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Surgical treatment of peyronie disease with dacron graft
SURGICAL TREATMENT
OF PEYRONIE DISEASE
WITH DACRON GRAFT D. H. LOWE, PETER
M.D.
C. LOWELL
C. HO, M.D.
JOSEPH
PARSONS,
D. SCHMIDT,
M.D. M.D.
From the Urology Section, Veterans Administration Medical Center, and the Division of Urology, Department of Surgery, University of California Medical Center, San Diego, California
ABSTRACT - Four seoere cases of Peyronie disease treated with plaque excision and insertion of a Dacron graft are presented. All 4 patients have had encouraging results, with follow-up ranging from six months to three and one-half years. They have little or no penile curvature, and all are capable of intercourse. One patient had a wound infection and skin slough necessitating pedicle grafting; but the Dacron graf was saued, and the patient has done well subsequently.
In 1743 Francois de la Peyronie, physician to Louis XIV, described a case of “rosary beads of scar tissue in the penis,” which later became known as Peyronie disease.’ Various other names, including “cavernositis” and “plastic induration of the penis,” have been used commonly. The pathophysiology of this disease is not well understood. Histologically, it occurs initially as an inflammation of the collagen fibers between the tunica albuginea and the corpora cavernosa, maturing into fibrosis. The greater the duration of disease, the more extensive the fibrosis. calcification, and sometimes Hyalinization, ossification may occur in time. Spontaneous regression has been reported to occur in up to 50 per cent of cases. 2 A literature survey of the many modalities of treatment indicates that no single modality is universally applicable in this disease.2-* Surgical therapy usually is reserved for more disabling forms of the disease. Recently, concurrent insertion of penile prostheses has been advocated for patients who are impotent preoperatively and for those whose disease is so advanced that postoperative impotence is expected.’ To the list of different materials used for covering excision defects we add the Dacron graft, which has been used successfully in the treatment of vascular diseases.
UROLOGY
/ JUNE 1982 / VOLUME
XIX, NUMBER
6
An artificial erection was produced by applying a tourniquet to the base of the penis as one of the corpora was injected with heparinized saline via a scalp vein needle. The curvature demonstrated with this artificial- erection allowed us to choose the site of a dorsal longitudinal penile incision or circumferential sleeve-type incision. After the corporeal plaque was identified it was excised along with a rim of normal corporeal tissue. Then a Dacron graft, trimmed to approximate the size of the corporeal defect, was sutured into place with 4-O nonabsorbable vascular suture. The graft was oriented such that the Dacron’s axis of greatest elasticity was parallel to the penile shaft. Repeated artificial erections indicated whether or not sufficient plaque tissue was removed. Case Reports Case 1 This twenty-two-year-old man had Peyronie plaques in the dorsal distal third of both corpora cavernosa. A left lateral chordee, together with pain and incomplete distal erection, made intercourse extremely difficult. Multiple trials of steroid and hyaluronidase injections failed to soften the plaques and progressive fibrosis ensued. The patient underwent excision of his plaques and Dacron grafting of both corporeal
609
defects. Two years postoperatively, he has returned to normal erections and intercourse with no curvature or pain. Case 2 This forty-two-year-old man with Peyronie plaques in the distal third of his left corpus cavernosum had been treated one and one-half years previously with plaque excision and dermal grafting. Scarring and retraction of the dermal graft made intercourse difficult. He had had steroid injections and oral phenylbutazone therapy without any discernible change. He underwent excision of the dermal graft and Dacron grafting with insertion of Small-Carrion penile prostheses. The patient did not cope well psychologically with his penile prostheses, and they were removed four months postoperatively. Three and a half years later he has erections with a slight left curvature and is capable of intercourse. Case 3 This fifty-three-year-old man presented with an extensive Peyronie plaque of his left corpus cavernosum and an almost 180 degree dorsal curvature of his penis on erection. The patient had undergone multiple trials of nonsurgical therapy without success, and his disease had progressed. Plaque excision and Dacron grafting were performed. Additional relaxing incisions in the remaining parts of his cavernosum were required which resulted in only slight curvature intraoperatively. Postoperatively, the patient had good erections but had a residual curvature of about 70 degrees. Three months later he underwent wider plaque excision, Dacron grafting, and insertion of Small-Carrion prostheses. Sloughing of the distal 2 cm. of penile skin necessitated abdominal pedicle grafting for wound healing. The wounds healed fully, and for the past two and one-half years he has been able to have intercourse with a straight penis. Case 4 This fifty-nine-year-old patient had rapid growth of a Peyronie plaque with progressive dorsal penile curvature. He also had pain which nearly precluded intercourse. He received oral potassium p-aminobenzoate (Potaba) and steroid injections without improvement, Subsequently he had excision of the plaque with Dacron grafting and has done well since surgery six months ago. Although he has minimal dorsal penile anesthesia with some slight persistent curvature, his
610
condition is much improved unimpaired intercourse.
and he is capable of
Comment It is well known that wide excision of a Peyronie plaque without repair of the tunica albuginea results in extensive scarring. of the multitude of materials used for repairing these defects, only the dermal graft seems to remain popular. Individuals treated with fat, vein, artery, or fascia grafts have been reported to experience postoperative contracture and scarring.’ Dermal grafts have been reported to yield satisfactory results in about 70 per cent of cases;‘O however, these grafts require meticulous preparation before the actual grafting procedure, and the fate of the adnexal glands and hair follicles in the dermal graft are also a matter of concern. In a few rare cases inclusion cysts have caused graft removal. For approximately twenty years, vascular surgeons have used the Dacron graft successfully as an arterial substitute. Dacron is an inert material whose long-term safety as a graft material in humans has been established. Dacron grafts are readily available and do not require any pre-grafting preparation other than preclotting with the patient’s own blood. We suggest that the Dacron graft offers a better choice than other materials in the repair of tunica albuginea defects after excision of Peyronie plaques. H-897 Division of Urology 225 Dickinson Street San Diego, California 92193 (DR. LOWE) References 1. de la Peyronie F: Sur quelques obstacles qui s’opposent a l’ejaculation naturelle de la semence, Mem. de l’Acad. Roy. de Chir. 1: 425 (1743). 2. Furlow WL, Swenson HE Jr, and Lee RE: Peyronie’s disease: a study of its natural history and treatment with orthovoltage radiotherapy, J. Ural. 114: 69 (1975). 3. Zarafonetis CJD, and Horrax TM: Treatment of Peyronie’s disease with potassium para-aminobenzoate (Potaba), ibid. 81: 770 (1959). 4. DeSanctis PM, and Furey CA Jr: Steroid injection therapy for Peyronie’s disease, ibid. 971 114 (i967). 5. Frank IN, and Scott WW: The ultrasonic treatment of Peyronie’s disease, i&d. 106: 883 (1971). 6. Devine CJ Jr, and Horton CE: Surgical treatment of Peyronie’s disease with a dermal graft, ibid. 111: 44 (1974). 7. Raz S, DeKemion JB, and Kaufman JJ: Surgical treatment of Peyronie’s disease: a new approach, ibid. 117: 598 (1977). 8. Das S: Peyronie’s disease: excision and autografting with tunica vaginalis, ibid. 124: 818 (1980). 9. Horton CE, and Devine CJ Jr: Peyronie’s disease, Plast. Reconstr. Surg. 52: 593 (1973). 10. Wild RM, Devine CJ Jr, and Horton CE: Dermal graft repair of Peyronie’s disease, J. Urol. 121: 47 (1979).
UROLOGY
/
JUNE 1982
/
VOLUME XIX, NUMBER 6
OF PEYRONIE DISEASE
WITH DACRON GRAFT D. H. LOWE, PETER
M.D.
C. LOWELL
C. HO, M.D.
JOSEPH
PARSONS,
D. SCHMIDT,
M.D. M.D.
From the Urology Section, Veterans Administration Medical Center, and the Division of Urology, Department of Surgery, University of California Medical Center, San Diego, California
ABSTRACT - Four seoere cases of Peyronie disease treated with plaque excision and insertion of a Dacron graft are presented. All 4 patients have had encouraging results, with follow-up ranging from six months to three and one-half years. They have little or no penile curvature, and all are capable of intercourse. One patient had a wound infection and skin slough necessitating pedicle grafting; but the Dacron graf was saued, and the patient has done well subsequently.
In 1743 Francois de la Peyronie, physician to Louis XIV, described a case of “rosary beads of scar tissue in the penis,” which later became known as Peyronie disease.’ Various other names, including “cavernositis” and “plastic induration of the penis,” have been used commonly. The pathophysiology of this disease is not well understood. Histologically, it occurs initially as an inflammation of the collagen fibers between the tunica albuginea and the corpora cavernosa, maturing into fibrosis. The greater the duration of disease, the more extensive the fibrosis. calcification, and sometimes Hyalinization, ossification may occur in time. Spontaneous regression has been reported to occur in up to 50 per cent of cases. 2 A literature survey of the many modalities of treatment indicates that no single modality is universally applicable in this disease.2-* Surgical therapy usually is reserved for more disabling forms of the disease. Recently, concurrent insertion of penile prostheses has been advocated for patients who are impotent preoperatively and for those whose disease is so advanced that postoperative impotence is expected.’ To the list of different materials used for covering excision defects we add the Dacron graft, which has been used successfully in the treatment of vascular diseases.
UROLOGY
/ JUNE 1982 / VOLUME
XIX, NUMBER
6
An artificial erection was produced by applying a tourniquet to the base of the penis as one of the corpora was injected with heparinized saline via a scalp vein needle. The curvature demonstrated with this artificial- erection allowed us to choose the site of a dorsal longitudinal penile incision or circumferential sleeve-type incision. After the corporeal plaque was identified it was excised along with a rim of normal corporeal tissue. Then a Dacron graft, trimmed to approximate the size of the corporeal defect, was sutured into place with 4-O nonabsorbable vascular suture. The graft was oriented such that the Dacron’s axis of greatest elasticity was parallel to the penile shaft. Repeated artificial erections indicated whether or not sufficient plaque tissue was removed. Case Reports Case 1 This twenty-two-year-old man had Peyronie plaques in the dorsal distal third of both corpora cavernosa. A left lateral chordee, together with pain and incomplete distal erection, made intercourse extremely difficult. Multiple trials of steroid and hyaluronidase injections failed to soften the plaques and progressive fibrosis ensued. The patient underwent excision of his plaques and Dacron grafting of both corporeal
609
defects. Two years postoperatively, he has returned to normal erections and intercourse with no curvature or pain. Case 2 This forty-two-year-old man with Peyronie plaques in the distal third of his left corpus cavernosum had been treated one and one-half years previously with plaque excision and dermal grafting. Scarring and retraction of the dermal graft made intercourse difficult. He had had steroid injections and oral phenylbutazone therapy without any discernible change. He underwent excision of the dermal graft and Dacron grafting with insertion of Small-Carrion penile prostheses. The patient did not cope well psychologically with his penile prostheses, and they were removed four months postoperatively. Three and a half years later he has erections with a slight left curvature and is capable of intercourse. Case 3 This fifty-three-year-old man presented with an extensive Peyronie plaque of his left corpus cavernosum and an almost 180 degree dorsal curvature of his penis on erection. The patient had undergone multiple trials of nonsurgical therapy without success, and his disease had progressed. Plaque excision and Dacron grafting were performed. Additional relaxing incisions in the remaining parts of his cavernosum were required which resulted in only slight curvature intraoperatively. Postoperatively, the patient had good erections but had a residual curvature of about 70 degrees. Three months later he underwent wider plaque excision, Dacron grafting, and insertion of Small-Carrion prostheses. Sloughing of the distal 2 cm. of penile skin necessitated abdominal pedicle grafting for wound healing. The wounds healed fully, and for the past two and one-half years he has been able to have intercourse with a straight penis. Case 4 This fifty-nine-year-old patient had rapid growth of a Peyronie plaque with progressive dorsal penile curvature. He also had pain which nearly precluded intercourse. He received oral potassium p-aminobenzoate (Potaba) and steroid injections without improvement, Subsequently he had excision of the plaque with Dacron grafting and has done well since surgery six months ago. Although he has minimal dorsal penile anesthesia with some slight persistent curvature, his
610
condition is much improved unimpaired intercourse.
and he is capable of
Comment It is well known that wide excision of a Peyronie plaque without repair of the tunica albuginea results in extensive scarring. of the multitude of materials used for repairing these defects, only the dermal graft seems to remain popular. Individuals treated with fat, vein, artery, or fascia grafts have been reported to experience postoperative contracture and scarring.’ Dermal grafts have been reported to yield satisfactory results in about 70 per cent of cases;‘O however, these grafts require meticulous preparation before the actual grafting procedure, and the fate of the adnexal glands and hair follicles in the dermal graft are also a matter of concern. In a few rare cases inclusion cysts have caused graft removal. For approximately twenty years, vascular surgeons have used the Dacron graft successfully as an arterial substitute. Dacron is an inert material whose long-term safety as a graft material in humans has been established. Dacron grafts are readily available and do not require any pre-grafting preparation other than preclotting with the patient’s own blood. We suggest that the Dacron graft offers a better choice than other materials in the repair of tunica albuginea defects after excision of Peyronie plaques. H-897 Division of Urology 225 Dickinson Street San Diego, California 92193 (DR. LOWE) References 1. de la Peyronie F: Sur quelques obstacles qui s’opposent a l’ejaculation naturelle de la semence, Mem. de l’Acad. Roy. de Chir. 1: 425 (1743). 2. Furlow WL, Swenson HE Jr, and Lee RE: Peyronie’s disease: a study of its natural history and treatment with orthovoltage radiotherapy, J. Ural. 114: 69 (1975). 3. Zarafonetis CJD, and Horrax TM: Treatment of Peyronie’s disease with potassium para-aminobenzoate (Potaba), ibid. 81: 770 (1959). 4. DeSanctis PM, and Furey CA Jr: Steroid injection therapy for Peyronie’s disease, ibid. 971 114 (i967). 5. Frank IN, and Scott WW: The ultrasonic treatment of Peyronie’s disease, i&d. 106: 883 (1971). 6. Devine CJ Jr, and Horton CE: Surgical treatment of Peyronie’s disease with a dermal graft, ibid. 111: 44 (1974). 7. Raz S, DeKemion JB, and Kaufman JJ: Surgical treatment of Peyronie’s disease: a new approach, ibid. 117: 598 (1977). 8. Das S: Peyronie’s disease: excision and autografting with tunica vaginalis, ibid. 124: 818 (1980). 9. Horton CE, and Devine CJ Jr: Peyronie’s disease, Plast. Reconstr. Surg. 52: 593 (1973). 10. Wild RM, Devine CJ Jr, and Horton CE: Dermal graft repair of Peyronie’s disease, J. Urol. 121: 47 (1979).
UROLOGY
/
JUNE 1982
/
VOLUME XIX, NUMBER 6