An Analysis of Case Logs From American Urologists in the Treatment of Peyronie's Disease

A survey of exposure to the use of Xiaflex for the treatment of Peyronie's disease among United States urology residency programs

Xiaflex® (collagenase clostridium histolyticum) is a Food and Drug Administration-approved treatment for patients with Peyronie's disease. Despite its approval and implementation, there is concern that urologists in training are offered minimal exposure to its use. Thus, the purpose of this study was to evaluate the exposure of urology residents to Peyronie's disease and its management, particularly Xiaflex®. A Google Forms survey regarding the exposure of residents to Peyronie's disease and use of Xiaflex® was created and disseminated through email to urology programs. Overall, 47 institutional responses were received. At 45 institutions (95.7%), residents receive training in directly evaluating and caring for patients with Peyronie's disease. At 46 institutions (97.9%), residents receive training in observing and/or performing surgical procedures for Peyronie's disease. Residents at 31 institutions (66.0%) receive observational or procedural training for non-surgical management of Peyronie's disease, specifically Xiaflex®. Residents receive non-surgical training from an academic faculty who is fellowship trained in sexual medicine at 25 institutions and an academic faculty not trained in sexual medicine at six institutions. There exists a glaring disparity in residency exposure to Xiaflex®. Further research is warranted to elucidate how programs can provide residents with further exposure to the use of Xiaflex® in patients with Peyronie's disease.

Real-world practice in Peyronie's disease management: Results from a national survey of urologists

BACKGROUND

Despite many available treatments for Peyronie's disease (PD), practice patterns of available therapeutics are not well characterized.

OBJECTIVE

We conducted a national survey of urologists to characterize real-world practice patterns of PD management and to characterize the use of therapies discouraged by the American Urological Association guidelines on PD management.

MATERIALS AND METHODS

A 34-item survey was distributed via RedCap to urologists who treat patients with PD in all American Urological Association sections. Questions elicited demographic information as well as practices in the diagnosis and treatment of PD. Comparisons were made with Pearson's chi-squared test. The primary outcome was reported use of therapies discouraged by the American Urological Association guidelines on PD.

RESULTS

A total of 145 respondents completed the survey, of whom 19% were fellowship trained in andrology/sexual medicine, 36% practiced in an academic setting, and 50% had at least 20 years in practice. Only 60% of respondents reporting performing in-office curvature assessment prior to commencing intralesional injection or surgical treatment, with higher prevalence in andrology/sexual medicine fellowship-trained versus non-fellowship-trained urologists (85% vs. 54%, p = 0.003). The most popular treatment modalities were collagenase clostridium histolyticum (61% of respondents), phosphodiesterase-5 inhibitors (54%), and penile traction (53%). Twenty-one percent of respondents reported currently using a treatment that is explicitly discouraged by the American Urological Association guidelines (extracorporeal shockwave therapy for curvature, L-carnitine, omega-3 fatty acids, or vitamin E).

DISCUSSION

Patients seeking PD treatment may be offered different therapies, some of which are not evidence-based, depending on the treating urologist. This study is limited by self-selection and response bias. Its strength is that it represents a cross-sectional overview of real-world practice patterns in PD management, which has not been previously described.

CONCLUSIONS

A significant proportion of urologists reported PD management practices that are not evidence-based and not guideline-supported.

Cost of Intralesional Collagenase Clostridium Histiolyticum Therapy Versus Surgery for the Management of Peyronie's Disease: A Claims-Based Analysis (2009-2019)

BACKGROUND

Collagenase Clostridium histolyticum (CCH), which was approved by the FDA for the treatment of Peyronie's disease (PD) in 2013, may obviate the need for surgery but its historically high cost must be considered when offering CCH vs surgical intervention to affected patients.

AIM

To compare trends of intralesional injections vs surgical treatment for PD and assess the contemporary cost of treatment with CCH vs surgical intervention.

METHODS

We reviewed 2009-2019 MarketScan Commercial Claims data to identify all men 18 years and older with PD. CPT and HCPCS codes were used to identify PD treatments for each patient. Associated insurance claims in USD were summed for each treatment type.

OUTCOMES

Total and out-of-pocket costs, as well as frequencies, for treatments were calculated on a yearly basis and the Cochran-Armitage test was used to compare frequencies before and after FDA approval of CCH.

RESULTS

Of 89,205 men diagnosed with PD, 21,605 (24.2%) underwent treatment; most required only intralesional injections, however 1,519 (7.0%) received only surgical therapy and 1,951 (9.0%) required medical and surgical therapy. Intralesional CCH use sharply increased after its FDA-approval in 2013 with a concomitant fall of intralesional verapamil use. The use of both surgical plication and plaque grafting decreased steadily from 2009 to 2019. The median cost per patient for all 3 treatments increased over the study time-period: $1,856 to $3,196 for plication, $2,233 to $3,631 for plaque grafting, and $6,940 to $8,895 per cycle for CCH. Out-of-pocket median patient contribution for plication, plaque grafting, and per cycle intralesional CCH injection were similar over the study period and never exceeded $300.

CLINICAL IMPLICATIONS

CCH is significantly more expensive than any surgical treatment option, however, the out-of-pocket patient contribution for surgery and CCH are similar.

STRENGTHS & LIMITATIONS

This study incorporated all procedure costs and is the most contemporary, comprehensive, and accurate reflection of overall and out-of-pocket costs to patients for surgical and intralesional PD therapies. We anticipate these data to allow for a more complete discussion between patients and providers regarding their care. The use of a commercial claims database prohibited assessment of post-procedural costs and treatment outcomes.

CONCLUSION

CCH use has increased significantly since its FDA approval in 2013 with out-of-pocket patient contribution comparable to surgical therapy despite significantly higher total treatment costs. Walton EL, Quinn TP, Mulloy E, et al. Cost of Intralesional Collagenase Clostridium Histiolyticum Therapy Versus Surgery for the Management of Peyronie's Disease: A Claims-Based Analysis (2009-2019). Sex Med 2022;10:100517.

Urologists' knowledge base and practice patterns in Peyronie's disease. A national survey of members of the italian andrology society

Peyronie's disease is a chronic inflammatory disease involving the formation of plaque in the tunica albuginea of the corpora cavernosa, resulting in penis deformity. It is often associated with penile pain, especially in younger patients, but it is not rare for pain to be absent; the disease is also associated with erectile dysfunction and a depressive state in a large percentage of cases.

OBJECTIVE

Aim of our study was to explore the basic knowledge base and diagnostic and therapeutic practice patterns in Peyronie's disease (PD) of a large number of physicians belonging to the Italian Andrology Society (SIA).

METHODS

Our survey is based on two questionnaires which were e-mailed to the members of the SIA. The first questionnaire explored diagnostic and therapeutic practice patterns of SIA physicians, while the second questionnaire focused on their knowledge of the disease, as well as their training and level of experience in the specific field. We then planned to compare our outcomes with similar PD surveys from other countries.

RESULTS

The first questionnaire was answered by 142 SIA physicians. The second questionnaire was answered by 83 SIA physicians. Most respondents (74.6%) chose penile ultrasonography as first-line diagnostic approach and 47.1% prefer to perform a color Doppler ultrasound after pharmaco-induced erection. Concerning the therapeutic practice patterns in active stage of the disease, most respondents (99.29%) prefer conservative medical therapy. Additionally, most respondents (64.78%), when failure of conservative treatment had been established, considered surgical treatment necessary, specifically corporoplasty, which may be associated with other techniques.

CONCLUSIONS

The results of our survey show that, in comparison to their foreign counterparts, Italian SIA uro-andrologists have a more proactive diagnostic approach right from when patients first present. When PD is still in its active stage, SIA uro-andrologists mostly opt for medical therapy. In advanced disease or if conservative treatment fails, our survey indicates a greater preference for surgical treatment. Answers to the theoretical knowledge questions showed that SIA physicians have a good understanding of the disease's etiology, epidemiology, and clinical picture, and of the appropriate indications for treatment.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Contemporary surgical and non-surgical management of Peyronie's disease

Numerous treatments have been proposed for Peyronie's disease (PD). As the evidence base has expanded, the field of operative and non-operative options for patients has narrowed. Collagenase clostridium hystolyticum (CCH) injection now comprises the medical option, and surgical possibilities entail penile plication, plaque incision/excision and grafting, and prosthesis implantation. Still, questions abound regarding the optimal approach and indication for each of these treatments. We conducted a review of literature exploring the contemporary management of PD with a particular focus on work since the last American Urologic Association's (AUA) guidelines update for PD. Recent results and discussion indicate trends toward minimal invasiveness, toward a more holistic approach to the PD patient, and away from algorithmic management, galvanized, in part, by data challenging long-held beliefs.

Peyronie's penile plication

Penile plication has become the preferred surgical technique for Peyronie's disease (PD) as it can be performed efficiently, safely, with a high success rate, low morbidity and a low complication rate. Here in we describe two modern plication techniques in detail: the Kiels Knot plication and the minimally invasive penoscrotal plication. Benefits of the techniques include no palpable sutures for the Kiels Knot Plication and less surgical trauma for the penoscrotal plication. Plication has a low rate of failure. However, when it does occur it is usually secondary to under-correction. Failures typically present early postoperatively and a contributing factor to underestimating the deformity is a poor intraoperative artificial erection. Complex, severe, or multiplanar deformities will require more sophisticated intraoperative decision-making, but can be managed effectively with penile plication nonetheless.