Erectile dysfunction after plaque incision and grafting: short-term assessment of incidence and predictors

Research advances in Peyronie's disease: a comprehensive review on genomics, pathways, phenotypic manifestation, and therapeutic targets

INTRODUCTION

Penile induration disease, commonly known as Peyronie's disease (PD), is a connective tissue disorder that affects the penis, leading to the development of fibrous plaques, penile curvature, and erectile dysfunction. PD is a common male reproductive system disease with a complex etiology involving multiple genes, signaling pathways, and different phenotypes.

OBJECTIVES

The etiology and pathogenesis of PD remain poorly understood, hindering the development of effective treatment strategies. By understanding the underlying mechanisms of PD, we can pave the way for targeted therapies and improved patient outcomes.

METHODS

We reviewed the epidemiology and pathophysiology of PD. We performed database searches on Google Scholar, PubMed, Medline, and Web of Science from inception to September 2023. The literature reviewed included priapism guidelines, review articles, current trial studies, and various literature related to PD.

RESULTS

This article provides a comprehensive overview of the current research progress on the disease, focusing on its genetic factors, signaling pathways, cellular mechanisms, phenotypic manifestations, and therapeutic targets. It can help identify individuals at higher risk, aid in early detection and intervention, and provide insights into fibrosis and tissue remodeling. It can also reveal potential therapeutic targets, guide accurate diagnoses and treatment strategies, and address the impact of the disease on patients' quality of life.

CONCLUSION

By integrating insights from genomics, molecular pathways, clinical phenotypes, and therapeutic potentials, our research aims to achieve a deeper and more comprehensive understanding of PD, propelling the field toward innovative strategies that enhance the lives of those affected by PD. The complex manifestations and pathogenesis of PD necessitate the use of multiple treatment methods for personalized care.

Grafts in Peyronie's surgery without the use of prostheses: a systematic review and meta-analysis

ABSTRACT

Peyronie's disease (PD) is characterized by abnormal penile curvature, and various surgical methods have been developed using different graft materials. However, there is currently no universal agreement on which type of graft is the best. The objective of this review was to evaluate the available literature and identify the most effective graft material for penile curvature correction in PD. A literature search was conducted using electronic databases, including PubMed, Scopus, and the Cochrane Library. The patients, intervention, comparison, and outcome (PICO) approach was used to define the eligibility of studies. Two authors independently selected studies, evaluated them, and extracted data. Random-effect models using the DerSimonian-Laird method were used. Most studies were single-arm studies and had a high risk of bias. Buccal mucosa grafts (BMG) were found to result in the highest penile straightening rates and were associated with the least de novo erectile dysfunction. TachoSil grafts demonstrated a high success rate in straightening despite a higher mean preoperative curvature, while Tutoplast grafts had a higher incidence of postoperative erectile dysfunction. BMG had the highest percentage of postoperative penile straightening. Overall, the TachoSil graft showed the best performance when preoperative curvature is taken into account. Based on the available literature, BMG appear to be the most effective for penile curvature correction in PD, but this is offset by the requirement for low preoperative curvature. The TachoSil graft shows the best overall performance when preoperative curvature is considered. Comparative randomized clinical trials are still needed to determine graft superiority.

Insurance approval rates for collagenase clostridium histolyticum prior to discontinuation: a Canada-wide analysis

Collagenase Clostridium histolyticum (CCh), the first approved non-surgical treatment for Peyronie's disease (PD), was withdrawn from the European, Canadian, and Asian markets due to poor demand and lack of government reimbursement options. We sought to assess insurance approval rates and usage of CCh across Canada to understand the factors that led to its withdrawal. Data on patients prescribed CCh for PD or Dupuytren's contracture was obtained through collaboration with BioScript Solutions to assess the association of variables with insurance approval and prescription filling. We identified 3297 insurance coverage applications for Xiaflex® from April 2018 to June 2020. Of all applications for PD, 92.9% applications were approved while 7.1% were rejected. Despite the withdrawal of CCh from Canadian markets, coverage application approval rates for 2018, 2019, and 2020 were 86.5%, 90.1%, and 89.1%, respectively. Of 2921 approved applications, 88.8% prescriptions were filled. For the 376 rejected applications, 66.4% of prescriptions were filled. Overall, 90% of the cost of Xiaflex® was covered in Canada among those with extended health benefits, with an out-of-pocket expense of $210.4. Insurance coverage requests for Xiaflex® were approved at a high rate in Canada with approved patients being very likely to proceed with therapy, despite interprovincial variation.

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.

ESSM Position Statement on Surgical Treatment of Peyronie's Disease

INTRODUCTION

Patients with Peyronie's disease may experience significat distress. The choice of treatment depends on a variety of factors, including the stage of the disease, the presence of pain, severity and direction of the curvature, penile length and the quality of erectile function.

AIM

To review the evidence associated with surgical treatment of Peyronie`s Disease and provide clinical recommendations on behalf of the European Society for Sexual Medicine. 131 peer-reviewed studies and systematic reviews, which were published from 2009 to 2019 in the English language, were included.

METHODS

MEDLINE, Google Scholar and EMBASE were searched for randomized clinical trials, meta-analyses, open-label prospective and retrospective studies.

MAIN OUTCOME MEASURE

The panel provided statements on clinically relevant questions including patient involvement in the decision process, indications for surgery, choice of the approach, and the management of patient expectations. A comparison of the different grafts used in patients who have undergone plaque incision/excision and grafting in order to identify an ideal graft, has been carried out. The prevalence of postoperative complications has been summarized. Levels of evidence were provided according to the Oxford 2011 criteria and Oxford Centre for Evidence-Based Medicine recommendations.

RESULTS

In order to allow shared decision making, a patient preoperative counselling regarding the pros and cons of each intervention is recommended. In particular, adverse effects of surgical treatments should be discussed to set realistic understanding and expectations of surgical outcomes and ultimately improve postoperative satisfaction rates. Surgical treatment should be only offered in the chronic phase of the condition, when the deformity and/or degree of erectile dysfunction, prevent patients from engaging in satisfying sexual interaction, or if the deformity is the cause of severe bother.

CONCLUSIONS

Current European Society for Sexual Medicine recommendations cover several aspects of Peyronie's disease treatment. These recommendations aim both to ensure patients and partners have accurate and realistic expectations of their treatment options, as well as to formulate algorithms to guide clinician management pathways. Osmonov D. et al., ESSM Position Statement on Surgical Treatment of Peyronie's Disease. Sex Med 2022;10:100459.

[French Urological Association (AFU) guidelines for Peyronie's disease assessment and treatment]

INTRODUCTION

Peyronie's disease is a common cause for consultation in urology. Many controversies surround its treatment. No French Guidelines have been published so far. The Committee of Andrology and Sexual Medicine of the French Association of Urology therefore offers a series of evidence-based recommendations.

MATERIALS AND METHODS

These recommendations are made according to the ADAPTE method, based on European (EAU, ESSM), American (AUA, ISSM) and Canadian (CAU) recommendations, integrating French specificities due to the availability of treatments, and an update of the recent bibliography.

RESULTS

The assessment of the disease is clinical. Patients with functional impairment or significant psychological repercussions may be offered treatment. The benefits and drawbacks of each treatment should be explained to the patient. Regarding non-surgical treatments, no available treatment has market authorization in France. Vitamin E is not recommended. Analgesic (oral or low-intensity shock waves) or proerectile treatments may be offered as needed, as well as traction therapy. Due to the unavailability of collagenase injections, verapamil injections may be offered. Surgical treatments are to be considered in the stabilized phase of the disease, and consist of performing a plication, an incision-graft or the placement of a penile implant according to the patient's wishes, the curvature and the penis size, as well as erectile function. Combination treatments can be offered.

CONCLUSION

The management of Peyronie's disease is complex, and the levels of evidence for treatments are generally low. The success of treatment will depend on the quality of the initial assessment, the patient's information and understanding of the expected effects, and the practitioner's experience.

Buccal mucosa graft in surgical management of Peyronie's disease: Ultrasound features and clinical outcomes

INTRODUCTION

Plaque incision and grafting represent the best surgical approach to the Peyronie's Disease (PD). The grafting procedures must be restricted to patients with normal preoperative status, excessive curvature and/or deformities. However, the ideal graft has not been identified yet. Buccal mucosa grafts (BMG) provided excellent short-term results, ensuring the fast return of spontaneous erections and preventing shrinkage, which is the main cause of graft failure. Another fearsome surgical complication is de novo erectile dysfunction (ED). We report our results with BMG focusing on the analysis of ultrasonographic and clinical data demonstrating buccal mucosa as determinant factor that allow to avoid complications.

MATERIALS AND METHODS

From 2013 to 2019 we performed at our Urology Unit 27 corporoplasties with BMG to correct complex penile curvature due to PD. Clinical, post-surgical and ultrasound follow up data were evaluated. All patients were no responders to medical treatment or previous surgical procedures. The evaluation period was 72 months. Data regarding pre-operative work-up, including IIEF (IIEF-5) questionnaire administration, detailed clinical history and penile dynamic ultrasound (PGE1-induced erection) were collected. The time of spontaneous erection resumption was recorded for each patient. To improve blood supply to the graft, a low-dose PDE5-i was prescribed for all patients for a period of two months, starting immediately after discharge. Check-ups were scheduled every 3 months, starting from 1 month after surgery. In each visit, patients underwent a penile ultrasound evaluation of graft features. After 6 and 12 months, all patients underwent a penile dynamic ultrasound for Erection Hardness Score determination, then standard ultrasound and clinical evaluation yearly. Our analyses were focused on BMG as a major determinant of the surgical success.

RESULTS

Mean age of 27 patients was 57 years (42-71) with a maximum follow up time of 72 months and minimum of 3. Site of penile curvature was dorsal in 18 (67%) patients, ventral in 2 (7%), complex in 7 (26%). The degree of the curvature was < 60° in 11 (41%) patients, > 60° in 16 (59%). Straightening of penis was reached in 100% of cases. Penile shortening resulted in 7.4% (2/27). De novo ED appeared in 2/27 cases with a post-operative rate of PDE5i users increasing from 12 to 14 patients (45% vs 52%). Ultrasound aspects of BMG, recorded at every follow up visit, results in a hypoechoic plaque with an iperechoic rim that become isoechoic over the time in all cases. No case of scars or seroma was registered. Small intra-graft cystic lesions were highlighted in 3 cases (11%).

CONCLUSIONS

BMG may represent a good choice in grafts procedures for PD surgical management. The functional results obtained by BMG procedures were related to the good anatomical characteristics of the patch and were highlighted in our series by use of penile ultrasound, during the follow up period.

Management of residual penile curvature after penile prosthesis placement

Residual penile curvature is a common situation following the implantation of a penile prosthesis in patients with Peyronie's disease. Currently, there is a variety of options for the correction of residual curvature, including penile modeling, plication techniques, as well as tunical incision/excision with or without grafting. A literature search of PubMed and Medline databases was conducted from 1964 until 2020, using search terms for all articles in the English language. In this article, we provide a review of the techniques and the outcomes, according to the published literature.

Modern treatment strategies for penile prosthetics in Peyronie's disease: a contemporary clinical review

Peyronie's disease is a common condition resulting in penile deformity, psychological bother, and sexual dysfunction. Erectile dysfunction is one common comorbid condition seen in men with Peyronie's disease, and its presence significantly impacts treatment considerations. In a man with Peyronie's disease and significant erectile dysfunction who desires the most reliable treatment, penile prosthesis placement should be strongly considered. In some instances, such as those patients with relatively mild curvature, prosthesis placement alone may result in adequate straightening. However, many patients will require additional straightening maneuvers such as manual modeling, penile plication, and tunica albuginea incision with or without grafting. For patients with severe penile shortening, penile length restoration techniques may also be considered. Herein, we provide a comprehensive clinical review of penile prosthesis placement in men with Peyronie's disease. Specifically, we discuss preoperative indications, intraoperative considerations, adjunctive straightening maneuvers, and postoperative outcomes.

Peyronie's disease: new paradigm for the treatment of a unique cause of erectile dysfunction

Peyronie's Disease is an incurable condition of the tunica albuginea of the penis associated with scarring, plaque formation, and penile deformity on erection. It is often associated with erectile dysfunction. Recent data have supported a familial and genetic predisposition to this chronic condition. The etiology of Peyronie's Disease is unknown, but is likely associated with multiple micro traumas to the erect penis in men who are susceptible to the scarring typical of Peyronie's Disease. The treatment of Peyronie's Disease has improved over the past decade as a result of animal studies and the approval of new medications. In the acute phase of the condition, phosphodiesterase type 5 inhibitors have been shown to have some benefit and are supported by animal studies demonstrating reduced fibrosis of the penis in animal models of Peyronie's Disease. In the stable phase of the disease, newer injectable agents have shown great promise. Collagenase clostridium histolyticum is approved for the treatment of Peyronie's plaques by direct injection into the scarred tissue with data showing satisfactory safety and efficacy. Surgical procedures for penile straightening have been refined with improved outcomes in the past decade. For those men with erectile dysfunction and Peyronie's Disease, penile implants can restore erectile function and form. As a result of the new understanding of the risk factors for Peyronie's Disease and recent advances in treatment options, the algorithm for the treatment of Peyronie's Disease has improved outcomes for patients and their partners.

[Reconstructive possibilities for Peyronie's disease]

The surgical treatment of Peyronie's disease involves a multistage procedure with increasing invasiveness. In addition to precise knowledge about the existing surgical treatment procedures, the indication and the informed consent process of the patient is extremely important. The dissatisfaction with the surgical results for many patients is due to false expectations and positivistic representations. If we can avoid this and make the right decisions during surgery, even these difficult-to-treat patients can be treated successfully.

Peyronie's disease: Contemporary evaluation and management

Peyronie's disease is a common yet poorly understood condition characterized by penile pain, curvature, sexual dysfunction and psychological bother. Peyronie's disease represents a penile wound healing disorder, and is thought to arise from exuberant scarring in response to penile trauma in genetically predisposed men. In the absence of active treatment, the majority of men experience stable or worsening symptoms, with few reporting spontaneous resolution in penile curvature or other deformity. In contrast, penile pain improves or resolves in the majority of men. Treatment options vary based on symptom severity and stability. Several oral therapies are commonly prescribed, although to date there are no strong data to support any oral agents as monotherapy for Peyronie's disease. Other options including penile traction therapy and intralesional injections result in modest improvements for many patients, particularly when used early after symptom onset. Penile straightening through approaches, such as penile plication and plaque incision or partial excision and grafting, represent the most rapid and reliable approach to correct penile curvature once the symptoms have stabilized. Side-effects vary based on the type of surgery carried out, and include penile shortening, sensation changes and erectile dysfunction in the minority of men. In patients with drug refractory erectile dysfunction and Peyronie's disease, placement of a penile prosthesis will address both issues, and is associated with high levels of patient satisfaction. The current review provides a practical approach to the modern evaluation and management of patients presenting with Peyronie's disease.

Strategies and current practices for penile lengthening in severe Peyronie's disease cases: a systematic review

Several strategies to optimize penile length in the presence of Peyronie's Disease (PD) have been described so far. In case of severe curvature and preserved erectile function, plaque incision/excision (PIG/PEG) are advisable in order to maximize penile length, despite the risk of postoperative erectile dysfunction (ED), recurrent curvature, or penile shortening. For men with PD deformities associated to a certain degree of ED several lengthening techniques associated to penile prosthesis (PPI) implantation can be considered. Because of the potential postoperative complications, the indication must be balanced between patient's risk factors and surgeon's experience. Furthermore, adjuvant surgeries, such as prepubic V-Y plasty, suspensory ligament release, suprapubic lipectomy, and ventral phalloplasty, can be performed simultaneously or in a staged fashion to maximize the outcomes. Restoration a decent penile length in the case of a severe PD represents a real challenge for reconstructive surgeons. We present a systematic review of the literature on the current practices for penile lengthening in severe PD, providing the reader with a practical overview on the existing surgical strategies and their surgical and functional outcomes.

Twenty Years of Plaque Incision and Grafting for Peyronie's Disease: A Review of Literature

Introduction

Plaque incision and grafting (PIG) is indicated for men with complex or severe penile curvature and, despite a multitude of incision types and grafting materials having been used, no individual technique has proven superiority.

Aim

To assess outcomes following PIG and to understand the operative technique.

Methods

A systematic review was performed to find all relevant studies reporting on use of the PIG technique to correct curvature resulting from Peyronie’s disease. Studies were included if they had >40 participants, were written in the English language, and no penile prosthesis was implanted.

Main Outcome Measures

Primary outcome measures included deformity correction, erectile dysfunction, and degree of penile lengthening/shortening. Secondary outcome measures included satisfaction, reoperation rate, and complications.

Results

Twelve studies were included in the quantitative synthesis, which overall report on the results of 1,025 patients. Careful patient selection was critical, with erectile function requiring assessment with the International Index of Erectile Function (IIEF), subjective patient reports, and consideration of whether erections are pharmacologically aided. There was no evidence of superiority in favor of any particular incision type or grafting material, and absorbable sutures were clearly favored. Postoperatively, 4.6%–67.4% required pharmacologically aided erections and 0–11.8% were completely unable to achieve erections. Successful straightening occurred in 80.0%–96.4%, although there was no consistent definition of success. Penile length was unchanged in 44.2%–95.0%; 88.0%–92.0% of the patients were satisfied, and .7%–4.7% required reoperation. Altered sensation occurred in 2.0%–22.5% of patients, of which 80.0%–100.0% was only a transient loss. All outcomes were heterogeneously reported. There are no clear predictive factors for erectile dysfunction following PIG surgery. No single incision type or grafting material has proven superiority.

Conclusion

PIG is an effective and safe technique for correction of complex or severe penile curvature in terms of satisfaction, length change, straightening, and complications.

Rice PG, Somani BK, Rees RW. Twenty Years of Plaque Incision and Grafting for Peyronie’s Disease: A Review of Literature. Sex Med 2019;7:115–128.

Penile Sensory Changes After Plaque Incision and Grafting Surgery for Peyronie's Disease

INTRODUCTION

Plaque incision and grafting (PIG) for Peyronie's disease (PD) is not devoid of complications such as erectile dysfunction and penile sensory changes.

AIM

To define the rate and chronology of penile sensation loss after PIG surgery and to define predictors of such.

METHODS

The study population consisted of patients with PD-associated penile curvature who underwent PIG surgery with at least 6 months of follow-up. Demographics and PD factors were recorded. Patient had preoperative assessment of penile sensation and deformity. Postoperative follow-up occurred at 1 week, 1 month, 6 months, and 1 year after surgery. Neurovascular bundle elevation was conducted with loupe magnification.

MAIN OUTCOME MEASURE

Penile sensation was evaluated with a biothesiometer and graded on a patient-reported visual analog scale (0-10) in which 0 defined a completely numb area and 10 defined perfect sensation. The degree of sensation loss was defined as extensive (any 1 area >5 cm), major (2-5 cm), and minor (≤2 cm). The penile sensation loss distribution was defined as focal (1 site) or diffuse (>1 site).

RESULTS

63 patients were analyzed. Mean age was 56 ± 10 years. Mean duration of PD at the time of PIG was 15 ± 7 (12-38) months. 75% had curvature alone, and 25% had hourglass/indentation deformities. Mean primary curvature was 64˚ ± 28˚. The mean operation duration was 3.5 ± 1.8 hours. 21% had some degree of sensation loss at 1 week, 21% at 1 month, 8% at 6 months, and 3% at 12 months. Only 1 patient (1.5%) at 2 years continued to have extensive sensation loss on the glans and distal shaft with a very elevated sensitivity threshold. Using multivariable analysis, the only predictor of penile sensation loss ≥6 months was a duration of operation >4 hours (odds ratio = 2.1; 95% confidence interval = 1.2-3.0; P < .01).

CLINICAL IMPLICATIONS

The study highlights the need during patient consent to discuss penile sensation loss. Patients should be informed that rates of penile sensation loss ranges from 2-30% and most patients will have complete resolution of any sensation loss within one year of follow-up.

STRENGTH AND LIMITATIONS

To our knowledge no other studies have described the chronology and severity of penile sensation following PIG, our study demonstrates the utility of biothesiometry in measuring penile sensation before and after PIG. Number of patients and absence of control group represent a limitation.

CONCLUSION

Sensation loss is not uncommon after PIG surgery. It decreases in frequency and severity with time with only rare cases occurring >12 months. Longer operations appeared to be more likely associated with sensation loss. Terrier JE, Tal R, Nelson CJ. Penile sensory changes after plaque incision and grafting surgery for Peyronie's disease. J Sex Med 2018;15:1491-1497.

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.

Penile Reconstructive Surgery in Peyronie Disease: Challenges in Restoring Normal Penis Size, Shape, and Function

To provide an overview of current approaches to penile reconstructive surgery in Peyronie disease (PD), and to discuss the challenges in restoring normal penile size and function. A systematic literature search was conducted to identify the published literature relevant to PD and penile reconstructive surgery. A summary of the published guidelines from major organisations is included in this review paper. Penile plication is simple and minimally invasive, and tends to preserve potency in most patients. However, plication invariably results in penile length loss and may, in fact, worsen the existing hour-glass or hinge effect. In contrast, graft reconstructive surgery can address issues relating to the loss of penile length and complex penile deformities, but long-term data highlight the risks of altered glans sensation, recurrent curvature, and/or loss of penile length from graft contracture, as well as the development of erectile dysfunction. Complex penile reconstruction with the concurrent placement of a penile prosthesis and/or graft material is a demanding operation that should be performed by surgeons with extensive prosthetic and reconstructive experience, as the risk of sensory loss, glans ischemia/necrosis, prosthesis-related complications, and failure to gain any meaningful length are serious concerns and cannot be underestimated. While surgical approaches remain the standard of care, they pose considerable risks and require prolonged postoperative rehabilitation. Obtaining proper informed consent and establishing realistic outcome expectations are imperative for successful postoperative outcomes.

Surgical patient selection and counseling

The objectives of patient selection and counseling are ultimately to enhance successful outcomes. However, the definition for success is often narrowly defined in published literature (ability to complete surgery, complications, satisfaction) and fails to account for patient desires and expectations, temporal changes, natural history of underlying diseases, or independent validation. Factors associated with satisfaction and dissatisfaction are often surgery-specific, although correlation with pre-operative expectations, revisions, and complications are common with most procedures. The process of appropriate patient selection is determined by the integration of patient and surgeon factors, including psychological capacity to handle unsatisfactory results, baseline expectations, complexity of case, and surgeon volume and experience. Using this model, a high-risk scenario includes one in which a low-volume surgeon performs a complex case in a patient with limited psychological capacity and high expectations. In contrast, a high-volume surgeon performing a routine case in a male with low expectations and abundant psychiatric reserve is more likely to achieve a successful outcome. To further help identify patients who are at high risk for dissatisfaction, a previously published mnemonic is recommended: CURSED Patient (compulsive/obsessive, unrealistic, revision, surgeon shopping, entitled, denial, and psychiatric). Appropriate patient counseling includes setting appropriate expectations, reviewing the potential and anticipated risks of surgery, post-operative instruction to limit complications, and long-term follow-up. As thorough counseling is often a time-consuming endeavor, busy practices may elect to utilize various resources including educational materials, advanced practice providers, or group visits, among others. The consequences for poor patient selection and counseling may range from poor surgical outcomes and patient dissatisfaction to lawsuits, loss of credibility, or even significant patient or personal harm.

Lengthening strategies for Peyronie's disease

Loss of penile length is a common complaint of men with Peyronie's disease (PD), both before and after corrective intervention, which has a significant negative effect on patient quality of life. We sought to identify and describe the methods by which penile length can be preserved or increased. We conducted an extensive, systematic literature review, based on a search of the PUBMED database for articles published between 1990 and 2015. Articles with the key words "Peyronie's disease", "penile length" and/or "penile lengthening" were reviewed if they contained subjective or objective penile length outcomes. Only English-language articles that were related to PD and penile size were included. We found no evidence in the literature that medical therapy alone increases penile length. Classic inflatable penile prosthesis (IPP) placement, plication procedures, and the Nesbit procedure appear likely to maintain or decrease penile length. Plaque incision (PI) and grafting appears likely to maintain or increase penile length, but is complicated by risk of post-operative erectile dysfunction (ED). There are several surgical procedures performed concomitantly with IPP placement that may be suitable treatment options for men with comorbid ED, and consistently increase penile length with otherwise good outcomes concerning sexual function. These include the subcoronal penile prosthesis (scIPP), Egydio circumferential technique, the sliding technique, the modified sliding technique (MoST), and the multiple slice technique (MuST). In addition, adjuvant therapies such as penile traction therapy (PTT), post-operative inflation protocols, suspensory ligament relaxation, lipectomy, and adjuvant medical therapy for glans engorgement appear to increase subjective and/or objective penile length for men at high risk of decreased penile length after PD surgery. Considering the psychological burden of length loss in men with PD, providers with adequate volume and expertise should attempt, if possible, to maintain or increase penile length for men undergoing surgical intervention. There are several evidence-based, safe, and effective ways to increase penile length for these men and multiple emerging adjuvant therapies that may help ensure adequate length.

Use of autologous grafts in the treatment of acquired penile curvature: An experience of 33 cases

AIM

The objective was to compare the use of autologous dermal and temporalis fascia grafts in the treatment of acquired penile curvatures.

MATERIALS AND METHODS

It was a prospective observational study of 33 cases, conducted in Sher-i-Kashmir Institute of Medical Sciences, Srinagar from March 2007 to September 2013. All the patients had stable Peyronies disease (PD). Dorsal, dorsolateral and vental curvatures with good preoperative erections were included. PD index with visual analog scales for curvature was used preoperatively. An informed written consent was taken from all the patients with main emphasis on erectile dysfunction.

RESULTS

After an average follow up of 2 years, complete straightening of penis was observed in all patients with satisfactory sexual intercourse in 30 patients (90%). Three patients (10%) required frequent use of type 5 phosphodiesterase inhibitors for adequate erections. Overall 91% of patients and partners were satisfied with the procedure and cosmetically donor site was better in temporalis fascia graft site. No rejection of any graft was noted and glans hypoesthesia was noticed in 4 patients (12%). None of the patients required penile prosthesis. Total operative time for harvesting and application of the graft was more in dermal grafts (>3 hrs) than for temporalis fascia graft (2 hrs).

CONCLUSION

Tunical lengthening procedures by autologous free grafts represents a safe and reproducible technique. A good preoperative erectile function is required for tunical lengthening procedure. Temporalis fascia graft is thin, tough membrane and effective graft for PD with good cosmetic and functional results.

[Operative therapy of Pyronie's disease]

The operative therapy of Pyronie's disease (penile induration) follows a staged scheme. If the deviation is > 45° a complex operative treatment in the sense of plaque incision and excision with subsequent defect coverage is necessary. This operation should be carried out under optical magnification to safeguard the vessel-nerve bundle. Defect coverage can currently be carried out using a collagen fleece with excellent outcome but alternative patches are also still available. The focus in patient management is on a realistic preoperative estimation of the situation in order to avoid any unrealistic preconceptions and expectations by the patient.

Practical Computerized Solution for Incision and Grafting in Peyronie's Disease

Introduction

Penile curvature correction with plaque incision and graft (PIG) increases the risk of erectile dysfunction (ED) and is associated with mechanical and geometric abnormalities.

Aims

The aim of this study was to create and validate a new PIG technique using minimum graft area to correct simple or complex penile curvature with or without hourglass deformity, while avoiding mechanical and geometric abnormalities.

Methods

Using our cotton fabric model, we created a mathematic solution for PIG with no residual defects. This was applied in nine men who had sufficient penile rigidity while penetrating their respective partners. They underwent fascia lata patch corporoplasty using the new developed technique (iPad [Apple Corp, Palo Alto, CA, USA] app: iGrafter). Subjects answered the 5-item version of the International Index of Erectile Function (IIEF-5) questionnaire preoperatively and at the end of follow-up.

Main Outcome Measures

The main outcome measures used were patient demographics, erectile function, residual curvature, patient satisfaction, graft area, and complications.

Results

After a mean follow-up of 17.8 months, no significant complication was noted. Complete penile straightening was achieved in all patients. The short side of the penis increased a mean of 3 cm in length, and the mean graft area was 12.4 cm². At the end of the follow-up, three patients developed recurrent deformity. One patient presented severe fibrosis in the corpora cavernosa and severe ED. There was no significant difference between the mean preoperative and postoperative IIEF-5 scores (20.6 vs 19.4, respectively). At the end of follow-up, all patients were able to have sexual intercourse (two with and seven without pharmacological aid). Eight of the nine patients were satisfied with the surgical result.

Conclusion

Penile curvature surgical correction using the iGrafter seems to be an efficient and safe procedure, which uses minimum graft area and preserves erectile function after penile rectification, without resulting in residual deformities. Further research is needed to confirm the efficacy of this procedure.

Therapeutic advances in the treatment of Peyronie's disease

Peyronie's disease (PD) is an under-diagnosed condition with prevalence in the male population as high as 9%. It is a localized connective tissue disorder of the penis characterized by scarring of the tunica albuginea. Its pathophysiology, however, remains incompletely elucidated. For the management of the acute phase of PD, there are currently numerous available oral drugs, but the scientific evidence for their use is weak. In terms of intralesional injections, collagenase clostridium histolyticum is currently the only Food and Drug Administration-approved drug for the management of patients with PD and a palpable plaque with dorsal or dorsolateral curvature >30°. Other available intralesional injectable drugs include verapamil and interferon-alpha-2B, however, their use is considered off-label. Iontophoresis, shockwave therapy, and radiation therapy have also been described with unconvincing results, and as such, their use is currently not recommended. Traction therapy, as part of a multimodal approach, is an underused additional tool for the prevention of PD-associated loss of penile length, but its efficacy is dependent on patient compliance. Surgical therapy remains the gold standard for patients in the chronic phase of the disease. In patients with adequate erectile function, tunical plication and/or incision/partial excision and grafting can be offered, depending on degree of curvature and/or presence of destabilizing deformity. In patients with erectile dysfunction non-responsive to oral therapy, insertion of an inflatable penile prosthesis with or without straightening procedures should be offered.

Surgical management of Peyronie's disease

Peyronie's disease (PD) has a significant impact on the quality of life of both patients and their partners due to the compromised sexual function and physical deformation resulting from the condition. PD is a connective tissue disorder marked by fibrotic healing of the tunica albuginea, leading to penile deformities including curvature, shortening, loss of girth, hourglass appearance, and hinging. Despite the multiple medical therapies available, surgery is the gold standard of treatment once the plaque has stabilized. We present a review of the disease process, preoperative evaluation, operative planning, surgical treatments with outcomes and complications, and nascent developments in surgical management and graft development. Options include tunical lengthening procedures, tunical shortening procedures, and penile prosthesis. Decision-making is governed by degree of curvature, erectile function, and associated penile deformities. In cases with curvature of less than 60-70 degrees, adequate penile length, and no hourglass deformity, patients are candidates for tunical shortening procedures. Patients with curvature greater than 60-70 degrees, penile hourglass or hinge-destabilizing deformities, and adequate erectile function should be counseled with regard to tunical lengthening procedures. Patients with poor preoperative erectile function should undergo inflatable penile prosthesis placement, with possible secondary straightening procedures. Technique selection should be based upon surgeon preference, expertise, and experience, as evidence does not necessarily support one procedure over another.

A critical analysis of the surgical outcomes for the treatment of Peyronie's disease

Peyronie’s disease (PD) is a relatively common condition, which can impair sexual function and result in emotional and psychological distress. Despite an abundance of minimally invasive treatments, few have confirmed efficacy for improving penile curvature and function. Surgical therapies include many different techniques and are reserved for patients with stable disease of ⩾12 months’ duration. We searched PubMed for all articles from 1990 to the present relating to the surgical management of PD. Preference was given to recent articles, larger series, and those comparing various techniques and/or materials. Outcomes were subsequently analysed and organised by surgical technique and the graft material used. Available surgical techniques include plication/corporoplasty procedures, incision and grafting (I&G), and placing a penile prosthesis with or without adjunctive procedures. Although several surgical algorithms have been reported, in general, plication/corporoplasty procedures are reserved for patients with adequate erectile function, simple curvatures of <60°, and with no deformities (hour-glass, hinge). I&G are reserved for complex curvatures of >60° and those with deformities. Penile prostheses are indicated for combined erectile dysfunction and PD. Overall outcomes show high rates of improved curvature and patient satisfaction, with mildly decreased erectile function with both plication and the I&G procedure (I&G >plication) and decreases in penile length (plication >I&G). Surgical management of PD remains an excellent treatment option for patients with penile curvature precluding or impairing sexual activity. Surgical algorithms are available to assist treating clinicians in appropriately stratifying surgical candidates. Additional research is needed to identify optimal surgical techniques and materials based on patient and disease characteristics.

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.

Penile length and girth restoration in severe Peyronie's disease using circular and longitudinal grafting

OBJECTIVE

To report patient outcomes and satisfaction with our technique for penile length and girth restoration in severe Peyronie's disease (PD).

PATIENTS AND METHODS

Between November 2006 and November 2011, 105 men with severe PD and erectile dysfunction (ED) underwent surgical correction using our new approach. The technique consists of penile prosthesis implantation with concomitant penile lengthening and girth restoration through circular and longitudinal incisions in the tunica albuginea according to geometric principles.

RESULTS

The overall patient satisfaction rate was 89.4%. The mean (sd; range) functional penile length gain was 3.6 (0.7; 2-5) cm. Patient satisfaction with penile length gain was 95.2%. Three patients (2.9%) developed retraction with residual curvature of up to 30°, but no re-operation was necessary. In one (1%) patient, the prosthesis had to be removed because of wound infection. At a mean (sd; range) follow-up of 18.2 (5.9; 6-46) months, 104 patients (99%) were able to have sexual intercourse.

CONCLUSIONS

Our surgical approach for penile length and girth restoration leads to high patient satisfaction rates and excellent functional outcomes. Our surgical approach is a safe and valid therapeutic method for the treatment of severe PD associated with ED.

A new, innovative, lengthening surgical procedure for Peyronie's disease by penile prosthesis implantation with double dorsal-ventral patch graft: the "sliding technique"

INTRODUCTION

Peyronie's disease is the result of the formation of fibrous plaques in the tunica albuginea of the penis; typical presentations of the disease are represented by pain during erection, erectile dysfunction, and penile deformities, such as curvature, narrowing, and penile shortening. The most complex treatment is related to penile shortening.

AIM

To find a safe procedure in penile shortening due to Peyronie's disease providing a satisfactory lengthening, allowing an early stabilization of the penis, and preventing axial tension on the neurovascular bundles during dilation.

METHODS

We describe a new lengthening surgical procedure based on a ventro-dorsal incision of the tunica albuginea, penile prosthesis implantation, and double dorsal-ventral patch grafting with porcine small intestinal submucosa. Three patients, affected by Peyronie's disease with penile shortening and erectile dysfunction, underwent this procedure with approval of our local ethical committee. We evaluated the penis lengthening, intraoperative and postoperative complications, patient's preoperative and postoperative sexual life satisfaction (International Index of Erectile Function [IIEF] questionnaire).

RESULTS

The average operative time was 2 hours and 50 minutes. No major intraoperative nor postoperative complications occurred. No significant bleedings were recorded. Patients were discharged after 48-72 hours. The average increase in length obtained was 3.2 cm. All patients resumed sexual intercourses with satisfaction; no significant loss of sensitivity or any sign of vascular distress of the glans was recorded. The follow-up is 13 months. The average IIEF score is 60.

CONCLUSIONS

The lengthening of the penis by a double dorsal-ventral patch graft is an innovative procedure that is based on current techniques of plaque incision and grafting, and that can easily resolve severe shortening of the penis due to Peyronie's disease. In the cases presented, this procedure resulted easily, effectively, and safely. Nevertheless, the technique proposed in this article shall be validated through prospective studies with larger samples.