Standard operating procedures for Peyronie's disease

Clinical Presentation of Peyronie's Disease: A Retrospective Study of 564 Cases

Peyronie's disease (PD) affects the penile albuginea, resulting in penile deformity, pain, erectile dysfunction (ED), and an anxious-depressive state. PD diagnosis involves a thorough medical history, penile palpation, documentation of the penile deformation, a dynamic penile echo color Doppler ultrasound (PCDU), and the completion of questionnaires for the evaluation of pain, ED, and psychometric tests. The aim of this study was to evaluate the symptoms of PD and their prevalence in PD patients in the active phase who had access to our andrology clinic. Inclusion criteria: availability of data on patients diagnosed with PD, including detailed medical history, blood tests, penile palpation, photographic documentation of penile deformity, and penile PCDU. Exclusion criteria: PD patients in the stable phase or those without the specified tests and data mentioned above. Our study found a higher prevalence of PD in younger patients (24.2%), a higher coexistence of PD with chronic prostatitis (35.6%), a higher percentage of cases of association between penile deformity and penile curvature (84.4%), a higher prevalence of "significant anxiety" (88.4%), a higher presence of plaque calcification (35.6%), and the detection of a longer duration of the first phase of PD (>18 months). The most frequently observed type of penile curvature was dorsal, followed by left lateral, right lateral, and, less commonly, ventral. We observed a significant statistical correlation between patient age and IIEF score, indicating that patients over the age of 40 years are at a higher risk of experiencing ED. We found a strong statistical relationship between VAS score and age. As age increases, the VAS score decreases, suggesting that younger patients reported more penile pain compared to those who were older than 40 years. Furthermore, we found that penile pain has a significant impact on the psychological state of PD patients. We also found that 38.8% of PD patients suffered from severe anxiety. In relation to this, psychotherapy should be integrated into PD treatment to improve the quality of life and treatment adherence.

Conservative treatment of Peyronie's disease: a guide

PURPOSE

To review the literature on the topic, to suggest a common line of treatment applicable across a wide community of specialists, and to contribute in maintaining the high level of interest in this disease.

METHODS

A comprehensive and exhaustive review of the literature was performed, identifying hundreds of articles on the topic.

RESULTS

Peyronie's disease is a condition that has been recognized, studied, and treated for centuries; despite this, if one excludes surgery in cases in which the deformity is stable, no clear treatment (or line of treatment) is available for complete relief of signs and symptoms. Treatment options were divided into local, oral, and injection therapy, and a wide variety of drugs, remedies, and options were identified.

CONCLUSIONS

Low-intensity extracorporeal shock wave therapy, vacuum therapy, penile traction therapy, phosphodiesterase type 5 inhibitors, hyaluronic acid, and collagenase of Clostridium histolyticum may be recommended only in specific contexts. Further studies on individual options or potential combinations are required.

Experience With Extra-Tunical Grafting and Tunica Albuginea Plication for Correction of Indentation Deformity in Men With Peyronie's Disease

OBJECTIVE

To further evaluate extra-tunical grafting (ETG), a relatively new surgical option to treat corporal indentation in those with Peyronie's disease without buckling or hinge effect, we report our experience, patient satisfaction, and surgical outcomes.

METHODS

Retrospective review of patients following ETG, including pre-operative deformity, type of graft, graft location (under or over Buck fascia), patient characteristics, and satisfaction. Overall cosmetic satisfaction with deformity correction between patients undergoing 2 different ETG locations and 3 different types of grafts, as well as perceived bother of graft visibility and palpability were assessed.

RESULTS

From 2018-2023, 35 patients underwent ETG and tunica albuginea plication (TAP) with 89.6% of patients having persistent correction on office examination at a median (interquartile range) follow-up of 23.5 (15.2) months. Overall satisfaction with penile appearance by grafting location via patient-reported questionnaires showed no statistical difference (P = .47). Patients undergoing TAP and ETG were satisfied with their erect appearance regardless of graft material. Patients reported grafting tissue was palpable (74.3%) and visible (48.6%) in the flaccid state as compared to the erect state (8.6% and 5.7%).

CONCLUSION

ETG presents a less invasive surgical option than traditional approaches to correct indentation deformities not associated with instability. Our experience shows high patient satisfaction rate following correction of indentation using graft tissue when placed under or over Buck fascia. At a median follow-up of almost 2 years, patients had persistent correction, and while some report visibility of the graft and palpability in the flaccid state, this tends to disappear in the erect state.

The 100 most-cited publications on Peyronie's disease: a bibliometric analysis and visualization study

This study aimed to summarize the characteristics of the top 100 most-cited publications on Peyronie's disease (PD) research and to analyse past and current research hotspots and trends. The SCI-E database of the Web of Science Core Collection (WoSCC) provided us with the top 100 most-cited publications in PD research, from which we took the following information: general trend of publication, year of publication, nation/region, institution, journal, author, and keywords. VOSviewer (version 1.6.18) and Excel (version 2016) were used for information analysis. Through a standardized search, we ultimately found 1019 papers in the field of PD research, from which we extracted the 100 articles that had received the highest citations. The articles were published between 1949 and 2016. The United States is a major contributor to PD research (n = 67). The University of California, Los Angeles, was the institution with the largest number of articles (n = 11). These articles were published in 16 journals, with the largest number appearing in the Journal of Urology (n = 47). The author with the most articles was Levine LA (n = 9). Gelbard MK's articles had the highest citation frequency (n = 1158). Erectile dysfunction (n = 19) was the keyword with the highest frequency, indicating that PD-related erectile dysfunction was the leading focus of research in this field. Most of the keywords that have appeared in the past decade are related to the clinical treatment of PD. Therefore, we believe that improving patients' erectile function to the greatest extent in clinical treatment is the frontier and hot spot of future research.

Measurement of Oxidative Stress Index (OSI) in Penile Corpora Cavernosa and Peripheral Blood of Peyronie's Disease Patients: A Report of 49 Cases

Peyronie's disease (PD) is a chronic inflammatory disease affecting the penile albuginea. Oxidative stress (OS) is important for the development of the disease; therefore, it seemed interesting to us to directly measure OS at both the site of the disease and in peripheral blood. For a precise OS study, it is necessary to evaluate not only the single results of the total oxidant status (TOS) and total antioxidant status (TAS) but also their ratio: OS index (OSI) (arbitrary unit) = TOS/TAS × 100. This study included 49 PD patients examined and diagnosed in our Peyronie's care center and a control group of 50 cases. We collected blood samples from both the penis and a vein in the upper extremity; we used d-ROMs and PAT-test (FRAS kit) for OS measurement. Pearson's study found a statistical correlation between penile OSI values and PD plaque volumes: p-value = 0.002. No correlation was found between systemic OSI values and PD plaque volumes: p-value = 0.27. Penile OSI values were significantly reduced after the elimination of the PD plaque (p < 0.00001). The mean value of the penile OSI indices in the PD patients after plaque elimination corresponded to 0.090 ± 0.016 (p = 0.004). The comparison between the penile OSI values of the PD patients (with plaque elimination) and the control group revealed no statistically significant differences (p = 0.130). The absence of a correlation between Peyronie's plaque volume and systemic OSI values indicates that it is preferable to carry out the OS study by taking a sample directly from the site of the disease. By carrying out a penile OSI study, it would be possible to obtain a precise plaque-volume-dependent oxidative marker. Even if the study did not demonstrate any correlation between OSI indices and anxious-depressive state, we detected a high prevalence of anxiety (81.6%) and depression (59.1%) in PD patients.

A systematic review of non-surgical management in Peyronie's disease

The efficacy of many non-surgical treatments for Peyronie's disease is unclear. This systematic review aims to critically assess the currently available options and provide a recommendation for treatment based on this. A systematic literature search utilising the Medline (Pubmed), Embase, global health and Cochrane library databases was conducted up to May 2021. All randomised controlled trials assessing non-surgical treatment modalities for Peyronie's Disease were included. Individual study risk of bias was evaluated using the Cochrane tool and GRADE was used to assess evidence strength. Outcome measures were the change in penile curvature (degrees), plaque size (volume or size), International Index of Erectile Function score, pain scores and change in penile length. Prospero registration number: CRD42017064618. Amongst the 5549 articles identified, 41 studies (42 reports) were included. Seven different oral treatment options including vitamin E supplementation showed evidence for improving outcomes such as penile curvature and plaque size. Of the intralesional treatments, Collagenase Clostridium Histolyticum showed evidence for improving penile curvature (Range: 16.3-17 degrees, moderate level certainty of evidence). Intralesional Interferon demonstrated some improvement in curvature (Range: 12-13.5 degrees), plaque size (Range: 1.67-2.2 cm2) and pain, whilst intralesional calcium channel blockers such as Verapamil showed variable evidence for changes in the plaque size and pain. Extracorporeal Shockwave Therapy consistently demonstrated evidence for improving penile pain in stable disease, and two mechanical traction devices improved curvature. Iontophoresis, topical medications, and combination therapies did not demonstrate any consistent improvements in outcome measures. Intralesional options demonstrate the best potential. Overall, results varied with few high-quality randomised trials present.

Predictors of hinge effect in patients with Peyronie's disease

BACKGROUND

Patients with Peyronie's disease present with a variety of penile deformities. Those with hinge effect can experience bothersome buckling of the erection and instability during penetrative sex; however, the actual characteristics and clinical implications are not fully understood.

AIM

To determine the factors that cause hinge effect and to assess the role on surgical intervention.

METHODS

This retrospective review included 1223 consecutive patients who were examined by a single surgeon and had a complete penile duplex evaluation with curvature and hinge assessment. Baseline demographics, penile duplex findings, and clinical outcomes were used to assess for predictors of hinge effect.

OUTCOMES

Analyses were performed to assess preoperative predictors of hinge effect and surgical intervention.

RESULTS

Hinge effect was observed at the time of penile duplex Doppler examination in 33% of patients. Circumferential girth discrepancy at point of indentation (odds ratio [OR] 1.82; P < .001), rigidity of erection (OR, 0.82; P = .002), and degree of primary curvature (OR, 1.03; P < .001) predicted the presence of hinge effect. When controlling for rigidity, a girth discrepancy >1 cm did appear to be associated with a hinge.

CLINICAL IMPLICATIONS

Circumferential girth discrepancy >1 cm, regardless of erectile rigidity, can be associated with hinge effect.

STRENGTHS AND LIMITATIONS

As a strength, this study included the largest cohort of patients with Peyronie's disease, all of whom were examined in a rigorous and uniform manner via the same operative counseling. However, the study is limited by its retrospective nature and potential for selection and observer bias, given that the treating physician was also assessing all penile deformities as well as performing operative intervention.

CONCLUSIONS

The presence of hinge effect can cause instability of erections during penetrative sex. Multiple factors may predispose patients to a hinge effect, including the quality of erection and severity of curvature. But when controlling for rigidity, a girth discrepancy >1 cm did appear to be associated with a hinge. While many factors, such as baseline erectile dysfunction and severity of curvature, are important in determining the optimal surgical intervention, assessing for preoperative hinge effect also influenced the surgical approach.

Role of Oxidative Stress in Peyronie's Disease: Biochemical Evidence and Experiences of Treatment with Antioxidants

BACKGROUND

Peyronie's disease (PD) is a chronic inflammatory condition affecting adult males, involving the tunica albuginea of the corpora cavernosa of the penis. PD is frequently associated with penile pain, erectile dysfunction, and a secondary anxious-depressive state. The etiology of PD has not yet been completely elucidated, but local injury is generally recognized to be a triggering factor. It has also been widely proven that oxidative stress is an essential, decisive component in all inflammatory processes, whether acute or chronic. Current conservative medical treatment comprises oral substances, penile injections, and physical therapy.

AIM

This article intends to show how antioxidant therapy is able to interfere with the pathogenetic mechanisms of the disease.

METHOD

This article consists of a synthetic narrative review of the current scientific literature on antioxidant therapy for this disease.

RESULTS

The good results of the antioxidant treatment described above also prove that the doses used were adequate and the concentrations of the substances employed did not exceed the threshold at which they might have interacted negatively with the mechanisms of the redox regulation of tissue.

CONCLUSIONS

We believe new, randomized, controlled studies are needed to confirm the efficacy of treatment with antioxidants. However, we consider the experiences of antioxidant treatment which can already be found in the literature useful for the clinical practice of urologists in the treatment of this chronic inflammatory disease.

Surgical Correction of Adult Congenital Penile Curvature: A Systematic Review

BACKGROUND

Congenital penile curvature (CPC) is corrected surgically by various corporoplasty or tunica albuginea plication techniques, but the optimal surgical approach is not well-defined.

AIM

To provide a comprehensive evaluation of the published literature pertaining to outcomes with penile plication and corporoplasty techniques for surgical management of CPC. To determine if plication or corporoplasty offers superior outcomes in surgical correction of CPC.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Checklist. The following databases were queried from inception to March 18, 2020 to search for studies describing surgical treatment of CPC: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus.

OUTCOMES

Objective and subjective postoperative outcomes including penile straightening, shortening, penile sensory changes, and reoperation rates for both corporoplasty and tunica albuginea plication were summarized.

RESULTS

Fifty-five articles comprising 2,956 patients with CPC who underwent a plication procedure (n = 1,375) or corporoplasty (n = 1,580) were included. The definition of "treatment success" varied widely and most often involved subjective patient reporting (22 studies; 40%) or objective assessment (15 studies; 27%). We considered curvature correction to be satisfactory if there was self-reported patient satisfaction or residual curvature after correction of <20˚. Reported rates of successful straightening ranged from 75 to 100% and 73 to 100% for plication and corporoplasty, respectively. A comprehensive and accurate assessment of surgical outcomes for CPC correction, such as satisfactory penile straightening, reoperation rates, glans sensory changes, and other complications was limited by significant inter-study heterogeneity with respect to the reporting of treatment outcomes.

CLINICAL IMPLICATIONS

While both plication and corporoplasty appear to be safe and effective options in the treatment of CPC, definitive conclusions cannot be drawn with respect to treatment superiority due to low-quality study design, methodology flaws, and significant heterogeneity in reporting.

STRENGTH & LIMITATIONS

This report represents the most comprehensive review of CPC surgical management. However, there is a significant lack of standardization in the reporting of treatment outcomes for CPC, thereby limiting the reliability of the published data summarization encompassed by our review.

CONCLUSION

Both plication and corporoplasty demonstrate high success rates and relatively low complication rates in the treatment of CPC, albeit with low-level evidence available in most research publications. Robust comparison of the surgical techniques used to correct CPC is limited by significant variation in reporting methods used in the literature. C. J. Britton, F. A. Jefferson, B. L. Findlay, et al. Surgical Correction of Adult Congenital Penile Curvature: A Systematic Review. J Sex Med 2022;19:364-376.

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.

Urologists' knowledge base and practice patterns in Peyronie's disease. A national survey of members of the italian andrology society

Peyronie's disease is a chronic inflammatory disease involving the formation of plaque in the tunica albuginea of the corpora cavernosa, resulting in penis deformity. It is often associated with penile pain, especially in younger patients, but it is not rare for pain to be absent; the disease is also associated with erectile dysfunction and a depressive state in a large percentage of cases.

OBJECTIVE

Aim of our study was to explore the basic knowledge base and diagnostic and therapeutic practice patterns in Peyronie's disease (PD) of a large number of physicians belonging to the Italian Andrology Society (SIA).

METHODS

Our survey is based on two questionnaires which were e-mailed to the members of the SIA. The first questionnaire explored diagnostic and therapeutic practice patterns of SIA physicians, while the second questionnaire focused on their knowledge of the disease, as well as their training and level of experience in the specific field. We then planned to compare our outcomes with similar PD surveys from other countries.

RESULTS

The first questionnaire was answered by 142 SIA physicians. The second questionnaire was answered by 83 SIA physicians. Most respondents (74.6%) chose penile ultrasonography as first-line diagnostic approach and 47.1% prefer to perform a color Doppler ultrasound after pharmaco-induced erection. Concerning the therapeutic practice patterns in active stage of the disease, most respondents (99.29%) prefer conservative medical therapy. Additionally, most respondents (64.78%), when failure of conservative treatment had been established, considered surgical treatment necessary, specifically corporoplasty, which may be associated with other techniques.

CONCLUSIONS

The results of our survey show that, in comparison to their foreign counterparts, Italian SIA uro-andrologists have a more proactive diagnostic approach right from when patients first present. When PD is still in its active stage, SIA uro-andrologists mostly opt for medical therapy. In advanced disease or if conservative treatment fails, our survey indicates a greater preference for surgical treatment. Answers to the theoretical knowledge questions showed that SIA physicians have a good understanding of the disease's etiology, epidemiology, and clinical picture, and of the appropriate indications for treatment.

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

BACKGROUND

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

AIM

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

METHODS

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

OUTCOMES

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

RESULTS

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

CLINICAL IMPLICATIONS

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

STRENGTHS & LIMITATIONS

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

CONCLUSION

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

Management of Disastrous Complications of Penile Implant Surgery

RATIONALE

Penile Prosthesis Implantation (PPI) is the definitive treatment for Erectile Dysfunction not responsive to conservative management strategies. Furthermore, it is a staple of surgical treatment of severe Peyronie's Disease (PD) and phallic reconstruction. Expert implantologists occasionally face disastrous complications of penile implant surgery which can prove to be very challenging. In this article we present a selected number of case reports which exemplify this kind of situations and discuss management strategies while also commenting on plausible aetiologies.

PATIENTS' CONCERNS

The first case describes a PPI performed in end-stage fibrotic corpora after multiple instances of implantation/explant. The second and third cases show two diametrically opposed approaches to the management of glans necrosis after PPI in post-radical cystectomy patients. The fourth case describes the history of a diabetic patient suffering from glandular, corporal and urethral necrosis after a complicated PPI procedure. The fifth case reports the surgical treatment of a case of recurring PD due to severe scarring and shrinking of a vascular Dacron patch applied in a previous operation.

DIAGNOSIS

Complication diagnosis in all patient was mainly clinical, intra- and postoperative, with Penile Color Doppler Ultrasonography performed when needed in order to demonstrate penile blood flow.

INTERVENTIONS

The patients underwent complex surgical procedures that addressed each specific complication. Complex penile implants with fibrosis-related complications, penile prosthesis explant with and without surgical debridement of necrotic areas, penile prosthesis explant with necrotic penile shaft and urethral amputation with perineostomy, and complex corporoplasty with scar tissue excision and patch application with PPI were performed in the five patients.

OUTCOMES

Penile anatomy and erectile function with PPI was achieved in 4 out of 5 patients. 1 of 5 patient is scheduled to undergo a total phallic reconstruction procedure at the time of this writing.

LESSONS

Management of disastrous complications of penile implant surgery can be very challenging even in expert hands. In-and-out knowledge of possible PPI and PD complications is required to achieve an acceptable outcome. Bettocchi C, Osmonov D, van Renterghem K, et al. Management of Disastrous Complications of Penile Implant Surgery. J Sex Med 2021;18:1145-1157.

Molecular Mechanisms and Current Pharmacotherapy of Peyronie's Disease: A Review

Peyronie’s disease (PD) is a localized fibrotic lesion of the penis that has adverse effects on men’s health. In this review, we summarized the molecular mechanisms and pharmacotherapies of PD. A literature search was conducted using PubMed and Cochrane Library during 2001–2020. Although no oral or topical medication demonstrated efficacy in monotherapy of PD, several intralesional medications have yielded promising results. Currently, the effective strategy in management of PD should be combined modality therapy, including but not limited to pharmacotherapy, mechanical therapy, and psychotherapy. Meanwhile, basic research is still necessary to facilitate the development of novel and more reliable treatments. In future, more attention should be given simultaneously to epigenetic changes, inflammatory cytokines, the abnormal wound-healing process, and profibrotic and anti-fibrotic factors to provide more options for this refractory disease.

[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.

Studies on Vibrio mimicus derived collagenase variants providing insights into critical role(s) played by the FAXWXXT motifs in its collagen-binding domain

Vibrio mimicus collagenase (VMC), a Class II Vibrio metalloprotease, contains an HEXXH motif in a zinc-binding catalytic domain, and two FAXWXXT motifs in its C-terminal domain, which is its collagen binding domain (CBD). To understand the functional role of the individual CBD motifs in the activity of VMC, if any, we created and characterized a series of VMC variants: i) VMA, with 51 amino acids deleted from the C-terminal end of full-length VMC; ii) VMT1, a form of VMA mutated in the first CBD motif; iii) VMT2, a form of VMA mutated in the second CBD motif; iv) DM, a form of VMA with both CBD motifs mutated; v) CT, a truncated form of VMA, lacking the entire CBD region; and vi) CBD, a construct containing the collagen binding domain alone. The activity of each variant was assessed by multiple means, in relation to VMA. We report that VMT1 and VMT2 show 1.6-fold and 10-fold reduced activity, respectively. The reduced activity of VMT2 correlates with reduced binding to insoluble collagen as well as an inability to cause structural perturbation of collagen. VMC appears to cause unwinding and structural alteration of the collagen triple helix prior to hydrolysis of the substrate (using both motifs for collagen binding), like Clostridium collagenases. In the absence of a known structure for VMC, our findings suggest that Vibrio collagenase, functions like Clostridium collagenases, although the two show very little sequence similarity. Also, VMC shows reduced activity with respect to Clostridium collagenases, making it an ideal enzyme for therapeutic applications.

Comparison of two different grafts for the surgical treatment of peyronie's disease

The aim of this study was to compare two different graft techniques, namely saphenous vein (SV) and buccal mucosa (BM) used together with plaque incision for the treatment of Peyronie's disease (PD) in terms of success, safety and patient and partner satisfaction. The study included 41 patients diagnosed with PD and treated with plaque incision and grafting between December 2015 and November 2019. Eighteen patients underwent plaque incision and BM grafting while the remaining 23 patients underwent plaque incision and SV grafting. Pre-operative plaque size, curvature angle, curvature start time and penis length were statistically similar between the SV and BM graft groups. No statistical difference was detected between the BM and SV graft groups in terms of the sixth- and 12th-month mean International Index of Erectile Function scores, Patient Global Impression of Improvement scores, penis lengths and final partner satisfaction rates during the follow-up period. Residual curvature was observed in three (13.1%) patients in the SV graft group and two (11.2%) patients in the BM graft group. With their high success and low side effect rates, both grafting techniques with plaque incision can be safely performed for tunical lengthening, based on the surgeon's experience.

The use of collagen fleece (TachoSil) as grafting material in the surgical treatment of Peyronie's disease. A comprehensive narrative review

Grafting for the treatment of Peyronie's disease (PD) can be performed with autologous grafts, allografts, xenografts and synthetic grafts, with all available materials presenting their own characteristics. Still, there is a current arising interest in the use of collagen fleece (TachoSil) as grafting material. We generated an extensive literature review, aiming to assess the use of TachoSil in the treatment of PD. TachoSil is currently indicated in men with PD and preserved erectile function for defect closure after partial plaque excision or incision. In addition, it is indicated for residual curvature correction during penile prosthesis implantation (PPI) in patients with PD and severe erectile dysfunction. Our literature search identified 12 studies evaluating the role of TachoSil for PD surgical treatment. We presented the surgical procedure of TachoSil grafting for the treatment of complex penile curvatures with or without simultaneous PPI and summarized the available evidence on the matter. Identified studies suggest that TachoSil is considered highly effective, reliable and safe in patients with PD. Moreover, it displays favorable properties compared to other grafting materials. It should be stressed that, despite some limitations of available data, TachoSil presents key strengths, which include easy application, decreased operative times, no risk of damaging the implant during PPI, preservation or increase in penile length, fewer cases of penile hypoesthesia, low risk of other adverse events, additional hemostatic effects and low cost. Still, randomized trials comparing TachoSil with different grafting materials are necessary to establish its efficacy.

Medical, non-invasive, and minimally invasive treatment for Peyronie's disease: A systematic review

BACKGROUND

The treatment of Peyronie's disease (PD) remains a dilemma as the true pathogenesis of PD remains an enigma. Consequently, new molecules and therapies continue to evolve. The safety and efficacy of conservative treatment for PD have not yet established.

OBJECTIVES

To provide the available information of the status of conservative therapy for PD.

METHODS

A systematic literature search was conducted using PubMed, EMBASE, and the Cochrane Library for English-language journal articles between January 2000 and July 2019, using the terms "Conservative treatment for PD", "medical treatment for PD", "non-invasive therapies for PD" and "minimally invasive therapies for PD". This systematic review was conducted in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) system. We also manually reviewed references from selected articles. The risk of bias in the included RCTs was assessed using the Cochrane Risk of Bias Assessment tool (RoB 2).

RESULTS

Conservative treatment is accepted as the initial treatment step in most of the cases. This kind of therapy includes various methods of treatment such as medical, non-invasive, and minimally invasive therapies. Ideal management of PD is not yet available. It is not possible to assess the value of treatment without well-designed, randomized, placebo-controlled, large-scale clinical studies.

CONCLUSION

Optimistically, in the near future, we may witness emergence of efficacious new agents and modalities to revolutionize medical, non-invasive, and minimally invasive treatment of this devastating condition.

Home modeling after penile prosthesis implantation in the management of residual curvature in Peyronie's disease

The aim of this study was to study the clinical effectiveness of a structured home modeling (HM) protocol in Peyronie's disease (PD) patients who have residual curvature up to 45° after inflatable penile prosthesis (PP) placement. A total of 92 patients with PD and coexistent refractory erectile dysfunction received inflatable PP. If residual curvature after manual modeling (MM) was more than 45°, incision-grafting was performed. If curvature was <45° after MM, patients were instructed to perform HM daily for 6 months, after 4 weeks from PP implantation. The mean preoperative penile curvature was 39.4 ± 5.7° (30-60). Sixteen (17.4%) patients required incision-grafting and the remaining 76(82.6%) patients followed HM protocol. The mean postoperative residual curvature after MM was 29.7 ± 3.2° (5-50). Sixty-five (85.5%) patients who underwent HM had 10° or less residual curvature after 3 months and 72 (94.7%) patients had 10° or less residual curvature after 6 months. Seventy (92.1%) patients responded as satisfied or very satisfied on the questionnaire with the outcome after 6 months. HM of the penis over Inflatable PP may straighten the penis without the need for an additional surgical maneuver in vast majority of the PD patients having residual curvature of <45°.

A decade of grafting techniques as a sole treatment for Peyronie's disease

BACKGROUND

Peyronie's disease (PD) can be a cosmetically and functionally devastating condition. Surgical approaches have been proposed in the chronic stages of PD as plication or plaque incision/excision with grafting to preserve penile size in complex cases. Although several surgeons nowadays are inclined toward the utilization of non-autologous grafts owing to the ease of their preparation and availability, synthetic graft procedures still await more technical improvements and supporting evidence before their consideration for standard care.

OBJECTIVES

In this review, our goal is to facilitate an insight into the most promising grafting materials used for the management of PD and techniques associated.

MATERIALS AND METHODS

A PubMed review was conducted for all the studies on our topic within the past ten years (January 2009 until December 2019). The outcome parameters we documented and compared comprised of operative time, follow-up time, postoperative penile cosmesis and function, and, finally, overall patient satisfaction related to each technique.

RESULTS

Our search yielded 23 English-written original study articles in addition to a single case report on the various grafting techniques utilized as the sole treatment for PD, each demonstrating different outcomes and points of comparison.

CONCLUSION

A successful grafting procedure for PD requires an appropriately tailored surgical modality and an experienced surgeon. Nevertheless, proper preoperative patient counseling on all aspects of his condition and opted treatment modality while setting clear and realistic expectations remains key for overall patient satisfaction.

Complex Peyronie's disease cases: surgery with or without penile prosthesis placement

INTRODUCTION AND OBJECTIVE

Surgery is the treatment of choice for patients with Peyronie's disease presenting difficulty in penetration or erectile dysfunction without adequate response to therapy. Several techniques have been described, and urologists must be aware of their possible complications and sequelae in order to offer the patient the best possible alternative.

PATIENTS AND METHODS

Three complex cases of patients with Peyronie's disease are presented. The first case exposes a complication after penile plication for the treatment of a major dorsal curve. The second case refers to difficult anal penetration secondary to a problem of erection direction after plaque incision surgery with oral mucosa grafting. The last case is a patient with a late post-operative complication of a three-piece prosthesis placement with plaque incision and equine collagen patch.

RESULTS

Surgical options for each case are detailed and discussed. After patients were informed, the decision was taken in a consensual manner.

CONCLUSIONS

Surgery for Peyronie's disease requires the urologist's consideration of the functional, aesthetic and psychological spheres. A systematic approach to all of these avoids complications, sequels and improves results.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Intraoperative methods for residual curvature correction during penile prosthesis implantation in patients with Peyronie's disease and refractory erectile dysfunction

Peyronie's disease, or fibrous transformations of the tunica albuginea of the corpora cavernosa that cause penile curvature, is estimated to affect 3.2-8.9% of the male population. Treatment options for PD are based on the severity of the penile deformity and erectile function; of which surgical options include manual modeling during penile prosthesis implantation, plication, plaque incision, and grafting. Multiple approaches may be employed; each with its own advantages, limitations, and risk/benefit ratios. In this regard, we sought to review and highlight the current approaches for the management of residual curvature, optimal patient selection, and preoperative planning.

Management of Peyronie's disease with collagenase Clostridium histolyticum in the acute phase

INTRODUCTION

Peyronie's disease (PD) can affect men of all ages and is associated with penile pain as well as curvature and erectile dysfunction. Treatment modalities for PD include conservative, less invasive and surgical treatments. Choice of treatment depends on the disease's phase. Injection of collagenase Clostridium histolyticum (CCH) is only the Food and Drug Administration approved treatment for the management of the chronic phase of the disease. Only a few limited studies have evaluated its potential benefits during the acute phase.

AIM

To evaluate the current evidence on the use of injectable CCH during the acute or active phase of PD.

METHODS

We performed a PubMed database search for articles published between 2015 and 2018 that investigated the use of CCH for the management of the acute phase of PD. Search keywords included "Peyronie's disease", "collagenase Clostridium histolyticum", and "acute phase".

MAIN OUTCOME MEASURES

Changes in penile curvature after treatment with injectable CCH.

RESULTS

Mean curvature decrease ranged between 15.8° and 22.6° corresponding to 27.4-37.4% decrease from baseline after 2.5-4 cycles, corresponding to 5-8 injections, of CCH treatment in patients during the acute phase of PD.

CONCLUSIONS

Intralesional CCH injection therapy during the acute phase of PD can be both safe and effective and clinically significant improvements in penile curvature may be achieved. Larger multi-institutional studies are, however, still needed to confirm these results and validate this additional indication for CCH.

[Adjuvant surgical maneuvers in penile prostheses implant to improve their aesthetic and functional outcomes]

Penile prosthetic surgery is the definitive treatment for those patients with erectile dysfunction refractory to medical treatment. Although it associates satisfaction rates>90%, it is known that men with Peyronie's disease, body mass index>30kg/m² or those previously operated on radical prostatectomy have lower satisfaction rates than the general population. The main reasons for dissatisfaction are the subjective loss of penile length and glans' flaccidity. Given such circumstance, several adjuvant surgical techniques have been described to improve aesthetic and functional outcomes after the implant. In our review, we wanted to investigate the different maneuvers used in patients with Peyronie's disease, those used to avoid the reduction of penile length and those used to avoid the floppy glans syndrome.

Cavernosopatía traumática crónica. Un nuevo síndrome de fibrosis peneana

Introdución La llamada genéricamente «enfermedad de Peyronie» es un diagnóstico que explica un porcentaje de ciertos estados de fibrosis peneana grave, pero se queda corta para abarcar la amplia gama de grises de la fibrosis peneana secundaria a microtrauma sexual repetido.

Objectivo Describir un nuevo síndrome por trauma repetido en el pene al que se propone denominar «cavernosopatía traumática crónica» (CTC), con 4 componentes: fibrosis (leve, moderada o grave), disfunción eréctil, curvatura y fugas venosas peneanas.

Materiales y métodos Se realizó un estudio de corte transversal en una base de datos de 128 pacientes que tenían al menos una ecografía de pene con vasoactivo y en los que se había detectado algún grado de fibrosis cavernosa según la clasificación de Levine. Se evaluó la presencia de disfunción eréctil, curvas y fugas venosas según el grado de fibrosis. El estudio contó con la aprobación del Comité de Ética en Investigación.

Resultados Se estudió a 128 pacientes con fibrosis, con 51,3 años de edad promedio (DE = 13). El grado de fibrosis fue leve (Levine 1) en 30 (23,43%), moderado (Levine 2) en 23 (17,96%) y grave (Levine 3) en 75 (58,6%). Se demostró que, a mayor fibrosis, mayor disfunción eréctil, 66,6; 83,6 y 96% para Levine 1, 2 y 3, respectivamente (p ≤ 0,0001). La frecuencia de curvatura secundaria (n = 71) fue de 0; 4,2 y 95,7% para Levine 1, 2 y 3, respectivamente (p ≤ 0,0001). La frecuencia en los 44 pacientes con fugas cavernosas fue de 9; 20,4 y 70,4% (p = 0,0060) y en los 15 de fugas dorsales fue de 80; 13,3 y 6,6% (p < 0,0001) para Levine 1, 2 y 3 respectivamente. El grupo de 79 pacientes (64,03%) con mayor posibilidad de CTC, con presencia de 3 o 4 criterios que incluyeran curvatura secundaria y fuga cavernosa, tuvo un promedio de edad de 59,2 años (DE = 8,7), comparado con 41,7 años (DE = 11,7) en el grupo de menor posibilidad, diferencia estadísticamente significativa (p ≤ 0,0001).

Conclusiones Proponemos que existe un síndrome de microtrauma repetido en el pene, que puede denominarse CTC, análogo a la encefalopatía traumática crónica, con 4 componentes: fibrosis cavernosa, disfunción eréctil, curvatura peneana y fugas venosas. La fibrosis es un continuum que el paciente recorre por fases leves y moderadas, a menudo inapreciables para los clínicos. Las curvaturas secundarias y las fugas cavernosas están relacionadas directamente con el grado de fibrosis y con mayor riesgo de disfunción eréctil. La edad empeora algunos factores de la CTC.

Multi-institutional Prospective Analysis of Intralesional Injection of Collagenase Clostridium Histolyticum, Tunical Plication, and Partial Plaque Excision and Grafting for the Management of Peyronie's Disease

OBJECTIVE

To compare in a prospective nonrandomized fashion, the outcomes of collagenase clostridium histolyticum (CCH) and surgical interventions (tunical plication [TP] and partial plaque excision and grafting [PEG]) in patients with Peyronie's disease (PD). Intralesional injection of CCH is the only Food and Drug Administration-approved nonsurgical intervention for PD.

MATERIALS AND METHODS

Between June 2015 and January 2017, 57 patients with PD and dorsal, dorsolateral, and/or lateral penile curvatures 30°-90° were included in this study. Patients with ventral curvature, hourglass deformity, and previous surgery for PD were excluded. All patients completed questionnaires and underwent penile measurements and penile vascular studies prior to and after completion of treatment, and were followed for at least 6 months.

RESULTS

CCH was administered to 18 patients, TP performed in 14, and PEG in 25. The median follow-up for the whole cohort was 12 months (6-28). Mean changes in curvature after treatment were 23.3° (34.4%) for CCH, 72.0° (92.2%) for TP, and 71.8 ° (94.9%) for PEG, P<.001. Mean changes in International Index of Erectile Function-5 scores were +5.7 for CCH, +4.9 for TP, and +2.2 for PEG, P = .395. Mean penile length changes were -0.2 cm for CCH, -1.0 cm for TP, and +0.9 cm for PEG, P<.001. Three patients in the CCH group had bothersome residual curvature and underwent uneventful TP.

CONCLUSION

Surgical options are associated with superior curvature correction. CCH is an effective and safe option for motivated patients who prefer to avoid surgery. PEG is associated with a small stretched penile length gain.

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.

Objective measurements of the penile angulation are significantly different than self-estimated magnitude among patients with penile curvature

Introduction:

The study was aimed to assess the presence of actual differences between the objective and the perceived magnitude of a curvature between patients affected by Peyronie's disease (PD) and congenital penile curvature (CPC).

Materials and Methods:

Wee analysed a cohort of 88 consecutive patients seeking medi- cal help for either CPC or PD. All patients were invited to provide a self-made drawing of their penis in erection in order to obtain self-provided description of the deformity. An objective measurement of the deformity was also performed drawing two intersecting lines through the center of the distal and proximal straight section of the penile shaft.

Results:

Our findings showed significant differences between patient self-estimation and the objective measurements of the penile angulation performed by trained experts, with only 32% of patients correctly assessing their own curvature. Overall, patients tended to overestimate (56%) their degree of curvature, but the results are different in patients with PD than those with CPC. In the 60 men (68%) who did not accurately assess their curvature, PD patients generally overestimated their curvature versus CPC patients (67% vs 16%). On the contrary CPC patients underestimated their curvature compared to PD (42% vs. 4%).

Conclusion:

In order to improve patients' satisfaction rates, the surgeon needs to take into consideration the patient's perception of the deformity when planning the type of surgical correction.

2018 Canadian Urological Association guideline for Peyronie's disease and congenital penile curvature

Peyronie’s disease (PD) is a highly prevalent condition that affects the physical and psychosocial well-being and quality of life (QoL) for thousands of Canadian men. The specific etiology of PD remains poorly understood and there remains a paucity of randomized placebo-controlled trials evaluating treatment interventions.1-3 PD can be found in up to 8.9% of men, a remarkable increase in cited prevalence that is attributable to growing awareness (as historical data suggested a rate of less than 1%); the burden of disease is significant, and PD is often present in otherwise healthy men. The following guidelines were crafted by the committee with a full awareness of the limitations of the literature, and sought to provide actionable recommendations to guide PD care in the Canadian health system.

Safety and feasibility of platelet rich fibrin matrix injections for treatment of common urologic conditions

Purpose

Autologous platelet rich plasma (PRP) is used increasingly in a variety of settings. PRP injections have been used for decades to improve angiogenesis and wound healing. They have also been offered commercially in urology with little to no data on safety or efficacy. PRP could theoretically improve multiple urologic conditions, such as erectile dysfunction (ED), Peyronie's disease (PD), and stress urinary incontinence (SUI). A concern with PRP, however, is early washout, a situation potentially avoided by conversion to platelet rich fibrin matrix (PRFM). Before clinical trials can be performed, safety analysis is desirable. We reviewed an initial series of patients receiving PRFM for urologic pathology to assess safety and feasibility.

Materials and Methods

Data were reviewed for patients treated with PRFM at our center from November 2012 to July 2017. Patients were observed immediately post-injection and at follow-up for complications and tolerability. Where applicable, International Index of Erectile Function (IIEF-5) scores were reviewed before and after injections for ED and/or PD. Pad use data was collected pre/post injection for SUI.

Results

Seventeen patients were identified, with a mean receipt of 2.1 injections per patient. Post-procedural minor adverse events were seen in 3 men, consisting of mild pain at injection site and mild penile bruising. No patients experienced complications at follow-up. No decline was observed in men completing pre/post IIEF-5 evaluations.

Conclusions

PRFM appears to be a safe and feasible treatment modality in patients with urologic disease. Further placebo-controlled trials are warranted.

Peyronie's graft surgery-tips and tricks from the masters in andrologic surgery

BACKGROUND

Grafting techniques in the surgical management of Peyronie's disease (PD) are challenging, especially in inexperienced hands. In order to improve surgical outcomes the urologist should follow a standard surgical approach, preferably of an established and reliable grafting technique. The aim of this study is to provide tips and tricks for graft surgery for PD.

METHODS

This report offers a step-by-step tutorial for grafting techniques in PD, especially for the Sealing technique and the partial plaque excision and grafting (PEG) procedure. Two senior surgeons (GH, LAL) describe their surgical technique in detail, and provide important aspects and tips one has to be aware of when performing a grafting technique in patients with PD. Special attention is also paid to preoperative considerations and adequate patient counseling. Moreover, postoperative penile rehabilitation programs are discussed.

RESULTS

Adequate preoperative counseling of patients is crucial, and should include possible adverse effects and negative outcomes, such as persistent or recurrent curvature, diminished sensation at the glans penis, diminished erectile function, or penile shortening. The correct indication for a grafting technique is imperative. There are many surgical details during grafting techniques, which have to be considered in order to achieve the best result possible. These include the correct preparation of the neurovascular bundle, the following partial plaque excision without damaging the underlying erectile tissue, and the sufficient closure of the resulting tunica albuginea defect. Defect closure can be done by grafts like pericardial graft (PEG procedure) or the collagen fleece (Sealing technique). Postoperatively, the patient should refrain from sexual activities for at least 6 weeks, and follow a penile rehabilitation program with Phoshodiesterase-Type-5 inhibitors, manual stretch, penile massage, and penile traction therapy.

CONCLUSIONS

The present paper offers a step-by-step tutorial for grafting techniques in PD, especially for the Sealing technique and the PEG procedure, in order to help the reader to understand major steps during surgery and to avoid pitfalls. Careful patient selection, a reliable and established surgical technique and a postoperative rehabilitation program are main predictors for treatment success. In summary, the ultimate goal should be improved patient care, safety and satisfaction.

Prevalence of Peyronie's Disease-Like Symptoms in Men Presenting With Dupuytren Contractures

Introduction

Peyronie's disease (PD) and Dupuytren contractures (DC) are often comorbid and are believed to have a similar underlying pathophysiologic mechanism.

Aim

To investigate the prevalence of PD-like symptoms (PDLS) in men with DC.

Methods

From October 2013 to December 2016, men who were seen and evaluated for DC were offered the opportunity to participate in an anonymous survey. The survey assessed several basic demographic and sexual health factors and included items from the International Index of Erectile Function and the Erection Hardness Scale. Men who reported PDLS were asked a series of questions derived from the Peyronie's Disease Questionnaire and for their opinions on theoretical treatment modalities for sexual problems and penile deformity.

Main Outcome Measure

Prevalence of PDLS in men with DC.

Results

One hundred forty men with DC were invited to participate; 85 surveys were returned (response rate = 61%). Twenty-two respondents (26%, 95% confidence interval = 17–35) reported PDLS. Approximately one fourth of all respondents had an Erection Hardness Scale score lower than 3. The most common specific PDLS concerns were penile curvature (91%), length loss (55%), narrowing (36%), and hinging (32%). In men with PDLS, 73% felt at least a little bothered by the symptoms when attempting sexual activity and 40% reported having sex less frequently because of the symptoms. Just 27% of men with PDLS had ever used a treatment for a sexual concern. In terms of treatments for penile deformities, 64% of men with PDLS expressed an interest in treatment administered in the form of an in-office procedure; 41% were potentially amenable to a surgical procedure.

Conclusion

The prevalence of PDLS in men with DC is similar to the prevalence of DC in men diagnosed with PD. A substantial number of these men have distress and would consider standard-of-care treatments for PD.

Shindel AW, Sweet G, Thieu W, et al. Prevalence of Peyronie's Disease-Like Symptoms in Men Presenting With Dupuytren Contractures. Sex Med 2017;5:e135–e141.

Use of a lyophilized bovine pericardium graft to repair tunical defect in patients with Peyronie's disease: experience in a clinical setting

Many different materials are available for grafting during surgery for Peyronie's disease (PD). To study the outcomes associated with the use of a lyophilized bovine pericardium graft (Peri-Guard®) to repair tunical defects in patients with PD, descriptive study of 43 patients with disabling penile curvature was performed. Curvature was measured before and after the intervention using a standardized procedure. Surgical technique was plaque excision and grafting of the tunical defect carried out by a single surgeon. A lyophilized bovine pericardium patch was used for grafting. We measured the change in penile curvature and length, the ability to perform successful sexual intercourse without further pharmacological or surgical treatment, and the satisfaction with treatment. Follow-up data were available for a total of 41 patients. Median age was 50 years (IQR 48-52); mean follow-up time was 14 ± 6 months. Complete penile straightening was achieved in 33 patients (80.5%) and five patients (12.2%) had curvature under 20°. Three months after surgery and stretching therapy, mean (s.d.) flaccid penile length increased from 11.2 ± 2.8 cm to 12.1 ± 2.9 cm (P = 0.062). Seventy-five percentage of patients reported being able to achieve successful intercourse without further treatment. Eighty-five percentage of patients reported to be satisfied with the treatment. There was no evidence of tissue rejection or infection, and only four patients suffered an adverse event. Plaque excision and grafting of the tunical defect with lyophilized bovine pericardium seems to be a safe and effective treatment for patients with PD.

Advances in stem cell research for the treatment of male sexual dysfunctions

PURPOSE OF REVIEW

To summarize recent literature on basic stem cell research in erectile dysfunction in cavernous nerve injury, aging, diabetes, and Peyronie's disease and to provide a perspective on clinical translation of these cellular therapies.

RECENT FINDINGS

Stem cell research has been concentrated on mesenchymal stem (stromal) cells from bone marrow and adipose tissue. Application of both cell types has produced positive effects on erectile function in various animal models of erectile dysfunction. In acute animal models, such as cavernous nerve injury-induced erectile dysfunction and chemically induced Peyronie's disease, engraftment and differentiation have not been observed, and stem cells are believed to interact with the host tissue in a paracrine fashion, whereas in chronic disease models some evidence suggests both engraftment and paracrine factors may support improved function. Clinical trials are now investigating therapeutic efficacy of cellular therapy, whereas the first safety studies in humans have recently been published.

SUMMARY

Evidence from preclinical studies has established stem cells as a potential curative treatment for erectile dysfunction and early phase clinical trials are currently performed.

Grafting techniques for Peyronie's disease

Peyronie’s disease (PD) is a benign fibrotic condition of the penile tunica albuginea. PD can be associated with penile pain, curvature, shortening, and erectile dysfunction (ED). The predominant and most bothersome symptom in affected patients is penile curvature, which can lead to inability to have sexual intercourse. In such cases, surgical correction of the curvature may be required. Plication techniques to correct curvature can cause penile shortening and therefore are generally reserved for curvatures <60°. Penile prosthesis implantation with simultaneous correction of curvature by various means is recommended in PD patients with ED not responding to medical therapy. Grafting techniques are the preferred surgical treatment in patients with penile curvatures >60°, short penis, or hourglass deformity. Patients scheduled for grafting surgery are required to have satisfactory erectile rigidity preoperatively. There are various grafting materials that can be used for closure of the tunica albuginea defect following plaque incision/excision. Both autologous and non-autologous grafts have been used for PD reconstructive surgery, and each graft has its advantages and disadvantages. Novel grafting materials are presented and discussed in this review. A major advantage of the available “off-the-shelf” grafts is that there is no harvesting from a donor site and, thus, morbidity is reduced, and operative times are minimized. Further investigations in regard to tissue-engineered grafts to improve surgical handling and postoperative outcomes are ongoing. Surgeon experience, careful patient selection, patient preference and type of penile deformity affect the choice of graft. This review summarizes the literature within the past 5 years regarding grafting techniques in PD. Surgical outcomes and limitations of grafting techniques are reported. A major objective of this review is dedicated to preoperative considerations and indications for grafting procedures, with the aim to improve surgical outcomes and increase patient satisfaction. Proper postoperative management of patients after incision/excision and grafting is important to avoid early and long-term complications and unwanted outcomes. This review provides an overview of recent advances and recommendations in regard to rehabilitation strategies after grafting procedures. Adequate preoperative patient counseling, careful patient selection, appropriate indications, and postoperative management is key to optimal surgical outcomes with high satisfaction rates after grafting techniques in PD surgery.

Research highlights on stem cell therapy for the treatment of Peyronie's disease

New treatment modalities have been developed to improve the treatment outcomes of Peyronie’s disease (PD). Stem cells are undifferentiated cell populations that are capable of self-renewal and of differentiation into various kinds of cells or new tissues. In addition, stem cells also have antiapoptotic, antifibrotic, and immunomodulatory properties. The results from preclinical studies support the potential role of adipose-derived stem cells (ADSCs) therapy for both the prevention and treatment of PD. However, there are several limitations of the animal model used in the studies. Further animal and clinical studies are still needed to validate the therapeutic effects and clinical application of ADSCs for the treatment of PD.

Oral therapy for Peyronie's disease, does it work?

Peyronie's disease (PD) is a localized, wound-healing, connective tissue disorder of the penis characterized by scarring of the tunica albuginea. This fibrous inelastic scar leads to penile pain, penile deformity and erectile dysfunction (ED), and a difficulty performing coitus. Over the past several decades, a myriad of oral agents for the treatment of PD have been studied and suggested. While the gold standard of care remains surgical therapy, many physicians continue to prescribe oral and intralesional injections for treatment during the acute phase of the disease. This article seeks to summarize the different oral therapy agents for PD and the research associated with each medication. While the American Urological Association has not recommended most of the mentioned medications for the treatment of PD, two newer therapies have shown success and have the potential of becoming baseline treatments for the acute phase of PD.

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.