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Surgical Therapy of Peyronie's Disease
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Surgical Therapy of Peyronie’s Disease Tom F. Lue, MD, San Francisco, California The correction of acquired penile deformity seen in Peyronie’s disease patients can be a challenge for the practising urologist. The degree of curvature, the type of deformity, erectile dysfunction, and penile length are all parameters that need to be assessed in choosing the best surgical intervention in Peyronie’s disease. Patient selection for a particular surgical intervention for Peyronie’s disease is paramount. There is no single standard surgical therapy in Peyronie’s disease. Each surgical intervention must be tailored to match the patient’s penile deformity, clinical manifestations, and expectations. The three main categories of surgical interventions include: 1. Plication surgeries and Nesbit/wedge resection procedures (shortening procedures); 2. Plaque incision/excision with grafting procedures (lengthening procedures); 3. Penile prosthesis implantation and the correction of curvature/deformity. Plication/wedge resection procedures
Plication surgery is an excellent option in a carefully selected patient. This type of surgery includes: Nesbit/wedge procedure, plication without incisions of the tunica albuginea, plication with partial thickness shaving of the tunica albuginea, and minimal tension plication techniques using multiple parallel plications. Plication procedures are reserved for patients with ample penile length and adequate erectile function. Using a low-tension plication technique, Gholami and Lue [1] have demonstrated a more than 90% success rate in their patient cohort with a mean followup of 2.6 years. The procedure involves multiple paired plications sutures placed over a long span on the penis. This procedure is carried out under local anesthesia, creating an erect penis using a corpus cavernosum injection of papaverine. The multiple sutures can easily be adjusted throughout the surgery before being tied, therefore accurately creating a straight penis. Patients are carefully counseled with regard to a possible penile shortening and possible palpable non-absorbable sutures beneath the penile skin. This technique eliminates the need for general anesthesia and is carried out as an outpatient surgical procedure. In a recent investigation using the Essed–Schroeder tunica plication technique, quality of life assessments from the patient’s perspective were reviewed [2]. Through a self-completed questionnaire, quality of life assessments were evaluated. Ninety per cent of patients were capable of sexual intercourse after the surgery; 78% of patients were satisfied with the outcome and 22% were dissatisfied. Seventy-four per cent of men reported a shorter penis after surgery. J Sex Med 2007;4(suppl 1):42–44
Recent investigations have also included the evaluation of suture materials used in plication surgeries. Van der Horst et al. [3] studied the use of polytetrafluoroethylene sutures compared with polypropylene sutures in the Essed–Schroeder tunical plication patient. The soft polytetrafluoroethylene suture was felt to be superior to the polypropylene suture with regard to patients’ quality of life and complication rates for patients undergoing plication surgery. In summary, the tunical shortening procedure is the least invasive surgical approach for the correction of penile deformity. The minimal tension approach (16 dots procedure) has the following advantages: 1. A minimal risk of erectile dysfunction or neurovascular damage; 2. Precise placement of sutures because the papaverine-induced erection allows suture adjustments until the penis is straight; and 3. The surgery can be performed with local anesthesia with or without sedation on an outpatient basis. The disadvantages are: penile shortening, palpable nodules from permanent sutures, and an occasional case of prolonged pain from sutures. Preoperative counseling usually minimizes the patient’s concern regarding penile length and nodules. In general, the stretched flaccid length of the penis is the expected length after the plication procedure and this must be demonstrated to the patient before surgery. Grafting procedures
Advances in grafting surgeries have been reported; new grafting materials have been studied as well as new techniques of grafting placement. One surgical approache is the use of a free tunica graft from the proximal corpus cavernosum [4]. The tunica was removed from the proximal corpus cavernosum and placed to the distal defect site. The limitation of this procedure includes the size of the tunica albuginea that can be excised and the narrowing of the proximal corpus cavernosum, which may weaken the support of the penis. New grafting materials have been investigated: cadaveric pericardium (Levine and Estrada [5]), porcine small intestine submucosa [6], fascia lata (Kargi et al. [7]), and porcine dermis. The short-term results are promising. One exciting prospect is tissue engineered tunica albuginea (Schulthesis et al. [8]). Although the best graft material for the tunica albuginea has yet to be determined, the excellent short-term results from using saphenous vein, porcine small intestine submucosa and cadaveric pericardium indicates that other factors may determine the outcome of the grafting surgery. The most important factor seems to be preoperative erectile function as evidenced by a
43
Surgical Therapy of Peyronie’s disease much higher rate of worsening erectile function in men with some degree of erectile dysfunction. In the report by Usta et al. [11], the incidence of postoperative erectile dysfunction increased when the size of the cadevaric pericardial graft was larger than 5 cm. Therefore, tissue reaction between the graft and the underlying spongy tissue as well as the remodeling (in the case of vein or dermis) or the replacement (in cadaveric pericardium or porcine small intestine submucosa) of the graft by the host tissue may also play an important role in determining the final outcome. In addition, because of the possibility of graft contracture, the size of the graft needs to be at least 10% larger than the tunical defect except the saphenous vein graft, which seems to be able to maintain its size without shrinkage. Penile prosthesis surgeries
Generally, the patients with severe penile curvature and erectile dysfunction require penile prosthesis placement for penile straightening and function. In the majority of patients with Peyronie’s disease with erectile dysfunction, the placement of the inflatable penile prosthesis is sufficient for straightening. However, if angulations of greater than 30 degrees persist, additional maneuvers are required to create a straight, functional penis. These maneuvers include: penile modeling, tunica albuginea incisions, tunical plication, and incisions with grafting. Patients with severe penile defects (narrowing, unilateral indentation, or curvatures greater than 90 degrees) preoperatively are most likely to require additional procedure after implantation of the prosthesis [12]. The appropriate penile prosthesis cylinders for the Peyronie’s disease patient are the AMS-CX or CXM (American Medical Systems, Minnetonka, MN, USA) or the Alpha One and Alpha Narrow (Mentor Corp., Santa Barbara, CA, USA). The placement of a cylinder larger than the corporal body should not be attempted. This may exaggerate the penile curvature or create an ‘S’ deformity. The larger cylinder will also create poor positioning of the prosthesis tip, which may lead to erosion [13]. Penile prosthesis placements in the Peyronie’s disease patient that require additional maneuvers have a higher risk of hematoma, urethral injury, and infection. Rahman et al. [13] advocated a new simplified technique in that plication sutures of 2-zero nonabsorbable braided polyester (Ticron) were placed before penile prosthesis placement. If the curvature persists after prosthesis implantation, the sutures were tied to correct the curvature. None of the patients had recurrent curvature or complications at a mean followup of 22 months. Conclusion
The unique patient characteristics in Peyronie’s disease require the urologist to select the surgical procedure
and materials necessary for successful treatment carefully. Only patients who have had failed medical management and have a stable disease process as well as a curvature that does not allow satisfactory intercourse should be considered for surgical intervention. The three main surgical options for patients with Peyronie’s disease include: penile shortening procedures (plication procedures or Nesbit/wedge resections), penile lengthening procedures (incision/excision of plaque with grafting), and penile prosthesis placement. New commercially available grafting materials may replace the need for autologous graft harvesting if the results prove to be as good in longer term studies. Tissue engineering advancements may also improve the quality of these ‘off-the-shelf’ grafting materials. Simpler plication surgeries still play a large role in carefully selected Peyronie’s disease patients. The advantages of the plication procedures are the technical ease for the urologist and the quick recovery time for the patient. Surgical outcomes appear to be equivalent in plication surgeries and grafting procedures, if careful patient selection is employed. Peyronie’s disease patients have a higher likelihood of suffering from erectile dysfunction. For these patients with erectile dysfunction and Peyronie’s disease, penile prosthesis placement remains the standard surgical intervention. References
1. Gholami SS, Lue TF. Correction of penile curvature using the 16-dot plication technique: a review of 132 patients. J Urol 2002; 167:2066–2069. 2. van der Horst C, Martinez-Portillo FJ, Seif C, et al. Treatment of penile curvature with Essed–Schroeder tunical plication: aspects of quality of life from the patients’ perspective. BJU 2004; 93:105–108. 3. van der Horst C, Martinez-Portillo FJ, Melchior D, et al. Polytetrafluoroethylene versus polyproplylene sutures for Essed–Schroeder tunical plication. J Urol 2003; 170:472–475. 4. Schwarzer JU, Muhlen B, Schukai O. Penile corporoplasty using tunica albuginea free graft from proximal ccorpus cavernosum: a new technique for treatment of penile curvaturein Peyronie’s disease. Eur Urol 2003; 44:720–723. 5. Levine LA, Estrada CR. Human cadaveric pericardial graft for the surgical correction of Peyronie’s disease. J Urol 2003; 170:2359–2362. 6. Knoll LD. Use of porcine small intestinal submucosal graft in the surgical management of Peyronie’s disease. Urology. 2001 Apr; 57(4):753–757. 7. Kargi E, Yesilli C, Hosnuter M, et al. Relaxation incision and fascia lata grafting in the surgical correction of penile curvature in Peyronie’s disease. Plast Recon Surg 2004; 113:254–259. 8. Schulthesis D, Lorenz RR, Meister R, et al. Functional tissue engineering of autologous tunica albuginea: a possible graft for Peyronie’s disease surgery. Eur Urol 2004; 45:781–786. 9. Mulcahy JJ, Wilson SK. Management of Peyronie’s disease with penile prosthesis. Int J Imp Res 2002; 14:384–388.
J Sex Med 2007;4(suppl 1):42–44
44 10. Rahman NU, Carrion RE, Bochinski D, Lue TF. Combined penile plication surgery and insertion of penile prosthesis for severe penile curvature and erectile dysfunction. J Urol 2004; 171:2346–2349. 11. Usta MF, Bivalacqua TJ, Sanabria J, et al. Patient and partner satisfaction and long-term results after surgical treatment for Peyronie’s disease. Urology 2003; 62:105–109.
J Sex Med 2007;4(suppl 1):42–44
Surgical Therapy of Peyronie’s disease 12. Mulcahy JJ, Wilson SK. Management of Peyronie’s disease with penile prosthesis. Int J Imp Res 2002; 14:384–388. 13. Rahman NU, Carrion RE, Bochinski D, Lue TF. Combined penile plication surgery and insertion of penile prosthesis for severe penile curvature and erectile dysfunction. J Urol 2004; 171:2346–2349.
Surgical Therapy of Peyronie’s Disease Tom F. Lue, MD, San Francisco, California The correction of acquired penile deformity seen in Peyronie’s disease patients can be a challenge for the practising urologist. The degree of curvature, the type of deformity, erectile dysfunction, and penile length are all parameters that need to be assessed in choosing the best surgical intervention in Peyronie’s disease. Patient selection for a particular surgical intervention for Peyronie’s disease is paramount. There is no single standard surgical therapy in Peyronie’s disease. Each surgical intervention must be tailored to match the patient’s penile deformity, clinical manifestations, and expectations. The three main categories of surgical interventions include: 1. Plication surgeries and Nesbit/wedge resection procedures (shortening procedures); 2. Plaque incision/excision with grafting procedures (lengthening procedures); 3. Penile prosthesis implantation and the correction of curvature/deformity. Plication/wedge resection procedures
Plication surgery is an excellent option in a carefully selected patient. This type of surgery includes: Nesbit/wedge procedure, plication without incisions of the tunica albuginea, plication with partial thickness shaving of the tunica albuginea, and minimal tension plication techniques using multiple parallel plications. Plication procedures are reserved for patients with ample penile length and adequate erectile function. Using a low-tension plication technique, Gholami and Lue [1] have demonstrated a more than 90% success rate in their patient cohort with a mean followup of 2.6 years. The procedure involves multiple paired plications sutures placed over a long span on the penis. This procedure is carried out under local anesthesia, creating an erect penis using a corpus cavernosum injection of papaverine. The multiple sutures can easily be adjusted throughout the surgery before being tied, therefore accurately creating a straight penis. Patients are carefully counseled with regard to a possible penile shortening and possible palpable non-absorbable sutures beneath the penile skin. This technique eliminates the need for general anesthesia and is carried out as an outpatient surgical procedure. In a recent investigation using the Essed–Schroeder tunica plication technique, quality of life assessments from the patient’s perspective were reviewed [2]. Through a self-completed questionnaire, quality of life assessments were evaluated. Ninety per cent of patients were capable of sexual intercourse after the surgery; 78% of patients were satisfied with the outcome and 22% were dissatisfied. Seventy-four per cent of men reported a shorter penis after surgery. J Sex Med 2007;4(suppl 1):42–44
Recent investigations have also included the evaluation of suture materials used in plication surgeries. Van der Horst et al. [3] studied the use of polytetrafluoroethylene sutures compared with polypropylene sutures in the Essed–Schroeder tunical plication patient. The soft polytetrafluoroethylene suture was felt to be superior to the polypropylene suture with regard to patients’ quality of life and complication rates for patients undergoing plication surgery. In summary, the tunical shortening procedure is the least invasive surgical approach for the correction of penile deformity. The minimal tension approach (16 dots procedure) has the following advantages: 1. A minimal risk of erectile dysfunction or neurovascular damage; 2. Precise placement of sutures because the papaverine-induced erection allows suture adjustments until the penis is straight; and 3. The surgery can be performed with local anesthesia with or without sedation on an outpatient basis. The disadvantages are: penile shortening, palpable nodules from permanent sutures, and an occasional case of prolonged pain from sutures. Preoperative counseling usually minimizes the patient’s concern regarding penile length and nodules. In general, the stretched flaccid length of the penis is the expected length after the plication procedure and this must be demonstrated to the patient before surgery. Grafting procedures
Advances in grafting surgeries have been reported; new grafting materials have been studied as well as new techniques of grafting placement. One surgical approache is the use of a free tunica graft from the proximal corpus cavernosum [4]. The tunica was removed from the proximal corpus cavernosum and placed to the distal defect site. The limitation of this procedure includes the size of the tunica albuginea that can be excised and the narrowing of the proximal corpus cavernosum, which may weaken the support of the penis. New grafting materials have been investigated: cadaveric pericardium (Levine and Estrada [5]), porcine small intestine submucosa [6], fascia lata (Kargi et al. [7]), and porcine dermis. The short-term results are promising. One exciting prospect is tissue engineered tunica albuginea (Schulthesis et al. [8]). Although the best graft material for the tunica albuginea has yet to be determined, the excellent short-term results from using saphenous vein, porcine small intestine submucosa and cadaveric pericardium indicates that other factors may determine the outcome of the grafting surgery. The most important factor seems to be preoperative erectile function as evidenced by a
43
Surgical Therapy of Peyronie’s disease much higher rate of worsening erectile function in men with some degree of erectile dysfunction. In the report by Usta et al. [11], the incidence of postoperative erectile dysfunction increased when the size of the cadevaric pericardial graft was larger than 5 cm. Therefore, tissue reaction between the graft and the underlying spongy tissue as well as the remodeling (in the case of vein or dermis) or the replacement (in cadaveric pericardium or porcine small intestine submucosa) of the graft by the host tissue may also play an important role in determining the final outcome. In addition, because of the possibility of graft contracture, the size of the graft needs to be at least 10% larger than the tunical defect except the saphenous vein graft, which seems to be able to maintain its size without shrinkage. Penile prosthesis surgeries
Generally, the patients with severe penile curvature and erectile dysfunction require penile prosthesis placement for penile straightening and function. In the majority of patients with Peyronie’s disease with erectile dysfunction, the placement of the inflatable penile prosthesis is sufficient for straightening. However, if angulations of greater than 30 degrees persist, additional maneuvers are required to create a straight, functional penis. These maneuvers include: penile modeling, tunica albuginea incisions, tunical plication, and incisions with grafting. Patients with severe penile defects (narrowing, unilateral indentation, or curvatures greater than 90 degrees) preoperatively are most likely to require additional procedure after implantation of the prosthesis [12]. The appropriate penile prosthesis cylinders for the Peyronie’s disease patient are the AMS-CX or CXM (American Medical Systems, Minnetonka, MN, USA) or the Alpha One and Alpha Narrow (Mentor Corp., Santa Barbara, CA, USA). The placement of a cylinder larger than the corporal body should not be attempted. This may exaggerate the penile curvature or create an ‘S’ deformity. The larger cylinder will also create poor positioning of the prosthesis tip, which may lead to erosion [13]. Penile prosthesis placements in the Peyronie’s disease patient that require additional maneuvers have a higher risk of hematoma, urethral injury, and infection. Rahman et al. [13] advocated a new simplified technique in that plication sutures of 2-zero nonabsorbable braided polyester (Ticron) were placed before penile prosthesis placement. If the curvature persists after prosthesis implantation, the sutures were tied to correct the curvature. None of the patients had recurrent curvature or complications at a mean followup of 22 months. Conclusion
The unique patient characteristics in Peyronie’s disease require the urologist to select the surgical procedure
and materials necessary for successful treatment carefully. Only patients who have had failed medical management and have a stable disease process as well as a curvature that does not allow satisfactory intercourse should be considered for surgical intervention. The three main surgical options for patients with Peyronie’s disease include: penile shortening procedures (plication procedures or Nesbit/wedge resections), penile lengthening procedures (incision/excision of plaque with grafting), and penile prosthesis placement. New commercially available grafting materials may replace the need for autologous graft harvesting if the results prove to be as good in longer term studies. Tissue engineering advancements may also improve the quality of these ‘off-the-shelf’ grafting materials. Simpler plication surgeries still play a large role in carefully selected Peyronie’s disease patients. The advantages of the plication procedures are the technical ease for the urologist and the quick recovery time for the patient. Surgical outcomes appear to be equivalent in plication surgeries and grafting procedures, if careful patient selection is employed. Peyronie’s disease patients have a higher likelihood of suffering from erectile dysfunction. For these patients with erectile dysfunction and Peyronie’s disease, penile prosthesis placement remains the standard surgical intervention. References
1. Gholami SS, Lue TF. Correction of penile curvature using the 16-dot plication technique: a review of 132 patients. J Urol 2002; 167:2066–2069. 2. van der Horst C, Martinez-Portillo FJ, Seif C, et al. Treatment of penile curvature with Essed–Schroeder tunical plication: aspects of quality of life from the patients’ perspective. BJU 2004; 93:105–108. 3. van der Horst C, Martinez-Portillo FJ, Melchior D, et al. Polytetrafluoroethylene versus polyproplylene sutures for Essed–Schroeder tunical plication. J Urol 2003; 170:472–475. 4. Schwarzer JU, Muhlen B, Schukai O. Penile corporoplasty using tunica albuginea free graft from proximal ccorpus cavernosum: a new technique for treatment of penile curvaturein Peyronie’s disease. Eur Urol 2003; 44:720–723. 5. Levine LA, Estrada CR. Human cadaveric pericardial graft for the surgical correction of Peyronie’s disease. J Urol 2003; 170:2359–2362. 6. Knoll LD. Use of porcine small intestinal submucosal graft in the surgical management of Peyronie’s disease. Urology. 2001 Apr; 57(4):753–757. 7. Kargi E, Yesilli C, Hosnuter M, et al. Relaxation incision and fascia lata grafting in the surgical correction of penile curvature in Peyronie’s disease. Plast Recon Surg 2004; 113:254–259. 8. Schulthesis D, Lorenz RR, Meister R, et al. Functional tissue engineering of autologous tunica albuginea: a possible graft for Peyronie’s disease surgery. Eur Urol 2004; 45:781–786. 9. Mulcahy JJ, Wilson SK. Management of Peyronie’s disease with penile prosthesis. Int J Imp Res 2002; 14:384–388.
J Sex Med 2007;4(suppl 1):42–44
44 10. Rahman NU, Carrion RE, Bochinski D, Lue TF. Combined penile plication surgery and insertion of penile prosthesis for severe penile curvature and erectile dysfunction. J Urol 2004; 171:2346–2349. 11. Usta MF, Bivalacqua TJ, Sanabria J, et al. Patient and partner satisfaction and long-term results after surgical treatment for Peyronie’s disease. Urology 2003; 62:105–109.
J Sex Med 2007;4(suppl 1):42–44
Surgical Therapy of Peyronie’s disease 12. Mulcahy JJ, Wilson SK. Management of Peyronie’s disease with penile prosthesis. Int J Imp Res 2002; 14:384–388. 13. Rahman NU, Carrion RE, Bochinski D, Lue TF. Combined penile plication surgery and insertion of penile prosthesis for severe penile curvature and erectile dysfunction. J Urol 2004; 171:2346–2349.