Penile prosthesis implant in the management of Peyronies' disease

Long-term outcomes of extracorporeal shock wave therapy for acute Peyronie's disease: a 10-year retrospective analysis

The aim of this paper was to describe the long-term outcomes of extracorporeal shock wave therapy (ESWT) in patients with acute Peyronie'disease (PD). An observational retrospective study was conducted in men with acute PD who underwent ESWT between 2009-2013 at a single institution. ESWT protocol consisted of 1 session (3000 shock waves, 0.10-0.25 mJ/mm^2, 4-6 Hz) per week for 4 weeks. Penile pain was chosen as the primary outcome. Penile curvature angle, erectile function, and satisfaction with ESWT were selected as secondary long-term outcomes. A total of 194 patients were included. The mean follow-up duration after ESWT was 125.6 months. Mean penile curvature worsened significantly at 3 months (18.3 vs. 21.5 degrees; p = 0.023) and 12 months (21.5 vs. 28.6 degrees; p = 0.001) and stabilized over the long-term (28.6 vs. 28.8 degrees; p = 0.335). Mean penile pain improved significantly at 3 months (6.5 vs. 3.1 points; p < 0.001) and 12 months (3.1 vs. 1.0 points; p = 0.001), remaining stable over time (1.0 vs. 1.0 points; p = 0.074). The mean five-item version of the International Index of Erectile Function (IIEF-5) increased significantly at 3 months (14.5 vs. 17.9 points; p = 0.001), remaining stable at 12 months (17.9 vs. 18.5 points; p = 0.082), and deteriorating in the long-term (18.5 vs. 15.8 points; p = 0.003). A high satisfaction rate with ESWT was recorded at 3 months (92.3%), remaining similar at 12 months (91.2%) and over the long-term (90.2%). No new acute phase and low rate of PD surgery (4.1%) were recorded in the long-term analysis. In patients with acute PD, ESWT seems to be associated with early and persistent relief of penile pain, transient improvement in erectile function, no significant effect on penile curvature, and a high rate of patient satisfaction constant over time.

Treatment preferences of patients with erectile dysfunction: a systematic review of randomized controlled trials

INTRODUCTION

Patients' treatment preferences (PTP) depend on the complex interaction of numerous patient- and treatment-related factors; their assessment can guide therapy and promote compliance of patients with erectile dysfunction (ED). We aimed to systematically describe the literature evaluating the treatment preferences of patients with ED, published in the last 25 years.

EVIDENCE ACQUISITION

A comprehensive bibliographic search of multiple databases was conducted in June, 2023. The literature search was limited to the articles published since 1998. Articles were deemed eligible if they described male patients with ED (P) undergoing treatment for this condition (I) compared with other treatments, placebo or sham therapy (C), and reported PTP (O). Only randomized controlled trials (RCTs) and post-hoc analyses of RCTs were selected (S). The data were presented in a narrative fashion. The risk of bias (RoB) was evaluated using the RoB 2 tool and the Mulhall-Montorsi model.

EVIDENCE SYNTHESIS

A total 14 RCTs evaluating 6,841 patients and 4 post-hoc analyses of RCTs were included. All RCTs were considered to be at high RoB. No validated tool was used to investigate PTP. Sildenafil was the most frequently evaluated ED treatment (9 RCTs). Sildenafil was chosen over placebo by 78-100% of subjects and over ICI in 70% of patients due to its easier route of administration. No significant difference in patient preference was recorded between Sildenafil tablets and orodispersible (53% vs. 47%, P>0.05). Tadalafil was preferred over Sildenafil by 66-73% of patients (P<0.05), mainly because it allowed an erection long after taking the drug (55-67%). Tadalafil as-needed was chosen over Tadalafil 3 times/week by 57-59% of the patients (P<0.05).

CONCLUSIONS

The available RCTs support the preference of ED patients for Sildenafil over ICI, Tadalafil over Sildenafil, and Tadalafil as-needed over Tadalafil 3 times/week. However, these findings should be considered at high RoB.

Long-term outcomes after plaque excision grafting for Peyronie's disease and subanalysis of patients who undergo the procedure despite preoperative counseling against it

BACKGROUND

Plaque excision and grafting (PEG) has been recommended for patients with Peyronie's disease (PD) with >60° curvature and/or hinge effect and strong preoperative erections, while placement of an inflatable penile prosthesis (IPP) is recommended when rigidity is suboptimal. Nevertheless, many patients counseled to undergo an IPP decline and insist on proceeding with PEG due to personal preference or desire to avoid an implant.

AIM

We aim to review long-term outcomes in patients who underwent PEG for PD at our institution and investigate whether there is any difference in long-term outcomes in patients who undergo PEG despite a recommendation to undergo IPP.

METHODS

We conducted a retrospective chart review from 2007 to 2021 on PEG surgery performed at a single tertiary care institution in patients ≥18 years old who had >3 months of follow-up.

OUTCOMES

Postoperative information was gathered from the electronic medical record, including postoperative erectile function, patient satisfaction, and the ability to engage in penetrative sexual intercourse.

RESULTS

An overall 251 patients underwent PEG with a median follow-up of 12 months (IQR, 6-54). Among these, 54 (22%) were initially advised to undergo IPP but elected for PEG. Patients who underwent PEG despite counseling to undergo IPP reported lower postoperative ability to engage in intercourse (51% vs 76%). Seven (13%) patients initially advised to undergo IPP eventually received an IPP, relative to 7 (4%) initially advised to undergo PEG.

CLINICAL IMPLICATIONS

Thorough preoperative assessment of erectile function and penile deformity can guide clinician counseling and manage patient expectations during decision making between PEG surgery and IPP implantation for PD.

STRENGTHS AND LIMITATIONS

Limitations of this study include its retrospective nature, high attrition to follow-up, and risk of recall and selection bias. This is a large study with a median follow-up of 12 months, with a high-volume single surgeon who treats patients in a specialized population of complex cases.

CONCLUSION

Patients who were initially counseled to undergo IPP due to suboptimal erectile rigidity but elected for PEG had worse postoperative ability to engage in penetrative intercourse, and a higher proportion of these patients eventually received an IPP.

Penoscrotal approach for inflatable penile prosthesis implant: why it should be preferred

INTRODUCTION

Inflatable penile prosthesis are the definitive treatment for erectile dysfunction. The two most used surgical approaches to position the implants are the penoscrotal and the infrapubic. Current trends showed that the penoscrotal approach is extensively preferred however, there is not conclusive evidence demonstrating the superiority of one technique over the other. The aim of this review is to summarize the scientific evidence available and to underline strengths and weaknesses of the two techniques.

EVIDENCE ACQUISITION

We conducted a comprehensive search of MEDLINE, Cochrane Library, and National Center for Biotechnology Information PubMed to identify relevant published articles. The included studies had to explicitly examine the use of three-piece inflatable penile prosthesis with a focus on the surgical access method and complications.

EVIDENCE SYNTHESIS

Twenty-six articles were included in the review: seven narrative reviews, five retrospective observational studies, five prospective observational studies, and nine mixed methodology studies. The most frequent approach was the penoscrotal, which was also found more comfortable (RG1) by the operators in one study. The infrapubic approach lasts less and one study demonstrated higher satisfaction by the patients.

CONCLUSIONS

There is no evidence of significant differences in complications among the penoscrotal and infrapubic approaches. While the infrapubic approach is faster and patients were more satisfied, the penoscrotal approach is the most used by far. This is likely related to the more straightforward procedure through this access and the excellent surgical field exposure. For these reasons, it is also preferred in the most complex cases.

History of penile implants: from implants made of bone to modern inflatable penile implants

Penile prostheses are implantable devices used to definitively treat erectile dysfunction when previous forms of treatment have failed. The first example of a penile implant dates to 1935, when a rib was inserted in a neo-phallus reconstructed after a traumatic amputation. Since then, alternative artificial devices were adopted as penile prosthetic implants. The evolution of prosthetic devices had a dramatic thrust in 1973 when the first inflatable penile prosthesis was worldwide presented. Thanks to advances in device materials, design, surgical implant techniques, and perioperative management, nowadays inflatable penile prostheses are one of the most adopted definitive therapy for patients with drug-refractory erectile dysfunction or refusing alternative forms of treatments. Moreover, the clinical indications for inflatable penile prosthesis have also expanded, including female-to-male transmen or men underwent penile reconstruction due to congenital aphallia or traumatic or surgical penile amputation. In order to summarise the process behind the development and evolution of penile prosthesis, we aimed at performing a historical review of the currently available literature to provide an easy and comprehensive overview of the topic. The understanding of the historical process behind the evolution of inflatable penile prostheses will drive further innovation to increase efficiency and the rate of patients satisfaction.

Molecular Mechanisms and Risk Factors Related to the Pathogenesis of Peyronie's Disease

Peyronie's disease (PD) is a benign condition caused by plaque formation on the tunica albuginea of the penis. It is associated with penile pain, curvature, and shortening, and contributes to erectile dysfunction, which worsens patient quality of life. In recent years, research into understanding of the detailed mechanisms and risk factors involved in the development of PD has been increasing. In this review, the pathological mechanisms and several closely related signaling pathways, including TGF-β, WNT/β-catenin, Hedgehog, YAP/TAZ, MAPK, ROCK, and PI3K/AKT, are described. Findings regarding cross-talk among these pathways are then discussed to elucidate the complicated cascade behind tunica albuginea fibrosis. Finally, various risk factors including the genes involved in the development of PD are presented and their association with the disease summarized. The purpose of this review is to provide a better understanding regarding the involvement of risk factors in the molecular mechanisms associated with PD pathogenesis, as well as to provide insight into disease prevention and novel therapeutic interventions.

The use of collagen fleece to correct residual curvature during inflatable penile prosthesis implantation (PICS technique) in patients with complex Peyronie disease: a multicenter study

BACKGROUND

The PICS technique (penile implant in combination with the sealing) was recently described as a valuable option to correct residual curvature during inflatable penile prosthesis (IPP) implantation in patients with complex Peyronie disease (PD).

AIM

To report the surgical and functional outcomes of the PICS technique in a multicentric series of patients.

METHODS

A consecutive series of patients with complex PD who underwent PICS were recruited. Patients were from 2 European tertiary referral centers. Data regarding baseline characteristics and perioperative, postoperative, and functional outcomes were retrospectively evaluated.

OUTCOMES

Complete penile straightness, duration of operative time and hospital stay, as well as postoperative complications (including hematoma, IPP infection, and IPP mechanical failure) were recorded, whereas functional outcomes were evaluated through the administration of validated questionnaires at baseline and 12 months postoperatively: International Index of Erectile Function-5, Sexual Encounter Profile questions 2 and 3 (SEP-2 and SEP-3), and Erectile Dysfunction Inventory of Treatment Satisfaction.

RESULTS

Thirty-seven patients with a median age of 62 years (IQR, 57-70 years) were enrolled. Median preoperative curvature was 75° (IQR, 65°-77°). Median residual curvature after IPP implantation was 60° (IQR, 50°-70°). Overall, 31 patients (84%) achieved a totally straight penis. Only 6 patients (16%) experienced a residual penile curvature (<20° in all cases) after the procedure. No intraoperative complications were detected. Nine patients (24%) developed an early postoperative complication, 3 (8%) a transient fever, and 6 (16%) a genital hematoma. A single case of IPP acute infection requiring device explantation was recorded. The survey response rate was 100%. At the 12-month follow-up evaluation, the median IIEF-5 score was 23.5 (IQR, 22.2-25) with evident improvement vs the baseline value of 10 (IQR, 8-12). Accordingly, 92% of the patients responded positively to SEP-2 and SEP-3. For the Erectile Dysfunction Inventory of Treatment Satisfaction, patients recorded a median postoperative value of 25 (IQR, 21-30) 1 year after PICS.

CLINICAL IMPLICATIONS

Complex PD is an end-stage disease featured by severe penile curvature, penile shortening, and erectile dysfunction: the gold standard approach is deemed to be penile prosthesis implantation, aiming to address penile curvature and erectile dysfunction, but in a limited percentage of cases, additional maneuvers are deemed necessary to manage residual penile curvature.

STRENGTHS AND LIMITATIONS

Our study has some limitations: the retrospective nature, relatively short follow-up, and limited number of patients.

CONCLUSION

The PICS technique may represent a reliable and effective treatment option to address significant residual curvature after IPP implantation.

Voice Assistants as Consultants for Male Patients with Sexual Dysfunction: A Reliable Option?

The aim of this study was to evaluate the ability of Google Assistant, Alexa, and Siri to recognize and answer questions about male sexual health. Each VA was tested on a smart speaker: Alexa on Amazon Echo Dot 4th Gen., Google Assistant on Google Home Mini, and Siri on Apple HomePod. A pool of patients' frequently asked questions regarding erectile dysfunction (ED), premature ejaculation (PE), Peyronie's disease (PD), male infertility, and other aspects of male sexual health were identified by authors. The recognition of question was evaluated ("yes" or "not"). For each recognized question, the response characteristics (domains) were rated on a scale from 0 to 10 (according to the quality). We chose the recognition rate of the questions as the primary outcome and the quality of the answers as the secondary outcome. Overall, the best VA in recognizing questions was Siri, with a total of 83.3% questions compared with 64.0% for Alexa (p = 0.024) and 74.0% for Google Assistant (p = 0.061). Siri was associated with a significantly higher recognition rate than Alexa for PE (80% vs. 40%; p = 0.002) and PD (66.7% vs. 33.3%; p = 0.010). The quality of the responses was classified as low in 57 out of 105 cases (54.3%), intermediate in 46 cases (43.8%), and high in only 2 cases (1.9%), highlighting an overall intermediate-low quality of the answers. Male infertility was the condition associated with the highest mean scores in "Targeted response to the problem" (7.32 ± 2.57), "Scientific correctness of the answer", (5.9 ± 2.76) "Completeness of the answer" (5.14 ± 2.56), and "Understandability of the response for a patient" (5.3 ± 2.51) domains. Siri was associated with significantly higher scores than Alexa (p < 0.05) in several domains of all conditions evaluated. The question recognition rate of VAs is quite high; however, the quality of the answers is still intermediate-low. Siri seems superior to Alexa in both question recognition and response quality. Male infertility appears to be the sexual dysfunction best addressed by VAs.

Impact of extracorporeal shockwave therapy for erectile dysfunction and peyronie's disease on reproductive and hormonal testicular function

Introduction

Extracorporeal shock wave therapy is an established treatment for erectile dysfunction and Peyronie's disease. Concerns regarding the safety of extracorporeal shock wave therapy for andrological purposes on testicular function were raised by animal studies.

Aim

To evaluate the impact of extracorporeal shock wave therapy for erectile dysfunction or Peyronie's disease on reproductive and hormonal testicular function.

Methods

We designed a prospective controlled study in which consecutive patients were enrolled. Males aged between 18 and 40 years with mild vasculogenic erectile dysfunction or acute inflammatory Peyronie's disease and normozoospermia were included. All enrolled patients were offered extracorporeal shock wave therapy, and subjects who refused extracorporeal shock wave therapy for any reason were considered as the Control group. All patients in the Intervention group were treated with DUOLITH SD1 T‐TOP by a single expert urologist. Semen analysis and serum total testosterone dosage were performed before the start (T0) and 3 months after the end of extracorporeal shock wave therapy (T1) in Intervention group. The same parameters were evaluated after the extracorporeal shock wave therapy refusal (T0) and at the end of the following 3 months (T1) in Control group. Normozoospermia was chosen as the primary outcome, serum total testosterone concentration was selected as the secondary outcome.

Results

A total of 94 patients were enrolled in the study (48 Group A, 46 Group B). At T0, all patients were normozoospermic in both groups (p = 0.563), and no significant difference in mean ± SD total testosterone levels was recorded between the groups (582.5 ± 107.2 vs. 634.6 ± 108.4 ng/dl; p = 0.221). At T1, no significant deterioration (p > 0.05) in semen parameters was recorded in both groups. Only a statistically significant reduction in seminal pH was found after extracorporeal shock wave therapy compared to baseline (7.9 ± 0.3 vs. 7.5 ± 0.2; p < 0.001) and untreated patients (7.8 ± 0.2 vs. 7.5 ± 0.2; p < 0.001). No significant difference in total testosterone levels was recorded in Intervention group after extracorporeal shock wave therapy compared to baseline (p = 0.584).

Conclusion

Extracorporeal shock wave therapy in erectile dysfunction and Peyronie's disease patients does not seem to affect reproductive and hormonal testicular function.