penile plication (PP) can be offered to men who have adequate erectile function and penile length (>13 cm), with a curvature <60° and a predicted shortening of maximum 20% of the penis. The aim of this paper is to review the new developments that have emerged in the last years about the use of PP in patients with PD. A nonsystematic review of the literature was carried out searching in the PubMed and EMBASE databases from January 01, 2009 to April 01, 2019 including the words 'Peyronie', 'penile curvature', 'penile induration', 'plication', and 'plicature'. New developments in PP in the last 10 years include avoiding degloving by using a penoscrotal incision, a new mathematical model to predict loss of length after PP, a wider range of indications including patients with severe (≥60°) or complex curvatures, burying knots to avoid later discomfort, and thinning or incising the plaque to prevent excessive shortening. PP is a well-founded procedure with great results in appropriately selected patients. Given the lack of any prospective randomized trial, no clear recommendation can be made of one technique over another.

Clinical characteristics and surgical outcomes in men undergoing tunica albuginea plication for congenital penile curvature who present with worsening penile deformity

PURPOSE

Men with congenital penile curvature (CPC) can develop new onset worsening of their lifelong curvature. We sought to evaluate clinical characteristics and postoperative outcomes after tunica albuginea plication (TAP) in patients presenting with CPC who reported new onset worsened curvature (CPC-WC), and compare these with patients reporting stable lifelong curve ("CPC-only").

METHODS

A retrospective review of demographics, history/exam findings, and postoperative outcomes for patients with CPC who underwent TAP from 2012 to 2018 was performed. Patients were differentiated based on whether or not they reported new onset worsening of their penile curvature preoperatively (CPC-WC versus CPC only). Statistical analysis was performed to identify differences in clinical characteristics and postoperative outcomes after TAP.

RESULTS

60 patients were included [CPC only (n = 39) and CPC-WC (n = 21)]. Mean curvature was 62° (SD 23). CPC-WC patients were older [median 34 years (IQR 27:52) versus 24 years (IQR 20:34); p = 0.004], and more likely to report penile shortening and psychological bother (p < 0.05). On physical examination, CPC-WCs were more likely to have a discrete palpable tunical scar and diminished penile elasticity (p ≤ 0.0002). With median follow up of 12 months, satisfactory straightening with TAP was reported in 56/60 patients (93%) including 35/39 (90%) CPC only and 21/21 (100%) CPC-WC.

CONCLUSIONS

In men undergoing TAP for CPC, we found that 35% reported new onset worsening of their original curvature preoperatively. These patients were older and more likely to report penile shortening or exhibit palpable tunical scarring with decreased elasticity on examination compared to those with lifelong stable curvature. Regardless, TAP resulted in satisfactory penile straightening in the majority of patients.

Plication for Severe Peyronie's Deformities Has Similar Long-Term Outcomes to Milder Cases

INTRODUCTION

Penile plication (PP) for Peyronie's disease (PD) is an established treatment option for mild to moderate curvature, but scant data exist regarding its utility in severe deformities.

AIM

To evaluate long-term outcomes among men undergoing PP for PD, comparing severe to mild/moderate penile deformities.

METHODS

We performed a retrospective review of patients who underwent PP for PD between 2009 and 2017. All patients underwent multiple parallel tunical plication without degloving. Severe PD was defined as either curvature ≥60 degrees or biplanar curvature ≥35 degrees. Patient demographics and surgical outcomes were analyzed. A modified PD Questionnaire and International Index of Erectile Function (IIEF)-5 were administered by telephone.

MAIN OUTCOME MEASURE

Long-term patient-reported outcomes were evaluated from a modified survey incorporating the PD Questionnaire and IIEF-5.

RESULTS

Of 327 PP patients, 102 (31%) responded to the telephone survey at a median 59.5 months (interquartile range 28.3-84) since surgery. Patients were equally distributed into severe (n = 51) and mild/moderate (n = 51) groups. Despite a greater mean degree of curvature in severe compared to mild/moderate patients (71.6 degrees vs 37.7 degrees, respectively, P < .001), correction of penile curvature was achieved in 91% of patients, with a mean change of 60.7 degrees in severe cases compared to 31.4 degrees in mild/moderate cases (P < .001). Equal numbers of patients in severe and mild/moderate groups reported improvement of penile curvature (74.5% vs 74.5%, P = 1.0) and sexual function (51.0% vs 49.0%, P = .84). PD Questionnaire metrics were likewise similar between severe and mild/moderate patients (P > .1), as were rates of subjective penile shortening (62.7% vs 62.7%, P = 1.0) and IIEF-5, both pre-operatively (19.5 vs 19.7, P = .9) and post-operatively (19.4 vs 17.6, respectively, P = .15). On multivariate logistic regression, worsening sexual function was significantly associated with increased age (odds ratio 1.07, P = .01) and pre-operative IIEF (odds ratio 1.14, P = .02).

CLINICAL IMPLICATIONS

PP should be considered in PD patients with severe deformities, as outcomes are favorable and comparable to those with milder curvature.

STRENGTH & LIMITATIONS

This is a novel study evaluating long-term patient-reported outcomes after PP, comparing patients with severe deformity to those with mild/moderate curvature. The study was limited by retrospective design, relatively low survey response rate (31%), and lack of validated post-operative PD questionnaire.

CONCLUSION

Long-term patient-reported outcomes of PP for severe PD deformities are comparable to mild/moderate cases, supporting broader application of PP beyond milder deformities. Reddy RS, McKibben MJ, Fuchs JS, et al. Plication for Severe Peyronie's Deformities Has Similar Long-Term Outcomes to Milder Cases. J Sex Med 2018;15:1498-1505.

Therapeutic effects of modified Devine surgery for concealed penis in children

OBJECTIVE

Considerable controversy exists regarding the surgical indications for a concealed penis. We herein describe a modified technique for correction of a concealed penis. The superfluous inner plate is resected to accelerate the disappearance of the postoperative lymphedema, and the skin between the penis and scrotum is trimmed to recover the penoscrotal angle.

METHODS

From January 2014 to October 2017, 79 patients with a concealed penis underwent our modified Devine penoplasty procedure. We measured the penile length preoperatively and postoperatively to confirm the improvement. A questionnaire was administered to the patients' parents to assess satisfaction regarding penile size, morphology, voiding status, and hygiene.

RESULTS

The perpendicular penile length was 1.88 ± 0.76 cm preoperatively and 4.42 ± 0.48 cm postoperatively, representing a significant improvement(p < 0.05). The parents' satisfaction grades for penile size, morphology, voiding status, and hygiene were significantly improved postoperatively (p < 0.05). Almost every patient had postoperative penile lymphedema; however, this symptom had spontaneously resolved by 6 weeks. No other complications occurred, such as skin necrosis, tissue contracture, or wound infection.

CONCLUSION

The herein-described modified repair technique for a concealed penis was technically feasible and safe, and excellent postoperative satisfaction was achieved. Additionally, the postoperative penis exhibited a good cosmetic appearance. Because of the successful outcomes with few complications, we believe that this surgical method for selected patients with a concealed penis is more effective than the traditional method.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

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.

2018 Canadian Urological Association guideline for Peyronie's disease and congenital penile curvature

Peyronie’s disease (PD) is a highly prevalent condition that affects the physical and psychosocial well-being and quality of life (QoL) for thousands of Canadian men. The specific etiology of PD remains poorly understood and there remains a paucity of randomized placebo-controlled trials evaluating treatment interventions.1-3 PD can be found in up to 8.9% of men, a remarkable increase in cited prevalence that is attributable to growing awareness (as historical data suggested a rate of less than 1%); the burden of disease is significant, and PD is often present in otherwise healthy men. The following guidelines were crafted by the committee with a full awareness of the limitations of the literature, and sought to provide actionable recommendations to guide PD care in the Canadian health system.