International Conference on Peyronie's disease advances in basic and clinical research. March 17-19, 1993. Introduction

The articles in this section of the Journal support the theory that the lesion of Peyronie's disease is a scar that has developed following trauma to the erect penis in a susceptible individual. The scar involves only the tunica albuginea and does not extend into the erectile tissue. Factors related to the formulation of this scar, discussed on a biochemical and cellular level, are elucidated in the following papers.

Proposal: trauma as the cause of the Peyronie's lesion

PURPOSE

We define the cause of the occurrence of Peyronie's disease.

MATERIALS AND METHODS

Clinical evaluation of a large number of patients with Peyronie's disease, while taking into account the pathological and biochemical findings of the penis in patients who have been treated by surgery, has led to an understanding of the relationship of the anatomical structure of the penis to its rigidity during erection, and how the effect of the stress imposed upon those structures during intercourse is modified by the loss of compliance resulting from aging of the collagen composing those structures. Peyronie's disease occurs most frequently in middle-aged men, less frequently in older men and infrequently in younger men who have more elastic tissues. During erection, when full tumescence has occurred and the elastic tissues of the penis have reached the limit of their compliance, the strands of the septum give vertical rigidity to the penis. Bending the erect penis out of column stresses the attachment of the septal strands to the tunica albuginea.

RESULTS

Plaques of Peyronie's disease are found where the strands of the septum are attached in the dorsal or ventral aspect of the penis. The pathological scar in the tunica albuginea of the corpora cavernosa in Peyronie's disease is characterized by excessive collagen accumulation, fibrin deposition and disordered elastic fibers in the plaque.

CONCLUSIONS

We suggest that Peyronie's disease results from repetitive microvascular injury, with fibrin deposition and trapping in the tissue space that is not adequately cleared during the normal remodeling and repair of the tear in the tunica. Fibroblast activation and proliferation, enhanced vessel permeability and generation of chemotactic factors for leukocytes are stimulated by fibrin deposited in the normal process of wound healing. However, in Peyronie's disease the lesion fails to resolve either due to an inability to clear the original stimulus or due to further deposition of fibrin subsequent to repeated trauma. Collagen is also trapped and pathological fibrosis ensues.

Principles in repair of hypospadias

Hypospadias, a common congenital deformity, is the result of incomplete formation of the urethra during the 10th- to 14th weeks of gestational life. Surgery to repair the foreshortened urethra and penile curvature in hypospadias has a history of more than 150 years. To date, more than 300 surgical procedures with accompanying variations have been proposed for the repair of hypospadias. With modern techniques of tissue transfer, even the most severe case of hypospadias is amenable to repair. The modern era of hypospadias surgery has allowed the application of skin grafts and flap techniques to add significantly to urethral length. At the same time, a variety of new techniques have been proposed to "minimize" hypospadias surgery. In this article the authors argue that for the worst cases of hypospadias, complete dissection of the abnormal anatomy and modern tissue transfer techniques should be used to reconstruct the deformity.

Penile prosthesis implantation in total phalloplasty

A series is presented of 8 patients who had undergone either total phalloplasty or free flap penile reconstruction. Our experience with prosthetic implantation is reviewed as is a brief history of phallic construction, including previously reported efforts at achieving rigidity with prosthetic implantation, autologous material implantation and so forth. We present in detail our current technique of implantation in these 8 patients, who underwent 10 attempts at implantation. In 4 patients infection necessitated removal of the prosthesis (2 have since undergone successful reimplantation). Of the 8 patients in whom implantation was attempted 6 (60%) currently have prostheses in place.

Repair of the complications of hypospadias surgery

In 1992 a retrospective review was conducted of 190 patients evaluated and treated for complications of hypospadias surgery during 1979 through 1990 at the Devine Center for Genitourinary Reconstructive Surgery of Sentara Norfolk General Hospital and Children's Hospital of the King's Daughters. We could not contact 13 patients and 8 are awaiting a second stage procedure. Of the 177 patients 167 (94.35%) have had a successful outcome, defined as a controllable urinary stream, functional erection and an acceptable cosmetic appearance, and 2 (1.13%) are considered failures. Details of presenting problems, surgical techniques and recent modifications of these procedures are presented.

New incision for penile surgery

We present a recent modification of the surgical incision used for patients with Peyronie's disease of the dorsal penile shaft and/or who require a concomitant complete dorsal vein ligation procedure. This approach spares the penile skin from trauma and torsion, and allows for improved access to the more proximal penile shaft. Our experience to date has demonstrated no evidence of increased morbidity with excellent cosmetic results.

Phallic construction in prepubertal and adolescent boys

During the last 10 years we performed microsurgical phallic reconstruction in 7 prepubertal and 4 adolescent boys. Indications for surgery included post-traumatic amputation, circumcision accident, developmental anomalies and micropenis. In addition, we performed phalloplasty on 5 other patients 18 to 24 years old. Total phallic reconstruction consisted of 1-stage microsurgical tissue transfers that included urethral reconstruction, coaptation of erogenous nerves, aesthetic refinement and, in some cases, scrotal reconstruction. All postpubertal patients recovered erogenous sensibility in the reconstructed phallus and the ability to masturbate. Surgical indications, techniques and results are discussed.

Microsurgical forearm "cricket bat-transformer" phalloplasty

Presently, the donor flap of choice for microsurgical phallic reconstruction is the radial forearm flap. The success of several different design modifications confirms the reliability of the radial and ulnar forearm flaps. Farrow et al. described their experience with the "cricket bat" concept in 1980. To the previous "cricket bat" design, we now wish to add modifications. These modifications utilize longitudinal and transverse rotations of the linear forearm tissues to create a phallus--much like the transformation of a toy robot into a truck. Deepithelialized flaps and a full-thickness skin graft coronoplasty complete glans reconstruction. The "cricket bat-transformer" flap appears to produce the most predictable results in subtotal phallic reconstructions and phallic constructions in the pediatric and transgender patient groups.

The surgical treatment of chordee without hypospadias in men

During a 2-year period we treated 26 young men for chordee without hypospadias. Many of these patients had straight erections as children but a ventral curvature developed as they achieved puberty. We describe the anatomical findings and discuss the possible cause for the development of this anomaly. Surgical therapy begins with a circumcising incision and reflection of the skin to expose the shaft of the penis. The corpus spongiosum containing the urethra was mobilized by resecting the dysgenetic tissue in the dartos and Buck's fascia layers. In 1 patient this dissection was sufficient to straighten the penis but in the remaining 25 the penis was not straight. In those patients we mobilized the dorsal bundle of vessels and nerves, and removed 1 or several ellipses of tunica albuginea to equalize the lengths of the ventral and dorsal aspects of the corpora cavernosa. The corpus spongiosum usually is elastic and the curve almost never is caused by shortness of the urethra, which stretches to fit the straightened penis. In 24 of the 26 patients the curvature was resolved with 1 operation, while 2 needed a second procedure.

Urethral reconstruction using the carbon dioxide laser: an experimental evaluation

In an effort to test the efficacy of the carbon dioxide laser in urethral reconstruction, patch graft urethroplasty was carried out comparing laser repair to microsurgical repair. The male Sprague Dawley rat was used as the model. An oval defect was created in the ventral urethra in 65 animals and repaired with a full thickness preputial skin graft conventional microsurgical repair, laser assisted microsurgical repair, or laser repair with a protein solder. The success rate, defined as the number of animals surviving without complications at the end of 21 days, was 50, 20, and 65% respectively. In conclusion, laser assisted repair using the protein solder was significantly better than microsurgical repair (p less than 0.05).

Primary realignment of the disrupted prostatomembranous urethra

Urethral scarring resulting in stricture formation can be avoided or minimized by proper treatment after injury. On presentation of the trauma patient, the possibility of such injury must be suspected and the urethra evaluated prior to any attempts at catheter placement. Diversion in all cases of posterior urethral injury should be by a suprapubic tube, with any urinary extravasation drained at the site of the injury. If the patient's general condition allows it, the disrupted urethra should be realigned by a catheter after the puboprostatic ligaments have been divided. These measures allow the prostate to return to the urogenital diaphragm without tension and in line with the distal urethra. Until the prostate is released, no amount of traction will reapproximate the urethra, and after it is released, traction is not necessary. The suprapubic catheter provides diversion, preventing further complications caused by urinary extravasation; urethral alignment minimizes subsequent stricture formation. When the stricture develops, if it is urodynamically significant, it can be repaired in 4 to 6 months. If one is fortunate, the stricture will be short and amenable to internal urethrotomy. If not, open reconstruction will be greatly facilitated by the attempts to guide the distracted ends of the urethra together.

Isolation and characterization of collagen in Peyronie's disease

Peyronie's disease is characterized histologically by excessive collagen deposition in the lesion. We examined the collagen types in Peyronie's disease plaque tissues compared to unaffected tissues from the same patient, other control tissues, and Dupuytren's contracture. Gel electrophoresis of pepsin-solubilized collagen demonstrated the presence of type I collagen and an increased content of type III collagen in plaque tissue. Increased type III collagen was detected in apparently normal tissue adjacent to the plaque and in Dupuytren's lesion, confirming previous findings. Although the cause of excessive collagen accumulation of Peyronie's disease is unknown, the results suggest an imbalance in the regulation of extracellular matrix production leading to pathologic fibrosis.

Phallic reinnervation via the pudendal nerve

Total phallic reconstruction presents the genitourinary reconstructive surgeon with one of the most difficult surgical challenges. The development of microsurgical techniques and free tissue transfers have advanced phallic reconstruction by reducing the number of surgical procedures and by allowing more selectivity in choosing the best innervated donor tissue. During the last 5 years 16 patients underwent total phallic reconstruction using free tissue transfers from distant donor sites. The pudendal nerve was coapted routinely to the major sensory nerves of the donor free flap. The most accurate objective baseline parameters of penile sensibility are pressure and vibratory thresholds, and electrically evoked potentials. We examined 30 normal subjects and 7 patients at least 1 year postoperatively for penile (phallic) sensibility. A pressure aesthesiometer, a biothesiometer and electrodiagnostic studies were used for testing. The 7 postoperative patients (in all of whom the pudendal nerve was incorporated into the reconstruction) had an encouraging return of tactile and erogenous sensibility compared to normal subjects. This is a promising advance in phallic reconstruction.

Peyronie's disease

For patients with Peyronie's disease requiring surgery, the authors' treatment is to excise the plaque and replace the diseased area of the tunica with a dermal graft. The goal of the surgery is to create a functional penis without prosthesis. For the first few months, sexual therapy and counseling are very important to help the patient and partner work together toward rehabilitation.

An evaluation of skin grafts for reconstruction of the penis and scrotum

Skin grafting remains a primary modality for reconstruction of genitourinary defects. Many of these conditions are discussed and emphasis has been placed on the different indications for full-thickness, split-thickness, and dermal grafts. Complications have been few, and long-term results excellent. This experience has allowed the formulation of a number of surgical principles, which are presented. Refinements in reconstruction are currently being evaluated to obtain the optimal result.

Laser welding in urethral surgery: improved results with a protein solder

Reconstruction of the rat urethra using the CO2 laser and a protein solder has dramatically decreased the postoperative fistula rate and decreased surgical time over conventional microsurgical reconstruction. Using the rat as a model, a partial transection of the ventral urethra was repaired in one of three ways in 39 animals: conventional microsuture repair, laser assisted microsuture repair and laser assisted microsuture repair with a protein solder. The success rate in each group was 50%, 58% and 90% respectively. Therefore, the laser repair is an efficacious as conventional microsuture repair. More importantly, laser with solder is significantly better than either the conventional method or laser alone.

Chromosome abnormalities in Peyronie's disease

Peyronie's disease is a localized and progressive fibrosis of unknown etiology that affects the tunica albuginea of the penis. We examined cytogenetically cell cultures derived from plaque, adjacent tunica, dermis and lymphocytes in patients with Peyronie's disease, and compared the results to cell cultures established from the tunica albuginea of control patients. Chromosomal abnormalities were detected in 9 plaque-derived cell cultures from 7 of 12 Peyronie's disease patients (58 per cent). Cells cultured from adjacent tunica, dermis and lymphocytes from the same patients were karyotypically normal, as were cultures derived from control (chordee and penile scar) patients. Chromosomal aberrations consisted of 5 numerical changes and 4 structural rearrangements, and included chromosomal additions (trisomy 7 and trisomy 8), deletions (45X,-Y), reciprocal translocations and inversions or markers. In 2 instances cultures derived from plaque tissue contained 2 independent chromosomal abnormalities. The apparently random chromosomal changes associated with Peyronie's disease suggests that karyotypic instability may be a common feature of cells within the plaque. It presently is unclear whether this finding represents multiple pathways for the development of Peyronie's disease or secondary consequences of Peyronie's disease.

New concepts in phallic reconstruction

Over the past four years we have performed total phallic reconstructions in 12 patients. Six patients underwent reconstruction following trauma, 3 were female-to-male transsexuals, and 3 had micropenis deformities. These reconstructions were one-stage microsurgical tissue transfers that included urethral reconstruction and coaptation of erogenous nerves. The surgical indications, techniques, and results are discussed.

Peyronie's disease

More than 16 years' experience with approximately 1,000 cases of Peyronie's disease and a review of 110 patients evaluated more than 1 year postoperatively are presented. Peyronie's disease is difficult to treat. There is no known etiological agent, and because occasional spontaneous disappearance of the lesion occurs, the assessment of therapy is difficult. Our operation has been successful in relieving penile curvature and pain in a substantial number of patients (84%). Therefore, we recommend that in all severe, sexually disabling cases of Peyronie's disease unresponsive to conventional therapy, excision of the diseased tunica albuginea and replacement with dermal graft be considered. Organic impotence, which is occasionally seen preoperatively in association with Peyronie's disease, requires thorough investigation, sex counseling, and consideration of a penile implant.

Current hypospadias techniques

Hypospadias repairs must encompass straightening of the penis and construction of the neourethra at the tip of the penis. In addition to an outline of preoperative and postoperative management, five techniques of single-stage surgical repair are discussed. All hypospadias defects can be repaired using one of these five basic procedures.

Müllerian duct cysts: conservative management

Three cases of the unusual entity, müllerian duct cyst, are presented. Each was managed differently, demonstrating that with appropriate patient selection either aspiration alone, aspiration and instillation of a sclerosing agent, or transurethral resection of bladder base to establish communication and cyst drainage are successful.

Urinary bladder reinnervation

The ability of mixed spinal nerve roots to regenerate and reinnervate the urinary bladder was examined in young adult female cats. Using microsurgical technique, a unilateral extradural spinal nerve root anastomosis of a lumbar (L7) to a sacral root (S1) either with or without a nerve graft was performed. Remaining ipsilateral sacral roots were transected. The contralateral normal sacral roots remained intact and allowed the animals adequate urination during the period necessary for axonal regeneration. At the time of restudy seven months later, stimulation of the anastomosed nerve root proximal to the anastomosis (isolated from the spinal cord) elicited a bladder contraction. Significant lumbar axonal regeneration was substantiated by compound action potentials recorded across the anastomosis. In addition, redirection of axons from a lumbar to a sacral distribution was demonstrated. The contralateral normal sacral roots provided control cystometric and electrophysiological data against which responses from the previously anastomosed nerve roots were compared. In conclusion, significant bladder reinnervation can occur after an anastomosis of a lumbar and sacral root with or without a nerve graft. This technique, or variations thereof, may have a clinical role in selected patients with neurogenic bladder dysfunction to reinnervate the bladder and restore central control.

Microsurgical hypospadias repair

Successful primary hypospadias repair depends on careful execution of surgical principles, particularly during the urethroplasty portion of the procedure. These principles include careful tissue handling, development of well-vascularized flaps, and avoidance of placing sutures in the uroepithelial surface. Despite meticulous repair, the complication rate requiring secondary surgery is 15 to 30 percent. For the past year, the authors have utilized an operating room microscope, microsurgical instruments, a specially designed microsuture, and a Biooclusive dressing to decrease the postoperative morbidity and subsequent complications requiring secondary surgery (6.5 percent). A comparison of 50 hypospadias patients on whom no microsurgical repair had been used was made with 62 patients on whom microsurgical techniques were employed. The nonmicrosurgical group had 17 complications, 12 of which required reoperation (24 percent). The microsurgical group had 8 complications, 4 of which required reoperation (6.5 percent).

Urethroplasty using diverticular tissue

Diverticula that occur in the neourethra following repair of hypospadias, epispadias or urethral stricture generally are associated with obstruction distal to the dilated segment. This diverticular tissue can be moderately elastic and well vascularized. We have been able to relieve the stenosis by developing and advancing a diverticular flap, simultaneously reducing the size of the diverticulum.

Intraoperative consultation for the urethra

The urologist is frequently summoned to the operating room to assist with urethral catheterization. This article presents the authors' method and techniques for dealing with the "impassible urethra." Oftentimes the patient has been traumatized. A sequential plan is presented that allows for maximal evaluation of the entire urinary tract along with eventual urethral catheterization. In the case of the disrupted urethra, diversion must be accomplished. The authors have found that the placement of a urethral catheter along with division of intact puboprostatic ligaments in the stable patient frequently limits the eventual morbidity of the trauma.

Penile curvatures

Penile curvatures are common. They are caused by tethering inelastic tissues that can be from the skin externally, from the congenital fibrous tissue of hypospadias and epispadias, and from inelastic tunica albuginea as in fractures, trauma, or Peyronie's disease. At the present time, with sexual organs exposed in photographs, human sexuality talked about with more freedom, and sexual experiences more open, a great deal of mental stress and anxiety can be produced by penile curvatures. Adjunct to this are impotency and other sexual problems. Surgical treatment is generally curative with grafts, flaps, excision of tunica albuginea, or repositioning and coaptation of the corporal bodies. Also, the use of a sex therapist can offer additional aid to the physician and realistic acceptance by the patient. More attention should be given to the patient with this problem. It is not well recognized by most physicians, and therefore, patients may suffer needlessly in silence without adequate help.

Evaluation of erectile dysfunction in patients with Peyronie's disease

Of 62 hospitalized patients with Peyronie's disease 18 (29 per cent) had abnormal nocturnal penile tumescence studies that were characterized as indicating organic impotence. However, the majority of these patients had some underlying disease or factor other than the plaque itself to explain the altered nocturnal penile tumescence. In only 5 per cent of these patients could the abnormal nocturnal penile tumescence be attributable to the plaque itself. Primary excision of the plaque and dermal grafting improved erectile function in all except a minority of patients who required insertion of a penile prosthesis to alleviate continued erectile impotence. For this reason we do not recommend insertion of a penile prosthesis during plaque excision. The plaque of Peyronie's disease does not appear to impede vascular flow distal to the plaque. However, previous excision may result in altered hemodynamics that can result in erectile impotence.

The treatment of psychogenic impotence after dermal graft repair for Peyronie's disease

We studied 20 men who failed to resume coitus after a dermal graft repair for Peyronie's disease. Psychogenic causes were found in 15 men, 10 of whom were treated locally by the sex counselors who interviewed all the couples. Psychogenic dysfunction was related to waiting for healing or for a specified period, then approaching first coitus either with idealized expectations or as if it were a test. Of the 10 treated men 3 also had marital conflict and 5 others had lack of a partner or poor motivation, including 1 who also suffered some instability of erection possibly of structural cause. In most of the treated men relief of anxiety and conflict proved effective, and coitus was restored. We are now evaluating possible improved results in new operative candidates through preoperative and postoperative counseling, which emphasizes a less pressured approach to coitus postoperatively.

Urethral hemangioma: treatment by total excision and grafting

Capillary hemangiomas of the urethra are rare benign tumors that may behave in a persistently recurrent manner. Radical extirpative surgery may be necessary to cure the patient. We describe a new 2-stage technique for replacing long segments of urethra.

Posterior urethral injuries associated with pelvic fractures

The types of fracture of the bony pelvis are categorized, and a system for diagnosis and treatment is recommended which should prevent many strictures and make those which do develop, easier to repair secondarily. This system of treatment should reduce trauma to the nerves and blood vessels.

Cell culture of Peyronie's disease plaque and normal penile tissue

Cell cultures derived from Peyronie's disease plaque and normal penile tissue were characterized morphologically and examined by immunofluorescence for actin cable formation, and their growth properties were compared. Relative to normal penile cell cultures which grew as contact inhibited, poorly refractile fibroblast-like cells, plaque derived cell cultures consisted of round and spindle shaped cells that were more refractile and exhibited random crisscross growth patterns. Scanning electron microscopy of plaque derived cell cultures revealed changes in cell surface topography characterized by the appearance of surface membrane blebs amd microvilli. Transmission electron microscopy demonstrated cells containing organized cytoplasmic microfilament bundles and nuclear indentations which resembled myofibroblasts. Such alterations were less extensive or absent in normal penile cell cultures. The amount and extent of actin cable formation was increased in plaque derived compared to normal penile cell cultures. Plaque derived cells also exhibited differences in growth properties and grew to higher saturation densities than their normal counterparts. These results demonstrate that cells derived from Peyronie's disease plaque can be grown in vitro and that these cells are morphologically altered and have an enhanced proliferative capacity. The availability of these cell cultures will permit studies directed at understanding the etiology and pathogenesis of Peyronie's disease.

Mechanisms of calcification in Peyronie's disease

Scanning and transmission electron micrographs demonstrate a calcification process in the penile plaques of patients with Peyronie's disease. Osteoid formation originates from vascular lumina via osteoblast-like cells, which align the calcified plaque. These cells are surrounded gradually by calcified connective tissue. Collagen fibers demonstrate calcification and decreased periodicity.

Hypospadias cripples

The term "hypospadias cripple" is an apt one. The successful surgery of this condition requires radical correction of all deformities, preferably in a single stage. In doing this one must be conversant with virtually all the existing methods of hypospadias repair and be able to apply them appropriately.

Advancing V-flap dismembered pyeloplasty

Advancing V-flap dismembered pyeloplasty reconstruction of obstructive ureteropelvic function was used in 31 patients. This modification of the dismembered pyeloplasty compares well in the long-term follow-up when matched with 57 patients treated with other types of dismembered pyeloplasty. Foley Y-V (11 cases), Scardino (4 cases), and Culp (2 cases) pyeloplasties are included in this follow-up of our 105 cases.

Fistulas of the penile urethra

Urethral fistula, the most common complication of urethroplasty, is discussed. There has been no classification for these disorders, and the plethora of reconstruction procedures available often leads to confusion. The classification presented here for acquired fistulas attempts to give direction in the selection of appropriate management in individual cases. Early, acute fistulas are managed conservatively. In the case of mature single fistulas, local tissue may be used for surgical repair. These are subdivided, depending on the size of the opening. Chronic, multiple, large lesions draining the urethra require tissue from a distance for repair. In severe surgical cripples, a total new urethral reconstruction will be required. A new technique to expose the urethra, allowing correction of urethral fistulas with stricture and diverticulum, is described.

Epispadias

Surgical procedures in 14 patients with epispadias not associated with exstrophy of the bladder are reviewed. In the continent patient, repair of epispadias can be accomplished in one stage; however, a multistaged technique is advocated in patients with incontinence or with persistent chordee.

Panel: complications of hypospadias repair

Complications of hypospadias repair result from errors in the initial evaluation of a patient, the design of the operation, the surgical technique, or the postoperative care. The most commonly encountered complications are discussed, with emphasis both on methods of prevention and of treatment.

Utricular configuration in hypospadias and intersex

To evaluate the incidence and significance of an enlarged prostatic utricle in hypospadiac patients without underlying intersex 44 patients with the meatus located in the perineum, penoscrotal junction or proximal two-thirds of the penis were evaluated with cystourethroscopy immediately before the operation. There was an abnormally enlarged utricle in 57 per cent of the perineal, 10 per cent of the penoscrotal and none of the penile hypospadias and intersex revealed a high incidence of enlarged utricle or the presence of a vagina masculinus. Utricular enlargement in itself doses not indicate intersexuality but careful cystoscopic examination of its vault needs to be undertaken, searching for a cervix. An enlarged utricle can be a manifestation of delayed mullerian duct regression or decreased androgenic stimulation of the urogenital sinus.

Free full thickness skin graft urethroplasty: current technique

We present details of our current techniques for skin graft urethroplasty. We believe that careful attention to the details of these operative techniques is important to their success. The changes from our previous reports include: 1) preparation of patch grafts with rounded ends, 2) preparation of tube grafts with fishmouth spatulation, 3) fixation of the stent catheter to the anterior abdominal wall, 4) leaving a stent catheter inlying for 2 weeks and replacing with a smaller catheter if a voiding cystourethrogram shows extravasation, 5) fixation of the graft during preparation by dermatome adhesive, 6) irrigation of the wound with irrigant before closure and 7) urodynamic flow study for non-invasive postoperative followup.