Concordance between patient and physician assessment of the magnitude of Peyronie's disease curvature

The Emerging Role of Artificial Intelligence and Automated Platforms for the Assessment of Penile Curvature: A Scoping Review

PURPOSE OF THE REVIEW

The estimation of penile curvature is an essential component in the assessment of both Peyronie's disease and hypospadias-associated congenital penile curvature, as the degree of curvature can significantly impact treatment decision-making. However, there is a lack of standardization in curvature assessment and current methodologies are prone to inaccuracies. With the rise of artificial intelligence (AI) in urology, new research has explored its applications in penile curvature assessment. This review aims to evaluate the current uses of AI and other automated platforms for assessing penile curvature.

RECENT FINDINGS

Several novel and promising tools have been developed to estimate penile curvature, some utilizing AI-driven models and others employing automated computational models. These platforms aim to improve curvature assessment in various settings, including at-home evaluation of Peyronie's disease, in-office assessments using three-dimensional (3D) methodologies, and preoperative evaluations for hypospadias repair. In general, these new platforms produce highly accurate and reproducible angle estimates in non-clinical studies, however their effectiveness and relation to patient outcomes has had limited evaluation in clinical settings. Significant advancements have been made in the assessment and estimation of penile curvature in both Peyronie's and pediatric patients, largely driven by AI and other automated platforms. Continued research is needed to validate these findings in clinical studies, confirm their efficacy, and assess their feasibility for real-world applications.

Patients' attitude with surgery for Peyronie's disease: results from a multicentric European study

BACKGROUND

Despite the existence of conservative therapies for Peyronie's disease (PD), surgery is commonly utilized for the treatment of bothersome curvatures due to its potential effectiveness, although it carries intrinsic risks and may not universally lead to satisfactory outcomes.

AIM

To explore the rate and factors influencing patients' willingness to undergo surgery for PD.

METHODS

Data were prospectively collected in 5 European academic centers between 2016 and 2020. Data included age, time from PD onset, penile pain, curvature degree, difficulty at penetration, hourglass deformity, erectile dysfunction (ED), and previous treatments. All patients were offered conservative treatments, either medications or injections. Tunical shortening or lengthening procedures were offered as an alternative to conservative treatments, when indicated. Penile prosthesis was offered to those with concomitant ED. Patients' attitudes with surgery were recorded. Logistic regression analyses tested the profile of patients who were more likely to be willing to undergo surgery.

OUTCOMES

Patients' willingness to undergo surgery for PD.

RESULTS

This study included 343 patients with a median age of 57.3 years (IQR, 49.8-63.6) and a median penile curvature of 40.0° (IQR, 30.0°-65.0°). Overall, 161 (47%) experienced penetration difficulties and 134 (39%) reported ED. Additionally, hourglass deformity and penile shortening were reported by 48 (14%) and 157 (46%), respectively. As for previous treatments, 128 (37%) received tadalafil once daily; 54 (16%) and 44 (13%), intraplaque verapamil and collagenase injections; and 30 (9%), low-intensity shock wave therapy. Significant curvature reduction (≥20°) was observed in 69 (20%) cases. Only 126 (37%) patients were open to surgery for PD when suggested. At logistic regression analysis after adjusting for confounders, younger age (odds ratio [OR], 0.97; 95% CI, 0.95-1.00; P = .02), more severe curvatures (OR, 1.04; 95% CI, 1.03-1.06; P < .0001), and difficulty in penetration (OR, 1.88; 95% CI, 1.04-3.41; P = .03) were associated with a greater attitude to consider surgical treatment.

CLINICAL IMPLICATIONS

The need for effective nonsurgical treatments for PD is crucial, as is comprehensive patient counseling regarding surgical risks and benefits, particularly to younger males with severe curvatures.

STRENGTHS AND LIMITATIONS

Main limitations are the cross-sectional design and the potential neglect of confounding factors.

CONCLUSIONS

Patients with PD, having a lower inclination toward surgery, emphasize the need for effective nonsurgical alternatives and accurate counseling on the risks and benefits of PD surgery, particularly for younger men with severe curvatures.

3D-printed phantoms to quantify accuracy and variability of goniometric and volumetric assessment of Peyronie's disease deformities

Characterization of Peyronie's disease (PD) involves manual goniometry and penile length measurement. These techniques neglect volume loss or hourglass deformities. Inter-provider variability complicates accuracy. Using 3D-printed models, we aimed to evaluate measurement accuracy and variability and establish computational assessment workflows. Five digital phantoms were created: 13.0 cm cylinder, 13.0 cm hourglass cylinder, 15.0 cm cylinder with 40° angulation, 12.0 cm straight penis, and 12.9 cm PD penis with 68° angulation and hourglass. Lengths, volumes, and angles were determined computationally. Each phantom was 3D-printed. Ten urology providers determined lengths, angles, and volumes with measuring tape, goniometer, and volume calculator. Provider versus computational measurements were compared to determine accuracy using t-tests or Wilcoxon rank-sum tests. No significant differences were observed between manual assessment of length of penile models and designed length in penile models. Average curvature angles from providers for bent cylinder and PD phantoms were 38.3° ± 3.9° (p = 0.25) and 57.5° ± 7.2° (p = 0.006), respectively. When assessing for volume, hourglass cylinder and bent cylinder showed significant differences between designed volume and provider averages. All assessments of length, angle, and volume showed significant provider variability. Our results suggest manual measurements suffer from inaccuracy and variability. Computational workflows are useful for improved accuracy and volume assessment.

Treatment-related Outcomes for Patients With Atypical Peyronie's Disease Using Xiaflex Injections

OBJECTIVE

To evaluate the efficacy and safety of collagenase Clostridium histolyticum (CCH) for the management of penile deformities in patients presenting with different categories of atypical Peyronie's disease (PD).

METHODS

We conducted a retrospective review of charts of patients who presented to a men's health clinic with atypical PD between October 2016 and June 2019. We included patients in the stable phase of the disease, had completed a penile duplex Doppler ultrasound before any intervention, and proceeded with CCH treatment. Gathered data included patient demographics, treatment details, outcomes, and complications. Outcomes collected were both quantitative (curvature assessments) and qualitative using the symptom bother domain (last 6 questions; Q10 to Q15) of the Peyronie's Disease Questionnaire.

RESULTS

Twenty-one men with stable PD underwent CCH inject therapy after penile duplex Doppler ultrasound. The mean number of injections was 8.4 (standard deviation [SD] = 3.3), and the mean follow-up was 20.5 months (SD = 5.9). The overall mean change in penile curvature was -19.2° ± 8.3°, which corresponded to a -39% ± 13% improvement in curvature (P = .0079). In men who presented with an indentation or hourglass deformity, 11 of 17 (64%) were satisfied and reported subjective improvement in narrowing/indentation after receiving CCH injections. The average composite symptom bother domain of the Peyronie's Disease Questionnaire decreased by 6.7 (P = .0029).

CONCLUSION

Our results suggest that CCH appears to be safe and provide significant clinical improvements in men presenting with atypical PD.

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.

The Effectiveness of 3-D Computed Tomography in the Evaluation of Penile Deformities in Patients With Peyronie's Disease: A Pilot Study

Background

Anatomic and functional evaluation of the penis before treatment is very important in the choice of treatment in patients with Peyronie’s disease (PD).

Aim

To compare 3 different methods for the evaluation of the penile deformity, including auto-photography, combined intracavernous injection stimulation test (CIS), and 3-dimensional computed tomography (3D CT) during artificial penile erection in patients with PD.

Methods

Pretreatment penile deformities of patients with PD were compared with those detected with auto-photography, using goniometer after intracavernosal vasoactive agent, and 3D CT correlations among these 3 methods were investigated.

Main Outcome Measures

Assessments of penile curvature with auto-photography, CIS, and 3D CT.

Results

The mean age of 36 patients who were included in the study was 58 ± 8.25 (36–72) years, and the mean time since the onset of the disease was 25 ± 24 months (2–144). Degrees of penile curvatures measured using auto-photography, CIS, and CT were determined as 24° (0°–80°), 40° (0°–90°), and 34° (0°–80°), respectively. When general correlation analysis was performed to evaluate the penile curvatures of all patients using 3 methods, a moderate correlation between auto-photography and both CIS (r = 0.72, P < .001) and 3D CT (r = 0.56, P < .001) was detected, whereas a strong correlation was noticed between CIS and 3D CT (r = 0.78, P < .001). When the correlation analysis between patients with and without ED was examined, a statistically significant decrease in the strength of correlation between CIS and auto-photography in patients with ED (0.629 vs 0.925, P < .05), however, was detected without any statistically significant difference in patients without ED (0.694 vs 0.813, P > .05).

Conclusion

The superiority of 3D CT over auto-photography and its strong correlation with CIS in most parameters have been demonstrated. However, it was found that CT did not give more information than the evaluation with CIS. Current limitations and cost increases limit the use of 3D CT in the assessment of PD.

Özmez A, Ortac M, Cevik G, et al. The Effectiveness of 3-D Computed Tomography in the Evaluation of Penile Deformities in Patients With Peyronie's Disease: A Pilot Study. Sex Med 2019;7:311–317.

What about the partner? -factors associated with patient-perceived partner dyspareunia in men with Peyronie's disease

Background

Limited data are available on how partners of men with Peyronie's disease (PD) are affected by the disease. We sought to characterize PD patients whose curvatures result in pain for their partners during penetrative intercourse.

Methods

We queried a database of all men undergoing initial evaluation for PD at a single clinic between March 2014 and June 2016. Patients were administered a questionnaire regarding sexual health concerns with domains including erectile dysfunction, ejaculatory dysfunction, libido, and penile curvature. In the penile curvature section, patients were specifically asked: "Does the curvature cause your partner any pain during penetrative intercourse? (Y/N)." Patients' partners were not directly evaluated for conditions associated with dyspareunia. Additionally, patients interested in treatment for PD underwent objective curve assessment after intracavernosal injection of erectogenic medications along with penile duplex Doppler ultrasound. Statistical analysis was performed to identify differences in clinicopathologic variables and patient-responses to questionnaire prompts between patients who did and did not report partner pain with intercourse.

Results

A total of 322 patients with information available on partner pain were included in the study. Patients who reported partner pain had significantly higher subjective erectile rigidity (mean 5.9/10 vs. 4.8/10, P=0.02) and patient-reported penile curvature (47.7° vs. 33.3°, P<0.001) compared to those who did not report pain. Ventral curvatures were more common in men with partner pain (21% vs. 9% of men without, P<0.05). Furthermore, patients complaining of partner pain were more likely to report that PD had a negative impact on relationships and were more interested in pursuing surgical corrections.

Conclusions

Men with superior erectile function, higher degrees of penile curvature and ventral curvatures were more likely to report partner pain during penetrative intercourse. These specific disease characteristics reported in this series may assist clinicians in identifying men who are more motivated to select more invasive therapies.

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.

The test-retest reliability of the Peyronie's disease questionnaire

INTRODUCTION

The Peyronie's Disease Questionnaire (PDQ) is a disease-specific, patient-reported outcome instrument designed to measure the psychosexual consequences and treatment outcomes of Peyronie's disease (PD).

AIM

The aim of this study was to evaluate the test-retest reliability of the PDQ.

METHODS

Adult men with PD were recruited through eight clinical sites across the United States. Participants completed the PDQ during two study visits scheduled 7 (± 3) days apart. At Visit 1, participants completed a sociodemographic questionnaire, the PDQ, and the International Index of Erectile Function (IIEF). At Visit 2, participants repeated the PDQ and completed an Overall Treatment Effect (OTE) scale. Test-retest reliability of the PDQ was assessed in a stable subsample (as determined by responses to the OTE). Intraclass correlation coefficients (ICCs) were calculated to evaluate the degree of association between the three PDQ subscale scores at Visits 1 and 2. Internal consistency of the subscales was also evaluated using Cronbach's alpha.

MAIN OUTCOME MEASURE

The main outcome measure was the PDQ.

RESULTS

Of the 61 PD patients (mean age 59.3) who took part in the study, the majority were not receiving treatment for their PD (n=35, 57.4%). The sample's mean score on the erectile function domain of IIEF was 19.7 (± 8.2), indicating mild-moderate dysfunction. Nearly two-thirds reported penile pain at baseline (n=37, 63.8%). Of the participants with baseline PDQ data and who had engaged in vaginal intercourse in the past 3 months, 57 completed both study visits. The PDQ demonstrated excellent test-retest reliability in 53 stable patients. The ICC was 0.85 for the Psychological and Physical Symptom subscale, 0.89 for the Peyronie's Symptom Bother subscale, and 0.88 for the Penile Pain subscale. The Cronbach's alpha estimates for all three subscales were acceptable at the >0.70 level.

CONCLUSIONS

The PDQ is a highly reproducible measure of PD and can be an effective end point in clinical trials evaluating treatments for PD.