Outcomes of Surgery in Peyronie’s Disease Following Intralesional Collagenase Clostridium Histolyticum Injections

ESSM Position Statement on Surgical Treatment of Peyronie's Disease

INTRODUCTION

Patients with Peyronie's disease may experience significat distress. The choice of treatment depends on a variety of factors, including the stage of the disease, the presence of pain, severity and direction of the curvature, penile length and the quality of erectile function.

AIM

To review the evidence associated with surgical treatment of Peyronie`s Disease and provide clinical recommendations on behalf of the European Society for Sexual Medicine. 131 peer-reviewed studies and systematic reviews, which were published from 2009 to 2019 in the English language, were included.

METHODS

MEDLINE, Google Scholar and EMBASE were searched for randomized clinical trials, meta-analyses, open-label prospective and retrospective studies.

MAIN OUTCOME MEASURE

The panel provided statements on clinically relevant questions including patient involvement in the decision process, indications for surgery, choice of the approach, and the management of patient expectations. A comparison of the different grafts used in patients who have undergone plaque incision/excision and grafting in order to identify an ideal graft, has been carried out. The prevalence of postoperative complications has been summarized. Levels of evidence were provided according to the Oxford 2011 criteria and Oxford Centre for Evidence-Based Medicine recommendations.

RESULTS

In order to allow shared decision making, a patient preoperative counselling regarding the pros and cons of each intervention is recommended. In particular, adverse effects of surgical treatments should be discussed to set realistic understanding and expectations of surgical outcomes and ultimately improve postoperative satisfaction rates. Surgical treatment should be only offered in the chronic phase of the condition, when the deformity and/or degree of erectile dysfunction, prevent patients from engaging in satisfying sexual interaction, or if the deformity is the cause of severe bother.

CONCLUSIONS

Current European Society for Sexual Medicine recommendations cover several aspects of Peyronie's disease treatment. These recommendations aim both to ensure patients and partners have accurate and realistic expectations of their treatment options, as well as to formulate algorithms to guide clinician management pathways. Osmonov D, Ragheb A, Ward S et al, ESSM Position Statement on Surgical Treatment of Peyronie's Disease. Sex Med 2022;10:100459.

[Efficacy and safety of local injections treatments for Peyronie's disease: Review of the literature]

AIM

To assess the efficacy and safety of local injection used to reduce penile curvature in Peyronie's disease.

METHODS

A review of the literature was carried out according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyzes) on the Medline database in April 2020, with the research: "collagenase"[All Fields] OR "Interferon"[All Fields] OR "verapamil"[All Fields] OR "betamethasone"[All Fields] OR "hyaluronic acid"[All Fields] OR "Platelet-Rich Plasma"[All Fields] OR "Stem Cells"[All Fields] AND "peyronie's"[All Fields] AND Controlled Clinical Trial[ptyp]. Only controlled studies with placebo group were included in this review.

RESULTS

Of the 35 articles identified, 6 placebo-controlled studies were finally included. Intra-plaque injections of verapamil did not show improvement in penile curvature. Injections of interferon α 2b and clostridium histolyticum collagenase allowed a statistically significant improvement in terms of curvature reduction: 13.5 versus 4.5 degrees P<0.01) and 17 versus 9.3 degrees P<0.0001 respectively. However, interferon α 2b is not available in France for Peyronie's disease and clostridium histolyticum collagenase is no longer authorized since March 1, 2020. No controlled studies are available on corticosteroids, hyaluronic acid, platelet-rich plasma or stem cells injections.

CONCLUSION

To correct the deformity in Peyronie's disease in the chronic phase, there is no effective solution currently available in France based on controlled studies. Surgery retains its place for the correction of a curvature of at least 30° associated with a sexual handicap in the stable phase, however at the cost of potential adverse effects. Stem cell or Platelet-Rich Plasma injection might be an injectable therapeutic alternative but need controlled studies.

Intralesional low-dose methylprednisolone for the treatment of active phase Peyronie's disease: A single-centre, preliminary prospective non-randomised study

AIM

There are a few types of drugs that can be used in the active phase of Peyronie's disease. Methylprednisolone is a corticosteroid with a strong anti-inflammatory effect. In this study, we aimed to evaluate the effect of intralesional low-dose methylprednisolone treatment on patients in the active phase of Peyronie's disease.

PATIENTS AND METHODS

Forty-eight patients suffering from Peyronie's disease active phase symptoms were included in the study. Methylprednisolone was administered intralesionally for 8 weeks, once per week, at a dose of 40 mg. The injection was applied to the plaques, which causes maximum curvature. Patients were evaluated before and after treatment for plaque size, angle of curvature, and erectile dysfunction according to the International Index of Erectile Function-5 and Peyronie's Disease Questionnaire.

RESULTS

The mean age of the patients was 61.1 (43-78) years. The mean duration of the symptoms was 3.4 (0-9) months. The average plaque size before treatment was 13.6 mm (7.1-16.8) and after treatment, this value decreased to 10.8 mm (4.3-14.6) (P: .025). The average scores of Peyronie's Disease Questionnaire elements; symptom severity, penile pain, and bother/discomfort were 12.3, 19.1, and 6.2, respectively, before the treatment. These scores were decreased to 8.9, 9.6, and 4.4, respectively, after treatment. All subgroups of Peyronie's Disease Questionnaire scores were significantly improved after treatment (P: .001, P < .001, P: .045, respectively). No adverse events were observed during or after treatment.

CONCLUSION

In order to recover the symptoms and signs, new and easily accessible drugs are required for use in the acute period of Peyronie's disease. In this context, treatment with intralesional low-dose methylprednisolone in acute phase Peyronie's Disease is a promising and safe treatment option.

Surgical outcomes after collagenase Clostridium histolyticum failure in patients with Peyronie's disease in a multicenter clinical study

In the present study we aimed to investigate the surgical outcomes of patients with persistent penile curvature (PC) after Collagenase Clostridium histolyticum (CCH) intraplaque injections. Data from 90 patients with persistent PC after CCH in a multicentre study from 6 andrological centres were retrospectively reviewed. Three standardized surgical techniques were performed. Group 1: plaque incision grafting (PIG) with penile prosthesis implant (PPI); Group 2: PIG without PPI; Group 3: Nesbit technique. Hospital stay, operative time, postoperative complications and PC persistency/recurrence (> 20°) were evaluated. Overall satisfaction and functional outcomes were assessed through International Index of Erectile Function-Erectile Function (IIEF-EF), Peyronie's Disease Questionnaire (PDQ), Female Sexual Function Index (FSFI) administered pre and 3 months postoperatively. Of all, 25 (27.8%) patients received grafting procedure + PPI (Group 1), 18 (20.0%) patients belonged to Group 2, and 47 (52.2%) to Group 3. Bovine pericardium graft and collagen fleece have been used in in 22 (51.2%) and 21 (48.8%) patients, respectively. Median penile length after surgery was 13.0 cm (IQR 12.0-15.0). After surgery, Group 1 showed higher increase in penile length after surgery and better improvements in terms of PDQ-PS. In contrast, both IIEF-EF and FSFI scores did not differ among groups. Overall, 86 (95.6%) did not report any complication. 4 (4.4%) patients had PC recurrence; of those, 2 (8.0%), 1 (5.6%) and 1 (2.1%) cases were observed in Group 1, Group 2 and Group 3, respectively. In case of persistent PC after CCH, surgical correction by grafting with or without concomitant PPI or Nesbit technique emerged as a technically feasible, effective and safe procedure, with no significant postoperative complications.