Optimizing collagenase Clostridium histolyticum therapy for Peyronie's disease using a novel approach with percutaneous needle tunnelling

Efficacy of collagenase Clostridium histolyticum combination therapies for Peyronie's disease: a systematic review and meta-analysis

INTRODUCTION

Peyronie's disease (PD) is a common penile disorder characterized by the formation of fibrous noncompliant hard nodules in the tunica albuginea of the penis. Collagenase Clostridium histolyticum (CCH) is an injectable drug that treats PD by enzymatically degrading plaque interstitial collagen. CCH has been used in patients with varying curvature, as well as in the acute and stable phases of the disease, through a variety of treatment regimens and combinations. We carried out a systematic review and meta-analysis to assess the efficacy of CCH combination therapies for PD.

METHODS

We selected 4 observational comparative studies and 3 randomized controlled trials including 532 participants from the PubMed, Embase, and Cochrane databases (until December 2023) to evaluate the efficacy of CCH combination therapies for PD. The primary outcome was clinical efficacy as evaluated by improvement in penile curvature and penile length, as well as by scores on the Peyronie's Disease Questionnaire (PDQ) for symptom bother, penile pain, and psychological symptoms. Continuous data were represented by mean difference (MD) and 95% CI. All data were analyzed by Review Manager version 5.3.

RESULTS

For penile length (MD, 0.81 cm; 95% CI, 0.17-1.45; P = .01), PDQ symptom bother (MD, -1.02; 95% CI, -1.83 to -0.21; P = .01), and PDQ penile pain (MD, -0.93; 95% CI, -1.50 to -0.36; P = .001), CCH combination therapy showed significantly greater improvements vs CCH monotherapy. However, in the other indicators, penile curvature and PDQ psychological symptoms, there was no significant difference between the therapies.

CONCLUSION

This meta-analysis supports that CCH combination therapies can partially increase penile length and ameliorate symptom bother and penile pain to some extent. However, CCH combination therapies still need to be evaluated through more high-quality research.

Safety and feasibility of percutaneous needle tunneling with platelet-rich plasma injections for Peyronie's disease in the outpatient setting: a pilot study

The objective of this study is to evaluate the safety and feasibility of the combined simultaneous percutaneous needle tunneling coupled with injection of platelet-rich plasma in the outpatient department for the treatment of Peyronie's disease. This prospective, non-randomized, cohort and preliminary study included patients who underwent this procedure from November 2020 to July 2022. The main outcome was an improvement in penile curvature. Fifty-four patients were enrolled and underwent 6 sessions under local anesthesia followed by vacuum therapy for the treatment of Peyronie's disease in our outpatient unit. The amendment of the curvature angle was significant with a median correction percentage of -44.40% interquartile range (-66.70 to (-39.70)), [p-value = 0.001, 95% CI (-29.76 to (-18.02)), paired Student's t-test]. The median pre-treatment curvature angle was 45° (40-75), and the median post-treatment was 30° (20-40). The median score for pain during the procedure was 3 (0-4.25) according to a 10-point visual analogic scale. After two hours, 20.37% of patients still had pain but none required any pain medication. 50% of patients had a minor hematoma and 75.93% patients reported penile ecchymosis. A single patient reported an injection site skin infection. In our experience percutaneous needle tunneling with platelet-rich plasma injections for Peyronie's disease in the outpatient setting is a safe, effective, and feasible treatment of penile deformity for PD.

New protocol in the treatment of Peyronie's disease by combining platelet-rich plasma, percutaneous needle tunneling, and penile modeling: Preliminary results

INTRODUCTION

Intra-lesional injections of collagenase (Xiapex®) were the only non-invasive treatment option for Peyronie's disease (PD), until their withdrawal from the European market.

OBJECTIVE

To evaluate the feasibility, efficacy, and safety of a combined treatment of percutaneous needle tunnelling (PNT) with penile modelling (PM) and the injection of platelet-rich plasma (PRP) under general anesthesia in the treatment of PD.

PATIENTS AND METHOD

A prospective case series study included patients with PD in a stable phase who underwent this procedure between March 2020 and January 2023. The main outcome was an improvement in curvature.

RESULT

Thirty-six patients underwent this novel approach for the treatment of PD. The pretreatment mean±standard deviation (SD) curvature degree was 57.5±20.61° (range 20-90°). After the protocol, the mean curvature degree was 40.86±25.13° (range 0-90°). The curvature angle improved significantly (P=0.0001), with a mean improvement difference of 16.85±14.81° (range 0-50°) and a mean improvement percentage of 47.7±40.29% (range 0-100%).

CONCLUSION

Our preliminary experience suggests that PNT and PRP injections with PM are effective and safe for the treatment of penile deformity of PD.

LEVEL OF EVIDENCE

4: case series study.

A Consistent Lack of Consistency in Defining the Acute and Chronic Phases of Peyronie's Disease: A Review of the Contemporary Literature

INTRODUCTION

Treatment recommendations for Peyronie's Disease (PD) differ based on whether a patient is in the acute/active versus chronic/stable phase of the disease, yet there are no agreed upon criteria for defining these clinical entities.

OBJECTIVES

To review the criteria used to define acute and chronic phase PD in modern PD intervention studies.

METHODS

We performed a search engine review to identify indexed publications for PD intervention studies and review articles / meta-analyses from the year 2011-2020. Outcomes results were catalogued and summarized across articles. As a result of the substantial heterogeneity of outcome measures and follow-up intervals, meta-analytic techniques were not applied to the data analysis.

RESULTS

We identified a total of 104 studies that met inclusion criteria and had available information for review (n = 79 primary intervention studies; n = 25 review articles/meta-analyses/guidelines). Among the queried studies, we were unable to identify a consensus with respect to the criteria used to define acute and chronic phases of PD. 33% of primary intervention studies did not specifically define their criteria for acute and chronic phase PD, despite referencing these populations as part of the inclusion criteria in many instances. Studies used heterogenous criteria including total symptom duration, duration of "stable" symptoms, and presence/absence of pain.

CONCLUSION

Due to varying definitions across the literature, we were unable to create a standardized definition of acute and chronic phase Peyronie's in terms of time. Our findings emphasize the need for greater consensus in defining the treatment cohorts with future studies that assess treatment for men with PD.

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

INTRODUCTION

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pharmacotherapy in Peyronie's disease: a state-of-the-art review on established contemporary and emerging drugs

INTRODUCTION

Current clinical guidelines on Peyronie's disease (PD) advocate non-surgical treatment options as the first-line therapy despite inconsistent clinical outcomes when compared to definitive penile reconstructive surgery.

AREAS COVERED

This article examines the current understanding of established contemporary and emerging pharmacotherapies for PD. Emphasis has been placed on published clinical studies on drugs in the last 10 years.

EXPERT OPINION

Published studies have shown that combination therapy is likely more effective than monotherapy. Combined treatment modalities involving various oral and/or intralesional pharmacotherapies together with mechanical devices or clinical psychosexual therapy may provide additional or synergistic benefits for PD patients. A multidisciplinary approach coupled with more novel targets for pharmacological intervention could deliver a more effective treatment paradigm to prevent or at least delay the need for definitive penile reconstructive surgery. Drugs targeting the inhibition of TGF-β1 pathway and myofibroblast transformation are of great interest and studies into next-generation genetic sequencing and transcriptional biomarker regulatory pathways in PD will provide useful insights into the pathophysiology of PD, and assist the development of future regenerative technology including cellular-based therapies to target various anti-fibrotic molecular mechanisms and the potential to be integrated into existing treatment armamentarium for PD.

The Use of Penile Traction Devices for Peyronie's Disease: Position Statements from the European Society for Sexual Medicine

INTRODUCTION

Penile traction therapy (PTT) aims to non-surgically reduce curvature, enhance girth, and recover lost length. Available clinical practice guidelines however lack clear recommendations regarding their use.

AIM

To present a comprehensive review and recommendation regarding the available evidence to the use of PTT in Peyronie's disease (PD).

METHODS

A systematic literature search was performed on Pubmed and Medline for relevant studies from all times until 2019. Studies of PTT (monotherapy and in combination) in patients with PD with any documented degree of curvature and in either the acute or chronic phase of the disease were included. Full texts not published in English language were excluded.

MAIN OUTCOMES MEASURES

Several scenarios, including preclinical data have been investigated. For each topic covered evidence was analyzed and expert opinion was stated.

RESULTS

The paucity of high-level studies precluded any strong recommendations, however, specific statements on this topic, summarizing the ESSM position, were provided. The available data about the use of PTT in PD are still poor, and the impact of this therapy for the treatment of PD has not been clearly stablished. Available data in the clinical setting are still poor, and the impact of these devices on PD evolution has not been clearly established.

CONCLUSION

PTT seems to be a valid treatment option for PD, although there is not enough evidence to give any definitive recommendation in any clinical scenario. García-Gómez B, Aversa A, Alonso-Isa M et al. The Use of Penile Traction Devices for Peyronie's Disease: Position Statements from the European Society for Sexual Medicine. Sex Med 2021;9:100387.

Efficacy and safety of collagenase Clostridium histolyticum in Peyronie's disease following a modified treatment protocol

INTRODUCTION

Collagenase Clostridium histolyticum (CCH) is the only approved treatment for conservative management of Peyronie's disease (PD) that has demonstrated efficacy and safety in clinical trials. However, as the standard treatment protocol is time and resource consuming, we are introducing a new CCH treatment protocol with a more cost-effective profile. Our goal is to evaluate its efficacy and safety.

MATERIALS AND METHODS

We included patients with PD in stable phase, with curvatures of 30-90degrees. Ventral curvatures and complex deformities were excluded. The treatment protocol consists of a full dose of CCH injected along the PD plaque, forming two lines of four injections. Patients were educated in daily penile modeling activities. The need for a new treatment cycle, up to a maximum of 8 cycles or until the 30-degree curve was decreased, was reevaluated every 4weeks. Changes in curvature and number of cycles were recorded to evaluate the efficacy. Regarding safety evaluation, treatment-related adverse events (TRAEs) were recorded, including rupture of the corpora cavernosa, penile hematoma, hematuria, and local infection.

RESULTS

Thirty-one patients were treated under the modified protocol. The mean initial curvature was of 49.84 (±15.83) degrees. Curvature improvement was recorded in 25 patients (80.6%), with a mean absolute reduction of 20.65 (±15.42) degrees and relative reduction of 44%. The mean curvature after treatment was 30.67 (±17.25) degrees. Most patients required one (19.4%) or two (54.8%) injections. No patient presented TRAEs.

CONCLUSIONS

The results suggest that the modified CCH treatment protocol is effective and safe, but more studies should be carried out to optimize the current standard protocol.

Conservative Therapy for Peyronie's Disease: a Contemporary Review of the Literature

PURPOSE OF REVIEW

To analyze the literature on current conservative treatment options for Peyronie's disease (PD).

RECENT FINDINGS

Conservative therapy with intralesional collagenase clostridium histolyticum (CCH) is safe and efficacious in either the acute or chronic phases of PD. Combination treatment with penile traction therapy (PTT) can produce even better results. While most PTT devices require extended periods of therapy up to 8 h per day, the RestoreX® device can be effective at 30-90 min per day. A variety of conservative therapies are available for treatment of PD. The available literature does not reveal any treatment benefit of oral therapies. Intralesional therapy is the mainstay conservative treatment of PD. Intralesional CCH therapy is the first Food and Drug Administration-approved intralesional therapy and represents the authors' preference for medical therapy. The most effective conservative management of PD likely requires a combination of therapies.

[Non-surgical management of Peyronie's disease: State of current knowledge]

BACKGROUND

Peyronie's disease is an inflammatory disorder of the penis, where scar tissue creates a plaque at the level of the albuginea, limits its extension, and leads to a bent and shorter penis during erections. There are no international standards for the evaluation and the treatment of the disease. The aim of this article is to review the current knowledge about the management of Peyronie's disease and to suggest an algorithm to help physicians evaluate and manage this condition.

MATERIAL AND METHODS

A literature review was conducted through PubMed database following PRISMA guidelines using the Mesh terms: Peyronie, disease, treatment and diagnosis. Results are presented in a descriptive manner.

RESULTS

Multiple treatment strategies have been proposed, but no conclusive randomized clinical trial is done to assess their efficacies. The oral treatment was shown to be more beneficial in the setting of a multi-modal approach to treat the acute phase. The non-steroidal anti-inflammatories and the potassium para-aminobenzoate are superior to the other molecules of oral therapy for pain management. Local treatment with topical verapamil, iontophoresis and intra-lesional injection of verapamil, interferon alfa-2b and collagenase clostridium histolyticum (CCH) revolutionized the management of the disease by the modification of the plaque size and angulation. Alternative treatments using extra-corporeal shock wave or traction devices are promising. Intra-lesional injection of CCH is the only therapy approved by the Food and Drug Administration for this condition after the stabilization of the disease. The channeling of the plaque before CCH injections is making better results than the initial protocol, concerning angulation improvement.

CONCLUSION

Multiple therapeutic strategies exist for the management of the Peyronie's disease, but they lack evidence based data. Further randomized clinical trials are needed to evaluate the current practices and to study more efficient treatments.

Evaluating collagenase Clostridium histolyticum administration protocols in the treatment of Peyronie's disease

PURPOSE OF REVIEW

Treatment of Peyronie's disease with collagenase Clostridium histolyticum (CCh) has gained world-wide adoption following the phase III clinical trials IMPRESS I and II. However, the optimal treatment parameters remain largely unknown. Many groups have made modifications to CCh treatment in Peyronie's disease in recent years. This review aims to discuss the variations in CCh treatment reported and associated outcomes.

RECENT FINDINGS

Variations in CCh treatment protocols include administering higher CCh doses (0.9 mg) less frequently (q1month), use of home penile modeling, use of angulating penile traction devices, and vacuum therapy devices. Authors have reported different injection techniques to include three-point fans and tunneling techniques. Patient selection has expanded to include and evaluate responses among men with some extent of plaque calcification, and ventral curves.

SUMMARY

Since publication of the IMPRESS trials, several variations of CCh treatment have been reported with similar treatment responses to the original trials. However, future studies are required with prospective, randomized comparative designs to identify the optimal treatment strategies for men with Peyronie's disease.

Review of Intralesional Collagenase Clostridium Histolyticum Injection Therapy and Related Combination Therapies in the Treatment of Peyronie's Disease (an Update)

INTRODUCTION

Collagenase Clostridium histolyticum (CCH) is an injectable agent used to treat Peyronie's disease (PD) by enzymatically degrading the interstitial collagen in plaques. CCH has been administered via multiple treatment protocols, in combination therapies, to patients with varying curvatures and in both the acute and stable phases of this condition.

OBJECTIVES

To review the current literature and provide an update on CCH as an injectable therapy for PD, as a singular therapy or in conjunction with combination therapies, and its associated complications. We provide a brief background of PD treatments, evaluate CCH efficacy in penile curvature reduction and subjective improvement in a variety of protocols, and compare combination therapies (penile traction, sildenafil), plaque location, and efficacy in both acute and stable diseases.

METHODS

We performed a systematic review of the existing PubMed literature pertaining to CCH injection therapy in the treatment of PD and compared the effectiveness to different treatment modalities.

RESULTS

CCH is a safe and effective injectable agent for all curvature directions in both acute and stable PD. It can be used in conjunction with multiple penile modeling techniques, in combination with sildenafil, and following a shortened administration protocol. Moderate to severe treatment-related adverse events occur at a rate of 9% and are typically managed conservatively.

CONCLUSION

Intralesional injections of CCH are FDA approved as a nonsurgical treatment for men with PD. The IMPRESS trials were instrumental in demonstrating the efficacy and safety of CCH and provided a standard protocol for administration. Additional studies are required to optimize treatment protocols and use in combination therapies. Further investigation of patients with ventral curvatures, hourglass deformities, and those in acute phase is needed. Natale C, McLellan D, Yousif A, et al. Review of Intralesional Collagenase Clostridium Histolyticum Injection Therapy and Related Combination Therapies in the Treatment of Peyronie's Disease (an Update). Sex Med 2021;9:340-349.