Surgical treatment of Peyronie's disease: a single center experience with 145 patients

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

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.

Residual penile curvature correction by modeling during penile prosthesis implantation in Peyronie's disease patients

With the advent of new surgical techniques to treat Peyronie's disease with concomitant erectile dysfunction, there remains a question of whether manual modeling (MM), an older technique, still has a place in the treatment algorithm within penile prosthesis (PP) surgery. While the implantation of a PP often corrects moderate to severe curvature, penile curvature can remain greater than 30°, even when concurrent MM is performed during prothesis implantation. There are new variations of the MM technique that have been recently utilized in the intraoperative and postoperative setting to achieve penile curvature less than 30° when the implant is fully inflated. The inflatable PP, regardless of the specific model of choice, is preferred over the noninflatable PP when utilizing the MM technique. MM should be the first line of treatment for persisting intraoperative penile curvature after the placement of a PP due to its long-term efficacy, noninvasive approach, and significantly low risk of adverse effects.

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, Ragheb A, Ward S et al, ESSM Position Statement on Surgical Treatment of Peyronie's Disease. Sex Med 2022;10:100459.

Use of grafting materials during penile prosthesis implantation in patients with Peyronie's disease-a systematic review

Severe Peyronie's disease (PD) and concomitant erectile dysfunction (ED) may require plaque incision/excision and grafting (PIG) as an adjunct to penile prosthesis implantation (IPP). Currently, there is no available consensus on the best graft material to use. Our aim was to systematically review graft materials used as patches following PIG + IPP. Literature search was performed in March 2021. Only original articles in English with a series of 10 or more patients were included. Overall, a total of 17 studies were included, corresponding to a cohort of 662 patients. The mean age ranged from 45 to 65 years and most patients had curvatures >45°. Average penile lengthening ranged from 1 to 3.5 cm, average residual curvatures from 0 to 20% and decreased glans sensitivity from 0 to 20%. Eighty to 100% of patients were satisfied with cosmetic and functional results. PIG + IPP with the use of various grafts offers promising results for the treatment of patients suffering from severe PD with concomitant ED. Unfortunately, the absence of high quality and comparative studies makes it difficult to establish the optimum graft. Therefore, the level of experience of the surgical team with one or more methods should guide their choice.

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.

A comprehensive narrative review of residual curvature correction during penile prosthesis implantation in patients with severe erectile dysfunction and concomitant Peyronie's disease

Residual curvature correction during penile prosthesis implantation (PPI) is usually needed in patients with severe erectile dysfunction (ED) and concomitant Peyronie’s disease (PD). The aim of the study was to assess the different existing techniques for treating residual penile curvature during PPI in patients with severe PD and ED. We generated a comprehensive narrative review of the literature until August 2020 on the use of PPI in combination with straightening reconstruction techniques, in treating patients with severe PD and ED. We included studies published in English, assessing the PPI as primary intervention in patients with PD and ED. Secondary research studies and studies with insufficient data were excluded from final analyses. We included a total of 33 clinical articles with 1,612 patients that assessed the effects of PPI combined with straightening surgical techniques for the treatment of severe PD and ED. Based on the severity of penile curvature, the concomitance of additional penile deformities (i.e., hourglass deformity), the penile length, the presence of previous penile operations and the surgeon’s experience, four main categories of surgical techniques were identified: (I) PPI with plication of the penis on the convex side of the curvature, (II) transcorporeal plaque incision/excision, (III) PPI with plaque/tunical incision(s) on the concave side of the curvature and (IV) PPI with plaque incision/excision plus grafting. Patients with severe PD and ED can expect excellent outcomes with PPI and surgical correction of residual penile curvature and minimal side effects. Overall, all the above techniques seem to able to correct the residual penile curvature during prosthesis implantation. Grafting techniques seem to be favorable in patients with additional severe penile shortening. Still, no definite conclusions can be drawn regarding the superiority of one technique over the other.

[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.

Comparison of two different grafts for the surgical treatment of peyronie's disease

The aim of this study was to compare two different graft techniques, namely saphenous vein (SV) and buccal mucosa (BM) used together with plaque incision for the treatment of Peyronie's disease (PD) in terms of success, safety and patient and partner satisfaction. The study included 41 patients diagnosed with PD and treated with plaque incision and grafting between December 2015 and November 2019. Eighteen patients underwent plaque incision and BM grafting while the remaining 23 patients underwent plaque incision and SV grafting. Pre-operative plaque size, curvature angle, curvature start time and penis length were statistically similar between the SV and BM graft groups. No statistical difference was detected between the BM and SV graft groups in terms of the sixth- and 12th-month mean International Index of Erectile Function scores, Patient Global Impression of Improvement scores, penis lengths and final partner satisfaction rates during the follow-up period. Residual curvature was observed in three (13.1%) patients in the SV graft group and two (11.2%) patients in the BM graft group. With their high success and low side effect rates, both grafting techniques with plaque incision can be safely performed for tunical lengthening, based on the surgeon's experience.

The use of collagen fleece (TachoSil) as grafting material in the surgical treatment of Peyronie's disease. A comprehensive narrative review

Grafting for the treatment of Peyronie's disease (PD) can be performed with autologous grafts, allografts, xenografts and synthetic grafts, with all available materials presenting their own characteristics. Still, there is a current arising interest in the use of collagen fleece (TachoSil) as grafting material. We generated an extensive literature review, aiming to assess the use of TachoSil in the treatment of PD. TachoSil is currently indicated in men with PD and preserved erectile function for defect closure after partial plaque excision or incision. In addition, it is indicated for residual curvature correction during penile prosthesis implantation (PPI) in patients with PD and severe erectile dysfunction. Our literature search identified 12 studies evaluating the role of TachoSil for PD surgical treatment. We presented the surgical procedure of TachoSil grafting for the treatment of complex penile curvatures with or without simultaneous PPI and summarized the available evidence on the matter. Identified studies suggest that TachoSil is considered highly effective, reliable and safe in patients with PD. Moreover, it displays favorable properties compared to other grafting materials. It should be stressed that, despite some limitations of available data, TachoSil presents key strengths, which include easy application, decreased operative times, no risk of damaging the implant during PPI, preservation or increase in penile length, fewer cases of penile hypoesthesia, low risk of other adverse events, additional hemostatic effects and low cost. Still, randomized trials comparing TachoSil with different grafting materials are necessary to establish its efficacy.

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.

Salvage Penile Plication Is an Effective Modality for Resolving Residual Curvature After Surgery for Peyronie's Disease

INTRODUCTION

Penile plication is highly successful in appropriately selected patients with Peyronie's disease; however, a minority of patients experience residual curvature or delayed recurrence of curvature. Revision surgery outcomes are seldomly reported.

AIM

To determine the efficacy of salvage penile plication for the correction of residual and recurrent curvature.

METHODS

Our institutional review board-approved prospective single-surgeon database of patients with Peyronie's disease was reviewed for cases performed from 2011 to 2019. Patients requiring salvage procedures were analyzed. A successful salvage was defined by residual curvature <20° with patient-reported satisfaction. Potential etiologies for initial plication failure were examined.

MAIN OUTCOME MEASURE

The outcomes of this study are subjective and patient-reported success of salvage plication.

RESULTS

Data analysis identified 134 men treated surgically for Peyronie's disease. Management involved plication in 105 (78.4%), incision and grafting in 14 (10.4%), excision and grafting with inflatable penile prosthesis in 7 (5.2%), plication with inflatable penile prosthesis in 6 (4.5%), or grafting, plication, and inflatable penile prosthesis in 2 (1.5%). Mean preoperative degree of curvature before initial surgery was 55° (30°-90°). Of this cohort, 5.2% (n=7) required salvage plication for a median residual or recurrent curvature of 45° (35°-90°). Initially, 3 men (43%) received an 8-dot plication, 3 (43%) underwent 16-dot plication, and 1 (14%) received plaque incision and grafting. Among salvage patients, 4 (57%) had initially satisfying results followed by recurrence of curvature and 3 (43%) desired correction of residual curvature. Salvage plication entailed an 8-dot plication in 3 (42.9%) and a 16-dot plication procedure in 4 (57.1%). The median time to salvage surgery was 9 (3-15) months, with all patients showing intraoperative resolution of curvature. At a median follow-up of 12 (1-20) months, 6 (85.7%) patients reported satisfaction with residual curvature <20°.

CONCLUSION

Patients with residual or delayed recurrence of curvature after plication for Peyronie's disease can be effectively managed with salvage plication. Deebel NA, Scarberry K, Dutta R, et al. Salvage Penile Plication Is an Effective Modality for Resolving Residual Curvature After Surgery for Peyronie's Disease. Sex Med 2020;8:686-690.

Penile prosthesis implant in the management of Peyronies' disease

INTRODUCTION

Penile prosthesis implantation (PPI), performed with or without adjunct straightening techniques, is one of the available surgical options in cases of Peyronie's disease (PD) with concomitant erectile dysfunction (ED). The aim of the study was to systematically identify and evaluate evidence regarding IPP in patients with PD and ED.

EVIDENCE ACQUISITION

Using Cochrane's methodological recommendations on systematic reviews, we conducted a systematic review of the literature on clinical research regarding the use of PPI, alone or in combination with any straightening maneuvers in the treatment of patients with PD and ED. The search was carried until January 2020. We included studies in English language with primary population patients with PD and ED who underwent IPP with the intent to treat the PD. All studies that were not original clinical research articles, reported insufficient data or included fewer than 5 patients were excluded from the final analysis.

EVIDENCE SYNTHESIS

In total 43 clinical articles with more than 2000 patients (N.=2143) investigating the effects of penile prosthesis implantation (PPI) for the treatment of PD with or without ED were included in the study. Depending on the severity of the penile curvature, additional penile deformities (i.e. hourglass deformity), penile length, prior operations and surgeons experience, 6 main categories of surgical techniques of PPI for penile straightening and treatment of PD were identified: PPI only, PPI with modelling of the penis, PPI with plication of the penis on the convex side of the curvature, PPI with plaque incision(s), PPI with plaque incision/excision plus grafting and PPI with grafting and penile lengthening.

CONCLUSIONS

Overall, patients with PD and ED can expect excellent outcomes with PPI against a minimal risk of side effects. No definite conclusions can be made regarding which technique is superior.

Penile curvature after Peyronie's disease surgery: What are the risk factors?

Surgery is the golden standard for the treatment of patients with Peyronie's disease in chronic phase (12-18 months). Learning risk factors for post-surgical curvature (>20°) would aid both surgeon and patient in their decision-making process. The aim of this study was to investigate the risk factors for residual/recurrent curvatures. The clinical data of the patients, who underwent reconstructive surgery for PD between 1997 and 2016, were retrospectively reviewed. Follow-ups were performed via physical examination, surveys and phone calls. For shortening surgery (Nesbit/plication), initial bi-planar curvature was proved to be a predictor of post-operative curvature (p = .05). Lateral and ventral curvatures were associated with higher recurrence rates in patients who underwent grafting surgery (p = .01). In terms of baseline comorbidities, only diabetes mellitus had an association with curvature nonrecurrence for both shortening and lengthening surgeries (p < .05). Grafting surgery may be suggested to patients who had bi-planar curvatures instead of Nesbit surgery. Nesbit plication surgery may be preferred for patients with lateral and ventral curvatures instead of grafting surgery. Higher cavernosal blood pressures and more nocturnal erections of nondiabetic young patients might impede plication sutures and grafts and therefore increase penile curvature recurrence.

Surgical Management of Peyronie's Disease With Co-Existent Erectile Dysfunction

INTRODUCTION

Surgical intervention in Peyronie's disease (PD) should ideally be delayed until the resolution of acute inflammatory phase.

AIM

The objective of this review was to highlight the results of penile prosthesis to correct refractory erectile dysfunction (ED) in patients with PD, and the secondary procedures that may be required to correct the penile curvature.

METHODS

A systematic search on PubMed online database using Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations was done using the MeSH terms "Peyronie's disease" and "erectile dysfunction."

MAIN OUTCOME MEASURE

Success and satisfaction rates of various procedures.

RESULTS

The search yielded 324 language-specific (English and Spanish language) articles and 58 articles were retained for final review. The following variables were assessed in different studies: number of patients, types of secondary procedure to correct the curvature, satisfaction rates, and follow-up period.

CONCLUSION

The aim of the surgery in PD should be to achieve a functionally straight penis (<20 degree curvature) with good erection. Patients with refractory ED in PD are candidates for penile prosthesis. Secondary procedures, like manual modeling, plication, plaque incision, or excision grafting, may be required depending on the degree of penile curvature and penile length. In quest for the best graft, TachoSil graft seems to have gained popularity in Europe. Krishnappa P, Fernandez-Pascual E, Carballido J, et al. Surgical Management of Peyronie's Disease With Co-Existent Erectile Dysfunction. Sex Med 2019;7:361-370.

Comparison of Patient's Satisfaction and Long-term Results of 2 Penile Plication Techniques: Lessons Learned From 387 Patients With Penile Curvature

OBJECTIVE

To compare the patient's satisfaction and long-term results of 2 penile plication procedures in patients with penile curvature.

METHODS

This retrospective study included 387 patients with congenital penile curvature (n = 260) and Peyronie's disease (n = 127) who underwent surgical correction of penile curvature with penile plication procedures. Of the patients, 202 underwent plication of tunica albuginea with the Lue's 16-dot technique, while 185 underwent highly superficial excision of tunica albuginea with the modified Nesbit corporoplasty. Surgical outcomes and patient's satisfaction were compared between the 2 techniques in all patients.

RESULTS

The mean duration of surgery was significantly shorter in the 16-dot plication technique (48.1 ± 7.5 minutes), compared with the modified Nesbit corporoplasty (63 ± 16.9 minutes) (P = .001). Complete penile straightening was achieved in 87.6% of the patients who underwent 16-dot plication technique and in 89.7% of the patients who underwent modified Nesbit plication, revealing no difference (P = .514). The rates of penile sensory loss (P = .001) and de-novo erectile dysfunction (P = .016) were significantly higher in the modified Nesbit corporoplasty than in the 16-dot plication technique, but rate of suture related complications was significantly higher in the 16-dot plication technique than in the modified Nesbit corporoplasty (P = .001). The patients with congenital penile curvature had significantly less ratio of postoperative penile length loss and de-novo erectile dysfunction than Peyronie's disease patients.

CONCLUSION

Overall, both surgical techniques have very high success and satisfaction rates with very low complication rates. However, the types of complications are significantly different between the 2 surgical procedures. Therefore, patients with penile curvature should be informed about outcomes of penile plication procedures, and surgical method should be preferred based on patient's preference and surgeon's experience.

Combined Plaque Incision, Buccal Mucosa Grafting, and Additional Tunica Albuginea Plication for Peyronie's Disease

INTRODUCTION

Surgery remains the gold standard for treatment in stable patients with penile deformity associated to Peyronie's disease (PD).

AIM

To evaluate the long-term results of plaque incision and buccal mucosa grafting (BMG), with or without additional tunica albuginea plication (TAP), in the correction of severe penile curvatures secondary to PD.

METHODS

72 patients with severe curvature caused by PD, normal erections, and stable disease entered this prospective study. Preoperatively, they underwent penile duplex ultrasounds with measurement of curvature and length of affected side. All procedures were carried out by 1 surgeon. Patients were seen at 1, 3, 6, and 12 months postoperatively, then yearly. Subjective outcome was assessed by the Sexual Encounter Profile (SEP) questionnaire, and objective outcome was assessed by an intracavernous injection (ICI) test performed within the first year for evaluating penile rigidity, straightness, and length.

MAIN OUTCOME MEASURE

Long-term outcomes include penile straightening, penile shortening, and sexual satisfaction.

RESULTS

Mean curvature was 71.32 ± 17.6° (range 40-110); 33 (45.8%) patients had a 2-sided curvature with a mean second curvature of 33.79 ± 12.2° (range 10-60). Additional TAP was needed in 60% of patients for complete straightening or graft stretching. All patients resumed unassisted intercourse 1 month after surgery; 4 (5.5%) refused follow-up, claiming excessive penile shortening. In the remaining 68, the ICI test showed no recurvature, shortening, or de novo erectile dysfunction. At mean follow-up of 62.01 ± 34.3 months (range 12-135), all were able to obtain an erection (SEP-1), 97.1% to penetrate (SEP-2), and 89.7% to successfully complete intercourse (SEP-3); 80.9% of them were satisfied with erection hardness (SEP-4) and 86.8% were overall satisfied (SEP-5), with the main reason for dissatisfaction being expectation of better length and rigidity.

CONCLUSION

BMG, with or without TAP, provides excellent long-term results and is safe and reproducible, representing a valuable treatment option for PD, but great care should be taken in patient counseling to avoid unrealistic expectations. Cormio L, Mancini V, Massenio P. Combined Plaque Incision, Buccal Mucosa Grafting, and Additional Tunica Albuginea Plication for Peyronie's Disease. Sex Med 2019;7:48-53.

Microsurgical tunica albuginea transplantation in an animal model

Several andrological diseases require surgical repair or reconstruction of tunica albuginea, which envelops the corpora cavernosa penis. Despite intense research efforts involving a variety of biological materials, such as skin, muscle aponeurosis, human dura mater, tunica vaginalis, and pericardium, engineered tunica albuginea suitable for graft use is yet to be obtained. The study investigates microsurgical tunica albuginea allotransplantation in an animal model with the purpose of creation of an organ-specific tissue bank to store penile tissue, from cadaveric donors and male-to-female trans-sexual surgery, for allogeneic transplantation. Materials were tunica albuginea tissue explanted from 15 donor rats, cryopreserved at −80°C, gamma-irradiated, and implanted in 15 recipient rats, of which three rats were used as controls. Penile grafts were explanted at different time intervals; after macroscopic evaluation of the organ, the grafts were processed to morphological, histochemical, and immunohistochemical examinations by light microscopy. Detection of pro-inflammatory cytokines was also performed. Examination of the tunica albuginea allografts collected 1, 3, or 6 months after surgery and of control tunica albuginea fragments showed that tunica albuginea implants achieved biointegration with adjacent tissue at all-time points. The integration of cryopreserved rat tunica albuginea allografts, documented by our study, encourages the exploration of tunica albuginea allotransplantation in humans. In conclusion, the effectiveness and reliability of the tunica albuginea conditioning protocol described here suggest the feasibility of setting up a tunica albuginea bank as a further tissue bank.

Evidence-Based Management Guidelines on Peyronie's Disease

INTRODUCTION

Despite recent advances in our knowledge and treatment strategies in Peyronie's Disease (PD), much remained unknown about this disease.

AIM

To provide a clinical framework and key guideline statements to assist clinicians in an evidence-based management of PD.

METHODS

A systematic literature search was conducted to identify published literature relevant to PD. The search included all relevant articles published up to June 2015, including preclinical studies and published guidelines. References used in the text were assessed according to their level of evidence, and guideline recommendations were graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Owing to the paucity of larger series and randomized placebo-controlled trials with regard to surgical intervention, guideline statements are provided as clinical principle or expert opinion.

MAIN OUTCOME MEASURES

This literature was discussed at a panel meeting, and selected articles with the highest evidence available were used to create consensus guideline statements for the Fourth International Consultation on Sexual Medicine guidelines on PD.

RESULTS

In addition to existing Third International Consultation on Sexual Medicine guidelines on PD, seven new summary recommendations were created.

CONCLUSION

A greater understanding of the scientific basis of PD is greatly needed to address our understanding of the pathophysiology, clinical epidemiology, psychosocial, and diagnostic assessment as well as treatment strategies.

Peyronie's disease surgery: Surgical outcomes of 268 cases

Objective

To assess the outcomes of the surgical techniques used in Peyronie's disease (PD) surgery.

Material and methods

Two hundred and sixty-eight patients received surgical treatment for PD. Fifty four and 144 patients underwent simple corporoplasties (shortening procedure, SP, group 1) or plaque incision and grafting surgery (lengthening surgery, LP, group 2), respectively, whereas 70 patients with erectile dysfunction underwent penile prosthesis implantation.

Results

Penile plication and Nesbit surgeries were performed in 5 (9%) and 42 (78%) patients out of total 54 patients. In the remaining 7 (13%) patients, Nesbit and plication suture combination was required for complete penile straightening. Mean curvature degree was 52.2±12.3 degrees. Follow up time was 36.1±29.4 months. No significant difference was demonstrated between the two groups in the baseline features and co-morbidities except age. In 144 patients who underwent plaque incision and grafting, mean age and PD onset duration were 54.1±9.2 years and 28.2±17.3 months respectively. Mean curvature degree was 58.4±18.9 degrees. Post-operative follow up time of the second group was 51.1±39.6 months. Additional plication suture was used in 48 patients (33%) patients. Degree of curvature improvement was 37.9±19.1 and 52.1±23.5 in SP and LP respectively (p=0.01). The initial anatomic success rates were 90.4% and 87.5% at their early post-operative follow-ups for group 1 and 2 respectively. These rates dropped to 82.7% and 83.6% at the long term follow-up (36 and 51 months) respectively (p=0.9). Although the average follow-up time of LP group was longer than SP group (52.1 mo vs. 37.0 mo), recurrence rates of these two groups were comparable. The combined functional and anatomical success of patients were demonstrated to be 79% and 75% in shortening and grafting surgery. Shortening surgery was not statistically superior to grafting surgery for patients in terms of having erection with or without the aid of PDE-5 inhibitors (94.4% vs. 88.2%, p=0.28). Shortening surgery makes a difference in the long term follow-up for patients who had erections without the aid of PDE-5 inhibitors (90.7% vs. 67.3%, p=0.02).

Conclusion

Both SP and LP are successful in terms of penile straightening in the short and long-term follow-up. Curvature degree improvement is greater in LP. Patients who undergo LP surgery may suffer from ED in the long-term follow-ups. Greater percentage of patients who underwent LP require PDE-5 inhibitors usage for sexual intercourse. Despite stated shortcomings, combined success (anatomic and functional) is achieved in three out of four patients for both groups. Penile prosthesis implantation should be preferred for patients with ED and penile deformity.

10 Years' Plaque Incision and Vein Grafting for Peyronie's Disease: Does Time Matter?

INTRODUCTION

Surgical correction is advocated in patients with stable Peyronie's disease (PD) and severe curvature of the penis. Contemporary series demonstrate favorable outcomes based on relatively short follow-up periods. However, long-term follow-up is rarely reported and there is a paucity of evidence on the influence of patients' age, comorbidities, and natural history on surgical outcomes.

AIMS

The present study aims to examine the influence of patient's age, comorbidities, severity of the disease, and natural history of PD on long-term outcomes and satisfaction following plaque incision and vein grafting for PD.

METHODS

Patients with follow-up of more than 10 years who underwent plaque incision and grafting (Lue technique) for stable PD were included in the study.

MAIN OUTCOME MEASURES

A combination of prospective and retrospective analysis of patients' histories, anatomical, functional, and surgical parameters, development of PD recurrences, improvements of sexual functions, and overall satisfaction were performed between 1992 and 2014. Multiple logistic regression models were applied to calculate adjusted odds ratios for predictors for development of erectile dysfunction (ED) and PD recurrence.

RESULTS

Thirty patients with a median age of 57.5 years were eligible for inclusion in the study with a mean follow-up of 13.0 years (range 10.0-17.6). Angle of preoperative penile deviation was 40° to 110° (median 90°). On follow-up, 26 men (86.7%) had a straight erect penis. Eleven men (36.7%) developed ED, of whom 2 (6.7%) had other comorbidities contributing to their ED. Twenty-five men (83.3%) were still sexually active with or without medication. The mean percentage improvement in sexual function was 69.0%, with 17 men (56.7%) reporting 100% improvement and 7 (23.3%) reporting no improvement. Perceived penile shortening occurred in 13 patients (43.3%) and 6 patients (20.0%) experienced penile hyposensitivity. PD/plaque recurrence was found in 7 men (23.3%). The mean overall satisfaction with the procedure was 73.0%, with 18 men (60.0%) still 100% satisfied and 6 (20.0%) reporting satisfaction below 50%.

CONCLUSION

Improvement of sexual function and overall satisfaction remain high at 10 years follow-up and make the technique a safe and effective form of treatment in carefully selected patients.

Cavernoplasty with oral mucosa graft for the surgical treatment of Peyronie's disease

BACKGROUND

Peyronie's disease is a disorder of the tunica albuginea and causes penile curvature, requiring surgical correction when the deformity impedes penetration.

MATERIAL AND METHODS

Retrospective analysis of the short-term results (penile length, angle of curvature and erectile function) of treating Peyronie's disease in 10 patients through cavernoplasty with oral mucosa graft. Essentially, the treatment included the incision of the fibrotic plaque with electrical scalpel and the subsequent coating of the cavernous defect using a patch of oral mucosa. At month 6, we measured the penile length and curvature and recorded the erectile function using the International Index of Erectile Function-5 (IIEF-5) questionnaire. Finally, the patients were asked "Would you undergo the same operation again?".

RESULTS

The mean age was 53.4 years. The average and median follow-up was 22.7 months and 24 months, respectively. The mean preoperative curvature was 68.5° (50°-90°), the mean penile length was 11.2cm (9-15) and the mean IIEF-5 score was 16.1 (8-25). The mean postoperative penile length was 10.7cm, and the mean IIEF-5 score was 18.9. The differences between the preoperative and postoperative values were not statistically significant (P=ns). One patient developed erectile dysfunction. In all cases, the residual curvature was <20°. Nine patients (90%) stated that they would undergo the same operation.

CONCLUSIONS

The short-term results suggest that cavernoplasty with oral mucosa graft can be an alternative to traditional grafts for surgically correcting Peyronie's disease.

Penile Prosthesis Surgery: Current Recommendations From the International Consultation on Sexual Medicine

INTRODUCTION

Penile prosthesis implantation has emerged as a definitive treatment to restore sexual function to the motivated man with erectile dysfunction. Substantial improvements in the design of inflatable devices have been made since they first became available more than four decades ago.

AIM

To review the history of the penile prosthesis, the indications, preoperative evaluation, and patient and partner satisfaction. The current approaches to addressing intra- and postoperative complications, provide an understanding of prosthesis infection, and placement of these devices will be reviewed.

METHODS

A committee of worldwide experts in this field was assembled during the 2015 International Consultation on Sexual Medicine (ICSM) and performed a systematic review of the peer-reviewed published medical literature pertaining to penile prosthesis. Particular attention was given to higher level trials when available. Recommendations are based upon the Oxford Criteria.

MAIN OUTCOME MEASURES

Unfortunately there is limited level 1 and 2 evidence, and where expert opinion was utilized, the decision was unanimous within the committee with a goal of presenting a clinically relevant guideline pertaining to penile prostheses.

RESULTS

Penile prosthesis has undergone an evolution over the past 40 years resulting in a more effective and reliable treatment for advanced erectile dysfunction not responding to less invasive methods including oral treatment with PDE5 inhibitors, vacuum erection device, and intracorporal injection therapy. It should be considered an appropriate treatment option for the man who wishes to restore erectile function and who understands the potential risk of mechanical failure and infection, both of which are less common now as a result of improvements made in device design as well as surgical protocols adhered to in the operating room. Patients must be clearly informed of the risks associated with penile prosthesis including mechanical failure, infection, shortening of the penis, change in sensation and configuration of the penis, as well as injury to local structures. Intraoperative complications are unusual but do occur and can usually be addressed intraoperatively to allow placement of the device at the time of initial surgery. Postoperative complications may also be addressed when they occur but may require more advanced reconstructive surgical techniques. Men with Peyronie's disease, corporal fibrosis due to infection, trauma, prior prosthesis explantation, priapism, and men who have undergone construction of a neophallus may require additional advanced maneuvers to obtain optimum results with a penile prosthesis.

CONCLUSION

Penile prosthesis remains as an important, viable, and effective treatment for male erectile dysfunction that does not respond to other less invasive approaches or when these approaches are contraindicated or not acceptable to the patient. These devices provide the patient with the ability to engage in penetrative sexual activity without interfering with urination, ejaculation, sensation, or orgasm. Although mechanical failure can occur, the current devices are more reliable as a result of design modifications. Infection remains the most dreaded complication but since the introduction of antibiotic and hydrophilic coatings, infection is less common. Overall, patient and partner satisfaction appear to be reasonably high when a penile prosthesis is used to restore erectile function.

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.

Surgical treatment of Peyronie's disease with autologous tunica vaginalis of testis

Background

To investigate the feasibility and safety of surgical treatment for Peyronie’s disease (PD) by excising and repairing plaque using autologous tunica vaginalis of testis.

Methods

From March 2007 to December 2012, total 19 patients with PD underwent surgical treatment at our center. All patients had significant phallocampsis during erection. All patients complained of decreased sexual function. During the operation, the fibrotic plaque was excised and neurovascular bundle (NVB) was spared. A size-matching autologous tunica vaginalis of testis was harvested as the graft and patched to the defect. All patients received follow up every 3 months in the first year and 6 months in the following years. Data on sexual function before and after the operation was collected and compared.

Results

All operations were completed successfully without serious complications. The mean operative time was 74 min. The mean size of excised plaque was 3.0 cm². Postoperative pathological studies revealed the fibroplastic hyperplasia of excised tissue. All patients had satisfactory correction of penile appearance. The erectile penile length between pre- and post-operation didn’t show significant difference. Postoperative intercourse satisfaction and overall satisfaction measured by IIEF-5 were significant improved.

Conclusions

Our surgical treatment is feasible and safe for patients with PD. It can effectively improve the penile cosmetic appearance and patients’ intercourse/overall satisfaction on sexual life.

Long-Term Results of Reconstructive Surgery for Peyronie's Disease

INTRODUCTION

Peyronie's disease (PD) is an acquired benign connective tissue disorder that involves the tunica albuginea of the penis and can cause penile deformity and shortening. Because this condition is frequently associated with cardiovascular risk factors, a degree of erectile dysfunction is frequently present. The surgical management of PD should be offered once the acute phase of the disease has settled and the deformity is stable.

AIM

To critically review the most recent literature published on the surgical management of PD.

METHODS

A nonstructured PubMed-based review of the literature published in the last 10 years, searching for the words "Peyronie's disease," "erectile dysfunction," "plication," "grafting," "plaque," and "penile prosthesis," has been carried out.

MAIN OUTCOME MEASURE

The outcome of the various surgical procedures is reported.

RESULTS

Surgery represents at present the gold standard treatment for PD. The type of procedure should be decided according to the degree of deformity, the quality of the erection, and penile length.

CONCLUSIONS

Surgery still represents the gold standard treatment in patients with PD and aims at obtaining a penis straight, rigid, and long enough for penetrative sexual intercourse. Adequate preoperative patient's selection, counselling and the choice of the right type of procedure according to the degree of penile shortening, the type of deformity and the quality of the erection are paramount to achieving satisfactory results. Garaffa G, Kuehhas FE, De Luca F, and Ralph DJ. Long-term results of reconstructive surgery for Peyronie's disease. Sex Med Rev 2015;3:113-121.

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.

Intraoperative Decision-making for Precise Penile Straightening During Inflatable Penile Prosthesis Surgery

OBJECTIVE

To present a novel algorithm for definitive reconstruction of penile curvature in men undergoing inflatable penile prosthesis (IPP) surgery as an alternative to manual penile modeling and grafting procedures.

METHODS

Patients with erectile dysfunction and concomitant penile curvature undergoing IPP placement were divided into 2 treatment groups: (1) group 1, penile deformity known preoperatively, and (2) group 2, penile curvature recognized intraoperatively after IPP placement. Group 1 patients underwent penile plication after artificial erection and immediately before IPP insertion via the same penoscrotal incision, whereas group 2 patients were treated with a Yachia (Heineke-Mikulicz) corporoplasty over the intact cylinders. Patients completed postoperative Patient Global Impression of Improvement (PGI-I) questionnaires assessing overall satisfaction.

RESULTS

Among 405 men receiving IPP at our institution from 2007 to 2014, 30 patients received synchronous correction of penile curvature (7%). Group 1 included 23 of 30 (77%) patients, and 7 of 30 (23%) were in group 2. Overall mean initial curvature was 36°, and all patients were corrected to < 10°. Average operative times were 18 minutes longer compared with patients who underwent IPP placement alone (82 vs 64 minutes, P <.05). At an average follow-up of 13 months (range 7-32), 19 of 20 (95%) group 1 and 6 of 7 (86%) group 2 patients who completed surveys reported an improved overall condition. No patient reported chronic pain, recurrent deformity, or device malfunction.

CONCLUSION

Penile curvature can be safely and reliably corrected at the time of IPP placement, regardless of whether the deformity was identified preoperatively.

Rotation of the corpora cavernosa for the treatment of congenital penile curvature

INTRODUCTION

Congenital penile curvature (CPC) is caused by a disorder in the embryonic development of the urethra and corpora cavernosa. The condition causes difficulty for penetration, requiring surgical correction when it prevents intercourse.

MATERIAL AND METHODS

We present the cases of 2 men in their 40s who had ventral curvature greater than 60° of 2 years of evolution, with maintained erections. The patients underwent surgery for rotation of the corpora cavernosa. After the complete denudation of the penis, athermal release of the neurovascular bundle of the penis from the ventral side to the dorsal was performed. Once the curvature was verified using artificial erection, an incision was performed in the tunica albuginea of both corpora cavernosa, continuously suturing both internal and external margins with resorbable monofilament. The rectification of the curvature was then checked, and the mucocutaneous plane was reconstructed.

RESULTS

The surgical time was 120minutes and there were no intraoperative complications. Both patients were discharged 24h after the surgery. At 1 week, the patients experienced spontaneous night-time erections and were able to maintain sexual relations 1 month after the surgery. At 6 months, the residual curvature was less than 20°, the penile shortening was less than 1 centimeter and the International Index of Erectile Function-5 was 25 for both cases.

CONCLUSIONS

Surgery for rotation of the corpora cavernosa helps correct CPC without significant penile shortening or erectile dysfunction. In our opinion, the procedure is an appropriate treatment for patients with CPC but requires studies with long-term follow-up in order to consider it the technique of choice.

Surgical management of Peyronie's disease

Peyronie's disease (PD) has a significant impact on the quality of life of both patients and their partners due to the compromised sexual function and physical deformation resulting from the condition. PD is a connective tissue disorder marked by fibrotic healing of the tunica albuginea, leading to penile deformities including curvature, shortening, loss of girth, hourglass appearance, and hinging. Despite the multiple medical therapies available, surgery is the gold standard of treatment once the plaque has stabilized. We present a review of the disease process, preoperative evaluation, operative planning, surgical treatments with outcomes and complications, and nascent developments in surgical management and graft development. Options include tunical lengthening procedures, tunical shortening procedures, and penile prosthesis. Decision-making is governed by degree of curvature, erectile function, and associated penile deformities. In cases with curvature of less than 60-70 degrees, adequate penile length, and no hourglass deformity, patients are candidates for tunical shortening procedures. Patients with curvature greater than 60-70 degrees, penile hourglass or hinge-destabilizing deformities, and adequate erectile function should be counseled with regard to tunical lengthening procedures. Patients with poor preoperative erectile function should undergo inflatable penile prosthesis placement, with possible secondary straightening procedures. Technique selection should be based upon surgeon preference, expertise, and experience, as evidence does not necessarily support one procedure over another.

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.

Neurovascular bundle dissection for Nesbit procedure in congenital penile curvature patients: medial or lateral?

The objective of this study was to compare the outcomes of the modified Nesbit procedure using different techniques for dissecting the neurovascular bundle (NVB) to correct ventral congenital penile curvatures (CPCs). The bundle was mobilized using the medial and lateral dissection technique in 21 (Group 1) and 13 (Group 2) patients, respectively. In the medial technique, Buck's fascia is opened at the dorsal side of the penis, the deep dorsal vein is removed at the most prominent site of the curvature and a diamond-shaped tunica albuginea (TA) is excised from the midline of the penis. In the lateral technique, the bundle is mobilized using a longitudinal lateral incision of the Buck's fascia above the urethra at the 5 and 7 o’clock positions via a bilateral approach. The localization and degree of curvature was evaluated using the combined intracavernous injection stimulation test or from the patients’ photographs. The mean patient age and degree of curvature were similar between groups. The mean operation time was longer for Group 2 (P = 0.01). In Group 1, nine patients (42.8%) required one diamond excision, 10 (47.6%) required two diamond excisions and two (9.5%) required more than two excisions; in Group 2, six patients (46.2%) required two diamond excisions and seven patients (53.8%) required more than two diamond excisions (P = 0.019). The differences in penile shortening, penile straightening and numbness of the glans penis were not statistically significant. Medial dissection of the bundle for the modified Nesbit procedure reduces the number of diamond-shaped removals of TA and thus shortens operation time in comparison with its lateral counterpart.

A critical analysis of the surgical outcomes for the treatment of Peyronie's disease

Peyronie’s disease (PD) is a relatively common condition, which can impair sexual function and result in emotional and psychological distress. Despite an abundance of minimally invasive treatments, few have confirmed efficacy for improving penile curvature and function. Surgical therapies include many different techniques and are reserved for patients with stable disease of ⩾12 months’ duration. We searched PubMed for all articles from 1990 to the present relating to the surgical management of PD. Preference was given to recent articles, larger series, and those comparing various techniques and/or materials. Outcomes were subsequently analysed and organised by surgical technique and the graft material used. Available surgical techniques include plication/corporoplasty procedures, incision and grafting (I&G), and placing a penile prosthesis with or without adjunctive procedures. Although several surgical algorithms have been reported, in general, plication/corporoplasty procedures are reserved for patients with adequate erectile function, simple curvatures of <60°, and with no deformities (hour-glass, hinge). I&G are reserved for complex curvatures of >60° and those with deformities. Penile prostheses are indicated for combined erectile dysfunction and PD. Overall outcomes show high rates of improved curvature and patient satisfaction, with mildly decreased erectile function with both plication and the I&G procedure (I&G >plication) and decreases in penile length (plication >I&G). Surgical management of PD remains an excellent treatment option for patients with penile curvature precluding or impairing sexual activity. Surgical algorithms are available to assist treating clinicians in appropriately stratifying surgical candidates. Additional research is needed to identify optimal surgical techniques and materials based on patient and disease characteristics.

Penile prosthesis implantation and tunica albuginea incision without grafting in the treatment of Peyronie's disease with erectile dysfunction

We evaluated penile prosthesis implantation with tunica albuginea-relaxing incisions without grafting in the treatment of Peyronie's disease associated with erectile dysfunction. Between April 2005 and June 2011, 62 patients underwent surgery due to severe Peyronie's disease associated with erectile dysfunction. Malleable and inflatable penile prostheses were inserted in 49 and 13 cases, respectively. Penile prostheses were inserted into the corpora cavernosa using the standard ventral approach. After lifting the neurovascular bundle, the tunica albuginea was incised and opened at the plaque region to correct the deformities and to lengthen the penis. Subsequently, the wide neurovascular bundle was replaced, and all incisions of the tunica albuginea were covered to prevent corporal grafting. In the median follow-up of 35 months (range 14-82 months), the penis was completely straightened in 59 (95%) patients. Numbness of the glans, which the patients found initially upsetting, decreased or disappeared spontaneously 3-6 months later. Penile prosthesis implantation with tunica albuginea incisions is a viable alternative in the treatment of Peyronie's disease because the extensive dissection of the neurovascular bundle allows a good approach to the plaque and provides excellent covering of the incised tunica albuginea without additional grafting.

Surgery for Peyronie's disease

Peyronie's disease (PD) is most simply referred to as a fibrotic wound-healing disorder of the tunica albuginea. It is both a physically and psychologically devastating disorder that causes penile deformity, curvature, hinging, narrowing and shortening, which may compromise sexual function. Although a variety of non-surgical treatments have been suggested, none to date offer a reliable and effective correction of the penile deformity. As a result, surgery remains the gold standard treatment option, offering the most rapid and reliable treatment which will be the focus of this article. We review the preoperative evaluation, surgical algorithm, graft materials and postoperative management of PD. Outcomes for tunical shortening, tunical lengthening and penile prosthesis placement for penile straightening are reviewed. Tunica albuginea plication is the preferred method of straightening for men with adequate rigidity and less severe disease defined as curvature less than 70° without narrowing/hinging. Men who have more severe, complex deformity, but maintain strong preoperative erectile function should be considered candidates for straightening with plaque incision or partial excision and grafting. Finally, for those men who have inadequate rigidity and PD, penile prosthesis placement with straightening is the best approach to address both problems.

Peyronie's Disease: Still a Surgical Disease

Peyronie's Disease (PD) remains a challenging and clinically significant morbid condition. Since its first description by François Gigot de la Peyronie, much of the treatment for PD remains nonstandardized. PD is characterized by the formation of fibrous plaques at the level of the tunica albuginea. Clinical manifestations include morphologic changes, such as curvatures and hourglass deformities. Here, we review the common surgical techniques for the management of patients with PD.

Treatment of Peyronie's disease: 2012 update

Peyronie's disease (PD) is the occurrence of a fibrous inelastic scar of the tunica albuginea of the penis. It is a relatively common disorder among men, with a reported prevalence of 3% to 8%. It is often associated with penile pain, anatomical deformities in the erect state, and difficulty with intromission. Because the exact pathophysiology of PD remains unknown and standards for evaluating or reporting treatment outcomes are unclear, research on effective therapies has been limited. The benefits of nonsurgical treatment options are conflicting and further controlled studies are required before any therapy can be fully recommended. The success of surgery has been well documented; however, surgery is invasive and costly and carries potential side effects. Patients who report stable disease that has been present for longer than 12 months and who experience penile deformity preventing satisfactory sexual intercourse are best suited for surgery. Additionally, failed conservative management and a patient's preference for definitive correction are important additional indications for surgical treatment.

Simultaneous penile lengthening and penile prosthesis implantation in patients with Peyronie's disease, refractory erectile dysfunction, and severe penile shortening

INTRODUCTION

Due to loss of length, patients who had penile prosthesis implantation for Peyronie's disease (PD) show a statistically significant reduction in their levels of satisfaction when compared with the general implant population.

AIM

The aim of this study is to report our experience of penile lengthening with circumferential graft during penile prosthesis implantation in patients with PD and severe penile shortening.

METHODS

Between March 2006 and February 2008, 23 patients with PD, refractory erectile dysfunction, and severe penile shortening underwent penile lengthening with circumferential graft and concomitant implantation of an inflatable penile prosthesis.

MAIN OUTCOME MEASURES

Surgical outcome and complications have been recorded during postoperative follow-up. Patients' satisfaction has been assessed 6 months postoperatively with the administration of the modified Erectile Dysfunction Index of Treatment Satisfaction (EDITS) questionnaire.

RESULTS

After an average follow-up of 22 months (range 6-36), 20 patients attended all the postoperative follow-up visits and returned the EDITS questionnaire. An average length gain of 2.8 cm (range 2.2-4.5) was recorded, and all patients were able to cycle the device and engage in penetrative sexual intercourse. Patient recorded complications included diminished glans sensitivity in four (20%) and persistent dorsal curvature of less than 15° in three (15%). Overall, 18 patients (90%) were satisfied with the cosmetic and functional result of surgery.

CONCLUSION

Penile lengthening with circumferential graft during penile prosthesis implantation in patients with PD represents a safe and reproducible technique that yields higher satisfaction rates than penile prosthesis implantation alone in patients with severe penile shortening.