Surgical and minimally invasive treatments for Peyronieʼs disease:

Extracorporeal Shockwave Therapy in Peyronie's Disease: Systematic Review and Meta-Analysis

BACKGROUND

Peyronie's disease (PD) is associated with penile pain, deviation, and sexual dysfunction. Up till now, there is no conservative standard treatment for PD. However, the role of Extracorporeal Shock Wave Therapy (ESWT) is gaining increasing interest.

AIM

To evaluate the effect of ESWT on penile deviation, plaque size, erectile function, pain scale, and the rate of complications in PD patients.

METHODS

PubMed database was searched for articles published from January 2000 to November 2020, using related keywords and including randomized controlled trials (RCTs) only. Meta-analysis and forest plots were carried out using RevMan, and outcomes were reviewed by 2 authors independently. PRISMA guidelines were used in this article to achieve the quantitative and qualitative synthesis of data.

OUTCOMES

Changes in penile deviation, plaque size, erectile function, pain scale, and the rate of ESWT related complications.

RESULTS

The search yielded 73 articles. Three RCTs, including 117 patients in the ESWT group and 121 patients in the placebo group, were reviewed. ESWT is associated with reduction in plaque size (OR = 2.59, 95% CI (1.15-5.85), P= .02). No significant difference in reduction of penile deviation angle or rate of bruises were detected in post ESWT group when compared to placebo. No evidence was found to show an effect of ESWT on erectile function or pain scale.

CLINICAL IMPLICATIONS

Based on the available RCTs, ESWT fails to improve penile curvature or pain in men with PD.  Although ESWT may reduce plaque size, this remains of questionable clinical significance.

STRENGTHS & LIMITATIONS

RCTs used different metrics to report the same outcome. Missed data were imputed to match the requirements of meta-analysis. However, there is still much data that cannot be estimated.

CONCLUSION

The current data suggest that ESWT fails to improve penile curvature or pain in men with PD.  Although ESWT may reduce plaque size, this remains of questionable clinical significance, and further studies are required to confirm findings. Bakr AM, El-Sakka A. Extracorporeal Shockwave Therapy in Peyronie's Disease: Systematic Review and Meta-Analysis. J Sex Med 2021;18:1705-1714.

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.

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.

Outcomes of surgical treatment of Peyronie's disease

The aims of the present review were to assess the literature on published outcomes and complications associated with surgical treatments for Peyronie's disease (PD) and to assist clinicians in the effective management of PD by increasing understanding and awareness of the outcomes associated with current surgical treatment options. A PubMed literature search was conducted to identify relevant, peer-reviewed clinical and review articles published between January 1980 and October 2013 related to outcomes of surgical correction of PD. Search terms for this non-systematic review included 'Peyronie's disease', 'outcomes', 'complications', 'erectile dysfunction or ED', 'patient expectation', and 'patient satisfaction'; search terms were searched separately and in combination. Case studies and editorials were excluded, primary manuscripts and reviews were included, and bibliographies of articles of interest were reviewed and key references were obtained. Assessment of the study design, methodology, clinical relevance and impact on the surgical outcomes of PD was performed on the sixty-one articles that were selected and analysed. Currently, there are several investigational minimally invasive and non-surgical treatment options for PD; however, surgical treatment remains the standard of care for patients with stable disease and disabling deformity or drug-resistant erectile dysfunction. Each of the different surgical procedures that are used for treatment of PD, including tunical shortening, tunical lengthening (plaque incisions or partial excision and grafting), and use of inflatable penile prostheses, carries its own advantages and disadvantages in terms of potential complications and postoperative satisfaction. Because of the variety of ways that PD may present in affected patients, no single, standard, surgical treatment for this disorder has prevailed and multiple variations of each type of procedure may exist. Surgical outcomes of the most commonly used procedures are not substantially different; therefore, the appropriateness of each treatment option may often depend on disease and patient characteristics (e.g. deformity and erectile function). Surgical algorithms have been published to guide surgeons and patients through the selection of surgical procedures in the absence of conclusive, long-term outcome data. Accumulating data on outcomes associated with established procedures, modifications to these procedures, and new surgical techniques and materials may serve to further guide practice and refine evidence-based selection of the surgical approach.

Extracorporeal shock wave therapy in Peyronie's disease: results of a placebo-controlled, prospective, randomized, single-blind study

INTRODUCTION

Extracorporeal shock wave therapy (ESWT) for treatment of Peyronie's disease (PD) is controversial.

AIM

To study the efficacy of ESWT by a placebo-controlled, randomized trial.

METHODS

Patients with PD (n=102) were randomly assigned (n=51) to each group (ESWT or placebo). All patients were given 6 weekly treatments. Patients in the ESWT-group received 2,000 shock waves per session, using the Piezoson 100 lithotripter (Richard Wolf, Knittlingen, Germany). Patients in the placebo-group were treated with interposition of a plastic membrane, which prevented any transmission of shock waves.

MAIN OUTCOME MEASURES

Primary end point was decrease of pain between baseline and after 4 weeks follow-up. Secondary end points were changes in deviation, plaque size, and sexual function. Pain was assessed by a visual analog scale. Deviation was measured by a goniometer after artificial erection using Alprostadil (Viridal®, Schwarz Pharma, Monheim, Germany). Plaque size was measured with a ruler and sexual function assessed by a scale regarding the ability to perform sexual intercourse.

RESULTS

Overall, only 45 patients experienced pain at baseline. In the subgroup analysis of these patients, pain decreased in 17/20 (85.0%) patients in the ESWT group and 12/25 (48.0%) patients in the placebo group (P=0.013, relative risk [RR]=0.29, 95% confidence interval: 0.09-0.87). Penile deviation was not reduced by ESWT (P=0.66) but worsened in 20/50 (40%) and 12/49 (24.5%) patients of the ESWT and placebo-group, respectively (P=0.133). Plaque size reduction was not different between the two groups (P=0.33). Additional, plaque size increased in five patients (10.9%) of the ESWT group only. An improvement in sexual function could not be verified (P=0.126, RR=0.46).

CONCLUSIONS

Despite some potential benefit of ESWT in regard to pain reduction, it should be emphasized that pain usually resolves spontaneously with time. Given this and the fact that deviation may worsen with ESWT, this treatment cannot be recommended.

Recapitulation of fibromatosis nodule by multipotential stem cells in immunodeficient mice

Musculoskeletal fibromatosis remains a disease of unknown etiology. Surgical excision is the standard of care, but the recurrence rate remains high. Superficial fibromatosis typically presents as subcutaneous nodules caused by rapid myofibroblast proliferation followed by slow involution to dense acellular fibrosis. In this study, we demonstrate that fibromatosis stem cells (FSCs) can be isolated from palmar nodules but not from cord or normal palm tissues. We found that FSCs express surface markers such as CD29, CD44, CD73, CD90, CD105, and CD166 but do not express CD34, CD45, or CD133. We also found that FSCs are capable of expanding up to 20 passages, that these cells include myofibroblasts, osteoblasts, adipocytes, chondrocytes, hepatocytes, and neural cells, and that these cells possess multipotentiality to develop into the three germ layer cells. When implanted beneath the dorsal skin of nude mice, FSCs recapitulated human fibromatosis nodules. Two weeks after implantation, the cells expressed immunodiagnostic markers for myofibroblasts such as α-smooth muscle actin and type III collagen. Two months after implantation, there were fewer myofibroblasts and type I collagen became evident. Treatment with the antifibrogenic compound Trichostatin A (TSA) inhibited the proliferation and differentiation of FSCs in vitro. Treatment with TSA before or after implantation blocked formation of fibromatosis nodules. These results suggest that FSCs are the cellular origin of fibromatosis and that these cells may provide a promising model for developing new therapeutic interventions.