Multi-institutional Prospective Analysis of Intralesional Injection of Collagenase Clostridium Histolyticum, Tunical Plication, and Partial Plaque Excision and Grafting for the Management of Peyronie's Disease

Current trends in non-surgical management of Peyronie's disease-A narrative review

Peyronie's disease (PD) is a connective tissue disorder affecting the tunica albuginea. It can cause pain and penile deformation, and its prevalence increases with age. Although surgery is the gold standard for the chronic phase of the disease, there are several conservative treatment methods available, and the optimal management of the acute phase of the disease remains a matter of debate. In this article, we aim to summarize the recent trends in research on the subject of non-surgical treatment of PD. The search was performed in PubMed, Scopus, and Web of Science databases and included studies in English published between 2012 and 2022 investigating the clinical outcomes of non-surgical PD management in humans. We have identified 20 distinct conservative treatment strategies. Among the oral therapeutics, only the use of phosphodiesterase type 5 inhibitors is currently recommended for clinical use in patients with concomitant erectile dysfunction. The use of collagenase from Clostridium histolyticum is supported by the best quality evidence in terms of intralesional injections for patients suffering from significant penile curvature; however, interferon alpha-2b can also be an option in such patients. Among other non-invasive methods, extracorporeal shockwaves can be useful for pain reduction, and penile traction therapy can lead to a reduction in penile curvature and plaque size. Despite a wide range of non-surgical methods available for PD treatment, the majority are not supported by sufficient scientific evidence, and the treatment efficacy is underwhelming. Further research on the subject of non-surgical management of PD is highly warranted.

Non-surgical therapies for Peyronie's disease

BACKGROUND

Peyronie's disease is a condition that results in the development of penile plaques that can lead to penile curvature, pain, and erectile dysfunction, making sexual activity difficult. A number of non-surgical interventions exist to improve this condition, which include topical and injection agents as well as mechanical methods; however, their effectiveness remains uncertain. We performed this review to determine the effects of these non-surgical treatments.

OBJECTIVES

To assess the effects of non-surgical therapies compared to placebo or no treatment in individuals with Peyronie's disease.

SEARCH METHODS

We performed a comprehensive search using multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Google Scholar, and Web of Science), trials registries, other sources of grey literature, and conference proceedings, up to 23 September 2022. We applied no restrictions on publication language or status.

SELECTION CRITERIA

We included trials in which men with Peyronie's disease were randomized to undergo non-surgical therapies versus placebo or no treatment for penile curvature and sexual function.

DATA COLLECTION AND ANALYSIS

Two of four review authors, working in pairs, independently classified studies and abstracted data from the included studies. Primary outcomes were: patient-reported ability to have intercourse, quality of life, and treatment-related adverse effects. Secondary outcomes were: degree of penile curvature, discontinuation from treatment (for any reason), subjective patient-reported change in penile curvature, and improvement in penile pain. We performed statistical analyses using a random-effects model. We rated the certainty of evidence (CoE) according to the GRADE approach.

MAIN RESULTS

Our search identified 1288 relevant references of which we included 18 records corresponding to 14 unique randomized controlled trials (RCTs) with 1810 men. These informed 10 distinct comparisons with relevant outcome data that were mostly extracted from single trials. In this abstract, we focus only on the most clinically relevant comparisons for the three primary outcomes and also include the outcome of degree penile curvature. Injectional collagenase (short-term): We found no short-term evidence on injectional collagenase for patients' self-reported ability to have intercourse and treatment-related adverse effects compared to placebo injection. Injectional collagenase may result in little to no difference in quality of life (scale 0 to 20 with lower scores indicating better quality of life; mean difference (MD) 1.8 lower, 95% confidence interval (CI) -3.58 to -0.02; 1 study, 134 participants; low CoE) and there may be little to no effect on the degree of penile curvature (MD 10.90 degrees less, 95% CI -16.24 to -5.56; 1 study, 136 participants; low CoE). Injectional collagenase (long-term): We also found no long-term evidence on injectional collagenase for patients' self-reported ability to have intercourse compared to placebo injection. It likely results in little to no effect on quality of life (MD 1.00 lower, 95% CI -1.60 to -0.40; 1 study, 612 participants; moderate CoE). Treatment-related adverse effects are likely increased (risk ratio (RR) 2.32, 95% CI 1.98 to 2.72; 1 study, 832 participants; moderate CoE). Injectional collagenase likely results in little to no change in the degree of penile curvature (MD 6.90 degrees less, 95% CI -9.64 to -4.14; 1 study, 612 participants; moderate CoE). Injectional verapamil (short-term): We are very uncertain how injectional verapamil may affect patients' self-reported ability to have intercourse compared to placebo injection short-term (RR 7.00, 95% CI 0.43 to 114.70; 1 study, 14 participants; very low CoE). We found no evidence for the outcome of quality of life. We are very uncertain how injectional verapamil may affect treatment-related adverse effects (RR not estimable; 1 study, 14 participants; very low CoE). Similarly, we are very uncertain how injectional verapamil may affect degree of penile curvature (MD -1.86, 95% CI -10.39 to 6.67; 1 study, 14 participants; very low CoE). We found no long-term data for any outcome. Extracorporeal shock wave treatment (ESWT) (short-term): We are very uncertain how ESWT affects patients' self-reported ability to have intercourse short-term (RR 1.60, 95% CI 0.71 to 3.60; 1 study, 26 participants; very low CoE). ESWT may result in little to no difference in quality of life (MD 3.10, 95% CI 1.57 to 4.64; 2 studies, 130 participants; low CoE). We are very uncertain if ESWT has an effect on treatment-related adverse effects (RR 2.73, 95% CI 0.74 to 10.14; 3 studies, 166 participants; very low CoE). ESWT may result in little to no difference in the degree of penile curvature compared to placebo (RR -2.84, 95% -7.35 to 1.67; 3 studies, 166 participants; low CoE). We found no long-term data for any outcome. Penile traction therapy (short-term): We found no evidence for whether penile traction compared to no treatment affects patients' self-reported ability to have intercourse. We are very uncertain how traction therapy may affect quality of life (MD 1.50 lower, 95% CI -3.42 to 0.42; 1 study, 90 participants; very low CoE). We are also very uncertain how traction therapy may affect treatment-related adverse effects (RR not estimable; 1 study, 90 participants; very low CoE) and how it affects the degree of curvature (MD 7.40 degrees less, 95% CI -11.18 to -3.62; 1 study, 89 participants; very low CoE). We found no long-term data for any outcome.

AUTHORS' CONCLUSIONS

There is little evidence supporting the effectiveness of most non-surgical treatments for Peyronie's disease. Existing trials are mostly of poor methodological quality and/or fail to address patient-centered outcomes. Injectional collagenase appears to have some effectiveness; however, many individuals may not experience the improvement as clinically relevant, and this comes with the risk of increased adverse events. There is a critical need for better non-surgical treatment options for men with Peyronie's disease.

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.

Clinical Significance of Shortened Penile Length and Alterations in Penile Length Following Treatment for Peyronie's Disease

INTRODUCTION

Across many cultures, penis size has been associated with virility, and concerns about penile length are commonplace. Peyronie's disease (PD) is a known acquired cause of penile shortening.

OBJECTIVES

This paper describes the psychosocial impacts of penile length on men and their partners, both generally and in men with PD, and evaluates the effect of PD treatments (eg, collagenase clostridium histolyticum , surgery, mechanical therapy) on this outcome measure.

METHODS

A PubMed database search was performed for English language articles through July 2021. Main outcome measures were association of penile length with emotional well-being, selfesteem, and relationship satisfaction in men with PD, and change from baseline penile length after treatment.

RESULTS

Shortened penile length caused by PD can negatively impact patient and partner quality of life, including effects on body image, emotional well-being, sexual function, and interpersonal relationships. In men with PD, studies have demonstrated an association between loss of penile length and emotional problems, reduced satisfaction with sexual performance, poor self-esteem, depression, and relationship difficulties. Loss of penile length can frequently occur after surgery for PD (including plication, plaque incision/excision with grafting, and penile implant). Advanced surgical techniques may preserve/increase penile length, but the increased risks associated with these complex procedures must be carefully considered. Treatment with collagenase clostridium histolyticum does not appear to negatively impact penile length, and 5-year follow-up data suggest potential longterm posttreatment improvements in this outcome measure. Penile traction therapy, either alone or as adjunctive therapy, may increase penile length in men with PD, but nonadherence may limit improvement.

CONCLUSION

Changes in penile length are important to many men, particularly those with PD, and should be considered during PD treatment selection. Penile length should be measured objectively before and after treatment for PD and should be included as an outcome measure in future studies on treatment effectiveness. Goldstein I, Gelbard MK, Lipshultz LI. Clinical Significance of Shortened Penile Length and Alterations in Penile Length Following Treatment for Peyronie's Disease. Sex Med Rev 2022;10:409-420.

Trends in treatment of Peyronie's disease in adult men in the United States from 2008 to 2017-results from an encounter and claims database

Treatments for Peyronie's Disease (PD) include oral medications, intralesional injections, and surgery. Collagenase Clostridium histolyticum (CCh) is the only FDA-approved treatment for PD. We sought to examine current trends in treatment of PD across the United States. Using data in the MarketScan Database, we conducted a retrospective study of men with PD in the United States. Cases were identified by ICD-9 and 10 codes, and treatments were identified using NDC and CPT codes. Treatment rates were analyzed using a linear regression model, and a Cox proportional hazard function test was performed for time-to-treatment analysis. About 27.8% of men with PD were treated within a year of diagnosis. The annual treatment rate increased from 23.2 to 35.4%, and intralesional injection was the most used treatment. Over the study period, the percentage of men receiving treatment with oral medication increased from 0.66 to 20.5%, while the use of intralesional injection and surgery decreased. Increased odds of treatment were observed in men 45-54 years (odds ratio [OR] 1.35; 95% confidence interval [CI], 1.21-1.50; p = 0) and in the southern region (OR 1.48; 95% CI, 1.39-1.56; p = 0). Trends in treatment of PD have changed over time. Intralesional injection remains the most used treatment option for men with PD.

Predictors of Pursuing Intralesional Xiaflex in Peyronie's Disease Patients

BACKGROUND

Intralesional collagenase such as Xiaflex (ILX) has become a standard treatment for Peyronie's disease (PD). Many robust studies have demonstrated its clear efficacy in the treatment algorithm.

AIM

To examine predictors of the patient decision to pursue ILX in PD patients.

METHODS

The study included PD patients (i) with stable disease (ii) who had doppler duplex ultrasonography (DUS) at least 6 months prior to analysis date and (iii) did not choose an operation. All patients received a standard discussion regarding treatment options, specifically, observation, ILX and penile reconstructive surgery (plication, plaque incision and grafting, implant surgery). Patients who opted to use ILX were compared to those who opted against it. Comorbidity, demographic and PD characteristics were recorded at the initial PD visit. All patients completed three validated questionnaires including the PD questionnaire (PDQ), Self-Esteem and Relationship (SEAR) questionnaire and a depression questionnaire (CES-D). Logistic regression was used to determine predictors of ILX use.

OUTCOMES

Predictors of ILX utilization.

RESULTS

Four hundred and fifty stable PD men had DUS completed 6 months before to allow sufficient time for treatment decision. Of these, 111 (24.7%) patients had ILX treatment and 339 (75.3%) did not. Mean age, relationship status and pain occurrence were similar between groups, but ILX patients had less bother defined as PDQ ≥ 9 (46.8% vs 53.7%, P = .02). ILX patients had more complex curves (79.3% vs 47.8%, P < .01) and more severe instability (32.4% vs 15.3%, P = .01). ILX patients also had higher PDQ domain scores (Psychological 11.5 ± 6.4 vs 7.5 ± 6.2, P < .01; Pain 6.2 ± 6.0 vs 4.3 ± 5.6, P = .02; and Bother 9.8 ± 4.7 vs 6.6 ± 4.8, P < .01). On univariable statistics, significant bother (OR 2.41, 95% CI 1.36-4.28, P<0.01), complex curvature (OR 4.18, 95%CI 2.52-6.93, P < .01), moderate and/or severe instability (OR 1.98, 95%CI 1.18-3.30, P < .01) and PDQ-Bother scores (OR 1.15, 95%CI 1.08-1.22 P < .01) predicted ILX use. On multivariable analysis, instability (OR 2.58, 95%CI 1.02-6.57, P = .05) and significant bother (OR 1.23, 95%CI 1.04-1.45, P = .01) predicted ILX use.

CLINICAL IMPLICATIONS

Educates providers as to which patients are more likely to choose ILX.

STRENGTHS & LIMITATIONS

Our study has a large sample size and all patients received the same standardized treatment discussion. Our study is limited by the absence of insurance data on all patients, and its retrospective single center design.

CONCLUSION

ILX was chosen by the minority of stable PD patients. While moderate to severe instability and significant bother is predictive of ILX use, other demographic factors including relationship status, sexual orientation or pain were not. Punjani N, Nascimento B, Salter C, et al. Predictors of Pursuing Intralesional Xiaflex in Peyronie's Disease Patients. J Sex Med 2021;18:1258-1264.

Continuing Collagenase Clostridium Histolyticum Injections Among Initial Nonresponders Results in Significant Curvature Improvements in the Majority of Peyronie's Disease Men

BACKGROUND

It is currently unclear if men with Peyronie's Disease (PD) who achieve minimal benefits with the first 2 series of Collagenase Clostridium Histolyticum (CCH) injections should continue with additional injections.

AIM

To analyze curvature improvements from the final two series of CCH injections based on amount of improvement during the first 2 series.

METHODS

A prospective registry was analyzed of all men undergoing CCH injections for PD at a single institution. Men were included if they had completed a full 4 series (8 injections) of CCH and had baseline, interval (after 2 series), and/or final (after 4 series) curvature assessments available. Men were stratified into cohorts using baseline-to-interval assessments of ≤10° (or ≤20%) and >10° (or >20%), and improvements were compared using interval-to-final assessments.

OUTCOMES

The primary outcome was interval-to-final curvature improvements stratified by ≤10°/>10° or ≤20%/>20% improvements achieved during the baseline-to-interval period. Secondary outcomes included analyses of demographic and pathophysiologic variables to determine associations with significant improvements during the final 2 CCH series.

RESULTS

A total of 296 PD men were identified as receiving at least one CCH injection, of whom 175 had baseline-to-interval, 84 interval-to-final, and 115 with baseline-to-final measurements. Mean age was 56.6, PD duration 28.6 months, baseline curvature 63.4°, hourglass deformity 36.2%, and calcification 20%. Mean overall curve improvement was -21.5° (33.1%). Among men who experienced ≤20% improvements after 2 series, the mean subsequent curvature change was -24.6% during the final two series (vs +4.3% of those with >20% initial improvement, P< .001), and they were 2.7x more likely to experience >20% subsequent curve improvements. Thirty-one percent of those who achieved >10° during the first 2 series experienced benefits during the final 2 series compared to 70% of men who had ≤10° improvement initially. No demographic or pathophysiological variables predicted likelihood for improvements during the final 2 series of injections.

CLINICAL IMPLICATIONS

Men who fail to achieve significant benefits with 2 series of CCH injections may benefit from completing the final 2 series.

STRENGTHS AND LIMITATIONS

Strengths including a relatively large, prospective series. Limitations include a single center, nonrandomization, nonblinded assessments, and restriction to men who completed eight injections.

CONCLUSIONS

In the current series, approximately 2/3 of men who fail to achieve >10° or 20% curve improvements with an initial 2 series of CCH injections achieved >10° or 20% improvements with the subsequent 2 series. Alom M, Burgon H, Ziegelmann M, et al. Continuing Collagenase Clostridium Histolyticum Injections Among Initial Nonresponders Results in Significant Curvature Improvements in the Majority of Peyronie's Disease Men. J Sex Med 2021;18:1092-1098.

Treatment Patterns and Healthcare Outcomes with Collagenase Clostridium Histolyticum vs Surgery in Peyronie's Disease: A Retrospective Claims Database Analysis

Introduction

Treatments for Peyronie's disease (PD) include surgical management and collagenase clostridium histolyticum (CCH).

Aims

To evaluate PD treatment trends after CCH approval and compare clinical outcomes in CCH- and surgery-treated cohorts.

Methods

Patients newly diagnosed with PD between January 2011 and December 2017 were identified in a U.S. claims database. Cohorts initiating treatment with CCH or surgery between January 2014 and June 2017 were included. Patients were continuously enrolled ≥6 months before and ≥12 months after index date. Post-treatment penile complications and analgesic use were compared 1 year after procedure in propensity score-matched cohorts.

Main outcome measures

The main outcome measures of this study were treatment patterns, penile complications, and analgesic use.

Results

In the newly diagnosed PD cohort, 1,609 patients received CCH and 1,555 patients had surgery. Overall CCH or surgery treatment rate/year increased from 9.8% in 2014 to 15.5% in 2017, with <1% receiving verapamil or interferon. Initial treatment ratios of CCH to surgery increased from approximately 1:1 (2014) to 2:1 (2017). In the unmatched CCH (n = 1,227) and surgery (n = 620) cohorts, more (P < .05) surgery-treated patients received analgesics (particularly opioids), oral PD therapies, vacuum erection devices, and phosphodiesterase-5 inhibitors before the index date. After propensity score matching (n = 620/cohort), newly occurring postprocedural complications during the follow-up period were higher in the surgery cohort (25.3% vs 18.4%, P = .003). The surgery cohort had significantly (P < .05) higher rates of erectile dysfunction (65.0% vs 44.8%), penile pain (17.9% vs 8.9%), and penile swelling (8.1% vs 5.2%) and was more likely to be prescribed opioids (93.3% vs 38.9%; P < .0001) or non-steroidal anti-inflammatory drugs (27.0% vs 20.3%; P = .006).

Conclusion

CCH demonstrated fewer complications and less analgesic use than surgery and was used as the initial therapy for PD twice as often as surgery.

L Trost, H Huang, X Han, et al. Treatment Patterns and Healthcare Outcomes with Collagenase Clostridium Histolyticum vs Surgery in Peyronie's Disease: A Retrospective Claims Database Analysis. Sex Med 2021;9:100321.

The Management of Penile Fracture: a Review of the Literature with Special Consideration for Patients Undergoing Collagenase Clostridium Histolyticum Injection Therapy

PURPOSE OF REVIEW

To review the current literature on acute management of traumatic penile fracture, with a specific discussion of those injuries following collagenase clostridium histolyticum (CCH) injections for the treatment of Peyronie's disease.

RECENT FINDINGS

The immediate repair of traumatic penile fracture injury is associated with significantly better prognosis for long-term sexual health. Corporal disruption following CCH administration has several distinct features, and the trend is to manage these patients conservatively in the absence of urethral injury. Traumatic penile fracture repair continues to have excellent results when performed immediately following injury. The post-CCH treatment setting portends increased difficulty during surgical management and can be successfully managed in most cases by conservative measures.

The use of collagen fleece (TachoSil) as grafting material in the surgical treatment of Peyronie's disease. A comprehensive narrative review

Grafting for the treatment of Peyronie's disease (PD) can be performed with autologous grafts, allografts, xenografts and synthetic grafts, with all available materials presenting their own characteristics. Still, there is a current arising interest in the use of collagen fleece (TachoSil) as grafting material. We generated an extensive literature review, aiming to assess the use of TachoSil in the treatment of PD. TachoSil is currently indicated in men with PD and preserved erectile function for defect closure after partial plaque excision or incision. In addition, it is indicated for residual curvature correction during penile prosthesis implantation (PPI) in patients with PD and severe erectile dysfunction. Our literature search identified 12 studies evaluating the role of TachoSil for PD surgical treatment. We presented the surgical procedure of TachoSil grafting for the treatment of complex penile curvatures with or without simultaneous PPI and summarized the available evidence on the matter. Identified studies suggest that TachoSil is considered highly effective, reliable and safe in patients with PD. Moreover, it displays favorable properties compared to other grafting materials. It should be stressed that, despite some limitations of available data, TachoSil presents key strengths, which include easy application, decreased operative times, no risk of damaging the implant during PPI, preservation or increase in penile length, fewer cases of penile hypoesthesia, low risk of other adverse events, additional hemostatic effects and low cost. Still, randomized trials comparing TachoSil with different grafting materials are necessary to establish its efficacy.

Conservative management of suspected fractures in men undergoing collagenase clostridium histolyticum for Peyronie's Disease is not associated with worsening of erectile function

The optimal management of suspected penile fractures post collagenase clostridium histolyticum (CCH) remains indeterminate, with some advocating for observation and others surgical repair. To address this issue, the current study sent surveys to 158 men with Peyronie's Disease (PD) who completed four CCH injection series. The survey included the Erectile Function Domain from the International Index of Erectile Function (IIEF-EFD) and questions regarding potential symptoms of corporal rupture (hematoma, popping, and detumescence). Men were categorized as having a suspected fracture (SF+) if they reported a popping sensation or rapid detumescence. All SF(+) men were managed conservatively without surgical intervention. Results were compared statistically against baseline IIEF-EFD values and between SF(+) and SF(-) groups. The key study objective was to determine whether erectile function was negatively impacted by conservative management of suspected fractures. Of the 53 returned surveys, 45 had complete data for review. The sample was statistically representative of the broader cohort of 158 men, except being older (60.0 vs 57.1 [SD 6.0 vs 9.0], p = 0.01) with shorter durations of PD (median 9 [IQR 5, 19] mo vs 13 [IQR 8, 24], p = 0.01). Overall, 7/45 (16%) of men were defined as SF(+), with all fractures occurring within 6 weeks of CCH administration. No demographic or pathophysiologic characteristics predicted SF(+). Importantly, SF(+) men did not experience worsened erectile function compared to SF(-), with a median IIEF-EFD change of +2 vs +1, p = 0.16, respectively. Curvatures were improved to a greater degree among SF(+) men (primary: median -30 [IQR -20, -32.5] vs -15 [-5, -26], p = 0.04; composite: -35 [-25, -40] vs -25 [-7, -30], p = 0.15). We concluded that suspected penile fractures in PD men undergoing CCH may be reasonably managed without surgical intervention and portend greater improvements in curvature correction.

Modern treatment strategies for penile prosthetics in Peyronie's disease: a contemporary clinical review

Peyronie's disease is a common condition resulting in penile deformity, psychological bother, and sexual dysfunction. Erectile dysfunction is one common comorbid condition seen in men with Peyronie's disease, and its presence significantly impacts treatment considerations. In a man with Peyronie's disease and significant erectile dysfunction who desires the most reliable treatment, penile prosthesis placement should be strongly considered. In some instances, such as those patients with relatively mild curvature, prosthesis placement alone may result in adequate straightening. However, many patients will require additional straightening maneuvers such as manual modeling, penile plication, and tunica albuginea incision with or without grafting. For patients with severe penile shortening, penile length restoration techniques may also be considered. Herein, we provide a comprehensive clinical review of penile prosthesis placement in men with Peyronie's disease. Specifically, we discuss preoperative indications, intraoperative considerations, adjunctive straightening maneuvers, and postoperative outcomes.

A state-of-art review on collagenase Clostridium Histolyticum and Peyronie's disease: drug profile, clinical evidence and safety outcomes

Introduction: Collagenase clostridium histolyticum (CCH) is the first and only licensed medical treatment for men with Peyronie's disease (PD). Published literature shows intralesional CCH injection as an effective and safe minimally invasive treatment in a specific subgroup of PD patients.Areas covered: The authors discuss pharmacodynamics and pharmacokinetics as well as clinical outcomes and safety profile from major CCH studies in PD. All relevant CCH studies published in PubMed and EMBASE databases up to June 2019 were included.Expert opinion: Given the variability in treatment schedule and drug access coupled with the potential need for further treatment, strict patient selection and the use of adjunctive strategies are key determinants to maximize clinical efficacy of intralesional CCH. Furthermore, longer-term follow-up data on the clinical outcomes, safety and durability of CCH in larger multi-center studies and post-marketing surveillance data are necessary to provide a comparison to other standard PD treatment options.

Peyronie's disease: Contemporary evaluation and management

Peyronie's disease is a common yet poorly understood condition characterized by penile pain, curvature, sexual dysfunction and psychological bother. Peyronie's disease represents a penile wound healing disorder, and is thought to arise from exuberant scarring in response to penile trauma in genetically predisposed men. In the absence of active treatment, the majority of men experience stable or worsening symptoms, with few reporting spontaneous resolution in penile curvature or other deformity. In contrast, penile pain improves or resolves in the majority of men. Treatment options vary based on symptom severity and stability. Several oral therapies are commonly prescribed, although to date there are no strong data to support any oral agents as monotherapy for Peyronie's disease. Other options including penile traction therapy and intralesional injections result in modest improvements for many patients, particularly when used early after symptom onset. Penile straightening through approaches, such as penile plication and plaque incision or partial excision and grafting, represent the most rapid and reliable approach to correct penile curvature once the symptoms have stabilized. Side-effects vary based on the type of surgery carried out, and include penile shortening, sensation changes and erectile dysfunction in the minority of men. In patients with drug refractory erectile dysfunction and Peyronie's disease, placement of a penile prosthesis will address both issues, and is associated with high levels of patient satisfaction. The current review provides a practical approach to the modern evaluation and management of patients presenting with Peyronie's disease.

Minimally invasive therapies for Peyronie's disease: the current state of the art

Peyronie's disease (PD) is a relatively common condition that can result in significant penile deformity, sexual dysfunction, and psychological bother. Surgical straightening offers the highest probability of success during the stable phase of the disease. However, for men in the acute phase of PD or for those with less severe deformity who elect to avoid surgery, a variety of non-surgical treatment options are available. Oral therapies, including L-citrulline and pentoxifylline, are most useful as part of a combination regimen rather than as monotherapy. Intralesional therapy with IFN-α2b, verapamil, and collagenase clostridium histolyticum (CCH) can cause significant reduction in penile curvature, yet these results may not be clinically significant for men with more severe curvature. Further investigation into the timing of administration and optimal patient characteristics is required. Penile traction therapy offers a clinically significant improvement in penile length and curvature. However, this has traditionally required hours of daily therapy. Overall, a combination of oral, topical, injection and traction therapies may provide the most significant benefit among the non-surgical modalities for PD.

Clinical characteristics and surgical outcomes in men undergoing tunica albuginea plication for congenital penile curvature who present with worsening penile deformity

PURPOSE

Men with congenital penile curvature (CPC) can develop new onset worsening of their lifelong curvature. We sought to evaluate clinical characteristics and postoperative outcomes after tunica albuginea plication (TAP) in patients presenting with CPC who reported new onset worsened curvature (CPC-WC), and compare these with patients reporting stable lifelong curve ("CPC-only").

METHODS

A retrospective review of demographics, history/exam findings, and postoperative outcomes for patients with CPC who underwent TAP from 2012 to 2018 was performed. Patients were differentiated based on whether or not they reported new onset worsening of their penile curvature preoperatively (CPC-WC versus CPC only). Statistical analysis was performed to identify differences in clinical characteristics and postoperative outcomes after TAP.

RESULTS

60 patients were included [CPC only (n = 39) and CPC-WC (n = 21)]. Mean curvature was 62° (SD 23). CPC-WC patients were older [median 34 years (IQR 27:52) versus 24 years (IQR 20:34); p = 0.004], and more likely to report penile shortening and psychological bother (p < 0.05). On physical examination, CPC-WCs were more likely to have a discrete palpable tunical scar and diminished penile elasticity (p ≤ 0.0002). With median follow up of 12 months, satisfactory straightening with TAP was reported in 56/60 patients (93%) including 35/39 (90%) CPC only and 21/21 (100%) CPC-WC.

CONCLUSIONS

In men undergoing TAP for CPC, we found that 35% reported new onset worsening of their original curvature preoperatively. These patients were older and more likely to report penile shortening or exhibit palpable tunical scarring with decreased elasticity on examination compared to those with lifelong stable curvature. Regardless, TAP resulted in satisfactory penile straightening in the majority of patients.

Evolution of the surgical sealing patch TachoSil® in Peyronie's disease reconstructive surgery: technique and contemporary literature review

PURPOSE

The aim of this study is to review the current literature that reports outcomes of Peyronie's disease (PD) reconstructive surgery using the collagen fleece TachoSil^® (Baxter, CA, USA), a novel graft that has self-adhesive properties and gained popularity in recent years.

METHODS

A literature review was performed through PubMed between 2013 and 2018 regarding the use of TachoSil^® in PD penile reconstructive surgery. Keywords used for the search were: Peyronie's disease, surgical therapy, surgical outcomes, grafting techniques, graft materials, collagen fleece, surgical patch, and TachoSil.

RESULTS

Grafting procedures are indicated for men with PD and preserved erectile function. TachoSil^® is a novel graft used for defect closure after tunical incision or partial plaque excision. Long-term results of this technique are encouraging and reliable. One major advantage over other grafts is that the TachoSil^® does not require suture fixation leading to significantly decreased operative times. Another indication is residual curvature correction by plaque incision and grafting/sealing with TachoSil^® during penile prosthesis implantation in patients with PD and severe erectile dysfunction. Besides reduced operative times, the major advantage is that there is no risk of device puncture because of the self-adhesive properties of the TachoSil^®.

CONCLUSIONS

The TachoSil^® has emerged as a safe, reliable, and promising graft in PD reconstructive surgery. Until now, this graft has met the expectations as a durable and effective graft, not only for grafting techniques but also for residual curvature correction during penile prosthesis implantation. However, future research is encouraged, preferably within prospective multicenter studies.

A Comparison of Hemostatic Patches Versus Pericardium Allograft for the Treatment of Complex Peyronie's Disease With Penile Prosthesis and Plaque Incision

OBJECTIVE

To compare outcomes between hemostatic patches (HP) versus pericardium allografts (PA) for complex Peyronie's disease with erectile dysfunction managed with inflatable penile prosthesis (IPP) and plaque incision and grafting (PIG).

METHODS

We reviewed all men who underwent IPP with PIG for PD at our institution (4/2010-9/2018). PIG was performed via relaxing tunical incisions during IPP implantation following manual modeling if there was persistent curve >30^° and/or significant narrowing. Tunical defects >2 cm were grafted. PA (Coloplast, Minneapolis, MN) or HP consisting of either Evarrest, Nu-Knit (Ethicon Inc., Somerville, NJ), or TachoSil (Baxter Int., Deerfield, IL) were used.

RESULTS

HP was placed in 18 men (n = 10 Evarrest, n = 6 Nu-Knit, and n = 2 TachoSil), 15 had PA. There was no difference in mean age, preoperative curvature (HP:75° vs PA:78°), or grafted area (HP:11.9 cm² vs PA:10.9 cm²) between HP and PA cohorts. Mean operative time was shorter for HP (122 vs 166 minutes, P = .01). Median follow-up: 6.6 months (range: 2-27 months) for HP and 34.6 months (range: 13-103 months) for PA. Residual curvature >20° was present following HP in 16.7% (n = 3) and PA in 13.3% (n = 2; P = 1.0). There were no complications attributable to HP/PA material and no IPP herniation through the tunical defect. Postoperatively, 94.4% (n = 17) of HP and 93.3% (n = 14) of PA patients were engaged in penetrative intercourse (P = 1.0).

CONCLUSION

HP are effective materials to cover the tunical defect over an IPP following plaque incision for PD. HP outcomes are similar to PA, while operative time is shorter for HP.