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

Surgical management of complex curvature in Peyronie's disease

PURPOSE

About 10% of Peyronie's patients are complex cases with severe curvature (>60 degrees), ventral plaque, multiplanar curvature, hour-glass/hinge deformity, notching deformity, and ossified plaque. In patients with complex Peyronie's disease (PD), different techniques (shortening procedures, lengthening procedures, and penile prosthesis implantation (IPP)) may be necessary to achieve successful result. This review aims to analyze the various surgical techniques employed in the management of Peyronie's disease, with a specific focus on patients with complex deformity.

METHODS

Articles focusing on the surgical management of complex curvature in Peyronie's disease were searched in MEDLINE and PubMed published between 1990 and 2023.

RESULTS

Shortening procedures are linked to penile shortening and are not recommended for complex cases such as notching, hour-glass deformity, or ossified plaque. Lengthening procedures are suitable for addressing complex curvatures without erectile dysfunction (ED) and are a more appropriate method for multiplanar curvatures. Penile prosthesis implantation (IPP), with or without additional procedures, is the gold standard for patients with ED and Peyronie's disease. IPP should also be the preferred option for cases of penile instability (hinge deformity) and has shown high satisfaction rates in all complex cases.

CONCLUSION

While surgical interventions for complex curvature in Peyronie's disease carry inherent risks, careful patient selection, meticulous surgical techniques, and post-operative care can help minimize complications and maximize positive outcome.

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.

Use of grafting materials during penile prosthesis implantation in patients with Peyronie's disease-a systematic review

Severe Peyronie's disease (PD) and concomitant erectile dysfunction (ED) may require plaque incision/excision and grafting (PIG) as an adjunct to penile prosthesis implantation (IPP). Currently, there is no available consensus on the best graft material to use. Our aim was to systematically review graft materials used as patches following PIG + IPP. Literature search was performed in March 2021. Only original articles in English with a series of 10 or more patients were included. Overall, a total of 17 studies were included, corresponding to a cohort of 662 patients. The mean age ranged from 45 to 65 years and most patients had curvatures >45°. Average penile lengthening ranged from 1 to 3.5 cm, average residual curvatures from 0 to 20% and decreased glans sensitivity from 0 to 20%. Eighty to 100% of patients were satisfied with cosmetic and functional results. PIG + IPP with the use of various grafts offers promising results for the treatment of patients suffering from severe PD with concomitant ED. Unfortunately, the absence of high quality and comparative studies makes it difficult to establish the optimum graft. Therefore, the level of experience of the surgical team with one or more methods should guide their choice.

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

INTRODUCTION

Penile prosthesis (PP) implantation combined with grafting techniques is indicated in patients with Peyronie's disease (PD) and erectile dysfunction (ED) nonresponsive to medical and conservative treatment that present with residual penile curvature greater than 30°, severe penile deformity or significant penile shortening.

OBJECTIVES

To address the preoperative evaluation, the surgical procedure and the functional outcomes of grafting techniques combined with PP implantation in patients with PD and concomitant ED and to provide future perspectives on the matter.

METHODS

We performed a systematic review of the literature based on the PRISMA statement (PROSPERO ID: CRD42021224517). Records were identified by searching Medline, Scopus, The Cochrane Library and Web of Science databases as well as sources of gray literature from inception to December 2020. The quality of all included records was assessed based on a modified version of the Newcastle-Ottawa Scale for cohort studies.

RESULTS

A total of 935 patients with a mean age of 59.6 ± 9.2 years from 23 studies were included in this systematic review. All studies reported excellent short- and long-term postoperative results, as well as high satisfaction rates ranging from 80 to 100%. A mean increase of 2.7 ± 1.4 cm in penile length was observed. Among different grafting materials and different types of PP, no significant differences in terms of preoperative, perioperative and postoperative functional outcomes or complications were demonstrated. Still, the operative time was shorter in studies applying the collagen fleece TachoSil.

CONCLUSIONS

PP implantation combined with grafting is a safe and highly effective surgical procedure in patients with PD and concomitant ED. All grafting materials provide similar beneficial outcomes, but TachoSil subsequently reduces the operative time and does not require suturing. Still, no definite conclusions can be drawn regarding the superiority of one grafting technique over the other, as randomized clinical trials are lacking. Sokolakis I, Pyrgidis N, Ziegelmann M, et al. Penile Prosthesis Implantation Combined With Grafting Techniques in Patients With Peyronie's Disease and Erectile Dysfunction: A Systematic Review. Sex Med Rev 2021;XX:XXX-XXX.

A comprehensive narrative review of residual curvature correction during penile prosthesis implantation in patients with severe erectile dysfunction and concomitant Peyronie's disease

Residual curvature correction during penile prosthesis implantation (PPI) is usually needed in patients with severe erectile dysfunction (ED) and concomitant Peyronie’s disease (PD). The aim of the study was to assess the different existing techniques for treating residual penile curvature during PPI in patients with severe PD and ED. We generated a comprehensive narrative review of the literature until August 2020 on the use of PPI in combination with straightening reconstruction techniques, in treating patients with severe PD and ED. We included studies published in English, assessing the PPI as primary intervention in patients with PD and ED. Secondary research studies and studies with insufficient data were excluded from final analyses. We included a total of 33 clinical articles with 1,612 patients that assessed the effects of PPI combined with straightening surgical techniques for the treatment of severe PD and ED. Based on the severity of penile curvature, the concomitance of additional penile deformities (i.e., hourglass deformity), the penile length, the presence of previous penile operations and the surgeon’s experience, four main categories of surgical techniques were identified: (I) PPI with plication of the penis on the convex side of the curvature, (II) transcorporeal plaque incision/excision, (III) PPI with plaque/tunical incision(s) on the concave side of the curvature and (IV) PPI with plaque incision/excision plus grafting. Patients with severe PD and ED can expect excellent outcomes with PPI and surgical correction of residual penile curvature and minimal side effects. Overall, all the above techniques seem to able to correct the residual penile curvature during prosthesis implantation. Grafting techniques seem to be favorable in patients with additional severe penile shortening. Still, no definite conclusions can be drawn regarding the superiority of one technique over the other.

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.

Management of residual penile curvature after penile prosthesis placement

Residual penile curvature is a common situation following the implantation of a penile prosthesis in patients with Peyronie's disease. Currently, there is a variety of options for the correction of residual curvature, including penile modeling, plication techniques, as well as tunical incision/excision with or without grafting. A literature search of PubMed and Medline databases was conducted from 1964 until 2020, using search terms for all articles in the English language. In this article, we provide a review of the techniques and the outcomes, according to the published literature.

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.

Penile prosthesis implant in the management of Peyronies' disease

INTRODUCTION

Penile prosthesis implantation (PPI), performed with or without adjunct straightening techniques, is one of the available surgical options in cases of Peyronie's disease (PD) with concomitant erectile dysfunction (ED). The aim of the study was to systematically identify and evaluate evidence regarding IPP in patients with PD and ED.

EVIDENCE ACQUISITION

Using Cochrane's methodological recommendations on systematic reviews, we conducted a systematic review of the literature on clinical research regarding the use of PPI, alone or in combination with any straightening maneuvers in the treatment of patients with PD and ED. The search was carried until January 2020. We included studies in English language with primary population patients with PD and ED who underwent IPP with the intent to treat the PD. All studies that were not original clinical research articles, reported insufficient data or included fewer than 5 patients were excluded from the final analysis.

EVIDENCE SYNTHESIS

In total 43 clinical articles with more than 2000 patients (N.=2143) investigating the effects of penile prosthesis implantation (PPI) for the treatment of PD with or without ED were included in the study. Depending on the severity of the penile curvature, additional penile deformities (i.e. hourglass deformity), penile length, prior operations and surgeons experience, 6 main categories of surgical techniques of PPI for penile straightening and treatment of PD were identified: PPI only, PPI with modelling of the penis, PPI with plication of the penis on the convex side of the curvature, PPI with plaque incision(s), PPI with plaque incision/excision plus grafting and PPI with grafting and penile lengthening.

CONCLUSIONS

Overall, patients with PD and ED can expect excellent outcomes with PPI against a minimal risk of side effects. No definite conclusions can be made regarding which technique is superior.

Long-term outcomes after plaque incision and grafting for Peyronie's disease: comparison of porcine dermal and bovine pericardium grafts

BACKGROUND

Plaque incision and grafting (PEG) is one of the mainstays in surgical therapy for severe penile curvature in Peyronie's disease (PD). Different kinds of grafts are available for covering albugineal defects during PEG, both allografts and xenografts. However, to date, none of these proved superior to others.

OBJECTIVES

To compare two different types of xenograft, porcine dermal matrix and bovine pericardium matrix in PEG for PD.

MATERIALS AND METHODS

From 2010 to 2019, 63 patients with PD underwent PEG, using porcine dermal (n = 25; Group 1) and bovine pericardium (n = 38; Group 2) grafts. Long-term outcomes were evaluated through multi-disciplinary questionnaires administration by phone interview. The following items were considered: correction of penile bending, quality of erection, intercourse ability, penile shortening, and sensitiveness. Overall satisfaction and impact of surgery on sexual activity and quality of life were also investigated.

RESULTS

Plaque median (IQR) size was 29 (22-33) mm and was smaller in Group 1 (27.5 vs. 31 mm; P = .03). Complete follow-up data were available for 53 patients (84%). Considering post-operative outcomes, no differences were found when considering ED rates, penile shortening, sensitiveness, complications, and penile straightening (all P > .1). Patients in Group 2 were more likely to have palpable penile nodules at follow-up (20.6 vs. 0%; P = .03). However, patient's post-operative sexual life satisfaction was consistent between the two groups, with just 1 (5.3) and 8 (23.5) patients in Group 1 and 2 respectively referring a worsening in sexual life satisfaction (P = 0.2). At follow-up, 84.9% of patients that would still undergo surgery for PD, with no statistical difference between the two groups (P = .4).

CONCLUSIONS

Corporoplasty with PEG is an effective treatment for men with PD. Porcine dermal and bovine pericardium xenografts seem to have similar long-term outcomes.

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.

Multicenter Experience Using Collagen Fleece for Plaque Incision With Grafting to Correct Residual Curvature at the Time of Inflatable Penile Prosthesis Placement in Patients With Peyronie's Disease

BACKGROUND

Adjuvant maneuvers are often necessary to correct residual curvature during inflatable penile prosthesis (IPP) placement in patients with Peyronie's disease (PD).

AIM

We present our multicenter experience using collagen fleece as graft material for plaque incision and grafting (PIG) during IPP placement in patients with moderate to severe PD.

METHODS

We retrospectively reviewed 51 patients with IPP from 3 sites who underwent PIG with Tachosil (Baxter, IL) collagen fleece. Coloplast (Minneapolis, MN) IPP devices were used. Factors associated with residual curvature, revision, and patient satisfaction were performed using chi-squared analysis.

OUTCOMES

We evaluated postoperative outcomes including factors associated with residual curvature, revision, and patient satisfaction.

RESULTS

The mean compound curvature was 69.6°. The mean follow-up was 10.6 (range 1-38) months. All patients reported erections sufficient for penetrative intercourse at the last follow-up. Residual curvature <15° was noted in 6 of 51 (12%) patients. 3 patients required device revision. 2 patients experienced temporary glanular paresthesia, and no patients experienced device infection.

CLINICAL IMPLICATIONS

In our multicenter study, patients experienced substantial curve correction with minimal complications, and in the few patients who had persistent mild curvature, severe preoperative curvature (>60°) was found to be the only risk factor.

STRENGTHS & LIMITATIONS

Our study represents the largest series of patients coming from multiple centers undergoing surgical correction of PD with IPP and collagen fleece grafting. Limitations of this study include the retrospective study design, lack of a comparison group, and modest follow-up.

CONCLUSION

PIG using collagen fleece is a safe and effective means of correcting residual curvature after IPP placement in patients with moderate to severe PD. Hatzichristodoulou G, Yang DY, Ring JD, et al. Multicenter Experience Using Collagen Fleece for Plaque Incision With Grafting to Correct Residual Curvature at the Time of Inflatable Penile Prosthesis Placement in Patients With Peyronie's Disease. J Sex Med 2020;17:1168-1174.