Xiaflex for Treatment of Peyronie's Disease

Collagen inhibits phagocytosis of amyloid in vitro and in vivo and may act as a 'don't eat me' signal

BACKGROUND

Systemic amyloidosis refers to a group of protein misfolding disorders characterized by the extracellular deposition of amyloid fibrils in organs and tissues. For reasons heretofore unknown, amyloid deposits are not recognized by the immune system, and progressive deposition leads to organ dysfunction.

METHODS

In vitro and in vivo phagocytosis assays were performed to elucidate the impact of collagen and other amyloid associated proteins (eg serum amyloid p component and apolipoprotein E) had on amyloid phagocytosis. Immunohistochemical and histopathological staining regimens were employed to analyze collagen-amyloid interactions and immune responses.

RESULTS

Histological analysis of amyloid-laden tissue indicated that collagen is intimately associated with amyloid deposits. We report that collagen inhibits phagocytosis of amyloid fibrils by macrophages. Treatment of 15 patient-derived amyloid extracts with collagenase significantly enhanced amyloid phagocytosis. Preclinical mouse studies indicated that collagenase treatment of amyloid extracts significantly enhanced clearance as compared to controls, coincident with increased immune cell infiltration of the subcutaneous amyloid lesion.

CONCLUSIONS

These data suggest that amyloid-associated collagen serves as a 'don't eat me' signal, thereby hindering clearance of amyloid. Targeted degradation of amyloid-associated collagen could result in innate immune cell recognition and clearance of pathologic amyloid deposits.

Lateral herniation during treatment with collagenase Clostridium histolyticum (Xiaflex) for Peyronie's disease

Background

Collagenase Clostridium histolyticum (CCH), also know as Xiaflex, with penile modeling is considered to be the gold standard non-surgical option for management of Peyronie’s disease and is known to be safe and efficacious. Corporal rupture is a rare but known adverse event of CCH treatment, however there are limited studies describing corporal herniation without rupture. Here we present a patient who experienced a rare complication following CCH injections for Peyronie’s disease: lateral herniation of the tunica albuginea in the setting of a dorsal penile plaque.

Case presentation

A 58-year-old male presented to our clinic seeking treatment for Peyronie’s disease. On exam, he was found to have a palpable dorsal plaque and > 30 degrees leftward curvature of the penis. He was deemed an appropriate candidate for and patient decided to proceed with CCH and modeling. He received 2 cycles of CCH injections (4 total CCH injections) with in-office and at-home penile modeling, per manufacturer’s protocol. Two weeks following in-office modeling during his second CCH cycle, the patient reported a painless, soft swelling involving the left side of his penile shaft only occurring with erection. Exam and history were suggestive of lateral herniation rather than corporal rupture. CCH was discontinued. Patient declined further evaluation with penile ultrasound.

Conclusions

This is the first case report detailing lateral herniation with CCH injections. Symptoms and exam that should raise suspicion of corporal herniation are a soft, painless mass with erection.

Augmentation Phalloplasty for Acquired Penile Shortening: A Systematic Review of Techniques, Outcomes, Patient Satisfaction, and Limitations

INTRODUCTION

Although an infrequent cause of small penile size in adult men, acquired penile shortening represents a particular reconstructive challenge due to preexisting penile anatomic deformities.

AIM

With numerous techniques being performed, the purpose of our study is to assess available literature on length enhancement procedures used for acquired penile shortening deformities.

METHODS

A systematic review was performed using the guidelines outlined in the Preferred Reporting Items for Systematic reviews and Meta-analyses. Medline/PubMed, Scopus, and Cochrane Databases were used to identify papers on augmentation Phalloplasty in non-transgender males with acquired penile shortening from 1990 to 2018.

MAIN OUTCOME MEASURE

Outcomes, complications, and patient-reported satisfaction were analyzed.

RESULTS

12 articles, involving 931 patients and 8 primary procedures, met our inclusion criteria. The majority of articles had level of evidence of 4 (83%) and Newcastle Ottawa Scale score of 6 (92%, moderate risk of bias). All studies reported mean penile length gain; however, inconsistent methodology was used when measuring penile dimensions. Mean length gain ranged from 0.6 to 6.4 cm. Overall, the mean complication rate for all techniques ranged from 0% to 50%. Post-operative satisfaction was reported in 10 (83%) studies, 7 of which used a validated scale. Patients were generally satisfied, with reported satisfaction rates ranging from 77% to 100%.

CLINICAL IMPLICATIONS

While numerous procedures have been described, the significant limitations in the available data preclude identifying a single superior procedure.

STRENGTHS & LIMITATIONS

The significant heterogeneity in the reported literature is a limitation of this study and highlights the need for standardized reporting. However, this study is the first to analyze augmentation phalloplasty literature in the setting of acquired penile shortening.

CONCLUSION

Augmentation phalloplasty techniques for acquired penile shortening are evolving and are continuously being modified; best-practice guidelines are crucial to achieve safe and satisfactory outcomes in this population. Abu-Ghname A, Banuelos J, Davis MJ, et al. Augmentation Phalloplasty for Acquired Penile Shortening: A Systematic Review of Techniques, Outcomes, Patient Satisfaction, and Limitations. J Sex Med 2020;17:331-341.

Impact of the Advent of Collagenase Clostridium Histolyticum on the Surgical Management of Peyronie's Disease: A Population-Based Analysis

INTRODUCTION

Penile plication or partial excision with grafting has traditionally been the first-line treatment for stable Peyronie's disease (PD). Numerous injection therapies (ITs) have been introduced over the last few decades. Intralesional collagenase clostridium histolyticum (CCH) was U.S. Food and Drug Administration approved in 2013 for patients with stable disease, curvature ≥30° and ≤90°, and intact erectile function. The impact of the advent of CCH on the surgical management of PD is unknown.

AIM

We studied the effect of IT on the surgical management of PD in a population-based analysis.

METHODS

The Statewide Planning and Research Cooperative System database, which provides statewide level of all-payer data on patients in the outpatient, inpatient, ambulatory, and emergency department setting in New York State was reviewed. Patients undergoing a penile prosthesis for concurrent erectile dysfunction were excluded.

MAIN OUTCOME MEASURE

Descriptive statistics and multivariable logistic regression modeling were used to assess factors influencing choice of injection therapy vs surgical therapy (penile plication or partial excision with grafting).

RESULTS

From 2003-2016, 547 patients with PD presented for management. Median age was 56 years and 57% were white. Over the study period, surgical management was used less often as the primary procedure with a concurrent increase in use of IT (P < .001). On multivariable modeling, patients more likely to receive IT as treatment for penile curvature were younger (odds ratio [OR]: 1.26; P = .002; CI: 1.09-1.46), of higher socioeconomic status (OR: 1.14; P = .037; CI: 1.01-1.29), presented in the post-CCH era (OR: 1.17; P = .018; CI: 1.03-1.33) and presented to a surgeon with a high volume practice (OR: 1.25; P = .007; CI: 1.07-1.48). Patients presenting in the post-CCH era were 17% significantly more likely to receive IT.

CLINICAL IMPLICATIONS

ITs like CCH are increasingly displacing surgical management as the primary treatment option of Peyronie's disease.

STRENGTHS & LIMITATIONS

The Statewide Planning and Research Cooperative System database is particularly useful for this analysis because it is an all-payer database that tracks patients longitudinally across various health care settings-outpatient and inpatient.

LIMITATIONS

It only includes patients in New York State limiting generalizability. The retrospective nature of the analysis makes it subject to the biases inherent in such reports. Specific disease level characteristics (eg, degree of curvature, duration of disease, and associated deformities) were not available.

CONCLUSION

Since the introduction of CCH, there has been a markedly decreasing trend in the utilization of surgery as the primary modality in the management of PD-associated penile curvature. Sukumar S, Pijush DB, Brandes S. Impact of the Advent of Collagenase Clostridium Histolyticum on the Surgical Management of Peyronie's Disease: A Population-Based Analysis. J Sex Med 2020;17:111-116.