Penile Prosthesis Implantation Combined With Grafting Techniques in Patients With Peyronie's Disease and Erectile Dysfunction: A Systematic Review

Long-term histological and hemodynamic findings of repairing penile tunica albuginea defects with collagen fleece in dogs

Clinically, collagen fleece patching of the penile tunica albuginea (TA) has been successful. However, the histopathological and hemodynamic outcomes are not known. We studied in vivo TachoSil® patching in two beagle dogs weighing 16.8 (16.7-16.9) Kg. Bilateral intracavernous pressures (ICP) response to 10 mg papaverine hydrochloride were measured. A full-thickness defect was created on the left side in TA 1 × 0.5 cm, and four transverse incisions 1 cm long were made on the right side, placed 0.5 cm apart, and covered with TachoSil®. Six months later, ICP measurements were repeated, and the penis was excised for histopathology. Grossly, the graft site was indistinguishable. The mean baseline ICP was 19.3 ± 2.98 mmHg and increased after papaverine injection to a mean peak ICP of 122 ± 26.1 mmHg. The ICP measurement before and after grafting did not show a significant difference in the baseline (p = 0.068) or the peak pressure (p = 0.465). Histologically, minimal foreign body reaction was seen, and the TA was completely regenerated. The underlying cavernous tissue did not show inflammation or necrosis. The study is the first to show the long-term histopathologic regeneration of TA after collagen fleece patching while maintaining the hemodynamic response to papaverine.

Simultaneous penile prosthesis placement and collagen fleece (TachoSil) grafting. Where do we stand in 2024?

Surgical therapy of Peyronie's disease is the gold standard for correction of the associated penile curvature. In patients with co-existing erectile dysfunction, not responding to medical/conservative treatment, penile prosthesis implantation is indicated and recommended. Severe residual curvature in these cases can be addressed by plaque incision and grafting. The novel collagen fleece TachoSil® (Corza Medical, MA, USA) has emerged as a reliable and robust graft for this purpose, with favorable results. Hatzichristodoulou was the first to publish his new technique of plaque incision and grafting with TachoSil® for residual curvature correction during penile prosthesis implantation in 2018 (PICS Technique). Since then, this technique was adopted and used by various surgeons. In the current narrative review all publications using this novel graft after plaque incision for residual curvature correction will be presented and respective results discussed. Moreover, the surgical technique will be highlighted in detail. The TachoSil® has self-adhesive properties which make it unique and the ideal graft for this indication. Results of the studies on this topic, that are available so far, are excellent. The technique is safe. However, data from more patients and even more long-term follow-up results of patients treated with this technique and graft are requested.

First worldwide correction of ventral Peyronie's disease utilizing rigicon inflatable penile prosthesis combined with plaque incision & grafting with collagen fleece (PICS-technique) for residual curvature

Adjunctive residual curvature correction by plaque incision and grafting with a sutureless graft during inflatable penile prosthesis (IPP) implantation in patients with Peyronie's disease (PD) is our preferred technique. The PICS Technique (Penile Implant in Combination with the Sealing Technique) uses a self-adhesive collagen fleece (TachoSil®, Corza Medical, MA, USA) to cover the defect after plaque incision. The graft does not require sutures improving operative speed and avoiding needle stick of the implant cylinders. In this article, we present the first known application worldwide of a Rigicon Infla10® X (Rigicon, Ronkonkoma, NY, USA) device to Peyronie's ventral curvature. The patient's residual curvature of 80° after implantation was corrected by PICS through an additional subcoronal incision. At the conclusion of surgery, the penis was totally straight and rigid. No intra- and postoperative complications occurred. At the early follow-up of 12 weeks postoperatively, the patient was able to inflate and deflate the device and sexual intercourse was possible. A combination of the Rigicon Infla10® X and the PICS Technique represents a safe and successful approach for residual curvature correction during IPP in patients with ventral Peyronie's curvature. The Rigicon Infla10® X device showed excellent rigidity, and controlled expansion of the X cylinders means it can be used with the PICS Technique without restrictions. Early results are promising. Long-term follow-up and more patients are needed.

Postoperative Progress of Deep Grid Incision and Sealing with Collagen Fleece for Treatment of Peyronie's Disease: Prospective Observational Study for 3 Years

PURPOSE

Despite recent popularity, partial plaque excision and sealing with TachoSil has concern about tunica regeneration from graft and lack of long-term results. Previously, we introduced multiple deep grid incisions of Peyronie's plaque to minimize tunical defect with consequent veno-occlusal erectile dysfunction. To assess the efficacy of modified grid incision of plaque and sealing with collagen fleece in postoperative progress of 34 patients for 3 years.

MATERIALS AND METHODS

From Aug 2018, 34 patients with stable Peyronie's disease (PD) underwent surgery involving three major steps: 1) dissection of the neurovascular bundle or urethra according to plaque location, 2) multiple deep grid incisions of plaque for complete curvature correction, and 3) sealing with collagen fleece without suture. We assessed the stretched penile length, totally straightness, penile sonography, erectile function preoperatively and 3, 6, 12 months and annually postoperatively. This study was approved by the Institutional Review Board.

RESULTS

Mean age was 59.4 years (29-72 years). Mean curvature was 53.5 degree (35-100 degree), with hinge and hourglass deformity in 12 and 8 patients, respectively. Five patients required inflatable penile prosthesis (IPP) insertion, with one more at 30 months. The mean follow-up was 42.3 months. Penile rehabilitation, including daily massage, reduced subcutaneous thickening by 12 months postoperatively. All patients initially achieved complete straightness, with two experiencing recurrent curvature. Four patients had subcutaneous hematomas, subsiding in two. Minor skin issues occurred in three IPP patients. Postoperative erectile function was satisfactory in 85.0% of patients. Most regained preoperative length by 1.6 years. Global Assessment Questionniare satisfaction increased from 69.0% at 1 year to 90.0% until 3 years.

CONCLUSIONS

The modified grid incision with collagen fleece sealing effectively treats PD without causing tunica albuginea defects. Long-term follow-up is essential for monitoring erectile function and penile length recovery, ensuring successful clinical outcomes.

Research advances in Peyronie's disease: a comprehensive review on genomics, pathways, phenotypic manifestation, and therapeutic targets

INTRODUCTION

Penile induration disease, commonly known as Peyronie's disease (PD), is a connective tissue disorder that affects the penis, leading to the development of fibrous plaques, penile curvature, and erectile dysfunction. PD is a common male reproductive system disease with a complex etiology involving multiple genes, signaling pathways, and different phenotypes.

OBJECTIVES

The etiology and pathogenesis of PD remain poorly understood, hindering the development of effective treatment strategies. By understanding the underlying mechanisms of PD, we can pave the way for targeted therapies and improved patient outcomes.

METHODS

We reviewed the epidemiology and pathophysiology of PD. We performed database searches on Google Scholar, PubMed, Medline, and Web of Science from inception to September 2023. The literature reviewed included priapism guidelines, review articles, current trial studies, and various literature related to PD.

RESULTS

This article provides a comprehensive overview of the current research progress on the disease, focusing on its genetic factors, signaling pathways, cellular mechanisms, phenotypic manifestations, and therapeutic targets. It can help identify individuals at higher risk, aid in early detection and intervention, and provide insights into fibrosis and tissue remodeling. It can also reveal potential therapeutic targets, guide accurate diagnoses and treatment strategies, and address the impact of the disease on patients' quality of life.

CONCLUSION

By integrating insights from genomics, molecular pathways, clinical phenotypes, and therapeutic potentials, our research aims to achieve a deeper and more comprehensive understanding of PD, propelling the field toward innovative strategies that enhance the lives of those affected by PD. The complex manifestations and pathogenesis of PD necessitate the use of multiple treatment methods for personalized care.

[Current treatment concepts for Peyronie's disease]

Plastic induration of the penis (PIP, Peyronie's disease) is an acquired and chronic disease of the penis, which is characterized by penile pain, distortion and deformation of the penis as well as the resulting impairments in sexual activity of the patient. The most probable causes are microtrauma and macrotrauma within the tunica albuginea of the corpora cavernosa, which due to an abnormal wound healing subsequently leads to the formation of fibrosis in this region. Various predisposing factors and also a genetic predisposition are discussed. The PIP occurs most frequently in the fifth to sixth decades of life. The prevalence is 0.3-20% depending on the investigated collective and the risk factors present. The PIP is subdivided into an acute inflammatory phase and a chronic postinflammatory phase. Various conservative and surgical treatment options include oral medication, penile traction therapy, intralesional injections and surgical procedures.

Complications and troubleshooting in primary penile prosthetic surgery-a review

Penile implant surgery is the gold standard to treat erectile dysfunction with success rates of over 90%. The first penile implants were developed in the early 1900s. Since then, several types of implants have been developed including malleable implants, two-piece inflatable implants, and three-piece inflatable implants. The three-piece inflatable penile prosthesis, which was introduced in 1973, is the most widely used type of penile implant in the United States. Penile implant surgery has undergone numerous advancements over the years, improving outcomes and patient satisfaction. However, as with any surgical procedure, there are risks and complications associated with penile implant surgery. It is important for surgeons to understand these potential complications and to have strategies in place to manage and prevent them to achieve the best possible outcomes for their patients.

Intermediate-term results of TachoSil grafting to correct residual curvature during inflatable penile prosthesis implantation in patients with Peyronie's disease

Grafting techniques may be mandatory to improve residual penile curvature during inflatable penile prosthesis (IPP) implantation in Peyronie's disease patients. We aimed to report the intermediate-term outcomes of grafting with TachoSil (Corza Health, San Diego, USA) in patients with severe erectile dysfunction and concomitant complex Peyronie's disease through a prospective cohort study. We included 25 patients that underwent the PICS (penile implant in combination with Sealing) technique from 2017 to 2020 and were evaluated 24 months after surgery. Their mean age was 61.8 ± 8.7 years. Total straightness of the penis was achieved in 21 cases, while 4 (16%) patients presented a residual penile curvature of less than 15°. The mean penile length increased significantly (15 ± 1.2 to 16.4 ± 1.6 cm, p < 0.001). No intraoperative complications occurred, while, postoperatively, two patients developed fever and three scrotal hematoma, which resolved spontaneously. At three and six weeks, as well as at 24 months after surgery, no further complications occurred, and no cases of penile glans hyposensitivity were observed. At the 24-month follow-up evaluation, the 5-item score of the International Index of Erectile Function was 23.7 ± 1.4 (range: 20.5-25) and all patients responded positively to questions 2 and 3 of the sexual encounter profile questionnaire (p < 0.001 for all outcomes compared to baseline). Accordingly, the Erectile Dysfunction Inventory of Treatment Satisfaction score improved from 45.8 ± 6 at baseline to 25.6 ± 4.6 at 24 months, p < 0.001. Grafting with TachoSil to improve residual penile curvature during IPP is a safe and effective procedure. Nevertheless, careful patient selection and counseling, surgeon's experience with the technique, and strict postoperative penile rehabilitation are the main factors for treatment success and high satisfaction rates.

Comparison of patient-reported outcomes after penile prosthesis placement in men with and without Peyronie's disease

We evaluated outcomes in patients undergoing penile prothesis (PP) implantation for erectile dysfunction (ED) and concurrent Peyronie's Disease (PD). A clinician-developed survey to assess satisfaction was sent to 354 patients who underwent PP placement from 2012-2018 by a single-surgeon. Results were compared based on the presence or absence of concurrent PD. 79 patients completed the survey (response rate 22%), including 38 patients (48%) with concurrent ED and PD (ED/PD). Mean follow-up was 31 months (standard deviation 19). 87% felt their condition was "very much" or "much" improved. There was no significant difference in patient-reported overall satisfaction with their PP or satisfaction with current penile length/girth based on the presence or absence of PD. 87% of patients with PD were satisfied with their degree of penile straightening after PP plus or minus concurrent straightening maneuvers such as modeling, plication, or incision/grafting. Sub-group analyses were performed to evaluate outcomes in those with concurrent PD/ED who required plaque incision/grafting at the time of PP placement for more severe deformity (n = 19). 47% of these patients were dissatisfied with their current penile length, compared with only 16% of those patients with PD/ED who did not require grafting (p = 0.05). In conclusion, the presence of PD alone may not impact PP satisfaction, but patients with more severe baseline deformity who require incision/grafting may be less satisfied with outcomes including penile length.

The use of collagen fleece to correct residual curvature during inflatable penile prosthesis implantation (PICS technique) in patients with complex Peyronie disease: a multicenter study

BACKGROUND

The PICS technique (penile implant in combination with the sealing) was recently described as a valuable option to correct residual curvature during inflatable penile prosthesis (IPP) implantation in patients with complex Peyronie disease (PD).

AIM

To report the surgical and functional outcomes of the PICS technique in a multicentric series of patients.

METHODS

A consecutive series of patients with complex PD who underwent PICS were recruited. Patients were from 2 European tertiary referral centers. Data regarding baseline characteristics and perioperative, postoperative, and functional outcomes were retrospectively evaluated.

OUTCOMES

Complete penile straightness, duration of operative time and hospital stay, as well as postoperative complications (including hematoma, IPP infection, and IPP mechanical failure) were recorded, whereas functional outcomes were evaluated through the administration of validated questionnaires at baseline and 12 months postoperatively: International Index of Erectile Function-5, Sexual Encounter Profile questions 2 and 3 (SEP-2 and SEP-3), and Erectile Dysfunction Inventory of Treatment Satisfaction.

RESULTS

Thirty-seven patients with a median age of 62 years (IQR, 57-70 years) were enrolled. Median preoperative curvature was 75° (IQR, 65°-77°). Median residual curvature after IPP implantation was 60° (IQR, 50°-70°). Overall, 31 patients (84%) achieved a totally straight penis. Only 6 patients (16%) experienced a residual penile curvature (<20° in all cases) after the procedure. No intraoperative complications were detected. Nine patients (24%) developed an early postoperative complication, 3 (8%) a transient fever, and 6 (16%) a genital hematoma. A single case of IPP acute infection requiring device explantation was recorded. The survey response rate was 100%. At the 12-month follow-up evaluation, the median IIEF-5 score was 23.5 (IQR, 22.2-25) with evident improvement vs the baseline value of 10 (IQR, 8-12). Accordingly, 92% of the patients responded positively to SEP-2 and SEP-3. For the Erectile Dysfunction Inventory of Treatment Satisfaction, patients recorded a median postoperative value of 25 (IQR, 21-30) 1 year after PICS.

CLINICAL IMPLICATIONS

Complex PD is an end-stage disease featured by severe penile curvature, penile shortening, and erectile dysfunction: the gold standard approach is deemed to be penile prosthesis implantation, aiming to address penile curvature and erectile dysfunction, but in a limited percentage of cases, additional maneuvers are deemed necessary to manage residual penile curvature.

STRENGTHS AND LIMITATIONS

Our study has some limitations: the retrospective nature, relatively short follow-up, and limited number of patients.

CONCLUSION

The PICS technique may represent a reliable and effective treatment option to address significant residual curvature after IPP implantation.

Assessment of Conservative Combination Therapies for Active and Stable Peyronie's Disease: A Systematic Review and Meta-analysis

CONTEXT

In patients with Peyronie's disease (PD), oral, injected, or topical agents provide limited efficacy. In this setting, combination of two or more conservative treatments may improve symptoms further.

OBJECTIVE

To explore the effects of available conservative combination therapies for active and stable PD through a systematic review and meta-analysis.

EVIDENCE ACQUISITION

We searched multiple databases and sources of gray literature until June 2021. We included randomized or observational comparative studies assessing any conservative combination therapies for PD. We undertook a random-effect meta-analysis when at least two studies employed the same treatment modality (PROSPERO: CRD42021224517).

EVIDENCE SYNTHESIS

Overall, 13 studies on active PD and ten on stable PD (1962 participants) were included. Most included studies raised methodological concerns. In patients with active or stable PD, the available evidence is inconclusive to support the use of any combination treatment modality, such as intralesional verapamil injections, antioxidants, and other oral, injected, or topical agents. Based on data availability, we performed a meta-analysis to compare the effect of collagenase Clostridium histolyticum (CCH) plus adjunctive mechanical therapies (penile traction or vacuum pump) versus CCH monotherapy on penile curvature and length in patients with stable PD. CCH and adjunctive mechanical therapies resulted in an additional decrease of 0.3° in penile curvature (95% confidence interval [CI]: -3.97 to 4.49, I² = 0%) and in an increase of 0.5 cm in penile length (95% CI: -0.32 to 1.4, I² = 70%) compared with CCH monotherapy.

CONCLUSIONS

The available combination treatment modalities, including the addition of adjunctive mechanical therapies to CCH, do not improve symptoms further compared with monotherapy and should not be implemented in patients with active or stable PD. Further high-quality randomized trials combining only recommended treatments are mandatory.

PATIENT SUMMARY

Despite the interest in and optimism for combination treatment modalities, the road to an effective conservative therapy for Peyronie's disease still seems long.