Long-term follow-up of penile curvature correction utilizing autologous albugineal crural graft

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.

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.

Avaliação morfofuncional do enxerto de túnica albugínea suína na cistoplastia em ratos

RESUMO O objetivo deste trabalho é avaliar o uso da túnica albugínea suína na cistoplastia em ratos, avaliando funcionalidade, capacidade de reparação do órgão e possibilidades de complicações. Foram selecionados 30 ratos Wistar, machos, de seis meses de idade, divididos em: um grupo teste (TA), em que os animais receberam o enxerto de túnica albugínea suína após a cistectomia parcial e um grupo controle (C), em que os animais sofreram somente a cistectomia parcial. Os animais pertencentes a ambos os grupos foram divididos igualmente em subgrupos de cinco animais cada, que sofreram eutanásia em sete, 28 e 42 dias de pós-operatório. Foi realizada uma análise macroscópica e, posteriormente, uma análise histopatológica da região da ferida cirúrgica. Aos sete e 28 dias, os animais pertencentes ao grupo C e ao grupo TA apresentaram urotelização, regeneração da lâmina própria e da musculatura, porém o grupo TA apresentou menores sinais inflamatórios e maior organização tecidual, principalmente com relação à formação das fibras musculares. Aos 42 dias de pós-operatório, ambos os grupos já apresentavam características histológicas normais. Concluiu-se que o enxerto de túnica albugínea suína obteve sucesso na regeneração da bexiga de ratos, mantendo a funcionalidade do órgão, sem rejeição, e favorecendo a migração celular.

Evidence-Based Management Guidelines on Peyronie's Disease

INTRODUCTION

Despite recent advances in our knowledge and treatment strategies in Peyronie's Disease (PD), much remained unknown about this disease.

AIM

To provide a clinical framework and key guideline statements to assist clinicians in an evidence-based management of PD.

METHODS

A systematic literature search was conducted to identify published literature relevant to PD. The search included all relevant articles published up to June 2015, including preclinical studies and published guidelines. References used in the text were assessed according to their level of evidence, and guideline recommendations were graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Owing to the paucity of larger series and randomized placebo-controlled trials with regard to surgical intervention, guideline statements are provided as clinical principle or expert opinion.

MAIN OUTCOME MEASURES

This literature was discussed at a panel meeting, and selected articles with the highest evidence available were used to create consensus guideline statements for the Fourth International Consultation on Sexual Medicine guidelines on PD.

RESULTS

In addition to existing Third International Consultation on Sexual Medicine guidelines on PD, seven new summary recommendations were created.

CONCLUSION

A greater understanding of the scientific basis of PD is greatly needed to address our understanding of the pathophysiology, clinical epidemiology, psychosocial, and diagnostic assessment as well as treatment strategies.

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.

Cavernoplasty with oral mucosa graft for the surgical treatment of Peyronie's disease

BACKGROUND

Peyronie's disease is a disorder of the tunica albuginea and causes penile curvature, requiring surgical correction when the deformity impedes penetration.

MATERIAL AND METHODS

Retrospective analysis of the short-term results (penile length, angle of curvature and erectile function) of treating Peyronie's disease in 10 patients through cavernoplasty with oral mucosa graft. Essentially, the treatment included the incision of the fibrotic plaque with electrical scalpel and the subsequent coating of the cavernous defect using a patch of oral mucosa. At month 6, we measured the penile length and curvature and recorded the erectile function using the International Index of Erectile Function-5 (IIEF-5) questionnaire. Finally, the patients were asked "Would you undergo the same operation again?".

RESULTS

The mean age was 53.4 years. The average and median follow-up was 22.7 months and 24 months, respectively. The mean preoperative curvature was 68.5° (50°-90°), the mean penile length was 11.2cm (9-15) and the mean IIEF-5 score was 16.1 (8-25). The mean postoperative penile length was 10.7cm, and the mean IIEF-5 score was 18.9. The differences between the preoperative and postoperative values were not statistically significant (P=ns). One patient developed erectile dysfunction. In all cases, the residual curvature was <20°. Nine patients (90%) stated that they would undergo the same operation.

CONCLUSIONS

The short-term results suggest that cavernoplasty with oral mucosa graft can be an alternative to traditional grafts for surgically correcting Peyronie's disease.

Rotation of the corpora cavernosa for the treatment of congenital penile curvature

INTRODUCTION

Congenital penile curvature (CPC) is caused by a disorder in the embryonic development of the urethra and corpora cavernosa. The condition causes difficulty for penetration, requiring surgical correction when it prevents intercourse.

MATERIAL AND METHODS

We present the cases of 2 men in their 40s who had ventral curvature greater than 60° of 2 years of evolution, with maintained erections. The patients underwent surgery for rotation of the corpora cavernosa. After the complete denudation of the penis, athermal release of the neurovascular bundle of the penis from the ventral side to the dorsal was performed. Once the curvature was verified using artificial erection, an incision was performed in the tunica albuginea of both corpora cavernosa, continuously suturing both internal and external margins with resorbable monofilament. The rectification of the curvature was then checked, and the mucocutaneous plane was reconstructed.

RESULTS

The surgical time was 120minutes and there were no intraoperative complications. Both patients were discharged 24h after the surgery. At 1 week, the patients experienced spontaneous night-time erections and were able to maintain sexual relations 1 month after the surgery. At 6 months, the residual curvature was less than 20°, the penile shortening was less than 1 centimeter and the International Index of Erectile Function-5 was 25 for both cases.

CONCLUSIONS

Surgery for rotation of the corpora cavernosa helps correct CPC without significant penile shortening or erectile dysfunction. In our opinion, the procedure is an appropriate treatment for patients with CPC but requires studies with long-term follow-up in order to consider it the technique of choice.

Surgery for Peyronie's disease

Peyronie's disease (PD) is most simply referred to as a fibrotic wound-healing disorder of the tunica albuginea. It is both a physically and psychologically devastating disorder that causes penile deformity, curvature, hinging, narrowing and shortening, which may compromise sexual function. Although a variety of non-surgical treatments have been suggested, none to date offer a reliable and effective correction of the penile deformity. As a result, surgery remains the gold standard treatment option, offering the most rapid and reliable treatment which will be the focus of this article. We review the preoperative evaluation, surgical algorithm, graft materials and postoperative management of PD. Outcomes for tunical shortening, tunical lengthening and penile prosthesis placement for penile straightening are reviewed. Tunica albuginea plication is the preferred method of straightening for men with adequate rigidity and less severe disease defined as curvature less than 70° without narrowing/hinging. Men who have more severe, complex deformity, but maintain strong preoperative erectile function should be considered candidates for straightening with plaque incision or partial excision and grafting. Finally, for those men who have inadequate rigidity and PD, penile prosthesis placement with straightening is the best approach to address both problems.