The management of Peyronie's disease

The future of penile prosthetic surgery in the UK

Introduction:

The provision of penile prosthetic surgery (PPS) in the United Kingdom needs to be reviewed given the twin popular philosophies of Centres of Excellence, as defined by high case volume yielding best outcomes, and Getting It Right First Time (GIRFT), defined as effective and efficient use of resources.

Methods:

To recognise centres of high volume of PPS and their location, we interrogated Hospital Episode Statistic (HES) data between 2014 and 2017. From this analysis we advance a model of the 10 British Association of Urological Surgeons (BAUS) regions in England providing PPS, working largely to recommendations made by National Health Service (NHS) England through its Clinical Commissioning Policy for Penile Prosthesis.

Results:

Between 2014 and 2017, there were 2361 surgical procedures undertaken, and of these, primary implantations numbered 1330 and revisions 1031. University College London Hospitals performed more than 50% of all primary implantations and 52% of all revisions. Across England for the year 2017, there were 301 primary implantations and 442 revisions.

Discussion:

We suggest that revision surgery for device mechanical failure should be within the remit of these centres but referral of complex revision surgery irrespective of aetiology may warrant referral to defined tertiary centres in London, the Midlands and the North of England.

Conclusion:

Prospective data on patient outcomes from PPS are urgently needed, and NHS England should regard a national database of PPS as essential. We advance a model of the 10 BAUS regions in England providing PPS as a distributed and geographically equitable network for primary implantation. A regionalised network of revision surgery should be considered.

Level of evidence:

Not applicable for this multicentre audit.

Surgical Outcomes of Plaque Excision and Grafting and Supplemental Tunica Albuginea Plication for Treatment of Peyronie's Disease With Severe Compound Curvature

BACKGROUND

There are limited data in the literature that describe the management of Peyronie's disease (PD) with severe compound curvature, which often requires additional straightening procedures after plaque excision and grafting (PEG) to achieve functional penile straightening (<20 degrees).

AIM

This study highlights the clinical distinction and our experience with men with PD and severe compound curvature treated with PEG and supplemental tunica albuginea plication (TAP).

METHODS

We performed a retrospective chart review of patients with PD and acute angulation who underwent PEG (group 1) and patients with compound curvature who underwent PEG with TAP (group 2) between 2007 and 2016.

OUTCOMES

Primary post-operative outcomes of interest include change in penile curvature, change in measured stretched penile length, and subjective report on penile sensation and sexually induced penile rigidity.

RESULTS

240 Men with PD were included in the study, of which 79 (33%) patients in group 1 underwent PEG and 161 (67%) in group 2 underwent PEG and TAP. There was no difference in associated PD co-morbidities including age, hypertension, hyperlipidemia, hypogonadism, diabetes, or tobacco use. After artificial induction of erection with intracorporal trimix injection, the average primary curvature was 73 (range, 20-120) degrees for group 1 compared to 79 (range, 35-140) degrees for group 2 (P = .01). Group 2 had an average secondary curvature of 36 (20-80 degrees). After completion of PEG, men in group 2 had an average residual curvature of 30 (range, 20-50) degrees which required 1-6 TAPs to achieve functional straightness (<20 degrees). At an average follow-up of 61 months, there was no difference for group 1 and group 2, respectively, for recurrent curvature (11.4% vs 12.4%, P = .33), change in penile length (+0.57 vs +0.36 cm, P = .27) or decreased penile sensation (6% vs 13%, P = .12). In all, 81% of group 1 and 79% of group 2 were able to engage in penetrative sex after penile straightening with or without pharmacotherapy (P = .73).

CLINICAL TRANSLATION

Our review shows promising surgical outcomes for the use of PEG and supplemental TAP for this subtype of complex PD.

STRENGTHS AND LIMITATIONS

This article reports the largest experience with treatment of PD with compound curvature to date. Limitations of this study include the retrospective nature of the analysis as well as the lack of a validated objective measurement of erectile function after penile straightening.

CONCLUSION

Our study found no baseline difference in underlying co-morbidities in men with severe compound curvature compared with men with acute severe angulated curvature. Men with severe compound curvature represent a severe and under-recognized population of men with PD who can be surgically corrected with PEG and supplemental TAP(s) when needed without an increased risk of loss of penile length, recurrent curvature, decreased penile sensation, or erectile dysfunction when compared to men treated with PEG alone. Chow AK, Sidelsky SA, Levine LA. Surgical Outcomes of Plaque Excision and Grafting and Supplemental Tunica Albuginea Plication for Treatment of Peyronie's Disease With Severe Compound Curvature. J Sex Med 2018;15:1021-1029.

A review of surgical strategies for penile prosthesis implantation in patients with Peyronie's disease

The introduction of the inflatable penile prosthesis (IPP) has revolutionized the treatment of patients with both Peyronie's disease (PD) and erectile dysfunction (ED). A thorough literature review was performed in order to review the surgical strategies used to treat PD, using the PubMed online database with the keywords "penile prosthesis", "surgical management" and "Peyronie's disease". Patient satisfaction rates of 72-100% and partner satisfaction rates of 89% have been reported in the literature, although strong preoperative education may be needed to prepare patients for risks such as penile shortening, seen in up to 54% of patients. Three-piece IPPs are most commonly used, and when comparing the two most popular models (AMS 700 CX vs. Coloplast Titan), no significant differences were seen in functional outcomes or patient satisfaction. Simple insertion of an IPP has been shown to resolve curvature in 33-90% of patients, but surgeons may often need to also utilize ancillary straightening procedures for residual curvatures. Manual modeling can correct residual curvature with an 86-100% success rate, but with a 4% risk of urethral injury. When the post-modeling residual curvature exceeds 30 degrees, a plaque-releasing incision or plication is recommended to further reduce curvature. Grafting is recommended if the resulting incisional defect is larger than two centimeters. Alternative straightening techniques such as plication prior to IPP insertion, endoscopic plaque resection, the "scratch technique" and bone saw plaque incision have also been described.

Penile curvature: an update for management from 20 years experience in a high volume centre

Our aim was to review the literature and discuss about penile curvature in order to have an update for management after 20 years experience in the field.Penile curvature may be congenital or acquired. Congenital penile curvature is a relatively uncommon condition that may present in late adolescent or early adult life. The incidence is estimated to be 0.6 %. On the other side, acquired penile curvature has an overall prevalence of 0.5-13%. Three main factors seem to increase the risk of developing an acquired penile curvature, often related to Peyronie's disease: penile traumatism, genetic and familiar conditions and a history of diseases of the genital tract. In treating Peyronie's disease, no medical therapy is fully effective, and surgery remains the gold standard in cases of severe deformity and/or erectile disfunction. Peyronie's disease is associated with significant psychological stress for patients and their partners. Appropriate treatment should be individualized and tailored to the patient's goals and expectations. There is not the 'best' surgical technique and outcomes are satisfactory when proper treatment decisions are made.

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.

Tunica albuginea allograft: a new model of LaPeyronie's disease with penile curvature and subtunical ossification

The pathophysiology of LaPeyronie's disease (PD) is considered to be multifactorial, involving genetic predisposition, trauma, inflammation and altered wound healing. However, these factors have not yet been validated using animal models. In this study, we have presented a new model obtained by tunica albuginea allograft. A total of 40, 16-week-old male rats were used. Of these, 8 rats served as controls and underwent a 10 × 2-mm-wide tunical excision with subsequent autografting, whereas the remaining 32 underwent the same excision with grafting of the defect with another rat's tunica. Morphological and functional testing was performed at 1, 3, 7 and 12 weeks after grafting. Intracavernous pressure, the degree of penile curvature and elastic fiber length were evaluated for comparison between the allograft and control groups. The tissues were obtained for histological examination. The penile curvature was significantly greater in the allografted rats as compared with the control rats. The erectile function was maintained in all rats, except in those assessed at 12 weeks. The elastin fiber length was decreased in the allografted tunica as compared to control. SMAD2 expression was detected in the inner part of the allograft, and both collagen-II- and osteocalcin-positive cells were also noted. Tunica albuginea (TA) allograft in rats is an excellent model of PD. The persistence of curvature beyond 12 weeks and the presence of ossification in the inner layer of the TA were similar to those observed in men with PD. Validation studies using this animal model would aid understanding of the PD pathophysiology for effective therapeutic interventions.

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.

Tadalafil once daily and intralesional verapamil injection: A new therapeutic direction in Peyronie's disease

INTRODUCTION

The aim of this study was to evaluate the combination of intralesional verapamil injection (IVI) therapy with and tadalafil in men affected by Peyronie's disease (PD).

MATERIALS AND METHODS

In this study, 59 patients diagnosed with PD, were divided into three groups. Group A (GA) counted 23 patients treated with IVI; Group B (GB) treated 19 patients with tadalafil 5 mg once a day, and Group C (GC) treated 17 patients with IVI and tadalafil for 3 months. There were assessed at baseline and follow-up: Erectile function, presence and severity of painful erections, penile plaque size and penile curvature degree.

RESULTS

After 3 months pain resolved completely in 57% cases of GA, 61% of GB and 76% of GC; the final mean curvature degree further decreased in all groups without statistically significant differences; mean plaque size remained stable in GA: 1.57 versus 1.59 at baseline (P = 0.364) and GB: 1.51 versus 1.52 at baseline (P = 0,265), while a further decrease was evident in GC: 1.46 versus 1.58 at baseline (P = 0.03). Mean International Index of Erectile Function-5 score further improved significantly in the group treated with verapamil plus tadalafil: 23.1 versus 14.4 of GA and 18.2 of GB (P ≤ 0.01).

CONCLUSIONS

The association of IVI and tadalafil showed better pain control while reducing penile curvature and erectile function, improving the quality of life.

The role of intrinsic pathway in apoptosis activation and progression in Peyronie's disease

Peyronie's disease (PD) is characterized with formation of fibrous plaques which result in penile deformity, pain, and erectile dysfunction. The aim of this study was to investigate the activation of the intrinsic apoptotic pathway in plaques from PD patients. Tunica albuginea from either PD or control patients was assessed for the expression of bax, bcl-2 and caspases 9 and 3 using immunohistochemistry and by measurement of apoptotic cells using TUNEL assay. Bax overexpression was observed in metaplastic bone tissue, in fibroblasts, and in myofibroblast of plaques from PD patients. Little or no bcl-2 immunostaining was detected in samples from either patients or controls. Caspase 3 immunostaining was very strong in fibrous tissue, in metaplasic bone osteocytes, and in primary ossification center osteoblasts. Moderate caspase 9 immunostaining was seen in fibrous cells plaques and in osteocytes and osteoblasts of primary ossification centers from PD patients. Control samples were negative for caspase 9 immunostaining. In PD patients the TUNEL immunoassay showed intense immunostaining of fibroblasts and myofibroblasts, the absence of apoptotic cells in metaplasic bone tissue and on the border between fibrous and metaplastic bone tissue. Apoptosis occurs in stabilized PD plaques and is partly induced by the intrinsic pathway.

Treatments for fibrosis of the corpora cavernosa

Introduction

Corporal fibrosis usually occurs after explantation of an infected penile prosthesis, severe penile trauma, refractory low-flow priapism, Peyronie’s disease, or the chronic intracavernous injection of vasoactive drugs.

Methods

We analysed current treatmentss for penile fibrosis. We searched PubMed using the keywords ’penile corporal fibrosis’, ’treatment’ and ’penile fibrosis’, resulting in 63 matches, of which 19 articles met the inclusion criteria.

Results and conclusions

This review covers conservative medical therapy for corporal fibrosis and surgical therapeutic methods. The roles of phosphodiesterase- 5 inhibitors and pentoxifylline are analysed. Surgical therapy includes implantation of a penile prosthesis and corporal reconstruction, and these are reviewed. Corporal fibrosis is a major problem for patients, and is associated with severe erectile dysfunction. Conservative treatment options can be applicable in the early phase, but simultaneous corporal reconstruction procedures with concomitant implantation of a penile prosthesis should be attempted in severe cases of corporal fibrosis.

Standard operating procedures for Peyronie's disease

INTRODUCTION

Peyronie's disease (PD) refers to a penile deformity that is associated with sexual dysfunction.

AIM

To provide recommendations and Standard Operating Procedures (SOPs) based on best evidence for diagnosis and treatment of PD.

METHODS

Medical literature was reviewed and combined with expert opinion of the authors.

MAIN OUTCOME MEASURES

Recommendations and SOPs based on grading of evidence-based medical literature.

RESULTS

PD is a fibrotic wound-healing disorder involving the tunica albuginea of the corpora cavernosa. The resulting scar is responsible for a variety of deformities, including curvature, shortening, narrowing with hinge effect, and is frequently associated in the early phase with pain. Patients frequently experience diminished quality erections. All of these conditions can compromise sexual function for the affected male. The etiopathophysiology of PD has yet to be clarified and as a result, effective, reliable, mechanistic directed non-surgical therapy is lacking.

CONCLUSIONS

The management of PD consists of proper diagnosis and treatment, ranging from non-surgical to surgical interventions. The main state of treatment for PD rests at this time on surgical correction that should be based on clear indications, involve surgical consent, and follow a surgical algorithm that includes tunica plication, plaque incision/partial excision and grafting, and penile prosthesis implantation.

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.

Three-piece Inflatable Penile Prosthesis: Surgical Techniques and Pitfalls

Penile prosthesis surgery plays a vital role in the treatment of erectile dysfunction (ED). As far as outcome is concerned, it is one of the most rewarding procedures for both patients and surgeons. We describe our surgical technique for implantation of the three-piece inflatable penile prosthesis and point out the major surgical pitfalls accompanying this procedure and their specific management. The psychological outcome of penile prosthesis surgery is also discussed. Different surgical approaches are available when performing the procedure. A number of procedure-related problems can be encountered and a thorough knowledge of these is of paramount importance. Penile prosthesis surgery has a favorable psychological outcome. Surgery for implantation of an inflatable penile prosthesis is a rewarding procedure, with a high yield of patient satisfaction. Urologists should have thorough understanding of the surgical pitfalls peculiar to this procedure and their management.

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.

Tissue engineering for penile surgery: comparative study of noncellular and cell-seeded synthetic grafts for tunica albuginea replacement

INTRODUCTION

Surgical treatment outcomes in Peyronie's disease remain controversial because of high rates of recurrence.

AIM

The aim of this study was to engineer in vitro a new type of tunica albuginea (TA) autologous graft obtained by culture of autologous fibroblast on a polyglycolic acid (PGA) scaffold. This engineering graft was compared with PGA with morphological and functional outcomes for TA replacement, 4 months after graft upon corpus cavernosum in a rat model.

METHODS

Thirty-nine Sprague Dawley adult male rats were divided into four groups: (i) control group (C) with resection and resuture of a 5 mm long and 2 mm large piece of original TA; (ii) PGA scaffold group (P) with the same resection of TA and suture of PGA scaffold; (iii) autologous fibroblast-seeded on PGA scaffold graft after resection of the same piece of TA (F + P); and (iv) sham group for functional and histological comparison.

MAIN OUTCOME MEASURE

The main outcome measure was assessment of graft size variation at 4 months and comparison between the three test groups. The secondary objective is assessment of erectile function by measuring erectile response to cavernous nerve electrical stimulation in each group.

RESULTS

At 4 months, there was a significant difference in graft area retraction between the groups (P = 0.0081) with higher retraction in P group vs. in C or F + P groups. Erectile response to cavernous nerve stimulation significantly differed between the groups and was sham equivalent to C equivalent to F + P superior to P group.

CONCLUSIONS

This study provides experimental evidence for the feasibility and the functionality of fibroblast-seeded scaffold compared with acellular graft for TA replacement.

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.

The association between Peyronie's and Dupuytren's disease

Peyronie's disease (PD) is known to be associated with Dupuytren's disease (DD) since 1828. The aim of this study was to investigate the coexistence of DD in a consecutive series of patients with PD and their clinical characteristics. From January 1988 to December 2009 all patients, presenting at our outpatient urological clinic, with PD were also examined for DD. The sample consisted of 415 male subjects with PD, 89 (22.1%) also had DD. A total of 28 men (6.7%) reported to have one or more first or second degree relatives with DD.

The management of residual curvature after penile prosthesis implantation in men with Peyronie's disease

OBJECTIVE

• To report our experience in the management of residual curvature after implantation of a penile prosthesis in men with Peyronie's disease (PD).

PATIENTS AND METHODS

• From January 1985 to June 2009, 62 (29%) of the 209 patients with PD that have undergone the insertion of a penile prosthesis have required an additional straightening procedure to correct the residual curvature after the insertion of the cylinders of the implant. • The types of additional manoeuvres, their success in correcting the residual curvature and eventual complications have been reported.

RESULTS

• Among the additional straightening procedures, modelling was more successful in achieving straightening when performed on an inflatable device (84%) than on a malleable implant (54%). • If the curvature persisted after modelling or if the curvature was ventral, straightening was achieved with tunical plications or incision with or without grafting.

CONCLUSION

• Although it is common for the simple implantation of cylinders alone to straighten the penis, some patients will present a residual curvature that must be successfully corrected with additional straightening procedures.

Inflatable penile prosthesis placement in men with Peyronie's disease and drug-resistant erectile dysfunction: A single-center study

INTRODUCTION

Erectile dysfunction (ED) frequently accompanies Peyronie's disease (PD) and changes the therapeutic approach.

AIM

To evaluate a single-center experience with inflatable penile prostheses (IPP) in men with medication refractory ED and PD.

METHODS

Ninety men underwent placement of an IPP with straightening maneuvers as necessary to address their deformity and ED.

MAIN OUTCOME MEASURES

Preoperative assessment included International Index of Erectile Function-erectile function domain (IIEF-EF) and duplex ultrasound to confirm ED and measure erect deformity. Postoperative assessment included a modified Erectile Dysfunction Index of Treatment Satisfaction (EDITS) questionnaire, as well as office visits at 1, 6, and every 12 months thereafter.

RESULTS

Complete chart review was performed with mean follow-up of 49 months. Mean preoperative IIEF-EF score was 11. Full rigidity was not obtained in any patient during duplex ultrasound. Mean curvature at maximum erection was 53°. There were seven mechanical failures requiring device replacement, two revision surgeries for pump or reservoir malposition, one infected device, and two corporoplasties for distal tunica erosion. Postoperative office assessment revealed a functionally straight (i.e., <20°) erect penis and a properly positioned as well as operational device in all patients. The modified EDITS questionnaire was returned by 56 (62%). Overall, 84% of patients were satisfied with their outcome, yet only 73% were satisfied with their straightness. Patient perceived postoperative curvature correction stabilized quickly and was complete by 3 months in 84% of patients. Satisfaction with ease of inflation, deflation, and concealability was 84%, 71%, and 91%, respectively. Coital activity was reported by 91% of men in this group.

CONCLUSION

In men with PD and ED, IPP placement allowed reliable and satisfactory coitus for the great majority of men. Mechanical failure was 7%. Men with PD undergoing IPP placement should be counseled regarding potential penile length loss and residual curvature, neither of which appeared to interfere with coitus but may reduce satisfaction.

The management of Peyronie's disease: evidence-based 2010 guidelines

INTRODUCTION

The field of Peyronie's disease is evolving and there is need for a state-of-the-art information in this area.

AIM

To develop an evidence-based state-of-the-art consensus report on the management of Peyronie's disease.

METHODS

To provide state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical management of Peyronie's Disease, representing the opinion of leading experts developed in a consensus process over a 2-year period.

MAIN OUTCOME MEASURES

Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.

CONCLUSIONS

The real etiology of Peyronie's disease and the mechanisms of formation of the plaque still remain obscure. Although conservative management is obtaining a progressively larger consensus among the experts, surgical correction still remains the mainstay treatment for this condition.

A cross-sectional study for the analysis of clinical, sexual and laboratory conditions associated to Peyronie's disease

INTRODUCTION

Although Peyronie's Disease (PD) was first described over 250 years ago, its precise etiology remains obscure.

AIM

Analyze a variety of potential associated factors with PD, including erectile dysfunction.

MATERIALS AND METHODS

This cross-sectional study included 83 consecutive men with PD and 252 age-matched controls. All men completed the International Index of Erectile Function (IIEF) and were evaluated regarding their clinical and demographic characteristics, comorbidities, and used medications. Anthropometric measures included body mass index and waist circumference (WC). Fasting blood glucose, lipid profile, total testosterone, and dehydroepiandrosterone-sulfate were determined.

MAIN OUTCOME MEASURES

Clinical and laboratory characteristics associated to PD.

RESULTS

The mean age was 59.2 + or - 10 years in the cases and 59.7 + or - 12 years in the controls. Marital status, current smoking, and excessive consumption of alcoholic beverages were similar between groups (P > 0.05). PD was more common among white skin color males (P = 0.001). The mean score for each IIEF domain and the androgen levels were similar in the two groups. Thiazides were the only medication associated to PD (P = 0.03). Dupuytren's disease was more frequent among individuals with PD (P = 0.001). The distribution of all other comorbidities investigated was similar between groups (P > 0.05). The characteristics WC > 102 cm and levels of low-density lipoprotein (LDL) > 130 mg/dL were more prevalent in the controls (P < 0.05). After multivariate analysis, white skin color (OR: 8.47, 95%CI: 1.98-36.24) and thiazide use (OR: 2.29, 95%CI: 1.07-4.90) were associated to PD, and LDL > 130 mg/dL (OR: 0.55, 95%CI: 0.32-0.92) and WC > 102 cm (OR: 0.53, 95%CI: 0.29-0.96) were inversely associated to PD.

CONCLUSIONS

In this study, PD was more common among white skin colored males. An inverse relationship with the presence of elevated serum levels of LDL and WC was observed. We found no association with medications other than thiazides and comorbidities other than Dupuytren's disease. Androgen serum levels and sexual dysfunction had also no association to PD.

Surgical correction of Peyronie's disease via tunica albuginea plication or partial plaque excision with pericardial graft: long-term follow up

INTRODUCTION

Limited publications exist regarding long-term outcomes of surgical correction for Peyronie's Disease (PD).

AIM

To report on long-term postoperative parameters including rigidity, curvature, length, sensation, function, and patient satisfaction in men with PD treated surgically via Tunica Albuginea Plication (TAP) or Partial Plaque Excision with Tutoplast Human Pericardial Grafting (PEG).

MAIN OUTCOME MEASURES

Objective and subjective data regarding patients who underwent either TAP or PEG.

METHODS

We report on 142 patients (61 TAP and 81 PEG) with both objective data and subjective patient reports on their postoperative experience. Patients underwent either TAP or PEG following our previously published algorithm. Data was collected via chart review and an internally generated survey, in which patients were asked about their rigidity, straightness, penile length, sensation, sexual function and satisfaction.

RESULTS

Average follow up for TAP patients was 72 months (range 8-147) and 58 months (range 6-185) for PEG patients. At survey time, 93% of TAP and 91% of PEG patients reported curvatures of less than 30o. Rigidity was reportedly as good as or better than preoperative in 81% of TAP and 68% of PEG patients, and was adequate for coitus in 90% of TAP and 79% of PEG patients with or without the use of PDE5i. Objective flaccid stretched penile length measurements obtained pre and postoperatively show an average overall length gain of 0.6 cm (range -3.5-3.5) for TAP and 0.2 cm (range -1.5-2.0) for PEG patients. Sensation was reportedly as good as or better than preoperative in 69% of both TAP and PEG patients; 98% of TAP patients and 90% of PEG are able to achieve orgasm. 82% of TAP patients and 75% of PEG patients were either very satisfied or satisfied.

CONCLUSION

Our long-term results support both TAP and PEG as durable surgical therapy for men with clinically significant PD.

Surgical outcomes and patient satisfaction after dermal, pericardial, and small intestinal submucosal grafting for Peyronie's disease

INTRODUCTION

Peyronie's disease, a localized fibrosis of the tunica albuginea surrounding the penile corpora, results in penile curvature and sexual dysfunction. Surgical management involving grafting to straighten the penis is the treatment of choice in conditions unresponsive to conservative therapy where penile length preservation is important.

AIM

To determine surgical outcomes and patient satisfaction after dermal, pericardial, and small intestinal submucosal grafting for Peyronie's disease.

MAIN OUTCOME MEASURES

The International Index of Erectile Function (IIEF), postoperative self-reports, patient satisfaction, and clinical characteristics were used to measure outcomes.

METHODS

We retrospectively reviewed charts of 36 patients who underwent surgery for Peyronie's disease requiring grafting from 1999 to 2005. Follow-up to subjectively assess outcomes was conducted.

RESULTS

Average patient age at surgery was 55 +/- 1 years. Body mass indexes were similar among all groups. Erectile dysfunction risk factors were comparable with 36% reporting hypertension and 22% hypercholesterolemia. Overall patient follow-up time was 673 +/- 98 days. Self-reported resolution of penile curvature was noted in 60% of dermal, 100% of Tutoplast, and 76.9% of Stratasis graft recipients. Stratasis patients maintained presurgery length (54%) and rigidity (77%) more so than dermal (30%, 60%) and Tutoplast (23%, 39%) patients. Assessment of erectile dysfunction using the IIEF-5 captured significant improvements in patients receiving Stratasis grafts (preoperative: 10.1 +/- 1.1 vs. postoperative: 17 +/- 1.6). Overall, 89% of patients reported satisfaction following surgical intervention.

CONCLUSIONS

Surgical management of Peyronie's disease results in correction of penile curvatures and high rates of patient satisfaction. Loss of penile length and decreased rigidity occurred to a lesser degree with Stratasis grafts. While detailed informed consent is essential in this patient population, novel materials such as Tutoplast and Stratasis grafts improve outcomes following surgical correction of Peyronie's disease.

Peyronie’s Disease: Lights and Shadows

Peyronie's disease (PD) is characterized by the onset of fibrous plaque inside the tunica albuginea of the penile corpora cavernosa that can cause pain and bending during the erection, making intercourse difficult or impossible. Evidence of the literature supports the autoimmune etiology of PD and suggests genetic and familiar conditions, penile traumatisms, and a history of genital tract diseases as risk factors, but no definitive conclusions arise about the pathogenesis of the disease. Few randomized trials demonstrated that medical therapies, such as vitamin E, colchicine, potassium aminobenzoate, tamoxifen, and injection therapy with verapamil, can stabilize the acute phase of the disease. Extracorporeal shock wave therapy and iontophoresis cannot be considered first-line or gold standard therapies. Satisfactory results have been published with the Nesbit operation in large series with low-stage disease, whereas plication procedures have shown significant relapse rates. A high incidence of long-term penile retractions has been reported in high-stage disease treated with plaque incision and simple graft insertion. Malleable, soft, or inflatable prostheses combined with graft implantation have given the best results in terms of penile straightening and lengthening and patient satisfaction. In conclusion, the etiopathogenesis of PD is not yet clearly understood, no medical therapy is fully effective, and surgery remains the gold standard in patients with severe deformity and/or erectile dysfunction.

Penile prosthetic surgery and its role in the treatment of end-stage erectile dysfunction - an update

The treatment of erectile dysfunction has been revolutionised with the introduction of orally active phosphodiesterase inhibitors which are successful in 70-80% of men. However, there remain a group of men in whom conservative treatment fails and surgical insertion of a penile prosthesis is required. This type of surgery has in the past been associated with technical difficulties and a high complication rate. This has spurred numerous developments in prosthesis design and surgical technique with the field changing at a rapid pace. Perhaps the most significant is the use of antimicrobial coatings on prostheses that have been shown to reduce the infection rate significantly. This review highlights those developments reported in the last 5 years.

Role of Shock wave Therapy in Peyronie's Disease

Shock wave therapy (ESWT) for the treatment of Peyronie's Disease (PD) is still controversial. The aim of this study is to evaluate the efficacy of shock wave therapy in patients candidates for surgical treatment of stable PD for at least 12 months.

238 patients affected by PD were treated with ESWT since January 2000. We selected those patients (65 cases) who were having a stable disease for at least 12 months, previously treated unsuccessfully with different therapy (pharmacological, ionophoresis or infiltrations), and with an adequate follow-up. The parameters considered were the size modification of the lesion, the reduction of the penile deviation and the overall satisfaction for reaching an adequate sexual activity after the ESWT treatment. All patients received a 3000 shock waves treatment in 4 occasions during 2 weeks according to the institutional protocol.

All the study patients reported to have an inadequate sexual function before the ESWT treatment. The mean age was 57 years, the penile deviation varied between 30° and 90° and the average follow-up was 18 months. In 43 cases (66%) the ultrasounds revealed a significant reduction of the penile deviation and 39 patients (60%) reported to have reached an adequate sexual activity after the ESWT treatment.

ESWT represents a valid option in the treatment of PD considering that the patients’ main goal is to regain a satisfactory sexual activity. Therefore this non-invasive treatment should be included in the therapeutic guidelines of PD together with other non-surgical treatments.

Extracorporeal Shockwave Therapy for Peyronie's Disease: Who Benefits?

BACKGROUND AND PURPOSE

Extracorporeal shockwave therapy (ESWT) has been reported to improve the symptoms of Peyronie's disease. However, the response rates to this treatment appear to be variable. This study aimed to determine whether any patient or plaque characteristics are associated with a better outcome.

PATIENTS AND METHODS

A series of 36 patients with Peyronie's disease received ESWT as a primary treatment. Subjective response rates were compared on the basis of patient age, degree of pretreatment penile curvature, predisposing medical factors, duration of disease, and extent of plaque calcification.

RESULTS

Ten men (27.8%) reported subjective improvements in curvature after ESWT. Of the factors considered, only age and pretreatment curvature influenced outcomes: 50% of the men below the mean age reported improvement compared with 5.6% of older men and 62.5% of men with mild curvature reported improvement compared with 8.3% of those with severe curvature.

CONCLUSION

The response to EWST is not the same for all men with Peyronie's disease. Younger men and those with milder curvature have the best outcomes.

The dorsal lamina of the rectus sheath: a suitable grafting material for the penile tunica albuginea in Peyronie's disease?

OBJECTIVE

To estimate the morphological suitability of human connective tissue structures from different regions as graft material in Peyronie's disease, and to present preliminary results from 12 patients with grafting of corporal bodies using autologous rectus sheath.

PATIENTS AND METHODS

In five male cadavers the penile tunica albuginea was compared with the dorsal lamina of the rectus sheath, the palmar aponeurosis, the iliotibial tract and the Achilles tendon by using histological sections stained with haematoxylin and eosin, Crossmon's trichrome stain and resorcin-fuchsin. Surgical results and complication rates were investigated in 12 patients with Peyronie's disease after grafting the corporal bodies with autologous rectus sheath to correct their penile curvature.

RESULTS

On histology, the penile tunica albuginea showed a three-dimensional meshwork of collagenous and elastic fibres. The dorsal lamina of the rectus sheath had a remarkably similar fibre structure. The other tissues had a different histology, with long collagenous fibres in parallel orientation and elastic fibres restricted to the loose connective tissue around blood vessels and nerves. Clinically, the penile deviation was successfully corrected in 10 patients; there were two residual deviations (15 degrees and 35 degrees ). There were minor complications after surgery in six patients, not requiring surgery.

CONCLUSIONS

The dorsal lamina of the rectus sheath has similar morphological characteristics to the tunica albuginea, and therefore represents an ideal autologous graft; the first clinical results are promising.

DOES SMOKING CHANGE THE EFFICACY OF COMBINATION THERAPY WITH VITAMIN E AND COLCHICINES IN PATIENTS WITH EARLY-STAGE PEYRONIE'S DISEASE?

This study was conducted to find out if smoking has an effect on the results of combination therapy with vitamin E and colchicines in patients with early-stage Peyronie's disease (PD). A total of 58 potent patients suffering from early-stage PD were included in the study (mean age 47.3 years, range 25-73 y). The time from onset of the disease was <6 months and no patient had ED. The patients with severe fibrotic or calcified plaques were not included in the study. Of the patients, 36 were smokers (Group 1) and 22 were non-smokers (Group 2). All the patients received vitamin E (800 IU daily) and colchicines (1 mg daily) for 6 months. Follow-up ranged from 5 to 13 months (mean 10.3 m). The combination therapy was effective and well tolerated in both groups. There were no significant differences between the two groups according to age, disease duration, related disease (diabetes, hypertension, hypercholesterolemia, and hypertriglyceridemia), plaque sizes, and plaque numbers. The resolution in pain and increase in penile curvature and plaque size were similar rates in both groups (p > 0.05), while decrease in penile curvature and plaque size were higher in Group 2 (p < 0.05). No patient discounted the therapy due to side effects. The oral combination therapy with vitamin E and colchicines appears to be an effective procedure in patients with early-stage PD and smoking may have worsening effects on the treatment results.