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A SURGICAL ALGORITHM FOR THE TREATMENT OF PEYRONIE'S DISEASE
oo22-5347/97/1586-2149$03.00/0
Vd.168,2149-21622,
TIIEJOURNAL OF UROLOGY Copyright 8 1997 by AMERICAN UROLCGICAL Assocuno~,INC.
1997
Printed in U . S A
A SURGICAL ALGORITHM FOR THE TREATMENT OF PEYRONIE’S DISEASE LAURENCE A. LXVINE AND ERIC L. LENTING From the Department of Umlosy Rush-Presbyterion-St.Luke’sM e d i d Center, Chicago, IL
ABSTRACT
Purpose: When conservative treatment of Peyronie’s disease fails, the optimal surgical approach is not well defined. Multiple factors, including penile rigidity, degree of curvature, shaft narrowing with hinge effect and erectile response to vasoactive penile injections,indicate that no single approach is likely to solve the problem in all patients. Materials and M e t h k A surgical algorithm was developed for the treatment of Peyronie’s Disease based on our previous surgical experience, which was used prospectively in 103 consecutive men. Penile straightening without prosthesis was offered to patients with adequate rigidity for coitus. Specifically,for mild to moderate curvature less than 60 degrees without hourglass or hinge effect deformity the less complicated tunica albuginea plication procedure was performed. For those men with more severe, complex curvature greater than 60 degrees and/or signiscant hourglass or hinge effect deformity plaque incision or partial excision with dermal grafting was offered to limit shaft shortening and to reconstruct a shaft with normal caliber to provide optimal axial support during intromission. For men with poor sexually induced erections and/or inadequate response to intracavernosal pharmacotherapy penile prosthesis placement was m m mended to provide adequate straightening and rigidity. Results: Of 22 patients who underwent plication procedures 91% remained potent and the penis remained straight postoperatively. Of 52 patients who underwent an incision or partial excision and grafting procedure, 48 had dermal grafts with the penis remaining straight in 94% and 75% remaining potent postoperatively. A total of 29 patients received a prosthesis with the penis remaining straight in 93% who were sexually active postoperatively. During the follow up period (mean 22.3 months) there have been no mechanical device faifures. Conclusions: Surgical outcome was optimized with this algorithm, which correlates eurgical complexity to the underlying seventy of the penile deformity and erectile capacity. KEYWORDS: penile induration. surgery Peyronie’s disease, or plastic induration of the penis, was described by de la Peyronie in 1743 and for many years was thought to be associated with sexually transmitted disease.’ Prevailing theories today for the etiology of Peyronie’s disease implicate a traumatic injury to the erect penis with an associated loss of elasticity of the tunica albuginea.2 The development of the disease can be thought of as an inappm priate response to wound healing resulting in scar formation, deformity and, not infrequently, dimininhed rigidity.’ Athough spontaneous regression of the disease has been reported in up to 13% of cases, further disease progression has been noted in 42% of untreated patients.4 Patients with Peyronie’s disease seek medical attention for various reasons, including a palpable nodule, painful erections, curvature ofthe penile shaft andlor diminished erectile hnction. The disease may result in severe erectile dysfunction caused by multiple factors, including structural, VasCUlar and psychogenicmechanisme.6.BWhen conservativemeasures fail and progression of the disease prevents coitus, surgical repair is indicated. Variations in the nature.and severity of penile deformity and erectile capacity indxate that a single surgical approach would be insufficient to all surgical candidates. Based on previous surgical experience and review of the literature, an algorithm to aid in deciding which surgical approach is best suited to each individual was developed..In this study patient evaluation and the prospective applicabon Ampted for publication May 23,1997.
of this surgical algorithm to a large, consecutive patient population are described. MATERIALS AND METHODS
Initial evaluation of 103 patients with Peyronie’s disease included a detailed medical and sexual history, a questionnaire completed by the patient and a thorough physical examination. Each patient also underwent penile duplex ultrasound as previously described.’ A 60 mg. intracorporeal injection of papaverine was used to evaluate penile vasculature, including collateral circulation from the dorsal penile arteries and erectile capacity. The location and dimensions of the plaque, degree of curvature. presence of an hourglass deformity and erectile quality were assessed and recorded. Calcification within the plaque could also be identified. ARer subjective and objective evaluation the following algorithm was applied (see Appendix): l) tunica albuginea plication, as described by Baskin and Duckett,* was offered to those patients with full subjective (as reported by the patient) and/or objective erections (as observed during pharmacological duplex ultrasound), a unidimensional curve of less than 60 degrees and without hourglass defarmity or hinge effect, 2) plaque incision or partial excision with dermal grafting, as described by Devine and Horton,9 and Gelbard and Haydenlo with some modification, was offered to those patients with 111 subjective and/or objective erections, a complex, bidirectional curvature (dorsal and lateral)and/or a significanthourglass or hinge effect deformity or 3)pmthesis placement was recommended to thrjse patients with poor
2149
SURGICAL ALGORITHM FOR PEYRONIES DISEASE
2150
TABLE1. Patient population surgiealprocedure
No.
Age Mean (range)
Tunica alhuginea plication Ihcision or partial excision and dermal grafhg Tunica vaginalis grafting Prosthesis placement
22 48 4 29
40 (21-68) 47 (16-67) 41 (2%52) 54 (40-75)
spontaneous or sexually induced erections and/or an inadequate response to intracavernosal pharmacotherapy. From July 1991 to July 1996 this algorithm was prospectively applied to a total of 103 patients who following evaluation were found to be suitable candidates for a surgical procedure (table 1).Of the patients 22 (mean age 40.0 years, range 21 to 68)underwent tunica albuginea plication procedures, 48 (mean age 47.0 years, range 16 to 67)underwent incision or partial excision with dermal grafting, 4 (mean age 41.0years, range 29 to 52)underwent tunica vaginalis grafting and 29 (mean age 54.0 years, range 40 to 75)underwent prosthesis placement. Penile deformity in all patients not scheduled for prosthesis placement was further assessed during surgery using the Carvopump system.* Briefly, following intracavernosal injection of papaverine an artificial erection was created by infusing saline through a 19 gauge butterfly needle into a corpus cavernosum through the glans penis. Avoiding the use of a tourniquet with this approach allowed for a more undistorted evaluation of the deformity. This system was also useful in evaluating the completeness of correction of the deformity during the course of the procedure. Before surgery the postoperative concerns discussed with the patient were reduced potency, recurrent curvature, diminished sensation, delayed ejaculation and penile shortening. RESULTS
Degrees Preop. Curvature Mean (range)
Mos. Followup Mean (range)
39 (30-90) Dorsal 62,lateral 61, ventral 90 55 (30-90) 55 (0-90)
19.5 (3-39) 19.6 (3-48) 33.0 (30-37) 22.3 (3-45)
TABLE2. Postoperative results for 22 patients undergoing tunica albuginea plicatwn procedures No. (9~) Full erectile capacity Complete straightening Persistent curvature (less than 30 degrees) Penile shortening (less than 3 cm.) Decreased sensation Erectile insufficiency
20 (91) 20 (91) 2 (9) 2 (9) l(4.5) 2 (9)
TABLE3. Postoperative results for patients undergoing incision or partial excision and grafting No. (%) Tunica vaginalis grafts (4 pts.): Full erectile capacity Complete straightening Persistent curvature Intracavernous injection therapy Dermal g r a h (48 pts.): Complete straightening Persistent curvature Full erectile capacity Intracavernous injection therapy Penile shortening (0.5-2cm.) Decreased sensation Delaved eiaculation
TABLE4. Postoperative results for 29 patients undergoing penile
prosthesis placement Of the 22 patients who underwent plication procedures 91% remained potent and the penis remained straight postoperatively (table 2). During the followup period (mean 19.5 Full erectile capacity 29 (100) months, range 3 to 39)2 patients (9%) experienced persistent Decreased sensation 2 (7) Mild shortening 3 (10) postoperative curvature, 1 of whom had a preoperative 90 Delayed ejaculation 1 (3.5) degree dorsal curve and a postoperative 30 degree lateral Postouerative infection 1 (3.5) curve, and 1 with a preoperative 90 degree ventral curve and a postoperative 20 degree dorsal curve. One patient (4.5%) experienced decreased sensation, 2 (9%) described postoperative shortening (less than 3 cm.), and 2 (9%) complained of tion therapy postoperatively, 2 ultimately required placement of a penile prosthesis and 1 with residual bending postoperative erectile insufficiency. Of the 52 patients who underwent an incision or partial denied further treatment. Nine patients (19%) complained of excision and grafting procedure 4 had tunica vaginalis grafts mild penile shortening (0.5to 2 cm.), 7 (15%) experienced (table 3). During a mean followup of 33 months (range 30 to transient decreased sensitivity (3 to 6 months) and 4 (8%) 39) 2 had recurrent curvature thought to be secondary to experienced delayed ejaculation (2to 6 months). Of the 29 patients receiving a prosthesis and shaft excessive contraction of the tunica vaginalis graft. Also, 2 patients, who had demonstrated suboptimal preoperative ar- straightening 12 had penile prosthesis placement with manterial flow but responded fully to papaverine, required post- ual molding, 11 had placement of a prosthesis with incision of
operative intracavernous injection therapy. The remaining 48 patients underwent dermal grafting. Typically 1 to 2 grafts (2to 5 x 2 to 4 cm.) were harvested from the hypogastric region (table 3).During followup (mean 19.6 months, range 3 to 48)the penis has remained straight in 45 (94%) and 36 (75%)have remained potent. Of the 3 men with residual curvature (mean 22 degree, range 20 to 30) 2 are sexually active and did not require further surgery to straighten the penis, and 1 has insufficient rigidity for intercourse. Of the 12 men with postoperative erectile dysfunction 9 (75%) demonstrated preoperative suboptimal mean peak systolic flow (less than 30 cm. per second) suggestive of arterial insufficiency but they experienced a full erectile response to papaverine injection. Five men (42%)reported preoperative erectile dysfunction and refused penile prosthesis placement. Of the 12 men 9 required intracavernosal injec-
* Life-Tech, Inc., Houston, Texas.
the plaque and 6 had placement of the prosthesis with incision of the plaque and 1 mm. polytetrafluoroethylene (GoreTex), (table 4).One patient, who had a plaque incision defect greater than 2 cm. following prosthesis placement, had recurrent curvature that required re-incision of the tunica with polytetrafluoroethylene grafting. Since that experience, all prosthesis patients with a tunical incision defect greater than 2 cm. have had polytetrafluoroethylene grafting to prevent contracture with recurrent curvature or cylinder herniation. Of 2 patients (7%) who complained of persistent decreased sensation 1 was a long-term insulin dependent diabetic and the other was 66 years old. Three patients (10%) experienced mild postoperative shortening (less than 2 cm.). In 1 brittle diabetic patient postoperative infection necessitated removal of 1 cylinder. He remains sexually functional with a single Dynaflexi cylinder. During followup (mean 22.3 t American Medical Systems, Inc., Minnetonka, Minnesota
SURGICAL ALGORITHM FOR PEYRONIE'S DISEASE
2151
ease and a suboptimal erectile response to papaverine or alprostadil injection. Of our patients 21 received CX700 prostheses, 2 received Dynaflex prostheses and 6 more recently received Ambicor* prostheses. These devices have controlled DISCUSSION expansion type cylinders that expand in girth only and posWhile many patients with Peyronie's disease do not expe- sess intrinsic cylinder rigidity that aids in preserving rience persistent intense pain or curvature preventing coitus straightness. When plaque incision is necessary to straighten or severe erectile dysfunction, those presenting to a tertiary the penis fully, the silicone outer sheath also allows use of referral center are often in an advanced stage of disease. electrocautery without injury to the underlying cylinder. I t Typically, these patients have been referred after conserva- should be noted that the tunica albuginea incision is made tive therapies have failed or the disease has persisted for after opening Bucks fascia and elevating a portion of t h e greater than 1 year. This fact may explain the relatively neurovascular bundle with the prosthesis fully inflated so large percentage of Peyronie's disease patients seen at our that the maximum curvature is demonstrated. Incision is institution who have undergone surgical repair. best made through the tunica albuginea only, leaving a layer As stated by Brock et al, we also believe that a preoperative of cavernosal tissue covering the cylinders. The prosthesis is hemodynamic assessment with duplex ultrasound is appropri- then left partially inflated for 6 weeks to prevent contraction ate in patients with impotence associated with Peyronie's dis- of the tunical defect and recurrent curvature. Furthermore, if ease." This evaluation allows for a more precise definition of incision of the plaque creates a tunical defect greater than 2 the vascular etiology of the erectile dysfunction as well as de- cm. polytetrafluoroethylene grafting should be performed to termines erectile response to an injected vasodilator. One may reduce the likelihood of cylinder herniation or recurrent curalso assess the location of the dorsal penile artery perforating vature due to cicatrix contraction, as occurred in l of our vessels that may be interrupted during elevation of the vascular patients. A 1 mm. polytetrafluoroethylene soft tissue patch bundle which may exacerbate erectile dysfunction postopera- graft should be sized in situ with the prosthesis inflated and tively in those with borderline erectile capacity. As the de- secured with polytetrafluoroethylene suture while the prosscribed algorithm indicates, our surgical approach is conserva- thesis is deflated to avoid injury to the cylinders. tive, performing the least invasive type of procedure that will properly correct the deformity. Simply placing a prosthesis in every Peyronie's disease patient, with its attendant risks of CONCLUSIONS infection and malfunction, may be too aggressive and unacceptFor those men with simple minor curvature a tunica albuable to many patients, especially when more conservative and ginea plication is recommended. This procedure is the least effective surgical alternatives exist. In this study the successful outcomes of plication procedures invasive and results in limited shortening and narrowing of in patients with unidimensional curvature of less than 60 de- the shaft. For complex or bidimensional curvature or signifgrees correlate well with the results of others reporting on this icant hourglass deformity incision or partial excision with procedure. 12-14 Deformity in patients with curvatures greater dermal grafting is recommended to straighten and provide a than 60 degrees may be significantly more difficult to stable penile shaft of uniform caliber. It also theoretically straighten completely and result in a more significant decrease preserves shaft length when reconstruction is necessary for in penile length. In fact, the 2 patients with incomplete straight- more severe deformities. For those patients with suboptimal, ness following tunical plication had preoperative curvatures of subjective or objective erectile capacity prosthesis placement 90 degrees but insisted on this surgical approach. We also is recommended. Penile straightening is performed following consider the presence of an hourglass deformity a relative con- prosthesis placement. If manual molding does not provide traindication to the plication procedure. Theoretically, a cylin- sufficient straightening, then plaque incision should be perder is weakest at its narrowest point, thereby allowing a hinge formed. If the defect is greater than 2 cm. polytetrafluoroetheffect or buckling to occur at that region, particularly when ylene grafting is recommended to prevent cylinder herniation axial forces are placed on the penis, such as attempting vaginal or cicatrix contracture with recurrent curvature. Following a penetration.15 However, patients with ventral curvatures with- thorough history, physical examination and hemodynamic out shaft narrowing are good candidates for plication proce- evaluation, the surgical algorithm presented offers each padures, since the urethra does not need to be mobilized for tient a thoughtful and effective approach that allows a return to normal sexual function. placement of the plication sutures. For those patients with a complex, bidimensional curvature, visible hourglass deformity, hinge effect described by the patient and/or demonstration of these defects during the A P P E N D I X ALGORITHM API'LID FOR SL'R(;l('.AL T K E A T h l E N T lntraoperative induced erection, good results were obtained O F PEYROKIE'S DISEASE using incision or partial excision with grafting. This finding was true particularly for patients who demonstrated adeSurtncal Procedure Indications quate spontaneous or vasoactive drug induced erections with Tunica Alhuginea Plication 'Subjective full t?rectile capacity and/or normal vascular sufficiency on duplex ultrasound. We prefer +Objective full erectile capacity Simple curvature less than 60 degrees dermal grafts harvested from the lower abdominal wall since No hourglass deformity or hinge effect it is more congruous with normal tunica albuginea in terms of thickness, strength and elasticity. It also has a predictable degree of contraction (approximately 2 5 4 ) and is readily Incision or Partial Excision Subjective full erectile capacity andlor Objective full erectile capacity and Dermal Grafting available in sufficient quantity.16 The primary disadvantage Complex or hidimmsional curvature of dermal grafting is that a separate incision is required to C'urvnturv Lze;itt.rthan 60 degrees harvest the graft. Our limited experience with tunica vagiSignificant hourgLis5 deformity or hinge nabs grafts demonstrated a large amount of graft contraction rffect Postoperatively with resultant recurrent curvature and, therefore, we no longer use these grafts. Others have found Penile Prosthesis Placement Suhoptimiil erectile capacity satisfactory results using dura mater, temporalis fascia and Subjective erectile capacity as reported by patient in response to sexual vein n a f t s . LO. 17. IR stimulus. Placement of a prosthesis was performed only when pre' t Ohjective erectile capacity as noted by physician or technician following Operative evaluation demonstrated significant vascular dis- intracorporeal inJection of vasoactive agent
months, range 3 to 45) there have been no mechanical device failures.
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SURGICAL ALGORITHM FOR PEYRONIE’S DISEASE REFERENCES
1. de la Peyronie, F.: Sur quelques obstacles qui s’opposent a I’ejaculation naturell de la semence. Mem. Acad. Roy. Chir. 1: 425, 1743. 2. Devine, C. J . , Sommers, K. D.. Wright, G. L., J r , Gilbert. D. A., Horton. C. E. and Schlossberg. S. M.: A working model for the genesis of Peyronie’s disease derived from its pathobiology. J. Urol.. part 2, 1 3 9 286A, abstract 495, 1988. 3. Levine. L. A., Merrick, P. F. and Lee, R. C.: Intralesional verapamil injection in t h e treatment of Peyronie’s disease. J. Urol., 151: 1522, 1994. 4. Gelbard, M. K., Dosey, F. and James, K.: The natural history of Peyronie’s disease. J. Urol., 144: 1376, 1990. 5. Ralph, D. J., Hughes, T., Lees, W. R., and Pryor, J . P.: Preoperative assessment of Peyronie’s disease using colour Doppler sonography. Brit. J. Urol., 6 9 629, 1992. 6. Krane, R. J.: Pharmacocavernosometry in Peyronie’s disease. In: Programs and Abstracts of the First International Conference on Peyronie’s Disease: Advances in Basic and Clinical Research, Bethesda. Maryland, March 18, 1993. 7. Levine. L. A. and Coogan, C. L.: Penile vascular assessment using color duplex sonography in men with Peyronie’s disease. J. Urol., 155: 1270, 1996. 8. Baskin, L. S. and Duckett, J. W.: Dorsal tunica albuginea plication for hypospadias curvature. J. Urol., 151: 1668, 1994.
9. Devine, C. J., J r . and Horton, C. E.: Surgical treatment of Peyronie’s disease with a dermal graft. J. Urol., 111: 44, 1974. 10. Gelbard. M. K. and Hayden, B.: Expanding contractures of the tunica albuginea due to Peyronie’s disease with temporalis fascia free grafts. J. Urol., 145: 772, 1991. 11. Brock, G., Kadioglu, A. and Lue, T. F.: Peyronie’s disease: a modified treatment. Urology, 4 2 300, 1993. 12. Ralph, D. J., Al-Akraa,M. and Pryor, J. P.: The Nesbit operation for Peyronie’s disease: 16-year experience. J. Urol., 154. 1362, 1995. 13. Erpenback, K., Rothe, H. and Derschum, W.: The penile plication procedure: a n alternative method for straightening penile deviation. J. Urol., 146: 1276, 1991. 14. Benson, R. C., J r . and Patterson, D. E.: The Nesbit procedure for Peyronie’s disease. J. Urol., 1 3 0 692, 1983. 15. Gelbard, M. K.: Relaxing incisions in the correction of penile deformity due to Peyronie’s disease. J . Urol., 1 5 4 1457, 1995. 16. Jordan, G. H.: Peyronie’s disease and its management. In: Clinical Urology. Edited by R J. Krane, M. B. Siroky and J . M. Fitzpatrick. Philadelphia: J . B. Lippincott, chapt. 90 pp. 12821297, 1994. 17. Fallon, B.: Cadaveric dura mater graft for correction of penile curvature in Peyronie’s disease. Urology, 35: 127, 1990. 18. Moriel, E. Z., Grinwald, A. and Rajfer, J.: Vein grafting of tunical incisions combined with contralateral plication in t h e treatment of penile curvature. Urology, 43:697, 1994.
Vd.168,2149-21622,
TIIEJOURNAL OF UROLOGY Copyright 8 1997 by AMERICAN UROLCGICAL Assocuno~,INC.
1997
Printed in U . S A
A SURGICAL ALGORITHM FOR THE TREATMENT OF PEYRONIE’S DISEASE LAURENCE A. LXVINE AND ERIC L. LENTING From the Department of Umlosy Rush-Presbyterion-St.Luke’sM e d i d Center, Chicago, IL
ABSTRACT
Purpose: When conservative treatment of Peyronie’s disease fails, the optimal surgical approach is not well defined. Multiple factors, including penile rigidity, degree of curvature, shaft narrowing with hinge effect and erectile response to vasoactive penile injections,indicate that no single approach is likely to solve the problem in all patients. Materials and M e t h k A surgical algorithm was developed for the treatment of Peyronie’s Disease based on our previous surgical experience, which was used prospectively in 103 consecutive men. Penile straightening without prosthesis was offered to patients with adequate rigidity for coitus. Specifically,for mild to moderate curvature less than 60 degrees without hourglass or hinge effect deformity the less complicated tunica albuginea plication procedure was performed. For those men with more severe, complex curvature greater than 60 degrees and/or signiscant hourglass or hinge effect deformity plaque incision or partial excision with dermal grafting was offered to limit shaft shortening and to reconstruct a shaft with normal caliber to provide optimal axial support during intromission. For men with poor sexually induced erections and/or inadequate response to intracavernosal pharmacotherapy penile prosthesis placement was m m mended to provide adequate straightening and rigidity. Results: Of 22 patients who underwent plication procedures 91% remained potent and the penis remained straight postoperatively. Of 52 patients who underwent an incision or partial excision and grafting procedure, 48 had dermal grafts with the penis remaining straight in 94% and 75% remaining potent postoperatively. A total of 29 patients received a prosthesis with the penis remaining straight in 93% who were sexually active postoperatively. During the follow up period (mean 22.3 months) there have been no mechanical device faifures. Conclusions: Surgical outcome was optimized with this algorithm, which correlates eurgical complexity to the underlying seventy of the penile deformity and erectile capacity. KEYWORDS: penile induration. surgery Peyronie’s disease, or plastic induration of the penis, was described by de la Peyronie in 1743 and for many years was thought to be associated with sexually transmitted disease.’ Prevailing theories today for the etiology of Peyronie’s disease implicate a traumatic injury to the erect penis with an associated loss of elasticity of the tunica albuginea.2 The development of the disease can be thought of as an inappm priate response to wound healing resulting in scar formation, deformity and, not infrequently, dimininhed rigidity.’ Athough spontaneous regression of the disease has been reported in up to 13% of cases, further disease progression has been noted in 42% of untreated patients.4 Patients with Peyronie’s disease seek medical attention for various reasons, including a palpable nodule, painful erections, curvature ofthe penile shaft andlor diminished erectile hnction. The disease may result in severe erectile dysfunction caused by multiple factors, including structural, VasCUlar and psychogenicmechanisme.6.BWhen conservativemeasures fail and progression of the disease prevents coitus, surgical repair is indicated. Variations in the nature.and severity of penile deformity and erectile capacity indxate that a single surgical approach would be insufficient to all surgical candidates. Based on previous surgical experience and review of the literature, an algorithm to aid in deciding which surgical approach is best suited to each individual was developed..In this study patient evaluation and the prospective applicabon Ampted for publication May 23,1997.
of this surgical algorithm to a large, consecutive patient population are described. MATERIALS AND METHODS
Initial evaluation of 103 patients with Peyronie’s disease included a detailed medical and sexual history, a questionnaire completed by the patient and a thorough physical examination. Each patient also underwent penile duplex ultrasound as previously described.’ A 60 mg. intracorporeal injection of papaverine was used to evaluate penile vasculature, including collateral circulation from the dorsal penile arteries and erectile capacity. The location and dimensions of the plaque, degree of curvature. presence of an hourglass deformity and erectile quality were assessed and recorded. Calcification within the plaque could also be identified. ARer subjective and objective evaluation the following algorithm was applied (see Appendix): l) tunica albuginea plication, as described by Baskin and Duckett,* was offered to those patients with full subjective (as reported by the patient) and/or objective erections (as observed during pharmacological duplex ultrasound), a unidimensional curve of less than 60 degrees and without hourglass defarmity or hinge effect, 2) plaque incision or partial excision with dermal grafting, as described by Devine and Horton,9 and Gelbard and Haydenlo with some modification, was offered to those patients with 111 subjective and/or objective erections, a complex, bidirectional curvature (dorsal and lateral)and/or a significanthourglass or hinge effect deformity or 3)pmthesis placement was recommended to thrjse patients with poor
2149
SURGICAL ALGORITHM FOR PEYRONIES DISEASE
2150
TABLE1. Patient population surgiealprocedure
No.
Age Mean (range)
Tunica alhuginea plication Ihcision or partial excision and dermal grafhg Tunica vaginalis grafting Prosthesis placement
22 48 4 29
40 (21-68) 47 (16-67) 41 (2%52) 54 (40-75)
spontaneous or sexually induced erections and/or an inadequate response to intracavernosal pharmacotherapy. From July 1991 to July 1996 this algorithm was prospectively applied to a total of 103 patients who following evaluation were found to be suitable candidates for a surgical procedure (table 1).Of the patients 22 (mean age 40.0 years, range 21 to 68)underwent tunica albuginea plication procedures, 48 (mean age 47.0 years, range 16 to 67)underwent incision or partial excision with dermal grafting, 4 (mean age 41.0years, range 29 to 52)underwent tunica vaginalis grafting and 29 (mean age 54.0 years, range 40 to 75)underwent prosthesis placement. Penile deformity in all patients not scheduled for prosthesis placement was further assessed during surgery using the Carvopump system.* Briefly, following intracavernosal injection of papaverine an artificial erection was created by infusing saline through a 19 gauge butterfly needle into a corpus cavernosum through the glans penis. Avoiding the use of a tourniquet with this approach allowed for a more undistorted evaluation of the deformity. This system was also useful in evaluating the completeness of correction of the deformity during the course of the procedure. Before surgery the postoperative concerns discussed with the patient were reduced potency, recurrent curvature, diminished sensation, delayed ejaculation and penile shortening. RESULTS
Degrees Preop. Curvature Mean (range)
Mos. Followup Mean (range)
39 (30-90) Dorsal 62,lateral 61, ventral 90 55 (30-90) 55 (0-90)
19.5 (3-39) 19.6 (3-48) 33.0 (30-37) 22.3 (3-45)
TABLE2. Postoperative results for 22 patients undergoing tunica albuginea plicatwn procedures No. (9~) Full erectile capacity Complete straightening Persistent curvature (less than 30 degrees) Penile shortening (less than 3 cm.) Decreased sensation Erectile insufficiency
20 (91) 20 (91) 2 (9) 2 (9) l(4.5) 2 (9)
TABLE3. Postoperative results for patients undergoing incision or partial excision and grafting No. (%) Tunica vaginalis grafts (4 pts.): Full erectile capacity Complete straightening Persistent curvature Intracavernous injection therapy Dermal g r a h (48 pts.): Complete straightening Persistent curvature Full erectile capacity Intracavernous injection therapy Penile shortening (0.5-2cm.) Decreased sensation Delaved eiaculation
TABLE4. Postoperative results for 29 patients undergoing penile
prosthesis placement Of the 22 patients who underwent plication procedures 91% remained potent and the penis remained straight postoperatively (table 2). During the followup period (mean 19.5 Full erectile capacity 29 (100) months, range 3 to 39)2 patients (9%) experienced persistent Decreased sensation 2 (7) Mild shortening 3 (10) postoperative curvature, 1 of whom had a preoperative 90 Delayed ejaculation 1 (3.5) degree dorsal curve and a postoperative 30 degree lateral Postouerative infection 1 (3.5) curve, and 1 with a preoperative 90 degree ventral curve and a postoperative 20 degree dorsal curve. One patient (4.5%) experienced decreased sensation, 2 (9%) described postoperative shortening (less than 3 cm.), and 2 (9%) complained of tion therapy postoperatively, 2 ultimately required placement of a penile prosthesis and 1 with residual bending postoperative erectile insufficiency. Of the 52 patients who underwent an incision or partial denied further treatment. Nine patients (19%) complained of excision and grafting procedure 4 had tunica vaginalis grafts mild penile shortening (0.5to 2 cm.), 7 (15%) experienced (table 3). During a mean followup of 33 months (range 30 to transient decreased sensitivity (3 to 6 months) and 4 (8%) 39) 2 had recurrent curvature thought to be secondary to experienced delayed ejaculation (2to 6 months). Of the 29 patients receiving a prosthesis and shaft excessive contraction of the tunica vaginalis graft. Also, 2 patients, who had demonstrated suboptimal preoperative ar- straightening 12 had penile prosthesis placement with manterial flow but responded fully to papaverine, required post- ual molding, 11 had placement of a prosthesis with incision of
operative intracavernous injection therapy. The remaining 48 patients underwent dermal grafting. Typically 1 to 2 grafts (2to 5 x 2 to 4 cm.) were harvested from the hypogastric region (table 3).During followup (mean 19.6 months, range 3 to 48)the penis has remained straight in 45 (94%) and 36 (75%)have remained potent. Of the 3 men with residual curvature (mean 22 degree, range 20 to 30) 2 are sexually active and did not require further surgery to straighten the penis, and 1 has insufficient rigidity for intercourse. Of the 12 men with postoperative erectile dysfunction 9 (75%) demonstrated preoperative suboptimal mean peak systolic flow (less than 30 cm. per second) suggestive of arterial insufficiency but they experienced a full erectile response to papaverine injection. Five men (42%)reported preoperative erectile dysfunction and refused penile prosthesis placement. Of the 12 men 9 required intracavernosal injec-
* Life-Tech, Inc., Houston, Texas.
the plaque and 6 had placement of the prosthesis with incision of the plaque and 1 mm. polytetrafluoroethylene (GoreTex), (table 4).One patient, who had a plaque incision defect greater than 2 cm. following prosthesis placement, had recurrent curvature that required re-incision of the tunica with polytetrafluoroethylene grafting. Since that experience, all prosthesis patients with a tunical incision defect greater than 2 cm. have had polytetrafluoroethylene grafting to prevent contracture with recurrent curvature or cylinder herniation. Of 2 patients (7%) who complained of persistent decreased sensation 1 was a long-term insulin dependent diabetic and the other was 66 years old. Three patients (10%) experienced mild postoperative shortening (less than 2 cm.). In 1 brittle diabetic patient postoperative infection necessitated removal of 1 cylinder. He remains sexually functional with a single Dynaflexi cylinder. During followup (mean 22.3 t American Medical Systems, Inc., Minnetonka, Minnesota
SURGICAL ALGORITHM FOR PEYRONIE'S DISEASE
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ease and a suboptimal erectile response to papaverine or alprostadil injection. Of our patients 21 received CX700 prostheses, 2 received Dynaflex prostheses and 6 more recently received Ambicor* prostheses. These devices have controlled DISCUSSION expansion type cylinders that expand in girth only and posWhile many patients with Peyronie's disease do not expe- sess intrinsic cylinder rigidity that aids in preserving rience persistent intense pain or curvature preventing coitus straightness. When plaque incision is necessary to straighten or severe erectile dysfunction, those presenting to a tertiary the penis fully, the silicone outer sheath also allows use of referral center are often in an advanced stage of disease. electrocautery without injury to the underlying cylinder. I t Typically, these patients have been referred after conserva- should be noted that the tunica albuginea incision is made tive therapies have failed or the disease has persisted for after opening Bucks fascia and elevating a portion of t h e greater than 1 year. This fact may explain the relatively neurovascular bundle with the prosthesis fully inflated so large percentage of Peyronie's disease patients seen at our that the maximum curvature is demonstrated. Incision is institution who have undergone surgical repair. best made through the tunica albuginea only, leaving a layer As stated by Brock et al, we also believe that a preoperative of cavernosal tissue covering the cylinders. The prosthesis is hemodynamic assessment with duplex ultrasound is appropri- then left partially inflated for 6 weeks to prevent contraction ate in patients with impotence associated with Peyronie's dis- of the tunical defect and recurrent curvature. Furthermore, if ease." This evaluation allows for a more precise definition of incision of the plaque creates a tunical defect greater than 2 the vascular etiology of the erectile dysfunction as well as de- cm. polytetrafluoroethylene grafting should be performed to termines erectile response to an injected vasodilator. One may reduce the likelihood of cylinder herniation or recurrent curalso assess the location of the dorsal penile artery perforating vature due to cicatrix contraction, as occurred in l of our vessels that may be interrupted during elevation of the vascular patients. A 1 mm. polytetrafluoroethylene soft tissue patch bundle which may exacerbate erectile dysfunction postopera- graft should be sized in situ with the prosthesis inflated and tively in those with borderline erectile capacity. As the de- secured with polytetrafluoroethylene suture while the prosscribed algorithm indicates, our surgical approach is conserva- thesis is deflated to avoid injury to the cylinders. tive, performing the least invasive type of procedure that will properly correct the deformity. Simply placing a prosthesis in every Peyronie's disease patient, with its attendant risks of CONCLUSIONS infection and malfunction, may be too aggressive and unacceptFor those men with simple minor curvature a tunica albuable to many patients, especially when more conservative and ginea plication is recommended. This procedure is the least effective surgical alternatives exist. In this study the successful outcomes of plication procedures invasive and results in limited shortening and narrowing of in patients with unidimensional curvature of less than 60 de- the shaft. For complex or bidimensional curvature or signifgrees correlate well with the results of others reporting on this icant hourglass deformity incision or partial excision with procedure. 12-14 Deformity in patients with curvatures greater dermal grafting is recommended to straighten and provide a than 60 degrees may be significantly more difficult to stable penile shaft of uniform caliber. It also theoretically straighten completely and result in a more significant decrease preserves shaft length when reconstruction is necessary for in penile length. In fact, the 2 patients with incomplete straight- more severe deformities. For those patients with suboptimal, ness following tunical plication had preoperative curvatures of subjective or objective erectile capacity prosthesis placement 90 degrees but insisted on this surgical approach. We also is recommended. Penile straightening is performed following consider the presence of an hourglass deformity a relative con- prosthesis placement. If manual molding does not provide traindication to the plication procedure. Theoretically, a cylin- sufficient straightening, then plaque incision should be perder is weakest at its narrowest point, thereby allowing a hinge formed. If the defect is greater than 2 cm. polytetrafluoroetheffect or buckling to occur at that region, particularly when ylene grafting is recommended to prevent cylinder herniation axial forces are placed on the penis, such as attempting vaginal or cicatrix contracture with recurrent curvature. Following a penetration.15 However, patients with ventral curvatures with- thorough history, physical examination and hemodynamic out shaft narrowing are good candidates for plication proce- evaluation, the surgical algorithm presented offers each padures, since the urethra does not need to be mobilized for tient a thoughtful and effective approach that allows a return to normal sexual function. placement of the plication sutures. For those patients with a complex, bidimensional curvature, visible hourglass deformity, hinge effect described by the patient and/or demonstration of these defects during the A P P E N D I X ALGORITHM API'LID FOR SL'R(;l('.AL T K E A T h l E N T lntraoperative induced erection, good results were obtained O F PEYROKIE'S DISEASE using incision or partial excision with grafting. This finding was true particularly for patients who demonstrated adeSurtncal Procedure Indications quate spontaneous or vasoactive drug induced erections with Tunica Alhuginea Plication 'Subjective full t?rectile capacity and/or normal vascular sufficiency on duplex ultrasound. We prefer +Objective full erectile capacity Simple curvature less than 60 degrees dermal grafts harvested from the lower abdominal wall since No hourglass deformity or hinge effect it is more congruous with normal tunica albuginea in terms of thickness, strength and elasticity. It also has a predictable degree of contraction (approximately 2 5 4 ) and is readily Incision or Partial Excision Subjective full erectile capacity andlor Objective full erectile capacity and Dermal Grafting available in sufficient quantity.16 The primary disadvantage Complex or hidimmsional curvature of dermal grafting is that a separate incision is required to C'urvnturv Lze;itt.rthan 60 degrees harvest the graft. Our limited experience with tunica vagiSignificant hourgLis5 deformity or hinge nabs grafts demonstrated a large amount of graft contraction rffect Postoperatively with resultant recurrent curvature and, therefore, we no longer use these grafts. Others have found Penile Prosthesis Placement Suhoptimiil erectile capacity satisfactory results using dura mater, temporalis fascia and Subjective erectile capacity as reported by patient in response to sexual vein n a f t s . LO. 17. IR stimulus. Placement of a prosthesis was performed only when pre' t Ohjective erectile capacity as noted by physician or technician following Operative evaluation demonstrated significant vascular dis- intracorporeal inJection of vasoactive agent
months, range 3 to 45) there have been no mechanical device failures.
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SURGICAL ALGORITHM FOR PEYRONIE’S DISEASE REFERENCES
1. de la Peyronie, F.: Sur quelques obstacles qui s’opposent a I’ejaculation naturell de la semence. Mem. Acad. Roy. Chir. 1: 425, 1743. 2. Devine, C. J . , Sommers, K. D.. Wright, G. L., J r , Gilbert. D. A., Horton. C. E. and Schlossberg. S. M.: A working model for the genesis of Peyronie’s disease derived from its pathobiology. J. Urol.. part 2, 1 3 9 286A, abstract 495, 1988. 3. Levine. L. A., Merrick, P. F. and Lee, R. C.: Intralesional verapamil injection in t h e treatment of Peyronie’s disease. J. Urol., 151: 1522, 1994. 4. Gelbard, M. K., Dosey, F. and James, K.: The natural history of Peyronie’s disease. J. Urol., 144: 1376, 1990. 5. Ralph, D. J., Hughes, T., Lees, W. R., and Pryor, J . P.: Preoperative assessment of Peyronie’s disease using colour Doppler sonography. Brit. J. Urol., 6 9 629, 1992. 6. Krane, R. J.: Pharmacocavernosometry in Peyronie’s disease. In: Programs and Abstracts of the First International Conference on Peyronie’s Disease: Advances in Basic and Clinical Research, Bethesda. Maryland, March 18, 1993. 7. Levine. L. A. and Coogan, C. L.: Penile vascular assessment using color duplex sonography in men with Peyronie’s disease. J. Urol., 155: 1270, 1996. 8. Baskin, L. S. and Duckett, J. W.: Dorsal tunica albuginea plication for hypospadias curvature. J. Urol., 151: 1668, 1994.
9. Devine, C. J., J r . and Horton, C. E.: Surgical treatment of Peyronie’s disease with a dermal graft. J. Urol., 111: 44, 1974. 10. Gelbard. M. K. and Hayden, B.: Expanding contractures of the tunica albuginea due to Peyronie’s disease with temporalis fascia free grafts. J. Urol., 145: 772, 1991. 11. Brock, G., Kadioglu, A. and Lue, T. F.: Peyronie’s disease: a modified treatment. Urology, 4 2 300, 1993. 12. Ralph, D. J., Al-Akraa,M. and Pryor, J. P.: The Nesbit operation for Peyronie’s disease: 16-year experience. J. Urol., 154. 1362, 1995. 13. Erpenback, K., Rothe, H. and Derschum, W.: The penile plication procedure: a n alternative method for straightening penile deviation. J. Urol., 146: 1276, 1991. 14. Benson, R. C., J r . and Patterson, D. E.: The Nesbit procedure for Peyronie’s disease. J. Urol., 1 3 0 692, 1983. 15. Gelbard, M. K.: Relaxing incisions in the correction of penile deformity due to Peyronie’s disease. J . Urol., 1 5 4 1457, 1995. 16. Jordan, G. H.: Peyronie’s disease and its management. In: Clinical Urology. Edited by R J. Krane, M. B. Siroky and J . M. Fitzpatrick. Philadelphia: J . B. Lippincott, chapt. 90 pp. 12821297, 1994. 17. Fallon, B.: Cadaveric dura mater graft for correction of penile curvature in Peyronie’s disease. Urology, 35: 127, 1990. 18. Moriel, E. Z., Grinwald, A. and Rajfer, J.: Vein grafting of tunical incisions combined with contralateral plication in t h e treatment of penile curvature. Urology, 43:697, 1994.