Conservative management of suspected fractures in men undergoing collagenase clostridium histolyticum for Peyronie's Disease is not associated with worsening of erectile function

Collagenase Clostridium histolyticum for Peyronie's disease: a contemporary atlas of complications and their management

INTRODUCTION

Collagenase Clostridium histolyticum (CCH) remains the only Food and Drug Administration-approved medical treatment for Peyronie's disease (PD). The initial IMPRESS I and II trials (Investigation for Maximal Peyronie's Reduction Efficacy and Safety), which led to Food and Drug Administration approval, revealed a rate of treatment-related adverse events as high as 84%. Studies fail to provide clear definitions of complications.

OBJECTIVES

To review complications, provide a CCH complication atlas, and propose management strategies for commonly encountered complications.

METHODS

We performed a literature review using PubMed. A photographic atlas was provided regarding complications in patients in a high-volume CCH center for PD.

RESULTS

Complications were identified and classified by nature and severity. We followed a standardized previously published grading system for hematomas. Complications include bruising, swelling, hematoma formation, back pain, and, rarely, corporal rupture. Complications were discussed, and hematomas were graded by penile surface area. Complication photographs were graded and displayed. Treatment-related adverse effects do not affect overall results.

CONCLUSION

Recognizing and grading complications associated with CCH therapy for PD is crucial for effective patient management and informed decision making. A standardized grading system allows for consistency in reporting and comparing hematoma complication rates across studies and patient populations. Herein we provide images that will help clinicians identify and confidently manage common complications that may occur in any CCH program.

A review of the literature and proposed algorithm for penile fracture management

INTRODUCTION

In the management of penile fractures, immediate surgical repair has resulted in better outcomes when compared with a conservative approach; however, there is currently no consensus on the treatment of patients presenting beyond the immediate period (>24 hours) following injury.

OBJECTIVES

To examine the latest literature on management strategies in penile fracture and propose an optimal algorithm for the treatment of patients with delayed presentation.

METHODS

A comprehensive search was conducted following the PRISMA-P 2020 guidelines. A search was performed in several databases with the following strategy: ("Penile fracture" OR "fracture of penis" OR "rupture of corpora cavernosa" OR "rupture of tunica albuginea") AND (management OR treatment OR surgery OR "surgical reconstruction" OR "surgical repair"). This resulted in 108 relevant articles. Two independent reviewers screened these articles according to the inclusion criteria. Full-text review of 56 articles was performed, and ultimately 20 studies were selected. Measures included the use of diagnostic imaging, timing of surgical repair (immediate, <24 hours after injury; delayed, >24 hours), surgical approach, and long-term complications (ie, erectile dysfunction and penile curvature).

RESULTS

The review highlighted the benefits of immediate surgical repair in penile fractures, demonstrating improved patient outcomes. Furthermore, it found that surgical repair should be considered even in cases with delayed presentation (>24 hours after injury). To better evaluate the long-term impact of delayed surgical intervention on patient outcomes, we recommend standardized postoperative follow-up, with routine assessments of erectile function and penile curvature.

CONCLUSION

Contemporary literature suggests that immediate and delayed surgical repair of penile fractures leads to adequate postoperative outcomes, and patients presenting >24 hours after injury should still be considered for surgery.

Incremental Treatment Response by Cycle With Collagenase Clostridium Histolyticum for Peyronie's Disease: A Pooled Analysis of Two Phase 3 Trials

OBJECTIVE

To evaluate cumulative and incremental changes in penile curvature after each treatment cycle of collagenase clostridium histolyticum (CCH) in men with Peyronie's disease (PD).

METHODS

Data from 2 phase 3, randomized, placebo-controlled trials were analyzed post hoc. Treatment was administered in up to 4 treatment cycles (per cycle: 2 injections, 1-3 days apart, of CCH 0.58 mg or placebo; subsequent penile modeling) at 6-week intervals. Penile curvature was measured at baseline and after each treatment cycle (weeks 6, 12, 18, and 24). Successful response was defined as ≥20% reduction from baseline penile curvature.

RESULTS

Overall, 832 men (CCH, n = 551; placebo, n = 281) were included in the analysis. After each cycle, mean cumulative percent reduction from baseline penile curvature was significantly greater with CCH vs placebo (P <.001). Following one cycle, 29.9% of CCH recipients exhibited a successful response. Among nonresponders, additional cycles of injections led to further successful responses: 60.8% of first cycle failures achieved response after fourth cycle (8 injections), 42.7% of cycle 1-2 failures achieved response after fourth cycle, and 23.5% of cycle 1-3 failures achieved response after fourth cycle.

CONCLUSION

Data showed incremental benefits from each of the 4 CCH treatment cycles. Completion of a full series of 4 CCH treatment cycles may optimize improvements in penile curvature in men with PD, including among those who did not clinically respond to previous treatment cycles.

Improved Peyronie's Disease Curvature Outcomes Using a Novel Collagenase Administration Protocol

OBJECTIVE

To report outcomes of a novel collagenase clostridium histolyticum (CCH) injection protocol.

METHODS

A prospective, sequential database was maintained of all Peyronie's men undergoing CCH injections since 2015. Our protocol has evolved to include changes with injection technique, timing, aggressive modeling/traction, and wrapping. Results of the "traditional" and "novel" techniques were compared using two definitions: "most recent" assessment and final assessments among men who "completed eight (injections) or were satisfied."

RESULTS

A total of 509 men underwent greater than or equal to 1 CCH series (traditional, n = 280; novel n = 229). Baseline demographic/clinicopathologic characteristics were similar between groups. Results demonstrated significantly greater curve improvements with the novel technique ("most recent" median 30° vs 20° or 46% vs 28%; "completed eight or satisfied" 34° vs 20° or 58% vs 30%). Using the "completed eight or satisfied" definition, 94% vs 66% of men achieved greater than or equal to 20% improvement (odds ratio 7.6), and 60% vs 24% achieved greater than or equal to 50% improvements (odds ratio 5.0) in the novel cohort (all P < .0001). Importantly, the International Index of Erectile Function Erectile Function Domain score was unchanged, and subjective erectile function (50% vs 5%, P < .0001) and sensation improved (17% vs 8% improved, P = .01) with the new protocol. The novel cohort also reported higher rates of surgery prevention (53% vs 18%), restored/facilitated penetration (57% vs 21%), and hematomas (56% vs 26%), necessitating changes to wrapping procedures (all P < .0001).

CONCLUSIONS

Use of the novel CCH protocol results in significant improvements with curvature without negatively impacting erectile function or sensation. Given its specialized nature, it is not recommended for low-volume CCH injectors.