Twenty Years of Plaque Incision and Grafting for Peyronie's Disease: A Review of Literature

Surgical management of complex curvature in Peyronie's disease

PURPOSE

About 10% of Peyronie's patients are complex cases with severe curvature (>60 degrees), ventral plaque, multiplanar curvature, hour-glass/hinge deformity, notching deformity, and ossified plaque. In patients with complex Peyronie's disease (PD), different techniques (shortening procedures, lengthening procedures, and penile prosthesis implantation (IPP)) may be necessary to achieve successful result. This review aims to analyze the various surgical techniques employed in the management of Peyronie's disease, with a specific focus on patients with complex deformity.

METHODS

Articles focusing on the surgical management of complex curvature in Peyronie's disease were searched in MEDLINE and PubMed published between 1990 and 2023.

RESULTS

Shortening procedures are linked to penile shortening and are not recommended for complex cases such as notching, hour-glass deformity, or ossified plaque. Lengthening procedures are suitable for addressing complex curvatures without erectile dysfunction (ED) and are a more appropriate method for multiplanar curvatures. Penile prosthesis implantation (IPP), with or without additional procedures, is the gold standard for patients with ED and Peyronie's disease. IPP should also be the preferred option for cases of penile instability (hinge deformity) and has shown high satisfaction rates in all complex cases.

CONCLUSION

While surgical interventions for complex curvature in Peyronie's disease carry inherent risks, careful patient selection, meticulous surgical techniques, and post-operative care can help minimize complications and maximize positive outcome.

Measurement of Oxidative Stress Index (OSI) in Penile Corpora Cavernosa and Peripheral Blood of Peyronie's Disease Patients: A Report of 49 Cases

Peyronie's disease (PD) is a chronic inflammatory disease affecting the penile albuginea. Oxidative stress (OS) is important for the development of the disease; therefore, it seemed interesting to us to directly measure OS at both the site of the disease and in peripheral blood. For a precise OS study, it is necessary to evaluate not only the single results of the total oxidant status (TOS) and total antioxidant status (TAS) but also their ratio: OS index (OSI) (arbitrary unit) = TOS/TAS × 100. This study included 49 PD patients examined and diagnosed in our Peyronie's care center and a control group of 50 cases. We collected blood samples from both the penis and a vein in the upper extremity; we used d-ROMs and PAT-test (FRAS kit) for OS measurement. Pearson's study found a statistical correlation between penile OSI values and PD plaque volumes: p-value = 0.002. No correlation was found between systemic OSI values and PD plaque volumes: p-value = 0.27. Penile OSI values were significantly reduced after the elimination of the PD plaque (p < 0.00001). The mean value of the penile OSI indices in the PD patients after plaque elimination corresponded to 0.090 ± 0.016 (p = 0.004). The comparison between the penile OSI values of the PD patients (with plaque elimination) and the control group revealed no statistically significant differences (p = 0.130). The absence of a correlation between Peyronie's plaque volume and systemic OSI values indicates that it is preferable to carry out the OS study by taking a sample directly from the site of the disease. By carrying out a penile OSI study, it would be possible to obtain a precise plaque-volume-dependent oxidative marker. Even if the study did not demonstrate any correlation between OSI indices and anxious-depressive state, we detected a high prevalence of anxiety (81.6%) and depression (59.1%) in PD patients.

Grafts in Peyronie's surgery without the use of prostheses: a systematic review and meta-analysis

ABSTRACT

Peyronie's disease (PD) is characterized by abnormal penile curvature, and various surgical methods have been developed using different graft materials. However, there is currently no universal agreement on which type of graft is the best. The objective of this review was to evaluate the available literature and identify the most effective graft material for penile curvature correction in PD. A literature search was conducted using electronic databases, including PubMed, Scopus, and the Cochrane Library. The patients, intervention, comparison, and outcome (PICO) approach was used to define the eligibility of studies. Two authors independently selected studies, evaluated them, and extracted data. Random-effect models using the DerSimonian-Laird method were used. Most studies were single-arm studies and had a high risk of bias. Buccal mucosa grafts (BMG) were found to result in the highest penile straightening rates and were associated with the least de novo erectile dysfunction. TachoSil grafts demonstrated a high success rate in straightening despite a higher mean preoperative curvature, while Tutoplast grafts had a higher incidence of postoperative erectile dysfunction. BMG had the highest percentage of postoperative penile straightening. Overall, the TachoSil graft showed the best performance when preoperative curvature is taken into account. Based on the available literature, BMG appear to be the most effective for penile curvature correction in PD, but this is offset by the requirement for low preoperative curvature. The TachoSil graft shows the best overall performance when preoperative curvature is considered. Comparative randomized clinical trials are still needed to determine graft superiority.

A study of the histopathology of collagen fleece (TachoSil) patching of tunica albuginea in the rat penis and a literature review of penile graft materials in experimental animals

Background

A penile tunica defect may arise during surgery in patients with Peyronie's disease. Collagen fleece (TachoSil) has recently gained popularity in penile surgery to cover the tunica albuginea (TA) defect associated with clinical success. However, it is not known what the histological outcomes of these grafts are in the penis. We aimed to study the histopathology of the TachoSil graft in an experimental animal model for the regeneration of TA, inflammation, fibrosis, and the underlying cavernous tissue.

Methods

Six adult male Sprague Dawley rats were used. The penis was degloved through a circumferential subcoronal incision. A longitudinal 1 mm × 10 mm defect was created at the base of the lateral aspect of the penis. A TachoSil patch (Takeda, Japan) was applied to the defect. The penile skin covering was then restored. At 2 months, the rat penis was excised and examined with hematoxylin, eosin, and trichrome stains. We conducted a literature review of penile grafts in animals for comparison.

Results

Rats weighed 369.2 gm (standard deviation: 31.5). At 2 months, all rats showed normal-looking penis with complete healing, no scaring, tethering, or gross inflammatory features. Histopathology of the patch site showed fibrosis, chronic inflammation, and foreign body giant cell reaction. There was no generation of a new TA, or new vascularity. No inflammatory or pathological reaction affected the underlying corpus cavernous tissue. One rat died on the 6th postoperative day. Postmortem showed massive multiorgan hemorrhage consistent with disseminated intravascular coagulopathy (DIC). Unlike some other reported grafts, there is no TA regeneration.

Conclusions

TachoSil patching of penile TA defect forms a distinctive barrier against inflammation, protecting the underlying corpus cavernosum. However, no regeneration of the tunica defect is observed at 2 months. DIC is a potential complication of systemic absorption of TachoSil.

Peyronie’s Disease: A Brief Overview

Peyronie's disease is an acquired connective tissue disease of the tunica albuginea of the penis which usually presents with penile curvature/deformity and a palpable penile plaque. It is more common in Caucasian men over the fifth decade of life, but it is an under-reported disease. Conservative and non-surgical options are supported by limited evidence except for intralesional injection of collagenase clostridium histolyticum and have limited success. The improved outcome of surgical treatment is accompanied by the risk of erectile dysfunction. This is a brief overview of Peyronie's disease, its impact on the patient, and the available treatment options.

Peyronie's disease development and management in diabetic men

BACKGROUND

Peyronie's disease (PD) is a fibrosing disorder of the penis resulting in plaque formation and penile deformity that negatively affect sexual and psychosocial function of patients. A multifactorial etiology of PD is assumed with diabetes mellitus (DM) being a potential risk factor.

OBJECTIVES

The aim of this narrative review was to investigate diabetes role in PD pathophysiology, diagnosis, and treatment.

MATERIALS AND METHODS

A non-systematic narrative review of original articles, meta-analyses, and randomized trials was conducted, including articles in the pre-clinical setting to support relevant findings.

RESULTS

Diabetes is one of the most common comorbidity observed in PD patients, with a prevalence of about 11% and a strong association with erectile dysfunction (ED). DM is associated with both a higher risk of developing PD and has also an impact on the outcomes of PD's treatments.

DISCUSSION

Evidence from literature underlines that metabolic alterations typical of DM are pivotal factors in the development of PD and resistance to its medical treatment.

CONCLUSION

The role of DM in development of PD is still debated, while its role in PD development is not completely clear, there is a clear impact of DM on PD treatment outcomes.

Chronological perspective of substitute materials used for the surgical treatment of Peyronie’s disease: A scoping review of literature

This comprehensive scoping review aimed to identify all up-to-date original publications relating to substitute materials used for the surgical treatment of Peyronie’s disease (PD), and characterize what material in which chronological trends were published in the current literature. Using the PCC framework (P: population, C: concept, and C: context), a search strategy was developed and used in four electronic databases, in addition to the Google scholar. All current published, in-press, and pre-print manuscripts with available English full-text were included. Eligible studies were required to be original research articles of any study design, reporting the usage of grafts on surgical treatment of PD. Included studies were reported in a narrative synthesis format. A total of 3379 articles were identified via an electronic search of databases and a total of 171 articles entered this scoping review. Most studies originated from Europe ( n = 72) and North America ( n = 66). Reports from the other continents increase in number in the 21st century. Highest number of the published papers was seen in 2001 to 2005 pentad. Autologous grafts (53.5%). Allografts (22.7%) and xenografts (15.7%) were the most frequently reported materials. Time flow of the used material and the alterations in trends for them is quite considerable. A global perspective of relevant publications on substitute materials in the surgical management of PD is presented in this review. The information in this summary may assist in establishing future research priorities in this area.

Clinical Significance of Shortened Penile Length and Alterations in Penile Length Following Treatment for Peyronie's Disease

INTRODUCTION

Across many cultures, penis size has been associated with virility, and concerns about penile length are commonplace. Peyronie's disease (PD) is a known acquired cause of penile shortening.

OBJECTIVES

This paper describes the psychosocial impacts of penile length on men and their partners, both generally and in men with PD, and evaluates the effect of PD treatments (eg, collagenase clostridium histolyticum , surgery, mechanical therapy) on this outcome measure.

METHODS

A PubMed database search was performed for English language articles through July 2021. Main outcome measures were association of penile length with emotional well-being, selfesteem, and relationship satisfaction in men with PD, and change from baseline penile length after treatment.

RESULTS

Shortened penile length caused by PD can negatively impact patient and partner quality of life, including effects on body image, emotional well-being, sexual function, and interpersonal relationships. In men with PD, studies have demonstrated an association between loss of penile length and emotional problems, reduced satisfaction with sexual performance, poor self-esteem, depression, and relationship difficulties. Loss of penile length can frequently occur after surgery for PD (including plication, plaque incision/excision with grafting, and penile implant). Advanced surgical techniques may preserve/increase penile length, but the increased risks associated with these complex procedures must be carefully considered. Treatment with collagenase clostridium histolyticum does not appear to negatively impact penile length, and 5-year follow-up data suggest potential longterm posttreatment improvements in this outcome measure. Penile traction therapy, either alone or as adjunctive therapy, may increase penile length in men with PD, but nonadherence may limit improvement.

CONCLUSION

Changes in penile length are important to many men, particularly those with PD, and should be considered during PD treatment selection. Penile length should be measured objectively before and after treatment for PD and should be included as an outcome measure in future studies on treatment effectiveness. Goldstein I, Gelbard MK, Lipshultz LI. Clinical Significance of Shortened Penile Length and Alterations in Penile Length Following Treatment for Peyronie's Disease. Sex Med Rev 2022;10:409-420.

Saphenous Vein Graft for Treatment of Peyronie’s Disease, a Comparison between Single and Multiple Graft Reconstruction

Background:

Surgical reconstruction is the gold standard of treatment for Peyronie’s disease (PD). Grafting procedures provide satisfactory outcomes in patients with complex curvature, short penile length, and without previous erectile dysfunction (ED). We aimed to compare two different grafting methods of reconstruction in patients with PD.

Method:

Fifty-two PD patients at Imam-Reza hospital of Mashhad from October 2011 to January 2019 with stable plaque, penile angulation of >60˚, complex curvature, and without ED who consented to cooperate, included in our study and divided into two groups. The first group consists of 26 patients, undergone grafting through a double-Y incision and a single saphenous graft placed within the incision. For the second group, two smaller saphenous vein grafts were placed in the two parallel incisions. ED assessed pre- and post-operational via the International index of erectile function. Penile angulation less than 20 degrees was considered a favorable outcome. Patients followed for 18 months, and sacculation, penile shortening, post-operation infection, and penile hypoesthesia were assessed as complications. We used a paired t-test to compare these two groups.

Results:

ED was 25% and 12% in the first and the second group, respectively. Statistics showed no difference between the two groups regarding pre and post-operational ED (P=0.1). Regarding complications during follow-up, sacculation occurred in four patients of the first group and none of the second group patients but no significant difference (P=0.23).

Conclusion:

We found no superiority to declare between these two procedures, although regarding the small sample size of our study, further evaluations are needed to establish more reliable results.

A Critical Analysis of Reporting in Systematic Reviews and Meta-Analyses in the Peyronie's Disease Literature

BACKGROUND

Despite an increasing number of publications on Peyronie's disease (PD), evidence-based clinical decision-making remains challenging due to the small number of well-designed clinical trials.

AIM

To perform a critical analysis of reporting quality in PD systematic reviews (SR) and meta-analyses (MA).

METHODS

Study protocol registration was performed on the Open Science Framework platform. In January 2021, a systematic electronic search of the Medline/PubMed, Embase, Ovid, Scopus, Joanne Briggs Institute, and Cochrane databases was performed. Search terms included "Peyronie's disease" and "systematic review OR meta-analysis OR meta-analysis." Eligibility criteria were English-language, relevance to PD and specification of "systematic review" or "meta-analysis" in the title or abstract. Oxford Center for Evidence-Based Medicine levels of evidence were used to classify original studies reviewed within each publication. Risk of bias was assessed using the ROBIS tool. Data were tabulated and reported as means with standard deviation, median with interquartile range and t-testing as appropriate. Strength of association between variables was calculated using Pearson correlation coefficient. Statistical analyses were performed on RStudio (version 1.4.1106).

OUTCOMES

Outcomes included review type, level of evidence, authorship, journal, publication date, "A MeaSurement Tool to Assess systematic Reviews" (AMSTAR-2) score and "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) score.

RESULTS

From 1974 to 2021, 340 articles were identified. After review, 17 full length articles were included. Thirteen were SR, 2 MA and 2 was combined. Significant heterogeneity was seen in evidence level of included studies. There was median 54% adherence to AMSTAR-2 criteria and 74% adherence to PRISMA criteria. Overall AMSTAR-2 confidence rating was Critically Low in 11 of 17 studies. Correlation analysis revealed very high positive association between AMSTAR 2 and PRISMA adherence (+0.95). ROBIS revealed "High" concern regarding methods used to collect data and appraise 12/17 studies (71%), and "High" concern regarding synthesis and findings in 8 of 17 studies (47%).

CLINICAL IMPLICATIONS

Many SR include markedly heterogenous levels of evidence and fail to meet accepted methodological criteria for reporting.

STRENGTHS AND LIMITATIONS

Main strengths include extensive literature review and analysis of standardized study reporting. One limitation is that aggregate scoring of AMSTAR-2 and PRISMA is not intended as primary method of quality assessment; however effect was minimized by reporting critical domains, overall quality assessments and specifics on globally poorly reported domains.

CONCLUSION

More high quality randomized controlled PD trials are necessary; SR and MA should focus on these studies alone. Bole R, Gottlich HC, Ziegelmann MJ, et al. A Critical Analysis of Reporting in Systematic Reviews and Meta-Analyses in the Peyronie's Disease Literature. J Sex Med 2022;19:629-640.

ESSM Position Statement on Surgical Treatment of Peyronie's Disease

INTRODUCTION

Patients with Peyronie's disease may experience significat distress. The choice of treatment depends on a variety of factors, including the stage of the disease, the presence of pain, severity and direction of the curvature, penile length and the quality of erectile function.

AIM

To review the evidence associated with surgical treatment of Peyronie`s Disease and provide clinical recommendations on behalf of the European Society for Sexual Medicine. 131 peer-reviewed studies and systematic reviews, which were published from 2009 to 2019 in the English language, were included.

METHODS

MEDLINE, Google Scholar and EMBASE were searched for randomized clinical trials, meta-analyses, open-label prospective and retrospective studies.

MAIN OUTCOME MEASURE

The panel provided statements on clinically relevant questions including patient involvement in the decision process, indications for surgery, choice of the approach, and the management of patient expectations. A comparison of the different grafts used in patients who have undergone plaque incision/excision and grafting in order to identify an ideal graft, has been carried out. The prevalence of postoperative complications has been summarized. Levels of evidence were provided according to the Oxford 2011 criteria and Oxford Centre for Evidence-Based Medicine recommendations.

RESULTS

In order to allow shared decision making, a patient preoperative counselling regarding the pros and cons of each intervention is recommended. In particular, adverse effects of surgical treatments should be discussed to set realistic understanding and expectations of surgical outcomes and ultimately improve postoperative satisfaction rates. Surgical treatment should be only offered in the chronic phase of the condition, when the deformity and/or degree of erectile dysfunction, prevent patients from engaging in satisfying sexual interaction, or if the deformity is the cause of severe bother.

CONCLUSIONS

Current European Society for Sexual Medicine recommendations cover several aspects of Peyronie's disease treatment. These recommendations aim both to ensure patients and partners have accurate and realistic expectations of their treatment options, as well as to formulate algorithms to guide clinician management pathways. Osmonov D. et al., ESSM Position Statement on Surgical Treatment of Peyronie's Disease. Sex Med 2022;10:100459.

Penile Prosthesis Implantation Combined With Grafting Techniques in Patients With Peyronie's Disease and Erectile Dysfunction: A Systematic Review

INTRODUCTION

Penile prosthesis (PP) implantation combined with grafting techniques is indicated in patients with Peyronie's disease (PD) and erectile dysfunction (ED) nonresponsive to medical and conservative treatment that present with residual penile curvature greater than 30°, severe penile deformity or significant penile shortening.

OBJECTIVES

To address the preoperative evaluation, the surgical procedure and the functional outcomes of grafting techniques combined with PP implantation in patients with PD and concomitant ED and to provide future perspectives on the matter.

METHODS

We performed a systematic review of the literature based on the PRISMA statement (PROSPERO ID: CRD42021224517). Records were identified by searching Medline, Scopus, The Cochrane Library and Web of Science databases as well as sources of gray literature from inception to December 2020. The quality of all included records was assessed based on a modified version of the Newcastle-Ottawa Scale for cohort studies.

RESULTS

A total of 935 patients with a mean age of 59.6 ± 9.2 years from 23 studies were included in this systematic review. All studies reported excellent short- and long-term postoperative results, as well as high satisfaction rates ranging from 80 to 100%. A mean increase of 2.7 ± 1.4 cm in penile length was observed. Among different grafting materials and different types of PP, no significant differences in terms of preoperative, perioperative and postoperative functional outcomes or complications were demonstrated. Still, the operative time was shorter in studies applying the collagen fleece TachoSil.

CONCLUSIONS

PP implantation combined with grafting is a safe and highly effective surgical procedure in patients with PD and concomitant ED. All grafting materials provide similar beneficial outcomes, but TachoSil subsequently reduces the operative time and does not require suturing. Still, no definite conclusions can be drawn regarding the superiority of one grafting technique over the other, as randomized clinical trials are lacking. Sokolakis I, Pyrgidis N, Ziegelmann M, et al. Penile Prosthesis Implantation Combined With Grafting Techniques in Patients With Peyronie's Disease and Erectile Dysfunction: A Systematic Review. Sex Med Rev 2021;XX:XXX-XXX.

Surgical Planning and Strategies for Peyronie's Disease

INTRODUCTION

Peyronie's disease results in penile curvature, shortening, instability, or pain upon erection-hindering sexual performance and leading to psychological distress. Despite extensive research, surgery is still the mainstay of treatment.

OBJECTIVE

To present an organized description of the most common surgical techniques used in the correction of Peyronie's disease and to propose a surgical algorithm to guide management.

METHODS

Using PubMed, we reviewed the published literature regarding surgical treatment of Peyronie's disease and its outcomes. We identified original articles, review articles, and editorials addressing the subject, with a focus on surgical techniques, their indications, and outcomes.

RESULTS

Peyronie's disease can be treated by corporoplasty or penile prosthesis implantation. Corporoplasty includes convex side-shortening procedures and concave side lengthening procedures. It is indicated when the erectile function is adequate. Shortening procedures include excisional, incisional, and plication-only techniques, and lengthening procedures include partial excision or incision followed by grafting. When refractory erectile dysfunction is present, placement of a penile prosthesis with or without further straightening maneuvers is recommended. We reviewed the indications, advantages, disadvantages, and outcomes of the available techniques and proposed a surgical algorithm to guide management.

CONCLUSION

Penile shortening procedures are usually indicated in curvatures <60°, in penises with adequate length. Partial excision/incision and grafting are indicated for curvatures >60°, hourglass or hinge deformities, and short penises, if the patient's erectile function is adequate. The presence of "borderline" erectile function and/or ventral curvature tilts the choice toward shortening procedures, and refractory erectile dysfunction is an indication for penile prosthesis placement. Peyronie's disease management remains challenging with many options available, making an accurate risk/benefit assessment of each case and meticulous patient counseling critically important. Almeida JL, Felício J, Martins FE. Surgical Planning and Strategies for Peyronie's Disease. Sex Med Rev 2021;9:478-487.

Intralesional injection of the calcium channel blocker Verapamil in Peyronie's disease: A critical review

OBJECTIVE

To assess the effectiveness of an intralesional injection of verapamil in men with Peyronie's disease (PD).

MATERIALS AND METHODS

The data provided in the current review are based on a thorough review of the available original articles on PD retrieved with a systematic literature search using PubMed- Medline, and the Cochrane Central Register of Controlled Trials, up to December 2019, to identify studies dealing with Peyronie's disease and its treatment. Included were only original articles, that we thoroughly evaluated. We searched for the primary and secondary terms of: "Peyronie's disease," "Penile curvature," "Erectile dysfunction," "Verapamil and Peyronie's disease," "Calcium channel blocker," and "Intralesional injection."

RESULTS

The initial search of the databases yielded a total of 1240 studies (PubMed: 1058; Cochrane: 182), as of December 2019. Seventy studies were removed due to duplication. Further 986 studies were removed due to not being in English (except for one study by Arena F. for which we got a translation form Italian), being about animal experimentations, not being full-text, and not being clinical trials. Likewise, studies not referring at all to verapamil were excluded (148). From the remaining 36 full-text articles we focused on 13 studies which met the inclusion criteria, mainly being deemed relevant to the context of this study.

CONCLUSIONS

Calcium channel blockers have been shown in both in vitro and in vivo studies to inhibit the synthesis and secretion of extracellular matrix molecules, as well as to increase collagenase activity. Patients with localised plaque are the best candidates for intralesional injections of verapamil. The beneficial effects of intralesional verapamil are apparent within the first three months. For patients who respond to treatment, the injections should be continued for six months. Patients who fail to respond to intralesional verapamil or whose angulation is greater than 30° at presentation should be considered candidates for surgery. Injection of verapamil is clinically safe for patients with Peyronie's disease, and it appears to induce a rapid, beneficial effect in patients for the reduction of plaque size. Intralesional verapamil injection for Peyronie's disease could reduce pain, decrease penile curvature, and improve sexual function.

Multicenter Prospective Study of Grafting With Collagen Fleece TachoSil in Patients With Peyronie's Disease

BACKGROUND

A xenograft consisting of equine collagen coated with human fibrinogen and thrombin (TachoSil; Baxter, CA) has recently been introduced in grafting procedures for Peyronie's disease (PD).

AIM

To describe the results of a multicenter prospective registry on patients with PD undergoing plaque incision or and grafting (PIG) or plaque excision and grafting (PEG) with collagen fleece TachoSil, to evaluate the efficacy and safety of this procedure.

METHODS

A prospective non-controlled multicenter study of patients with PD was performed between May 2016 and March 2018. Patients from 10 centers with stable PD for at least 3 months, difficulties in sexual intercourse, normal erectile function with or without pharmacological treatment, curvature >45°, and/or penile shortening and/or complex deformities were included. All patients underwent PIG/PEG with collagen fleece TachoSil.

OUTCOMES

The main outcome measure of this study were penile curvature correction (intraoperative), penile shortening (intraoperative), erectile function with the 5-item version of the International Index of Erectile Function (IIEF-5) and the Erection Hardness Score, subjective patient outcomes with non-validated questionnaires, and complications.

RESULTS

A total of 52 patients were enrolled in the study. The mean (SD) preoperative penile curvature was 72.8° (17.0). PIG was the preferred technique (80.8%). Intraoperatively, complete curvature correction was achieved in 92.3%, and no significant penile shortening was recorded in 80.8% of subjects. Subjective penile shortening was reported in 83.3% of patients at 6 months. No objective measurement of penile curvature and length was recorded during follow-up. No statistically significant difference from the baseline was found in IIEF-5 and Erection Hardness Score at 3 or at 6 months, although 16.7% of men experienced a worsening of IIEF-5 scores and 14.3% required de novo phosphodiesterase type 5 inhibitor use. 6 months after surgery, 78.5% of men were satisfied with intervention. Swelling and ecchymosis/hematoma were the most common perioperative complications (40.4%). 2 cases (3.8%) of wound infection were recorded. At 6 months, 35.7% of patients reported mild penile hypesthesia.

CLINICAL IMPLICATIONS

Our results confirm the high success rate of grafting with TachoSil, and the surgeon perceived low percentage of penile shortening.

STRENGTH & LIMITATIONS

This is the first multicentre study on patients with PD undergoing grafting with TachoSil without concomitant placement of penile prosthesis. The main limitations are the short follow-up and the relatively small sample size.

CONCLUSION

Grafting with TachoSil after PIG/PEG in patients with PD is an effective and safe procedure. Among the main advantages of this technique, there are ease of use of the graft and reduced operative time. Fernández-Pascual E, Manfredi C, Torremadé J, et al. Multicenter Prospective Study of Grafting With Collagen Fleece TachoSil in Patients With Peyronie's Disease. J Sex Med 2020;17:2279-2286.

Home modeling after penile prosthesis implantation in the management of residual curvature in Peyronie's disease

The aim of this study was to study the clinical effectiveness of a structured home modeling (HM) protocol in Peyronie's disease (PD) patients who have residual curvature up to 45° after inflatable penile prosthesis (PP) placement. A total of 92 patients with PD and coexistent refractory erectile dysfunction received inflatable PP. If residual curvature after manual modeling (MM) was more than 45°, incision-grafting was performed. If curvature was <45° after MM, patients were instructed to perform HM daily for 6 months, after 4 weeks from PP implantation. The mean preoperative penile curvature was 39.4 ± 5.7° (30-60). Sixteen (17.4%) patients required incision-grafting and the remaining 76(82.6%) patients followed HM protocol. The mean postoperative residual curvature after MM was 29.7 ± 3.2° (5-50). Sixty-five (85.5%) patients who underwent HM had 10° or less residual curvature after 3 months and 72 (94.7%) patients had 10° or less residual curvature after 6 months. Seventy (92.1%) patients responded as satisfied or very satisfied on the questionnaire with the outcome after 6 months. HM of the penis over Inflatable PP may straighten the penis without the need for an additional surgical maneuver in vast majority of the PD patients having residual curvature of <45°.

A decade of grafting techniques as a sole treatment for Peyronie's disease

BACKGROUND

Peyronie's disease (PD) can be a cosmetically and functionally devastating condition. Surgical approaches have been proposed in the chronic stages of PD as plication or plaque incision/excision with grafting to preserve penile size in complex cases. Although several surgeons nowadays are inclined toward the utilization of non-autologous grafts owing to the ease of their preparation and availability, synthetic graft procedures still await more technical improvements and supporting evidence before their consideration for standard care.

OBJECTIVES

In this review, our goal is to facilitate an insight into the most promising grafting materials used for the management of PD and techniques associated.

MATERIALS AND METHODS

A PubMed review was conducted for all the studies on our topic within the past ten years (January 2009 until December 2019). The outcome parameters we documented and compared comprised of operative time, follow-up time, postoperative penile cosmesis and function, and, finally, overall patient satisfaction related to each technique.

RESULTS

Our search yielded 23 English-written original study articles in addition to a single case report on the various grafting techniques utilized as the sole treatment for PD, each demonstrating different outcomes and points of comparison.

CONCLUSION

A successful grafting procedure for PD requires an appropriately tailored surgical modality and an experienced surgeon. Nevertheless, proper preoperative patient counseling on all aspects of his condition and opted treatment modality while setting clear and realistic expectations remains key for overall patient satisfaction.

A Novel Penile Splint as Early Traction Therapy After Grafting Techniques for Peyronie's Disease

BACKGROUND

Some studies showed encouraging results on the efficacy and safety of penile traction therapy after Peyronie's disease (PD) surgery. The early traction therapy (ETT) could be an effective and safe approach to minimize penile shortening in patients undergoing PD surgery.

AIM

To evaluate the feasibility, efficacy, and safety of a novel penile splint as ETT in patients with PD undergoing grafting techniques.

METHODS

Patients with PD underwent plaque incision and grafting technique; at the end of the procedure, a novel penile splint (ETT) was applied to all patient. The device consisted of 2 10CH intubating stylets, self-adapted to each patient, that kept the penis stretched with the aid of non-absorbable sutures. The total expense for the materials needed to build each penile splint was less than 15 euros. This active traction was maintained for 1-3 weeks; then, we removed the stitches leaving the device on-site for a passive traction. Within 3-4 weeks from surgery, the penile splint was replaced by a standard penile traction device.

OUTCOMES

The main outcomes evaluated at 6 months included stretched penile length (SPL), penile curvature, International Index of Erectile Function-erectile function (IIEF-EF) domain, patient satisfaction, and time to first satisfactory sexual intercourse.

RESULTS

A total of 46 patients were enrolled. The median preoperative IIEF-EF, penile curvature, and SPL were 27 points, 70°, and 13 cm, respectively. The median follow-up was 15 months. The median postoperative IIEF-EF was 25 points (P < .001). The median residual penile curvature was 10° (P < .001). The median postoperative SPL was 13 cm (P = .269). 8 patients (17.4%) lost 1 cm of SPL; no shortening greater than 1 cm was recorded. The median time to first satisfactory sexual intercourse and patient satisfaction score was 6 weeks and 9 points, respectively.

CLINICAL IMPLICATIONS

Our results could pave the way for a new line of research, which in turn could lead to an improvement in the postoperative management of the patient undergoing surgery for PD.

STRENGTH & LIMITATIONS

This is the first study evaluating the ETT after PD surgery. The main limitation of this study is the lack of a randomized control group. Other weaknesses are the small sample size and the short follow-up time.

CONCLUSION

Our novel penile splint is inexpensive, easy to assemble, and adaptable to the patient. ETT using this novel device, followed by standard traction therapy, seems to be feasible, effective, and safe. Fernández-Pascual E, Manfredi C, Cocci A, et al. A Novel Penile Splint as Early Traction Therapy After Grafting Techniques for Peyronie's Disease. J Sex Med 2020;17:1819-1824.

Long-term outcomes of surgery for Peyronie's disease: focus on patient satisfaction

Immediate outcomes of surgery for Peyronie's disease (PD) are fairly easy to analyze. However, it is the patient-reported long-term outcomes which eventually determine the success of PD treatment. The goal of this observational study was to evaluate patients' satisfaction with results of surgical treatment for PD at long-term follow-up. The primary outcome was the proportion of patients who were completely satisfied with their erectile function and penile appearance. We retrospectively identified 374 patients who underwent surgery for PD (median follow-up: 9.5 years) and attempted to invite them for follow-up visit; 342 patients were available for follow-up. Only 285 (83.3%) were sexually active. Among all patients, 197 (57.6%) were completely satisfied with penile appearance; among sexually active patients, 139 (40.6%) were completely satisfied with their erections. Only 101 patients (29.5%) were completely satisfied with penile appearance and erectile function. Logistic regression analysis revealed preoperative IIEF-EF score (OR = 1.668 per 1 point; 95% CI 1.469-1.894), tunica albuginea plication (OR = 5.599; 95% CI = 1.014-30.92), use of saphenous vein (OR = 8.517; 95% CI = 2.491-29.115), and cadaveric pericardium (OR = 61.388; 95% CI = 7.674-491.11) as significant predictors of satisfaction with erectile function. Severity of curvature (OR = 0.926 per 5°; 95% CI = 0.907-0.946) and tunica plication (OR = 0.117; 95% CI = 0.019-0.738) were negative predictors of satisfaction with penile appearance. Preoperative IIEF-EF (OR = 1.497 per 1 point; 95% CI = 1.322-1.694), severity of penile curvature (OR = 0.967 per 5°; 95% CI = 0.95-0.983), and use of pericardium allograft (OR = 10.728; 95% CI = 1.363-84.46) were predictors of both endpoints (satisfaction with erectile function and cosmesis). Despite excellent surgical outcomes in PD, patients' satisfaction with penile appearance and erectile function is far from absolute and depends on many patient-related and treatment-related factors.

Peyronie's disease: Contemporary evaluation and management

Peyronie's disease is a common yet poorly understood condition characterized by penile pain, curvature, sexual dysfunction and psychological bother. Peyronie's disease represents a penile wound healing disorder, and is thought to arise from exuberant scarring in response to penile trauma in genetically predisposed men. In the absence of active treatment, the majority of men experience stable or worsening symptoms, with few reporting spontaneous resolution in penile curvature or other deformity. In contrast, penile pain improves or resolves in the majority of men. Treatment options vary based on symptom severity and stability. Several oral therapies are commonly prescribed, although to date there are no strong data to support any oral agents as monotherapy for Peyronie's disease. Other options including penile traction therapy and intralesional injections result in modest improvements for many patients, particularly when used early after symptom onset. Penile straightening through approaches, such as penile plication and plaque incision or partial excision and grafting, represent the most rapid and reliable approach to correct penile curvature once the symptoms have stabilized. Side-effects vary based on the type of surgery carried out, and include penile shortening, sensation changes and erectile dysfunction in the minority of men. In patients with drug refractory erectile dysfunction and Peyronie's disease, placement of a penile prosthesis will address both issues, and is associated with high levels of patient satisfaction. The current review provides a practical approach to the modern evaluation and management of patients presenting with Peyronie's disease.

Verapamil and collagenase differentially affect collagen metabolism in experimental model of Peyronie's disease

OBJECTIVES

Peyronie's disease (PD) is accompanied by remodelling of connective tissue into fibrotic plaque. Treatment of the inflammatory and fibrotic phases of the disease is not established. The aim of the study was to evaluate the effect of verapamil (VER) and bacterial collagenase (COLL) on collagen metabolism and cell migration in fibroblasts with experimental wound healing and inflammation as an in vitro model of PD.

MATERIALS AND METHODS

In vitro model of PD was designed using experimental model of inflammation induced by Interleukin-1 (IL-1) in cultured fibroblasts and mechanical damage of the cells. Cell viability, cell proliferation, collagen biosynthesis, prolidase activity and cell migration were studied in both models of the cells treated with VER and COLL.

RESULTS

VER decreased cell viability, DNA and collagen biosynthesis and increased prolidase activity in control fibroblast, while in "wounded" fibroblasts it significantly decreased all the processes. COLL did not affect cell viability and DNA biosynthesis, while inhibited collagen biosynthesis and prolidase activity in both control and "wounded" fibroblasts. In IL-1-treated fibroblasts VER inhibited all studied processes except prolidase activity, while COLL inhibited only collagen biosynthesis and prolidase activity. COLL accelerated cell migration, while VER attenuated the process in fibroblast model of wound healing, compared to control cells.

CONCLUSION

VER and COLL attenuate collagen biosynthesis in both fibroblast models. The VER-dependent inhibition of collagen biosynthesis was accompanied by inhibition of DNA biosynthesis at high prolidase activity, while COLL affected this process through inhibition of prolidase activity at high rate of DNA biosynthesis. It shows that anti-fibrotic activity of VER/COLL and anti-inflammatory activity of VER may represent approach to establish standard treatment of PD.